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LESBIAN, GAY, BISEXUAL, AND TRANSGENDER CLIENTS | for therapists
What Is Cognitive Behavior Therapy?

Behavior Therapy and Cognitive Behavior Therapy are types of treatment that are based firmly on research findings. These approaches aid people in achieving specific changes or goals.

Changes or goals might involve:

  • A way of acting: like smoking less or being more outgoing;
  • A way of feeling: like helping a person to be less scared, less depressed, or less anxious;
  • A way of thinking: like learning to problem-solve or get rid of self-defeating thoughts;
  • A way of dealing with physical or medical problems: like lessening back pain or helping a person stick to a doctor’s suggestions.
Behavior Therapists and Cognitive Behavior Therapists usually focus more on the current situation and its solution, rather than the past. They concentrate on a person’s views and beliefs about their life, not on personality traits. Behavior Therapists and Cognitive Behavior Therapists treat individuals, parents, children, couples, and families. Replacing ways of living that do not work well with ways of living that work, and giving people more control over their lives, are common goals of behavior and cognitive behavior therapy.

HOW TO GET HELP: If you are looking for help, either for yourself or someone else, you may be tempted to call someone who advertises in a local publication or who comes up from a search of the Internet. You may, or may not, find a competent therapist in this manner. It is wise to check on the credentials of a psychotherapist. It is expected that competent therapists hold advanced academic degrees. They should be listed as members of professional organizations, such as the Association for Behavioral and Cognitive Therapies or the American Psychological Association. Of course, they should be licensed to practice in your state. You can find competent specialists who are affiliated with local universities or mental health facilities or who are listed on the websites of professional organizations. You may, of course, visit our website (www.abct.org) and click on "Find a CBT Therapist"

The Association for Behavioral and Cognitive Therapies (ABCT) is an interdisciplinary organization committed to the advancement of a scientific approach to the understanding and amelioration of problems of the human condition. These aims are achieved through the investigation and application of behavioral, cognitive, and other evidence-based principles to assessment, prevention, and treatment.

What will you learn in this fact sheet?
  • What is sexual orientation?
  • What does it mean to be transgendered?
  • Therapists’ responsibilities when treating clients who hold a minority sexual or gender identification?
  • How to facilitate discussion of lesbian, gay, bisexual, or transgender (LGBT) issues?
  • Resources for therapists and clients.

Sexual Orientation

  • Sexual orientation refers to an enduring emotional, romantic, sexual, or affectionate attraction to individuals of the same and/or opposite sex.
  • Sexual orientation includes the following dimensions:
    – how the client identifies her- or himself;
    – to whom the client is attracted or with whom s/he desires to be romantically or sexually involved;
    – the client’s sexual behavior.
  • Common sexual orientation identities are:
    – “Homosexual” refers to attraction to people of the same sex. Homosexual orientations are further separated by gender:
    –“Gay” is usually used for men who are homosexual. “Gay” is also sometimes used for homosexual women.
    –“Lesbian” is used for homosexual women.
    –“Bisexual” is used for people who are attracted to both men and women.
    –“Heterosexual” or “straight” is used for people who are attracted to members of the opposite sex.
  • Sexual orientation should be thought of on a continuum, and clients may describe themselves in other ways (e.g., “queer” or “dyke”). It is best to ask the client how s/he prefers to be described.
  • Estimates of same-gender sexual orientation range from 2% to 10% of the population.
  • The degree to which the presenting problem is related to sexual orientation varies. Therefore, therapists should not make assumptions regarding the importance or relevance of sexual orientation to a client’s presenting concerns.

A client’s presenting problem may be closely related to issues of sexual orientation, so it is important to ask a client about her or his sexual and romantic identity, desires, and behaviors during an initial interview.

On the other hand, LGBT-identified clients may present for reasons that have little or nothing to do with their sexual orientation. In such cases, however, it may still be important to acknowledge that presenting issues can still be indirectly impacted by their sexual orientation identity.

