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Culturally Responsive Services with Persons Who Are LGBTQ2IK
Dr. Dawn-Elise Snipes, PhD, LPC-MHSP, LMHC
Executive Director,
Podcast Host: Counselor Toolbox
~ Learn terminology specific to the LGBTQ2IK community
~ Explore specific verbal and nonverbal communication issues
~ Learn the stages of the coming out process
~ Review Neisen's 3-Phase Model for Recovery From Shame and counselor tasks
~ Identify LGBTQ2IK Cultural Issues
~ Identify how race, culture and ethnicity impact identity development and acculturation
~ Identify specific treatment issues which may be unique to this population
~ Learn about the Family Acceptance Project

~ Sex: Genetic and anatomical characteristics with which people are born
~ Intersex: Some individuals are born with a reproductive/sexual anatomy that does not fit typical definitions of male or female. Not all of these individuals identify as intersex.
~ Sexual orientation: A person’s emotional, sexual, and/or relational attraction to others including heterosexual, gay/lesbian, bisexual
~ Gender identity: Our internal sense of being male, female Because gender identity is internal, it is not necessarily visible to others.
~ “transgender” describes people whose gender identity/expression is different from that typically associated with their assigned sex at birth. gender identity, in many cases, is independent of sexual orientation
~ A transgender person “transitions” to express gender identity through various changes including wearing clothes and adopting a physical appearance that aligns with their internal sense of gender.

~ Gender expression: The manner in which people represent their gender to others individual through mannerisms, clothes, and personal interests.
~ Two-Spirit: An inclusive term created specifically by and for Native American communities. It refers to American Indian/Alaskan Native American people who (a) express their gender, sexual orientation, and/or sex/gender roles in indigenous, non-Western ways, using tribal terms and concepts, and/or (b) define themselves as LGBTQI in a native context.
~ Heterosexism resembles racism or sexism and denies, ignores, denigrates, or stigmatizes nonheterosexual forms of emotional and affectional expression, sexual behavior, or community.
~ Homophobia is defined as the irrational fear of, aversion to, or discrimination against LGBT behavior or persons.
~ Internalized homophobia describes the self-loathing or resistance to accepting an LGBT sexual orientation and is an important concept in understanding LGBT clients
~ Lesbians are people who identify as female, who are attracted to others who identify as female
~ Gay: means anyone who’s attracted to people of the same sex
~ Bisexuals are attracted to both the male and female sex
~ Transgender born a certain sex but identify as a different gender
~ Queer: a very inclusive term for anyone in the LGBT+ community. Choosing to identify as ‘queer’ can mean individuals don’t have to belong to a more specific category if they aren’t sure of their sexuality/ gender or simply don’t want any other label
~ Intersex: intersex it means they are born a certain gender but their sexual or reproductive anatomy is from the opposite sex
~ Asexual: When a person is asexual it simply means that they aren’t very sexually attracted to either sex and have a generally low level of interest and desire to take part in sexual activities.
~ Pansexual: When someone is pansexual it means they are attracted to people regardless of their gender. They are attracted to individuals rather than one particular gender or sexuality
~ Polygamous/ polyamorous: People who identify as polygamous/ polyamorous have consenting open relationships with more than one person at a time.
~ Kink is about those who have kinky fantasies. This could involve BDSM (Bondage and Discipline, Dominance and Submission, and Sadomasochism); Female Led Relationships, Dom/sub relationships

