Working therapeutically with LGBTI

clients: a practice wisdom resource

Working therapeutically with LGBTI clients:
a practice wisdom resource
Practice Wisdom Guide Coordinator and Editor:
Dr Marcus O’Donnell, University of Wollongong
Mindout! Senior Project Officer:
Barry Taylor, National LGBTI Health Alliance

Practice Wisdom Resource Practitioners Panel:

Ben Bradstreet, Western Australian AIDS Council
Suzanne Calver, FPWA Sexual Health Services
Rodney Kent, psychotherapist in private practice, Queensland
Tim Klein, psychologist in private practice, Queensland
Mani B Mitchell, Counsellor, E.D. ITANZ, New Zealand
Dr Daniel Parker, North Metropolitan Older Adult Mental Health Service,
Western Australia
Mary Rawson, Bisexual Alliance Victoria
Dr Liz Short, Victoria University, and community and clinical psychologist
in independent practice
Vikki Sinnott, psychologist in private practice, Victoria
Angela Trevaskis, ACON
Vanessa Watson, psychologist at YouthLink, Western Australia

National LGBTI Health Alliance

PO Box 51 Newtown NSW 2042
Inquiries: [email protected]
Phone: 02 8568 1123
www.lgbtihealth.org.au

© 2014. National LGBTI Health Alliance.

This resource was developed as part of the MindOUT! LGBTI Mental Health
and Suicide Prevention Project with funding from the Commonwealth
Department of Health through the Taking Action to Tackle Suicide Funding.

2 Working therapeutically with LGBTI clients: a practice wisdom resource

Contents

Introduction 4
Why is an LGBTI counselling guide needed? Two key things you need to know 5
Some other things to remember when working with LGBTI people 9
Some things you will need to explore before working with LGBTI clients 11
Working well with LGBTI clients 29
Working with LGBTQI subgroups and special issues of concern 38
References and resources 49

Working therapeutically with LGBTI clients: a practice wisdom resource 3

Introduction with the language and terms used in these communities;
but the basic rules of listening to your client and creating a
safe affirmative space for them, are the same as those you
would use with any other client.
The following manual draws from the consulting room
experience of a number of psychologists, psychotherapists
and counsellors who have worked with a broad range of What is this document and how was
sex, sexuality and gender diverse clients. it produced
The National LGBTI Health Alliance uses “LGBTI” This document is not a formal set of clinical guidelines;
as a recognisable acronym to collectively refer to a group there are already a range of these produced by national
of identities that includes lesbian, gay, bisexual, trans/ psychological associations and LGBTI organisations – a
transgender and intersex people and other sexuality number of which are listed in the resources section of
and gender diverse people, regardless of their term of this guide. This is a collection of practice wisdom from
self-identification because they all share experiences the consulting room. Although at times we will refer to
around sexual and/or gender identity and sexual and/ certain theories and to research done about the needs
or gender expression that are outside the dominant of LGBTI clients, this is primarily a resource that compiles
paradigms of Australian society. Each of these groups the professional experiences of those working with
also has a unique set of experiences that will colour the LGBTI people.
therapeutic encounter.
It was written through a unique consultative process that
You will recognise here principles of good therapy that you involved workshops and interviews with some of Australia
will know from your experience with other clients, because and New Zealand’s most experienced counsellors,
working with LGBTI clients has much in common with psychologists and therapists working with LGBTI clients.
the encounter any therapist has with any client. But the
It is designed to assist a broad group of helping
special context and specific lived experience of LGBTI
professionals who may want to work with LGBTI
people will often bring a particular focus or emphasis to
clients. It may be useful to psychologists, counsellors,
the way we use these familiar techniques.
psychotherapists, social workers, community workers or
Allies of all genders and sexualities are important in youth workers.
building a society that is affirming and safe for LGBTI
Throughout the text we use the terms “therapy”
clients. Affirmation by therapists from outside their own
or “counselling” in flexible and various ways to
communities can be a very important experience of
refer to mental health interactions between clients
acceptance for LGBTI clients, just as awkward or non-
and professionals.
affirming experiences can add to a sense of isolation. That
is why building the capacity of all helping professional to The need for such a resource was identified as part of the
deal effectively with LGBTI clients is so important. MindOUT! LGBTI Mental Health and Suicide Prevention
Project. This project of the National LGBTI Health Alliance
Some of the practitioners consulted during the
was funded by the Commonwealth Department of Health
development of this resource have been contacted by
to improve the mental health and suicide prevention
colleagues who had questions about how to work well
outcomes for LGBTI people. As part of the project’s work
with LGBTI clients. Some expressed concern that they
to assist mainstream mental health and suicide prevention
didn’t have the expertise, or experience, to deal with
organisation to increase to response to the particular
LGBTI clients. The response of these practitioners and the
social and therapeutic needs of LGBTI people, a series of
message of this resource, is that if you are willing to listen
resources were produced. This practice wisdom resource
to your client and do some research about the needs of
should be used with reference to the other resources in
LGBTI people there is no reason to think you may not have
the series:
the skills or expertise to deal with issues of sex, sexuality
and gender. In some cases you may need to seek advice l The cultural competency framework – which looks
from colleagues more experienced than yourself, just as at how organisations as a whole can increase their
you would in other situations. You may also find issues capacity to take on LGBTQI issues, and
brought up by LGBTI clients challenge your own values, l Going upstream: a framework for promoting the
beliefs or experiences – just as any other client might do mental health of Lesbian, Gay, Bisexual, Transgender
– and you need to seek appropriate professional support and Intersex (LGBTI) people – a framework for
in supervision. Yes, there are important areas of context undertaking mental health promotion and suicide
you should be aware of; yes, it is important to be familiar prevention with LGBTI people.

4 Working therapeutically with LGBTI clients: a practice wisdom resource

Why is an LGBTI counselling guide needed?
Two key things you need to know
Working with LGBTI people is similar to working with Although laws have been improved, discrimination is still
clients from any cultural group. Like other cultural institutionalised in some areas and discrimination and
minorities LGBTI people have a series of particular prejudice is still widespread. One recent survey (Robinson
experiences and particular stresses in their lives that can 2013) of Australian LGBTI youth revealed that 64% of the
impact on their mental health. Gaining an understanding participants, aged 16-25, had been verbally abused, 18%
of their social situation, and potential needs, is the first physically abused, and 32% experienced other types of
step in conducting effective psychological work with LGBTI homophobia and transphobia.
clients. That is why resources like this one are needed.
Prejudice and discrimination tells LGBTI people that
Most LGBTI people live fulfilling lives with the same range they are less important than their peers and can lead
of psychological issues and problems that confront their to experiences of shame, isolation, lack of confidence
heterosexual and cisgender colleagues and friends. or trauma.
Legal reforms and social changes have meant that
discrimination against LGBTI people in Australia has This does not mean that all LGBTI clients will present in
decreased and many LGBTI people now live open and therapy with under-developed confidence or shame about
successful lives in all sectors and regions of the country. their sex, sexuality or gender. But many will present with
some residual expressions of trauma simply because
However, in spite of the many advances in achieving they have lived with a sense of chronic stress due to their
equality and cultural acceptance, LGBTI people still position in society as a member of a minority group.
regularly experience discrimination, marginalisation,
bullying, and rejection. The cumulative as well as the This experience of stress and the potential threat of
acute effects of these experiences lead to higher levels of discrimination, rejection and/or violence endured by
mental health issues in LGBTI populations. The mental members of various cultural minorities has been theorised
and physical damage caused by these social pressures by psychologists as “Minority Stress”. Ilan Meyer (1995,
are often an important part of presenting and/or underlying 2003, 2008) has shown how this is experienced in
therapeutic issues. LGBTI people. Meyer, and other psychologists who
have worked with his theories, conceptualise that LGBTI
LGBTI people are resilient in the face of such challenges people experience a variety of stresses in their lives.
and will have individually crafted sets of resilient strategies These include:
to allow them to navigate a world that marks them 1. External stressful events
as different. This narrative of resilience is an equally These could include a range of discrimination and
important part of the therapeutic work with LGBTI people. prejudice from ongoing alienation by family to
While acknowledging the social and cultural stresses that physical violence
cause psychological distress is important, developing a
2. Expectations of such events
focus on resilience supports strength-based, affirmative
This not only produces anxiety but also calls for
psychological work.
hyper-vigilance which produces its own stresses
3. The possible internalisation of negative
Discrimination and minority stress societal attitudes
All LGBTI people, even those who have grown up with Potential shame, guilt and negative attitudes about
supportive family and friends, will most likely have sexuality, sex and gender difference
experienced some degree of discrimination or prejudice. 4. Concealment
Even for those who are in some ways “out” they may
This is a complex experience because discrimination still engage in some level of concealment as part of
manifests in a range of ways, some of which is very explicit their vigilance strategies
and some of which is very subtle and even possibly
unintentional. It includes such things as name-calling, Researchers have concluded that this experience of
bullying, and exclusion by peers or family, through to job acute and chronic, low-level stress – from external and
loss or denial of services. At its most extreme, prejudice internalised events and process – contributes to the
and discrimination leads to violence, or the threat of notably high levels of stress related physical illness, anxiety,
violence, and can be life threatening for LGBTI people. depression and even suicidality reported in LGBTI clients.

Working therapeutically with LGBTI clients: a practice wisdom resource 5

In the report cited above, of Australian queer youth, in devising ways of transforming hardships into
41% of participants had thought about self-harm and/or opportunities, and continue to make significant
suicide, while 33% had harmed themselves, and 16% had contributions to society despite being denied
attempted suicide (Robinson 2013). access to environmental supports available to
most other groups.
In working with LGBTI clients it is important to
acknowledge the key role that minority stress, arising from Seeking out supportive communities – individual and
negative social attitudes and discriminatory practices, group support – is one of the key ways that minority group
can play in the psychological wellness of LGBTI people. members develop a resilient response to discriminatory
The higher incidence of reported mental health issues in experience. However in their efforts to remain self-
LGBTI populations stems from these circumstances and is contained and “hardy,” reaching out or help seeking skills,
not a product of sexual orientation, intersex status, gender may remain underdeveloped. Finding a balance between
expression or identity. Clarifying this point with clients can an internally generated sense of strength and having this
be particularly powerful: to help individuals understand validated through supportive others is sometimes difficult
that their anxiety and distress may, at least in part, be for LGBTI people. An exploration of these different internal
due to chronic stress and social stigma, rather than and external strategies of resilience in client’s lives is an
some ‘fault’ or ‘badness’ of their own making, is often important part of developing an affirmative strengths-
very liberating. based assessment.

This experience of stress can lead to major presenting

symptoms like depression and anxiety but it will
also often lead to internalised self-doubt and LGBTI people’s lives are also resilient in the
self-patholigising stories and beliefs which disrupt face of challenges and each LGBTI person
LGBTI people’s lives in subtle and not so subtle ways. will have an individually crafted set of resilient
Part of good therapy or counselling will involve listening
strategies to allow them to navigate a world that
for beliefs and stories of self that contain social negativity
about being LGBTI and the beliefs and stories that resist marks them as different.
these cultural stereotypes.

For many LGBTI clients the therapeutic journey is part Individual coping styles will vary enormously.
of a journey out of trauma, and it often begins by openly
recounting the narrative of distress or possible trauma, Smith and Gray, in their study focus on what they call
and resilience in their lives. “The courage to challenge” as one marker of LGBTI
self-efficacy. Part of developing a resilient approach can
be developing a sense of personal efficacy through the
Survival and resilience readiness to publically challenge negative views about
Because LGBTI people often do experience a lack of LGBTI people and issues encountered in their
acceptance and varying degrees of discrimination, day-to-day life.
prejudice and trauma, they are often unusually resilient
However other LGBTI people, or even some of those
– they will have developed a set of unique personal
who exhibit an ability to challenge on some occasions,
strategies to deal with societal prejudice and to survive in a
may strategically choose to avoid unnecessarily hurtful
stressful environment.
events. Some LGBTI clients will attend family events and
Although much of the psychological research on LGBTI debate with non-supportive family members while others
issues is still “deficit-based” – what are the problems will adopt a protective strategy of staying away. Neither
LGBTI people experience? – psychologists have now is a right or a wrong strategy and individuals may adopt
begun to investigate LGBTI resilience. a different strategy at different points in their life, or in
different situations.
Mark Smith and Susan Gray (2009) noted in their study:
Those who regularly encounter individuals who Therapy with LGBTI clients involves identifying and
may be lesbian, gay, bisexual, or transgender validating existing strategies for resilience and where
know from first-hand experience that the many possible assisting clients to develop additional ones.
stereotypes found in popular media that have
become so deeply etched in public perception
have little correspondence with actual experience.
In fact, practitioners familiar with LGBT individuals
find that their clients are usually quite tough, that
they respond to hardships and personal tragedies
with notable resiliency, are remarkably creative

6 Working therapeutically with LGBTI clients: a practice wisdom resource

I’m told I just need to allow my mind to allow the war
zone between my legs to be at peace. So then what?
What happens when I tell my body that this time it better
enjoy sex or else – and my body still doesn’t? Then will
people believe me that it’s not just in my head? … my
scar tissue is not in my head. My skin, my muscles and
my bones have memorised it. I feel it every time they
draw my blood and I have a panic attack. I feel it every
time I go on a date with someone, or go to bed with
someone, and I know that the playing field is uneven.
It’s not that I can’t love. I can. I just hate what they did to
me. And so, I try to ignore it. But pretending I don’t know
what I know isn’t working anymore.
— Intersex Activist Pidgeon Pagonis

Working therapeutically with LGBTI clients: a practice wisdom resource 7

I keep thinking about power. The intuitive flash of power
that ‘coming out’ can give: I have an indestructible
memory of walking along a particular block in new York
City, the hour after I acknowledged to myself that I loved
a woman, feeling invincible. For the first time in my life
I experienced sexuality as clarifying my mind instead of
hazing it over; that passion, once named, flung a long,
imperative beam of light into my future. I knew my life
was decisively and forever different; and that change felt
to me like power.
— Poet Adrienne Rich

8 Working therapeutically with LGBTI clients: a practice wisdom resource

Some other things to remember when
working with LGBTI people
LGBTI people have rich intersex, facilitating connections with LGBTI community
organisations or events can be a helpful step. However,
multi-component identities just like any community, the LGBTI communities are
Sexuality and gender identity are often an important part of diverse and have a range of problems, restrictions and
all clients’, including those who are LGBTI. Even if a LGBTI codes of behavior that can be less welcoming to new
client’s presenting issues are not explicitly about sexuality, LGBTI people. Some LGBTI people of diverse cultures
sex or gender issues their experience as an LGBTI person experience racism, for example, and commercial venues
will more than likely provide important background. are often focused around stereotypical measures of age
and beauty. So while connections with community may
However LGBTI people are not defined by their LGBTI well be an important aid for LGBTI people, any therapist
experience; they also have a range of other identities and must realise that it can also be a source of challenges.
associations. Race, ethnicity, religion, gender, age, class
and professional identities are valuable other lenses that Many LGBTI people feel an important sense of affirmation
will be equally important in understanding and assessing through participation in these communities and their
clients’ experiences and needs. It is essential to look at the social and political events and organisations. But for some
intersections of all these various identities rather than looking LGBTI people, sub-cultural expectations are experienced
at sexuality, intersex status or gender identity in isolation. as a new set of stereotypes or constraints.

