Homework Assignments and Handouts for LGBTQ+ Clients: A Mental Health and Counseling Handbook 0367542692, 9780367542696

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Table of contents :
Cover
Half Title
Title Page
Copyright Page
Dedication Page
Contents
Foreword
Introduction
SECTION I Homework, Handouts, and Activities for the Coming-Out Process across the Life Span
1. A Pet-Assisted Intervention during Coming-Out Experiences
2. Assisting Individuals in Coming Out in Later Life as Lesbian, Gay, or Bisexual
3. Transgender Teens and Gender-Identity Disclosure
4. Assisting Youth with Disclosing Their Sexual Orientation and/or Gender Identity Using an Ecomap
5. Must Be the Music: Musical Autobiography and Critical Lyric Analysis
6. Cinematherapy for LGBT Clients
7. How Does God See Me? A Reflective Exercise
SECTION II Homework, Handouts, and Activities for Managing Oppression and Building Resilience
8. Survival in an Unjust World: A Tool for Coping with Multiple Forms of Oppression
9. Managing the Intersections: A Narrative Approach to Guiding Queer People of Color in Navigating Multiple Oppressions
10. A Lovingkindness Meditation to Heal from Heterosexism, Transphobia, and Other Forms of Oppression
11. From Stress to Strength: A Group Intervention for Processing Minority Stress Experiences with Transgender and Gender-Nonconforming Individuals
12. Exploring Multiple Marginalized Identities in LGBT Clients of Color
13. Somos Latinx: Exploring Cultural Values of Sexually and Gender-Diverse Latinx Clients
14. Building Resilience with Clients Who Face Multiple Forms of Oppression
15. Building a Stronger Advocacy Role for Older LGBT+ Adults in Nursing Home Settings
16. A Toolkit for Collaborative Safety and Treatment Planning with Transgender Youth of Color
17. Healing from Heterosexism: An Empirically Based Exercise for Processing Heterosexist Experiences
18. At the Intersection of the Autism Spectrum and Sexual and Gender Diversity: Case Studies for Use with Clinicians and Clients
19. Clinical Work with LGBTQ Asylum Seekers
20. Value-Driven Exploration of Intersections between Sexual and Religious Identity
SECTION III Homework, Handouts, and Activities for Relationships
21. Exploring and Navigating Sexual Desire in Relationships
22. Intimate Partner Violence: Initial Interventions for LGBTQ Clients
23. Transgender Youth and Healthy Relational Skills
24. Two Stars and a Wish: Termination Activities for Groups with Sexual- and Gender-Identity Diverse Clients
25. The Quadrant Exercise of Relationship Exploration for Sexual- and Gender-Identity Diverse Clients
26. Negotiating Information and Communication Technologies with Sexual and Gender Minority Youth and Young Adults
27. BDSM Exploration and Communication within LGBT Relationships
SECTION IV Homework, Handouts, and Activities for LGBTQ Parenting and Family Therapy
28. Transgender-Affirmative Parenting: Practicing Pronouns
29. Family Mapping Exercises (FMEs) for Adults and Children in LGBTQ-Parented Families
30. Expanding Binary Thinking: A Reflective Activity for Parents and Caregivers of Transgender and Gender-Expansive Youth
31. Parents of Transgender Teens and the Initial Disclosure Process
32. Maintaining the Family Unit When an Adolescent Family Member Comes Out as a Sexual or Gender Minority
33. Empty-Chair Work for Coping with Heterosexist and/or Transphobic Family Rejection
34. Addressing Blended Family and Trauma Issues with Sexual and Gender Minority Parents
35. An Informative Intervention for Parents and Caregivers of Transgender and Gender-Nonbinary Children and Adolescents
36. Circles of Outness: Systemic Exploration of Disclosure Decisions in Mixed-Orientation Relationships
SECTION V Homework, Handouts, and Activities for Gender and Sex Identity Exploration
37. The Matrix for Sexuality and Gender: My Sexual and Gendered Self in the World of Sexual and Gender Diversity
38. Exploring Gender Identity with a Photo Diary
39. Creative Interventions for Traumatized Transgender and Gender-Nonconforming (TGNC) Youth
40. The Importance of Language: Creating Nonbinary Assessment Forms That Reflect a Full Range of Gender Identities
41. Mapping of Desires and Gender: Explorations at the Intersections
42. Asexuality: An Introduction for Questioning Clients
43. Inhabiting Our Bodies: Working with Gender Dysphoria in Transgender and Gender-Nonbinary Children and Adults through Body Maps
44. Using Expressive Art Therapy with LGBTQ Youth: A Picture Is Worth a Thousand Words
45. An Eight-Week Identity Exploration Group for Transgender and Gender-Nonconforming Individuals
46. Using Mindfulness to Enhance Identity Integration for LGBTQ clients
47. Managing Religious and Sexual Identity Intersections
48. Rose as a Name Is So Much Sweeter: Navigating the Name-Change Process with Transgender and Gender Nonbinary Clients
49. The Aging Transgender Client: Mapping the Acceptance of Experience
SECTION VI Homework, Handouts, and Activities for Substance Use Disorders
50. A Relapse-Prevention Intervention for LGBTQ Clients with Substance Use Disorders: The C3PO
51. Exploring the Concept of Honesty with Transgender Clients in Recovery from Addiction
52. Using Art Therapy to Address Body Dysphoria, Body Image, and Eating Concerns with Trans and Nonbinary Clients
53. The Inextricable Relationship between Marginalization and Addiction: Bridging the Gap through Charting
54. LGB Addiction Recovery and Community Membership
SECTION VII Homework, Handouts, and Activities for Career, Employment, and Education Issues
55. Job Search and Career Resources for LGBT People
56. Sexual-Identity Management in the Job-Search Process with Lesbian and Gay Clients
57. Strategies for Helping LGBTQ Clients Address Discrimination in the Workplace
58. Exploring Values in Career Exploration with Adolescent LGBTQ Clients
59. The College Search: Campus Climate Checklist
60. Exploring Career Decision-Making Self-Efficacy with Sexual and Gender Minority College Students
SECTION VIII Homework, Handouts, and Activities for Use in Outreach Programming and Training Workshops
61. Intersecting Identities: A Self-Reflective Activity for Outreach Programming and Workshops
62. Building Community on Campus: A Workshop on Sharing and Support for LGBTQ College Students
63. Outreach Ally-Training Activities
64. Reflections of Assumptions
65. The Papercut Activity: Understanding the Subtle and Ongoing Effects of Microaggressions
66. Examining Our Blind Spots: Considerations in Working with Lesbian, Gay, and Bisexual Clients with Disabilities
67. Outreach on a College Campus: Understanding the Campus Climate
68. Understanding Me, You, and LGBTQ: An Outreach Workshop for General Audiences and Allies
69. Living in Intersectional Spaces: Exploration of Social Identities in the LGBT Community
70. Creating Consciousness to Create Connection: Attending to Biases When Working with Queer Victim-Survivors of Sexual Violence
71. Addressing Anti-Trans Prejudice: Decoding the Gender Matrix
About the Editors and Contributors
Index
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HOMEWORK ASSIGNMENTS

AND HANDOUTS

FOR LGBTQ+ CLIENTS

Featuring over 70 affirming interventions in the form of homework assignments, handouts, and activities, this comprehensive volume helps novice and experienced counselors support LGBTQ+ community members and their allies. Each chapter includes an objective, indications and contraindications, a case study, suggestions for follow-up, professional resources, and references. The book’s social justice perspective encourages counselors to hone their skills in creating change in their communities while helping their clients learn effective coping strategies in the face of stress, bullying, microaggressions, and other life challenges. The volume also contains a large section on training allies and promoting greater cohesion within LGBTQ+ communities. Counseling and mental health services for LGBTQ+ clients require between-session activities that are clinically focused, evidence based, and specifically designed for one or more LGBTQ+ sub-populations. This handbook gathers together the best of such LGBTQ+ clinically focused material. As such, it will appeal both to students learning affirmative LGBTQ+ psychotherapy/counseling and to experienced practitioners. Offering practical tools used by clinicians worldwide, the volume is particularly useful for courses in clinical and community counseling, social work, and psychology. Those new to working with LGBTQ+ clients will appreciate the book’s accessible foundation to guide interventions. Joy S. Whitman, PhD, is a licensed professional counselor (LPC) in Missouri and a licensed clinical professional counselor (LCPC) in Illinois. She is clinical professor at The Family Institute of Northwestern University in the master’s Counseling@Northwestern program. A past president of ALGBTIC, Joy serves as a board member of The International Academy for LGBT+ Psychology and Related Fields. She maintains a private practice in Missouri. Cyndy J. Boyd, PhD, is a licensed psychologist, consultant, and psychotherapist in private practice in Philadelphia. She is Director of Training at Counseling and Psychological Services at the University of Pennsylvania. She has served on the APA Commission on Accreditation, the board of directors of ALGBTIC of the American Counseling Association, the supervision and training section of Division 17 of the American Psychological Association (APA), and the Association of Counseling Center Training Agencies.

