As helping professionals, we share a united goal of empowering the individuals with whom we work to meet their goals. Though it remains important to address social issues on a large scale (e.g., protests, donations, advocating for policy change), a lot of what we do as helpers happens one-on-one. That is, most of us work to empower individuals interpersonally through therapy.

With this in mind, I would like to share tangible ways to support LGBTQQIA (Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Intersex, Asexual) and/or gender non-conforming (individuals who do not identify as cisgender, meaning they have gender identities that do not match the sex they were assigned at birth, and/or those who reject the gender binary, or do not identify as male or female) clients in session while also acknowledging the importance of social justice advocacy on a much larger scale.

For the purposes of this article, I will refer to LGBQ and gender non-conforming identities separately. Though these identities sometimes intersect, many of the concerns these identities share are inherently separate — relating to sexual orientation and gender uniquely.

The increase of hate crimes, mass shootings of targeted identities, and other instances of oppression highlight how important it is for clinicians to effectively and thoughtfully support a diverse range of clients. Some of the many individuals currently under fire in the current socio-political climate include members of LGBTQQIA communities. The struggles our clients face every day are not new, but the current socio-political zeitgeist in the United States has only made systemic inequities like racism, sexism, ableism, homophobia, heteronormativity, and cis-normativity incredibly visible and salient.

As therapists and trainees, many of us are familiar with the struggle that has been happening every day for LGBTQQIA  communities over time (see APA guidelines for working with LGB individuals here [1] and APA guidelines for working with transgender & gender non-conforming individuals here [2]).

As such, we have been having these conversations in the psychological disciplines for some time, though these conversations remain incredibly relevant. I firmly believe that as imperfect human beings, we never “arrive” to cultural competence. Further conversation and action are always needed.

My own experiences as an AFAB (assigned female at birth) nonbinary psychologist who identifies as pansexual, experiences passing-privilege (i.e., passing as heterosexual), and being married to a cisgender, straight man, admittedly impacts my recommendations.

Additionally, working with LGBQ and gender non-conforming clients pre- and post-election has given me many opportunities to reflect on my own practice. Many therapists and trainees, me included, struggle to support marginalized clients in ways that feel both helpful and appropriate in therapy.

In an effort to provide some concrete action steps moving forward, I have generated a list of five ways to actively support LGBQ and gender non-conforming clients in session.

1. Explore Identity

Our work as therapists requires navigating the myriad of identities our clients bring with them into the room. One way to actively support individuals who identify with LGBQ and gender non-conforming communities is to integrate the exploration of human identity regularly.

Identity can be defined in many ways — it is multi-faceted and complicated. One common framework for conceptualizing human identity within the fields of sociology and psychology comes from Pamela Hay’s ADDRESSING Framework of human diversity. ADDRESSING is a mnemonic and each letter stands for a different arena of human identity: Age, Disability, Religion, Ethnicity, Social Class, Sexual Orientation, Indigenous Background, National Origin, and Gender [3].

Though certainly not exhaustive, the ADDRESSING framework begins to capture how multifactorial human identity is, and how identity is related to more or less power. For example, identifying/being perceived as heterosexual is related to having more power and privilege in a heteronormative society while identifying/being perceived as LGBQ is related to the possession of less power and increased experiences of oppression.

Similarly, identifying as/being perceived as cisgender is related to the possession of power and privilege in a cis-normative society, and vice versa.

I have found that incorporating Hay’s ADDRESSING framework into my clinical work is incredibly helpful. Discussing identity early with clients, regardless of presenting concerns, sets a precedent that often creates space to continue the conversation — especially when individual experiences of current events make marginalized identities particularly relevant in session.  

For example, one client* of mine identifies as both gender non-binary (e.g., neither male nor female) and bisexual (e.g., attracted to both ends of the traditional gender binary). We began discussing identity in early sessions, including sexual orientation and gender identity. After the election, this client suddenly endorsed suicidal ideation. The client then disclosed that their suicidal thoughts were directly related to their identity as a gender-nonconforming and bisexual human being. In later sessions, they reported that disclosing suicidality after the election was much easier because we had already been talking about their LGBQ and gender non-conforming identities.

Discussing identity in session can be scary; discussions about identity are tricky — they are deeply personal and we are bound to mess them up from time to time. Approaching the conversation from a place of humility and genuine curiosity is a great place to start. Ask clients about how they experience themselves and their many identities. An open question without labels we often use to describe sexuality and gender allows the client to describe for themselves who they are and which identities are important to them.

2. Engage in Self Awareness

Another common fear among therapists and trainees when approaching conversations about identity with clients involves the reality that there are (at least) two human beings in the room. The therapeutic relationship is already an odd one; it is naturally lopsided. Clients leave our offices having bared their souls and knowing very little about their therapists.

Regardless of theoretical orientation, to discuss human identity requires thoughtful self awareness. As we explore these themes with our clients, we must also explore them within ourselves. Ask yourself the same questions you ask your clients. For instance:  

• How do I define and describe my sexuality?
• How do I describe my gender?
• What does my sexual orientation/gender expression mean to me?
• Which pieces of myself feel the most important to me?

