
Competent and Ethical Counseling of
LGBTQ
Persons
Presented by:
Traci Hill, LPC
Human Development and the Development of ‘Coming Out’…
Predominance (per the Williams Institute, UCLA School of Law – 2011)

There are more than 8 million adults in the US who are lesbian,
gay or bisexual, comprising 3.5% of the adult population.
Human Development and the Development of ‘Coming Out’…
Predominance

In total, their study suggests that
approximately 9 million
Americans – roughly the
population of New Jersey –
identify as LGBT.

1.8% identify as bisexual

1.7% identify as lesbian or gay
Human Development and the Development of ‘Coming Out’…
Predominance

Estimates of those who report any lifetime same-sexual behavior
and any same-sex sexual attraction are substantially higher than
estimates of those who identify as LGB.

There are nearly 700,000 transgender individuals in the US

19 million Americans (8.2%) report they have engaged in samesex sexual behavior.

Nearly 25.6 million Americans (11%) acknowledge at least some
same-sex sexual attraction.
Human Development and the Development of ‘Coming Out’…
The Stages of Coming Out
The Cass Model (1979):
1. Identity Confusion
2. Identity Comparison
3. Identity Tolerance
4. Identity Acceptance
5. Identity Pride
6. Identity Synthesis
Human Development and the Development of ‘Coming Out’…
The Stages of Coming Out
The Cass Model (1979):
1. Identity Confusion
 Sees self as member of mainstream group.
Denial of inner feelings.
 Who am I?
 Am I different?
Human Development and the Development of ‘Coming Out’…
The Stages of Coming Out
The Cass Model (1979):
2. Identity Comparison
 Begin to come out of the "fog."
 Maybe I am gay.
 I'm alone.
 What are gay people like?
Human Development and the Development of ‘Coming Out’…
The Stages of Coming Out
The Cass Model (1979):
3. Identity Tolerance
 Encounter someone or something that breaks
through the denial system.
 I accept the possibility that I may be gay.
 Where are other gay people?
Human Development and the Development of ‘Coming Out’…
The Stages of Coming Out
The Cass Model (1979):
4. Identity Acceptance
 Exploring subculture activities, readings, etc.
 I am gay.
 Am I okay?
 I can come out to some people.
Human Development and the Development of ‘Coming Out’…
The Stages of Coming Out
The Cass Model (1979):
5. Identity Pride
 Feel arrogance/pride in new identity and deep rage
toward majority culture. May adopt/heighten
stereotypical behaviors or characteristics (i.e. "I'm
different and proud of it!".) May isolate self from
mainstream values and activities.
 I am proud to be gay.
 I don't (and won't) pass for straight.
Human Development and the Development of ‘Coming Out’…
The Stages of Coming Out
The Cass Model (1979):
6. Identity Synthesis
 Acceptance and integration of new identity. May
go through five stages of grief to let go of old
identity and all advantages of heterosexual
privilege. Internalize pride/positive feelings
about identity. Typically is "out" (with friends,
family, at work). More at peace with self.
 I am an okay person who happens to be gay.
Human Development and the Development of ‘Coming Out’…
The Stages of
Coming Out
PASSING
COVERING
EXPLICITY
OUT
OUT
Lying
Censoring
Truth without
LGBT labels
Affirming
LGBT identity
I assume you
do not know.
I assume you
do not know.
I assume you
know, but I
am not sure.
I know you
know. You
know I know
you know.
See me as
heterosexual
Do not see
me as LGBT
You can see
me as LGBT if
you want to
See me as
LGBT
Identity
Management
(Griffin, 1992)
IMPLICITLY
Human Development and the Development of ‘Coming Out’…
Coping with Family/Social Reactions
(Handbook of Counseling and Psychotherapy with LGBT Clients, 2nd editon, Bieschke, Perez, Debord)
There are two different aspects to coming out.
1. Acceptance of one’s non-heterosexual identity
Coping with internalized homophobia
2. Disclosing ones identity to others
An affirmative counselor can model a positive response that can
facilitate the client’s movement toward self-acceptance.
Conversely, a counselor who reinforces negative social messages
can thwart this process or cause additional distress.
Human Development and the Development of ‘Coming Out’…
Coping with Family/Social Reactions
Coming out is a life-long process… LGBT individuals have to do it
over and over…
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Family
Work
Friends
Others…
Human Development and the Development of ‘Coming Out’…
Coping with Family/Social Reactions
Factors which mediate impact of family reaction:
(Coming Out and Internalized Homophobia, C. House)
 Strength of religious values
 Family values regarding traditional gender roles
 Family’s view of itself in relation to the community
Human Development and the Development of ‘Coming Out’…
Stages of Adjustment For Families
1. Subliminal Awareness