“Overall this is a very strong guidebook for helping professionals who work with LGBTQ+ clients. The editors should be applauded for organizing each facet of this massive notebook into a cohesive book.” — Michael P. Chaney, Oakland University “This text stimulates clinicians to think of the many questions they should ask to ensure that their counseling sessions are LGBTQQ+ affirming. I believe the drive to ask and answer even more questions about queer and trans mental health therapy is this text’s ultimate contribution to the discipline and the profession. It provides resources that we might not have even realized that we need.” — Anneliese Singh, PhD, University of Georgia “The resources in this book represent a significant source of activities for LGBTQ+ clients regardless of their social location. Authors of the homework exercises have been very thoughtful in the design of their activities, clearly identifying when an activity would not be indicated. Many activities are devoted to transgender and nonbinary clients. If you work with LGBTQ+ clients, you need this in your library!” — lore m. dickey, PhD, North Country HealthCare “Joy Whitman and Cyndy Boyd share a queer treasure trove of innovative and practical exercises for use with LGBTQ+ clients. This must-have resource brings together top clinicians and scholars who share therapeutic best practices for affirming and supporting queer and trans clients across a variety of contexts and issues.” — David P. Rivera, PhD, Queens College, City University of New York “Homework Assignments and Handouts for LGBTQ+ Clients is a welcome addition to any mental health training program, or post-master’s advanced seminar in counseling members of the LGBTQ+ community. [It provides] intriguing exercises and interventions that can supplement empathic treatment planning for best practice with a focus on intersectionality in counseling. A solid, engaging addition to the literature.” — Catherine Roland, EdD, LPC, NCC, past president, American Counseling Association “Doctors Whitman and Boyd have woven together a revolutionary resource that is desperately needed by mental health professionals. This incredibly creative compilation of exercises not only applies effortlessly to allies and members of the LGBTQ+ communities but also cuts across issues related to lifespan milestones and the intersectionality of multiple identities. I know of no other resource in existence—buy it, use it in the class­ room, use it with your clients and, dare I say it, use it with yourself. Bravo!” — Colleen R. Logan, PhD, LPC-S, Southern Methodist University

HOMEWORK ASSIGNMENTS AND HANDOUTS FOR LGBTQ+ CLIENTS

A MENTAL HEALTH AND COUNSELING HANDBOOK EDITED BY

JOY S. WHITMAN AND CYNDY J. BOYD

First published 2021 by Routledge 52 Vanderbilt Avenue, New York, NY 10017 and by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2021 selection and editorial matter, Joy S. Whitman and Cyndy J. Boyd; individual chapters, the contributors Te right of Joy S. Whitman and Cyndy J. Boyd to be identifed as the authors of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. Te purchase of this copyright material confers the right on the purchasing institution to photocopy pages which bear the photocopy icon and copyright line at the bottom of the page. No other part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission in writing from the publisher. Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for identifcation and explanation without intent to infringe. Publisher’s Note Tis book has been prepared from camera-ready copy provided by Ciano Design. Library of Congress Cataloging-in-Publication Data Names: Boyd, Cynthia J., editor. | Whitman, Joy S., editor. Title: Homework assignments and handouts for LGBTQ+ clients : a mental health and counseling handbook / edited by Joy S. Whitman and Cyndy J. Boyd. Description: New York, NY : Routledge, 2021. | Includes bibliographical references and index. Identifers: LCCN 2020019452 (print) | LCCN 2020019453 (ebook) | ISBN 9780367542726 (hardback) | ISBN 9780367542696 (paperback) | ISBN 9781003088639 (ebook) Subjects: LCSH: Sexual minorities—Mental health—Problems, exercises, etc. | Sexual minorities—Counseiing of.—Problems, exercises, etc. | Psychotherapy—Problems, exercises, etc. | Counseling—Problems, exercises, etc. Classifcation: LCC RC451.4.G39 H6572 2021 (print) | LCC RC451.4.G39 (ebook) | DDC 616.890086/6—dc23 LC record available at https://lccn.loc.gov/2020019452 LC ebook record available at https://lccn.loc.gov/2020019453 ISBN: 978-0-367-54272-6 (hbk) ISBN: 978-0-367-54269-6 (pbk) ISBN: 978-1-003-08863-9 (ebk) Typeset in Minion Pro by Ciano Design

This book is dedicated to Bill Cohen and Patricia Chalem Kupelian. Bill, as the former publisher and editor-in-chief of Harrington Park Press, was the creative force behind this book and a champion of LGBTQ+ education and psychology. Without his gentle nudge, we would not have recreated the original book and landed on this current and more inclusive one. We miss his energy, wit, and belief in ensuring LGBTQ+ scholarship was at the forefront of social and behavioral sciences. Our deep gratitude as well to Patricia. Without her legal counsel and advocacy, this book would have never been published. When we reached a stopping point because of Bill’s unexpected passing, Patty’s generosity, creativity, and talent led the way. Patty, we do not know how to thank you enough for the hours you dedicated to this project and your dogged pursuit for what is right and fair. Thank you from the bottom of our hearts.

CO NTEN T S Foreword Anneliese Singh

xii

Introduction Joy Whitman and Cyndy Boyd

xiv

SECTION I Homework, Handouts, and Activities for the Coming-Out Process across the Life Span 1. A Pet-Assisted Intervention during Coming-Out Experiences Michael P. Chaney and Kathryn L. Pozniak

1 4

2. Assisting Individuals in Coming Out in Later Life as Lesbian, Gay, or Bisexual Vincent M. Marasco and Randall L. Astramovich

14

3. Transgender Teens and Gender-Identity Disclosure Laura R. Haddock

22

4. Assisting Youth with Disclosing Their Sexual Orientation and/or Gender Identity Using an Ecomap Richard A. Brandon-Friedman and M. Killian Kinney

30

5. Must Be the Music: Musical Autobiography and Critical Lyric Analysis Kiahni Nakai

40

6. Cinematherapy for LGBT Clients Jennifer Lancaster and Angelica Terepka

52

7. How Does God See Me? A Reflective Exercise Hannah B. Bayne and Anita A. Neuer Colburn

60

SECTION II Homework, Handouts, and Activities for Managing Oppression and Building Resilience

67

8. Survival in an Unjust World: A Tool for Coping with Multiple Forms of Oppression Jessica Chavez

70

9. Managing the Intersections: A Narrative Approach to Guiding Queer People of Color in Navigating Multiple Oppressions Jayleen Galarza

76

10. A Lovingkindness Meditation to Heal from Heterosexism, Transphobia, and Other Forms of Oppression Eve M. Adams, Tracie L. Hitter, and Virginia Longoria

82

11. From Stress to Strength: A Group Intervention for Processing Minority Stress Experiences with Transgender and Gender-Nonconforming Individuals Caroline Carter and Diane Sobel

