Module 4
Sexual Orientation
A. Intersectional Issues for LGBTQ+ Individuals
Multicultural counseling has expanded to include various intersections of identity,
including sexual orientation. Counseling from this perspective must incorporate an
understanding of the complexities associated with multiple identities inherent in clients,
including the fact that many come from multiple oppressed statuses. Multicultural
competence with respect to sexual orientation may be addressed through increased
awareness of counselors’ assumptions, values, and biases regarding sexual orientation;
awareness of clients’ worldviews regarding sexual orientation; and clinical and advocacy
intervention strategies that are culturally appropriate. This chapter defines and discusses
concepts relevant to sexual orientation and presents implications for counseling lesbian,
gay, bisexual, queer, and other nonheterosexual clients. In addition, we discuss the
intersections of sexual orientation with race, gender, ethnicity, and culture because clients
may hold multiple marginalized statuses. Since the research on sexual orientation and
heterosexism often intersects with gender and sexism, some information in this chapter
relates to a broader group of lesbian, gay, bisexual, transgender, questioning, and other
nonheterosexual and gender expansive (LGBTQ+) individuals. Given that sexual
orientation and gender identity is increasingly viewed as fluid, the above acronyms do not
necessarily capture all categories of sexual and gender identities. Thus, information
contained in this chapter may not necessarily be generalizable to all of the
nonheterosexual and gender expansive clients with whom you work.
Sexual orientation is sometimes difficult to define and distinguish because it is
often related to gender under the term sexual identity. Sexual identity includes (a)
physical identity, (b) gender identity, (c) social sex role identity, and (d) sexual
orientation identity (American Psychological Association, 2011). Whereas sex is a
category, historically framed in the male-female binary, and is assigned at birth based on
primary sex characteristics, gender identity is the belief a person has about his, her, or
their gender (i.e., the psychological sense of being male, female, both, or neither), and
social sex role identity is the gender roles people adopt or adhere to based on cultural
norms for feminine, masculine, or androgynous behaviors. For example, a male assigned
at birth may have a female gender identity, feeling more like a woman emotionally and
spiritually, and may have a female social sex role identity, adopting societal behaviors
and appearances of a woman. Sexual identity is different from gender identity, involving
a person’s sexual and emotional attractions or lack of attractions to members of the other
and/ or the same gender.
Sexual orientation is described as consisting of a set of seven variables: (a) sexual
behaviors; (b) emotions; (c) sexual fantasies; (d) sexual attractions; (e) social preference;
(f) living life as a heterosexual, bisexual, or gay or lesbian; and (g) self-identification
(American Institute of Bisexuality, 2012). Heterosexuality, gay identity, bisexuality, and
asexuality are all possible culminations of the process of sexual orientation identity
development. Heterosexuality, the most common sexual orientation identity, refers to
aesthetic, romantic, or sexual attraction to members of the opposite gender (in a binary
male–female system). People may or may not use the term straight to describe someone
who is heterosexual, because it can be considered a value-laden term. Homosexuality,
then, is one type of sexual orientation identity; however, homosexual is no longer a
preferred term used to refer to an individual or a group of people who have same-sex
feelings and behaviors and who identify with the LGBTQ+ community. Gay and lesbian
are acceptable terms because they are associated with positive, nonpathological identities,
include individuals’ emotional and affectional feelings, and refer to a cultural minority
group (i.e., the gay community; Chaney & Brubaker, 2018). In addition, the term gay can
be used to refer to men, women, and transgender people in a broad community and
culture. Bisexuality, another sexual orientation identity, refers to aesthetic, romantic, or
sexual attraction to members of either the same or the opposite gender. Most bisexual
people are not equally attracted to men and women, and many are exclusively attracted to
one or the other gender at different points in their lives. In addition, how bisexual people
define their relationships may differ from person to person (Bowes-Catton & Hayfield,
2015). Questioning is a term that refers to an individual who is questioning their sexual
orientation and/or gender identity. For many people, Q represents queer, a broad term that
includes anyone who does not identify as heterosexual. As societal attitudes toward
nonheterosexuals change, individuals are increasingly using nonbinary categories to
describe their sexual orientations, including pansexual (an individual whose sexual and/or
affectional attractions are not limited to what is based on gender identity or biological
sex) and heteroflexible (someone who identifies as primarily heterosexual, but may
engage in limited situational same-sex sexual behavior yet does not identify as bisexual).
Asexual people often do not experience sexual attractions to others, and though they may
feel romantic feelings, they may not act on those feelings in a sexual manner. Culturally
sensitive counselors will ask clients how they refer to themselves and will use language
the client uses.
Some researchers have suggested the use of the term affectional orientation
(Lambert, 2005) to describe sexual marginalized identities (i.e., LGBTQ+ individuals)
because it broadens the discussion beyond simply sexual attraction. Sexual orientation is
seen by some as a societal construct that serves to oppress, marginalize, and reduce
LGBTQ+ individuals’ identity to the largely taboo realm of sexual behavior. Because
LGBTQ+ relationships are not based solely on sexual attraction, perhaps affectional
orientation may be a more accurate term. Like heterosexual relationships, LGBTQ+
relationships involve attraction based on intelligence, emotional stability, communication
style, and other interpersonal factors and feelings that exist for many couples. The term
affectional orientation may also be more appropriate because it allows the LGBTQ+ or
questioning clients to use a broader spectrum of emotional language to explore or
accurately represent the experience of attraction. In sum, LGBTQ+ identity is one
component of sexual orientation identity. A gay or lesbian identity includes having same-
sex behaviors, but also includes attractions, emotions, and a sense of connection with a
gay community.
Heterosexism is defined as the oppression of LGBTQ+ individuals that involves
prejudice and discriminatory behavior (Jun, 2018). Societal norms valuing heterosexual
identity and practices are a major component of heterosexism, which in turn may devalue
the lives of LGBTQ+ people. Heterosexism also includes the enforcement of
heterosexual norms that may be consciously or unconsciously endorsed by individuals
and institutions. In this manner, prejudicial and discriminatory acts, policies, and
behaviors are heterosexist. Heterosexism in these forms is additionally problematic
because it considers heterosexuality to be the “norm” and model of sexual identity for all
people. Because heterosexism is a systematic oppression of LGBTQ+ identity, counselors
will likely work with LGBTQ+ individuals who have internalized this devaluation of
their sexual orientation. Internalized heterosexism, the internalization of society’s
negative attitudes toward nonheterosexuals, may emerge in counseling sessions as a
comparison to a heterosexual norm and an overriding belief system that heterosexuals are
“better than” individuals who are LGBTQ+. Internalized heterosexism often manifests in
LGBTQ+ clients as unrecognized shame. Heterosexism originates from, and is
maintained by, stereotypes that individuals hold about those who are LGBTQ+.
To illustrate the development of heterosexism and how deeply ingrained it is
within our society, one only needs to explore the experiences of the Berdaches, or two-
spirit people of North America. In simple terms, Berdaches and two-spirit refers to First
Nations and Indigenous people who may identify as LGBTQ+. Historically, in many
Native traditions, two-spirit people were an important part of the social and religious
structures. Two-spirit people were viewed as having the ability to move between two
worlds, the physical and spiritual realms (Robinson, 2019). They would bring what they
learned in both worlds back to their tribes to teach others about balance. Thus, many
Native societies valued the contributions of two-spirit people. However, colonization
brought with it puritanical, heteropatriarchical and heteronormative values, which were
forced upon Native people. Many Native people assimilated to these heteronormative
attitudes and beliefs, which were handed down, intentionally and unintentionally, from
generation to generation. As a result, many Indigenous people condemn and have
negative attitudes about LGBTQ+ Native people because of the influence of European
and American religion and culture.