LGBT Language
~ LGBT individuals have a creative vocabulary on the subject of sexual orientation because they may often use code words for safety reasons.
~ Some LGBT individuals disapprove of words used to describe them (ask!)
~ The term “homosexual” overemphasizes sexuality and seems to indicate that the sex act is more important to homosexuals than it is to heterosexuals. It also resurrects memories of when homosexuality was considered a psychiatric disorder. Hence, the words “homo,” “bi,” “queer,” or “gay” are preferred by some LGBT persons.
~ Some LGBT persons are offended by the term “queer.” Some lesbians may prefer to be called dyke or gay, instead of lesbian.
~ Transgender persons may prefer the less clinical term “trans.”
~ Important to call a transgender client by his or her preferred name and always to use the gender designation that the client has chosen.
LGBT Nonverbal
~ LGBT individuals rely tremendously on nonverbal cues to establish whether the situation is safe for them to be themselves
~ Evidence that they are accepted and welcome.
~ A rainbow-colored flag
~ “Straight But Not Narrow”
~ A mission statement that includes a commitment to honoring diversity or a commitment to treating LGBT clients
~ Gay or lesbian staff members
~ Materials used in treatment that acknowledge the LGBT experience
LGBT Cultural Issues
~ In contrast to how members of ethnic cultures are marginalized, LGBT individuals may receive disapproval and censure from those whom they most trust and rely on—parents, relatives, religious leaders, teachers, and friends.
~ Most members of ethnic minorities can escape discrimination by returning to a supportive family or neighborhood. This is not always true for LGBT persons
~ When they are growing up, their positive role models are not easy to identify
~ The LGBT culture is one that is not developed, taught, or transmitted by families
~ Part of gay culture is a celebration of being gay.
LGBT Cultural Issues
~ Messages About LGBT Individuals
~ Because public acceptance is important, many LGBT persons want to advance the message that LGBT individuals are no different from non-LGBT persons.
~ Some LGBT persons worry that highlighting the similarities and the positive aspects of gay culture will mean the loss of that culture as the LGBT community is accepted into mainstream culture.
~ Some believe that the gay community should try to transform mainstream society rather than join it.
LGBT Cultural Issues
~ How to Be Gay
~ Another aspect of the debate involves differences about whether there is only one way to be gay which may lead not honoring LGBT persons with other lifestyles or opposing views.
~ Bisexuals experience that lesbians and gay men do not accept bisexuality as a legitimate sexual orientation but regard it as a developmental phase on the way to acceptance of a lesbian or gay identity
Ethnicity, Race and Culture
~ Cultural factors do not impede sexual identity formation
~ Cultural Factors do delay/negatively impact
~ Identity integration involving internal and external acceptance and comfort being known as LGBT
~ Positive engagement in LGBT social activities
~ These cultural factors affect internalized anxiety and avoidance as they relate to LGBTQI2-S individual’s experiences with attachment figures.
~ For example, secure attachment during the coming out process functions to enhance coping with antigay prejudice, self-acceptance, and self-esteem
Ethnicity, Race and Culture
~ In addition to understanding a client’s ethnic background, counselors should keep in mind how the client’s culture views LGBT individuals and the effect this viewpoint has on the client.
~ Each ethnic minority group has norms and values about LGBT members and behavior
~ LGBT persons of color cope with trying to fit into the gay and lesbian communities in the face of racism and discrimination. For some, the added burden of these issues makes finding a comfortable place in society even more complex and difficult
Ethnicity, Race and Culture
~ In certain collectivist cultures cohesiveness of the group is an important value, and because of this, shame is a frequently used social constraint to control or deter expressions of homosexual behavior
~ Homophobia in the African-American community is often more intense than in the dominant community.
~ Many LGBT African Americans say that they do not feel welcome or comfortable in predominantly Caucasian LGBT settings
~ In Hispanic culture, some men who have sex with men do not consider themselves gay if they play the dominant role in the sexual act. When treating Hispanic clients, providers should respect this distinction.
~ Because of the concept of machismo, males are the center of the family, and many gay, bisexual, and transgender men find it difficult to acknowledge their sexual and gender identities
Enhancing Assets
~ Early and continuous attachment positively shapes relationship development in later years among all young children, adolescents, and adults An internal locus of control facilitates self-efficacy
~ Protective factors in one setting can compensate for risks in multiple settings
~ Studies of resilience for youth who are a sexual/gender minority have demonstrated:
~ Positive social relationships moderate the relationship between stress and distress
~ Affirming faith experiences contribute to less internalized homonegativity, more spirituality, and psychological health
~ Current Perspectives by Religion
~ Episcopal church approves ordination of transgender people
~ In 2010 150 Orthodox rabbis and educators signed a declaration calling for the welcoming of LGBTQ Jews in the Orthodox community
~ Family support and acceptance explains adolescent comfort and resilience in later life
Coming Out

~ The term “coming out” refers to the experiences of lesbians and gay men as they work through and accept a stigmatized identity, transforming a negative self-identity into a positive one.
~ There is no correct process or single way to come out, and some LGBT persons do not come out.
The CASS Model
Stage I: Identity Confusion
Occurs when a person begins to realize that he/she may relate to or identify as being LGBT, a process of personalizing the identity.
~ Tasks: Exploration and increasing awareness
~ Feelings: Anxiety, confusion
~ Defenses: Denial
~ Recovery: Having a confidential support person

~ Occurs when a person accepts the possibility the he/she might be LGBT

– Tasks: Exploration of implications, encountering others like oneself
– Feelings: Anxiety, excitement
– Defenses: Bargaining and rationalizing
– Recovery: Meeting gays/ lesbians/ bisexuals/transgender persons
Stage III: Identity Tolerance
~ Occurs when a person comes to accept the probability that he/she is an LGBT person.