A non-heterosexual orientation may be suspected
because of specific behaviors, same sex-friends, not
dating heterosexually, dress and language use, changes
in communication (not addressing certain subjects)
Human Development and the Development of ‘Coming Out’…
Stages of Adjustment For Families
2. Impact
Occurs when the truth is made apparent
The revelation crisis: the negotiation of new family roles

Experience of loss of the member’s previous family role

Feelings of guilt/failure (for “abnormality”)

Siblings may react with anger/confusion, experienced as
stranger despite shared childhood
Human Development and the Development of ‘Coming Out’…
Stages of Adjustment For Families
3. Adjustment
 Involves the family’s initial attempt to adapt to the
non-heterosexual family member
 Role clarification and adjustment
Human Development and the Development of ‘Coming Out’…
Stages of Adjustment For Families
4. Resolution

The family discards the fantasized heterosexual identity for
the non-heterosexual identity of the family member

Family members begin to examine their own values about
non-heterosexuality and modify them in light of new and
often intimate knowledge of non-heterosexual persons
Human Development and the Development of ‘Coming Out’…
Stages of Adjustment For Families
5. Integration

Family adjusts values in order to incorporate the nonheterosexual identity into the family

Family members learn to de-emphasize the small part of
the non-heterosexual family member’s identity that is
different and retain the majority of the person’s known
and loved attributes
Human Development and the Development of ‘Coming Out’…
Gay Adolescence
 Identity Pride (Stage 5 of The Cass Model)

Recommended for review: ‘Does Your Gay Age Match
Your Chronological Age?’ at www.joekort.com
 Typical behaviors and impacts… and issues seen in
counseling at this stage?
Human Development and the Development of ‘Coming Out’…
Developing Healthy Social Support and a
Chosen Family
Identity Acceptance (Stage 4 of The Cass Model)

Ex’s, Mentors, and other Accepting Individuals
Provide a lifetime of emotional support from people who
understand them in a way that straight family never will.

“Family of Choice”, “Gay Family”
(this may include ex-partners)
Compounding Issues / Impact Themes
LGBTQ? Can I accept myself? Will others accept me?
Family or Origin Issues/Trauma
Organic/Genetic: mood disorders, anxiety, etc.
Compounding Issues / Impact Themes
LGBTQ? Can I accept myself? Will others accept me?
 Mental Health

Recommended for review:



‘New Data on Lesbian, Gay and Bisexual Mental Health’, DeAngelis, APA,
Vol. 33, No.2
‘Prevalence of Mental Disorders, Psychological Distress, and Mental
Health Services Use Among Lesbian, Gay, and Bisexual Adults in the
United States’, Cochran, Sullivan, and Mays, Journal of Counseling and
Clinical Psychology, 2003, Vol. 71, No. 1
And regarding the possible development of Axis II symptoms…
‘Personality Disorders in Gay, Lesbian, Bisexual and Transgender
Chemically Dependent Patients’ by Grant, Flynn, Odlaug, and Schreiber
Compounding Issues / Impact Themes
LGBTQ? Can I accept myself? Will others accept me?
Substance Use/Abuse
Recommended for review:
Healthy People 2010, Substance
Abuse Report (CDC)
Compounding Issues / Impact Themes
LGBTQ? Can I accept myself? Will others accept me?
Overcompensation / Overachievers –
self-esteem and worthiness issues
“The Gay Tax”
Recommended for review: “Another Consequence of Homophobia:
Overcompensation”, by Dr. Anthony Grollman, 2013.
“The Best Little Boy in The World,” by Andrew Tobias
Cultural Concerns
The LGBTQ Community / “Gay Culture”
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The flag and other symbols
Terms / language / code
Subcultures
Small communities
“Gayborhoods”
Gathering places
“Gaydar”
OKC / Oklahoma LGBTQ Culture
Boundaries
Cultural Concerns
Spiritual Considerations
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In Oklahoma
Books that may be helpful:
The Lord is my Shepherd and He Knows I’m Gay by Troy Plummer
Stranger at the Gate by Mel White
Christianity, Social Tolerance and Homosexuality by John Boswell
The Alchemist by Paula Coelho
We Were Baptized Too by M. Alexander and J. Preston
Also helpful to family members:
“Letter to Louise” by Bruce Lowe
Cultural Concerns
LGBTQ AND:

Native American… the “two-spirit people”…

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2-Spirit Organizations: Native Out – www.nativeout.org, Central Oklahoma Two
Spirits Society
Asian… “…a failure of the parents and a rejection of family and culture”
(Bieschke, Perez, Debord)


Latino… possibly ok if in “the active or insertive role…” (Bieschke, Perez, Debord)

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The Gaysian, The Gay Asian’s Lifestyle Guide – includes a list of resources and
organizations supportive to gay Asian-Americans
Llego’, The National Latino/a LGBT Organization: 202-544-0092
African American… “The Down Low / DL”

