Sexual Orientation & Gender Identity
lgbt • queer • intersex • orientation questioning
Providing LGBTQQI Affirmative Services
Philip T. McCabe CSW, CAS, CDVC, DRCC
UMDNJ-School of Public Health, Office of Public Health Practice
Robert Wood Johnson Medical School
Rutgers Summer School of Alcohol and Drug Studies
National Association of Lesbian and Gay Addiction Professionals
NJ Coalition Against Sexual Assault
American Academy of Health Care Providers in the Addictive Disorders
American Public Health Association
LGBTQQI
Terminology
1
Understanding the Differences
One size does not fit all…
♥
♥
♥
♥
Gay
G
Lesbian
Bisexual
Transgender
Terminology LGBTQIA =
‡
Lesbian, Gay, Bisexual,
‡
Transgender: someone whose gender identity does not
match their anatomical sex at birth
‡
Queer (sometimes Questioning)
‡
Intersex: an individual who is born with external/internal
genitalia and/or secondary sex characteristics determined
y male nor female
as neither exclusively
‡
Ally: someone who doesn’t identify as, but supports
alphabet soup. (More on being an ally later…)
2
Other Terms
‡
‡
‡
‡
‡
‡
‡
‡
‡
‡
Queer
MSM WSW,
MSM,
WSW WSWM,
WSWM MSWM
MTF
FTM
Gender Variant
Two-Spirit
Gender Queer
Same Gender Loving
Heteroflexible
Bi-Currious
Terminology
‡ Sex
‡ Biological
Sex
‡ Sex/Gender Role
‡ Sexual Orientation
‡ Gender Identity
y
‡ Sexuality / Sexual Identity
‡ Transgender
‡ Transsexual
3
Sexual Orientation
Describes ones erotic and affectional
attraction to another person
person, including
erotic fantasy, erotic behaviors, sexual
desire for, lust for, romantic attachments
to others.
‡ Heterosexual
‡ Homosexual
‡ Bisexual
‡ Asexual
‡
Gender Identity
‡
Is ones inner sense of ones self, a persons
self concept in terms of gender.
‡
Gender Identity is not always derived from
genital anatomy.
4
Sexuality/ Sexual Identity
‡
Integration of physical/ emotional/
intellectual/ social aspects of a person.
‡
Expressing male/ female personhood.
Transgender
An umbrella term to identify gender nonconformists.
conformists
‡ May include: drag queens, drag kings,
cross-dressers, transvestites, bigender,
pre-op, post-op and non-op transsexuals.
‡ Complex phenomenon which must be
viewed with in cultural context.
context
‡
5
Transsexual
A person whose gender identity originally
conflicts with his or her anatomy.
anatomy
‡ A person who desires or actually crosses
over emotionally and /or physically to the
sex that truly fits their gender identity.
‡
Gender Identity
y and
Sexual Orientation
are separate issues
6
Not everyone has the same understanding
Gay for Pay / Gay for the Stay
Straight on the Streets, Queen in the Sheets
Straight Acting, DL, Down Low, NSA, PnP,
Beard, Fag Hag
Homo Thug Batty boy HeShe Butch
GirlyMan Punk, Bitch, Lezzie, Q Boi, Tranny,
Hot Mess, Miss Thing, Carpet muncher, Butt
Pirate, Backdoor booty, Mangina, Bromance
Developing
p ga
LGBT Identity
7
Kinsey Report on Human Sexuality
1
2
3
4
5
6
Klein's Sexual Orientation Grid
Sexual Attraction
‡ Sexual Behavior
‡ Sexual Fantasies
‡ Emotional Preferences
‡ Social Preferences
‡ Cultural/ Community Integration
‡ Self Identification
‡
8
Sexual Identity Development
Sexual Attraction
Perception
Emotional
Preference
Sexual Behavior
Self
Identification
Social
Preference
Authentic Self
Sexual Fantasies
Cultural / Community
Coming Out
9
Coming Out
Coming out is a process of
understanding,
d
t di
accepting,
ti
and
d valuing
l i
one's sexual orientation/identity.
‡ Coming out includes both exploring
one's identity and sharing that identity
with others. It also involves coping with
societal responses and attitudes toward
GLBT people.
‡
Coming Out Continued…
The coming out process is very
personal. This process happens in
different ways and occurs at different
ages for different people.
‡ Some people are aware of their sexual
identity at an early age; others arrive at
this awareness only after many years.
