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

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Presentation on theme: "Invisible Diversity: Affirmative Psychotherapy with LGBT Patients Kerry L. Holland, Ph.D. Director, Behavioral Health & Wellness Clinic, Department of."— 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.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 (APA.org) 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

40

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 48

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 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

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

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


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