A related term that many people often confuse with heterosexism is homophobia.
Homophobia is defined as fear and hatred of people who are LGBTQ+ (Bullough, 2018).
Homophobic acts may include hate crimes against individuals who are LGBTQ+ and
their communities—crimes that range from verbal to physical assault and are therefore a
component of the larger system of heterosexist oppression. Indeed, hate crimes are a real
concern for the LGBTQ+ community, especially because the Federal Bureau of
Investigation (FBI) ranks anti-LGBTQ+ violence as the third-largest group of hate
crimes, after racial and religious-based hate crimes, in the United States (U.S.
Department of Justice, 2018). In fact, 17.0% of all single-bias hate crimes documented by
the FBI in 2018 were motivated by sexual orientation (and many anti-LGBTQ+ hate
crimes go unreported). These crimes were associated with anti-gay male bias (59.8%),
anti-LGBT bias (mixed group,G 25.1%), anti-lesbian bias (12.2%), anti-bisexual bias
(1.5%), and anti-heterosexual bias (1.5%). The same report revealed that the perpetrators
of the hate crimes were more likely to be White males (53.6%) and over the age of 18
years (84.7%). Most of the hate crimes took place in or near residences and homes
(29.4%), on highways, roads, alleys, streets, or sidewalks (21.7%), and at schools or
colleges (8.1%). Hate crimes involving sexual orientation are some of the most brutal and
violent hate crimes that have been documented and include murder (National Coalition of
AntiViolence Programs, 2021). Fortunately, in 2009 the U.S. Congress passed federal
hate crimes legislation that included laws against hate crimes motivated by sexual
orientation or gender identity (National Gay and Lesbian Task Force, 2014). In thinking
about the systemic oppression of people who are LGBTQ+, it is important that counselors
keep in mind that researchers and social justice advocates have recommended using terms
such as homonegativity (Berg etGal., 2016) to acknowledge the devaluation of individuals
who are LGBTQ+. Regardless of the terminology used, the systemic heterosexist and
homophobic oppression contributes to individuals who are LGBTQ+ being treated as one
of the most denigrated and invisible groups in society, often because they live outside the
box of traditional heterosexual norms.
A system of heterosexism confers unearned advantages onto heterosexual people
— a phenomenon called heterosexual privilege. It is important for heterosexual
counselors to recognize this privilege and its related impact on the mental health of
people who are LGBTQ+. (See Activity 6.2.) Heterosexual privilege includes adoptive
and child rights, fewer economic barriers, and family counseling approaches that assume
patriarchal family structure as indicative of a functioning family system. Heterosexism
also gives heterosexuals the privilege of having their relationships validated by the media
and by colleagues in the workplace, in addition to being able to arrange to be in the
company of other heterosexual people in most environments.
There is much controversy surrounding the actual number of men and women
who identify as LGBTQ+. Current statistics do not include individuals who may be
uncomfortable disclosing an LGBTQ+ identity, youths and adults who have not yet
realized that they are LGBTQ+, and heterosexually married individuals who may also
identify as LGBTQ+. A 2011–2013 survey conducted by the National Center for Health
Statistics that included 9,175 Americans, aged 18 to 44, found that 6.2% of men and
17.4% of women had same-sex sexual experiences by age 44 years. Approximately 1.3%
of women between the ages of 18 and 44 years identified as lesbian and 5.5% bisexual;
approximately 2% of males between the ages of 18 and 44 years identified as gay and 2%
as bisexual (Copen etGal., 2016). Note that a samesex intimate encounter does not
necessarily constitute an LGBTQ+ identity, nor does the absence of a same-sex sexual
experience mean that someone is heterosexual. These discrepancies illustrate the
difficulty in accurately identifying the precise number of individuals who are LGBTQ+.
Although the statistics are likely underestimated, a 2017 Gallup poll reported that 4.4%
of Americans identified as LGBT (Newport, 2018). The Williams Institute estimated that
there are 13Gmillion people, 13 years and older, in the United States who identify as
LGBT.
Because many helping professionals and researchers discuss LGBTQ+ people
only in terms of sexual identity and sexual behavior, issues of race, class, ability, and
gender are either forgotten or ignored. Indeed, the above-mentioned poverty statistics
highlight the intersection of multiple identities that may negatively influence the well-
being of LGBTQ+ communities. Culturally sensitive, nonheterosexist counselors should
assess the multiple identities of their clients who are LGBTQ+. Scholars have discussed
the experiences of individuals who have two to three oppressed statuses based on race,
culture, gender, or sexual and affectional orientation (Overstreet etGal., 2020). For
example, a Black lesbian may experience oppression in the form of sexism because she
identifies as a woman, racism because of her racial heritage, and heterosexism for
identifying as a lesbian. A major issue for individuals who are LGBTQ+ of color is
establishing healthy racial and sexual identities simultaneously. It can become quite
complex to disentangle how various forms of oppression (e.g., heterosexism, racism)
affect an individual’s sexual orientation identity.
Like other people of color, Black individuals who are LGBTQ+ have to negotiate
multiple identities that have been historically oppressed. Having to deal with both racist
and heterosexist societal messages increases their risk of internalized oppression.
Internalized racism and heterosexism are detrimental to one’s self-esteem and increase
emotional distress (Velez etGal., 2015). In addition, it seems that, for these individuals,
internalized heterosexism is a greater predictor of psychological distress than internalized
racism. One explanation for this link could be due to the role the Black church has
historically played in the lives of many Black individuals. Because religion and
spirituality have been a foundation within this community, persistent negative messages
about same-sex behavior are pernicious to these individuals’ identity development and
psychological well-being. The problem is that, although individuals may internalize
negative messages from the church, many Black individuals who are LGBTQ+ look to
the church as a source of support. In this regard, early research found a buffering effect of
religious faith against the shame of internalized heterosexism among LGBTQ+ Black
adults, a finding that may be explained by resiliency from these social support networks
(Garrett-Walker & Longmire-Avital, 2018). These findings demonstrate the complex
intersection of the multiple identities counselors and clients must navigate.
Individuals of Asian and Asian American descent and who are LGBTQ+ also
contend with the negative consequences associated with multiple oppressed statuses.
Stigma management is one strategy used by oppressed groups to deal with the
disenfranchisement. Among individuals who are LGBTQ+ and Asian and Asian
American descent, stigma management is often a collective behavior. Han etGal. (2014)
found that one way that men who identify as gay and of Asian descent manage the racial
stigma they experience within the larger White gay community, is by distancing
themselves from all things perceived to be Asian and aligning themselves with things
associated with the larger White dominant community. However, this cultural distancing
can lead to lower self-esteem and greater marginalization from the White gay
community. Lack of support and acceptance is not limited to the dominant White gay
community. Because some Asian cultures devalue LGBTQ+ identities, many LGBTQ+
individuals who are of Asian descent do not receive needed support from their families
and communities after coming out— a situation that can lead to profound distress and
rejection. For those individuals, heterosexism in Asian American communities is a
predictor of psychological distress (Ching etGal., 2018). Clearly, for many of these
LGBTQ+ individuals who are of Asian and Asian American descent, managing their
multiple identities becomes a complex balancing act.