‡ Coming out is a continuing, sometimes
lifelong, process.
‡
10
The Six Stages of Integrating Lesbian Gay
Identity into the Self Concept
¾
¾
¾
¾
¾
¾
Identity confusion
Identity comparison
Identity tolerance
Identity acceptance
Identity pride
Identity synthesis
Development Theory Vivian Cass Model
Identity Confusion
"Could I be gay?" Person is beginning to wonder if "homosexuality" is
personally relevant. Denial and confusion is experienced.
‡
Task: Who am I? - Accept, Deny, Reject.
‡
Possible Responses: Will avoid information about
lesbians and gays; inhibit behavior; deny homosexuality
("experimenting," "an accident," "just drunk"). Males: May
keep emotional involvement separate from sexual contact;
Females: May have deep relationships that are non-sexual,
though strongly emotional.
‡
Possible Needs: May explore internal positive and
negative judgments. Will be permitted to be uncertain
regarding sexual identity. May find support in knowing that
sexual behavior occurs along a spectrum. May benefit from
being permitted and encouraged to explore sexual identity
as a normal experience (like career identity, and social
identity).
11
Identity Comparison
"Maybe this does apply to me." Will accept the possibility that she
or he may be gay. Self-alienation becomes isolation.
Task: Deal with social alienation.
alienation
Possible Responses: May begin to grieve for losses and the
things she or he will give up by embracing their sexual
orientation. May compartmentalize their own sexuality.
Accepts lesbian, gay definition of behavior but maintains
"heterosexual" identity of self. Tells oneself, "It's only
temporary"; I'm just in love with this particular
woman/man," etc.
Possible Needs: Will be very important that the person
develops own definitions. Will need information about
sexual identity, lesbian, gay community resources,
encouragement to talk about loss of heterosexual life
expectations. May feel the need for "permission" to keep
some "heterosexual" identity (it is not an all or none issue).
Identity Tolerance
"I'm not the only one." Accepts the probability of being homosexual and
recognizes sexual, social, emotional needs that go with being lesbian and gay.
Increased commitment to being lesbian or gay.
Task: Decrease social alienation by seeking out lesbians and
gays.
gays
Possible Responses: Beginning to have language to talk and
think about the issue. Recognition that being lesbian or gay
does not preclude other options. Accentuates difference
between self and heterosexuals. Seeks out lesbian and gay
culture (positive contact leads to more positive sense of
self, negative contact leads to devaluation of the culture,
stops growth)
growth). May try out variety of stereotypical roles.
roles
Possible Needs: Be supported in exploring own shame
feelings derived from heterosexism, as well as external
heterosexism. Receive support in finding positive lesbian,
gay community connections. It is particularly important for
the person to know community resources.
12
Identity Acceptance
"I will be okay." Accepts, rather than tolerates, gay or lesbian selfimage. There is continuing and increased contact with the gay and
lesbian culture.
Task: Deal with inner tension of no longer subscribing to society's
norm, attempt to bring congruence between private and public
view of self.
Possible Responses: Accepts gay or lesbian self identification. May
compartmentalize "gay life." Maintains less and less contact with
heterosexual community. Attempts to "fit in" and "not make
waves" within the gay and lesbian community. Begins some
selective disclosures of sexual identity. More social coming out;
more comfortable being seen with groups of men or women that
are identified as "gay." More realistic evaluation of situation.
Possible Needs: Continue exploring grief and loss of heterosexual
life expectations. Continue exploring internalized "homophobia"
(learned shame for heterosexist society). Find support in making
decisions about where, when, and to whom he or she self
discloses.
Identity Pride
"I've got to let people know who I am!" Immerses self in gay and lesbian
culture. Less and less involvement with heterosexual community. Us-them
quality to political/social viewpoint.
T k Deal
Task:
D l with
ith incongruent
i
t views
i
off heterosexuals.
h t
l
Possible Responses: Splits world into "gay" (good) and
"straight" (bad). Experiences disclosure crises with
heterosexuals as he or she is less willing to "blend in."
Identifies gay culture as sole source of support; all gay
friends, business connections, social connections.
Possible Needs: Receive support for exploring anger issues.
Find
d support ffor exploring
l
issues off heterosexism.
h
Develop
l
skills for coping with reactions and responses to disclosure
of sexual identity. Resist being defensive!