Biological Sex, Gender and Transgender
  • Biological sex is the degree to which a client was born genetically male or female. “Gender” is the client’s personal sense of feeling and behaving as female and/or male.
  • A client’s biological sex may or may not be the same as her or his gender.
  • Transgender is an umbrella term that refers to individuals whose psychological perception of their gender identity does not match the gender they were assigned at birth. Included under this term are transvestites (cross-dressers), transsexuals (male-to-female and female-to-male), and gender nonconformists, among others. A transgender individual is someone who was born biologicallly one sex, but feels like they have born into the wrong body
  • It is important to note that being transgendered is not related to sexual orientation.
  • Gender should be thought of on a continuum, and clients may be uncomfortable with your choice of pronoun use (“he” instead of “she”). Generally, transsexuals prefer to be referred to using the pronoun of identified gender (e.g., ‘she’ for male-to-female), regardless of their level of transition. Crossdressers tend to prefer the pronoun associated with their dress at the time (e.g., ‘she’ only when dressed as a woman). It is best to ask the client how s/he prefers to be described.
  • Gender Identity Disorder is a diagnosis often given to transgendered individuals. It is important to know that there is great controversy about this diagnosis, with many individuals feeling stigmatized by this label.

Important Facts for Therapists

  • Homosexuality was removed from American Psychiatric Association’s list of mental disorders in 1973, a move which was subsequently supported by the American Psychological Association (see the American Psychological Association’s policy statement at http://www.apa.org/pi/lgbpolicy/against.html).
  • Attempts to change sexual orientation with therapy (“conversion therapy”) have been largely unsuccessful, and often have harmful effects on clients. Such attempts may, for example, contribute to clients’ negative views of themselves (for being gay/lesbian/bisexual) and/or the world (by, for example, increasing expectations of societal or familial disapproval). These negative views may contribute to depression and suicidality.
  • APA has addressed these therapies. Please review Just the Facts Coalition statement: http://www.apa.org/pi/lgbc/publications/justthefacts.html#2
  • Coming out is best conceptualized as a lifetime process (not a discreet event), everyone is at different stages of coming out, and coming out may differ across settings, family, and friends for any given individual (e.g., you may be out to your friends, but not at work or with your family)
  • Adolescents who label themselves as LGBT early in life are at risk for suicidality; thus, pushing toward coming out too early might be unwise
  • Lesbian, gay, bisexual, and transgendered individuals may be at increased risk for certain psychological problems. Recent research suggests that:
    – Lesbian and bisexual women may be at increased risk for substance use disorders.
    – Gay and bisexual men may be at increased risk for mood or anxiety disorders.
    – Gay, lesbian, and bisexual youth may be at increased risk of social anxiety, depression, and suicide relative to their heterosexual counterparts.
    –Transgendered individuals are at increased risk for substance use, depression, and suicide. They are also vulnerable to hate crimes, and have the highest rates of violence and homicide perpetrated against them.
  • Higher prevalence of certain psychological problems among gay, lesbian, bisexual and transgendered populations have been linked to their experiences of greater stigmatization and harassment, decreased social support, and increased life stressors.
  • Therapists’ ethical obligations related to sexual orientation include:
    –Evaluating their own beliefs and feelings regarding LGBT issues and how these beliefs or feelings impact their work;
    –Obtaining the appropriate training, experience, consultation, or supervision necessary to provide competent services;

Some ideas for how to obtain this type of training include:

  • Reading articles with discussion and overviews of lesbian, gay, and bisexual communities (see D’Augelli & Garnets, 1995; Esterberg, 1996; Hutchins, 1996).
  • Contacting organizations that provide support to the families of lesbian, gay, and bisexual clients (e.g., Parents, Family, and Friends of Lesbians and Gays)
  • Contacting local GLBT agencies, state psychological associations, the American Psychological Association, or ABCT for referrals for consultants or supervisors. ABCT provides a referral service: www.findcbt.org
  • Obtaining training through conferences or continuing education: Make appropriate referrals when necessary. The following referral sources may be helpful:
    –Gay Lesbian International Therapist Search Engine: www.glitse.com
    –Lesbian Therapist Referral Network: www.lesbiantherapist.com.
    –Gay and Lesbian Medical Association: www.glma.org/index.shtml

