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Invisible Diversity: Affirmative Psychotherapy with LGBT Patients

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Presentation on theme: "Invisible Diversity: Affirmative Psychotherapy with LGBT Patients"— Presentation transcript:

1 Invisible Diversity: Affirmative Psychotherapy with LGBT Patients
Kerry L. Holland, Ph.D. Director, Behavioral Health & Wellness Clinic, Department of Psychology, ETSU

2 Learning Objectives Participants will be able to:
Describe APA Standards for working with LGBT patients Describe WPATH Standards of Care for work with transgender patients Identify strategies to create an affirmative environment for LGBT patients Describe the coming out process

3 I’m not an expert But I am very interested and always striving to do better. We’ll do this together.

4 “They’re just like everybody else
“I don’t treat them any differently”

5 Ethical Principles & Code of Conduct
Standard 2: Competence(b) Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation or supervision necessary to ensure the competence of their services, or they make appropriate referrals, except as provided in Standard 2.02, Providing Services in Emergencies.

6 BOE Psychology 9/13 Rule revision
Rule (1)(f) is deleted and amended to read: Three (3) CE hours shall pertain to cultural diversity as specifically noted in the title, description of objectives, or curriculum of the presentation, symposium, workshop, seminar, course or activity. Cultural diversity includes aspects of identity stemming from age, disability, gender, race/ethnicity, religious/spiritual orientation, sexual orientation, socioeconomic status, and other cultural dimensions. The topic of the presentation, symposium, workshop, seminar, course or activity need not be on cultural diversity, but one of the objectives or descriptions of the topics covered, shall clearly indicate attention to the cultural diversity.

7 CE Requirements CE audits in 2015 for 2 previous yrs will not require compliance CE audits in 2016 will

8 APA Practice Guidelines for LGB Clients
Guidelines revised because of advances in science and new socio/cultural pressures to re-pathologize homosexuality Developed in response to survey in early 90’s

9 Attitudes Toward Homosexuality and Bisexuality
1. Psychologists strive to understand the effects of stigma (i.e., prejudice, discrimination, and violence) and its various contextual manifestations in the lives of lesbian, gay, and bisexual people. 2. Psychologists understand that lesbian, gay, and bisexual orientations are not mental illnesses. 3. Psychologists understand that same-sex attractions, feelings, and behavior are normal variants of human sexuality and that efforts to change sexual orientation have not been shown to be effective or safe.

10 4. Psychologists are encouraged to recognize how their attitudes and knowledge about lesbian, gay, and bisexual issues may be relevant to assessment and treatment and seek consultation or make appropriate referrals when indicated. 5. Psychologists strive to recognize the unique experiences of bisexual individuals. 6. Psychologists strive to distinguish issues of sexual orientation from those of gender identity when working with lesbian, gay, and bisexual clients.

11 Relationships and Families
 7. Psychologists strive to be knowledgeable about and respect the importance of lesbian, gay, and bisexual relationships. 8. Psychologists strive to understand the experiences and challenges faced by lesbian, gay, and bisexual parents. 9. Psychologists recognize that the families of lesbian, gay, and bisexual people may include people who are not legally or biologically related.

12 10. Psychologists strive to understand the ways in which a person's lesbian, gay, or bisexual orientation may have an impact on his or her family of origin and the relationship with that family of origin.

13 Issues of Diversity 11. Psychologists strive to recognize the challenges related to multiple and often conflicting norms, values, and beliefs faced by lesbian, gay, and bisexual members of racial and ethnic minority groups. 12. Psychologists are encouraged to consider the influences of religion and spirituality in the lives of lesbian, gay, and bisexual persons.

14 13. Psychologists strive to recognize cohort and age differences among lesbian, gay, and bisexual individuals. 14. Psychologists strive to understand the unique problems and risks that exist for lesbian, gay, and bisexual youth.

15 15. Psychologists are encouraged to recognize the particular challenges that lesbian, gay, and bisexual individuals with physical, sensory, and cognitive-emotional disabilities experience. 16. Psychologists strive to understand the impact of HIV/AIDS on the lives of lesbian, gay, and bisexual individuals and communities.

16 Economic and Workplace Issues
 17. Psychologists are encouraged to consider the impact of socioeconomic status on the psychological well being of lesbian, gay, and bisexual clients. Guideline 18. Psychologists strive to understand the unique workplace issues that exist for lesbian, gay, and bisexual individuals.