Specific attributes of Latin culture contribute to the difficulties many LGBTQ+
individuals who are of Latin and Latin American descent experience during the coming-
out process. For example, traditionally, many individuals of Latin and Latin American
descent have a strong religious identification (e.g., Catholicism), and, historically, many
denominations have judged people who are LGBTQ+ negatively. For example, Schmitz
etGal. (2020) found that religious and cultural values were viewed as problematic when
one comes out and contributed to negative reactions on the part of family members. An
additional factor that makes coming out more difficult for some individuals of Latin and
Latin American descent is the role that masculinity plays in some Latin cultures within
the United States. Similar to members of the other cultural groups discussed, individuals
who are of Latin and Latin American descent and LGBTQ+ are just as prone to anti-
LGBTQ+ and racial discrimination because they possess multiple oppressed statuses:
being a person of color and being nonheterosexual (Velez etGal., 2015). Interestingly,
Ibañez etGal. (2009) noted that men who identify as gay and of Latin and Latin American
descent reported experiencing more racism within the gay community than in general,
although racist experiences were reported in general as well.
As previously mentioned, the term two-spirit has been used frequently in
academic literature in multiple ways to describe some individuals of Native American
descent, including those who do not identify as heterosexual, those who identify as
transgender, and those whose gender roles do not conform to the socially expected
behaviors of their assigned sex. Robinson (2017) wrote that the term two-spirit emerged
in 1990 to describe third or fourth gender Indigenous people. Historically, two-spirit
individuals had specific societal roles within their respective communities, such as
educating children and possessing specific spiritual responsibilities. In other words, they
were valuable members of their communities. Today, individuals who are LGBTQ+ and
of Native American descent experience the consequences of heterosexism, just like any
other group of individuals who are LGBTQ+. This situation is partially due to Western
cultural influences, but also due to long-held traditions about strict gender roles for men
and women that are passed down by some tribal communities. Gilley (2010) noted
exclusionary practices of two-spirit men in their tribal communities if they were openly
gay or gender different. Specifically, the men believed that they would not be able to
participate in tribal practices if they were open about their sexual orientation. Two-spirit
men who were open about their identities were denied the right to engage in ceremonies
or were asked to leave a ceremony. What this narrative illustrates is that many individuals
who are LGBTQ+ and of Native American descent—especially those who live within
tribal communities—often have to negotiate and balance their intersecting identities.
In general, there is very little published information about the counseling needs of
individuals of Middle Eastern, Arab, and/or Chaldean (MEAC) descent and only a couple
of published empirical studies that have focused on LGBTQ+ members of these cultural
groups specifically. One explanation for the lack of attention in the counseling literature
is the distinct challenges associated with the multiple oppressed identities of these
cultural groups. For many LGBTQ+ individuals who are MEAC, attempting to integrate
their sexual identities and religious or spiritual beliefs can lead to psychological and
social conflicts. Individuals who identify as Muslim and MEA (Chaldeans are
intentionally excluded here because of their Christian affiliation) may view their
nonheterosexual identities as a direct contradiction to Islamic messages that view same-
sex attractions or behaviors as an inappropriate social norm. Jaspal and Cinnirella (2014)
found that gay Muslim men perceived their Muslim identities as being jeopardized
because of their gay identities. This sense of vulnerability led the gay men to hyper-
affiliate with the Muslim faith as a way to protect the genuineness of their Muslim
identity. Similarly, LGBTQ+ individuals who are MEAC and Christian may also
experience distress as a result of negative messages about the incompatibility of same-sex
attractions and behaviors with traditional Christian doctrine.
Some queer studies writers (Adams-Santos, 2020; Butler, 2004; Johnson &
Henderson, 2020) have asserted that heterosexism is a “weapon” of sexism, in that
heterosexism functions to systemically and narrowly define gender roles and enforce
compulsory heterosexuality. Certainly, the link between heterosexism and sexism is
multifaceted and complex and goes beyond the mere fact that “sexism” is included in the
word heterosexism. In a classic composition, feminist activist and academic bell hooks
(1981) asserted that “challenging sexist oppression is a crucial step in the struggle to
eliminate all forms of oppression” (pp.G 35– 36). In terms of complexity, the connection
between heterosexism and sexism includes the enforcement of gender roles through
socialization practices. For instance, boys are raised with the goal of “becoming a man,”
which often includes values of emotional restraint, assertiveness, the role of “protector”
of the family, competition, and the avoidance of displaying vulnerability. The intersection
of sexism and heterosexism becomes clear in the derogatory language (e.g., “faggot,”
“sissy”) that is used when a boy steps outside traditional gender norms for males. Girls,
by contrast, are socialized to be caregivers, to be dependent on others, to display
emotions, and to avoid being viewed as “too strong.” When girls and women cross the
boundaries of strict gender roles, they are often the recipients of epithets such as “bitch”
or “aggressive” when asserting their needs. Culturally competent counselors should have
a firm understanding of the aforementioned definitions because much of the power of
heterosexism is rooted in the meanings society gives to nontraditional behaviors,
thoughts, and emotions. In addition, culturally competent counselors should understand
how heterosexism intersects with classism.
Counselors who work with adolescents should be aware of the unique pressures
faced by LGBTQ+ youths. With the threats of rejection, discrimination, and violence,
sexual and gender minority youth experience higher levels of sadness and risk of suicide
compared to their heterosexual peers (Johns etGal., 2020). In fact, the Gay, Lesbian and
Straight Education Network (GLSEN, 2014) reported that, among 16,713 youth between
the ages of 13 and 21 years, 68.7% noted experiencing verbal harassment based on their
sexual orientation, 25.7% reported physical harassment (e.g., being pushed or shoved),
and 11.0% reported physical assault (e.g., being injured with a weapon or punched;
Kosciw etG al., 2020). Some of the bullying was electronic; 44.9% of students reported
being harassed via text or other social media venues, such as Facebook. Many public
schools have successfully fought against racism and sexism but dealing with homophobia
has been more challenging. High schools may be reticent to show approval of gay and
lesbian youths out of fear of appearing to overstep parental authority or religious
doctrine. The general thinking seems to be that the schools are telling students what to
think, and they may be teaching them attitudes that are opposite what is being taught at
home.
Some adolescents who are LGBTQ+ exist in social, emotional, and informational
isolation because teachers and other school staff do not take steps to protect them from a
hostile environment (Kosciw etG al., 2020). GLSEN reported that 98.8% of students
identifying as LGBTQ+ had heard the word gay used in a negative way, and over 95.2%
had heard homonegative words used to describe people who are LGBTQ+. Students who
are LGBTQ+ risk losing peer status by letting others know about their personal feelings,
so they may choose to remain silent and try to “pass.” Although many schools often fail
to protect and affirm students who are gay, the federal government, courts, and mass
media are taking proactive steps to improve the lives of gay students. The Equal Access
Act (20 U.S.C. sectionsG4071–74) states that “it shall be unlawful for any secondary
school which receives Federal financial assistance to deny access or a fair opportunity to,
or discriminate against, any students who wish to conduct a meeting on the basis of the
religious, political, philosophical, or other content of the speech at such meetings.”
Despite this clear mandate, many local school boards are embroiled in a controversy over
the existence of gay– straight alliances. These noncurricular clubs seek to increase
understanding, promote respect, and diminish fear around sexual orientation issues. Many
school boards have refused to let such clubs meet, despite protection by the First
Amendment and the Equal Access Act.
