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Sexual and Gender Minority Populations
What you will learn in this fact sheet:
- What are sex and gender?
- What does it mean to be transgender or gender diverse?
- What is sexual orientation?
- Do sexual and gender minorities face prejudice?
For individuals who identify as sexual minorities (e.g., gay, lesbian, bisexual, queer) or gender minorities (e.g., transgender, gender diverse), you will also learn:
- Why might you want to go to therapy?
- What should you think about when choosing a cognitive-behavioral therapist?
For therapists, you will also learn:
- What are your responsibilities when you work with sexual and gender minority clients?
- How can you facilitate discussions related to gender and sexual orientation?
What are sex and gender?
“Sex” (or “sex assigned at birth”) refers to whether someone is labeled as male or female at birth (or before birth during an ultrasound). It is typically based on the appearance of their external genitalia. When someone’s external genitalia do not fit with expectations for males or females (referred to as “intersex”), other indicators (e.g., internal genitalia, chromosomes, hormones) are often considered in order to assign a sex.
“Gender” refers to a person’s internal sense of being a man, a woman, or another gender, as well as to gender experiences that are somewhere in betweenor outside of binary notions of gender (e.g., nonbinary, gender nonconforming, genderqueer, genderfluid, agender). A person can identify with any gender regardless of their sex assigned at birth.
- Gender identity: How someone labels themselves or identifies.
- Gender expression: How someone presents themselves, including their physical appearance and behaviors that express aspects of gender identity or role.
What does it mean to be transgender?
- Someone’s sex assigned at birth may or may not be the same as their gender.
- People whose gender aligns with their sex assigned at birth are referred to as “cisgender.” Most people are cisgender, although many people may be unaware of this term.
- “Transgender” refers to when someone identifies as a gender that is different than their sex assigned at birth. This is a broad category that captures a range of identities, such as trans men (people assigned female at birth who identify as men), trans women (people assigned male at birth who identify as women), and other people who may identify as somewhere in between or outside of binary notions of gender (e.g., nonbinary, gender nonconforming, genderqueer, genderfluid, agender).
- There is considerable variability in how transgender individuals choose to affirm their gender identity. Some people socially transition (e.g., change their name, change how they express their gender), others utilize various procedures to change their physical appearance (e.g., hormone therapy, medical procedures), and others do not make any noticeable changes to their gender expression or physical appearance.
- People who are transgender can be of any sexual orientation.
- For more information on transgender youth, see the ABCT Fact Sheet titled, “Transgender and Gender Nonconforming Youth.”
What is sexual orientation?
- Sexual orientation is commonly conceptualized as having at least three components:
- Who someone is romantically and/or sexually attracted to (i.e., attractions).
- Who someone has sex with (i.e., behavior).
- How someone labels themselves or identifies (i.e., identity).
- However, people can experience romantic/sexual attractions and use identity labels without engaging in sexual behavior.
- People can be attracted to one gender (referred to as monosexual) or more than one gender (referred to as nonmonosexual or bisexual+).
- Some people do not experience any sexual attraction (referred to as asexual or “ace”). Asexuality is considered a spectrum, such that some people experience a limited degree of sexual attraction or they only experience sexual attraction after developing a strong emotional bond with someone. Further, someone who is asexual can still experience romantic attraction. The term “asexual” specifically refers to a lack of sexual attraction, whereas the term “aromantic” refers to a lack of romantic attraction.
- Some people describe their romantic and sexual attractions differently. For example, someone can be sexually attracted to more than gender (“bisexual”), but romantically attracted to one gender (“heteroromantic” or “homoromantic”).
What are common terms for sexual orientations?
- “Gay” refers to only being attracted to people of the same gender. Some people use the term “homosexual” instead, but others consider “homosexual” to be an outdated and offensive term.
- “Lesbian” refers to women who are only attracted to other women. Some people use the term “gay” instead, but others differentiate between “gay men” and “lesbian women.”
- “Bisexual” refers to being attracted to people of more than one gender.
- “Pansexual” refers to being attracted to people of any gender. Some people use this term because they believe that “bisexual” refers to only being attracted to men and women (and not to transgender or nonbinary individuals). However, many bisexual individuals refute this definition of bisexuality and assert that “bisexual” refers to being attracted to people of one’s own gender and other genders (inclusive of transgender and nonbinary individuals).
- “Heterosexual” and “straight” refer to only being attracted to people of a different gender.
- Some people describe themselves using other terms, such as “queer” or “dyke.”
- Some of the terms listed above can also be used in negative ways to refer to sexual minorities.