Any client may be an LGBTI client

In many beliefs, concerns, and life choices
Many LGBTI clients are not going to present with an
individual LGBTI clients are just as different from LGBTI identified issue. Some may not bring up issues of
each other as they are from non-LGBTI people. intersex related experiences, sexual or gender identity and/
or expression unless explicitly asked or unless they feel
comfortable with you. In talking with your clients or taking
a history it is important that your questions don’t betray
The typical LGBTI client does not exist assumptions about their lives. For example don’t assume a
heterosexuality, exclusively heterosexual desires or behaviour
Although this resource is written in the belief that there are
or that the client is comfortable with their assigned gender.
some things that can be usefully said about working with
In asking about relationships don’t ask in a way which
LGBTI people, it must also be acknowledged that LGBTI
makes assumptions about the gender of their partner.
clients come in all shapes, sizes, personalities and states
of wellness. Although they share the common experience
of coming to terms with being LGBTI in a culture that is Behaviours, identities and experiences
ambivalent at best about differences in sexuality, sex and
In starting to think about sexuality, sex and gender it
gender, they are individuals whose personal experiences
is important to keep in mind the differences between
need to be understood. In many beliefs, concerns, and life
behaviours, identities and experiences. Although these
choices individual LGBTI clients are just as different from
categories can overlap they are not identical. People may,
each other as they are from non-LGBTI people.
for example, have had sexual experiences with both men
and women but not identify as gay, lesbian or bisexual.
LGBTI communities can bring support People may have had no physical sexual encounters but
still identify strongly as gay because of their experience
and conflict of sexual, affectional or romantic attraction. Some people
Part of the journey for LGBTI people as they discover more may have always lived as their assigned gender but will
about themselves is usually meeting and interacting with still claim a different gender identity. Intersex people have
other LGBTI people. Developing a sense of connection a vast range of experiences and how this impacts their
with other LGBTI people or community helps to overcome identity and relationships with others and their body. It is
feelings of isolation and aloneness. Often, if therapists important to listen to your client’s experience carefully and
are working with clients at an early stage of awareness discern what it is they are talking about and how they are
in relation to being lesbian, gay, bisexual, transgender or framing their own experiences.

Working therapeutically with LGBTI clients: a practice wisdom resource 9

By focusing on strengths and resilient capacities,
practitioners’ efforts to construct more comprehensive
and strength-focused assessments are enhanced.
As a direct result of strengths focused assessments,
practitioners can then develop more sensitive and
effective interventions with their clients that make better
use of already existing resilient attributes in their lives.
This can conceivably help practitioners to avoid reliance
on assessments and interventions that maintain a risk,
vulnerability, and deficit-based orientation to practice with
their LGBT clients.
— M. S. Smith and S. W. Gray, 2009

10 Working therapeutically with LGBTI clients: a practice wisdom resource

Some things you will need to explore before
working with LGBTI clients
This booklet is written in the belief that any mental sexuality and gender it is important to honestly look at your
health professional can work well with LGBTI clients if own attitudes before working with LGBTI clients.
they want to. Working with LGBTI clients involves using
a range of common psychological interventions. However To be open to someone’s experience, when it is really
mental health professionals who wish to work well with different from your own, means that you may be
LGBTI clients need to do so reflectively and supported challenged. Learning about their experience and seeking
by appropriate professional resources. further information is part of answering that challenge.
The other part is reflecting on your values, beliefs and
Firstly you will need to reflect on your own, perhaps attitudes: being open to how you might react positively and
unconscious, attitudes to sex, sexuality and gender. This negatively in such an encounter.
is the first step to ensuring that you are prepared to work
with this client group. You may also need to discuss this
with your regular supervisor. Think about your own socialisation
Thinking about your own socialisation and your own
Secondly, sometimes working with LGBTI clients may
attitudes to sex, sexuality and gender is essential.
bring up unfamiliar areas and you may need to seek
Questions you may ask yourself include:
advice or secondary supervision from colleagues
l What views of LGBTI people did you grow up with?
who have more experience with LGBTI people. The
need to seek advice, and to acknowledge and work l What were some of the sources of these views?
through uncomfortable feelings that may arise, are not l When and how did they change?
disqualifications for working with LGBTI people, they are l How and when did you decide about your
grist for the mill in any creative encounter. own sexuality?
l If you are heterosexual did you make a conscious
Finally acquaint yourself with research about LGBTI
choice?
experience and best practice therapeutic interventions
with LGBTI people. This is available in guides like this l When did you ‘come out’ as a heterosexual, bisexual
one, through professional training programs, through or homosexual?
professional journals and published clinical guidelines. l How do you understand the links between biology and
sexual orientation and gender identity?
Sex, gender and sexuality are important in all our l What do you believe about bisexuality and why?
lives and the emergence of vibrant gay, lesbian, trans,
l What makes you think of yourself as a man
bi, intersex and queer cultures and identities has enriched
or a woman?
the way we all think about ways of embodied being in
l How do you think about the role of gender in your life?
the world. So thinking about and learning from LGBTQI
clients can be an enriching experience both personally
and professionally. Explore your own fears and judgments
For all of us, regardless of our sexuality, sex or gender, our Whether or not you are LGBTI yourself, you may have a
experience of sexuality and gender has been socialised number of friendships or associations with LGBTI people.
and we have all experienced uncertainty, fear and Think critically about conversations you have had with
tentativeness around social restrictions on “appropriate” them. Are their elements of their experiences or choices
sexual behavior and gender expression. Some of us have that you find puzzling? What do you most admire about
grown up in more supportive environments than others them? Were there times when things they said shocked
but many of us, whether heterosexual or queer, have you? What have you learned from them?
had to struggle with sexuality-negative and/or gender
restrictive thinking in our society and our families. This Engage in an open conversation with LGBTI people
restrictive thinking about sex, sexuality and gender may you know in an effort to explore any hidden fears or
have also been present in the training many mental health judgments that you may have. Just as LGBTI people
professionals have completed. may have internalised homo/bi/trans -phobia, supportive
heterosexual and cisgender allies often also have to work
Although some mental health professionals will have through a set of assumptions and internalised fears or
already spent many years processing their attitude to sex, judgments about LGBTI people.

Working therapeutically with LGBTI clients: a practice wisdom resource 11

Non-judgementalism is a therapeutic ideal, however it’s attention. Think through strategies and reactions to a
impossible to be totally non-judgemental because all our situation like this before it catches you unawares. This is
lives are full of analysis and evaluations. Some unexpected an important issue to discuss with your supervisor.
judgements will shape and intrude into our thinking.
Clinically it is important that we avoid inadvertently
communicating our judgements to the client, and that
Think about your own race, cultural
we consider how they might shape and encroach on the identity and religion
therapeutic relationship. Ethnicity, culture and religion have powerful effects on
the ways we negotiate our sexual identities and the way
we perceive and relate to LGBTI people. If you have, for
Working with clients what is important is that example, been raised in a particular religious tradition that
we avoid inadvertently communicating our has negative views on LGBTI issues then you will need to
think seriously about how you will negotiate these beliefs.
judgements to the client and look at how they
might encroach on the therapeutic relationship. Because LGBTI people are used to negotiating their
identity in a world which assumes that heterosexuality
and gender conformity is the norm, they are often skilled
at picking up subtle or even unconsciously expressed
judgments. So before deciding to work with LGBTI clients
Explore aspects of LGBTI cultures
therapists should question their own beliefs and ask
Major cities will have LGBTI newspapers or magazines themselves if they can remain open to and respectful of
and both local and international publications are available LGBTI experiences in the therapy room.
online. LGBTI cultures are thriving in many cities and
towns and experiencing LGBTI events and festivals can If after reflection you sincerely believe that this may be
sometimes be helpful in deepening your understanding. a problem then you may consider referring clients to a
colleague you know to be LGBTI-friendly. This is an honest
There are a range of LGBTI themed films and TV shows and ethical decision and may not be a permanent one.
– both dramatic features and documentaries – that are
widely available which can help you think about LGBTI
people and their lives. Many novels with LGBTI themes
Coming out as an LGBTI specialist
regularly appear in the bestseller lists or win major and an ally
literary awards. If you have thought about these issues; if you have
One of the common experiences of LGBTI people is begun to see some LGBTI clients; if you have done some
growing up feeling like you are an outsider, of being not professional development training; it is then time to come
quite right, not fitting in, asking: “How will I make my way out yourself – as an LGBTI ally.
in the world and be okay?” Many other people will also Heterosexual allies – such as the Parents and Friends of
have had this experience because of their experience of Lesbian and Gays (PFLAG) organisations – have been
race or ethnicity or some other mark of difference but important contributors to the fight for LGBTI equality
many others grow up without this intense experience of and rights. Many people from President Obama through
outsider identity. In thinking about working with LGBTI to Lady Gaga have declared themselves allies through
clients it may be helpful to think about the ways that you participation in popular social media campaigns like the
have experienced being an outsider and the ways you “It Gets Better” video project, for example.
have experienced being an insider in our culture. Try to
find some connection in your own life that allows you to
feel like you don’t fit in or are not included or valued in the
same way that others are. Heterosexual allies have been important
contributors to the fight for LGBTI equality and
rights. Many people from President Obama through
Think about erotic issues and intimacy
to Lady Gaga have declared themselves allies.
issues in the therapy room
In any long-term therapeutic relationship personal
feelings – what the psychoanalytic literature would call You can show that you are supportive of LGBTI clients
transference and countertransference issues – may by simple things like including posters in your consulting
develop and these may or may not become erotised. This room or ensuring that your organisation has relevant
is true regardless of the gender and sexual orientation of literature in the waiting room. You can raise issues
the client and the gender and sexual orientation of the about LGBTI clients in meetings with colleagues or at
therapist. These issues need careful consideration and conferences and professional associations.

12 Working therapeutically with LGBTI clients: a practice wisdom resource

Same-sex development does not proceed in an orderly,
invariant, or universal manner or occur within a set, or
even typical, time frame (Savin-Williams, 2005). For
example, although most adolescents self-identify as
gay or bisexual prior to disclosing this information to
others or dating a same-sex partner, some youth enter
a committed romantic relationship before self-labeling.
Unlike previous cohorts of gay men, an equal proportion
of contemporary young men recognize that they are gay
before engaging in homoerotic sex as after (Dubé, 2000).
Whereas it is very common to recollect initial same-sex
attractions prior to pubertal onset, it is not uncommon for
attractions to first surface in high school, or later. Indeed,
the variability what some think about as ‘developmental
milestones’ related to sexuality is so large that in one
study the age range among all 10 ‘identified milestones’
overlapped (Floyd and Stein, 2002). Thus, sweeping
assumptions about “normal” or “typical” developmental
trajectories should be rejected.
— Ritch C. Savin-Williams and Kenneth M. Cohen, 2007

Working therapeutically with LGBTI clients: a practice wisdom resource 13

Some theories that might help you developed at a particular time and place, and by particular
people, influenced by their own social locations, and life
think about LGBTI people’s lives experiences and influences. However these ideas and
This is not a theoretical or academic text but it does theories remain influential, are widely available through
come from the experience of expert practitioners who are the internet, and will be well known to some LGBTI clients.
well aware of research in their field. Some key ideas and
Therapists may find that some clients use them to
theories might be helpful in framing the wisdom of the
think about themselves – sometimes, with inaccurate
counselling room. In this section we explore some key
or unhelpful consequences or implications, such as
ideas and theories about sexuality that can help inform
potentially thinking that if they are not ‘out’, that they are
positive counselling practices with LGBTI people. Each
somehow less ‘authentic’ or ‘developed’ than others. It is
of the “theories” presented here are also in their own
particularly important to avoid fostering overly-formulaic
way “practice wisdom” because they have been devised
and rigid frameworks and promoting ideas and constraints
by experienced clinicians or from large data pools of
based on what is considered ‘normal’.
aggregated LGBTI experience.