90

12. Exploring Multiple Marginalized Identities in LGBT Clients of Color Vanessa Dabel

100

13. Somos Latinx: Exploring Cultural Values of Sexually and Gender-Diverse Latinx Clients Zully A. Rivera Ramos, Amanda Lawson-Ross, and Carlos Hernández

108

14. Building Resilience with Clients Who Face Multiple Forms of Oppression Kristin N. Bertsch

124

15. Building a Stronger Advocacy Role for Older LGBT+ Adults in Nursing Home Settings

Angela Schubert

132

16. A Toolkit for Collaborative Safety and Treatment Planning with Transgender Youth of Color

Wendy Ashley, Allen Eugene Lipscomb, and Sarah Mountz

140

17. Healing from Heterosexism: An Empirically Based Exercise for Processing Heterosexist Experiences

Kathleen M. Collins, Meredith R. Maroney, Tangela S. Roberts,

Brianna M. Wadler, and Heidi M. Levitt

150

18. At the Intersection of the Autism Spectrum and Sexual and Gender Diversity: Case Studies for Use with Clinicians and Clients

Eva Mendes and Meredith R. Maroney

158

19. Clinical Work with LGBTQ Asylum Seekers Brianna M. Wadler, Meredith R. Maroney, and Sharon G. Horne

168

20. Value-Driven Exploration of Intersections between Sexual and Religious Identity Angelica Terepka and Jennifer Lancaster

176

SECTION III

Homework, Handouts, and Activities for Relationships

183

21. Exploring and Navigating Sexual Desire in Relationships Sara K. Bridges

186

22. Intimate Partner Violence: Initial Interventions for LGBTQ Clients Sabina de Vries

194

23. Transgender Youth and Healthy Relational Skills Luke R. Allen

206

24. Two Stars and a Wish: Termination Activities for Groups with Sexual- and Gender-Identity Diverse Clients

Theodore R. Burnes

212

25. The Quadrant Exercise of Relationship Exploration for Sexual- and Gender-Identity Diverse Clients

Theodore R. Burnes

218

26. Negotiating Information and Communication Technologies with Sexual and Gender Minority Youth and Young Adults

Nathaniel Amos

224

27. BDSM Exploration and Communication within LGBT Relationships Kandice H. van Beerschoten

234

SECTION IV

Homework, Handouts, and Activities for LGBTQ Parenting and Family Therapy

243

28. Transgender-Affirmative Parenting: Practicing Pronouns Jennifer M. Gess

246

29. Family Mapping Exercises (FMEs) for Adults and Children in LGBTQ-Parented Families

Fiona Tasker, Maeve Malley, and Pedro Alexandre Costa

254

30. Expanding Binary Thinking: A Reflective Activity for Parents and Caregivers of Transgender and Gender-Expansive Youth

Rebekah Byrd and Laura Boyd Farmer

264

31. Parents of Transgender Teens and the Initial Disclosure Process Laura R. Haddock and Hilary Meier

270

32. Maintaining the Family Unit When an Adolescent Family Member Comes Out as a Sexual or Gender Minority

Susannah C. Coaston, Patia Tabar, and Lori Barrett

280

33. Empty-Chair Work for Coping with Heterosexist and/or Transphobic Family Rejection

Cara Herbitter and Heidi M. Levitt

288

34. Addressing Blended Family and Trauma Issues with Sexual and Gender Minority Parents

Anthony Zazzarino, Veronica M. Kirkland, and Jenae Thompson

298

35. An Informative Intervention for Parents and Caregivers of Transgender and Gender-Nonbinary Children and Adolescents

Heather Kramer

306

36. Circles of Outness: Systemic Exploration of Disclosure Decisions in Mixed-Orientation Relationships

Mary R. Nedela, M. Evan Thomas, and Michelle M. Murray

314

SECTION V

Homework, Handouts, and Activities for Gender and Sex Identity Exploration

321

37. The Matrix for Sexuality and Gender: My Sexual and Gendered Self in the World of Sexual and Gender Diversity

K. Jod Taywaditep

326

38. Exploring Gender Identity with a Photo Diary M. Killian Kinney and Richard A. Brandon-Friedman

340

39. Creative Interventions for Traumatized Transgender and Gender-Nonconforming (TGNC) Youth

Alexandra M. Rivera and Crystal Morris

348

40. The Importance of Language: Creating Nonbinary Assessment Forms That Reflect a Full Range of Gender Identities Andrew Suth and Sorrel Rosin

354

41. Mapping of Desires and Gender: Explorations at the Intersections Shannon Solie

366

42. Asexuality: An Introduction for Questioning Clients Emily M. Lund, Bayley A. Johnson, Christina M. Sias, and Lauren M. Bouchard

376

43. Inhabiting Our Bodies: Working with Gender Dysphoria in Transgender and Gender-Nonbinary Children and Adults through Body Maps

Natasha Distiller

384

44. Using Expressive Art Therapy with LGBTQ Youth: A Picture Is Worth a Thousand Words

Jean Georgiou

392

45. An Eight-Week Identity Exploration Group for Transgender and Gender-Nonconforming Individuals

Julie M. Mullany

400

46. Using Mindfulness to Enhance Identity Integration for LGBTQ clients Marilia S. Marien

410

47. Managing Religious and Sexual Identity Intersections Matt Zimmerman

420

48. Rose as a Name Is So Much Sweeter: Navigating the Name-Change Process with Transgender and Gender Nonbinary Clients

Cadyn Cathers

426

49. The Aging Transgender Client: Mapping the Acceptance of Experience Dorian Kondas

436

SECTION VI

Homework, Handouts, and Activities for Substance Use Disorders

445

50. A Relapse-Prevention Intervention for LGBTQ Clients with Substance Use Disorders: The C3PO

Michael P. Chaney and Fiona D. Fonseca

448

51. Exploring the Concept of Honesty with Transgender Clients in Recovery from Addiction

Mia Ocean and George Stoupas

456

52. Using Art Therapy to Address Body Dysphoria, Body Image, and Eating Concerns with Trans and Nonbinary Clients

Jeannine Cicco Barker

464

53. The Inextricable Relationship between Marginalization and Addiction: Bridging the Gap through Charting

John J. S. Harrichand and Christian D. Chan

472

54. LGB Addiction Recovery and Community Membership George Stoupas and Mia Ocean SECTION VII Homework, Handouts, and Activities for Career, Employment, and Education Issues

482

489

55. Job Search and Career Resources for LGBT People Anita A. Neuer Colburn

492

56. Sexual-Identity Management in the Job-Search Process with Lesbian and Gay Clients Suzanne M. Dugger and Jason A. Owens

498

57. Strategies for Helping LGBTQ Clients Address Discrimination in the Workplace Randall L. Astramovich and Matthew J. Wright

508

58. Exploring Values in Career Exploration with Adolescent LGBTQ Clients Jane E. Rheineck and Tracy Peed

514

59. The College Search: Campus Climate Checklist Suzanne M. Dugger, Carina Lindsey, and Jason A. Owens

522

60. Exploring Career Decision-Making Self-Efficacy with Sexual and Gender Minority College Students Marilia Marien and Yuhong He

534

SECTION VIII Homework, Handouts, and Activities for Use in Outreach Programming and Training Workshops

543

61. Intersecting Identities: A Self-Reflective Activity for Outreach Programming and Workshops Laura Boyd Farmer and Christian D. Chan

546

62. Building Community on Campus: A Workshop on Sharing and Support for LGBTQ College Students Alaina Spiegel

552

63. Outreach Ally-Training Activities Brandy L. Smith

558

64. Reflections of Assumptions Jayleen Galarza and Matthew R. Shupp

566

65. The Papercut Activity: Understanding the Subtle and Ongoing Effects of Microaggressions Jeanne L. Stanley

574

66. Examining Our Blind Spots: Considerations in Working with Lesbian, Gay, and Bisexual Clients with Disabilities Michelle M. Murray