What if these labels don’t really fit me?
- People often do not fit neatly into any one sexual orientation group. For example, someone might usually only experience attraction to people of a different gender, but on occasion experience attraction to someone of the same gender. That does not mean they necessarily call themselves bisexual or pansexual. People might also experience fluctuation and change in their sexual orientation and identity over time.
- Someone may have a particular label that they identify with, but their sexual attractions and/or behaviors may or may not align with people’s expectations for someone with that label. For instance, someone may identify as straight, but engage in sex with someone of the same gender.
Prejudice against sexual and gender minorities
- “Sexual minority” is an umbrella term used to refer to anyone who is not heterosexual or straight (e.g., gay, lesbian, bisexual, pansexual, queer).
- “Gender minority” is an umbrella term used to refer to anyone who is not cisgender (e.g., anyone who identifies as transgender or gender diverse).
- If you are a member of a sexual or gender minority group, then you may experience discrimination such as:
- Verbal insults
- Threats of violence
- Physical assaults
- Discrimination in employment or housing
- Fewer (or lack of) legal protections under state and federal laws
- Prejudice and discrimination may increase your risk for some psychological problems. For example, research shows that:
- On average, sexual and gender minorities are at increased risk for depression, anxiety, suicidality, and substance use problems.
- Of note, bisexual individuals are at increased risk for these problems (on average) compared to both heterosexual and gay/lesbian individuals.
- This increased risk (referred to as “health disparities”) has been documented among adolescents and adults..
FOR INDIVIDUALS WHO IDENTIFY AS SEXUAL OR GENDER MINORITIES:
Why consider therapy?
- There are many reasons why you might seek therapy.
- Some are general reasons that anyone might seek therapy, such as:
- Treatment of depression, anxiety, or substance abuse
- Grief and loss
- Relationship problems
- Others are reasons that are related to your sexual orientation and/or gender:
- Support in coping with discrimination
- Concerns related to disclosing your sexual orientation or gender identity (referred to as “coming out”)
- Support navigating your social and/or physical gender transition
Therapy does not change sexual or gender orientation
- Having a minority sexual orientation or gender is not a mental disorder. Almost all cognitive and behavioral therapists agree that this is true, regardless of the fact that the Diagnostic and Statistical Manual of Mental Disorders (DSM) still includes “gender dysphoria.”
- Research shows that trying to change someone’s sexual orientation or gender with conversion therapy most often has harmful effects.
- Cognitive-behavioral therapies are not designed to change someone’s sexual orientation or gender.
Ways therapy can help
- Cognitive and Behavioral Therapy (CBT) can help you learn new skills.
- CBT can be a useful treatment for mental health problems, such as depression, anxiety, suicidality, and substance abuse.
- CBT can help you deal with many of life’s problems that may be related to your sexual orientation, gender, or others’ responses to your sexual orientation or gender.
- CBT can help you improve your relationships with your partners, family, friends, and others. For example, this could include learning new ways of communicating with people, thinking about your relationships, managing your feelings, or handling conflict situations.
Choosing a therapist
- Some people want to have a therapist who is also a sexual or gender minority. A sensitive therapist will be willing to talk about your preference and decide if they are a good fit for you.
- Interviewing possible therapists can be a helpful way to decide if they are right for you. This gives you a chance to see how comfortable you are with the therapist’s style. It is alright to ask about:
- The therapist’s training
- What to expect in therapy
- How much therapy will cost
- The therapist’s opinions about sexual orientation and gender
- The therapist’s experience with sexual and gender minority clients
- If you are a transgender person and seeking a letter of support for pursuing medical affirmation of your gender, it is also completely okay to ask your therapist about their policies on providing letters and how many sessions they anticipate you needing to have before they will do so.
- Many CBT therapists specialize in specific mental health problems, such as anxiety or alcohol and drug abuse. The success of your therapy may depend on the therapist’s expertise treating the problems you face. The best way to find out is to ask!
- A good therapist should be willing to talk about any worries you have about your therapy at any point. Your therapist should refer you to another therapist or agency if either of you feel that therapy is not working or there are issues that are keeping you from getting the most out of therapy. After all, it’s your time and money!
- CBT therapists often work through the most important problems first, so they might initially focus on one specific problem, leaving other areas alone for a time.
- Remember, your sexual orientation and gender are not disorders; you should never have to experience discrimination on the part of your therapist.