17 Education and Training
19. Psychologists strive to include lesbian, gay, and bisexual issues in professional education and training. 20. Psychologists are encouraged to increase their knowledge and understanding of homosexuality and bisexuality through continuing education, training, supervision, and consultation.

18 Research 21. In the use and dissemination of research on sexual orientation and related issues, psychologists strive to represent results fully and accurately and to be mindful of the potential misuse or misrepresentation of research findings.

19 APA Task Force on Guidelines for Practice with Transgender and Gender Non-Conforming Clients
Met in Atlanta in 2012 for first in-person meeting Prepared a timeline for developing Guidelines

20 WPATH Standards of Care
Transgender: umbrella term for persons whose gender identity, gender expression or behavior does not conform to that typically associated with the sex to which they were assigned at birth ( Gender nonconformity: the extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex (Institute of Medicine, 2011)

21 Gender dysphoria: discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) (Fisk, 1974; Knudson, DeCuypere, & Bockting, 2010b).

22 A disorder is a description of something with which a person might struggle, not a description of the person or the person’s identity. Thus, transsexual, transgender, and gender- nonconformingindividuals are not inherently disordered. Rather, the distress of gender dysphoria, when present, is the concern that might be diagnosable and for which various treatment options are available.

23 Treatment for Gender Dysphoria
Hormone therapy and surgery have been found to be medically necessary to alleviate gender dysphoria in many people (American Medical Association, 2008; Anton, 2009; World Professional Association for Transgender Health, 2008).

24 While many individuals need both hormone therapy and surgery to alleviate their gender dysphoria, others need only one of these treatment options and some need neither (Bockting & Goldberg, 2006; Bockting, 2008;Lev, 2004).

25 With the help of psychotherapy, some individuals integrate their trans or cross- gender feelings into the gender role they were assigned at birth and do not feel the need to feminize or masculinize their body. For others changes in gender role and expression are sufficient to alleviate gender dysphoria (Coleman et al., 2011)

26 Definition of Terms Lesbian Gay Down-low, MSM Transgender Transexual
Queer/Questioning Intersex Heterosexism/heterosexual privelege

27 Terms to Avoid lifestyle: A vague, often politically charged term sometimes used to describe the lives of lesbian, gay, bisexual and transgender people. practicing: Use “sexually active” as a modifier in circumstances when public awareness of an individual’s behavior is germane. sexual preference: Sexual orientation is preferred to describe innate sexual attraction.

28 Stages of Coming Out (Cass, ‘79) (Stage 1: Identity Formation)
Identity Confusion- “my behavior may be called homosexual”, incongruency between perception of behavior & perception of self Attempts to resolve this confusion: Correct & acceptable Correct & undesirable – inhibition of behaviors, restriction & control of information on homosexuality, denial that information is relevant Incorrect & undesirable

29 Stage 2: Identity Comparison
Begins to accept that may be homosexual in identity, but also begins to become aware of perceptions of others toward homosexuality – stigma/shame; may feel alienated Very often lack of identifiable positive role models

30 Four approaches to reducing feelings of alienation at this stage
Individual reacts positively to the idea of being different Accepts homosexual meaning of behavior, but finds the self-image undesirable Accepts self as homosexual and the behavior as homosexual, but views the behavior as undesirable. Lives asexual life. Successful inhibition leads to identity foreclosure. Self and behavior viewed as undesirable & wishes to change both

31 Stage 3: Identity Tolerance
Self-image has turned further away from heterosexual and more toward homosexual. Feelings of alienation may be accentuated, begins to seek out other homosexuals – gay subculture; tolerates rather than accepts identity Positive contacts make other homosexuals appear more significant & more favorable; comes to feel more positively about self Unrewarding contacts result in devaluation of gay subculture more likely to result->> self-hatred

32 Stage 4: Identity Acceptance
Increasing contact with gay community, allowing the individual to feel the impact of the subculture that validate and normalize homosexuality as an identity and way of life. Individual accepts rather than tolerates a gay self-image. Discovers preferences for gay social contexts >>> developing friendships with in gay community.

