Developing Clinical Competence in Working with
Lesbian, Gay, Bisexual and/or Questioning
Patients
Presented by Lisa A. Schimmel Ph.D
Staff Psychologist, OHSU Student Health Services
Learning Objectives
This initial lecture will provide you with the information to:
1. Describe specific external factors and internal processes impacting the lives and
mental health of Lesbian, Gay, Bi-sexual & Questioning patients/clients.
2. Discuss the nature of cohorts and ongoing coming out processes.
3. Develop awareness of your role as buffer in managing LGBQ patients’ external and
internal stressors.
4. Incorporate specific actions to enhance rapport and connection with LGBQ
patients.
5. Provide essential LGBQ/LGBT community resources to patients and colleagues.
LGBQ Sexual Orientations
Lesbian -- primary sexual attraction of women toward women
Gay Male – primary sexual attraction of men to men
Bi-Sexual – primary gender not necessarily a factor in attraction
Questioning – someone in process of identifying their sexual orientation
Bi-Curious –one who might explore the same and other-sex attractions
MSM – Men who have sex with men, but do not consider themselves to be gay
Gay – overarching term used by many non-heterosexual persons
LGBQ Relevant Issues/Terms
Heterocentrism/Heterosexist Bias
Belief in superiority of heterosexuality over
things non-heterosexual…
 May be part of conscious belief system
 May be overtly or subtly expressed
 May be also be an unconscious process
LGBQ-Sensitive/Gay-Affirmative
Clinicians
The Road from Discovery…
to Acceptance
Discovery of one’s sexual self may appear much earlier in life than
acceptance of it depending upon the number and type of hurdles
one has to navigate.
Buffers Cohort Heterocentrism LGBQ Community Access Political & Social Climate
Work/Life Pressures to Pass Cultural/Racial Variables Fear of Physical/Emotional/Spiritual Harm
Fear of loss of F.O.O. Limited F.O.C. Access to Affirmative Clinicians IPV Rural vs. City Status
Sexual Diversity Awareness Fear of loss of community (friends, religious, community) “Minority” Status
Access to GSAs Access to Role Models Access to Positive Media Portrayals Resilience
_______________________________________________________________________________________________________________________
Discovery
Acceptance
Multiple Minority Status &
Privilege
When working with a LGBQ populations it is essential to consider
the complexity of minority status 8
1.
Be conscious of multiple stigmatizing variables for the LGBQ patient related to race,
gender, financial limitations, disability, age, etc…
2.
Work to assess and navigate these identities with your patient by:
a. Educating self about the impact of ethnocentric, andro-centric and
heterocentric privilege on persons of multiple minority status
b. Teaching patient healthy self-soothing techniques
Family of Choice & “Family”
Cohorts & Coming Out
Cohort = of a specific time period or generation
LGBQs express variability in comfort levels in coming out
based on safety/political/social climate
Present period
Same-sex marriage/Civil Unions/Repeal DADT/Bullying exposed
1997-2000s
Affirmative media portrayals of LGBQ life/Civil Unions
1990s
Limited TV/Media exposure to positive LGBQ role models –
NARTH/Reparative/Conversion Organizations/DOMA/DADT
1980s
Reagan Era /GRID/AIDS /Closeted Time /Major losses /Rock
Hudson/ An Early Frost / Gay Straight Alliances (GSAs)
Late 60s/1970s
Stonewall Riot/ Homosexuality Dx removed from DSM by APA
Gay/Lesbian Identity -- Pride Parades Commemorate Stonewall
/1st Ex-Gay Ministry (Love in Action)
1960s & earlier
Homosexuality = Mental Disorder
**Attend to cohort /coming out differences when working
with LGBQ couples
Sexual Prejudice
Bisexuality Issues
 Bisexuals experience marginalization from
heterosexual & lesbian/gay communities.
 Lesbians & Gays view Bisexuals as “on the
fence” about sexual orientation.
 Heterosexual communities are often
uncomfortable with bisexual fluidity.
 Fewer visible role models than L & Gs
 Limited information/research regarding their
sexual orientation
 Less awareness of Bi-sexual peers than L&Gs
Deepening Connection & Rapport
Enhancing rapport with LGBQ patients involves:
 Eliminating hetero-centrist language and
assumptions
 Creating a sense of safety for and acceptance of
LGBQ patients
 Fostering an inclusive environment
 Educating yourself about and providing
appropriate LGBTQ resources
Managing Hetero-centric Language
& Assumptions
USE LANGUAGE OF CONNECTION & EMPLOY AWARENESS
 Utilize affirmative language
Sexual orientation vs. Sexual preference
Gay, Lesbian, Bi-sexual, Questioning (Identity) vs. Homosexual (Sexual Behavior)
Partner/Significant Other/Spouse vs. Friend
 Use terminology that resonates with the patient – (e.g., family, family of choice, top, stone
butch, gay woman)
 Feel free to ask them to define what you do not know and/or take time to access this
information on your own.
