What is meant by affectional and gender minorities?

Affectional and gender minority clients is a broad umbrella category for individuals who self-identify as LGBTQ+. We can think of this in two broad subcategories: gender identity and sexual orientation.

Gender identity

Gender identity refers to how someone feels or identifies their gender. It is sometimes congruent with one’s sex assigned at birth. For example, an individual who is assigned female sex at birth and identifies as a woman, would be regarded as cisgender. Someone who is assigned a sex at birth that does not match their gender identity, may identify as trans, non-binary, or more generally “queer” (please note, while queer was previously used as a derogatory term against the LGBTQ+ community, there has been recent movement towards reclaiming this term).

Gender identity may be expressed in a variety of ways – through clothing, accessories, makeup, hairstyle, etc. It may or may not align with someone’s identity. That is, someone who identifies as a woman, but has a male sex assigned at birth, may not feel comfortable or safe enough to express their feminine identity. Similarly, some individuals may identify as cisgender women, but may express themselves in more masculine fashions. Gender expression can come in a variety of ways and can also vary day-to-day.

Sexual orientation

Sexual orientation can be broken down into one’s emotional or affectional orientation towards others, as well as into sexual attraction. Emotional attraction refers to who you have a mental and affective connection to. Sexual attraction refers to who you have a physical attraction to.

Some key terms explained:
Gay – male-identified people who are attracted to other male-identified people
Lesbian – female-identified people who are attracted to other female-identified people
Bisexual – individuals who are attracted to both male- or female-identified people
Asexual – individuals who do not have a sexual attraction to other individuals, but might be emotionally attracted to others.
Pansexual – individuals who are attracted to others regardless of their gender identity, gender expression, and/or sex assigned at birth.

Sexual orientation is not always linked with sexual behaviors. For example, someone can identify as a straight (heterosexual) male, who is attracted to women, and also has sex with men. In short, identity is just that – how someone identifies themselves, not based off of their actions, behaviors, or other-imposed categories.

What types of barriers might SGM individuals face when entering therapy?

Research has shown that LGBTQ+ individuals enter therapy at higher rates than heterosexual and cisgender individuals (King, Semlyen, Killaspy, Nazareth, & Osborn, 2007). This is likely due to the high rate of discrimination, traumatization, depression and dysphoria, and anxiety that is experienced, in addition and in response to situational factors such as homelessness, unemployment, inadequate social support, etc.

However, LGBTQ+ individuals also report a great deal of dissatisfaction with health services centered on believing that their practitioners lack knowledge or education (Rispel, Metcalf, Cloete, Moorman, & Reddy, 2011), feeling that their therapist had a lack of empathy or did not fully understand them (Gu, Lau, Wang, Wu, & Tan, 2015), or was non-affirming of their intersectional identities (Victor & Nel, 2016).

Therapists may exhibit both implicit and explicit biases towards clients. These implicit biases (i.e., beliefs that are outside of our awareness) and explicit biases (i.e, beliefs that we are aware of consciously), can have clear and resounding impacts on LGBTQ+ clients, even if the focus of treatment is not on their sexual orientation or gender identity, in the form of micro and macro aggressions.

Having empathy is an important factor in shaping our biases. However, one study found that having previous contact with LGBTQ+ individuals was a more robust predictor of one’s implicit attitudes than empathy, in a sample of over 4400 heterosexual-identifying medical students (Burke et al., 2015).

Five Things Therapist Can Do When Working SGMs

1. Be open and welcoming.

• Beginning with your website and emails, which are often the first lines of communication with clients, consider including your pronouns (he/him/his; she/her/hers; they/them/theirs). By introducing yourself with your pronouns (I’m Amy, I use she/her/hers), it leaves the door open for anyone who is not cisgender to feel comfortable identifying themselves by their pronouns. We often make assumptions based on someone’s gender expression that we know what their gender identity is. There’s only one way to know for sure – to hear it from them. Putting your pronouns out there sends a clear message that the space you’re practicing from is one that is inclusive.
• Consider visual cues in your waiting room that can alert clients to their being in a safe space. Some ideas are hanging up pride flags or safe space stickers; if your practice includes pictures of families or individuals, ensuring that there are also inclusive photographs that consist of various constellations of families.
• Ensure that your intake paperwork is inclusive by incorporating open-ended questions such as: “Pronouns?”; “How would you describe your sexual orientation?”; “What is your gender?”; “What is your preferred name?”
• Avoid gendering language. Instead of greeting someone as “Mr. Smith?”, simply saying their preferred name listed on intake paperwork.