As with all ideas and theories, it is important to recognise The sexuality spectrum
that they are just that – ideas and theories – and to keep
an open-mind and engage in critical reflection. These Alfred Kinsey’s pioneering studies in the 1940s
ideas and theories are merely tools for thinking about the popularised the idea that it is common for people to have
varieties of LGBTI experience, and should not be used had a variety of sexual experiences. Kinsey proposed
therapeutically to measure ‘maturity’ or ‘progress’. Many that people’s sexual behavior could be mapped along a
of these ideas were developed a long time ago and reflect spectrum which ranged from exclusively heterosexual at
a much more combative understanding of the place of one end to exclusively homosexual at the other (Figure 1).
LGBTI people in society. It is important for therapists and
others to recognise that theories and ways of thinking are
Heterosexual

Homosexual

0 1 2 3 4 5 6

0 – Exclusively heterosexual with no homosexual

1 – Predominantly heterosexual, only incidentally homosexual
2 – Predominantly heterosexual, but more than incidentally homosexual
3 – Equally heterosexual and homosexual
4 – Predominantly homosexual, but more than incidentally heterosexual
5 – Predominantly homosexual, only incidentally heterosexual
6 – Exclusively homosexual

Figure 1 Heterosexual–homosexual rating scale. © The Kinsey Institute.

14 Working therapeutically with LGBTI clients: a practice wisdom resource

Increasingly contemporary youth are self-labeling while
still in high school, often by age 15. Furthermore,
fewer females than males ever label their feelings but
not themselves as gay; and they more often move
immediately from labeling attractions to labeling self. The
time lag from first same-sex attractions, behaviors, and
questioning to potential identification might span months,
years, or decades and is briefer among females than
males. One study reported that the average girl required
a little more than three years to go from first same-sex
attractions to self-labeling compared to five years for the
average boy.
— Ritch C. Savin-Williams and Kenneth M. Cohen, 2007

Working therapeutically with LGBTI clients: a practice wisdom resource 15

This “Kinsey Scale” explained sexuality as a fluid set of through as a right of passage to ‘resolve’ their sexuality
practices that may vary from person to person and may ‘authentically’. This popular idea of ‘coming out’ is at
vary over the course of a lifespan. However Kinsey’s odds with many LGBTI people’s experience for whom
model was based on surveys of sexual behavior not on ‘coming out’ is an extended process and one that does
an understanding of sexual identities, desires or romantic not necessarily mean that they inform all people in their
attractions and relationships. Some researchers have lives about their sexuality and/or gender. It does not
critiqued Kinsey’s methods, and certainly his famous take account of the experience of some LGBTI people
1 in 10 statistics have been superseded, but his basic in particular communities for whom a ‘full’ coming out
contribution: that sexual behaviors should be understood is simply not desirable or possible, or for the many
as a naturally occurring variable spectrum of experience people who strategically ‘come out’ or not on a flexible
has been critical to contemporary understandings and variable basis. Finally it doesn’t allow for many
of sexuality. contemporary ‘coming out’ stories which occur very
smoothly, with very little fanfare and no great “ah ha”
moments or anything to ‘come out’ from.
Coming Out/Coming In
The politics of coming out may indeed be important for
It was the work of Kinsey and other early sexologists who
some clients, but in the counselling context it is the shape
began to open up the public discussion which eventually
of the coming out story, if there is one, that is important.
led to the sexual liberation movements of the 1960s and
Twenty years ago, sociologist Ken Plummer wrote of
1970s. It was here that a wider discussion around sexual
potential benefits for some of “telling sexual stories”.
identity rather than just sexual behavior began to occur.
One of the primary ways that these movements began “Sexual stories aid in the creation of a past,
to talk about sexual identities was through the idea of a present or a future – marking out histories,
“coming out’. differences, unities and agendas for action.”
(Plummer 1995:78)
‘Coming out’ is not a theory of sexuality but it has
become a primary trope in popular culture for becoming In a range of different contexts, not just coming out stories,
public with being LGBTI. Although some trans and these sexual stories are stories of suffering and survival.
intersex people may frame publically acknowledging Although they may focus on discrimination and difference
their identities in terms of “coming out” it is primarily they are almost always stories of resilience. Plummer also
a concept developed and deployed by gay men and made the point that there is a strong intersection between
lesbian women and some bisexual people. It is important politics, community and identity in the traditional ‘coming
to understand the complexities which sit behind this out’ narrative and its deployment:
popular idea because it has become a kind of the short- For narratives to flourish there must be a
hand, “common sense”, expression that is rarely thought community to hear; that for communities to hear,
through thoroughly and does not fit with everyone’s there must be stories that weave together their
experiences. history, their identity, their politics. The one –
community – feeds upon and into the other – story.
‘Coming out’ or ‘coming out of the closet’ took on
particular importance with the rise of the gay liberation Plummer’s model may be useful in that it shapes the
movement in the seventies and eighties. With the rise of ‘coming out’ story as one of resilience and survival and
a public, politicised lesbian and gay movement, ‘coming marks it as one connected to the process and politics
out’ became a political strategy that emphasised the need of community. He also argues that ‘coming out’ like
for visibility and pride in a minority sexual identity. Rather other sexual stories are what he calls forms of “intimate
than a story LGBTI people told themselves or one another, citizenship”. They have relevance for individual lives, they
or at most to a few close personal friends, coming out have relevance for particular communities and sub-cultures
became a public political statement of “out and proud” and they have relevance for society more generally.
LGBTI people.
Although there may be some common themes or
Because of its prominence as a political strategy, and a pathways, individual stories heard in the counselling room
media strategy where high profile lesbian and gay people are precisely that: uniquely formed narratives. One of the
‘come out’ on the covers of magazines, it has come to be problems with the emergence of very public narratives of
almost synonymous in popular culture with the range of ‘coming out’ is that LGBTI people may feel further isolated
posited complex processes that LGBTI people might go if their ‘coming out’ story does not confirm to the publically
through in relation to communicating with others about celebrated model or if they don’t ‘come out’ much at all.
their sexuality and/or gender.
Maybe they grew up in a very supportive environment
In this sense it is often mistakenly regarded as a one- and never experienced their sexuality as a particularly
off triumphant process that people must or should pass problematic issue or something that needed to be

16 Working therapeutically with LGBTI clients: a practice wisdom resource

Those who regularly encounter individuals who may
be lesbian, gay, bisexual, or transgender know from
firsthand experience that the many stereotypes found
in popular media that have become so deeply etched
in public perception have little correspondence with
actual experience. In fact, practitioners familiar with
LGBT individuals find that their clients are usually quite
tough, that they respond to hardships and personal
tragedies with notable resiliency, are remarkably
creative in devising ways of transforming hardships
into opportunities, and continue to make significant
contributions to society despite being denied access to
environmental supports available to most other groups.
— M. S. Smith and S. W. Gray, 2009

Working therapeutically with LGBTI clients: a practice wisdom resource 17

communicated or announced to others. Young LGBTI Bisexual ‘identity formation’
people will now often say: “I never came out, because I
was never in”. Although ideas like the Kinsey continuum of sexuality,
recognises bisexuality as one part of the continuum of
However some clients will come from families or particular sexual expression, many bisexual men and women still
cultural or religious traditions where being other than experience a lack of validation of their identity. The force of
heterosexual and conventionally gendered is much less the public lesbian and gay movement and the prominence
accepted, and they are not willing to cut themselves of its ‘coming out’ narrative have led to a widespread
off from family and tradition by a dramatic ‘coming out’ perception that people who say or think they are bisexuals
declaration. are really gay men or lesbian women who haven’t
managed to ‘come out’ yet.
Maybe professional situations demand discretion about
private sexual and gender identities. Research on attitudes towards bisexual peoples shows that
they confront a range of very particular negative attitudes
Maybe by living in a small town where it is still not safe or
from both mainstream society and from within lesbian and
comfortable to ‘come out’.
gay sub-cultures. The view that bisexuality is a transitional
Maybe being are sick and tired of ‘coming out’ again and stage on the way to a full ‘coming out’ as lesbian or gay
again to different sets of people and just don’t want to talk stigmatises bisexuals as ‘inauthentic’. Because bisexuality
about their personal or family lives anymore. is regarded as an inauthentic choice, bisexual men and
women are often stereotyped as ‘untrustworthy’ and
‘Coming out’ rhetoric can be particularly problematic for because they are open to sexual experience with both
bisexual people who are often treated like they have one men and women they can be regarded as hyper-sexual,
foot in and one foot out of the closet and are critiqued promiscuous and therefore potentially disloyal partners
for a perceived inability to “make up their mind”. But (Klesse 2011).
increasingly people who are bisexual have adopted
a version of ‘coming out’ as a political statement that However like other queer communities, bisexual men and
validates their identity as bisexuals. women have begun to tell their own sexual stories and to
claim a sexual and cultural identity for themselves.

On the basis of interviews with 20 people in the early

The ‘coming out’ story is one of resilience and 1990s, Mary Bradford (2004) proposed a model of what
survival and is connected to the process and she called bisexual “identity formation” which shares
a number of the characteristics of the other models of
politics of community.
sexuality discussed in this chapter. However she proposed
that in many ways bisexual identity formation can be more
complex than that experienced by either heterosexuals or
‘Coming out’ is never a completed process because
gay and lesbian people.
assumed heterosexuality remains the expected norm in
much of our society. Even the most publically ‘out’ LGBTI Bradford noted that, because of the historic invisibility
person can be constantly surprised when they must yet of bisexuality in our culture, there can be a “questioning
again declare (or not) their sexuality or gender identity in a stage” during which, bisexual people can doubt their
new social or professional situation. experience of both or either same-sex and other-sex
attractions. She suggested that unlike lesbian and gay
Some writers have also started to talk about the
people who can rely on the public narrative of ‘coming
“coming in” process as a way of counterbalancing
out’, many bisexual people feel that they need to
this emphasis on public declarations of identity. What
invent their own identity and that even when they feel
about the more intimate development of self that occurs
comfortable with their own self-identification, they have
internally and/or with close intimate friends and family?
to engage in a long process of publically maintaining this
What about the process whereby LGBTI people are
identity.
welcomed ‘in’ by others that accompanies the process
of being ‘out’? Such a focus turns our attention to the Some bisexual people might use these processes as an
systemic prejudice in society which requires LGBTI opportunity to take social action and they further their
people to perform the act of ‘coming out,’ and asks personal growth through activism in the bisexual and
everyone to look at how we can make our culture a truly queer communities.
inclusive one for everyone: a place where no one has to
be indiscriminately “out” or “in”.

18 Working therapeutically with LGBTI clients: a practice wisdom resource

The unfolding of homoerotic development has been
deeply influenced by the sexual revolution that has
both normalised and destigmatised same-sex sexuality,
particularly among youth. One consequence has been
an accelerated evolution in which developmental
cohorts, or generations, transform every five years and
contain greater intragroup variability than during any
preceding era.
— Savin-Williams, 2005

The increasing acceptance of sexual diversity and

mainstreaming, rather than ghettoising, homoeroticism
have allowed contemporary cohorts of same-sex
attracted youth to incorporate and express life-styles,
perspectives, and languages that are similar to those
embraced by heterosexual youth. Stereotypes have
dwindled as gay youth increasingly reveal that they
vary among themselves in much the same way as
heterosexual youth vary – shaped more by their gender,
ethnicity, physical attributes, personality, and economic
class than by their sexuality.
— Ritch C. Savin-Williams and Kenneth M. Cohen, 2007

Working therapeutically with LGBTI clients: a practice wisdom resource 19

Recent studies indicate high levels of depression and
anxiety in bisexual people. One recent analysis of the peer
reviewed literature concluded:

International studies that explored bisexual people

separately from homosexual people showed
that bisexuals have higher rates of depression
or depressive symptoms than heterosexual
people and, further, are at the same or higher
risk for depression than homosexual people. This
tendency appears to be particularly robust for
women (young and adult); however, it is difficult
to make any firm conclusions about sex as the
data on bisexual men is much more limited,
and there were few findings that compared
bisexual men with bisexual women. The ARCSHS
studies support the proposition that high rates of
depression in Australian non-heterosexual people
may be slightly inflated due to even higher rates
of depressive symptoms in bisexuals. Indeed, in
all four ARCSHS studies described in this section,
bisexuals exhibited poorer mental health than
homosexuals. (Corboz et al 2008).

Queering the pitch

Queer Theory is both an academic and a political
movement that has reclaimed the derogatory term “queer”
as a way of reinvigorating thinking about the positive
connections between divergent sexualities, the normal
and the marginal. It also helps us to think about sexuality
and gender in different ways that go beyond simple and
frequently criticised ‘identity’ and ‘stage’ models.

For some it is used as a handy, gender-neutral shorthand

for all the members of the LGBTI alphabet. Others use the
term queer to distinguish new thinking about a politicised
sexual identity from an assimilationist or rights rhetoric of
the LGBTI movement.

One thing that queer reminds us about, in the counselling

room, is that difference can be positive and that traditional
psychological approaches, that have historically prioritised
‘adjustment’ and fitting in, are problematic, not necessarily
accurate, and that can have their own unintended
negative consequences or implications. For some,
queer identity is not about fitting in; it is about exploring
alternative visions of the world and the way it should be
and moving away from binary or rigid conceptualisations.

Queer also highlights a contested and open idea of identity-

in-process that doesn’t fit neatly into easy schemas of
identity development. It also draws attentions that sexual
identities intersects with, and are inseparable from, a range
of others such as those based on race, class and gender.
It is a critical perspective which acknowledges that diverse
sexuality and sexuality may provide particular vantage
points to look at and think about these intersections.