The National Black Justice Coalition, see website or call: 202-319-1552
Cultural Concerns
LGBTQ AND:
 Aging… risk of social exclusion / importance of community…
 “I do not want to be looked after by someone who dislikes me
because I am a lesbian.” Sheila, age 57

For more info see: Working with Older Lesbian, Gay and Bisexual
People, a Guide for Care and Support Services” by the Stonewall
organization
 SAGE (Services and Advocacy for LGBT Elders) – Tulsa Chapter –
SAGE@Okeq.org
 Outt Late – a support group for lesbians that came out later in life –
Cimarron Alliance, OKC
Cultural Concerns
LGBTQ AND:
 Youth… the rate of suicide attempts among GLB youth are
20 – 40% higher than among non-GLB youth – per NAMI.
 Trevor Suicide Prevention Line 1-800-850-8078
 Rainbow Youth Hotline 1-877-542-8984
 GLBTQ Youth Advocacy www.youthresource.com
 Locally: YES (Youth Equality Services)
 LGBTQ Support Group every Tue evening at Expressions,
in Common Grounds Coffee Shop at 2245 NW 39th
 Kris Williams, Coordinator 405-600-1052
Cultural Concerns
LGBTQ AND:
For Oklahoma Specific LGBTQ Community and Support
Information:

The Cimarron Alliance Equality Center – 405-495-9300
At 56th and N. May, www.equalityokc.org

Oklahomans for Equality, Tulsa – Helpline: 918-743-4297 or
www.okeq.org
The “T” (Transgendered)
Overview
Development / General Information
 “I knew something was different at age 4,5,6…”
 The Transexual Person in Your Life at www.tsfaq.info
 www.Susans.org
The “T” (Transgendered)
Overview
The Tg “Umbrella”
 Cross-dressing
 Transvestite
 Gender Queer
 Transexual
The “T” (Transgendered)

Diagnosis
 Gender Identity Disorder, now Gender Dysphoria…the criteria…
 Complications:
 Depression or anxiety
 Poor self concept
 Body image issues / obsession
 Emotional distress
 Feeling alone
 Suicide
The “T” (Transgendered)
Role of the Therapist
Standards of Care

Dr. Harry Benjamin / The Benjamin Standards of Care …
…1948, 1966, and today…
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World Professional Association for Transgender Health (WPATH)
The “T” (Transgendered)
Role of the Therapist
 Family-Centered Treatment
 Assisting parents, spouses/partners, children in the
adjustment process…
 Coping in the Community
 When, how, and to whom to “come out”…
 Advocacy
 Education / Consultation
 The “Bathroom Letter”
The “T” (Transgendered)
Role of the Therapist
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Youth and Children
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Timing / case-by-case
 Parents and split families
 Support
 Involving the doctor
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When to Refer / Consult
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“We shouldn’t have to educate our therapists.” -- a client in transition
 Thorough evaluation
 Comorbid issues
The “T” (Transgendered)
The Transition
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Social / Emotional
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Physical
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Hormones, hair and hips…
Medical
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Self
Family
Work
Community
Hormones
Surgical Options
Local resources
Every transition is different – a “completed transition” for one may be
very different than that of a another…
The “T” (Transgendered)
Developing a Healthy Support Network
 Online support/community
 Local support groups / community
 Cimarron Alliance – Saturdays at 5pm
 Local LGBTQ-friendly churches
Clinical Considerations
Personal Bias
Heterosexism: (Handbook of Counseling and Psychotherapy with
LGBT Clients, 2nd edition)

Defined as: “The ideological system that denies, denigrates,
and stigmatizes any nonheterosexual form of behavior, identity,
relationship or community.”

“…refers to the premise that all people are heterosexual unless
and until they indicate otherwise…therapists frequently operate
under this premise…”
Clinical Considerations
Personal Bias
Heterosexism:

“The client’s current identity may not be a fixed point, but
rather fluid… it is important not to make assumptions based on
current behavior or marital status”