33 Gay subculture increasingly important
Degree of “outness” – out publicly & privately; or not out publicly Totally “out” – will increase internal tension – more aware of external pressures Partially “out” – “fitting in” or “passing”

34 Stage 5: Identity Pride Individual’s awareness of incongruency of self perception as acceptable and society’s rejection increases Manages this incongruency by devaluing heterosexuals relative to homosexuals May experience increase in anger out of frustration & alienation Combination of anger & pride creates “activist”

35 Stage 6: Identity Synthesis
Decreases in viewing “us” vs “them”; “gay=good; straight=bad” More flexibility in view of self, others, outness, responses to negative views of others is dampened a bit

36 Shame Resilience Theory
Brene Brown (2006) Based on her work with women and shame – see some applications for working with individuals struggling with coming out

37 Terms Shame: “intensely painful feeling or experience of believing we are flawed and therefore unworthy of acceptance and belonging” Shame is a psycho-social-cultural construct

38 Main Concern for Individuals
Feelings of being trapped, powerless, and isolated Trapped – expectations and options Powerless – shame produces overwhelming, painful feelings of confusion, fear, anger & judgment, and/or need to hide; making it difficult to identify & act with consciousness on choices that would facilitate change Isolated – results from feeling trapped & powerless

39 Shame Web Layered, conflicting, and competing expectations
Expectations often imposed, enforced or expressed by individuals & groups, partners, friends, coworkers etc. Reinforced by media


41 Shame Resilience

42 Critical Awareness

43 Speaking Shame

44 Shame Triggers Unwanted identities
SRT connected to Relational-Cultural theory

45 Case Study: Bob, age 61 Coming out, limited sexual experience, no relationship history, extremely isolated, limited friendships “I want love in my life” “I don’t want to be gay”

46 Coming Out

47 Sexually Diverse Individuals
Face common struggles with societal oppression Face similar difficulty developing positive individual identities and healthy communities within that oppression As with other minorities, deserving of sensitivity when treating them.

48 The figure in this slide provides a visual representation of the dispersion of same-sex couples throughout the US. Each star represents 250 same-sex couples.

49 Human Sexuality… Believed to be characterized by a continuum rather than discrete categories Biological, physiological & genetic contributions combine to determine an individual’s ascribed or claimed sex

50 Whereas… Gender expression, sexuality, & sexual behavior are fluid, dynamic processes in which that person engages (Fausto-Sterling, 1998 in Bieschke, Perez, DeBord 2007)

51 Aspects of sexual identity can include…
Affectional & intimate preferences & attachments, gender identity, social sex roles, sexual behaviors, erotic fantasies, sexual & emotional arousal patterns, self-identification, lifestyle, community, disclosure, political commitments, social preferences, & consistency or change over time (Bieschke, Perez, and DeBord, 2007)

52 Behaviors and Identity
May self-identify as gay and not be sexual exclusively with same sex or at all May be sexual with same sex, but not self- identify as gay

53 In its simplest terms, sexual orientation is the emotional and sexual attraction one feels for others. Sexual orientation can range from exclusively homosexual (attraction to same sex only) to exclusively heterosexual (attraction to different sex only). The previous slide describes sexual orientation and terminology in these terms. However, people behave and define themselves sexually in more complex ways than this definition implies. It can be helpful to understand the different dimensions and manifestations of sexual orientation in order to build a better therapeutic relationship with your patients (e.g., avoiding assumptions and staying open to cultural differences). A helpful model for understanding sexual orientation is considering it as integrating three related concepts: 1) Identity in this context refers to how a person self defines or labels their sexuality. Traditional sexual self-identity labels include gay, lesbian, bisexual, straight, heterosexual, homosexual, asexual. Some use terms like queer, same-gender loving, polysexual. As people go through the process of understanding their sexuality and self-identity over time, they sometimes change how they define their sexual identity. For example, a patient may self-identify as heterosexual at one visit, and as bisexual at a later visit. 2) Behavior in this context generally refers to the gender(s) of a person’s sexual and romantic partners. Although most people’s sexual identity aligns with their behavior (e.g., women who consider themselves lesbians have female partners; men who consider themselves gay have male partners), this is not always the case. For example, some women who identify as lesbian have female and male partners; some people who identify as heterosexual have same-sex partners; some people who identify as queer or bisexual only have different-sex partners. Understanding behavior also involves learning about specific sexual behaviors that individuals engage in with their partner(s). 3) Attraction refers to the gender(s) a person is attracted to. As explained above, attraction usually but not always aligns with behavior or identity. The desire to be with someone of the same gender may never be acted upon and may not form part of someone’s sexual self-identity. In addition, some people do not discover their attraction to the same sex until later in life, or may be attracted to exclusively same-sex partners for much of their life, and later discover an attraction to a different sex partner or partners. Being open to discussing a patient’s undisclosed or newly developing sexual attractions may be the first step in helping a patient to “come out” and begin to feel comfortable with an identity that is aligned with their romantic or sexual desires. We’ll discuss specifics of how to bring up the topic of sexual desires, identity, and behaviors in Module 2. 53 53