20 Working therapeutically with LGBTI clients: a practice wisdom resource

This invisibility compared to lesbians and gay men is a
central component of what makes the experiences of
bisexual people specific. Stonewall’s (2010b) [UK] report
on the representation of lesbian, gay and bisexual people
on youth TV, Unseen on Screen, found that of the 126
hours, 42 minutes and 17 seconds of programming
analysed, bisexual people were portrayed for just 5
minutes and 9 seconds, compared to 4 hours and 24
minutes for gay men, and 42 minutes for lesbians. At
no point in this coverage were bisexuals portrayed in a
positive or realistic manner. Similarly language, and the
way it is used, can often be exclusive of bisexual people.
Using gay as shorthand for lesbian, gay, bisexual (LGB)
has a silencing effect on bisexual experience.
— Bradford, 2004

Working therapeutically with LGBTI clients: a practice wisdom resource 21

Thinking about gender and changes Transitioning is a process whereby trans people move to
live in a way that affirms their gender identity rather than
and variation in gender the gender they were assigned at birth. Transitioning takes
Despite prevailing cultural understandings that male on a range of different expressions for individual trans
and female gender identities are fixed and easily people. Most trans people will undergo a ‘social transition’
assigned, psychologists, physicians and social theorists where they express their gender more freely and openly,
have shown that gender identity and expression is best disclose their gender identity to others and inform them
seen as a flexible socially-constructed spectrum rather of their preferred pronouns and name. Some will take
than as a fixed binary classification. In this guide we refer hormones that will assist them in either feminising or
to trans people to indicate a variety of people who seek to masculinising their bodies in accord with their affirmed
affirm a gender identity, or expression, different to their gender identity. Some will also undergo surgery to further
sex assigned at birth. This includes transsexual people assist a physical transformation in line with their gender
who will employ a range of medical interventions to identity. However not all trans people will take hormones
effect this affirmation and a diverse group of other or engage in surgical procedures, some choose to live
transgendered people who express their gender as their affirmed gender without medical intervention.
independence in a range of ways. Facebook now provides Some might refer to themselves as genderqueer or
over 50 different alternatives when asking people to list transqueer because they prefer to take on a range of
their preferred gender. gender expressions and roles which they do not want to be
categorised as traditionally male or female.
Unfortunately the psychological literature often still
uses terms and concepts such as “gender dysphoria” Genderqueer clients need support in their choices to
and “gender identity disorders” as the primary ways of identify in ways which do not fit male female gender
describing the experience of people with non-traditional binaries as they commonly have particular problems
gender identities and their relationship to their assigned negotiating social systems which seem to demand definite
sex and bodies. Gender independent, gender diverse and binary gender choices. They may even sometimes
or gender variant are better ways of describing the feel pressure from other trans or LGBTI people to choose
experiences and identities of trans people without such a particular gender expression. Clinicians need to be
pathologising language. As recently as 2010 the World attuned to the variety of gender fluidity, expressions and
Professional Association of Transgender Health (WPATH) choices and not inadvertently pressure clients to make a
felt it necessary to produce a major statement drawing particular choice.
attention to this:
Trans people will also present with a variety of sexual
The expression of gender characteristics, orientations and these are independent of their gender
including identities, that are not stereotypically identity. It is important that practitioners do not make
associated with one’s assigned sex at birth assumptions about trans people’s sexual choices or likely
is a common and culturally-diverse human attractions. Many trans people will be heterosexual while
phenomenon [that] should not be judged as some others will be gay, lesbian, queer or bisexual.
inherently pathological or negative.
Transitioning is not just a physical or external process, it
In their most recent Standard of Care guidelines is a process whereby trans people become increasingly
WPATH make the important distinction between at home with their affirmed gender identity. Sociologist,
gender non-conformity and gender dysphoria as a Aaron Devor, in 2004, has expressed this in a 14 stage
psychological condition: model. It is useful in delineating some of the ‘stages’ that
Gender nonconformity refers to the extent some trans people might go through but like all such
to which a person’s gender identity, role, or conceptual models it is limited and far from universally
expression differs from the cultural norms applicable. It incorrectly assumes that there is a final stage
prescribed for people of a particular sex. Gender of trans identity formation, which is achieved through
dysphoria refers to discomfort or distress that medical intervention.
is caused by a discrepancy between a person’s
gender identity and that person’s sex assigned Devor introduces two potentially useful ideas when
at birth (and the associated gender role and/or discussing his model: the importance of witnessing and
primary and secondary sex characteristics). Only mirroring. He posits that in any processes of identity
some gender nonconforming people experience formation we may need to be seen by others for who
gender dysphoria at some point in their lives. we are – witnessed – and to see ourselves and our
possibilities in others who are like us: through a process of
If “coming out” is a primary metaphor used in relation to mirroring. This may be acutely important for trans people
lesbian and gay people to talk about developing sexual who often feel unseen for who they are because their
identity processes, “transitioning” is a common expression physical identity in the world does not match their own
in relation to changing gender identity processes. affirmed identity.

22 Working therapeutically with LGBTI clients: a practice wisdom resource

“You can argue that it’s a different world now than the
one when Matthew Shepard was killed, but there is a
subtle difference between tolerance and acceptance.
It’s the distance between moving into the cul-de-sac and
having your next door neighbor trust you to keep an eye
on her preschool daughter for a few minutes while she
runs out to the post office. It’s the chasm between being
invited to a colleague’s wedding with your same-sex
partner and being able to slow-dance without the other
guests whispering.”
— Jodi Picoult, Sing You Home

Working therapeutically with LGBTI clients: a practice wisdom resource 23

Devor’s posited 14 stages suggests that periods of what he Trans scholar and psychologist Gavriel Ansara and others
conceptualised hesitation, delay and identity comparison have adopted this term to describe the systemic forces in
occur even after trans people come in contact with society which mitigate against the recognition of trans and
ideas about transgender or transsexual identities and intersex experience:
experiences. Devor himself noted that this is not always Cisgenderist ideology involves multiple,
the case and that trans people position themselves in intersecting assumptions that construct people’s
various and flexible ways and after their discovery of own designations of their genders as less
transgender identities. valid than those made by external authorities.
Cisgenderist ideology constructs the world as
The ‘stages’ that Denver conceptualised included periods
having only two valid genders and sexes, thus
of: preferences for activities commonly associated with
ignoring societies in which there are more than
the gender that was not assigned at birth; first doubts
two official gender categories. Cisgenderist
about the suitability of the originally assigned gender;
ideology also ignores people who may self-identify
seeking and experimenting with gender identities;
with the adjective intersex, the most widely
learning about the existence of transsexual people and
preferred term internationally for people whose
transexualism; seeking further information; further
bodies are often excluded by medical norms
exploring transexualism and starting to disidentify with
that recognise only “female” and “male” bodies.
originally assigned gender; increasing identification as
Cisgenderist social norms treat biological sex as
transgender and increasing disidentification with original
an authoritative category distinct from gender,
assigned gender; seeking further information and looking
assuming that gender maps fit uniformly onto
for changed circumstances; telling others about a
sex. Based on these assumptions, a cisgenderist
changed gender identification; researching, planning and
perspective also assumes that gender is
undergoing sex and gender transitions; post-transition
universally experienced as a permanent and
life, including managing stigma and being involved in
intrapsychic identity, rather than as a shifting
advocacy in some way.
relational status, and that each “normal” person
Gender is one of our most entrenched social constructs, has a single “real” gender that does not shift
and as feminism and men’s studies have shown it is also across the lifespan (e.g., all boys grow up to be
deeply problematic. Even in the most enlightened families men, and boys who grow up to be women must
and social circles we grow up with a set of embedded have “really” been girls all along).” (Blumer,
gender cues that are rigorously tied to our assigned Ansara & Watson 2013)
birth sex. So no matter how deep seated the inner cues
This perspective challenges us to think carefully about our
experienced by trans people are, there is an inevitably
own assumptions in regard to gender expression, gender
difficult process making sense of them in the context of
roles and gender identity. It moves beyond any essentialist
our social conditioning.
understanding of gender and embraces what sociologists
Further, although the social visibility and acceptance of and psychologists would call a “constructionist” point of
trans people has improved dramatically in recent years, view: that gender and sexuality emerge in individual lives
trans identities are still not publically celebrated and and are part of a broad set of interacting social, cultural,
validated as readily as lesbian, gay and bi identities. This psychological and biological conditions. Because of its
means that opportunities for witnessing and mirroring broad embrace this is a particularly helpful framework
trans identity are often less apparent than those available for client-centered psychological interventions because it
to lesbian, gay and bi people. does not preclude choices or prescribe specific solutions.

Trans people who seek medical interventions also have

to negotiate an often confusing and expensive medical Intersex experience
system which further exacerbates the experience of stigma Intersex is an umbrella term that describes people
and adds a unique layer of stress to transition processes. who have natural physical variations that differ from
All these factors increase the stigma, minority stress and conventional ideas about ‘female’ or ‘male’ bodies. These
lack of public understanding that people experience natural variations may include genital, chromosomal and
before, after and during transition. a range of other physical characteristics. People are born
with many different kinds of bodies. Although intersex
The deeply embedded social resistance to an open people are often confused with trans people, the term
discussion about, and acceptance of, gender variant intersex refers to a diversity of physical characteristics.
experience has recently been described by trans scholars Most intersex people identify simply as women or men
as “cisgenderism”. but they are deeply affected by our medical, cultural and
psychological understandings of gender.

24 Working therapeutically with LGBTI clients: a practice wisdom resource

Early on I am told to get in line after a morning bell, girls
in one line, boys in another. I walk past the girls feeling
this strange, powerful gravity of association. Yet some
part of me knows I have to keep walking. As soon as
I look towards the other line, though, I feel a feeling of
differentiation that confuses me. I don’t belong there,
either. I stop between them. The nun I realise is staring
at me, she’s shouting at me. I don’t know what to do. She
grabs me, she’s yelling at me. I’m not trying to disobey,
I’m just trying to fit in. My silence starts to infuriate her,
and she starts to hit me … [My mother is called] She
jumps out of her car, she hurls herself at this nun. She
rips me away from her, rescues me. She warns the nun
never to touch me again. She takes me home and she’s
trying to understand what happened, but I have no real
language to describe it.
— Trans film director, Lana Wakowski

Working therapeutically with LGBTI clients: a practice wisdom resource 25

Children can be born with a large range of sex In the “Patient-Centered Model” intersex bodies are seen
characteristics. These natural variations may include as a relatively common natural variation and any medical
genital, and a range of other physical characteristics. intervention is regarded as a personal matter of choice
Studies have suggested that this occurs in 1 in 2000 live and only to be undertaken where clear physical health
births but numbers may be as high as 1 in 100 births concerns dictate this as necessary. Gender expression
because many will initially go undiagnosed. is regarded as a broad continuum and is not a simple
calculation that is medically assigned. Intersex children
Intersex bodies which manifest with a range of physical, and adults are regarded as autonomous subjects who can
hormonal and chromosomal variations challenge traditional determine their own gender identities and expressions
understandings of sex, gender, gender assignment and the and make choices about their medical needs. This is
medicalisation of gender. As such, intersex people have something that can happen over time and change with
had a long struggle to claim their rights to self-determined their growing understanding and evolving needs. The
gender expression and human rights. underlying assumption in this model is that intersex
Even well-meaning physicians have often insisted on people have the right to self-determination and that any
invasive and unnecessary surgery to “normalise” young unnecessary interventions by parents or physicians early
intersex bodies and to “naturalise” a given gender in life may irrevocably interfere with those rights.
assignment. However this surgery, apart from being Although contemporary health care practices have
imposed without choice, often leads to long-lasting, painful changed, many intersex clients will have grown up having
after-effects and is usually completely unnecessary from a been traumatised and shamed through their experience
health perspective. in a concealment-centered medicalised system of care.
Intersex people, therefore often grow up with a deep sense But like other LGBTI people they will have developed
of shame about their bodies and a sense that they have no a set of personal resilient strategies in response to the
control over their gender expression. discrimination and impositions that they have faced.
These clients will need deeply affirming person-centered
When working with young intersex clients it is critical that therapeutic work to support them in developing lives of
they are assured that their bodies are a natural human confident self-determination that validates their resilience
variation and that they do not have to make particular and acknowledges their pain.
choices to conform to common understandings of gender
or gender expression. They do have the options of Intersex people will make a range of choices in their
negotiating particular medical interventions at some point sexual partners and sexual orientation is independent and
if they feel this will affirm their chosen gender identity. unrelated to their physical sex characteristics or chosen
gender identity. Many will be heterosexual and some
Many intersex people will identify simply as a man or will be gay, lesbian, queer or bisexual. Whatever their
a woman but intersex people also now identify with a sexual orientation, intersex people may well present with
range of gender expressions and self-designated gender a range of issues around sex because the concealment-
identities which go beyond a male female binary. centered model tends to have contributed to a sense of
embarrassment about their bodies.
Treatment models and understandings of intersex identity
have changed a lot in the last decade and Alice Dreger
has described this as a movement from a “Concealment-
Centered Model” to a “Patient-Centered Model”.

In the “Concealment-Centred Model” being intersex

is treated as a problem or a rare medical abnormality
that needs to be concealed or masked through medical
intervention. This is done so the child might have a
“normal” life. Underlying assumptions governing this
model include beliefs that ambiguous or varied physical
gender expression will lead to suffering and lack of
social integration and ought to be avoided. Parents and
physicians under the sway of this model believe they have
an obligation to intervene to protect their intersex child. In
this model assigning a child’s gender is a mathematical
calculation based on a set of clinical hormonal tests and
unnecessarily pathologises intersex variations as ‘Disorders
of Sex Development’.