Lesbians and gay males in the U.S. population are relatively young, with mean
ages in the early forties (Gates, 2014a). Competent counselors take into consideration a
client’s emotional age, as well as chronological age, when strategizing effective
interventions for youths who are LGBTQ+. It is common for individuals who come out
as LGBTQ+ in adulthood to experience a late adolescence that they did not have when
most heterosexual peers went through adolescence. In relation to the process of
disclosing one’s sexual orientation to others or the self-realization of an LGBTQ+
identity (i.e., coming out), the average age a person comes out to others has decreased
over the decades, with more recent studies showing first disclosure about 14 years old
(Russell & Fish, 2016). Rothman and colleagues (2012) reported individuals are more
likely to first come out to their mothers than their fathers. This discrepancy is likely due
to stereotypical gender roles. For example, it may be easier to come out to mothers, who
are socialized to be nurturing and accepting, whereas fathers are expected to be strong
and masculine. There may also be a greater fear of being rejected by a father than by a
mother. Of those individuals who choose to come out, 10% to 15% are rejected by their
parents. Many youth who are LGBTQ+ and who have been rejected by their parents end
up homeless and struggling on the streets, a tragedy that will be discussed later in the
chapter.
In general, individuals who are lesbian or gay have more formal education than
their heterosexual counterparts. Approximately four in ten individuals who are LGB
(This particular study did not assess transgender and queer people) have college degrees,
compared with three in ten non-LGB people (Gates, 2014a). These statistics show that an
estimated 60% of LGB individuals do not have college degrees. This fact is important
because higher education and higher income have been found to be related to increased
odds of an individual identifying as LGBTQ+ and to living in a predominantly LGBTQ+
neighborhood (Badgett etGal., 2019). In addition, individuals who are LGB are just as
likely as heterosexuals to live in poverty, as is evidenced by a recent report that LGB
Americans are less likely than non-LGB individuals to be thriving financially (Gates,
2014b). Possible reasons for these findings are a lack of protection against employment
discrimination in most states and a lack of family support (Conron & Goldberg, 2020).
Another possible explanation for the discrepancies in educational attainment could be the
negative academic experiences that many LGBTQ+ youth have.
Although individuals who are LGBTQ+ generally have more education than their
heterosexual peers, potentially leading to higher paying jobs, a 2018 survey found the
home ownership for LGBTQ+ people (49%) is lower than the general population (64%;
Statista Research Department, 2019). Part of the reason may be that some states have
laws that prohibit unmarried couples from owning a home together. However, the U.S.
Census Bureau’s (2019b) American Community Survey reported that gay male couples
have higher mean household incomes than heterosexual couples have, and lesbian
couples have lower mean household incomes than heterosexual couples and same-sex
male couples (Glassman, 2020). Although individuals who are LGBTQ+ live everywhere
in the United States, many choose to live in large metropolitan cities, where there tends to
be greater acceptance. Gates (2015) reported that the following cities with populations
over 100,000 have the highest number of individuals who identify as LGBTQ+: San
Francisco (6.2%), Portland (5.4%), Austin (5.3%), New Orleans (5.1%), and Seattle
(4.8%). Because many individuals who are LGBTQ+ choose to live in these more
accepting cities, which generally have higher costs of living, members of the LGBTQ+
community who cannot afford to live in such cities often remain invisible. In fact, 26.1%
of LGBTQ+ people live in rural areas, and 21% live in urban areas (Badgett etGal., 2019).
Thus, many working-class LGBTQ+ people may not have the resources to move to
higher amenity queer neighborhoods. As a result, some working-class LGBTQ+ people
remain closeted, living in nonaccepting areas, where there is an increased likelihood of
experiencing psychological distress, physical violence, and poverty.
Although less so than the general U.S. population, over three-quarters of
individuals who are LGB participate in religious organizations, most of which are
Christian, identifying as Protestant (29.7%), Catholic (19.7%), or born again Christian
(17.5%; Herek etGal., 2010). Other groups represented in the LGB population are
Wiccans/Pagans (3.1%), Buddhists (2.6%), and Jews (1.2%), with the remaining quarter
(24.2%) identifying as atheist or agnostic, or reporting “none” for their religious
affiliation (Herek etGal., 2010). National data on transgender, queer, questioning, and
intersex populations are lacking. Because of the historical opposition of traditional
religious beliefs and same-gender attraction, as well as the rejection of nonconforming
gender identity, it is easy to see how many who identify as LGBTQ+ struggle to integrate
religious beliefs and practices into their lives.
Many queer individuals grow up in churches, mosques, or synagogues that abuse
them. Super and Jacobson (2012) define this religious abuse as “when a religious group
or leader, whether intentionally or unintentionally, uses coercion, threats, rejection,
condemnation, or manipulations to force the individual into submission of the religious
views about sexuality” (p.G180). Messages about feeling “dirty,” becoming a child
molester, and engaging in shameful acts are common examples of such abuse (Beagan &
Hattie, 2015). Unfortunately, this experience is common among those who identify as
LGBTQ+, both young and old, and the experience can be quite damaging. Consequences
include self-loathing, the loss of close relationships, poor body image, depression, and
suicide. Early research has shown that people who are gay or lesbian from nonaffirming
Christian traditions have higher rates of internalized heterosexism. More recently,
researchers found lesbian, gay, and bisexuals who engage in religious activity were more
likely to experience internalized heterosexism. Alternatively, spirituality was not
predictive of this form of internalized oppression (Stern & Wright, 2018). The response
to oppressive religious institutions varies, with some rejecting their LGBTQ+ identities,
others leaving organized religion altogether, and others integrating their seemingly
opposing identities (Beagan & Hattie, 2015). Although negative religious experiences can
be damaging, affiliating with affirming religious traditions may benefit psychological
well-being among LGBTQ+ populations (White etGal., 2020). Accordingly, it is less
surprising to see how integration is an appealing option for some. Beagan and Hattie
(2015) noted that integration strategies may include changing one’s beliefs, changing
congregations or denominations, changing the degree of participation, or even changing
to a new religious practice. With increasing options for affirming congregations,
denominations, and religions, it now appears that LGBTQ+ individuals and families have
more alternatives to engage in supportive communities of spiritual practice than ever
before. Counselors are often part of this support network, and in order to function in it
effectively, they must identify and address any value conflicts that may inhibit their
ability to serve their clients who are LGBTQ+.
U.S. Census Bureau (2020d) data estimate that 980,276 same-sex couples
(462,215 male–male couples, 518,061 female–female couples) live in the United States.
Of this total, 58% are married. In addition, LGBTQ+ couples are increasingly choosing to
expand their families, with 31% of same-sex couples raising children (U.S. Census
Bureau, 2020b). As will be discussed later in the chapter, the effects of institutional
heterosexism on lesbian and gay couples and their children are numerous. One example is
in the area of same-sex parent adoption. Following the defeat of Mississippi’s ban on
same-sex couple adoption in 2016, all 50 states legally allowed LGBTQ+ parents to
adopt, yet discrimination persists (Barbash, 2016). Without specific laws protecting the
rights of these couples, state agencies may continue to engage in discriminatory practices
(Farr & Goldberg, 2018). As of this writing, there are only 25 states and the District of
Columbia to provide LGBTQ+ individuals seeking to be adoptive or foster care parents
legal protections against discrimination based on their sexual orientation and gender
identity (Movement Advancement Project, 2020). In addition, 11 states allow child
welfare agencies licensed by the state to refuse services to LGBTQ+ parents based on
religious beliefs. Myths commonly used against LGBTQ+ individuals seeking to adopt or
foster children include the following: “Children need biological parents,” “Children
raised by same-sex parents are more likely to develop gender and sexual disorders,” and
“Children need a mother and a father”.
B. Consequences of Heterosexism
The effects of heterosexism on the lives of clients who are LGBTQ+ are many.
