1. LGBTQIA and Play Therapy
Amanda Gurock, LCSW

2. Goals of the Webinar
Define Sexual Orientation, Gender Identity, and Gender Expression
Define the Different Populations
Understand Gender Variance and Gender Fluidity
Change in Diagnosis (History to Present): The Debate
History of Treatment Modalities
LGBTQIA Competencies
Discuss unique issues that bring the LGBTQIA population into treatment
Learn different techniques to use in therapy
Beware of Ethical Considerations

3. Definitions of Terms by the APA Dictionary of Psychology
Sexual orientation: one’s enduring sexual attraction to male partners, female partners, or both. Sexual orientation may be heterosexual, same sex (homosexual -gay or lesbian), or bisexual.
Gender Identity: one’s self identification as male or female. Although the dominant approach in psychology for many years has been to regard gender identity as residing in individuals, the important influence of societal structures, cultural expectations, and personal interactions in its development is now recognized as well.

4. Definitions of Terms by the APA Dictionary of Psychology
Gender Expression: The presentation of an individual, including physical appearance, clothing choice and accessories, and behaviors that express aspects of gender identity or role. Gender expression may or may not conform to a person’s gender identity.

5. Definitions of Populations by the LGBTQIA Resource Center Library
Gay:  A sexual and affectional orientation toward people of the same gender; can be used as an umbrella term for men and women.
Lesbian: A woman whose primary sexual and affectional orientation is toward people of the same gender.
Bisexual: A person whose primary sexual and affectional orientation is toward people of the same and other genders, or towards people regardless of their gender.

6. Definitions of Populations by the LGBTQIA Resource Center Library
Transgender: Adjective used most often as an umbrella term, and frequently abbreviated to “trans” or “trans*” (the asterisk indicates the option to fill in the appropriate label, ie. Trans man). It describes a wide range of identities and experiences of people whose gender identity and/or expression differs from conventional expectations based on their assigned sex at birth. Not all trans people undergo medical transition (surgery or hormones). Some commonly held definitions: 1. Someone whose determination of their sex and/or gender is not universally considered valid; someone whose behavior or expression does not “match” their assigned sex according to society A gender outside of the man/woman binary Having no gender or multiple genders.

7. Definitions of Populations by the LGBTQIA Resource Center Library
Queer: One definition of queer is abnormal or strange. Historically, queer has been used as an epithet/slur against people whose gender, gender expression and/or sexuality do not conform to dominant expectations. Some people have reclaimed the word queer and self identity as such. For some, this reclamation is a celebration of not fitting into norms/being “abnormal.” Manifestations of oppression within gay and lesbian movements such as racism, sizeism, ableism, cissexism/transphobia as well as assimilation politics, resulted in many people being marginalized, thus, for some, queer is a radical and anti-assimilationist stance that captures multiple aspects of identities.  

8. Definitions of Populations by the LGBTQIA Resource Center Library
Questioning: The process of exploring one’s own gender identity, gender expression, and/or sexual orientation. Some people may also use this term to name their identity within the LGBTQIA community. 

9. Definitions of Populations by the LGBTQIA Resource Center Library
Intersex: People who naturally (that is, without any medical intervention) develop primary or secondary sex characteristics that do not fit neatly into society's definitions of male or female. Many visibly Intersex people are mutilated in infancy and early childhood by doctors to make the individual’s sex characteristics conform to society’s idea of what normal bodies should look like. Intersex people are relatively common, although the society's denial of their existence has allowed very little room for intersex issues to be discussed publicly. Hermaphrodite is an outdated and inaccurate term that has been used to describe intersex people in the past. 

10. Definitions of Populations by the LGBTQIA Resource Center Library
Asexual: A sexual orientation generally characterized by not feeling sexual attraction or a desire for partnered sexuality. Asexuality is distinct from celibacy, which is the deliberate abstention from sexual activity. Some asexual people do have sex. There are many diverse ways of being asexual.

11. Definitions from Brill and Pepper’s Book The Transgender Child
Gender Variance: Behaviors and interests that fall outside of what is considered normal for a person’s assigned biological sex. This may be indicated by choices in games, clothes, and playmates, or it may take the form of the child stating or restating that they wish to be the other sex.
Gender Fluidity: Conveys a wider, more flexible range of gender expression with personal appearance and behaviors that may change day to day. For some kids this can define their gender identity. They could feel that they are a boy one day and a girl on other days. This could also mean that they don’t feel either term describes them.