26 Working therapeutically with LGBTI clients: a practice wisdom resource

I am a therapist, I am an intersex person, I do not
identify as fully male or female but a wonderful blended
otherness. I know about gender variance, about the
possibilities outside the binary. I know how shame
silences. About the appalling discrimination that DSG
people often face in our culture. Yet my work with diverse
sex and gender remains the most challenging. It is a
place on the edge, a place often without language. Or
at least clear language. We have so few clear clinical
guidelines to fall back on and inform us. This kind
of work requires an exquisite attention to detail, a
willingness to learn and make mistakes, to be real, to ask
lots of questions and check understandings. The need
to constantly remind myself that I am working alongside
a person, a whole person who deserves and is entitled
to my fullest respect and the knowledge to do what it is
that we have agreed is the piece or work or our reason for
working together. My frame of reference, my anchor point
is often that of cross cultural work. I remind myself there
are things I know and much I do not.
— Mani Mitchell

Working therapeutically with LGBTI clients: a practice wisdom resource 27

The critical roles of biphobia and monosexism in
participants’ mental health experiences were apparent
in their responses. Bisexuality is often dismissed
or disallowed at a structural level, to the extent that
participants felt they were constantly required to justify
or explain their sexual identity: ‘‘[Y]ou’re either straight
or you’re gay/lesbian. [People] don’t see that there are
other possibilities’’ … Bisexual identity was structurally
disallowed for transgender and transsexual participants
in particular, as in the example of gatekeepers to gender
identity services: ‘‘The general stereotype is that if you’re
bisexual, you’re probably not transsexual, you’re just
confused. And that if you really are a transsexual and you
really are a woman, then you should only be attracted to
men, otherwise this is all bullshit’’ .
— Ross, et al., 2010

28 Working therapeutically with LGBTI clients: a practice wisdom resource

Working well with LGBTI clients

What LGBTI clients want from internalised negative social attitudes and shame, can
further complicate striking the right balance.
therapists
So respectfully dealing with issues of sexuality, intersex
Clients present with a range of issues in their lives when
status and gender identity in people’s lives involves fine-
coming to a mental health service or therapist.
tuned listening, to gather the nuances of their story and
In talking with a new client about their experiences, issues their range of presenting issues, experiences and beliefs.
of sexual or gender diverse identities may emerge in
different ways. Clients may mention in passing that they
are gay, lesbian, bisexual, transgender, queer or intersex. Whether homosexual, bisexual or heterosexual,
Clients may describe difficulties, because of social and whether intersex, or transgender or cisgender,
pressures, prejudice, or instances of discrimination they working with LGBTI clients demands the
have experienced because of being LGBTI. They may
development of empathy – finding a way into
describe relief and personal satisfaction of having worked
through these issues in the distant or recent past. For understanding LGBTI people’s experience.
some clients, realising and sharing with others their sexual
orientation, intersex status or gender identity may have
been relatively easy. Most LGBTI clients are not going to present saying: “I want
to talk about my sexuality” or “I want to talk about my
For some clients issues about sexuality and/or
gender” or “I want to talk about being intersex”.
gender identity construction and affirmation might be
foregrounded as a set of powerful current emotional Most LGBTI clients will present saying: “I am feeling more
experiences, for others these process may not seem anxious than usual” or “I’m feeling quite depressed lately”
particularly relevant or to be largely in the past. – in other words most LGBTI clients will present with the
same range of everyday, chronic and acute, issues as
Whatever way the client presents, one of the most
other clients.
important things to remember is that sexuality, sex and
gender are only part of a person’s life. LGBTI clients want to be able to talk freely about the
totality of their lives. So if it is relevant they will want to talk
Sometimes therapists feel somewhat in a bind or unsure
about their current feelings around sex, sexuality and/or
what to do.
gender but equally they may not want to talk about that at
On the one hand we want to appear supportive and open all or until later in the process when a deeper level of trust
to engaging with issues to do with sexuality, sex and/or has been established.
gender, but on the other hand honing in on these issues
Because many LGBTI people have learned to live with the
with too fine a focus leaves a range of other connected
stresses of being different over a long period of time, they
issues in their lives underexplored.
may not be aware of the toll that this experience of chronic
Sometimes in our enthusiasm to appear supportive we low-level stress creates. So a client may enter therapy, or
can over-emphasise the story of sexuality while under some other counselling relationship, thinking that they do
emphasising other important areas that need attention. not need to talk about their sexuality, intersex difference
This is the same for gender and sex, in our eagerness or gender identity. But slowly both the client and the
to affirm a person’s gender identity, we may not seek to therapist may discover – together – that the residual effect
explore connections and meanings the client’s exploration of this stress is a big part of a presenting problem such
of gender has with other issues. But equally, any lingering as depression.
discomfort around issues of sex, sexuality and gender may
Like any complex emotional issue, these sorts of
lead therapists to skate too quickly past these issues when
discoveries occur in an open supportive therapeutic
at first glance they do not seem to be related to pressing
relationship where the client leads the discovery.
presenting issues.

Clients’ own awkwardness in talking about aspects of

their sex, sexuality and/or gender, which may arise from

Working therapeutically with LGBTI clients: a practice wisdom resource 29

Therapy is relational unsaid can be very significant in their lives. So using
explicit language and asking explicit questions is important
The most obvious point to make about working in signaling that the therapist is open to exploring areas
therapeutically with LGBTI clients is that psychological that may have seemed unspeakable in other contexts.
work of any kind emerges out of a trusting relationship
between client and therapist.

Although this is true for all clients it is particularly In listening to LGBTI people’s stories the therapist
important to remember when working with LGBTI people, can play an important role in helping the client
nearly all or all of whom will have had some history of
acknowledge and name both strong and difficult
rejection and prejudice in their lives.
emotions and the quality of resilient responses that
For people who grew up feeling different, and or rejected, emerge in their narratives.
and who may have internalised negative societal
judgements about being LGBTI, being able to explore
their lives in a safe non-judgemental space is the first
requirement for productive therapy to occur. An important part of working empathically and
affirmatively with LGBTI people is paying careful attention
Whether the therapist or counsellor is homosexual,
to the language that clients use.
bisexual or heterosexual, and whether intersex, or
cisgender or transgender, working with LGBTI clients LGBTI people adopt a range of terms and labels to
demands the development of empathy – finding a way describe themselves, their lives and their identities.
into understanding the LGBTI experience. Empathy comes
from finding something in ourselves that we can use to Many men who present and talk about sexual attraction
understand the client’s issues - something that we have or relationships with men will be comfortable referring
experienced in our life, that might give us some idea of to themselves as gay. Likewise many same-sex-attracted
what it might be like for our client. women will label themselves as lesbian or gay. But the
therapist should never assume this is the case.
Therapists working with LGBTI people need to
demonstrate their knowledge and understanding, rather Some deliberately choose to avoid labels such as gay or
than a shared sexual or gender identity, but there are lesbian or bisexual. Some, particularly younger people,
a variety of ways to create connection to clients and may want to use the more inclusive term queer or not
sometimes it will be appropriate to use “we” language to use labels at all. Some women and men still prefer the
express solidarity. term homosexual. Some women don’t like lesbian and will
prefer gay or dyke.

Establishing a framework with Trans and intersex people will also label themselves
in a variety of ways: trans, transgender, transsexual,
your client genderqueer, intersex, FTM, MTF, female, male, gender
Part of developing this empathic, relational experience is fluid and many more.
establishing an explicit framework at the beginning of the
There are a range of personal reasons that people adopt
process and sending clear signals throughout.
or reject certain labels to describe their own behavior
Again this involves standard procedures used with any and identity and these choices are important to recognise
client: introductory negotiations about what the client and honour.
wants to get out of the sessions and some disclosure of It is important to recognise that people’s choice of different
the therapist’s approach. Although practitioners are rightly labels does not necessarily reflect anything about their
wary of inappropriately talking about themselves, shifting state of comfort with their sexual identity. For example,
the attention to themselves, or making a therapeutic someone who says “I don’t regard myself as gay just
relationship personal, some recent research (Borden et because I am having this relationship with a man,” may be
al 2012) suggests that both personal and professional expressing an understanding of fluid sexual identity and/or
disclosure can be important elements in therapists a strong bisexual identity.
establishing trusting, effective relationships with LGBTI
clients. This research suggests that LGBTI clients may be Similarly, be particularly attentive to the pronouns used by
more likely to trust those who give both a personal and trans clients in referring to themselves. Most will use the
professional introduction that discloses elements of their pronoun appropriate to their assumed gender but some may
psychological approach and their background. choose gender neutral pronouns such as “they” or “zie”.

Because many LGBTI people have grown up not Trans people refer to social and medical transitioning
disclosing their sexuality, sex or gender, what is said and processes in different ways. Take your lead from the

30 Working therapeutically with LGBTI clients: a practice wisdom resource

You are who you are, and the view I always took
when I went into Parliament is that I would be
completely open about who I am and not hide that
at all. I think you have to demonstrate that kind of
dignity in the face of criticism or offensive disrespect,
not just for yourself but because of how other people
fare. I think it is important to show people who are
marginalised that they are OK, not just by what you
say but also how you behave. When you stand up
and speak, someone who experiences racial abuse
or homophobic bullying hopefully see that ‘it’s not
about me, but it’s about them.’ They are OK and
they do not have to put up with it.
— Labor politician, Penny Wong

Working therapeutically with LGBTI clients: a practice wisdom resource 31

client and refer to transition processes in the way they While many therapists try to remain generally neutral in
do. For example, some will speak of “changing” gender the counselling room, sometimes working with LGBTI
while others will talk of “aligning” or “correcting” their clients (as with other people who have experienced
gender identity. Therapeutically, what’s important is to pay marginalisation and prejudice) requires making your
attention to what that means for the client. empathy and support explicit, because many LGBTI
clients may have grown up without the support of allies
As with all clients, relationship terms also need to be or peers.
attended to. While perhaps most clients will use the term
“partner” some will use other terms such as “lover”, Sometimes it will be important for the clinician to say,
“girlfriend” or “boyfriend”. With the advent of same-sex “What happened to you wasn’t okay. It shouldn’t be
marriage some LGBTI people prefer to use husband or like this.”
wife for their same-sex spouse. You should not assume
that the use of any of these terms implies a corresponding Deciding when, whether and how to adopt such an explicit
acceptance of the traditional gender roles often associated tone with a client will depend on a number of individual
with such relationship terms. circumstances. Just as with other clients, clinicians need
to pay careful attention to potential interpersonal dynamics
If after sustained and careful listening, if there is any and “transference” processes and decide when and if
doubt about getting the language right in relationship such an intervention will be heard and useful for the client.
to someone’s sexual and/or gender identity, intersex
difference and experiences, or relationship status it is best
to simply ask directly.
It is often important for LGBTI clients to hear
explicit statements of support for LGBTI people’s
Naming experience rights and explicit condemnation of social
Not long ago homosexuality was known as “the love that prejudices in the context of therapy.
dare not speak its name” both because of the prejudice
attached to gay and lesbian sex but also because a public
language did not widely exist to talk about gay and lesbian
lives. This is also true for bisexual, trans and intersex Going beyond a standard model of non-judgemental
people whose public visibility and rights have also slowly empathy can be important with some LGBTI clients so
evolved. It is only relatively recently that LGBTI people they can hear – maybe for the first time – this explicit
have been publically telling their stories in far greater message of support. This may then open up other spaces
numbers. Finding their own story and creating a unique in the therapeutic encounter: What is it like for the client to
personal script which goes against many of the dominant hear that message of support? How does the client make
scripts in our society is an important part of what is often sense of this experience? What impact does it have on
called the “coming out process” and is also an important them? How do they change patterns of behaviour knowing
part of what some refer as “coming in” to themselves. that support is available?

Therapy with LGBTI clients involves helping clients develop Even clients who present with very successful lives
stories and scripts for living that validate their experiences and demonstrate significant satisfaction of their LGBTI
and identities, which are in many ways different to the experiences and/or identities may reveal emotional
dominant narratives of sex, sexuality and gender. vulnerabilities as they explore and revisit their experiences
of facing prejudice or ignorance. Because LGBTI people
Part of this story telling and naming of experience involves encounter expressions of prejudice and discrimination
working with the dialectic of distress and resilience that from a very early age and continue to encounter it
is part of LGBTI people’s lives. Different clients will have throughout their lives they can often carry residual
reacted to this dialectic in different ways and differently distress into their later lives even while simultaneously
over time. Some may be very aware of the negative demonstrating pride in their LGBTI lives.
effects of the prejudice and discrimination that they have
experienced, without acknowledging their often resilient The counselling room may be the only opportunity that
navigation of such difficult circumstances. Others will these clients have of retelling their story: naming both
be very focused on their own strength to resist dominant the difficulties they experienced and the ways they have
narratives of oppression and might find it hard to overcome the barriers that culturally negative attitudes set
acknowledge the hurt they have experienced in their lives. against LGBTI people’s self-regard.