What follows is a brief summary of current scholarship addressing how individuals who
are LGBTQ+ are harmed by overt and covert heterosexism, homo-negativism, and
internalized homophobia. Historically, many mental health providers have attributed
mental health problems to individuals who are LGBTQ+ without considering
environmental factors affecting mental well-being. Attribution bias is a cognitive bias
that influences how we conclude who or what is responsible for an event. Attribution bias
is often unconsciously placed on clients who are LGBTQ+. Culturally sensitive
counselors are starting to realize that mental health problems are not necessarily a
product of “broken” individuals; rather, they are a function of social inequities that
become toxic for the individuals affected (Velez etGal., 2019). One aspect of poisonous
social environments that affect the mental health of individuals who are LGBTQ+ is
stereotypes. Often not thought about are the stereotypes associated with the entire
LGBTQ+ community’s mental health. Although stereotypes at times may help give
meaning to certain situations or groups of people, in general, stereotypes that lead to
selective discrimination and prejudice are socially unjust and can cause those to whom
they are applied much psychological pain. Some researchers have even proposed that
individuals who engage in heterosexist acts have their own psychopathology.
In general, individuals who are LGBTQ+ seek out counseling more than their
heterosexual counterparts (Grella etGal., 2011). It is not that individuals who are LGBTQ+
are innately more mentally unstable; rather, persons who are LGBTQ+ experience the
ramifications of heterosexism and homonegativism. Research has consistently
demonstrated that heterosexism, sexism, and internalized homophobia are related to
psychological distress. Specifically, individuals who are LGBTQ+ are more likely than
persons who are heterosexual to experience depression, suicide, anxiety, and substance
abuse disorders (Brubaker & Chaney, 2017; Greene etGal., 2016; Velez etGal., 2019). In
this regard, let us explore in greater detail the relationship between heterosexism, on the
one hand, and suicide and depression, self-esteem and stress, and the mental health of
youths who are LGBTQ+, on the other.
One of the most devastating mental health consequences of heterosexism among
many individuals who are LGBTQ+ is depression and suicidality (both ideation and
attempts). Individuals who are LGBTQ+ report disproportionately higher numbers of
suicidal thoughts and suicide attempts than their heterosexual peers. This statistic is often
attributed to growing up hearing negative messages about being LGBTQ+, to shame, and
to depressive symptoms related to living in a heterosexist and homophobic society.
Specifically, LGBTQ+ individuals are up to seven times more likely than heterosexuals
to attempt suicide (Haas etGal., 2011) and are overrepresented in the number of completed
suicides (Hatzenbuehler etGal., 2014). Meyer etGal., (2014) found that LGBTQ+ suicide
attempts are more likely to occur during developmental milestones associated with
coming out (e.g., first recognition of same-sex attraction, disclosing sexuality to others).
Interestingly, they also found that receiving mental health treatment or medical treatment
did not prevent the suicide attempts. In addition, LGBTQ+ individuals who sought out
religious or spiritual assistance were more likely to attempt suicide later than individuals
who received no treatment at all. A possible explanation for these results could be the
anti-LGBTQ+ messages conveyed by many, but not all, religious groups.
For LGBTQ+ people of color, the risk for depression and suicidal behavior is
exacerbated by their additional oppressed identities. For example, Meyer etG al. (2014)
found that individuals who are LGB and African/African American or Latin/Latin
American descent reported a greater proportion of serious suicide attempts than White
LGBs. This result is consistent with a recent study which showed that individuals of
African/African American and Latin/Latin American descent who are LGB are at an
increased risk for suicide attempts (O’Donnell etGal., 2011). Reports such as these are not
limited to individuals who are LGBTQ+ and of African/African American or Latin/Latin
American descent. For example, Bostwick etGal. (2014) reported that suicidal ideation and
attempts tend to be higher for individuals of Native American descent, Pacific Islanders,
and those of multiracial descent, but lower for those of Asian/Asian American and
African/African American descent. Belonging to multiple stigmatized cultural groups
contributes to the disparity in reports of depression and suicide. In addition, greater
pressure to conform to cultural values and norms among these populations increases the
risk of depressive symptomatology and suicidal behavior.
Among LGBTQ+ youths, abuse and harassment often lead to low self-esteem,
depression, suicidal ideation, and self-harm (Johns etGal., 2020; Kosciw etGal., 2020).
Across studies, sexual minority youths report significantly higher rates of depression and
suicidality than heterosexual youths, a finding attributed to the stigma, violence, and
other forms of oppression those young minorities encounter (Burton etGal., 2013). Their
disproportionately high numbers of suicide attempts and ideation may be attributable to
heterosexist and homophobic messages that individuals who are LGBTQ+ hear in
schools, churches, the media, and the larger society that directly attack an individual’s
self-perception and self-worth. For example, some common negative messages are direct
name-calling (e.g., faggot, dyke, queer), same-sex relationships are viewed as an
abomination in the eyes of God, and perceiving being gay as unnatural. More covert
negative messages are related to the lack of visible mentors and role models who are
LGBTQ+ in schools and universities, on television, and in music and other forms of
popular culture, although the number of “out” public figures is increasing. When
individuals who are LGBTQ+ are visible in popular culture (e.g., in movies or on
television), they are often stereotyped, pathologized, and used to entertain heterosexual
male audiences. Visible, positive representations of people who are LGBTQ+ and of
color are nearly nonexistent in popular culture. Thus, these messages increase levels of
internalized heterosexism and put members of the LGBTQ+ community at increased risk
for depression and suicide.
Stress associated with being a member of an oppressed group is called minority
stress. Meyer (2015) defined minority stress as the extreme stress experienced among
individuals from stigmatized social groups due to their marginalized social position.
According to Meyer, people who are LGBTQ+ have three general sources of minority
stress. First, they might experience stress caused by chronic or acute outward events or
conditions—for example, anti-LGBTQ+ slurs, anti–same-sex marriage laws, and bullying
of youths who are LGBTQ+. A second source of minority stress is the expectation of
discriminatory events and the anticipatory energy this expectation requires. It takes a lot
of mental and physical energy out of LGBTQ+ individuals to be constantly “on guard” in
anticipation of possible persecution and discrimination. Finally, internalizing society’s
negative attitudes and feelings toward individuals who are LGBTQ+ (i.e., internalized
homophobia) creates a large amount of stress. Thus, heterosexist acts not only increase
the risk of an individual who is LGBTQ+ experiencing greater levels of stress, but, as
studies have shown, also have negative effects on a person’s self-esteem (Velez etGal.,
2015). Because self-esteem is related to self-perception, and because how we perceive
ourselves affects how we perceive our environments, it is not surprising that the mental
well-being of individuals who are LGBTQ+ is compromised more than that of their
heterosexual peers. At particular risk for diminished self-esteem and psychological
distress are youths with LGBTQ+.
The mental health consequences of growing up in a heterosexist and homophobic
culture are particularly troubling for youth who are LGBTQ+. As with other youths, this
period of development can be fraught with many challenges related to identity
development, the exploration of intimate relationships, and preparation for an uncertain
future in adulthood. But, unlike others at this age, youths who are LGBTQ+ often lack
needed coping strategies, as well as the support of family, teachers, and other potential
adult role models to help them navigate the ever-present social and emotional stressors in
their lives. As noted previously in this chapter, LGBTQ+ youth experience extremely
high levels of harassment and threats of violence, leading to higher rates of depressive
symptoms and risk of suicide (Johns etGal., 2020). These students also reported hostile
school climates in which they were treated unequally regarding public affection, gender
expression, and the public display of clothing that supports LGBTQ+ issues (Kosciw
etGal., 2020). In such cases, youth are sent a clear message that their nonconforming
identities, expressions, and affiliations are not welcomed by peers and adults alike.