- In 1973, “homosexuality” was removed from the DSM. However, it was replaced with “Ego Dystonic Homosexuality” and, within the category of “Sexual Disorders Not Otherwise Specified,” there was an example using this label to describe someone who felt distressed about their sexual orientation. Therefore, even though “homosexuality” was removed from the DSM, sexual minorities continued to be pathologized in the DSM until at least 1987 (when “Ego Dystonic Homosexuality” was removed) or longer (given the “Not Otherwise Specified” category). It can be useful for therapists to know this history, because it can shape sexual and gender minority clients’ perceptions of the trustworthiness of mental health professionals.
- In 2013, 40 years after the removal of “homosexuality,” the DSM replaced the diagnosis of “Gender Identity Disorder” with “Gender Dysphoria.” Its inclusion in the DSM remains controversial, but a diagnosis is typically required for medical interventions to affirm a person’s gender.
- Attempts to change sexual orientation or gender identity with therapy (“conversion therapy”) have been largely unsuccessful, and most often have harmful effects on clients (e.g., increased psychological distress). Such attempts may contribute to clients’ negative views of themselves and the world. These negative views may contribute to mental health problems.
- Therapists’ ethical obligations related to sexual orientation and gender include:
- Evaluating their own beliefs and feelings regarding sexual orientation and gender, and how these beliefs and feelings impact their work;
- Obtaining the appropriate training, experience, consultation, or supervision necessary to provide competent services;
- Referring clients to appropriate treatment providers in situations where the therapist does not have the needed training or experience to provide competent services.
- It is best to ask clients how they prefer to be referred to, including their name, pronouns, sexual orientation, and gender identity.
- The degree to which a client’s presenting problem is related to sexual orientation or gender identity varies. A client’s presenting problem may be closely related to their sexual orientation or gender identity, so it is important to assess this during an initial interview. Asking will help to avoid making assumptions about clients that could impact the effectiveness of treatment.
- Sexual or gender minority (SGM) clients may present for reasons that have little or nothing to do with their sexual orientation or gender identity. In such cases, however, it may still be important to acknowledge that presenting issues can still be indirectly impacted by their sexual orientation and/or gender identity. Further, learning about these aspects of your clients’ identities can help you to understand their life experiences and who they are overall.
- “Coming out” (i.e., the process of disclosing one’s sexual orientation or gender identity) is best conceptualized as a lifelong process rather than a discreet event. Everyone is at a different stage of coming out, and coming out may differ across contexts and people (e.g., someone may be out to their friends, but not at work or with their family). Pushing clients toward coming out to a particular person or in a particular context is not recommended. Instead, it is considered preferable to help clients explore the potential risk and benefits of disclosing their sexual orientation or gender identity in a specific context and, if desired by the client, to develop a plan for doing so and for dealing with any potential negative consequences.
- A few interventions have been developed to help sexual minorities cope with stigma-related stress and related mental health problems. These interventions generally adapt CBT strategies (e.g., cognitive restructuring, behavioral activation, exposure) to focus on the unique stressors affecting sexual minorities (e.g., prejudice and discrimination, the internalization of negative attitudes toward sexual minorities, expectations of rejection). However, these interventions are in the early stages of efficacy testing and have primarily been tested in samples of gay men. There is a critical need for additional research on interventions for sexual minority women and bisexual individuals.
- There has been even less research on evidence-based approaches to clinical work with gender minority clients. However, emerging research focuses on applying CBT techniques to therapy with gender minority clients. As this research continues, we will learn more about the most effective strategies for therapy with this population.
Facilitating discussions related to sexual orientation and gender identity:
- SGM clients differ in their preference for a sexual or gender minority therapist, even though most SGM individuals believe that therapists do not have to be similar in this respect to be effective. When possible, it may be helpful to ask clients if they have a preference for a therapist of a particular demographic during the initial contact.
- SGM clients may have concerns about working with a heterosexual and/or cisgender therapist. Therapists should consider their perspective and how they wish to address such questions as:
- What is your sexual orientation/gender identity?
- Are you comfortable discussing sexual orientation, gender identity, and related topics?
- What are your personal beliefs about SGM individuals?
- Have you ever worked with SGM clients?
- Many SGM clients do not seek psychological services for issues related to their sexual orientation or gender identity. However, therapy with SGM clients may still be made more effective by:
- Becoming more familiar with norms in these communities.
- Avoiding the assumption that therapy experiences with eterosexual and/or cisgender clients generalize to therapy with SGM clients.
- Asking questions to understand a given SGM clients experience.
- Using inclusive language (verbally and in written materials), such as “partner” rather than “boyfriend” or “girlfriend.”