In listening to LGBTI people’s stories the therapist plays In working with clients’ experience it is often important
an important role in assisting the client acknowledge and for them to name these experiences and explore their
name both the depth of trauma and the quality of resilient emotional tone. Sometimes in these situations it might be
responses that emerge in their narratives. helpful to name the experience: “That sounds like it was

32 Working therapeutically with LGBTI clients: a practice wisdom resource

I have never had a satisfactory explanation to me
of how my loving relationship with my partner in
any way damaged the institution of marriage or
would if marriage were available to us, damage
that relationship, or diminish it or degrade it in
any fashion whatsoever … A loving relationship of
tenderness, of gentleness and affection, and fidelity
and support is a beautiful thing and anyone who
would disrespect it is not a kind person.
— Justice Michael Kirby

Working therapeutically with LGBTI clients: a practice wisdom resource 33

deeply hurtful for you.” This can provide an explicit sense Naming and mapping social networks
of validation for the client and an acknowledgment that
their pain is recognised by another – a pain that they may Because the experience of both distress and resilience
have hidden from themselves and others in an effort to involves the negotiation of a variety of both problematic
remain strong in the face of social negativity. and supportive social relationships, explicitly exploring a
client’s social networks is important.
Explicitly naming and celebrating achievements with
the client begins the equally important process of For many LGBTI people the first experience of difference,
exploring their repertoire of coping and personal- rejection or isolation is within their family of origin. Equally
development strategies. those who enjoy supportive families this is a tremendous
boon to successfully negotiating an LGBTI identity. So
talking about, and mapping, the story of family is often an
Adopting a sociological as well as a important and useful part of working with LGBTI clients.
psychological analysis Some therapists have found it helpful to use techniques
Part of the reason why the negotiation of early LGBTI like Genograms where clients draw a family tree and
people’s experiences often remain emotionally powerful, map and discuss their relationships as well as emotional
even into later life, is that prejudice and discrimination is relationships and emotional inheritance. Mapping on
still a reality. paper can be helpful in externalising the story of the
client’s relationships with their family and friendship
Even the current very public debate about same-sex networks. Both the strength of particular bonds and
marriage is a fraught public spectacle. It is energising for connections as well as feelings or experiences of isolation
LGBTI people to see broad public support developing for and difference can be explored in these types of activities.
the reality of their loving relationships, but the debate has
also become a site for the repetition of deeply offensive Partly because families of origin have often been sites
rhetoric about LGBTI people, their relationships and of rejection, many LGBTI people have developed strong
their families. groups or families of affiliation through tight, supportive
friendship networks within LGBTI and wider communities.
This constant experience of being treated a site of public It is important for therapists to recognise that these
debate and confrontation is inevitably wearing for many “families of choice” are often more important to and
LGBTI people. It can induce a range of emotions from more supportive of LGBTI people than families of origin.
anger, to sadness, to buoyant fighting spirit. It is therefore important to map the nature of these social
networks and include them in any diagraming of “family”.
Because the psychological lives of LGBTI clients are so
integrally related to the social negotiation of attitudes Because many LGBTI people have felt the need to conceal
around sex, sexuality, gender and gender expression, their intersex status, or sexual or gender identities, at
helping professionals must adopt a sociological as well as different points in their lives, the nature of who they are,
a psychological analysis. how they behave, and how they relate to others may be
markedly different in a range of different social situations
So in working with LGBTI clients it is important to not only
and social circles. Social prejudice and practices of
explore and name the many powerful emotional realities
concealment may mean the development of very different
experienced, it is particularly important to also explore
personas among family, in professional situations and
the social causes and implications of their experience.
among intimate friends. So mapping the quite different
It is important to place experiences of such things as
ways that social relationships are negotiated in these
belittlement, hurt and rejection, in their social context.
different situations can be important.
It is important to explicitly acknowledge that many LGBTI
experiences of hurt, rejection and social isolation arise
from the mechanisms of socially entrenched patriarchy, Culture and ethnicity
heterosexism and fear of difference. We have already made the important point that sexuality
sex or gender is only one of the focal elements of an
From a psychological point of view a clear sociological
LGBTI person’s identity. People are also deeply influenced
analysis assists any lingering sense of victim-blaming
by their race, ethnicity, socio-economic background
that can be a part of internalised homo/bi/transphobia
and culture.
or prejudice. But it is also part of making the counselling
room an explicitly, safe, affirming environment and an In a multicultural country like Australia it is important to
acknowledgement that prejudice and discrimination is recognise that there are a range of overlapping attitudes to
a social problem that everyone must address by taking LGBTI issues. While there has been a great advance in the
a stand. liberalisation of general attitudes to sexuality and gender
expression in the Australian community as a whole, there

34 Working therapeutically with LGBTI clients: a practice wisdom resource

are still specific sub-cultural groups who maintain very the LGBTI communities because of potential racism or
traditional attitudes influenced by religion and ethnic ethnocentrism.
cultural traditions. In addition, many families from cultures
that are often relatively more supportive of diverse sex, Carefully exploring these complex relationships, and
sexuality, gender and living arrangements are themselves weighing up the relative costs and benefits that come with
often not. participation in various aspects of all these cultures and
communities, is a critical part of coming into a full sense of
The proscription against LGBTI people’s lived experiences selfhood as an LGBTI person of colour or an LGBTI person
and identities in some ethnic communities is stronger of ethnic origin.
than in others. In these communities decisions about
relationships, marriage and family are deeply inter-related
and any deviation from traditional cultural practices can be Talking about relationships
seen to have repercussions not just for the individual but Like heterosexual, LGBTI relationships are incredibly
for the extended family network. While many Australians in diverse and LGBTI clients will present with a range of
ethnic communities have supported LGBTI offspring and relationship issues.
siblings, therapists should be aware that cultural traditions
often influence the negotiation of sexual identity and or But until recently LGBTI people’s relationships were largely
gender expression. not the subject of public discussion and there was less
expectation that they would conform to social norms such
as exclusive, long-term monogamy. So although many
LGBTI couples have relationships similar to the ideal of
Pride in an ethnic tradition, and participation in heterosexual marriage, many have been involved in more
community rites and practices, can be critical fluid and open relationships.
sources of strength for many LGBTI people and it
So it is important that therapists understand that even
is important not to merely focus on ethnicity as a though there is a very public campaign occurring for
potential site of conflict. marriage equality before the law, the shape of individual
long-term LGBTI relationships may vary even more than
heterosexual relationships do and may not resemble a
traditional marriage.
Some LGBTI people will react to strong cultural
proscriptions with outright rejection of these traditions. As we have emphasised throughout this booklet it is
This often comes at the steep cost of isolation from important for the counsellor to listen to how clients
their family and community. Other LGBTI people will describe their relationships and the types of terms
not be prepared to risk separation from their family and they use.
community and may decide to adopt a variety of strategies
that mean a traditional westernised “coming out” is not
desirable or possible. For some declaring their LGBTI The validation of clients’ relationships is important
identity publically may even result in threats to their life or
physical safety.
for LGBTI clients because some still feel that they
cannot readily talk about their partner in some
In looking at the complex interactions between these contexts, or walk arm in arm down the street.
different sites of identity it is critical to acknowledge
the multiple positive and negative influences that these
communities have in people’s lives. Pride in an ethnic
tradition, and participation in community rites and Since the emergence of the public LGBTI movements it
practices, can be critical sources of strength for many has been much easier for many LGBTI people to be open
LGBTI people and it is important not to merely focus on about their partnerships and to talk readily about them
ethnicity as a site of conflict. Those who decide to distance with colleagues and a wide range of others.
themselves from these communities, to live a more open
LGBTI life, will often need to work through complex issues The validation of clients’ relationships is important for
of grief and loss. LGBTI clients because some still feel that they cannot
readily talk about their partner in some contexts, or walk
An LGBTI person’s race or ethnicity may also cause arm in arm down the street. So part of the therapeutic
problems with their integration into the LGBTI process may simply involve providing a supportive space
communities. Non-anglo LGBTI people have described to talk openly about their life with a loving partner.
the experience of a double sense of difference: not feeling
at home in their ethnic communities because of their LGBTI clients might well present with a range of common
sexuality or gender expression and not feeling at home in issues around forming and maintaining relationships,

Working therapeutically with LGBTI clients: a practice wisdom resource 35

and these may revolve around intimacy, sex and Clients will talk about sex in a range of ways. Some will
communication. Many of these issues will be similar be more attuned to it having a role in developing intimacy
to problems experienced by other clients but often the in a relationship. Others might describe it as “play” or
way they are experienced will also be influenced or adventure. These types of cues in client language are
exacerbated by the tensions and stresses of the remaining important in helping understand and unpack people’s
negative social attitudes towards LGBTI peoples. attitudes to sex and the role it takes in their lives and
relationships.

Talking about sex As with non-LGBTI clients, many LGBTI clients will have
mundane sex lives but some may have explored a range
We shouldn’t assume that sex will be more or less
of broader sexual practices that mainstream culture might
important for LGBTI clients when compared to other
judge as “kinky”. There is a fairly large “leather” sub-
clients. But, because their sex life is intimately connected
culture among gay men, for example, and many of these
to their minority identity, feelings such as embarrassment
men engage in consensual B&D, role-play and other sex
or guilt may have become embedded in their attitudes
play. It is important to be open to conversations about this
to sex. For those from religious backgrounds, some may
type of sex if it is relevant to the client’s issues or well-
experience feelings of shame or ‘sinfulness’.
being. It is important to be non-judgemental and open to
Many practitioners don’t necessarily ask, as openly and people talking about sex.
as often as they perhaps could, about clients’ sex life. Sex
is an important area of personal development for many
clients and simply checking – “Are you happy with the sex
Outside the therapy room – advocacy
life that you’ve got?” can be an important part of talking and referral
about a client’s life experience. As we have already noted, because LGBTI people will
usually present to therapy having experienced some level
of discrimination in their lives, the establishment of a warm
Some therapists maintain that sex rarely comes up supportive relationship between therapist and client is
in therapy but often this is not necessarily because particularly important.
clients do not have sexual issues. It may be For the counsellor, part of the dual process of assisting
because they need supportive questioning to feel the client through distress and naming resilience that we
comfortable talking about their sex life. have referred to throughout this resource often requires
showing practical as well as emotional and support.

If the LGBTI client has experienced victimisation and

Some therapists working with LGBTI clients feel isolation in their social interactions with a heterosexist
comfortable discussing most aspects of LGBTI people’s culture it can be important that they recognise the
lives but are less comfortable talking about sex. Some therapist not just as a supportive listener but also an
therapists adopt an “I’m fine but I don’t want to know embracing advocate.
the details” approach about discussions to do with sex in
Depending on the circumstances of the individual and of
general. But often you have to be able to talk about details
the therapeutic relationship, this may involve providing
if that’s part of what arises as an issue. So it is important
information and support on some practical matters as an
to think through some of these areas and perhaps
advocate. Certainly an awareness of other practitioners,
discuss them with a supervisor if you find yourself not well
resources and agencies who have expertise or resoruces
equipped to talk about sex.
in these areas and who can provide such practical support
Some therapists maintain that sex rarely comes up in is essential for a therapist or counsellor who is serious
therapy but often this is not necessarily because clients about equipping themselves to work with LGBTI clients.
do not have sexual issues. It may be because there is
mutual avoidance. Clients may need supportive but gentle
questioning to feel comfortable talking about their sex life.
Public negotiation and discussion of sex and sexualities
of all kinds is still often complex and somewhat difficult.
So often clients will not raise issues relating to their sex
lives because of internalised shame or guilt – the very
issues that might need to be brought into the open in the
counselling room.

36 Working therapeutically with LGBTI clients: a practice wisdom resource

Gay identities continued to function as positive
anchorage points that brought affirmation to [these
young people’s] sense of self and…illustrates
young people’s capacity to reframe lesbian and
gay identities as points of affirmation and pride
and to reject homophobic discourses that often
accompany their first encounters with these
identity frames. Lesbian and gay identities were
not always discussed as cohesive or comfortable
subject positions as some participants conveyed
a reflexive awareness of the constraints of these
identity frames. This … finding emphasises young
people’s capacity to critique the apparent usefulness
of sexual categories. It shows young people
participating in a wider questioning about the utility
of existing sexual ‘taxonomies’ for framing their
individual lives, sexual attractions and relationships.
— Willis, 2012

Working therapeutically with LGBTI clients: a practice wisdom resource 37

Working with LGBTQI subgroups and special
issues of concern

LGBTI young people people to ‘come out’. A young person who is confused or
struggling with their sexuality, gender or the possibility or
The social conditions for acceptance of LGBTI people consequences of being intersex because of social stigma
have improved dramatically in western cultures in recent will not self-identify as LGBTI without the counsellor
years. So much so that some researchers are now providing the scaffolding to make this a safe disclosure.
proposing that we are in a “post-gay” world where the
default position for young LGBTI people is acceptance. A young person who is concerned about possible negative
Research in Australia (Hillier, 2010) and overseas (Savin- reactions, or who is struggling with socially fraught
Williams, 2009) indicates that same-sex attracted young attitudes to LGBTI sexualities, sexes and gender identities
people are ‘coming out’ at an increasingly younger age. It may or may not feel comfortable in self-disclosing early
is now common for young LGBTI people to self identify in on in the therapeutic relationship. They will need explicit
their early or mid teenage years. Even though this is the signs that this is a safe place for such disclosures. These
case for some young people, many still struggle with our include physical signs such as posters in your office or
dominant cultures’ remaining negative stances towards waiting room which indicate a commitment to LGBTI
non-heterosexual sexuality and non-cisgender identity, and equality and inclusion. It includes explicit invitations to
many are still experiencing discrimination and bullying begin the discussion in the way that the therapist frames
in their schools, communities and families. Intersex their questions.
differences are also still commonly seen as ‘not normal’
At least initially keep your questions gender neutral
and widespread ignorance remains.
and don’t assume that someone is likely to be, or likely
Some studies have suggested that up to 80% of LGBT not to be in a relationship. Ask about this directly but
young people are aware of their sexuality or gender identity carefully: “Who are the important people in your life at the
by the age of 15 years, and the highest risk of suicide is moment?” or “Are you in a relationship at the moment?”.
when a young person has ‘come out’ to themselves but It is also often supportive to explicitly speak in a way
not to anyone else. This has implications for psychological that indicates that you do not assume that a partner
support of all young people, regardless of their presenting would be of a particular gender such as: “Have you got
issue: each young person who sits down in front of you a girlfriend or boyfriend?” This immediately breaks the
might be struggling with issues related to their sexuality dominant paradigm of assumed heterosexuality and gives
or gender identity, and by not asking about this you could permission to talk about diverse sexual expression.
be missing a central issue that is increasing their risk of
suicide. Asking that question to, say a 14-year-old girl who is
questioning her sexuality: “Let’s talk about relationships,
The tendency for LGBTI people to self-identify and to do you have a girlfriend or a boyfriend?” gives permission
‘come out’ to peers at an earlier age has a range of both for a safe disclosure and might open up a range of
positive and some potentially negative effects. It may be conversations: “Well actually I don’t, but if I had a choice
a liberating experience for the individual or it may place I’d prefer to have a girlfriend”. Or it could be a really
them in a more vulnerable position, if they are subjected homophobic heterosexual young man, who says “What
to peer-bullying or abuse, or negative responses from their on earth are you talking about, what the fuck? I’m not
families. Defending themselves emotionally and physically a fag.” So that also presents a wonderful opportunity to
can then become both a very bruising experience as well have a conversation with that young man to find out where
as the first experiences of claiming a resilient identity. he learnt these attitudes and to work with him on his
homophobia. Asking questions like this are relevant for all
We began this resource by reminding counsellors that young people not just for LGBTI young people.
any client who presents for any issue may be an LGBTI
client. It is particularly important to state this simple fact Quite apart from issues to do with sexuality, sex and
again in regard to working with young people. Many gender, many young people will be uncomfortable with
counsellors effectively assume that their young clients are the whole process of seeing a counsellor or entering
likely to be heterosexual by putting the onus on young a mental health service for the first time. But a skilled

