Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) youth and adults are an increasingly visible component of the work of many behavioral health professionals. Who are LGBTQ clients and what information do you need to be culturally competent and prepared to work with this diverse population? Let’s take a look.
Don’t Make Assumptions
To begin with, it is important to understand that LGBTQ people are a diverse and nonhomogenous group of individuals. How they experience their sexual and gender identity varies from one person to the next, including their initial understanding of this facet of their lives, what their identity means to them, how they disclose to others or “come out,” how others respond, and how these individuals react to adversity, if relevant. LGBTQ people also have multifaceted identities—rural, urban, professional, cultural, ethnic, religious—and these can that affect their world views and resources. In addition, their reasons for needing services may or may not relate to their LGBTQ identity. For example, the death of a loved one may not relate to a client’s sexual orientation.
Allow clients to explain the importance and relevance of each of their identities, and acknowledge that they intersect. Let clients guide you as to whether their LGBTQ identity is relevant to their present behavioral health concerns.
Understanding the Terminology
At times the wide array of LGBTQ-related terms may seem confusing and perhaps even impossible to master. Here are a few key terms that will help all professionals to be more proficient and competent in their work.
According to the National Center for Transgender Equality, the term “gender identity” refers to “an individual’s internal sense of being male, female or something else. Since gender identity is internal, one’s gender identity is not necessarily visible to others” (2014)
All people have a gender identity. For some people this sense of their own gender is different from what society would expect from the sex assigned to them at birth, when a doctor looked at their genitals and declared “It’s a boy!” or “It’s a girl!” These individuals may use the words “transgender” or “trans” for short.
The National Center for Transgender Equality defines “sexual orientation” as “a term describing a person’s attraction to members of the same sex and/or a different sex, usually defined as lesbian, gay, bisexual, heterosexual or asexual.” (2014).
The term “gender expression” refers to “how a person represents or expresses one’s gender identity to others, often through behavior, clothing, hairstyles, voice or body characteristics.” (National Center for Transgender Equality, 2014).
Many of the terms that LGBTQ people use to describe themselves fall within the framework of these three terms. An important point to remember is that these three components are distinct, although they interact. For example, an individual who is transgender (gender identity) may not in any way identify as gay, lesbian or bisexual (sexual orientation) and may present themselves as masculine or feminine, androgynous or may cross society’s gender norms in their appearance (gender expression).
If you hear a word that you don’t understand, don’t be afraid to ask your clients for clarification.
Understand the difference and the possible intersections between gender identity, sexual orientation, and gender expression.
Understanding Mental Health and Addiction-Related Factors
In order to provide effective care to LGBTQ clients, it is helpful to understand the environmental challenges that many experience.
First, LGBTQ people disproportionately experience one-on-one discrimination in their everyday worlds, such as from friends and family; indeed, family rejection of LGB youth is linked to higher levels of depression, suicide attempts, illegal drug use, and unprotected sex (Ryan, Huebner, Diaz, & Sanchez, 2009). Perhaps due to high rates of family rejection, homeless youth are disproportionately LGBTQ (Quintana, Rosenthal, & Krehely, 2010). Many resort to survival sex for money, food, shelter, and/or drugs. Partially due to these circumstances LGBTQ young people are also overrepresented in the juvenile justice system; while LGBT youth are only 5 to 7 percent of the general population, they make up 15 to 17 percent of youth currently in the juvenile justice system (Hunt & Moodie-Mills, 2012).
Regarding substance use, meeting places for LGBTQ people historically are centered around bars and nightclubs, creating a culture of acceptance of alcohol and club drug use. Although meeting places have broadened considerably in many geographic areas, acceptance of alcohol consumption and drug use remains high, and there are higher rates of problem alcohol and some illicit drug use than for heterosexual people (Conron, Mimiaga, & Landers, 2010; Lipsky et al., 2012). Rates of smoking are much higher as well—30.8 percent for LGB adults versus 20.5 percent for heterosexual adults (Agaku et al., 2014), with rates for bisexual adults even higher (American Lung Association, 2010).
Abuse is also more common for LGBTQ people than for their non-LGBTQ peers. This includes verbal taunts or threats, peer bullying among youth (Kosciw, Greytak, Palmer, & Boesen, 2014), and physical violence. In addition, rates of sexual violence are high—including from an intimate partner—particularly for bisexual women and gay and bisexual men (Walters, Chen, & Breiding, 2013).
The hostile conditions that LGBTQ people often face include ones that are legally or governmentally sanctioned, such as living in a state with a same-sex marriage ban or being fired for being openly LGBTQ. Even if people do not experience discrimination personally, the public debate around LGBTQ rights can also contribute to their sense of insecurity (Rostosky, Riggle, Horne, & Miller, 2009).
Lastly, health care access is a challenge for this group. LGBTQ people in states where same sex marriage is not recognized often can’t get health coverage through their partner’s insurance. Some LGBTQ people have experienced discrimination or lack of understanding from clinicians and provider staff (or fear they will encounter it), coloring their interest in seeking services.