It is important to examine ourselves and our identities thoughtfully prior to and while we work with clients because who we are, and who the client is, shows up in session in obvious and subtle ways.

For example, my identity as a cisgender, bisexual woman means something completely different for me than how my client understands their own bisexual orientation as it intersects with their non-binary gender. Instead of assuming how this client feels, it became really important for me to ask them about their experiences while connecting to, but not imposing, my own.

One method I have used in session with my LGBQ and gender non-conforming clients to be thoughtful about my own identities and how they impact clients is to engage in the therapeutic use of self in session. There are varying opinions and comfort levels among clinicians in using the self therapeutically in session with clients. Different theoretical orientations provide different ways of using self therapeutically in session (or not).

Using the self in session can take the form of self-disclosure about personal “ally” or “queer” identities in a way that you may not typically do with straight identified clients. In other instances, it may look like asking if the client has any questions they’d like to ask you as you begin working together.

Coming from a more interpersonal type of approach in my own work as a beginning clinician, I occasionally use my own identities in the room to facilitate conversations about client identities. For example, when working with the client I mentioned previously who identifies as both bisexual and non-binary, I asked the client a process question akin to “what is it like to talk about your gender identity with a therapist who has a visibly feminine gender presentation?”

I find that tactful and thoughtful therapeutic use of the self in the room allows us, both client and therapist, to name the similarities and differences we share in the room that may or may not be visible or impactful. It can sometimes feel like naming the elephant in the room and sometimes it’s a breath of fresh air for clients.

Which identities I disclose depends largely on my own comfort level, the client in front of me, and their presenting concerns. It’s important, then, to be thoughtful about your own personal boundaries. You want to consider when, under what circumstances, and with which type of clients you will share specific identities or reactions.

One reaction of some of my colleagues when I talk about using my therapeutic self in session is “Kayla, what about countertransference? It’s too risky!” They are right that countertransference is inherently bound up with self-disclosure. It is important to be thoughtful about not only what we disclose as therapists, but why we disclose. Even if you are licensed, I would recommend continued consultation as you begin to integrate the use of your therapeutic self into your practice.

As trainees, we have the luxury of a lot of supervision, which is where I think through disclosure and self-as-tool prior to client sessions. With that said, address the countertransference but also welcome it. You are human after all. I like to think of countertransference as a friend I need to be mindful of lest she block my view, but she always provides me with unique data.

3. Label Caution

Though implied by point #1, I think it’s important to note that not every client appreciates labels like “gay,” “lesbian,” “bisexual,” or “gender-queer.” Some do. That’s why it’s important to ask open questions.

Psychology categorizes most everything into nice little boxes. Sometimes these boxes are useful; sometimes they are not. Sometimes these categories fit for clients and sometimes they don’t. I find asking descriptive questions helpful in avoiding unintentionally labeling clients.

For example, asking “What information led you to explore your sexual orientation?” is less risky than “When did you realize you were gay?” Once I took a step back and waited for clients to identify their own experiences, new and personalized descriptions of their experiences came up.

One client told me they preferred “gender and sexual minorities” to the LGBTQQIA acronym because it just wasn’t inclusive enough (and can become verbally cumbersome). It seems useful to ask how clients describe themselves, and then use the labels and descriptors they use to describe themselves.

One reason to avoid ascribing labels is the risk of mis-gendering clients. In fact, I would take extreme caution in mis-gendering any client, even if their presenting concern isn’t related to sexual orientation or gender identity. A simple to avoid the mistake of mis-gendering someone would be to offer up your own pronouns (she/her/hers; he/him/his; they/them/theirs; some other pronoun, or no use of pronouns at all). The use of the gender neutral “they/them/theirs” is a great default, and allows space for others to offer pronouns that describe gender at their own discretion and pace.

Different labels or descriptors mean different things to different people. Some people are truly empowered by an “official” label to what they are experiencing. Other clients actively resist those labels. It’s important to be considerate of how each client feels about labeling their own identities.

One client specifically asked me for a Gender Dysphoria diagnosis. We discussed what this would mean to this person, and it turned out that a diagnosis from an “expert” provided a sense of legitimacy for this client that they could fall back on when the oppressive world around them erased their existence. So, we busted out the DSM-V and went over all the criteria together, and the client (not I) determined which criteria matched for them and which didn’t. It was a truly powerful session and a meaningful intervention. The client liked it so much, they requested a copy of the diagnostic criteria so they could explain their distress to their parents.

4. Recognize Complexity

Lately, I’ve been taken aback — personally and professionally — by just how complicated identifying ourselves can be as therapists and for our clients. To Identify with a particular community can remain complicated and many people feel like they don’t completely fit in anywhere, regardless of identity labels.

This experience is well documented, for example, in individuals who identify as biracial or bisexual, and those who experience passing privilege. Many people find themselves in-between communities and feel forced into making choices between one or the other (e.g., identifying with a particular religious community and maintaining their LGB status), which doesn’t seem possible to them because they hold (and are) both.

As a bisexual woman married and attracted to a man, I don’t feel comfortable at LGBQ and gender non-conforming events because I pass as straight and am often perceived as “not gay enough.”