12. History of Treating Homosexuality: Theories
Freudian theory held that all children are inherently bisexual, developing a fixed sexual orientation only in adolescence through identification with the parent of the same sex. Freud himself had explicitly stated by 1935 that homosexuality was not an illness and strongly discouraged attempts to treat it; nevertheless, by the 1950s, his theories were widely misappropriated by conservative American and émigré psychiatrists vested in reaffirming the heterosexual, breadwinner-homemaker household in the wake of World War II.

13. History of Treating Homosexuality: Theories
Throughout the 1960s, psychiatrists Irving Bieber and Charles Socarides_argued that homosexual desire was a form of psychosocial maladjustment, resulting from childhood. With the popularization of behavioral therapies in the 1960s and ’70s also came new attempts to treat homosexuality, in the form of “aversion” therapies, including electric shocks.
Since the 1970s, reparative therapies have been reborn through “ex-gay” Christian ministries, including the umbrella group Exodus International, founded in Anaheim, Calif., in Mixing pastoral counseling, Bible study, individual and group psychotherapy, and aversion treatments, ex-gay ministries have promised a cure from—or at least avoidance of—homosexuality to thousands of men and women.
Little research is out there that looks at the successes of “conversion, reparative, and aversion” therapies. Most noted is the research that shows the criticisms and ethical concerns of the therapies.

14. History of Treating Homosexuality: Response to Theories
In 1994, the National Association of Social Workers stated that their members have the responsibility to inform clients about the lack of evidence supporting reparative therapies, but fell short of banning clinicians from using them.
The American Psychiatric Association, meanwhile, acknowledged the risks of reparative therapies in 1998—listing depression, anxiety and self- destructive behavior as likely outcomes—but has likewise failed to outlaw the practice among their members, or charge reparative clinicians with professional misconduct.
Action has come instead through State Legislatures and the Courts. Reparative therapy for minors is now illegal in California, New Jersey, and Washington D.C., with pending legislative action in nine other states.

15. History of Treating Homosexuality: Evolution of the Diagnosis
Homosexuality was in the DSM-I published in This did not address any gender identity concerns.
Homosexuality was in the DSM-II published in This did not address any gender identity concerns.
In December 1973, when the American Psychiatric Association voted to remove “homosexuality” from the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-II), which meant that homosexuality was officially no longer considered a disorder in itself. This also lead to the them considering the gender identity on its own.
The diagnosis of homosexuality was immediately replaced by “sexual orientation disturbance,” renamed “ego-dystonic homosexuality” in DSM-III, which was released in 1980 under the leadership of Spitzer and social worker Janet Williams.

16. History of Treating Homosexuality: Evolution of the Diagnosis
Ego-Dystonic Homosexuality was specifically aimed at patients who expressed ongoing distress or sadness about their sexual orientation. Now it was the internalization of homophobia that could make you sick. Many used the diagnosis of ego-dystonic homosexuality as an excuse to legitimize reparative therapy—and still do. This diagnosis was removed in 1987 with the DSM III-R.
Gender Identity Disorders were put into the DSM-III in 1980 and remined in the DSM III-R after the revision.
Gender Identity Disorder was put into the DSM-IV in 1994 and was limited in its explanation. Gender Identity Disorder remined in the DSM-IV-TR until May 2013.
“Gender dysphoria” in DSM-IV, released in May 2013, also bears a strong resemblance, framing the distress commonly associated with gender variance as an individual rather than social problem.

17. History of Treating Homosexuality: The Debate of Diagnosis
In the old DSM-IV, GID focused on the “identity” issue — namely, the incongruity between someone’s birth gender and the gender with which he or she identifies. While this incongruity is still crucial to gender dysphoria, the drafters of the new DSM- V wanted to emphasize the importance of distress about the incongruity for a diagnosis. (The DSM-5 uses the term gender rather than sex to allow for those born with both male and female genitalia to have the condition.)
This shift reflects recognition that the disagreement between birth gender and identity may not necessarily be pathological if it does not cause the individual distress said Robin Rosenberg, a clinical psychologist and co-author of the psychology textbook “Abnormal Psychology” (Worth Publishers, 2009). For instance, many transgender people — those who identify with a gender different than the one they were assigned at birth — are not distressed by their cross-gender identification and should not be diagnosed with gender dysphoria, Rosenberg said.