13
Identity Synthesis
Develops holistic view of self. Defines self in a more complete
fashion, not just in terms of sexual orientation
Task:
T
k Integrate
I t
t gay and
d lesbian
l bi
identity
id tit so that
th t instead
i t d off
being the identity, it is on aspect of self.
Possible Responses: Continues to be angry at
heterosexism, but with decreased intensity. Allows trust of
others to increase and build. Gay and lesbian identity is
integrated with all aspects of "self." Feels all right to move
out into the community and not simply define space
according to sexual orientation.
COMING OUT
Coming out is the term used to describe the
process of and the extent to which one identifies
p
oneself as lesbian, gay or bisexual.
There are two parts to this process: coming out to
oneself and coming out to others. Coming out to
oneself is perhaps the first step toward a positive
understanding of one's orientation.
It includes the realization that one is homosexual or
bisexual and accepting that fact and deciding
what to do about it.
14
COMING OUT
Coming out to others is an experience
unique to gay,
gay and lesbian and bisexual
individuals.
‡ The decision to come out to another person
involves disclosing one's sexual side, which
is for the most part viewed as being a
private matter.
matter
‡ Some are afraid of being rejected but
others worry that their sexual identity will
be the overriding focus in future
interactions with the other person.
‡
COMING OUT
‡
While coming out often does result in
negative consequences, it frequently leads
to a sense of relief and increased feelings
of closeness.
‡
Other issues are the extent of the
revelation (should everyone know or
should disclosure be selective?), timing
and anticipation consequences.
15
Passing
Is a person’s
person s being regarded as a member
of a social group other than his or her
own, such as a different gender, race,
sexuality, or disability status; generally
with the purpose of gaining social
acceptance
p
or g
gaining
g access to the
privilege of the power group.
Passing
‡
Our culture tends to assume heterosexuality and
persons who
h do
d nott correctt the
th heterosexual
h t
l
assumption are sometimes said to be "passing"
as heterosexuals.
‡
usually experience some conflict as they make
decisions on when to "pass" and when to be open
and some live with fear about their secret being
revealed.
may also experience some hostility from those
who are open and feel that they are not being
honest with themselves or others.
‡
16
Communicating with Patients
‡
‡
‡
Follow your patients’lead (how do they describe
themselves? their partners?)
If in doubt, ask patients what terms they prefer.
Be curious without worry about offending
patients.
Iff you “slip
“ l up,”apologize
”
l
and
d ask
k the
h patient
what they prefer. Patients will appreciate your
sincerity and good intentions!
Communication: Avoiding Assumptions
‡
‡
‡
‡
‡
‡
‡
Don’t assume all patients use traditional labels
Don’t assume all patients are heterosexual
Don’t assume sexual orientation based on
appearance
Don’t assume sexual behavior based on sexual
identity
Don’tt assume sexual behavior and identity have
Don
not changed since last visit
Don’t assume bisexual identity is only a phase
Don’t assume transgender patients are gay,
bisexual, or lesbian
17
Treatment
‡
P
Providing
idi
LGBT Affi
Affirmative
ti
Services
S
i
Gay Men: Risk Factors for Addiction
‡
‡
External
„ Social settings
‡ Gay
G
b
bars and
d clubs
l b
ƒ Alcohol
ƒ Crystal methamphetamine
ƒ Ecstasy
ƒ Ketamine
ƒ GHB and related compounds
‡ Circuit parties
„ Common sexual practices
‡ Sexual stimulants
ƒ Poppers- amyl nitrite
ƒ Butyl nitrite
‡ Sexual performance enhancers- Viagra and related
drugs
Internal
„ Unresolved internalized homophobia
„ Fear of homophobic violence
18
Lesbians: Risk Factors for Addiction
‡
‡
External Factors
„ Social settings
‡ Women’s
W
’ bars
b
ƒ Primarily alcohol in women over 35
ƒ Younger women using crystal, X, K, etc.
‡ Sports activities- usually sponsored by bars, breweries
ƒ Softball
ƒ Touch football, flag football
ƒ Golf
ƒ Tennis
„ Common sexual practices
‡ Use of sedative drugs for relaxation
ƒ Alcohol, benzodiazepines
ƒ Marijuana
‡ Use of stimulants to increase libido, arousal
Internal Factors
„ Self-medicating unresolved internalized homophobia
„ Self-medicating symptoms of PTSD
Bisexuals: Risk Factors for Addiction
Large, heterogeneous group
‡ Lack of a defined culture, more of an
anti-culture
‡
„
„
„
Some bisexuals define themselves by what
they’re not
Feel alienated, rejected and/or rejecting
S
Some
are leading
l di
a secrett life
lif
‡
‡
Married, seeing same-sex people on side
Using chemicals at home and in secret life
19
Bisexuality: Choice or Confusion?