38 Working therapeutically with LGBTI clients: a practice wisdom resource

counsellor can use this to open up broad areas for Some therapists have found it useful, if that is what client
discussion and to carefully work to build the young thinks might be helpful, for the client to invite a family
person’s respect and trust. member to a joint therapy session in order to inform them
about their LGBTI identity within the supported space of
All practitioners will have their own approaches to
the therapy room. This may be a good idea if the client is
beginning therapy but often it is a good idea when initially
experiencing a lot of anxiety about the process and/or is
working with young people to ask very broad and varied
expecting a negative reaction; on the other hand, those
questions. You could begin:
kinds of concerns might be an indication that talking with
“Today’s about me getting to know you a bit, and hearing family members would not be a good idea, for that client,
what it is you would like to talk about and what might be at that time.
helpful. I’ll ask you a bunch of questions, some will apply
‘Coming out’ for lesbian and gay people is becoming easier
to you and some won’t but I want you to know that I’m
and more common but ‘coming out’ as a trans person
happy to talk about whatever you’d like to bring up today
is still very difficult and tends to cause a range of issues
and if you don’t feel comfortable talking about some things
within families. The disclosure of trans identity is in some
that I ask about that’s okay too.“
ways both more problematic and a deeper imperative
This type of interaction sets the scene at the start and than for other LGBTI people. Because of lower levels of
enables the therapist to ask a range of questions which trans visibility and trans understanding in our culture,
may seem odd or intrusive in another context. If the client declaration of trans identity may be met with a deeper
has not given a clear answer about their relationships then shock or even incomprehension. But if a trans person is
you can still ask directly about their sexuality: “Are you to more fully engage with and communicate their identity,
usually attracted to guys, girls or both? Or have you not this is likely to involve a number of visible choices that
really experienced much attraction so far?” and they can cannot be easily concealed or segmented in their lives. So
place themselves on the continuum somewhere. it is especially vital that a young trans person who is about
to talk to their family about their gender identity for the first
Talking about gender identity can be a little more tricky time is fully prepared for and supported in this process.
because someone who is not familiar with ideas about
gender variation may well not understand the question.
But you can open up discussions with a range of LGBTI older adults
questions like: How are you feeling in your body? How do Just as LGBTI young people will have a range of
you feel about how others react to your body? Do you feel particular issues that relate to both their stage of personal
comfortable being a boy/girl? How do you feel about where development and the social era in which they grew up,
you’d place yourself in terms of your gender? How are older LGBTI adults may also present with a range of
you feeling about your gender? Some people find gender particular issues.
expectations difficult to handle, is this the case for you?
These types of questions signal that you are prepared The older the client is, the more likely it is that they will
to talk about gender in an open way and can provide have suffered significantly under the kind of discrimination
opportunities to explore further issues with trans people or or persecution that LGBTI people experience, which was
with other young people who find the constraints of gender especially prevalent in the 40s, 50s, 60s and into the 70s.
in our culture difficult to navigate. Therefore be aware in working with older LGBTI adults,
that they are likely to carry some scars of that experience.
Sometimes LGBTI young people may need strategic advice However as we have repeatedly suggested throughout
as well as emotional support. If they are planning to but this resource the experience of LGBTI discrimination
worried about disclosing their identity to friends and family, and oppression is almost always matched with a story
the counselling room may provide a “rehearsal” space of struggle or of personal resilience which allows the
for this. It is important to talk through this as a process, to individual to navigate that social terrain.
highlight that even if some people react negatively these
This involves listening carefully to clients narrate their own
attitudes often change over time and to try to discern
experiences of daily life: both their current lives and the
the right moment for the process to occur. Young people
experiences of their past. This again involves a delicate
sometimes feel pressured to ‘come out’ because they
balancing act of supportively unpacking examples of
have seen television shows where characters ‘come out’
difficulty and distress while affirming and celebrating the
or read articles in the media about celebrities ‘coming
stories of resistance, courage and resilience that shape
out’ and they experience it as a kind of social obligation. A
LGBTI people’s lives.
counsellor can play an important role here in assuring the
young person that there is no particular rush to confirm Not all older LGBTI people will have experienced
their sexual or gender identity and that it is up to them to significant personal discrimination but all will be aware of
engage in this, or not, at times of their own choosing. the social climate which was far from accepting of LGBTI

Working therapeutically with LGBTI clients: a practice wisdom resource 39

people’s lives. It is important not to make unfounded Counsellors should also be aware of the needs of older
assumptions about what their lives were like and to listen trans people. Transitioning can occur at any stage of
carefully to their stories. the lifecycle and it is not uncommon for trans people
to decide to transition later in life. Particular issues that
As older LGBTI people grew up in social conditions that older trans people may face in transitioning later include
did not facilitate openness about being LGBTI, many will the negotiation of their “new” identity in well-established
have adopted guarded behaviour that concealed elements professional and personal social networks. Issues of
of their identity and experiences from colleagues, peers continuity and change become particularly important in
and family members. Because they may have led quite this context.
concealed lives and become adept at holding things close,
and segmenting their lives, exploration in therapy may
be difficult. It may also mean that early experiences of HIV and AIDS
discrimination or bullying may now present very powerfully HIV/AIDS has been a critical dimension of the experience
because the therapeutic relationship facilitates disclosure of many LGBTI people for the last thirty years. It has
and discussion of the effects of these experiences and this of course been a particularly important part of gay and
may be one of the first times that these experiences have bisexual men’s experience. In Australia two thirds of new
been spoken about openly. diagnosis still occur in men who have sex with men and
it is estimated that about 10 % of Australian gay men are
In spite of social conditions many LGBTI older adults
HIV positive. In larger urban communities, such as Sydney
will have led defiantly open lives and will have at some
and Melbourne, the percentage of gay men infected with
point decided to refuse the social strictures around their
the virus would be much higher.
identities and experiences. It is important in hearing about
these clients’ lives to celebrate the strength that they found But the impact of HIV/AIDS on the lives of LGBTI people
in carving out their LGBTI identities. goes well beyond these statistics. The emergence of AIDS
in 1983 occurred at a time when the early lesbian and
gay rights movement was starting to achieve visibility
Older LGBTI adults may have led concealed lives and impact and at a time when community activist and
and become adept at holding things close so early commercial sub-cultures were well developed. Ironically,
experiences of discrimination or bullying may now the emergence of HIV/AIDS had both positive and negative
impacts on the LGBTI community. While a generation
present very powerfully because the therapeutic
of gay activists were lost to illness and death, before the
relationship gives permission for disclosure and intervention of life-saving drugs in the late nineties, the
discussion. emergence of strong activist networks and government
funded health programs meant community infrastructure
was ultimately strengthened.
LGBTI older adults will be experiencing a range of issues
similar to their non-LGBTI counterparts. This is a time of
transition and the full range of emotions associated with Research has shown that people with HIV are
major life changes and ageism in society will confront more likely to suffer from depression than the
them just as they will any other older person. However
general population. This is not surprising given
they will still also be facing discrimination and related
issues to being LGBTI. These, combined with any residual both the shock of diagnosis with a life threatening
issues relating to their being LGBTI, and the discrimination illness and the stigma still associated with HIV.
they have experienced in the past, will make navigating
these new transitions more difficult. Working with LGBTI
older adults is a layered process which involves working However this increased visibility also came at a cost, and
coherently with narratives of the past, narratives of the the early media coverage of AIDS was not sympathetic.
present and narratives of the future. This created an atmosphere of fear and stigma which still
lingers and this may well be a powerful memory for those
Some older LGBTI adults may have successfully adapted people with HIV who lived through those times.
a need for or a strategy of concealment and led lives
which segmented their professional life from their social Medically, HIV is now regarded as chronic manageable
life. They may well be happy with maintaining a degree of disease and most people with HIV can be effectively
privacy about their LGBTI identity and experiences, and treated with daily doses of anti-retroviral drugs. This allows
this may be an important part of their resilience strategy. most people with HIV to continue to live active healthy
These kinds of choices need to be respected as a valid lives. However some people, especially those with long
part of this person’s life journey and no less a valid way of term HIV infection, continue to experience a variety of
embracing LGBTI personhood. persistent physical and mental health issues.

40 Working therapeutically with LGBTI clients: a practice wisdom resource

Research has shown that people with HIV are more likely important to raise issues of safer sex when talking with
to suffer from depression than the general population. This younger gay men.
is not surprising given both the shock of diagnosis with a
life threatening illness and the stigma still associated with HIV/AIDS may be an issue for any LGBTI client, particularly
HIV. There is also some evidence that the virus itself has for gay men. Therapists should be conscious of the different
subtle effects on brain chemistry even in individuals who roles that HIV will have played in the lives of men of different
are successfully treated with anti-retroviral drugs. A small ages and the different issues that it may raise whether they
minority of clients with long-term infection may still present are themselves HIV positive or HIV negative.
with AIDS related dementia. Many gay men have been living well with HIV for 20+
For older gay men, whether they are HIV positive or not, years so uncovering their survival strategies and the stories
HIV/AIDS is likely to still be an emotionally significant of community support is yet another example of the dual
experience and many will have lost many friends to the strategy we have been recommending of working through
disease. As they grow older this loss of key members distress while celebrating resilience.
of their friendship networks may become increasingly Lesbian women and other members of the straight
significant. and queer communities played critical support roles
Most people with HIV continue to have an active sex life in the formation of the early organisation of HIV/AIDS
and as treatments improve and people live well longer, organisations. So many LGBTI people, not just gay men with
maintaining a healthy sex life becomes increasingly HIV, may present with stories of this struggle. It is important
important. Safe sex strategies such as condom use have to note that although men who have sex with men are still
meant that people with HIV have usually become used the majority of those with HIV in Australia, including other
to negotiating their sexual relationships with both HIV LGBTI people have also contracted the virus.
sero-positive and HIV sero-negative sex partners. But the
presence of the threat of infection can still create mental What do we know about LGBTQI
and physical issues for both partners, and can interfere
with a healthy sex life. It is therefore particularly important people and suicide?
that therapists ensure they address sexual and health A range of studies have shown that LGBTI people have
issues in a sex-positive framework when dealing with an increased risk of suicide compared to those in the
clients with HIV. general population. How do we understand this risk, and
what do counsellors need to know about assessing this
Mental health professionals should also be aware that
risk in LGBTI clients and working with LGBTI clients with
gay men may also negotiate a range of sexual strategies
suicidal ideation?
based on the HIV status of their partners. Sero-concordant
partners (either two HIV negative or two HIV positive Suicide must be understood not just as ending a life but
people) will often negotiate unprotected sex based on an also as ending pain. So the key to understanding LGBTI
understanding of their status. This demands a high level of people’s suicidal ideation is understanding the types of
trust, particularly where both partners are HIV negative. pain or traumatic experiences in their lives that have
become so seemingly unbearable that they feel they no
With advances in drug therapies, some activists and HIV
longer want to live.
organisations have advocated “treatment as prevention”.
These programs encourage early drug treatment for
all people with HIV on the basis that the more people
who have undetectable viral loads (i.e. suppressed Suicide must be understood not just as
virus in their system due to drug treatment) the fewer ending life but as ending pain. So the key
new infections there will be. This prevention strategy is
still the subject of much research and debate, so it is
to understanding LGBTI people’s suicidal
important that therapists remain up-to-date with the latest ideation is understanding the types of pain or
information because it is part of the range of calculated traumatic experiences in their lives that have
risk approaches being taken by individuals and talked become so seemingly unbearable that they
about by community groups. Talking openly and non-
judgmentally about these and other risk-taking and risk-
feel they no longer want to live.
reduction strategies may be an important area of working
with HIV positive clients.

Evidence from some recent surveys suggests that HIV/ We have already described the mixture of distress and
AIDS is not a significant concern of younger gay men. In trauma and resilience that shape many LGBTI people’s
fact recent statistics indicate a rise of unprotected sex lives and in assessing their risk for suicide it is the complex
and new diagnosis in men under 25. Therefore it may be relationship between these factors that may be crucial.