Beyond the school environment, sexual and gender minority children and youth are more
likely than their heterosexual and cisgender counterparts to be sexually abused or to be
abused by a parent (Atteberry-Ash etGal., 2020; Friedman etGal., 2011). In total, youth
who are LGBTQ+ commonly live in unsupportive school or home environments, either
of which may contribute to compromised mental health and wellness.
Many youth who are LGBTQ+ attempt to escape and self-medicate their feelings
of worthlessness, depression, and anxiety by abusing substances. Data from the 2017
National Youth Risk Behavior Survey revealed sexual minority youth used illicit
substances at nearly twice the rate of heterosexual peers (23.1% vs. 12.3%), a trend
comparable to the misuse of prescription opioids (Centers for Disease Control and
Prevention, 2020b). Similarly, tobacco, alcohol, and marijuana use are also reported at
higher rates among LGBTQ+ youth in comparison to their heterosexual counterparts
(Kahn etGal., 2016). Students who are LGBTQ+ and who experience direct and indirect
heterosexism and homophobia often report experiencing distress well into adulthood. For
example, one study indicated that 17% of students who were LGBTQ+ and who reported
being bullied at school because of their actual or perceived sexual orientation experienced
posttraumatic stress in adulthood (Rivers, 2004). Furthermore, many people who are
LGBTQ+ and who experienced homophobic acts during their youth reported increased
levels of internalized homophobia, depressive symptoms, and anxiety symptoms in
adulthood (Russell etGal., 2011). As a result of experiencing anti-LGBTQ+ abuse in their
schools, many youth who are LGBTQ+ drop out of school, and many end up living on
the streets. It is also important to note how the increased rates of stressful childhood
experiences, such as emotional and physical abuse and neglect, all contribute to higher
mental health concerns later in life.
Although substance abuse is classified as a mental health issue, we include it as a
physical consequence of heterosexism because of its physical effects, including its
relationship to HIV/ AIDS. Ward etGal. (2014) reported that approximately 33% of
lesbians and gays are heavy alcohol users, compared with 22% of heterosexuals.
Research has demonstrated that heterosexism and internalized homophobia are related to
alcohol abuse for the lesbian and gay population (e.g., Dorn-Medeiros & Doyle, 2018).
Because heterosexism can lead to internalized homophobia, shame, and poor self-
perception, some members of the LGBTQ+ community resort to substance abuse to mask
these negative feelings. Because places in society where it is safe for people who are
LGBTQ+ to congregate freely are limited, gay bars continue to be the primary gathering
place for many who are LGBTQ+, a situation that may explain the high rates of alcohol
abuse among those in this group. Although many different drugs are used by portions of
the LGBTQ+ community, certain drugs tend to be more prevalent. For example,
marijuana, cocaine, psychedelics, methylenedioxymethamphetamine (Ecstasy), nitrate
inhalants, and methamphetamine are often abused.
Men who have sex with men (MSM) continue to represent most new HIV
infections. In fact, according to the CDC (2020b), MSM accounted for approximately
69% of all new HIV infections in the United States in 2018. Of these men, MSM of color
(37%) were particularly overrepresented in recent HIV infection rates (CDC, 2020b).
Individuals who are transgender are also affected disproportionately by HIV, with an
estimated 27.7% of transgender women found to be HIV positive (Herbst etGal., 2008).
Heterosexism is partly responsible for the high HIV infection rates among individuals
who are LGBTQ+. When youths who are LGBTQ+ come out to their families, many
experience homophobic reactions, such as violence and rejection. Some youths who are
attracted to the same sex leave home, and others are kicked out of their homes. To
survive on the streets, many youths who are LGBTQ+ engage in sex for money to meet
basic needs (Polaris Project, 2019). They are, however, less likely to practice safe sex.
Youths who are LGBTQ+ and homeless are at increased risk for contracting HIV because
some of them engage in survival sex and substance use (Keuroghlian etGal., 2014). This
behavior in turn puts them at greater risk for contracting HIV and other sexually
transmitted infections. Finally, HIV-positive, LGBTQ+ individuals who choose to hide
their sexual orientation are at greater risk for developing opportunistic infections.
Strachan etGal. (2007) found that CD4 cell counts (i.e., counts of cells that fight infections
in the human body) increased in men who disclosed their sexual orientation to others.
This is likely due to the relief of the distress associated with keeping such an important
secret hidden.
The negative stereotypes people have about individuals who are LGBTQ+ are a
social consequence of heterosexism. Historically, gay men have been viewed as
displaying feminine characteristics and rejecting masculine gender roles, while lesbians
were seen as being masculine, aggressive, and sexually deviant (Kite & Bryant-Lees,
2016). Such views persist, especially among people who hold conservative political and
religious beliefs (Worthen etGal., 2017). Other studies examining mental health trainees’
stereotypes of individuals who are LGBTQ+ have found that trainees believe that most
LGBTQ+ individuals have anxiety, personality, mood, eating, and sexual and gender
identity disorders (Boysen etGal., 2006). These stereotypes may contribute to individuals
who are LGBTQ+ reporting dissatisfaction with counseling experiences.
There is often a distorted view of the social class of the LGBTQ+ population.
Many people believe that individuals who are LGBTQ+ live extravagant lives because of
a perception that they have excess financial resources. Thus, people who are LGBTQ+
are seen as not needing economic, social, or health-related services (Lind, 2004). This
stereotype contributes to the invisibility of poverty among individuals who are LGBTQ+.
Most people may not think of individuals who are LGBTQ+ as affected by poverty.
However, heterosexism is directly related to financial hardship, for several reasons. One
reason is a disparity in LGBTQ+ personal earnings compared with earnings of coworkers
who are heterosexual. Research has consistently shown that men who are openly gay or
bisexual earn significantly less than heterosexual men with similar backgrounds
(McFadden, 2015). By contrast, women who are openly lesbian or bisexual more often
experience a wage premium compared with the wages of heterosexual women, largely
because lesbian and bisexual women are less likely to have children and be penalized
economically for doing so. However, since earnings contribute to lifestyle, many
individuals who are LGBTQ+ cannot afford to live in the high-amenity metropolitan
cities that tend to be more accepting and tolerant of the LGBTQ+ community. This
restriction results in many people who are poor and LGBTQ+ living in areas that might
be more homophobic and less tolerant. (e.g., smaller, more conservative cities).
Another social consequence of heterosexism is legalized discrimination in the
form of institutional heterosexism. Institutional heterosexism is the institutional
enforcement of heterosexuality as superior while denigrating LGBTQ+ identities. Anti–
same-sex marriage laws were an example of institutional heterosexism and have since
been overturned by the U.S. Supreme Court. There remain numerous local and state laws,
however, that seek to limit the ability of individuals who are LGBTQ+ and their families
to participate fully in society. In reaction to progressive legislation to advance the rights
and protections of sexual minorities, states have passed “religious freedom restoration
acts,” which allow any individual to refuse secular services (e.g., serving food, renting
property) to those who identify as LGBTQ+. There are also proposed and approved
legislation that seeks to restrict transgender individuals from using public
accommodations. Such legislation seeks to override local antidiscrimination laws
protecting individuals who are LGBTQ+.