‡
Three general groups
„
„
„
‡
Comfortable in bisexual identity
Confused and conflicted about gender
orientation, pulled toward homosexual
partners but unable to accept GL label
Gay/ Lesbian persons leading a double life and
fooling
g themselves and/or
/ others
Culture plays major role
„
„
May be accepted or quasi-accepted practice
May be age-determined
Transgender: Male to Female
Often have longstanding history of
female-identified self- concept
‡ May have tried various experiments in
living as a woman
‡
„
„
Dressing as a woman
Prostitution
May find acceptance in gay society, but
may be sexually attracted to women
‡ Often use alcohol and other sedative
drugs, initially to medicate anxiety, fear
‡
20
Transgender: Female to Male
‡
Frequently have lifelong history of gender
dysphoria
„
„
‡
May use alcohol, other drugs to self-medicate
May seek help for depression, anxiety -> Rx
drug dependence
Gender orientation
„
„
While growing up female, may be attracted to
boys (heterosexual) or girls (homosexual)
Usually do not change orientation when make
transition to male gender
Other Groups
‡
“Gender
Gender Queer”
Queer
„
„
‡
Individuals who identify with and dress as
opposite gender
Resist any drastic action to change gender
(hormones, surgery)
Heterosexual cross-dressers
„
„
May or may not be pathological
In clubs and other gatherings, alcohol and
other drugs use very common
21
Special Challenges in Recovery
‡
Treatment programs are unwittingly
developed with heterosexual bias
„
„
‡
Gender separation rules
Gender-specific groups
Homophobia is ever-present
„
„
„
„
In pat
patient
e t population
popu at o
In staff attitudes
Internalized in patient
In Twelve Step rooms
Counseling LGBT Individuals
Not “special” but required unique
knowledge and skills
‡ Comfort with the population and related
issues -non-judgmental
‡ Awareness of potential boundary conflict
‡ Working knowledge of internalized
h
homophobia,
h bi heterosexism
h t
i
and
d anti-gay
ti
bias and their consequences
‡
22
Special knowledge needed
‡
‡
‡
‡
‡
See LGBT community from a “culturally competent”
point of view, similar to ethnicity and different culture
background effects
Comfort with taking sexual history, including
practices and intimate relationships
Know about ways people may meet and connect in
the LGBT network
Unde stand internalized
Understand
inte nali ed homophobia may
ma prevent
p e ent
some people from acting on desires
Understand terminology
Developmental Issues
Orientation not the p
pathology;
gy living
g with
a different orientation in a biased society
the source of the problems
‡ Psychology of difference
‡ Guilt for not having same attitudes,
values, and moral precepts of society?
‡ We are all “children of Alice Miller”:
Seeking parental rewards and approval
False selves and coming out
Acceptance and pain of rejection
Overcoming internalized homophobia
‡
23
Issues That Heterosexuals Do Not Face
‡
Awareness of orientation difference
‡
A
Acceptance
t
off that
th t difference
diff
‡
Decision to “come out”
‡
Decide who will/should know
‡
Creating supports and acceptance
‡
Living as a gay,
gay lesbian,
lesbian bisexual person;
‡
integration of a personal identity and a gay/lesbian identity
‡
Confronting societal bias
‡
(Bisexuals may face struggle for acceptance with gays and straights)
Aspects of Treatment Approach
Respect and comfort
‡ Self-awareness of internalized anti-gay
feelings
‡ If therapist is LGBT, do not assume patient
had similar life-experiences
‡ Comfort talking about sex
‡ Awareness of transference and sexual
feelings in therapist and patient
‡
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Treatment
“Repair” the Sexual Identity- ignore the
ATOD
‡ Treat the Sexual Identity – fix the addiction
‡ Treat the addictions, ignore the orientation
‡ Treat the ATOD, minimize the orientation
‡ Treat the ATOD,
ATOD acknowledge the SI
‡ Treat the ATOD, integrate SI into Recovery
‡ Intergrate SI as significant to Tx and
Recovery
‡
Ethical Issues -There are no “special” ethics for
LGBT therapists or patients
Boundary violations can occur is several
ways:
‡ Sexually- directly or indirectly (in the same
sexual venue)
‡ Socially- shared situations and possible
breaches of confidential information
‡ Sharing information with significant other
‡ Some borderline patients can create very
difficult “blackmail-like” situations
25
Interventions
‡
Conducting a Sexual History Interview
Interview
‡
Are you currently sexually active?