54 Bisexual Behavior In men, estimates range: 20.3% have ever had a same sex experience, 9.1% have had such experience since puberty, 4.9%-6.7% have had such experience since age 18 or 20 Less than 1% of U.S. men self-identify as bisexual (Rust, 2000c) in Bieschke, Perez, & DeBord (2007). 75% - 90% of lesbians report having engaged in heterosexual activity (Rankow, 1995)

55 LGBT & Racial/Ethnic Diversity

56 Bisexual Orientation

57 Health Risks Associated With Being a Sexual Minority
Avoidance of preventive/routine medical care Stress of being a sexual minority Sexual behavior Aging presents unique concerns

58 Stress Related Risks Both Sexes
Increased mental distress, emotional disorders, relationship issues, internalized homophobia Substance use and/or abuse (esp. young gay men) Suicide Victims of violence (hate crimes) Higher rates of tobacco use Certain cancers: due to suppression of immune system as a result of stress, such as melanoma

59 Risks for Lesbians Lesbians have higher occurrence of obesity and those associated health risks Increased risk of breast and gynecological cancers may be due to obesity, nulliparity and lack of early screening Domestic violence

60 Risks for Gay Men Prostate cancer Anal cancer Eating disorders

61 LGBT Youth Are at an even greater risk of homophobic related violence than their older peers Disproportionately represented in the runaway or “throwaway” youths Increased risk of suicide attempts and completions

62 LGB Adults who reported high rates of parental rejection as teens
Were 8.4 times more likely to have attempted suicide 5.9 times more likely to report high levels of depression 3.4 times more likely to use illegal drugs 3.4 times more likely to have unprotected sex than LGB peers who reported no or low levels of rejection (Peds, vol. 123, no.1)

63 Transgender Individuals
Experience many of the same health risks Additionally, may experience greater occurrences of violence, rejection, or harassment by others

64 While cultural competence is a very worthy goal, it may be a lot to expect that all clinicians will have knowledge of the unique and nuanced aspects of the lives of people from every different cultural background or sexual orientation. In addition there are many differences among patients that may transcend culture. Nevertheless, all clinicians should be able to provide non-judgmental, respectful care to all patients, regardless of culture. In this context it may be adaptive to speak of providing meaningful cross-cultural care rather expecting that all clinicians will always be culturally competent for all of their patients. This slide provides a model for cross-cultural care that can be applied to the care of LGBT patients. The model suggests that when caring for patients of any background different from your own, it is vitally important to maintain curiosity, respect, and empathy. More specifically: Be curious about the patient’s beliefs, practices, fears, and customs. Patients usually are happy that you’re interested. Have empathy towards your patients -- put yourself in their position and try to think about why they are acting in a certain way. Don’t just dismiss things that are different from what you would like or expect. Be respectful of what you may hear. (Green, 2002)

65 Cultural Competence in Practice…
Do your forms presume heterosexuality, and distinct gender? Unisex restrooms make it easier for transgender patients. Asking the patient, “How do you prefer to be addressed?” Create a more comfortable waiting area; special days of observance: Pride Week, National Coming Out Day, Transgender Day of Remembrance

66 In the consulting room... Use of safe zone stickers, lapel pins, artwork. During history taking, avoid heterosexist language: couple, partner, allow that sexual behavior can include same sex, both sexes, not presuming someone who has children is straight or that someone who is gay doesn’t have/want children

67 This module presented basic information about LGBT populations and how to better care for your LGBT patients. In addition, this module introduced an opportunity to reflect on your own attitudes toward LGBT patients as a means to improve your practice. Knowledge and attitudes are two elements of a triad of learning. The third element is skills. To continue your learning, pursue opportunities to practice skills related to working with LGBT clients. This may be done through participating in role-play exercises, by reviewing case studies on LGBT concerns, and/or by trying out what you have learned in your practice. See Handout 1-C for sample role-play exercises.

68 Check It Out Gay & Lesbian Medical Association:
Click on Fenway Institute

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