How heterosexism diminishes interpersonal relationships is another consequence
of heterosexism. Internalized heterosexism may prevent individuals who are LGBTQ+
from reaching out to, and participating in, the queer community for fear of being
identified as a sexual or gender minority. Similarly, heterosexuals who may want to
participate in social events or engage in meaningful platonic relationships with LGBTQ+
individuals may experience a fear of being perceived as LGBTQ+ by heterosexual peers.
Some individuals who are LGBTQ+ may isolate themselves from family, particularly if
the family is not aware of the LGBTQ+ identity. To overcome these challenges,
LGBTQ+ individuals often create their family of choice, which may consist of biological
kin and friends considered family, to widen their support (Allen & Lavender-Stott, 2020).
TableG6.1 presents several examples of media resources for you to analyze for examples
of heterosexism and how it negatively impacts LGBTQ+ people. As with all resources
you consume to educate yourself about LGBTQ+ issues, be intentional to seek out
resources that reflect LGBTQ+ history accurately, represents the diversity within the
LGBTQ+ communities (e.g., queer people of color, non-binary people, etc.), informs you
about the psychosocial consequences of heterosexism, and has the potential to make you
a more competent counselor.
C. Sexual and Affectional Orientation
Research related to sexual and affectional orientations has come a long way since
early researchers such as Havelock Ellis, Alfred Kinsey, and Evelyn Hooker began to
study LGBTQ+ identities in the 1930s, 40s, and 50s. Early research tended to focus on
whether queer identity was associated with pathology. Today, a great deal of research
related to sexual and affectional identities has focused on the consequences of
heterosexism in the lives of LGBTQ+ people. For example, recent research has found
experiences of heterosexism to be correlated with substance use (DornMedeiros & Doyle,
2018), employment discrimination and involuntary job loss (FredriksenGoldsen etGal.,
2017), and PTSD symptoms (Dworkin etGal., 2018) to name a few examples. To prepare
counselors to treat LGBTQ+ clients who have been impacted by heterosexism, a growing
body of conceptual research has focused on queer affirmative counseling strategies and
best practices. For example, published research provides guidelines for conducting
LGBTQ+ affirmative counseling when working with older LGBTQ+ adults (Chaney &
Whitman, 2020), LGBTQ+ clients with career related concerns (Speciale & Scholl,
2019), and providing trauma-informed affirmative care for LGBTQ+ clients (Ellis, 2020).
Although characteristics of LGBTQ+ affirmative counseling are described in detail
below, the fact that, as a practice, LGBTQ+ affirmative counseling is underscored in
current research demonstrates its importance and effectiveness. Moreover, given that
participation in training on how to utilize affirmative counseling practices with LGBTQ+
clients has been shown to increase counselor competence (Pepping etGal., 2018),
developing new habits related to searching for and consuming this type of research and
related training at the start of your counseling career, will only lead to more successful
experiences with future clients.
Also, reflected in the current state of research pertaining to sexual and affectional
orientations is increased visibility of research focused on queer people of color (QPOC),
albeit, this is also an area of research needing more attention. Given that QPOC are at
even greater risk to experience discrimination and stigma than people who identify as
queer and White, competent counselors must have access to the most current research
pertaining to this population. Using minority stress theory as a framework, Cyrus (2017)
examined current approaches to understanding the influence minority stress has on the
mental health of QPOC. Relatedly, a qualitative study reported intersecting (race by
sexual identity by gender) microaggressions that negatively influence QPOC including,
but not limited to, exoticization of women of color, disapproval of queer identities by
racial, ethnic, and religious groups, invisibility and desexualization of queer men of color
from specific cultural backgrounds (e.g., Asian American men), and gender specific
expectations for Muslim women and men (Nadal etGal., 2015). More research is needed
that explores evidence based practices for counseling QPOC.
The abovementioned research areas are just a few examples of the current state of
queer research. Individuals interested in advancing these lines of inquiry may expand
LGBTQ+ related research by considering the following recommendations. Researchers
should not approach their studies from heteronormative and cisnormative perspectives
that assumes their sample is only heterosexual or that LGBTQ+ participants are one
homogenous group (Chaney, 2019). Further, even though researchers may not
specifically be interested in LGBTQ+ issues for their particular studies, assessing and
reporting diverse sexual orientations and non-binary identities, may indirectly inform
them about their sample of interest, by highlighting similarities or differences among
culturally diverse populations.
D. Socially Just, Nonheterosexist Training and Clinical Practice
Clearly, the negative consequences described in the previous section are just
glimpses into how heterosexism affects the lives of many clients who are LGBTQ+.
Because heterosexism has such a salient presence in the dominant culture, clients are
likely to present with their side effects in session. For mental health providers to advocate
for their clients who are LGBTQ+, counselors need to possess knowledge and skills
related to nonheterosexist clinical training and practice.
In 1998, both the American Counseling Association (ACA) and the American
Psychological Association (APA) passed resolutions opposing prior conceptions that
people who are LGBTQ+, by their very nature, have mental disorders. In their guidelines
for the ethical treatment of lesbians and gay males, Chernin and Johnson (2002) cited the
APA resolution “Appropriate Therapeutic Responses to Sexual Orientation,” formulated
by the Committee on Lesbian and Gay Concerns. This resolution recognizes that
homosexuality has been long removed from the Diagnostic and Statistical Manual of
Mental Disorders (DSM; e.g., American Psychiatric Association [APA], 2013) and is not
a mental disorder; thus, counseling professionals should not pathologize the sexual
orientation of clients who are lesbian or gay. A revised and updated resolution reiterating
that same-sex feelings, attractions, and behaviors are “normal” and that an LGBTQ+
identity is not a mental illness was created by the American Psychological Association
(APA, 2009). The Human Rights Committee of the ACA proposed a similar resolution
—“Appropriate Counseling Response to Sexual Orientation”— and the ACA passed it in
1998. This resolution states that the ACA opposes conceptions that people who are
LGBTQ+ have a mental disorder and supports practice and research with LGBTQ+
people that affirm their sexual orientation. Nonetheless, although the ACA opposes the
idea that an LGBTQ+ identity is a mental disorder, some professionals and
paraprofessionals engage in counseling practices that attempt to “treat” LGBTQ+
identities.
Counselors must be aware of their attitudes and beliefs about people who are
LGBTQ+ as an initial step to providing nonheterosexist mental health services. Included
in such awareness is a necessary self-examination of the general and mental health
stereotypes a counselor might have about clients who are LGBTQ+ because these
stereotypes could interfere with the type and quality of counseling provided.
Traditionally, many educators teach students to refer clients if there is a large discrepancy
between the values of the counselor and client or if a counselor is not competent to work
with a particular client. However, this recommendation should not be used as a way to
avoid working with clients who are culturally different than the counselor. It is
unprofessional and damaging to refer LGBTQ+ clients solely based on a counselor’s
personal values and beliefs. The ACA Code of Ethics (2014) states that counselors have
an ethical responsibility to continually educate themselves and to become culturally
competent practitioners. This includes being aware of diverse cultural groups and
acquiring knowledge about others’ cultures. Counselors also have an ethical
responsibility not to partake in discriminatory practices.
There has been tension regarding personal religious values and professional
ethics: the standards have come into conflict with individuals in the field who claim it is
their constitutional right to follow their religious beliefs, even when they do not support
same-sex relationships (Francis & Dugger, 2014). The case of Ward v. Wilbanks (2010)
has affirmed the position of the American Counseling Association (ACA), recognizing
that counseling services cannot be denied to a client on the basis of the client’s sexual
orientation; nor can the client be referred to another counselor simply because a
counselor’s values conflict with the client’s (Kaplan, 2014). Other cases against
counselors who refuse to provide services to sexual minority clients have been upheld in
the courts, suggesting that counselors consider the legal ramifications of not addressing
their own biases and not providing competent services (Herlihy etGal., 2014). To address
these biases, Ametrano (2014) found that counseling students appreciated the opportunity
to explore differing positions by reading about those positions in ethical dilemma papers
and by discussing the positions in small groups. Through these experiences, students
were able to expand their tolerance for ambiguity and challenge any binaries they held.