Communicating openness to clients:
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Promotional materials / nondiscrimination statement
Forms
Office
Clinical Considerations
Overcoming Heterosexism:
 “A critical first step that counselors need to take to
avoid perpetuating heterosexism is to perform an
honest self examination of their own attitudes and
beliefs regarding sexual orientation,”
 “Mental health professionals live in the same
heterosexist society as everybody else and are subject
to biases and prejudices that permeate that culture.”
Clinical Considerations
Areas to explore:
1. To what degree do you consider a range of possibilities as
viable?
2. Do you perceive a variety of equally acceptable alternatives
with respect to sexual orientation, or is heterosexuality
considered preferable, with other identities being acceptable
but less preferable (or even unacceptable)?
3. To what extent do you place limits on those who do not identify
themselves as heterosexual (career, parenting, etc)?
Clinical Considerations
Areas to explore:
4. To what degree do you fully embrace the professional
organizations’ removal of homosexuality as mental illness?
5. Do you view LGBT orientation as indicative of instability,
regardless of the official position of your association?
6. What are your religious beliefs regarding the ‘shamefulness’
or ‘sinfulness’ of nonheterosexual orientations?
Clinical Considerations
Areas to explore:
 Religion can be a particularly difficult problem for LGBT
individuals, often bringing them into therapy.
 “Therapists need to be able to help clients address
religion and spirituality in ways that are affirmative, not
further condemning.”
 Conversion Therapy
Clinical Considerations
APA Practice Guidelines for LBG
 Understand the effects of stigma
 Understand these orientations are not mental
illnesses
 Understand that same sex attractions feelings
and behavior are normal variants of human
sexuality
Clinical Considerations
Boundaries
 Can we install and maintain the same boundaries
with LGBTQ clients as we would with
heterosexual clients? Or is there an ‘extra wall’?
Clinical Considerations
Confidentiality
 Do we maintain the same level of confidentiality
for nonheterosexual clients, or are some things
just too juicy not to share (even without names)?
 Small communities…
Clinical Considerations
Informed Consent
 Being open and ready to inform clients of how
much experience we have with their particular
population / issue
Clinical Considerations
Transference and Counter-Transference
 If symptoms of transference are recognized, can
we address them in the same way we would with
heterosexual clients? Is there an increased level
of fear / reactivity / revulsion?
Clinical Considerations
Transference and Counter-Transference
 Recommended for review: Countertransference
Issues in Psychotherapy with Lesbian and Gay
Clients, by Milton, Coyle, and Legg of the
University of Surrey, UK 2005, in the European
Journal of Psychotherapy Counseling and Health,
7, 181-197.
Clinical Considerations
Couples
 Impact of social stigma on the relationship
 Many variations…
2 men
2 women
Ts hetero
Ts gay
Polyamorous
Others?
Clinical Considerations
Couples
 Some relationship issues are the same, no matter what
‘type’ of couple; i.e. fidelity, abuse, finances, AoD, childrearing, etc.
 Issues common to LGBTQ couples:
 1 out, 1 not
 Lack of family support
 Increased incidence of AoD abuse/dependence?
 Others?
Clinical Considerations
Advocacy and Assisting in Coping with Discrimination

Being and providing a safe place for the individual to present as /
BE their true self…

Provide education to decrease stigma and increase safety…within
families, schools, communities,…
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Providing helpful documentation if needed

Being willing to contact, screen, and meet with other
professionals and community members as needed and as ROI’s
allow…e.g. school counselors, doctors, clergy, employers…
Clinical Considerations
Advice to Clinicians from LGBTQ Clients…
“Be understanding, open-minded and supportive of it. Don’t fight it.”
23 yr old MtF
“Gender is a spectrum. It’s not rigid.”
25 yr old MtF
“…the profoundness of the feeling of isolation; of being alone… The
most powerful, devastating beautiful thing is for someone to realize
they’re not alone and never have been…to internalize this as heart’s
knowledge --- if they can do that, they can do anything.”
40 yr old MtF
Clinical Considerations
“The reason I came back after the first time is because I heard:
‘there is no judgement here.’” 44 yr old lesbian
“We have the same relationship as straight people…we don’t lay in
bed all day being perverted. We get up, go to work and feed our
kids. Other than having a same-sex partner, our lives are pretty
boring.” 45 yr old lesbian
“Do research so you know what you’re talking about….to know
things like: trans people are not gay people. There are bad
therapists out there that try to convince trans people that they’re
really just gay. Have some resource knowledge, like doctors and
support groups.” 23 yr old FtM
Clinical Considerations
“Don’t tell someone that they aren’t what they think they are.
Don’t let them know if you don’t believe it. Be careful with the use
of pronouns. Be gentle because who knows what they’re missing
out on in their life because of who they are -- sometimes they need
someone to fill a role. Society’s recipe doesn’t work for everyone
and sooner or later it won’t work for anyone.”
24 yr old polyamorous, FtMQ
Things NOT to Say to LGBT People
1. “Wow. I never would have guessed that you’re [gay, lesbian, bi, or
transgender]!
2. “Is one of you the husband and one the wife? I don’t get it.”
3. To a transgender person: “What’s your real name? What did you used
to look like?”
4. “Your lifestyle is your business. We don’t need to talk about it here.”
5. “It’s too bad you’re gay.”
6. “I have a friend who’s [gay, lesbian, bisexual, transgender] that you
should meet.”
Things NOT to Say to LGBT People
7. You’re gay? That’s great. I love gay people.
8. Do you watch Glee?
9. What should I [wear, do with my hair]?
10. Do you know if [insert name] is gay too?
11. Does that mean you don’t want kids?
12. Wait, you’re not attracted to me … right?