Therapists should recognize that societal stigma and poor legal protections may negatively impact their GLBT clients. For example, both same-sex parents may not have legal rights to their children. Same-sex partners often lack legal rights, such as the right to make medical decisions, to receive health insurance via their partner’s employment, or to be listed as beneficiaries (such as for SSI benefits) in the event of their partner’s death. Legal restrictions often make it difficult or impossible to change gender on identification documents (e.g., driver’s license), creating confusion and exposing transgender individuals to discrimination when applying for jobs, traveling, voting, or during routine traffic stops.

Facilitating discussions of LGBT issues

  • LGBT clients differ in their preference for a LGBT therapist, even though most LGBT individuals believe that therapists do not have to be similar in this respect to be effective. It may be helpful to give LGBT clients an option of working with a “straight” or LGBT therapist during the initial contact.
  • LGBT clients may have concerns about working with a non-LGBT therapist. Therapists should consider their perspective and how they wish to address such questions as:
    –What is your sexual/gender orientation?
    –Are you comfortable discussing LGBT issues?
    –What are your personal beliefs about LGBT individuals?
    –Have you ever worked with LGBT clients?
    –Do you believe that LGBT individuals can provide appropriate parenting?
  • Most LGBT clients do not seek psychological services for issues related to their sexual orientation. However, therapy with LGBT clients may be made more effective by:
    –Becoming more familiar with norms in LGBT communities.
    –Avoiding the assumption that therapy experiences with non-LGBT clients generalize to work with LGBT clients.
    –Asking questions to understand the LGBT experience.
    –Using inclusive language (verbally and in written materials), such as “partner” or “romantic interest” rather than “boyfriend” or “girlfriend.”
    –Disclosing experiences working in LGBT communities.
    –Normalizing the LGBT experience.
    –Remaining neutral to allow clients to explore issues of gender and sexuality.
    –Appreciating and acknowledging the difficulty of the coming out process.
    –Providing a supportive atmosphere for LGBT clients to explore spiritual issues in the context of their gender and/or sexual orientation.
    –Addressing the ways in which CBT may address LGBT related and non- LGBT related issues
Publications on CBT with LGBT Youth and Adults and Related Clinical Issues

General Information

Bernstein, G.S. (1995). Not heterosexual: An educational program about gay, lesbian, and bisexual people. Denver, CO: GSB Productions.

Lev, A.I. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. Binghampton, NY: Haworth Clinical Practice Press.

Shipherd, J.C., & Harris, H.N. (2004). Gender as a continuum: Implications for trauma researchers and clinicians. Traumatic Stress Points, 18, 9-12.

Treatment

Bernstein, G.S,. & Miller, M.E. (1995). Behavior therapy with lesbian and gay individuals. In M. Hersen, R.M. Eisler, & P.M. Miller (Eds.), Progress in behavior modification: Vol. 30 (pp. 19-45). Newbury Park, CA: Sage.

Hart, T. A., & Heimberg, R.G. (2001). Presenting problems among treatment seeking gay, lesbian, and bisexual youth. Journal of Clinical Psychology, 57, 615-628. Israel, G.E., & Tarver, D.E. (1997). Transgender care: Recommended guidelines, practical information and personal accounts. Philadelphia, PA: Temple University Press.

Kaysen, D., Lostutter, T.W., & Goines, M.A. (2005). Cognitive processing therapy for acute stress disorder resulting from an anti-gay assault. Cognitive and Behavioral Practice, 12, 278-289.

Martell, C. R., Safren, S. A., & Prince, S. E. (2003). Cognitive-behavioral therapies with lesbian, gay, and bisexual clients. New York: Guilford Press. Purcell, D.W., Campos, P.E., & Perilla, J.L. (1996). Therapy with lesbian and gay men: A cognitive-behavioral perspective. Cognitive and Behavioral Practice, 2, 391-415.

Safren, S.A., & Rogers, T. (2001). Cognitive-behavioral therapy with lesbian, gay, and bisexual persons. Journal of Clinical Psychology, 57, 629-645.