For those already in the field, obtaining additional training and supervision that will
enhance competent and ethical practice is a high priority.
Counselors must be aware of how their race, gender, age, class status, ability
level, and sexual orientation affect the counseling relationship. In order to become
competent to work with any diverse population, one must identify their own biases and
address them through effective training (Bidell, 2014). Competent counselors will
explore with clients what their sexual orientations mean to each other and what the
identities mean in relation to the larger social context. Greene (2005) proposed that
current models of psychotherapy often perpetuate the social status quo, whereby they
become socially unjust tools of oppression, particularly for clients who are LGBTQ+
Examining the power behind the language that counselors choose to use with
clients is another way to minimize heterosexism in clinical practice. For example, queer
theory views categories such as “straight” and “gay” as contrivances of the dominant
culture. These dichotomous labels dismiss individuals who may not identify as
heterosexual or lesbian or gay and who may have adopted identities such as bisexual,
queer, pansexual, or asexual (Callis, 2014). Competent counselors will ask clients how
they want to be addressed and will use language that the client uses. Moreover, the use of
the term homosexual is not appropriate, because of its historical significance as a mental
disorder. Most persons who are lesbian, gay, or bisexual do not describe themselves as
“homosexuals,” and neither should culturally sensitive mental health professionals.
Observe how clients identify themselves (e.g., gay, lesbian, bisexual, queer); that is the
appropriate language to use. Last, counselors need to expand the meaning of the word
family, particularly when working with clients who are LGBTQ+. For many clients,
family does not necessarily refer to biological families of origin. As noted earlier in this
chapter, for many persons who are LGBTQ+, friends and other community members
constitute a family. In addition, because many same-sex couples are increasingly
choosing to expand their family through adoption, the term family is not limited to a
mom, dad, and kids.
Counselors addressing the needs of adolescents may attend to enhancing self-
esteem, coping, and general life skills. For youths who are LGBTQ+, this focus can mean
providing a space for clients or students to discuss their stressors openly and explore
strategies to find networks of affirming peers and adults. Counselors should also apply
caution when using evidence-based practices that have been unsupported for the
population the counselors are serving.
Because “outness” has been correlated with lower levels of stigma and a sense of
belonging to the queer community (Pistella etGal., 2016), counselors may also explore the
youth’s identity development as well as the level of support in the school and home
environment. Youths who are early in the coming-out process often need therapeutic
support, as do their parents. Goodrich and Gilbride (2010) found that parental
expectations, satisfaction with support, and family flexibility all contributed to higher
levels of general family functioning after a youth comes out. In this same study, parental
religiosity, fear, and surprise at disclosure all contributed to negative family functioning.
Attending to these factors may promote better outcomes for the youths and their families.
School counselors often serve in advocacy roles, not only providing direct support to
students, but also educating teachers, administrators, and staff about the social and
emotional concerns of LGBTQ+ students and implementing school-wide initiatives, such
as LGBTQ+ inclusive anti-bullying programming, in their curriculum plans (Gonzalez,
2017). They may also collaborate with students, parents, and community allies to
advocate for safe-school policies and provide resources for sexual and gender minority
students (Beck etGal., 2014; Gonzalez, 2017). Such advocacy efforts will be even more
likely to occur as counselors remove their biases toward LGBTQ+ students and develop
self-efficacy to enact change (Simons, 2018). Case Study 6.2 provides an example of a
professional school counselor advocating for LGBTQ+ students in the high school where
she works.
Efforts to alter same-sex or affectional orientations began in the mid-1800s with
studies examining the origins of same-sex attractions. Formerly called reparative therapy
(psychological approaches that aim to alter, or “repair,” sexual orientation or gender
identity from LGBTQ+ to heterosexual/cisgender) or conversion therapy (attempts to
“convert” individuals from LGBTQ+ to heterosexual/cisgender), the current umbrella
term used to describe any methodological attempts to change sexual orientation is sexual
orientation change efforts (SOCE). Historically, biological, behavioral, cognitive,
psychodynamic, and religious strategies have been used as part of SOCE. Excessive
bicycle riding, testicle transplants, exorcisms, electroshock therapy, forcing men to
engage in sexual activity with female prostitutes, aversion therapy, and hypnosis have all
been used as “treatments” for nonheterosexual orientations. Even Freud engaged in
SOCE with a female client. However, because his therapeutic attempts to change her
sexual orientation failed, he concluded that efforts to change same-sex orientations were
futile (APA, 2009). After homosexuality was removed from the DSM in 1973, SOCE
were not as prominent, but did not dissolve entirely.
Numerous studies have underscored the detrimental consequences associated with
SOCE. Many individuals who have participated in SOCE experienced negative side
effects, including depression, anxiety, avoidance of intimacy, sexual dysfunction,
internalized heterosexism, and suicidality (American Psychological Association [APA],
2009). In accordance with these findings, several organizations have resolutions opposing
the use of SOCE. The American Psychological Association’s Resolution on Appropriate
Affirmative Responses to Sexual Orientation Distress and Change Efforts states that there
is a lack of evidence to support the use of any type of SOCE (Anton, 2010). The ACA’s
Governing Council adopted a statement in 1999 that opposed the use of reparative
therapy as a cure for LGBTQ+. Further, counselors have an ethical responsibility “not
[to] use techniques/procedures/ modalities when substantial evidence suggests harm, even
if such services are requested”.
LGBTQ+ affirmative counseling involves counselors being aware of their own
strengths and weaknesses in working with LGBTQ+ clients, being able to use a variety of
counseling interventions, countering the negative societal messages often internalized by
LGBTQ+ clients, affirming LGBTQ+ identities, not pathologizing same-sex behavior
and affection or trans or non-binary gender identities, and understanding issues affecting
people who are LGBTQ+ (American Psychological Association [APA], 2009; Chaney &
Brubaker, 2014). Moreover, affirmative LGBTQ+ counseling has been defined as
professional counselors’ ability to create psychologically safe spaces where LGBTQ+
clients are supported and affirmed in a culturally responsive manner so that clients can
explore, grow, heal, and thrive throughout the lifespan (Chaney & Whitman, 2020).
Major issues to explore include the impact of negative societal attitudes toward
individuals who are LGBTQ+; discrimination in the legal, societal, and religious arenas;
same-sex relationship dynamics; the effect of HIV/AIDS and other health disparities; and
identity development issues.
The field of counseling has not been immune to heterosexual bias, and as a result,
these biases can be seen in classrooms, textbooks, and research. The lack of consistent
and accurate training often leads future helping professionals to feel anxiety and
incompetence when sitting across from clients who are targets of heterosexism. An action
step that counselors-in-training can take to become more competent to work with clients
who are LGBTQ+ is to engage in self-exploration. Because we all are gendered, sexed,
raced, classed, and sexually oriented, and because we possess various degrees of ability,
we are oppressed and privileged in various ways. Furthermore, we bring these identities
into classrooms and counseling sessions. Accordingly, counselor educators and students
might begin to examine how these identities function in classrooms, counseling sessions,
and society. Once we become aware of how our privileges oppress others, we get closer
to the creation of a socially just, nonheterosexist society.