580

67. Outreach on a College Campus: Understanding the Campus Climate Batsirai Bvunzawabaya and Matthew LeRoy

588

68. Understanding Me, You, and LGBTQ: An Outreach Workshop for General Audiences and Allies

Alaina Spiegel

596

69. Living in Intersectional Spaces: Exploration of Social Identities in the LGBT Community

Matthew LeRoy and Batsirai Bvunzawabaya

604

70. Creating Consciousness to Create Connection: Attending to Biases When Working with Queer Victim-Survivors of Sexual Violence

Deborah O’Neill and Laura Kay Collins

610

71. Addressing Anti-Trans Prejudice: Decoding the Gender Matrix Soumya Madabhushi

624

About the Editors and Contributors

634

Index

656

FORE WO R D For so many reasons, it’s a true honor to write this foreword to Homework Assignments and Handouts for LGBTQ+ Clients: A Mental Health and Counseling Handbook. The first reason I am honored to write this fore­ word is that I remember vividly the first time I held the precursor to this text, The Therapist’s Notebook for Lesbian, Gay, and Bisexual Clients (2003), in my hands. I had just started my counseling psychology doctoral program at Georgia State University. I was so excited to begin my doctoral program because I was so looking forward to learning all about how to counsel LGBTQQ+ (lesbian, gay, bisexual, trans, queer, questioning, and more) persons. What I found instead, however, was a more general training curriculum that didn’t address how to work with queer and trans people in counseling, much less queer and trans folks who had intersectional identities of race or ethnicity, social class, gender, sexual orientation, nationality, disability, and more. I found often that as a very green counselor I was teaching myself how to take up coun­ seling interventions with queer and trans clients. Of course, I’d had a basic multicultural counseling course and an advanced one as well, but I felt desperate to find LGBTQQ+ training that brought to life some of the basic ideas we learned (e.g., heterosexism exists) about how we can support queer and trans clients who are healing from societal oppression. So, you can imagine that, amid the huge vacuum of training in my program on LGBTQQ+ issues at the time, laying my hands on The Therapist’s Notebook for Lesbian, Gay, and Bisexual Clients was a mentoring moment I will never forget. The second reason I am honored to write this fore­ word is that Cyndy Boyd and Joy Whitman became my mentors off the page through our shared member­ ship in the American Counseling Association (ACA). Yes, the gifts they gave me through their text were important, and having a guidebook that made queerand trans-affirming counseling real was quite astound­ ing at the time. However, the bonus I received from

their mentoring influence during my graduate studies— when I often felt isolated and alone as a queer coun­ selor—well, that was sacred space. Through their men­ toring, I was able to see how they both led in the Association for LGBT Issues in Counseling (ALGBTIC, a division of ACA), which also astounded me. Here were two powerful queer women who helped show me what advocating for women, people of color, and others within the margins of a mostly gay-white divi­ sion full of men “looked like.” As you work with this text, I know that you will be inspired by the group of activities that Joy and Cyndy have brought together for use with your queer and trans clients. At the same time, I hope you will find ways to engage in leader­ ship on behalf of the most marginalized communities within the LGBTQQ+ community. The third reason I am honored to write this fore­ word is that it offers an opportunity to celebrate the current affirming work with queer and trans clients. In the not-so-recent past, it was a fight to get profes­ sional counseling organizations to address queer and trans issues in counseling. We still have a long way to go in establishing a solid foundation of what queerand trans-affirming counseling really means when we are in sessions with LGBTQQ+ clients and when we are working for justice in queer and trans commu­ nities. It is also important to celebrate our successes, however, and this book is one of them. All eight sections of the book focus on queer- and trans-affirming counseling practice. Each section pro­ vides homework, handouts, and activities that solidly situate us as counselors in intersectional approaches to LGBTQQ+ counseling. Section I lays the founda­ tion for intersectionality by taking a life-span approach. You will find practical approaches that help you affirm and empower queer and trans clients, whether they are just coming to understand themselves later in life— or whether they were able to identify and honor their gender and sexual orientation identities earlier on as youth. In this life-span approach, you also will see how the contributors use creativity (e.g., pet-assisted

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

xii

interventions, ecomaps, music, and cinematherapy) to help counselors tap into the very emotional process that coming to understand one’s LGBTQQ+ identity in an unjust world entails. The chapters in Section II focus on building resil­ ience to anti-LGBTQQ+ oppression. I study queer and trans people of color’s resilience to discrimination, so it is very exciting to see that intersectionality is woven into this section, along with an advocacy focus (e.g., work with LGBTQQ+ asylum seekers, intersections of LGBTQQ+ identities and religion, LGBTQQ+ expe­ riences of autism). Section III continues this focus on intersectionality, with a special emphasis on LGBTQQ+ people who are developing relationships. How we as queer and trans communities decide to engage (or not to engage) in relationships is still an understudied topic, but this book provides a plethora of informa­ tion to assist counselors in helping their clients develop relational skills in adolescence, identifying ways to address intimate partner violence, and exploring the importance of BDSM for some LGBTQQ+ people. Section IV provides all the resources you wish had existed a long time ago to support your work with families. From the basics of pronouns and family map­ ping with LGBTQQ+ families to experiential chair work, this section is packed with interventions you can use right now to affirm and empower the families of queer and trans people. The chapters in Section V provide an opportunity to dive more deeply into identi­ ties of sex and gender. Again, a life-span and intersec­ tional perspective is built across these chapters, with the main goal of helping LGBTQQ+ clients explore their assigned sex and gender, as well as their identified sex and gender, with care, compassion, and tenderness. Many of these chapters use a longer intervention (e.g., eight-week identity exploration for trans and nonbi­ nary youth) or expressive arts to explore these impor­ tant identities in nonverbal ways. I am also excited to note that this section includes the nascent counseling research on the experiences of asexual people. Section VI addresses the realities of substance abuse disorders. This is such a very important topic, and the homework, handouts, and activities consider the very real oppression, and other complications, that queer and trans clients face when they seek recovery. This section offers chapters on relapse prevention,

disordered eating and body concerns, and the critical role of community building in recovery, to name just a few of the topics covered here. Section VII provides helpful resources on support­ ing queer and trans people who face job discrimina­ tion. It also offers information on finding college cam­ puses that are affirming. This section is particularly important because anti-LGBTQQ+ bias is often related not only to homelessness for LGBTQQ+ young peo­ ple but also to their career decisions. The text wraps up with Section VIII, which encourages you to take up outreach programming and training workshops in a variety of settings (e.g., school, college, commu­ nity). Like the other sections in this text, Section VIII emphasizes intersections of identity that are critically important for queer and trans clients. Ultimately, this text stimulates clinicians to think of the many questions they should ask to ensure that their counseling offices and sessions are LGBTQQ+ affirming. These questions include: • Who are the queer and trans people on the margins? • What intersectional identities must I understand to work most effectively and affirmatively with a par­ ticular queer or trans client? • How can I increase my own awareness of my privi­ lege and oppression identities and experiences as a mental health therapist? • How can I advocate further for the basic human rights of queer and trans clients from a wide vari­ ety of intersectional backgrounds? And, I believe, the drive to ask and answer even more questions about queer and trans mental health ther­ apy is this text’s ultimate contribution to the discipline and the profession. Yes, it provides resources that we might not have even realized that we need; but, beyond that, it compels, motivates, and excites us to expect even more of ourselves as providers of queer- and transaffirming therapy. Anneliese Singh, PhD, LPC University of Georgia Trans Resilience Project Georgia Safe Schools Coalition