Many LGBTQ people have supportive people in their lives and positive identity-related experiences. Others have had hardships related to their sexual orientation and gender identities, but through those experiences may have developed a complex set of coping strategies. Through activism, mutual support, and personal growth in the face of adversity, LGBTQ individuals can bring enormous strengths to their communities. Practitioners can help clients identify their unique strengths and resources as well as encourage them to connect with positive informal or formal peer support networks.
For youth, The Trevor Project has several tools that may be helpful in promoting resilience, including “Coming Out as You!” and the “Coming Out Constellation.” Coming Out as You is a brief resource available online that helps guide young LGBTQ people through the experience of coming out, including identifying sources of support and personal strengths. The interactive “Coming Out Constellation” may be used in a collaborative way to facilitate a conversation with a young LGBTQ person to help them identify their own personal strengths (“Coming Out,” 2015).
Family systems can be an important protective factor in the lives of LGBTQ youth and adults. While family rejection can result in negative health outcomes, family acceptance can lead to a variety of positive health outcomes. When appropriate, treatment efforts should include family members of LGBTQ people with the goal of increasing family support and promoting the resiliency of LGBTQ clients (Ryan et al., 2009).
Understand the context of LGBTQ clients’ lives that may impact their treatment. Understand and promote resiliency and key protective factors.
Create a Safe Space
To lay a foundation for building a therapeutic relationship with your LGBTQ clients, there are tangible steps you can take to help them feel safe and supported, and to get them in the door in the first place. The Suicide Prevention Resource Center’s Suicide Prevention among LGBT Youth: A Workshop for Professionals Who Serve Youth (2014) is a good place to learn more. Begin in the physical space where you provide services: you could place LGBTQ-specific health resources in your waiting areas, put a “safe space” sticker or other affirming symbol (e.g., a rainbow flag) on your office door, website, advertising, and other places or materials seen by clients. While these measures may seem small, they can go a long way towards making LGBTQ clients feel welcome.
For youth, creating a safe space may also mean explaining as a matter of course what you can and cannot keep confidential. It is up to the youth to disclose sexual orientation or gender identity-related feelings or behaviors to others. Disclosing this information to a parent can sometimes provoke negative reactions from the parent and worsen the home situation, so do not do so without the youth’s explicit consent. If you are concerned about a young person’s mental and/or physical well-being due to “coming out” or identity-related bullying, share your general concerns with the parents without mentioning the reason why the young person is in distress. If the parents ask why the youth is feeling this way, encourage a direct discussion with the young person, and offer—to both the youth and the parents—to facilitate that conversation.
Creating a safe space for transgender clients includes being respectful of their identity. Ask them what words and pronouns they use to refer to themselves, and use those. Help other staff to do this as well, including front desk staff.
So that the safe space is consistent and comprehensive, advocate for supportive organization-wide policies and procedures. A few examples include:
- An organizational nondiscrimination policy that includes sexual orientation and gender identity
- An intake form (if applicable) that has optional sexual orientation and gender identity questions and an explanation of how this information will be used
- LGBTQ competency training for all of your agency’s staff, including front desk, social work, clinical staff, and others
Create a safe and welcoming environment for LGBTQ people.
Know and Refer to Appropriate Resources
Another way to assure that your services make LGBTQ clients feel safe and affirmed is to create and maintain a list of LGBTQ specific resources and services. It may undermine your effectiveness if you refer clients to a Twelve Step program, for example, that is not familiar with LGBTQ issues, or worse, is hostile. You may have to check on the LGBTQ competence of such services or providers yourself. You can also ask other clients who they trust. Making these resources readily available on your website, in your waiting room, in your office, and in treatment spaces sends a clear and affirming message to LGBTQ clients. If possible, connect transgender and bisexual clients to identity-specific supports (e.g., transgender social group, bisexual coming out support group) because these individuals may not feel welcomed or identify with gay- or lesbian-focused groups. If there are no local bisexual- or transgender-specific resources, supports are available online. See the text box for a brief list.
Commit to Ongoing Learning
Lastly, ongoing professional development is essential for providing competent and high quality care to LGBTQ clients. Examples of this include regularly attending educational events hosted by a local LGBTQ organization, reading journal articles related to LGBTQ health, and/or subscribing to LGBTQ related list-serves. Take advantage of online learning opportunities about LGBTQ mental health—from webinars to interactive online trainings and simulations. Some professional associations have created LGBTQ affinity groups or interest groups that may be helpful as well.
Whatever learning methods you use, building your LGBTQ competency will be a continual process. Don’t get discouraged if you find there are words or concepts that take some time to fully understand and integrate into your practice. As with any other expertise, it will take continual work to stay up to date with the newest research and emerging best practices. The resources below list a few key places for up-to-date information about the LGBTQ population, environmental concerns, substance use, and mental health.
Although it may seem daunting initially, with practice you can soon become more comfortable supporting LGBTQ people who need your help. When you are open-minded, nonjudgmental, and share that you are still learning, a little knowledge goes a long way.