18. History of Treating Homosexuality: The Debate of Diagnosis
In this regard, the change resembles the elimination of homosexuality from the manual 40 years ago.
“The concept underlying eliminating homosexuality from the DSM was recognizing that you can be homosexual and psychological healthy or be homosexual and psychologically screwed up. Being homosexual didn’t have to be the issue,” Rosenberg said.
The DSM-V also separates the diagnosis of gender dysphoria for children from that of adolescents and adults. The characteristics of gender dysphoria vary with age, and many children with gender dysphoria outgrow it as they age, the manual notes.

19. Gender Dysphoria American Psychiatric Association
In children, gender dysphoria diagnosis involves at least six of the following and an associated significant distress or impairment in function, lasting at least six months:
A strong desire to be of the other gender or an insistence that one is the other gender
A strong preference for wearing clothes typical of the opposite gender
A strong preference for cross-gender roles in make-believe play or fantasy play

20. Gender Dysphoria American Psychiatric Association
A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender
A strong preference for playmates of the other gender
A strong rejection of toys, games and activities typical of one’s assigned gender
A strong dislike of one’s sexual anatomy
A strong desire for the physical sex characteristics that match one’s experienced gender

21. Gender Dysphoria American Psychiatric Association
For children, cross-gender behaviors may start between ages 2 and 4, the same age at which most typically developing children begin showing gendered behaviors and interests. Gender atypical behavior is common among young children and may be part of normal development. Children who meet the criteria for gender dysphoria may or may not continue to experience it into adolescence and adulthood. Some research shows that children who had more intense symptoms and distress, who were more persistent, insistent and consistent in their cross-gender statements and behaviors, and who used more declarative statements (“I am a boy (or girl)” rather than “I want to be a boy (or girl)”) were more likely to become transgender adults.

22. Being an Ally
Ally: A person who is not LGBTQIA but uses their privilege to support LGBTQIA people and promote equality. Allies "stand up and speak out even when the people they're allying for aren't there," said Robin McHaelen, founder and executive director of True Colors, a non-profit that provides support for LGBTQIA youth and their families. In other words, not just at pride parades.

23. Ally Tips How to be an ally
Believe that issues related to oppression are everyone’s concern, not just the concern of those who are the targets of oppression.
Understand that people who are lesbian, gay, bisexual, transgender, queer, intersex, or asexual are experts on their own experience, and that you have much to learn from them.
Take responsibility for your own education on issues related to gender identity and sexual orientation.  Take the initiative to become as knowledgeable as you can on issues of concern to people who are LGBTQIA.
Making mistakes is part of the learning process of practicing ‘allyship’. Acknowledge and apologize for mistakes; learn from them, but do not retreat.

24. Ally Tips How to be an ally
Avoid trying to convince people who are lesbian, gay, bisexual, transgender, questioning and intersex that you are on their side; just be there.
Remember that ally is a verb - actions are more powerful than words.
Create opportunities for allies to join together in coalition to reduce oppression of LGBTQIA people.

25. Take a Minute to Think Questions for Yourself
What do I think of the LGBTQIA community?
Do I agree with their gender expression, variance, fluidity?
What does my religion say?
Can I ethically treat them?
Am I an ally or foe to this population and movement?
**You need to know yourself and explore yourself before working with this population**

26. ALGBTIC Association for Lesbian, Gay, Bisexual, & Transgender Issues in Counseling
The mission of ALGBTIC includes the recognition of both individual and social contexts presenting the confluence of race, ethnicity, class, gender, sexual orientation, ability, age, spiritual or religious belief system, indigenous heritage in order:
To promote greater awareness and understanding of LGBTQIA issues among members of the counseling profession and related helping occupations.
To improve standards and delivery of counseling services provided to LGBTQIA clients and communities.
To identify conditions which create barriers to the human growth and development of LGBTQIA clients and communities; and use counseling skills, programs, and efforts to preserve, protect, and promote such development.

27. ALGBTIC Association for Lesbian, Gay, Bisexual, & Transgender Issues in Counseling
To develop, implement, and foster interest in counseling-related charitable, scientific, and educational programs designed to further the human growth and development of LGBTQIA clients and communities.
To secure equality of treatment, advancement, qualifications, and status of LGBTQIA members of the counseling profession and related helping occupations.
To publish a journal and other scientific, educational, and professional materials with the purpose of raising the standards of practice for all who work with LGBTQIA clients and communities in the counseling profession and related helping occupations.

28. ALGBTIC Competencies http://www.algbtic.org/competencies.html
Human Growth and Development
Social and Cultural Foundations
Helping Relationships
Group Work
Professional Orientation and Ethical Practice
Career and Lifestyle Development
Assessment
Research and program Development

29. Play Therapy Association for Play Therapy
APT defines play therapy as "the systematic use of a theoretical model to establish an interpersonal process wherein trained play therapists use the therapeutic powers of play to help clients prevent or resolve psychosocial difficulties and achieve optimal growth and development.“
By using play therapy, you can help the child express their needs, wants, feelings, and develop new solutions to their difficult problems.