Foreword xiii

IN T RO D U C T I O N In 2003 we published an edited book titled The Ther­ apist’s Notebook for Lesbian, Gay, and Bisexual Clients: Homework, Handouts, and Activities for Use in Psycho­ therapy. At the time, fewer LGBTQ+-specific resources were available for clinicians working with LGBT cli­ ents. Thus, many clinicians needed to translate prac­ tical interventions designed for people who identified as heterosexual and cisgender into affirming inter­ ventions for those who identified as LGBTQ+. At the time, the LGBTQ+ community had few rights or access to institutions and services such as marriage, adoption, parenting, military service, and health care. Much has changed since the turn of the century, and this book reflects the influences of the current sociopolitical context on the mental health and well­ ness of people with diverse sexual and gender identi­ ties. For example, more countries are recognizing mar­ riage equality, and there is a greater understanding and appreciation of the fluidity of sexual and gender identities. LGBTQ+ people throughout the world still experience many forms of violence and oppres­ sion, however, and the risk of violence to LGBTQ+ persons of color in the United States continues to be much higher than for those who identify as white. Additionally, current U.S. policies vacillate between granting and then removing rights for people who identify as transgender or non-cisgender. Therefore, clinicians need to continue helping their clients navi­ gate oppression, shape identity, and build resilience. The optimistic news is that research and experience show us that a validating support system can mitigate the negative mental health consequences of margin­ alization that is based on social identities. Another notable change in the last decade is that the terms that people use to describe their gender and sexual identities have multiplied exponentially. In fact, terminology is still expanding and constantly evolving. To reflect the diversity of the LGBTQ+ com­ munity and the wide variety of ways in which people are currently identifying, many different terms and

perspectives are used in this book. Given that identity exploration is a dynamic process, it is likely that many of the terms in this book will be less common in the near future as they are replaced by new descriptors and that some of the identity descriptions will feel more applicable to certain clients than to others. Dozens of mental health professionals have con­ tributed their expertise to this new collection of over seventy affirming interventions. By “affirming,” we mean an approach to therapy that embraces a positive view of LGBTQ+ identities and relationships and addresses the negative influences that discrimination and oppression based on sexual and gender identi­ ties have on the lives of LGBTQ+ clients. The book is organized into eight content areas: (1) coming out across the life span; (2) managing oppression and building resilience; (3) relationship concerns; (4) par­ enting and family therapy; (5) gender and sex identity exploration; (6) substance use disorders; (7) career, employment, and education issues; and (8) outreach programming and training workshops. Because there is overlap among the content areas, they can also inform one another, and clinicians can combine activ­ ities, handouts, and homework to tailor them to their clients’ specific concerns. Within the content areas, each chapter follows the same format. Each chapter begins with an objective, followed by a rationale for the activity solidly grounded in the research and in affir­ mative practices. Instructions clearly describe how to use the homework, handout, or activity; a brief vignette then provides an example of how the activity can be used. Each chapter closes with suggestions for followup, a brief section on contraindications, and a list of resources for clinicians and for clients. Each activity is formatted for easy copying and distribution. This emphasis on activities and homework assign­ ments provides a powerful tool for clinicians, as meta­ analyses of studies have shown that engagement in homework assignments does indeed produce a posi­ tive effect on therapy outcome (Beutler et al., 2004;

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xiv

Kazantzis, Deane, & Ronan, 2000). The use of activi­ ties outside sessions is so powerful because it broadens the scope of the work by encouraging the client to be less dependent on the therapist and by providing them with more opportunities to work toward their goals (Nelson, Castonguay, & Barwick, 2007). It has been used as an intervention successfully by clinicians since the first days of psychoanalysis, as Freud (1924) believed that patients should extend their work in therapy to everyday situations. Cognitive therapy approaches are most strongly associated with using homework as a central compo­ nent of the process (Ellis, 1962), but practitioners from many schools of thought find homework assignments to be valuable and relevant to their work. In fact, a sur­ vey of 827 psychologists from a variety of theoretical orientations, including 24 percent who identify as psy­ chodynamic, showed that homework is a widespread feature of therapy (Kazantzis, Lampropoulos, & Deane, 2005). The term homework may be defined and integrated differently depending on the background of the practitioner, and it can include things like the application of insights, journaling, or information gathering (Kazantzis & L’Abate, 2005). Readers will find many different forms of activities and homework presented in this book that can be tailored to a variety of different approaches and client populations. There are some factors that make the integration of homework more successful. L’Abate (1997) noted, for instance, that it must be practiced on a regular basis. Another important point is that the most powerful source of motivation is intrinsic to the client and driven by the client’s clear understanding of the benefits of engaging in the activity (Kazantzis & L’Abate, 2005). The rationales provided by the authors in this book in many ways can assist the clinician in conveying the potential benefits of the highlighted intervention. Since all clients have both gender and sexual iden­ tities as well as many other social identities, we have chosen to organize the sections of the book according to overarching themes rather than to separate chap­ ters according to specific targeted identities. Although some chapters do emphasize the needs of clients with certain identities, it is our intention that most chapters are applicable and generalizable to a multitude of

LGBTQ+ clients. We have aspired to be as inclusive of diversity as possible, and so chapters include explicit discussions about working with clients from different backgrounds and intersecting identities. Each chapter also discusses ethical guidelines and the need for culturally competent care. A social justice perspective is also evident throughout, because of our belief that clinicians should support the LGBTQ+ com­ munity by showing through example that they, them­ selves, attempt to create meaningful change in the communities within which LGBTQ+ individuals live, work, and learn. Therefore, while this book’s activities are designed to bolster coping strategies in individual clients, many activities also serve to identify and fortify their available supports and resources. We are very pleased to feature a large number of activities on pro­ viding training to enhance ally communities as well as to promote greater cohesion in LGBTQ+ communities. We have worked to make this book accessible to all clinicians no matter their training and experience. For more seasoned clinicians, the chapters and activ­ ities may offer innovative ways to approach their cli­ ents’ complex issues. For those just beginning to work with LGBTQ+ clients, the content provides a solid foundation to guide interventions and perspectives. The diverse topics apply to a variety of age groups, modalities, and settings, while also addressing many of the typical clinical issues relevant to LGBTQ+ clients. In addition, the activities in this book can be used by professionals who train others to counsel LGBTQ+ clients. The case studies included through­ out this book will be particularly useful in training. We are humbled by the contributors’ creativity, as well as their commitment to working with LGBTQ+ clients. We hope the book finds a permanent place on your bookshelf and in your classrooms and supports your work with LGBTQ+ clients. We also want to thank the graduate assistants who helped us with the book. Danica M. Rodriguez, Samantha Ruda, Emma Davidson, and Lyn Parsons were invaluable to our work, and we just wanted to say thanks. Joy Whitman Cyndy Boyd

Introduction

xv

References Beutler, L. E., Malik, M., Alimohamed, S., Harwood, T. M., Talebi, H., & Noble, S. (2004). Therapist variables. In M. J. Lambert (ed.), Bergin and Garfield’s handbook of psycho­ therapy and behavior change, 5th edition, 227–306. New York: John Wiley & Sons. Ellis, A. (1962). Reason and emotion in psychotherapy. Secaucus, NJ: Lyle Stuart. Freud, S. (1924). Inhibitions, symptoms and anxiety. In R. M. Hutchins (ed.), Great books of the Western world, 718–734. Chicago: Encyclopedia Britannica. Johnson, D., Sikorski, J., Savage, T. A., & Woitaszewski, S. A. (2014). Parents of youth who identify as transgender: An exploratory study. School Psychology Forum, 8 (1), 56. Kazantzis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignments in cognitive and behavioral therapy: A meta-analysis. Clinical Psychology: Science and Practice, 7, 189–202. Kazantzis, N., & L’Abate, L. (2005). Theoretical foundations. In N. Kazantzis, F. P. Deane., K. R. Ronan., & L. L’Abate (eds.), Using homework assignments in cognitive behavior therapy, 9–33. New York: Routledge.