Agaku, I. T., King, B. A., Husten, C. G., Bunnell, R., Ambrose, B. K., Hu, S. S., . . . Day, H. R. (2014). Tobacco product use among adults—United States, 2012–2013. Morbidity and Mortality Weekly Report, 63(25), 542–7.
American Lung Association. (2010). Smoking out a deadly threat: Tobacco use in the LGBT community. Retrieved from http://www.lung.org/assets/documents/research/lgbt-report.pdf
“Coming out as you.” (2015). Retrieved from http://www.thetrevorproject.org/section/YOU
Conron, K. J., Mimiaga, M. J., Landers, S. J. (2010). A population-based study of sexual orientation identity and gender differences in adult health. American Journal of Public Health, 100(10), 1953–60.
Hunt, J., & Moodie-Mills, A. C. (2012). The unfair criminalization of gay and transgender youth: An overview of the experiences of LGBT youth in the juvenile justice system. Retrieved from https://www.americanprogress.org/issues/lgbt/report/2012/06/29/11730/the-unfair-criminalization-of-gay-and-transgender-youth/
Kosciw, J. G., Greytak, E. A., Palmer, N. A., & Boesen, M. J. (2014). The 2013 National School Climate Survey: The experiences of lesbian, gay, bisexual, and transgender youth in our nation’s schools. Retrieved from http://www.glsen.org/sites/default/files/2013%20National%20School%20Climate%20Survey%20Full%20Report_0.pdf
Lipsky, S., Krupski, A., Roy-Byrne, P., Huber, A., Lucenko, B. A., & Mancuso, D. (2012). Impact of sexual orientation and co-occurring disorders on chemical dependency treatment outcomes. Journal of Studies on Alcohol and Drugs, 73(3), 401–12.
National Center for Transgender Equality. (2014). Transgender terminology. Retrieved from http://www.transequality.org/sites/default/files/docs/resources/TransTerminology_2014.pdf
Quintana, N. S., Rosenthal, J., & Krehely, J. (2010). On the streets: The federal response to gay and transgender homeless youth. Retrieved from https://www.americanprogress.org/issues/lgbt/report/2010/06/21/7983/on-the-streets/
Rostosky, S. S., Riggle, E. D. B., Horne, S. G., & Miller, A. D. (2009). Marriage amendments and psychological distress in lesbian, gay, and bisexual (LGB) adults. Journal of Counseling Psychology, 56(1), 56–66.
Ryan, C., Huebner, D., Diaz, R. M., & Sanchez, J. (2009). Family rejection as a predictor of negative health outcomes in White and Latino lesbian, gay, and bisexual young adults. Pediatrics, 123(1), 346–52.
Walters, M. L., Chen, J., & Breiding, M. J. (2013). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 findings on victimization by sexual orientation. Retrieved from http://www.cdc.gov/violenceprevention/pdf/nisvs_sofindings.pdf
- Culturally Competent Care for LGBTQ Youth: A SPARK Talk video from the Suicide Prevention Resource Center featuring Ashby Dodge, Clinical Director at The Trevor Project. http://sparktalks.sprc.org/video/lgbtq
- The National LGBT Health Education Center: Archived webinars such as “Behavioral Health Care for Lesbian, Gay, and Bisexual People ” and “Mental Health Care and Assessment of Transgender Adults.” www.lgbthealtheducation.org
Finding Local Resources:
- GLBT Near Me: A collection of gay, lesbian, bisexual, and transgender resources. www.glbtnearme.org
- The Trevor Project’s List of Local Resources: The leading national organization focused on suicide prevention efforts among lesbian, gay, bisexual, transgender, questioning, and queer youth. www.thetrevorproject.org/pages/local-resources
- Fenway Health LGBT Help Line and Peer Listening Line: http://fenwayhealth.org/care/wellness-resources/help-lines
- Trans Lifeline: www.translifeline.org
LGBT Suicide Prevention Lifeline:
- The Trevor Project: www.thetrevorproject.org
- APA Division 44: American Psychological Association’s Society for the Psychological Study of Lesbian, Gay, Bisexual, and Transgender Issues. www.apadivision44.org
- NALGAP: The National Association of Lesbian, Gay, Bisexual, Transgender Addiction Professionals and their Allies. www.nalgap.org
- NASWDC: The National Association of Social Workers’ National Committee on Lesbian, Gay, Bisexual, and Transgender Issues. www.naswdc.org/governance/cmtes/nclgbi.asp
Specific Topics and Further Learning:
- BiNet USA: Advocates for bisexual communities in the US, includes listing of local bisexual groups. www.binetusa.org
- LGBTQ Issues and Child Trauma: Fact sheet and resource list from the National Child Traumatic Stress Network. www.nctsn.org/sites/default/files/assets/pdfs/safe_spaces_safe_places_flyer_2015.pdf
- SAGE: Services and advocacy for gay, lesbian, bisexual and transgender elders. www.sageusa.org
- Suicide Prevention Resource Center (SPRC): LGBT resources. www.sprc.org/search/apachesolr_search/LGBT?filters=