 **Listen for and attend to the language of “internalized homophobia/internalized homonegativity”
USE ASSESSMENT RATHER THAN ASSUMPTION
Avoid assuming patients are coming to you with a
hetero-sexual orientation
Investigate the way patients understand their own
sexual orientation
Assess for IPV (Intimate Partner Violence) issues within
same-sex relationships
Creating Safety & Acceptance
Fostering an Inclusive Environment
1. People in LGB communities utilize therapy in larger numbers
than non-LGBQs 2
1. A sense of safety and connection is built, in part, through
offering specific actions that promote LGBQ visibility and
awareness.
1. Making a space for them and asking questions that mirror
their experiences will aid in fostering an inclusive
environment.
Developing Competence
Within & Beyond the Work Setting
Review your professional association guidelines for treating
LGB/LGBT patients
http://www.apapracticecentral.org/ce/guidelines/index.as
px
http://www.psych.org/Departments/EDU/Library/APAOfficial
DocumentsandRelated/PositionStatements/200001.aspx
http://www.apa.org/pi/lgbt/resources/sexualorientation.aspx
http://www.ama-assn.org/ama/pub/about-ama/ourpeople/member-groups-sections/glbt-advisorycommittee/ama-policy-regarding-sexual-orientation.page
http://www.aamft.org/iMIS15/AAMFT/MFT_Resources/MFT_R
esources/Content/Resources/Position_On_Couples.aspx
Join your professional association’s LGB/LGBT division,
committee and/or listserv
http://www.aglp.org
http://www.apadivision44.org/
http://www.socialworkers.org/governance/cmtes/nclgbi.as
p
Keep abreast of socio-political and legal issues and/or
changes that impact the life of your LGB patients
www.lambdalegal.org/
www.glaad.org/
www.nytimes.com
Developing Competence
Within & Beyond the Work Setting (cont.)
Include study of LGB/LGBT populations in future research
Obtain clinical consultation for LGBQ patient care from LGBQ
affirmative/competent therapists
Self-reflect on your hetero-normative/hetero-centric assumptions, heterosexual privileges, internalized homo-negativity, and sexual identity and
the ways these may generalize to your life and work with your patients
http:www.ndsu.edufileadminhdfsMcGeorge___Carlson_Deconstructing_Hete
rosexism.pdf
Be alert to organizations that promote reparative or conversion therapies
aimed at “changing” sexual orientation.
Self-Exploration of Hetero-normative Assumptions, Heterosexual Privilege/Identity
Source : http://www.ndsu.edu/fileadmin/hdfs/McGeorge___Carlson_Deconstructing_Heterosexism.pdf
1. How did I learn about my sexual orientation and other sexual orientations?
2. What kinds messages did I receive from my family/friends/society about mine and other sexual orientations?
How do my actions reflect these messages in my life today?
3. Do I tend to assume a particular sexual orientation upon first meeting another person?
4. Do I respond to expression of affection, regardless of sexual orientation, the same way? If not, how do I respond?
What informs me to respond in that way?
5. How might it be to live in a society that may be hostile toward my sexual orientation?
How might this impact my wellbeing and mental health? How might it impact my comfort in getting help from others?
6. How does living in a hetero-centrist society impact my sense of self, my connections to others and my ease in navigating
life and work challenges?
7. What was the cause of my sexual orientation?
8. Looking back, when did I decide to make heterosexuality my preference?
9. How does my sexual orientation inform my work with patients of same or other sexual orientations?
10. How often do I worry that my heterosexuality might cause me to lose my job or status?
11. How often am I concerned about losing my life solely as a result of my heterosexual orientation?
12. How often am I worried about being perceived as unsafe to work with children because of my heterosexual preference?
13. Do I think it is possible to change my sexual orientation?
14. How do I feel about folks who consider themselves to be bi-sexual? What informs my feelings?
Consider researching these and other resources to provide to your patients
References
1 APA
Task Force on Appropriate Therapeutic Responses to Sexual Orientation. (2009). Report of the Task Force on Appropriate
Therapeutic Responses to Sexual Orientation. Washington, DC: American Psychological Association.
2 Fassinger,
R.E., & Richie, B.S. (1997). Sex matters: Gender and sexual orientation in training for multicultural counseling
competency. In D. B. Pope-Davis & H.L.K. Coleman (Eds.), Multicultural counseling competencies: Assessment, education,
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Goldberg, A.E. (2010) Lesbian and gay parents and their children: Research on the family life cycle. Washington, D.C:
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3
4 Greene,
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Readings 1
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Readings 6
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developmental counseling and therapy to address sexual orientation conflicts. Journal of LGBT Issues in
Counseling, 4(1), 32-47. doi:10.1080/15538600903552749
Pope, A. L., Murray, C. E., & Mobley, A. K. (2010). Personal, relational, and contextual resources and relationship
satisfaction in same-sex couples. The Family Journal, 18(2), 163-168. doi:10.1177/1066480710364501
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Contact Information
Lisa A. Schimmel, Ph.D.
Psychologist & Clinical Consultant
License Numbers: Psy15072 (CA) 1709 (OR)
Phone: 503.381.9524
Email: schimmli@ohsu.edu
Thoughts? Questions?
Thoughts? Questions?
Thoughts? Questions?
Thoughts? Questions?
Thoughts? Questions?
Questions?
Thoughts?