Working therapeutically with LGBTI clients: a practice wisdom resource 41

Exposure to discrimination and prejudice, and the likely Gay advocate and educator Eric Rofes in 1993 wrote an
internalisation of negative societal attitudes about being influential book about LGBTI people and suicide called ‘I
LGBTI, can lead to many LGBTI people commonly Thought People Like that Killed Themselves’ which takes
experiencing both acute and chronic stressors which it’s title from a quote about homosexuality by King George
put them at risk of suicide. These potentially traumatic V. This indicates the strong cultural association between
experiences must be looked at in the context of LGBTI people and suicide that have been emphasised in
concomitant development of tools for resilience. As many literature and film. For a long time, both suicide and same-
LGBTI people grow up with an ongoing sense of difference sex sexuality were regarded as deviant, both were seen
and an experience of discrimination they are forced to result from flawed character, both were a criminal act,
to develop a series of complex strategic coping skills. both were supposedly abhorrent to God. Although these
Their internal resilience is often quite strong – they cope attitudes and associations have changed dramatically
because they have to; they become hardy in the face of in recent decadess there are still lingering cultural
opposition. However this sometimes comes at the cost of associations between LGBTI people’s lives and suicide.
developing strong external resilience – being able to trust These attitudes have become internalised by some LGBTI
and rely on others for support. So at times of acute stress, people, particularly those who have grown up when these
when internal resilience is exhausted they may have a attitudes were more prevalent.
sense or experience of not having enough external support
to rely on. This is often particularly so for people who have So some LGBTI clients with strong suicidal ideation may
experienced rejection from family of origin and significant have internalised a sense that: “This is our lot”. This can
others. be compounded by experience of suicide within their
circle of friends and acquaintances. As suicide is higher in
Exploring LGBTI people’s repertoire of intrinsic and LGBTI populations, LGBTI people will know more friends
extrinsic resilience is an important part of general mental who have suicided and this is also a known risk factor for
health work with this group but it may have particular suicide.
relevance in understanding suicide risk and in building
protective factors with clients who are at risk. This again points to the importance of developing a clear
picture of LGBTI clients’ social networks and resources as
Because of the recent media coverage of young LGBTI part of exploring their narratives of identity.
people and suicide, many people imagine that this
is the common story of LGBTI people and suicide: a While it is important to be attuned to the variety of
young person who is struggling to ‘come out’ and cannot ways that suicidality can be a part of LGBTI people’s
envisage a better future because they are bullied, rejected, life narratives it is also important to be aware that there
and isolated. However LGBTI-questioning and LGBTI are many LGBTI people who are no more at risk for
people of all ages are at increased risk for suicide. Often suicide than any other client. Due to the negative cultural
people who have successfully negotiated sexual identity associations of LGBTI people and suicide it is important
and/or gender expression earlier in life confront stressors that this topic is handled sensitively within the context of
later in life which bring on suicidal ideation or actions. exploring a range of mental health issues and behaviours.

Often these LGBTI people describe being exhausted by a

perceived sense of remaining strong and proud in the face Working with LGBTI families
of ongoing experiences of prejudice and discrimination. Families are commonly central to the well-being of LGBTI
Sometimes these people have entertained suicidal people just as they are for their heterosexual counterparts.
thoughts or made suicide attempts earlier in life and an As with heterosexual clients, families may be a source of
acute stressor such as the end of a relationship or the loss both distress and support.
of a job may begin a process of entertaining those same
thoughts again. Many LGBTI people have very good support from, and
relationships with, their families of origin and extended
In working with LGBTI people it can be important to family members. However because LGBTI people have
explore this potential narrative. Have they ever felt so low often had to negotiate difficult experiences with their
that they have entertained suicidal thoughts? What was family of origin, it is not uncommon for LGBTI people
it at that point in their lives that gave them strength to to have ongoing problematic relationships with these
continue? Are those protective factors still active in their family members. They may have experienced, and may
lives? If not, why not, and how could they be re-actvated? still experience, disrespect, and at times, rejection from
family members. This stress and difficulty associated with
While internal psychological factors are important, a
families of origin makes it more common for LGBTI people
range of social and contextual factors are also critical to
to talk about their close friends, partners and ex-partners
understanding and working with LGBTI people who are at
as their “family of choice” which fulfills a special function
risk of suicide.
in their lives.

42 Working therapeutically with LGBTI clients: a practice wisdom resource

In spite of an increased risk of suicide attempts among LGB
compared to heterosexual respondents, those reporting
suicidal behavior are a clear minority of the LGB individuals
who have been studied, estimated at 12–19% of gay/
bisexual males, and a smaller percentage of lesbian/
bisexual women. Relatively little research has been done
on factors that protect the large majority of LGB people
from suicidal behavior. Analysis of data from a statewide
survey of 6th, 9th, and 12th grade students in Minnesota
found three factors to be significantly protective of reported
suicide attempts in youth with same-sex sexual experience:
family connectedness, perceived caring from other adults,
and school safety. A nonrandom study of self-identified
young and middle-aged LGB adults in New York City found
connectedness to a gay/lesbian community and positive
sexual identity were associated with greater social and
psychological well-being.
— Haas, et al., 2010

Working therapeutically with LGBTI clients: a practice wisdom resource 43

LGBTI families take many different shapes and it is So if two women, or two men, have had a child together,
essential to listen to the client’s story as everyone’s family, and have intended to have a child together, no matter
including heterosexually-based families, are very different. what the biological circumstances of the conception, both
Contemporary families are very diverse. With the divorce of those people need to be recognised and valued as
rate at around 40%, many people have multiple parents parents of that child.
for example, and most adults are likely to have had more
than one long-term partner. Although research indicates that many same-sex parents
and their families have close connections and experience
Increasingly LGBTI people are having and raising children high levels of support and respect from their families of
in a range of different circumstances and counsellors need origin, often the intersection of these new family units
to be attuned to a number of issues that can arise working and the couples’ traditional families of origin may also
with LGBTI individuals or couples who are parents. There be a cause of tension. Families are usually the site of
are many thousands of same-sex couples in Australia celebration when a couple have a child but in the case of
who have had children. Although most of those couples LGBTI couples, having a child might exacerbate tension
are women, an increasing number of gay men are also with their parents or siblings. LGBTI couples will, for
parenting and having children. Like different-sex couples, example sometimes put off telling their family they are
same-sex couples have children in their families as a pregnant for fear of a negative response, which doesn’t
result of birth, adoption, fostering, and through parenting happen as often with heterosexual couples. Clients may
as part of step and blended families. want to talk about experiences like this, so it’s important to
hear this but also to encourage them to talk about people
Across Australia, children born into the relationship who are able to recognise them as a family and to reflect
of two women will have both women registered on that back.
their birth certificates as their full legal parents, which
means that such children have legally recognised family As we have stressed before, language is key to negotiating
relationships with their birth and their non-birth mothers’ helpful therapeutic relationships with LGBTI people and it
families. Increasingly, legislative changes mean that is particularly important when talking about families and
children who are born into the relationship of two men via children of LGBTI couples.
surrogacy also have both men recognised as being legally
responsible as parents. For example, assume that two women, or two men,
bringing up a child are simply the child’s mothers or
Research indicates that same-sex parented families often simply the child’s fathers. It is usually not necessary for
experience high levels of social support and recognition, the counsellor to ask who the “biological parent” is. If
including from school, service providers and the wider this is a pertinent issue it will emerge organically from the
community. There have also been very significant discussion.
changes in Australia, in the last decade, which have
opened up equal access to fertility services and which Lesbian couples will often use a known sperm donor
have recognised same-sex couples as couples and the who may or may not play an active part in the child’s
families of same-sex couples as families. However, there upbringing. Avoid referring to this person as a ‘father’ or
are still widely disseminated and dominant ideas that a a ‘biological father’ unless that is the term of choice that
‘real’ family or a ‘proper’ family is biologically-based and this couple has adopted. The majority of men who provide
heterosexual: that a non-biological mother or father is sperm to single or lesbian women to conceive a child do
somehow not a ‘real’ parent. These ideas have not caught not relate to, and are not related to by, these children and
up with the contemporary shape of Australian families, families as a parent. A minority of sperm providers do
and nor have they caught up with the legal definitions of take on a co-parenting role, and many others are involved
family in Australia. For example, although non-biological/ in the child’s and family’s life as a significant and close
non-birth mothers in a lesbian relationship are now legal friend, so terms used will vary.
parents, many non-birth lesbian mothers still find that they In using these terms allow yourself to be led by the
are not always readily recognised by peers and service client and listen carefully for their signals regarding the
providers as a ‘real mother’. This can happen in subtle relationships they have mapped out.
ways: someone congratulating just the pregnant person
or someone asking the non-biological mother what kind of Many bisexual, trans and intersex people are parents too
role she will play in the child’s upbringing. and their families also come is a range of shapes and
structures.
Once again it is vitally important that the therapy room
becomes a place of recognition and does not repeat the The social and legal development of LGBTI families is a
experience of non-recognition that many couples may fast moving area and even some LGBTI people are not
have experienced in regard to their families and their roles all fully aware of their rights and obligations in this new
as parents. environment. This can become even more difficult when

44 Working therapeutically with LGBTI clients: a practice wisdom resource

The picture painted by recent research is mostly a
continuation of a story from earlier research – that
families with two lesbian parents (biological, social, or
step) exhibited a number of strengths. Research has
repeatedly shown that lesbian parent couples have high
levels of shared employment, decision making, parenting,
and family work, in part in the service of an egalitarian
ideology. Lesbian couples also averaged higher satisfaction
with their relationships with each other and with each
others’ parenting. Lesbian mothers had a strong desire for
children and devoted a great deal of time and thought to
choosing parenthood, and they tended to equal or surpass
heterosexual married couples on time spent with children,
parenting skill, and warmth and affection.
— Biblarz and Savci, 2010

Working therapeutically with LGBTI clients: a practice wisdom resource 45

couples with children separate. In some instances there their own self-expression and their family or community
is then a tendency to revert to and even try to promote but it’s a choice between a new sense of self and their
very conservative notions of biological motherhood in relationship with their “maker”. It is also walking away
negotiating shared custody, even when parenting has from something that has at times been deeply nourishing.
been fully shared up until that point. In these instances This produces a very complex set of deep psychological,
it is important for counsellors to be aware of the legal emotional and social ruptures which need to be
frameworks which may assist their clients as well as the negotiated.
psychological frameworks for affirming their rights and
meeting their responsibilities.
The LGBTI ‘coming out’ process could be seen
LGBTQI clients, religion and by some as a unique spiritual process. This can
spirituality be a useful framing of experience for some LGBTI
people, particularly those who have come from a
LGBTI clients are likely to have complex relationships
to religion and spirituality. Religious institutions have
religious background.
been particularly homophobic and have often led the
case against changes in LGBTI rights legislation. This is
currently true in the case of the fight for marriage equality. In deeply religious families and faith communities,
religious beliefs and values go beyond mere patterns of
LGBTI people who come from families with strong religious
behaviour. They are part of a deep personal identity and
traditions will often have experienced religious prohibitions
pattern of conditioning, so transitions away from this
against diverse sexualities and gender expression as a key
identity will involve a degree of deep distress and struggle,
cause of family conflict.
even if it is done freely, and with determination, to explore
However it is important that counsellors don’t make a new LGBTI identity.
assumptions about an LGBTI client’s relationship to
Even though many religious authorities may present this
religion or spirituality. Some will have a strong sense
transition as an ‘either or’ ‘choice’, between religious
of spirituality, others will find meaning through other
affiliation and sexual expression, there are more nuanced
frameworks, some will be involved in organised religions,
ways of integrating spirituality and sexuality and most
others will be very antagonistic to official religious
religious communities now have groups or communities
structures.
that are LGBTI affirming. Counsellors should make
If they have had a strong religious background, in a themselves aware of options in different faith traditions
more fundamentalist religious tradition however, this that they can use as referral points.
has probably made their self-acceptance processes
It is also helpful to distinguish between religion and
more difficult. Don’t underestimate how long lasting and
personal spirituality. In leading a self-affirming LGBTI life
intrusive the residual effects of these strong religious
some religious people dispense with all connection to
strictures may be in people’s lives.
the spiritual and then they find that there is something
Some clients may present after being part of a Christian missing and they experience a real grief in this absence.
fundamentalist “ex-gay movement” which claims to Simultaneously, there may also be resistance to exploring
“convert” same-sex attracted people to heterosexual alternative forms of spirituality because both religion
lifestyles. There is no evidence that this is possible and and spirituality have become associated with a bruising
most often these clients end up being further traumatised experience of rejection.
and often will present with experiences similar to victims
Spirituality is essentially the search for meaning, and
of other kinds of abuse. Clients often struggle with the guilt
does not necessarily have to be associated with traditional
and the shame instilled by this kind of treatment over a
religious paths. Some LGBTI people, who have had no
number of years.
association with traditional religion, may present to therapy
If an LGBTI client has been deeply religious, their because they come to feel that a critical “something”
sense of conflict may not be merely about the religious is missing in their life and they need to forge new ways
prohibitions against LGBTI expression. One of their key of connecting with, and creating meaning in their life. It
formative experiences may well have included the sense can be important for this search for meaning, purpose
of a relationship with a loving God that was then clouded and connection to be recognised as a personal spiritual
by these harsh institutional prohibitions. So walking process. But as we have recommended before, language
away from a faith tradition because of their rigid views on is critical and therapists need always to be guided by the
sexuality or gender identity is not just a choice between narrative that the client is creating. So the choice of terms

46 Working therapeutically with LGBTI clients: a practice wisdom resource

Gay spirituality may be one of those cracks placed in our
lives to enlighten [our] thinking. The cracks in our lives often
result from interacting with others who are different — those
who disrupt our status quo mentality bring new light that
illuminates our perceptions in the most unusual ways. . . .
Gay spirituality has become very personal for me because
of the people who have traversed my life, cracked it open,
and left me forever changed. As a result of this new light, I
want the world to treat the people I love with dignity, respect
and love. I want them to have an equal chance of life. I
want them to be blessed by the abundance of knowing that
they are beloved children of God and to realise that innate
sexuality does not preclude heartfelt spirituality.
— Kenneth Burr, 2009

Working therapeutically with LGBTI clients: a practice wisdom resource 47

like “spirituality” needs to arise organically in the course of
the therapeutic exchange if it is to be useful.

Some people regard the LGBTI ‘coming out’ process as a

unique spiritual process. At it’s deepest it might be viewed
by some as a type of death/rebirth process: leaving behind
the socially negative constructs that inhibit self-affirming
LGBTI identities. It might also be viewed as a spiritual
process where a person’s spirit, or inner psychological
resources, drives this formation of a new strong sense of
self and a new search for sexual connection and/or gender
identity. So, depending on the client, this can be a useful
framing of experience for some LGBTI people, particularly
those who have come from a religious background. But
like all such metaphors this is only useful if it arises
organically from the clients’ experience and with the
language and concepts they use.

48 Working therapeutically with LGBTI clients: a practice wisdom resource

References and resources
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Working therapeutically with LGBTI clients: a practice wisdom resource 49

 National LGBTI Health Alliance
PO Box 51, Newtown 2042 NSW Australia
www.lgbtihealth.org.au
General enquiries: [email protected]