~ Tasks: Recognizing social and emotional needs as a LGBT person
~ Feelings: Anger, excitement
~ Defenses: Reactivity
~ Recovery: How to be gay, lesbian, bisexual, or transgender and enjoy a rich and meaningful life
Stage IV: Identity Acceptance

~ Occurs when a person fully accepts rather than tolerates himself or herself as an LGBT person.

~ Tasks: Development of community and acculturation
~ Feelings: Rage and sadness
~ Defenses: Hostility towards straight culture
~ Recovery: Lesbian/gay/bisexual/ transgender community building

Stage V: Identity Pride

~ Occurs when the person immerses himself or herself in the LGBT community and culture to live out identity totally

~ Tasks: Full experience of being an LGBT person, confronting internalized homophobia
~ Feelings: Excitement and focused anger
~ Defenses: Arrogant pride and rejection of straight culture as the norm
~ Recovery: Integrating sexuality, identity, and recovery
Stage VI: Identity Synthesis
~ Occurs when a person develops a fully internalized and integrated LGBT identity and experiences himself or herself as whole when interacting with everyone across all environments.
~ Tasks: Coming out as fully as possible, intimate gay and lesbian relationship; self-actualization as a gay man, lesbian, bisexual, or transgender person
~ Feelings: Excitement and happiness
~ Defenses: Minimal
~ Recovery: Maintenance (end stage)

Neisen's 3-Phase Model for Recovery From Shame
~ Phase 1: Breaking the Silence parallels the process of coming out. It is important for LGBT individuals to tell their stories and to address the pain of being different in a heterosexist society.

Counselor Tasks:
• Facilitate client discussion of hiding LGBT feelings from others
• Explore emotional costs of hiding/denying one's sexuality
• Discuss how the client has tried to fit in and at what cost
• Examine negative feelings of self-blame, feeling bad or sick, and the effect of shaming messages on client
• Foster client's ability to be out

Phase Two: Establishing Perpetrator Responsibility

~ Phase 2: Allows clients to understand their struggle in the context of societal discrimination and prejudice.

Counselor Tasks:
• Facilitate focusing and, managing anger constructively, not destructively
• Help client understand and accept negative self-image as socio cultural, not personal
• Counteract client's experience of heterosexism and homophobia by role-modeling and by providing a treatment environment that is empowering for LGBT persons, not stigmatizing.
Phase Three: Reclaiming Personal Power
~ Phase 3: Involves improving self-concept, self-esteem, and self-confidence

Counselor Tasks:
 Facilitate client's self-concept and self-efficacy
 Identify and change negative messages to affirmations
 Recognize and release residual shame
 Develop a positive affirming spirituality
 Integrate public and private identities
 Build a support network, connect to community