Safren, S.A., Hollander, G., Hart, T.A., & Heimberg, R.G. (2001). Cognitive-behavioral therapy with lesbian, gay, and bisexual youth. Cognitive and Behavioral Practice, 8, 215-223.

Shidlo, A., & Schroeder, M. (2001, November). Changing one’s sexual orientation: A consumer’s report. Paper presented at the Annual Meeting of the Association for the Advancement of Behavior Therapy, Philadelphia.

LGBT Journals

International Journal on Transgenderism
http://www.haworthpress.com/store/product.asp?sku=J485

Journal of the Gay and Lesbian Medical Association
http://www.glma.org/pub/jglma/index.shtml

The Journal of Bisexuality
http://www.haworthpressinc.com/web/JB/

Journal of Homosexuality
http://www.haworthpressinc.com/web/JH/

Journal of Gay & Lesbian Social Services: Issues in Practice, Policy & Research

Print Resources for Clients

LESBIAN AND GAY

Mom, Dad, I’m Gay: How Families Negotiate Coming Out by Ritch C. Savin-Williams. American Psychological Association

TRANSGENDER

Transgender Care: Recommended Guidelines, Practical Information, and Personal Accounts by Gianna E. Israel, Donald E. Tarver, and Diane Shaffer
True Selves: Understanding Transexualism for Families, Friends, Co-workers and
Helping Professionals by Mildred L. Brown and Chloe Ann Rounsley
BISEXUAL
Bi Any Other Name: Bisexual People Speak Out by Loraine Hutchins and Lani Kaahumanu
Bi Lives: Bisexual Women Tell Their Stories by Kata Orndorff

Web Resources for Therapists and Clients

ABCT Special Interest Group (SIG) for the Sexual and Gender Minority
http://www.aabt.org/sigs/sigs.html

American Psychological Association (APA) Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients
http://www.apa.org/pi/lgbc/publications/guidelines.html

APA Policy Statements on Lesbian and Gay Issues
http://www.apa.org/pi/statemen.html

APA Division 44 (Society for the Psychological Study of Lesbian, Gay, and Bisexual Issues)
http://www.apa.org/divisions/div44
Contains information regarding APA’s position on working with LGB clients, current LGB research, and the Division 44 newsletter.

The Bisexual Resource Center
http://www.biresource.org/
The Bisexual Resource Center is an international organization providing education about and support for bisexual and progressive issues.

Gay and Lesbian Medical Association (GLMA)
http://www.glma.org.
Dedicated to ensure equality in health care for LGBT individuals and health care professionals.

The Kinsey Institute
http://www.indiana.edu/~kinsey/
The Kinsey Institute conducts research on sexual behavior and health and individual and gender differences in sexual response. Listing of current publications on their website.

AFFIRM: Psychologists Affirming their LGB Family.
http://naples.cc.sunysb.edu/CAS/affirm.nsf
Network of psychologists dedicated to supporting LGBT family members. Website includes an extensive bibliography of literature about working with LGBT clients and a list serve for therapists wishing to network with other professionals.

The Harry Benjamin International Gender Dysphoria Association, Inc: Guidelines for Care with Transgender Individuals
http://www.hbigda.org/
Professional organization dedicated to the understanding and treatment of gender identity disorders. Website includes information on standards of care for persons with gender identity disorders and links to other LGBT-related web resources.

The Queer Resources Directory
http://www.qrd.org/
International site with wide range of information and links to other sites including information on religion, parenting, legal issues, and health issues.

International Foundation for Gender Education
http://www.ifge.org/index.php
Foundation addressing a broad range of issues related to gender and sexual orientation. Website includes information about printed resources, employment issues facing LGBT individuals, and current LGBT-related news.

Transcend: Transgender Support & Education Society
http://www.transgender.org/transcend/index.htm
Organization dedicated to addressing the social, political and economic conditions that negatively impact transgender and intersex individuals. Provides peer advocacy and information about selecting an appropriate service provider.

 

For more information or to find a therapist:

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