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Introduction

Kazantzis, N., Lampropoulos, G. L., & Deane, F. P. (2005). A national survey of practicing psychologists’ use and atti­ tudes towards homework in psychotherapy. Journal of Consulting and Clinical Psychology, 73, 742–748. L’Abate, L. (1997). The paradox of change: Better them than us! In R. S. Sauber (ed.), Managed mental health care: Major diagnostic and treatment approaches, 40–66. Bristol, PA: Brunner/Mazel. Mustanski, B., & Liu, R. (2013). A longitudinal study of pre­ dictors of suicide attempts among lesbian, gay, bisexual, and transgender youth. Archives of Sexual Behavior, 42 (3), 437–448. Nelson, D. L., Castonguay, L. G., & Barwick, F. (2007). Direc­ tions for the integration of homework in practice. In N. Kazantzis & L. ĽAbate (eds.), Handbook of homework assignments in psychotherapy, 425–444. Boston: Springer. Snapp, S. D., Watson, R. J., Russell, S. T., Diaz, R. M., & Ryan, C. (2015). Social support networks for LGBT young adults: Low cost strategies for positive adjustment. Family Relations, 64 (3), 420–430. doi:10.1111/fare.12124.

SECTION I

HOMEWORK, HANDOUTS,

AND ACTIVITIES FOR THE

COMING-OUT PROCESS

ACROSS THE LIFE SPAN

We begin the book with a section on coming out, which is often a starting point in our work with LGBTQ+ clients. Feeling affirmed and safe in the com­ ing-out process is critical to the cognitive, emotional, and relational well-being of LGBTQ+ individuals (Ryan, Legate, & Weinstein, 2015). There are many ways to engage our clients in conversations about how, when, to whom, and if to come out, and the contribu­ tors in this section offer creative ideas and interven­ tions. They propose using pets, music, ecomaps, letter writing, and cinema to address the often complex decision and process of disclosing sexual and gender identities. They also emphasize the influence of the clients’ sociocultural contexts, facilitating greater understanding of the forms of oppression faced by cli­ ents with multiple marginalized identities. Addition­ ally, the chapters focus on clients at different devel­ opmental stages, speaking to the unique nuances of the coming-out process from adolescence through later life. Chapter 1, “A Pet-Assisted Intervention during Coming-Out Experiences,” by Michael P. Chaney and Kathryn L. Pozniak, offers a unique suggestion to use pets as confederate loved ones to practice coming out. Pet-assisted treatment is an accepted form of treatment and has been used with clients to success­ fully manage stress and anxiety (Bao & Schreer, 2016), to enhance mental health (Bao & Schreer, 2016), and to increase trust (Woolf & Brown, 2013). Chaney and Pozniak propose that practicing disclosures with a trusted pet companion can increase clients’ confidence and minimize the feelings of isolation and disconnec­ tion they sometimes experience when coming out. The next three chapters address coming out at various stages of development across the life span. Chapter 2, by Vincent M. Marasco and Randall L. Astramovich, “Assisting Individuals in Coming Out in Later Life as Lesbian, Gay, or Bisexual,” focuses on coming out at midlife or later adulthood and high­ lights the additional challenges that clients face at these ages. They propose the use of a cost-benefit anal­ ysis based on cognitive-behavioral therapy. The activ­ ity walks the client through the common life experi­ ences and themes experienced by those in midlife and later adulthood. The authors note, for instance, that compared to adolescent or young adult LGBTQ+ 2

clients, many older clients may have to negotiate sig­ nificant changes in long-term romantic relationships after coming out. Following this chapter are two that highlight the process for youth. Chapter 3, “Transgender Teens and Gender-Identity Disclosure,” addresses coming out as transgender in adolescence. Laura R. Haddock aptly discusses the potential loss of safety and emotional security these teens may face when coming out to their caregivers; she also underscores the resilience of teens who identify as transgender. Haddock points out that the alarming reality for trans individuals of color, who are six times more likely to experience hate violence than the white trans community (NCAVP, 2014), makes having a thoughtful strategy particularly essential for this community. Haddock shows counselors how to use letter writing to explore adolescent clients’ transgender identities. The focus is on self-awareness and self-affirmation followed by movement toward action. The second chapter on youth uses an ecomap to help adolescents disclose their sexual and/or gen­ der identities. Richard A. Brandon-Friedman and M. Killian Kinney, in “Assisting Youth with Disclosing Their Sexual Orientation and/or Gender Identity Using an Ecomap” (Chapter 4), demonstrate that the process of diagramming youth’s social environments facilitates the identification of the people to whom they want to come out and the potential relational support and loss in doing so. They explain that the emphasis on privileging clients’ own perspective of their world is especially empowering for youth. Using this strategy, clients are guided to explore the interplay between their web of relationships and their sociocultural context to make coming-out decisions that feel congruent with their lived experiences. The next two chapters of this section use two dif­ ferent forms of expressive arts to facilitate coming out for LGBTQ+ clients. “Must Be the Music: Musical Autobiography and Critical Lyric Analysis,” by Kiahni Nakai (Chapter 5), guides clients through the use of a musical autobiography assessment and a critical lyric analysis activity, helping them nonverbally express their needs and experiences and manage nonaccep­ tance and vulnerability. In addition, music has been shown to lower anxiety and improve immune func­ tioning (Novotney, 2013), thereby providing much­

needed support for many people during the com­ ing-out process. This approach is a powerful option for clients who use music as a mechanism to cope with oppression. Jennifer Lancaster and Angelica Terepka’s chapter, “Cinematherapy for LGBT Clients” (Chapter 6), offers a similar avenue of expression through the use of film. Many LGBTQ+ individuals are searching for visible role models in the coming-out process, and especially for those who hold multiple minority identities, role models may be hard to find. Using media represen­ tative of LGBTQ+ people and pairing these media with a film analysis worksheet, the authors aim to help clinicians validate and normalize clients’ identities, thereby easing the coming-out process. Both chapters provide clinicians with opportunities to use art and culture to situate LGBTQ+ clients’ experiences and augment the exploration of their identities. Finally, in the last chapter (Chapter 7), “How Does God See Me? A Reflective Exercise,” Hannah B. Bayne and Anita A. Neuer Colburn present an activity to deepen the self-exploration and the understanding of the effect of oppression and coming out when reli­ gious values conflict with one’s sexual identity. This is a common issue for LGBTQ+ clients and one often in need of discussion in treatment to ease the process of coming out.

References Bao, K., & Schreer, G. (2016). Pets and happiness: Examining the association between pet ownership and wellbeing. Anthrozoös, 29 (2), 283–296. doi:10.1080/08927936.2016 .1152721. National Coalition of Anti-Violence Programs (NCAVP) (2014). Lesbian, gay, bisexual, transgender, queer, and HIV-af­ fected hate violence in 2013. http://avp.org/wp-content/ uploads/2017/04/2013_ncavp_hvreport_final.pdf. Novotney, A. (2013, November). Music as medicine. Monitor on Psychology, 44 (10). www.apa.org/monitor/2013/11/ music.aspx. Ryan, W. S., Legate, N., & Weinstein, N. (2015). Coming out as lesbian, gay, or bisexual: The lasting impact of initial disclosure experiences. Self and Identity, 14 (5), 549 – 569. doi:10.1080/15298868.2015.1029516. Woolf, A., & Brown, A. (2013). Man’s best friend: The thera­ peutic impact of emotional relationships with animals. In C. Mohiyeddini (ed.), Emotional relationships: Types, challenges, and physical/mental health impacts, 161 – 178. Hauppauge, NY: Nova Science Publishers.