Treatment Issues
~ “One third of suicide first attempts (of LGB youth) occurred within the same year of self-identification as gay or bisexual.
~ Counselors need an understanding of the dynamics of LGBT interpersonal relationships including the internal and external problems of same-sex couples and the diversity and variety of relationships in the community.
~ Although many individuals have a life partner, others are single or in nontraditional arrangements outside the cultural norm of a heterosexual, monogamous, and legally sanctioned marriage.
~ Many LGBT individuals are parents and have children from a heterosexual marriage, adopted children, or have children through other means. Parenting issues and helping children deal with oppression may be issues
~ Growing up in a society that says they should not exist, LGBT clients may have internalized this homophobia.
~ LGBT people may be victims of antigay violence and hate crimes such as verbal and physical attacks.
Treatment Issues
~ LGBT persons experience stressors not only related to coming out but also “passing” as heterosexual
~ HIV/AIDS continues to be a major factor in gay male life.
~ Being effeminate is sometimes condemned in the gay community, and this characteristic adds to gay men’s shame.
~ Bisexuals may feel alienated not just from the heterosexual majority but also from the lesbian and gay community. Internalized biphobia may result in a struggle toward self-acceptance.
Treatment Issues
~ For transgendered persons hormone therapy is an often overlooked issue.
~ Hormone therapies can affect mood, especially when taken improperly.
~ Transgender clients may face an additional risk from using “street” or “black market” hormones.
~ Because testosterone must be injected, obtaining or using needles may be relapse triggers for clients in early recovery.
~ LGBT individuals have been marginalized by some health professionals, who historically labeled an LGBT sexual orientation deviant or pathological. As a result, LGBT individuals may not disclose their sexual orientation to health care providers
Family Acceptance Project
~ Clear link between family rejecting reactions to sexual orientation and gender expression during adolescence to negative health and mental health outcomes in LGB young adults
~ Recognizes that parents and caregivers who are seen as rejecting their LGBT child are motivated by care and concern to help their child “fit in,” have a “good life,” and be accepted by others.
~ Understands that family behaviors are not isolated incidents, but occur in a cultural context aimed at socializing their children and adolescents to adapt and be successful in a hetero-normative (heterosexual) society. These family behaviors aim to protect their children from harm, including victimization due to their LGBT identity and gender expression.

Family Acceptance Project
~ Uses research findings to link reactions to their child’s LGBT identity with health, mental health, and wellbeing.
~ Beyond building a strong alliance between families and providers, family awareness of the consequences of their behavioral reactions is the most important mechanism of change Understands that parents and families experience their lack of knowledge about LGBT issues as inadequacy that feels disempowering and shameful.
~ Many families perceive their children’s LGBT identity as a loss, particularly as a loss of control over their children’s future.
~ Providers should help families validate and address these feelings by affirming the importance of family support to build their child’s self-esteem, to promote their child’s well-being, and to buffer rejection and negative reactions from others.
Family Acceptance Project
~ Recognizes that when rejecting and accepting behaviors co-exist,
~ Parents and caregivers experience ambivalence
~ Their struggle to validate their LGBT child results in decreased support and increased risk
~ Education and learning how their reactions affect their LGBT children can improve communication and help parents and caregivers respond in ways that help their LGBT child feel supported and loved rather than misunderstood or rejected.
~ Guidelines for Working With LGBT Clients and Families
~ Demonstrate support and understanding for the client, the spouse, life partners, significant others
~ No universal terminology regarding significant others in the LGBT community
~ Acknowledge the individual’s self ‐ identification
~ Be careful of biases re: what a family should be
~ Understand the diversity and variety of relationships in the LGBT community
~ Do not assume there is no history of opposite ‐ sex relationships
~ Use culturally sensitive assessment measures
Avoid labeling your clients.
~ Meet clients where they are in the coming out process and respect their need to feel safe.
~ Be guided by your LGBT clients, listen to what they say is comfortable for them
~ Advocate and create safety for LGBT clients
~ Support and encourage positive images of LGBT
~ Develop a diversity preparedness plan for working with LGBT community
~ Work with the community to understand their particular needs and concerns
Assessment: Taking a Family History

All Clients:

~ What were the rules of the family system?
~ Was there a history of physical, emotional, spiritual, or sexual trauma?
~ Were all family members expected to behave or evolve in a certain way?
~ What were the family’s expectations in regard to careers, relationships, appearance, status, or environment?
~ In general, was sex ever discussed?

LGBT Clients:

~ Was anyone else in the family acknowledged to be or suspected of being a lesbian, gay, bisexual, or transgender individual?
~ How did the family respond to other individuals coming out or being identified as LGBT individuals?
~ Is the client out to his or her family?
~ If the client is out, what type of response did he or she receive?

Sexual Orientation Assessment Tool
~ Coleman Page 40
~ PFLAG (Parents, Families and Friends of Lesbians and Gays) membership of over 200,000
~ Eshel is dedicated to the work of supporting Orthodox LGBTQ Jewish individuals in their desire to live fully in their religious and cultural traditions.
~ National LGBT Health Education Center
~ SAMHSA A Provider’s Introduction to Treatment for LGBT Individuals
~ A Guide for Understanding, Supporting, and Affirming LGBTQI2-S Children, Youth, and Families
~ Asset-Based Approaches for Lesbian, Gay, Bisexual, Transgender, Questioning, Intersex, and Two-Spirit (LGBTQI2-S) Youth and Families in Systems of Care