2. Use client’s language and identities.

• Follow your client’s lead in terms of their self-described identity. If someone describes themselves as queer, it would be acceptable for you to use this word as well. It would not be appropriate however, if someone said that they were gay, and for you to then refer to them as queer.
• One place where this might not apply is when clients present with internalized homophobia (the belief that being LGBTQ+ is wrong or immoral). If a client, who identifies as gay, states that they are a “queer” and it is meant in a derogatory fashion, this might not be appropriate to mirror back. Instead, this can be a place for exploration of this belief system (is this belief yours, society’s, a family member’s or friend’s, etc.) and validation of discrimination and stigmatization that is present in LGBTQ+ persons lives.

3. Incorporate a Motivational Interviewing-spirit.

• Motivational Interviewing can be an incredibly important and useful tool given its client-centered and affirmative style approach.
• Motivational Interviewing refers to maintaining an empathic and collaborative approach.
• It also emphasizes clients determining what their problem areas are, rather than it being clinician-led.
• Clinicians focus on how a client is implementing change in their life, and also aims to foster this change talk through open-ended questions, genuine concern and interest, and shared decision-making.
• As an example, if a client who identifies as male and gay is engaging in unprotected sexual activity, the therapist who avoid directing the conversation and pointing out that this is wrong or immoral, nor would they offer input that the client should start using condoms. Instead, they would approach the situation with an open discussion, wondering about the client’s intentions in bringing this up in therapy, what their feelings are behind it and examining if there’s any anxiety or concern around these behaviors, and evaluating the pros and cons of continuing to engage in the risky behavior.

You can read more about how our research team is implementing motivational interviewing in working with GBTQ+ male-identifying sexual survivors here: https://www.peersformenshealthstudy.com/

4. Stay educated on factors that foster minority stress.

• Minority stress refers to the social, cultural, and political influences that are placed on individuals because of their minority status. Individuals who are in multiple minority categories (e.g., a black older adult transman) are at even higher risk for discrimination and stigmatization. This leads to issues in the domains of employment, housing, healthcare, and legal concerns. Minority individuals are also at higher risk for hate crimes (in fact, LGBTQ+ individuals experience hate crimes at higher rates than other minority populations; Park & Mykhyalshyn, 2016).
• Minority stress is also experienced in the form of needing to remain aware and hypervigilant of one’s surroundings due to hate crimes, or the need to “pass” as straight or cisgender due to intolerance, or the need to educate and advocate due to ignorance, can all place extreme stress on an individual.
• Practitioners should stay up to date on current legislature, social and political events, and other community stressors. This also includes understanding the impact of historical stressors (e.g., how the Orlando, FL pulse shooting affected the community as a whole), as well as day-to-day experiences of being judged, stigmatized, ignored, or made to feel “less than.”

5. Don’t assume; it’s always okay to ask

• While it is not our clients’ responsibilities to educate us, we also should not presume that we know everything about a population of individuals.
• Understanding the various minority stressors’ impact on individuals who identify LGBTQ+, we must also ask our clients about their unique experiences and beliefs.
• Rather than saying, “I don’t know what demisexual means – can you define that?” consider saying, “How do you feel about identifying with demisexuality?” or “Say more about how you feel this captures your identity.” And then, be certain to do some research on your own time about demisexuality (an individual who does not experience sexual attraction without first having an emotional attraction/connection).

Summary

A 2011 report suggested that 3.5% (that is, 9 million people) in the U.S. identify as LGBT (Gates). Thus, whether individuals come to therapy to specifically work on issues surrounding their sexual orientation or gender identity, we must stay educated and aware of the systemic, social, and political influences on this community, while also fostering collaborative therapeutic relationships with our clients who may identify as members of the LGBTQ+ community.

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Amy E. Ellis, Ph.D.

Dr. Amy E. Ellis is an Assistant Professor and the Director of the Trauma Resolution & Integration Program (TRIP) at Nova Southeastern University. She provides training and consultation on the provision of trauma-informed affirmative care and treating complex clinical cases. She is also has a private practice with a clinical focus in treating trauma, eating disorders, and personality disorders, and a special niche focusing on trauma-informed affirmative care for the LGBTQ+ community. She is a Consulting Editor on three of APA’s journals and recently served as Guest Editor of APA Division 42’s journal Practice Innovations on a special issue focusing on the role of evidence-based relationship variables in psychotherapy with sexual and gender minority individuals. Her current clinical and research interests focus on underserved populations who have increased exposure and risk to trauma (i.e., men, LGBTQ+, racial and ethnic minorities), tailoring evidence-based trauma treatments to these populations, and training and supervision in the field of trauma. She is currently the co-Principal Investigator of a large national grant funded through the Patient Centered Outcomes Research Institute focusing on the effectiveness of a peer-delivered online motivational interviewing intervention for GBTQ+ men with histories of sexual trauma.