3

1 A PET-ASSISTED INTERVENTION DURING COMING-OUT EXPERIENCES Michael P. Chaney and Kathryn L. Pozniak Suggested Uses: Activity, homework Objective

The purpose of this activity or homework assignment is to assist counselors with clients who are contem­ plating coming out by creating a safe and affirming context in which to do so. By involving a personal pet in the coming-out process, clients may experience an increase in confidence and a decrease in mental stress, providing them with a positive and supportive envi­ ronment in which to practice coming out to others. This exercise could be adapted to meet the needs of transgender clients in the coming-out process as well. Rationale for Use

Disclosure of sexual orientation, or coming out, is the process of acknowledging same-sex physical and/or affectional attractions and identifying to oneself or others as lesbian, gay, bisexual, queer, questioning, or some other nonheterosexual identity (LGBQQ+, Chaney, Filmore, & Goodrich, 2011). Coming out is an individual decision that has the potential to bolster one’s identity (Sand, 2015). Further, positive comingout experiences can lead to the development of an affirmatory sexual identity, greater self-esteem, and improved psychosocial well-being (Carnelley, Hepper, Hicks, & Turner, 2011). However, disclosure of nonheterosexual sexual/affectional orientations also can be a major struggle for many LGBQQ+ individuals owing to fear of perceived or actual negative repercus­ sions (Carnelley et al., 2011). Thus, affirming interven­ tions that maximize the potential for positive com­ ing-out experiences and minimize the risk of negative consequences are needed.

As societal attitudes toward LGBQQ+ individuals have become more accepting, individuals are coming out at younger ages. Just several years ago, Rothman, Sullivan, Keyes, and Boehmer (2012) reported that the average age at which individuals came out to parents was twenty-five, and participants were more likely to come out to mothers before fathers. More recent stud­ ies reported the average age of disclosure occurs as young as mid- to late teens (sixteen to eighteen years old) (Charbonnier & Graziani, 2016; Dunlap, 2016). Because these individuals are coming out at such young ages, it has been suggested, they may come out with less emotional maturity and minimal coping skills to assist them as they negotiate the disclosure process. Coming out is considered a stressor consisting of two stages (Riley, 2010). In the first phase, LGBQQ+ persons recognize and acknowledge a nonheterosexual identity within themselves. The second phase is char­ acterized by disclosing the nonheterosexual identity to others. The process of revealing sexual orientation to others can be extremely stressful, especially when disclosing to family members. A study that explored the coming-out experiences of four hundred LGB young adults (eighteen to twenty-six years old) revealed that when they came out, they believed they had lim­ ited coping skills, which ultimately influenced their perceived sense of control (Charbonnier & Graziani, 2016). Participants reported that the lack of control magnified the intensity of their stress when coming out. Therefore, counselors would serve their clients well to use affirming interventions that increase psy­ chological safety, emotional support, and perceived control and decrease the distress associated with com­ ing out. Involving a beloved pet in therapy to assist

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

4

with the coming-out process could give clients a sense of control, thus enhancing self-efficacy and empow­ erment as they navigate the disclosure process (Berget, Ekeberg, & Braastad, 2008). When working with clients who are considering whether to come out, affirming helping professionals should weigh the benefits and consequences of com­ ing out for those clients (Hill, 2009). Though there are numerous benefits associated with coming out, such as living authentically and personal empower­ ment, depending on clients’ contextual factors, dis­ closure of sexual orientation to others may not be the right decision at that particular time. Should a client decide not to come out, counselors should inform clients about potential risks associated with concealing one’s sexual identity. For example, concealment of sexual orientation is related to cognitive impairment and negatively influences a person’s ability to develop and maintain close interpersonal relationships (Ryan, Legate, & Weinstein, 2015). Schope (2004) reported that gay men who had not disclosed their sexual orien­ tations experienced greater fear of negative appraisal from others than peers who had disclosed. Moreover, hiding sexual orientation can lead to increased anxiety, damaged self-esteem, substance use, and other health risk behaviors (D’Amico & Julien, 2012; Rothman et al., 2012). The bottom line is this: counselors must not force LGBQQ+ clients to come out unless a client has coping skills to deal with some of the intense feel­ ings and reactions related to the coming-out process (Chaney et al., 2011). Affirming counseling for clients in the beginning stages of coming out should involve strategies to instill hope, promote positivity, and bolster a client’s sup­ port system (Budge, 2014). Furthermore, a critical component of affirming counseling is assisting clients in examining the meaning of their physical and/or affectional attractions for their sexual identities and, on the basis of conclusions reached, making decisions about disclosure (Hill, 2009). Throughout the coun­ seling process, affirming clinicians should help clients develop interpersonal skills as a way to connect with supportive others, which can counteract feelings of loneliness and alienation. Involving a trusted pet in the therapeutic process with LGBQQ+ clients who are in the process of com­

ing out could minimize feelings of loneliness and iso­ lation that many individuals experience. Studies have shown that during the coming-out process, self-esteem and overall satisfaction with life decrease, and feelings of loneliness increase (Halpin & Allen, 2004). One reason that some LGBQQ+ people feel disconnected and isolated when coming out is because of their dis­ engagement from heterosexual support networks as they seek support from and connection to other nonheterosexuals. Consequently, being out increases the potential to lose important social connections in a person’s life (Sand, 2015). For other LGBQQ+ people, rejection and other negative reactions upon disclosure exacerbate feelings of loneliness and alienation. Stud­ ies have shown that negative reactions from friends and family significantly influence levels of depression and self-esteem in negative ways (Ryan et al., 2015). Additionally, negative parental reactions to disclosure contribute to health problems and substance use dis­ orders among nonheterosexuals (D’Amico & Julien, 2012). Of utmost concern is that LGBQQ+ people who have experienced parental rejection upon coming out reported increased suicide attempts (Ryan, Huebner, Diaz, & Sanchez, 2009). On the other hand, LGBQQ+ individuals are more likely to come out to parents whom they perceive to be encouraging of autonomy while their children are growing up (Carnelley et al., 2011). For LGBQQ+ individuals who are in the pro­ cess of coming out, perceived parental acceptance can influence the decision to disclose to family mem­ bers. To that point, using a pet in therapy with clients struggling with coming out could serve as a source of unconditional acceptance and much-needed support. When working with LGBQQ+ clients who are deciding whether to come out, counselors must take into consideration cultural aspects of a client’s identity that could influence the disclosure process. Rosario, Schrimshaw, and Hunter (2004) proposed that cultural factors such as family, gender roles, religious and spiritual values, and oppression make the coming-out process more complicated. These ideas are consistent with studies that found LGBQQ+ people of color (e.g., African American, Asian and Pacific Islander, Latinx, etc.) are less likely to disclose sexual orientation to parents compared to white LGBQQ+ individuals (Grov, Bimbi, Nanin, & Parsons, 2006; Rosario et al., 2004).

A Pet-Assisted Intervention during Coming-Out Experiences

5

A more recent study illustrated the intersectionality of sexual orientation, race, and gender. Aranda and colleagues (2015) found that although African Amer­ ican lesbians were more likely to report depression than their white peers, Latina lesbians were not only least likely to come out to their family members, but also more likely than African American and white lesbians to struggle with depression. In sum, the coming-out process is difficult enough, and multiple oppressed and intersecting identities make the process that much more challenging. There­ fore, affirming counselors should have in their thera­ peutic toolbox effective strategies that make coming out less stressful for LGBQQ+ clients. One affirming intervention is to explore the influence of oppression in a client’s life and to validate feelings of anger and grief associated with oppression (Hill, 2009). In addi­ tion, depending on a client’s needs, affirming counsel­ ors will integrate diverse counseling strategies to facili­ tate the coming-out process. Counselors are reminded that they have an ethical obligation to be multicul­ turally competent and to acquire counseling knowl­ edge and skills to be effective with diverse client popu­ lations (ACA, 2014, C.2.a). Moreover, the counseling interventions and methods selected by counselors must be theory-based or have an empirical rationale (ACA, 2014, C.7.a). Although traditional methods of talk therapy can effectively be used to assist clients as they navigate the coming-out process, some LGBQQ+ cli­ ents may be more responsive to creative and innovative interventions that also have a scientific basis. For example, Aronoff and Gilboa (2015) examined the role music played in the lives of gay men as they were coming out. Many of the men revealed that not only did music serve as a companion (i.e., a source of support), but music also helped them practice dis­ closing their sexual orientations to others through the lyrics of particular songs. Men in the study went on to comment that music provided the support that they were not receiving from family and friends during the coming-out process. Other forms of art have been recommended to facilitate the coming-out process. Pelton-Sweet and Sherry (2008) suggested using art therapy to promote psychological safety for clients who are negotiating the process of coming out. Interestingly,