- Disclosing experiences working in these communities.
- Normalizing the experiences of SGM clients.
- Remaining neutral to allow clients to explore their gender and sexuality.
- Appreciating and acknowledging the difficulty of the coming out process.
Some ideas for how to obtain training related to working with SGM clients:
- Read articles with overviews of treatment considerations for SGM populations (see below).
- Contact organizations that provide support to the families of SGM individuals (e.g., Parents, Family, and Friends of Lesbians and Gays).
- Contact local LGBTQ agencies, state psychological associations, the American Psychological Association, or ABCT for referrals (either for therapists for SGM clients or for consultants/supervisors to obtain training). ABCT provides a referral service for therapists: www.findcbt.org
- Obtain training through conferences or continuing education.
Books on SGM populations and related topics:
GAY AND LESBIAN
- Mom, Dad, I’m Gay: How Families Negotiate Coming Out by Ritch C. Savin-Williams
- The New Gay Teenager by Ritch C. Savin-Williams
- The Velvet Rage: Overcoming the Pain of Growing up Gay in a Straight Man’s World, Second Edition by Alan DownsBISEXUAL:
- Bi Any Other Name: Bisexual People Speak Out edited by Lani Ka’ahumanu and Loraine Hutchins
- Bi Lives: Bisexual Women Tell Their Stories by Kata Orndorff
- Bi: Notes for a Bisexual Revolution by Shiri Eisner
- Getting Bi: Voices of Bisexuals Around the World, Second Edition edited by Robyn Ochs and Sarah E. Rowley
- Recognize: The Voices of Bisexual Men edited by Robyn Ochs & H. Sharif Williams
- Sexual Fluidity: Understanding Women’s Love and Desire by Lisa M. Diamond
- Mostly Straight: Sexual Fluidity Among Men by Ritch C. Savin-Williams
- The Invisible Orientation: An Introduction to Asexuality by Julie Sondra Decker
- Understanding Asexuality by Anthony F. Bogaert Transgender and gender diverse: How to Understand Your Gender:
- A Practical Guide for Exploring Who You Are by Alex Iantaffi and Meg-John Barker
- The Gender Quest Workbook: A Guide for Teens and Young Adults Exploring Gender Identity by Rylan Jay Testa, Deborah Coolhart, and Jayme Peta
- Transgender 101: A Simple Guide to a Complex Issue by Nicholas Teich
- The Queer and Transgender Resilience Workbook: Skills for Navigating Sexual Orientation and Gender Expression by Anneliese Singh and Diane Ehrensaft
- Fact sheets about sexual orientation and gender: http://www.apadivisions.org/division-44/resources/publications.aspx
- Information and resources related to SGM youth: http://www.youthresource.com
- Information and resources related to bisexuality: http://www.biresource.org
- Information and resources related to asexuality: https://www.asexuality.org
- Information and resources related to LGBTQ health: https://lavenderhealth.org
- Information and resources for queer and trans people of color: https://restforresistance.com
- American Psychological Association. (2012). Guidelines for psychological practice with lesbian, gay, and bisexual clients. American Psychology, 67, 10-42.
- American Psychological Association (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70, 832-864.
- Austin, A., & Craig, S. L. (2015). Transgender affirming cognitive behavioral therapy: Clinical considerations and applications. Professional Psychology: Research and Practice, 46, 21-29.
- 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.
- Singh, A. A., & dickey l. m. (2016). Implementing the APA guidelines on psychological practice with transgender and gender nonconforming people: A call to action to the field of psychology. Psychology of Sexual Orientation and Gender Diversity, 3, 195-200.
- Clarke, V., & Peel, E. (2007). Out in psychology: Lesbian, gay, bisexual, trans and queer perspectives. John Wiley & Sons Ltd.
- Eliason, M. J., & Chinn, P. L. (2015). LGBTQ Cultures: What healthcare professionals need to know about sexual and gender diversity (2nd ed.). Lippincott, Williams, & Wilkins.
- Martell, C. R., Safren, S. A., & Prince, S. E. (2003). Cognitive-behavioral therapies with lesbian, gay, and bisexual clients. New York: Guilford Press.
- Singh, A. A., & dickey, l. m. (2016). Affirmative counseling and psychological practice with transgender and gender nonconforming clients. Washington, D.C.: American Psychological Association.
- Skinta, M. D., & Curtin, A. (2016). Mindfulness and acceptance for gender and sexual minorities: A clinician’s guide to fostering compassion, connection, and equality using contextual strategies. Oakland: Context Press.