Are you sexually active with men, women
or both?
‡ If not active why not?
‡ In the past were you active with M/W/B?
‡
26
Sexual History Interviewing
‡
‡
‡
Do you currently have a primary intimate
partner/spouse or lover
Are you active with others ? Open/Closed
Poly-amorous, Serial, Committed, Anonymous
„ With/Without
‡ Involvement
‡ Consent
‡ Acknowledgement
‡ DADT
‡ Secret/Denied
Previous Health & Treatment
‡
Status STI/HIV when tested/results/Tx
27
Sexual Activity
O/V/A intercourse
intercourse- MWB?
‡ Receptive/insertive- MWB?
‡ Protective/Non protective
O/V/A intercourse
R-I role /versatile
‡
Sexual Activity and Substance Use
‡
‡
‡
‡
‡
Describe your current use of ATOD?
HOW about when having sex?
Use more before, during, after?
Do you think drinking or drugs makes sex easier,
better?
When under the influence do you make different
decisions about sex and or condoms?
28
Safe, Sane, Sober and Consentual Sex
Do you have any concerns about sex or
intimacy?
Sex without alcohol or drugs?
Sexual risk taking?
Sexual Compulsion, addiction or acting out ?
Relapse Prevention
‡
Ensure that discharge procedures help
LGBT clients develop relapse prevention
strategies for high-risk situations specific
to them, such as reentering bar-oriented
LGBT communities, coming out to their
family
y of origin
g if they
y decide to do so,,
and dealing with homophobia,
discrimination, and/or gay bashing.
29
Resources for Clients
Ensure that discharge procedures include
providing each LGBT client with a
comprehensive list of LGBT-specific and/or
LGBT-sensitive community resources and
services, along with clear information
about how to access these services.
‡ Local LGBT 12 step meetings,
meetings clean and
sober gay events
‡
CAGE Brief Assessment
cut down on your
‡
Have you ever felt you should
drinking?
‡
Have people
‡
Have you ever felt bad or
‡
H
Have
you ever h
had
dad
drink
i k fi
firstt thi
thing in
i the
th morning
i
(as
(
annoyed you by criticizing your drinking?
guilty about your drinking?
e
an “ ye opener”) to steady your nerves or get rid of a
hangover?
30
Heterosexual Questionnaire
‡
What do you think caused your heterosexuality?
‡
When and
Wh
d how
h
did you first
fi t decide
d id that
th t you were a
heterosexual?
‡
Is it possible that your heterosexuality is just a phase that you
will grow out of?
‡
Isn’t it possible that all you need is a good same-sex partner?
‡
Why do you people feel compelled to seduce others into your
heterosexual orientation?
‡
How can you enjoy a deep emotional bonding with persons of
the opposite sex when the obvious physical, biological, and
temperamental differences between you are so vast?
‡
The majority of child molesters are heterosexual (according to
FBI statistics). Do you really consider it safe to expose your
children to heterosexual teachers?
‡
With all of the societal support Marriage receives, the divorce rate
is spiraling. Why are there so few stable relationships among
heterosexuals?
‡
There seem to be very few happy heterosexuals. Techniques
h
have
been
b
developed
d
l
d with
ith which
hi h you might
i ht b
be able
bl to
t change,
h
if
you really want to. Have considered trying aversion therapy?
31
Substance Abuse and Mental Health
Services Administration
A Providers Introduction to
Substance Abuse Treatment
for Lesbian, Gay, Bisexual,
and Transgender Individuals
1 800 729 6686 for
1-800-729-6686
f # BKD392
32
Serving the Lesbian Gay, Bisexual & Transgender
Communities Since 1979
www.nalgap.org
g p g
33
Philip T. McCabe,
CSW, CAS, CDVC, DRCC
UMDNJ- School of Public Health
732-235-8229
mccabept@umdnj.edu
LGBT-Healthcare@lists.umdnj.edu
NJgayhealth.com
34