30. What Brings Gender Non Conforming Individuals and Families Into Your Office
Families could be confused and struggling with the child’s gender identity or gender expression.
Child could be confused and anxious about the mixed messages that they are receiving from home, community, and culture surrounding their gender expression.
Child could be experiencing depression and anxiety surrounding the suppression or expression of their gender identity.
The child and or family is feeling isolated from others going through the same challenges.
The family may be grieving the loss of the child’s gender.

31. Ideas to help Children with Gender Dysphoria
Gender Non Conforming Office
Have books that are gender neutral:
Sometimes a Spoon runs away with Another Spoon: Jacinta Bunnell
My Princess Boy: Cheryl Kilodavis
It’s OK to be Different: Todd Parr
Pirate Girl: Cornelia Funke

32. Ideas to help Children with Gender Dysphoria
Gender Non Conforming Office
Have toys that are gender neutral:
Dress Up Clothes
Sand Tray Figurines: represent all types of gender identities/ expressions.
Sand Tray Figures: ones with dual identities (mermaid, half human/horse)
Doll House and Dolls
Monster Trucks and Racing Cars
Super Heroes and Action Figures

33. Ideas to help Children with Gender Dysphoria
The Assessment (Observe)
Have a basket with 4 or 5 toys in it (examples truck, princess doll, cars, merman).
OBSERVE: watch for the families reactions to the toys that the child chooses to play with. The family’s reaction can give you insight to their acceptance and comfort level of the child’s choices.
Watch the family’s comfort level ith the client’s gender identity
Family’s communication style around gender

34. Ideas to help Children with Gender Dysphoria
Create Gender Variant Figures
Each family member creates a gender variant figure
Materials Needed: fabric, glue, yarn, markers, and wood peg dolls
Once each gender variant/ gender non conforming figure is created they can be used to help facilitate discussion:
1. What the person chooses to make and why?
2. Explore feelings of the figure.. EX: if real person, what would they need to feel happy/ loved?
3. In family Sculpture
4. Sand Tray
5. In pretend play: Doll house

35. Ideas to help Children with Gender Dysphoria
Sand Tray
Barbara Turner: “The act of creating three dimensional sand plays facilitates healing and transformation by bringing up conflicts from the unconscious in symbolic form and by allowing a healthy re-ordering of psychological contents.”
EXAMPLE: Client may continuously bury things in the sandtray which may mean that they have a secret or they need to keep something hidden in their life.
ACTIVITY:
Can bury their figures in the sand and find them again. Can ask question about what _______ needs in order to come out of the sand (Mokalla, 2011).
Helps to brings up difficulties for the children and find solutions to the conflict.

36. Ideas to help Children with Gender Dysphoria
Box of Love
Children struggling with gender dysphoria usually struggle with feeling accepted and loved. They have lower self-esteem.
Have parents write positive one liners on strips of paper.
The papers are then put into the box.
When the child feels down, he can pull out the strips of paper from the box and read them in order to feel better.

37. Ethical Considerations Keep in Mind
"While we are all free to hold our personal beliefs, a counselor must practice according to professional ethics that require him/her not to impose beliefs onto the clients."
"The specification of a code of ethics enables the association to clarify the nature of the ethical responsibilities held in common by its members“ -ACA Code of Ethics: Do the right thing.
Congruence and diversity
Impairment and referrals

38. Ethical Considerations Keep in Mind
Treatment modalities
Dual/multiple relationships
Don’t self disclose
Know yourself and if you can’t treat the population, refer out.
Don’t try to change your client, adhere to their wishes.

39. Other Resources Please Use Them
Gender Specturm:
Mermaids: mermaidsuk.org.uk
PFLAG:
TransKids Purple Rainbow Foundation:
Association for Lesbian, Gay, Bisexual, & Transgender Issues in Counseling:

40. Summary of the Webinar
Define Sexual Orientation, Gender Identity, and Gender Expression
Define the Different Populations
Understand Gender Variance and Gender Fluidity
Change in Diagnosis (History to Present): The Debate
History of Treatment Modalities
LGBTQIA Competencies
Discuss unique issues that bring the LGBTQIA population into treatment
Learn different techniques to use in therapy
Beware of Ethical Considerations