Similarly, I feel conflicting emotions when I am mis-labeled as heterosexual by my peers, even though I know that this passing affords me privilege. I have found the work of Dr. Beth Firestein on bisexual identity particularly useful in describing this complexity for this particular sexual orientation [4].

I have heard similar sentiments in my gender non-conforming and trans clients who “pass” as one gender or the other, regardless of how they personally identify. It is important to be mindful about what coming out means to clients, the complexity that comes with identifying in certain ways, and also how clients (and we) are perceived by others.

“Passing” poses its own unique challenges that aren’t always acknowledged as oppressive and can be incredibly painful and complicated for us as therapists and for clients. The conversation around “passing privilege” among the LGBTQQIA communities reminds me of how truly interconnected different identities are and we must remain intersectional in our approach to working with LGBTQQIA clients.

Just like white feminism, a brand of feminism centered on the struggle of white women, can be problematic for non-whites, a euro-centric understanding of LGBTQQIA concerns is also problematic. Queer individuals of color, for example, experience unique forms of oppression that are much different than the experiences faced by white members of these communities.

For further reading, explore what is described as the “invisibility of lesbianism” in Latinx cultures due to the intersection of machismo, matriarchal culture, marianismo, and queerness (see the Human Rights Campaign for a nice description of unique struggles LGB and gender-non conforming Latinx identified folks face) [5].

It is also important to reference the unique and dangerously oppressive experiences faced by transfeminine individuals and trans women who face extreme amounts of deadly violence each year as a result of cis-normativity (see data here) [6].

5. Action & Advocacy

I know I began this article by saying that although advocacy and large-scale social change is important, that I would focus on our individualized role as therapists. However, I think it is important to highlight that not all action and advocacy looks like marches and rallies (those are great, too!).

As therapists, we may have to go above and beyond for our LGBTQQIA clients in continuity and coordination of care and making LGBTQQIA concerns more visible within the many contexts we find ourselves. This can be as simple as making ally-ship more visible by having a rainbow sticker on your office door. As was done at the agency where I am completing training this year, it can look like advocating for LGBTQQIA groups and the creation of a trans-care team. It may involve being aware of local resources for the LGBTQQIA community.

Here in Eugene, multiple non-profits volunteer their time to make certain processes easier and more accessible for transgender clients by hosting workshops and helping individuals with complicated medical and legal procedures like gender transition procedures or legally changing their names to match their gender and pronouns.

As therapists, we can serve as a bridge between our clients and those extra services that could make all of the difference. While not all therapists will rally and protest, we all can work to increase visibility for LGBTQQIA communities and provide access to resources that can supplement individual therapy.

Traditionally, psychology hasn’t done this very well. I don’t know how many times I have heard members of LGBTQQIA groups describe negative experiences with a therapist that made them no longer want to seek psychological services. Hopefully, we will begin to see that many of these therapy-ending mistakes can be avoided by exploring client identities in ways that are non-judgmental and curious, having acute self-awareness, avoiding assigning labels for our clients, recognizing the complexity of identity, and taking action.

For some of you, these insights and suggestions may come as news to you. For others, these recommendations will feel basic, and they are. However, the current increase in hate crimes and mounting LGBTQQIA sociopolitical fear reminds me that a return to the fundamentals is more important than ever, especially for the field of psychology.

I am a beginning trainee, and I have so much to learn. Much of what I have recommended has developed within me through trial by fire. I hope these resources and recommendations will be helpful in your practice as we continue to move forward in our individual efforts of promoting equity, justice, and healing for all our clients, but especially our clients actively experiencing oppression in the LGBQ and gender-non conforming communities.

I am left with the words of Jason Collins, one of the first openly gay athletes in U.S. pro sports (find his bio here): “Openness may not completely disarm prejudice, but it’s a good place to start” [7].

Be well. Be safe. Be thoughtful. Be whole.

Authors Note: I would like to send a special thank you to Kendall Thornton, PsyD, and Kiona Hagen Niehaus, PhD, for their ongoing support, feedback, and assistance in writing this article.

*All clients described in this article have given permission to do so.

This article was originally published on February 12, 2018.

References

[1] American Psychological Association. (2012). American Psychologist, 67, 10-42. doi: 10.1037/a0024659

[2] American Psychological Association. (2015). American Psychologist, 70(9), 862-864. doi: 10.1037/a0039906

[3] Hays, P. (2008). Addressing Cultural Complexities in Practice, Second Edition: Assessment, Diagnosis, and Therapy. Washington, DC: American Psychological Association.

[4] Firestein, B. (1996). Bisexuality: the psychology and politics of an invisible minority. Thousand Oaks: Sage Publications.  

[5] Human Rights Campaign (2016). Coming Out Issues for Latinas and Latinos. Retrieved from http://www.hrc.org/resources/coming-out-issues-for-latinas-and-latinos

[6] National Coalition of Anti-Violence Programs. (2013). Hate Violence Against Transgender Communities. Retrieved from http://www.avp.org/storage/documents/ncavp_transhvfactsheet.pdf

[7] ESPN. (2016). Jason Collins. Retrieved from http://www.espn.com/nba/player/_/id/987/jason-collins