6

Chaney & Pozniak

one exercise they recommended was for a client to select an animal figurine and to craft a safe environ­ ment for the animal using art supplies. The chosen animal figurine metaphorically represents a facet of the client (e.g., sexual identity) that is to be kept safe in the created space. Like these creative arts– related counseling strategies, using pets in the counseling ses­ sions to facilitate positive coming-out experiences for clients is simply another innovative intervention that counselors might choose when dealing with this issue. The mission of creating an atmosphere of hope for clients, providing a safe space to explore and validate emotions while also affirming individuals’ unique coming-out processes, can be achieved through the involvement of a pet in the counseling relationship. A common theme within the professional litera­ ture pertaining to helping LGBQQ+ clients navigate disclosure of sexual orientation is practice. Saltzburg (2007) urged counselors to work with clients in behav­ ioral rehearsals of coming out to assist them in pro­ gressing in their sexual identity development. Coun­ selors need to meet their clients where they are in their identity development. In other words, when working with clients who are coming out, counselors must consider the timing and sequence of planned interventions. Russell and Hawkey (2017) recom­ mended that counseling related to coming out begin with imagined disclosures, then progress to enacted disclosures at the client’s pace, so that the process is not overwhelming and the client has the coping skills to handle the intense feelings and reactions that might arise. Therefore, integrating a trusted and loved pet into behavioral rehearsals could decrease anxiety related to coming out. Furthermore, clients who may not be comfortable about disclosing to friends or fam­ ily may be more comfortable practicing coming out to a nonjudgmental being such as a pet. The follow­ ing section explores pet-assisted therapy as an effective intervention to assist LGBQQ+ clients during the coming-out process. A unique bond exists between humans and ani­ mals, one that can aid individuals in their search for meaning and companionship in everyday life. Animals have been employed as a way to increase mental and physical well-being in humans since the 1860s, when

Florence Nightingale highlighted the importance of using animals to assist individuals in gaining a sense of purpose, increase nurturing capabilities, and decrease feelings of isolation and loneliness (Woolf & Brown, 2013). Helping professionals have been using animals for therapeutic purposes for years; literature on the topic began in the early 1960s, when the scientific value of the bond was explored for the first time (Menna et al., 2012). Animals can provide great comfort in the home life of many, and these benefits can be expanded into the counseling domain. Research has demonstrated the potential of animal-assisted interventions in both psychological and physiological contexts, as animals provide benefits to both mental and physical health. The use of pets in therapy has been found to lower mental stress, increase confidence, and decrease worry and pain. Headey and colleagues (2002) found a health savings of over $3 billion over a ten-year period related to a decrease in doctor visits in Germany and Australia among individuals who owned pets as com­ pared to their counterparts who did not. Several connections have been made between the overall happiness and well-being of individuals and their relationships with pets. Bao and Schreer (2016) found evidence to support the theory that individuals who have pets have better mental health, increased happiness, and lower rates of depression. Pet owners were more satisfied with their lives than the individ­ uals who did not own pets; they also experienced an increase in physical health, including lower blood pressure and an increased survival rate following a heart attack (Bao & Schreer, 2016). These results are consistent with the work of Woolf and Brown (2013), who found pet owners to report increased life satis­ faction, reduction of psychological stress, and signif­ icant increase in trust. In addition, they found that the presence of a pet can aid in building self-confidence and provide structure, while also allowing for increased connection and acceptance. Pets can offer people sup­ port by providing a nonjudgmental relationship in which trust is established. By involving pets in coun­ seling sessions, counselors may be able to explore pre­ senting issues, including coming-out issues, more thoroughly while also improving a client’s communi­

cation and social skills (Chitic, Rusu, & Szamoskozi, 2012; Fung & Leung, 2014). Research has demonstrated that pets can increase feelings of confidence in children (Gee, Church, & Altobelli, 2010; Gee, Gould, Swanson, & Wagner, 2012). In these studies, children were more successful at com­ pleting tasks with the supportive presence of a dog than they were without the animal. Further, children who struggled with reading have been shown to improve their abilities in the presence of therapy dogs as a result of feeling more confident in their abilities (Kirnan, Siminerio, & Wong, 2016). Though these studies relate to confidence building associated with basic skills in children, the same principles could be applied to LGBQQ+ clients of all ages who are dealing with the coming-out process. The mental and physical benefits associated with involving pets in counseling could help provide an atmosphere that minimizes distress associated with disclosure of sexual orientation. Furthermore, pets in counseling can serve as a surrogate friend or family member for coming-out role-playing and behavioral rehearsals. The use of a pet in therapy sessions may aid in producing a safe space in which clients can prac­ tice coming out in an unconditionally accepting envi­ ronment. Moreover, inviting a pet into a session may minimize the anxiety, isolation, fear of rejection, and shame associated with coming out, yet maximize the potential for a positive disclosure. Research has shown that a positive coming-out experience is related to the development of a positive identity, improved selfesteem, and better psychological adjustment (Carnelley et al., 2011). Although the American Counseling Association’s (ACA) and American Psychological Association’s ethical codes do not specifically address the use of ani­ mals in counseling practice, ethical implications must be considered. It is mandatory that counselors adhere to guiding ethical principles when working with ani­ mals in counseling and seek supervision when neces­ sary. The ACA (2014) ethical principles to be consid­ ered include autonomy, nonmaleficence, beneficence, justice, fidelity, and veracity, each of which needs to be observed for both the animal and the client. An eth­ ical counselor must assess a client’s level of comfort

A Pet-Assisted Intervention during Coming-Out Experiences

7

in working with an animal during a session and give a client the opportunity to decline. In addition, the animal needs to feel comfortable taking part in the activity, and it should not be forced to interact. Nonmaleficence means doing no harm to the client or the animal and may include informing the client of the risks involved in working with a pet, such as nat­ ural defense mechanisms, animals using their mouths to play, and allergies, while also considering that the animal may face risks interacting with the clients. Beneficence dictates that the counselor work for the good of both the client and the animal involved in the activity; their participation should be benefi­ cial for both client and animal. The final three ethical principles of justice, fidelity, and veracity protect the client and animal from poor intentions, providing a solid framework for ethical interactions. Both the client and pet should be treated equally and fairly, providing them with the opportunity to discontinue the treatment and decide on their level of interaction and participation. Fidelity ensures that the counselor honors commitments, which allows the client to feel comfortable and protected by the clinician. Finally, veracity pertains to truthfulness, which is essential for an effective client-counselor relation­ ship, as well as a strong human-animal bond. Ethical counseling practice provides a solid structure for successful relationships with clients, ensuring the welfare of both clients and animals. When the human-animal relationship is used ethically, it can be a beneficial intervention in a therapeutic setting. Instructions

There are a couple of ways that a pet may be integrated into the counseling process to assist a client who is contemplating coming out. The first set of instructions pertains to involving a pet as an in-session disclosure activity; the second set describes how to adapt the insession exercise to a coming-out homework assign­ ment. As an in-session activity, the first step is to make sure the client consents to the activity and that the intervention has been selected specifically for the bene­ fit of the client. This activity should be used only if cli­ ents have decided that they are ready to explore coming out. There should be no pressure from the counselor.

8

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Next, help the client relax by engaging in deep breathing exercises or muscle relaxation techniques. After the client is relaxed, direct the client to face the pet. Encourage the client to imagine a future comingout situation or simply have the client remain in the here and now. When the client is ready, have the client verbalize the disclosure of sexual orientation to the pet. Support the client’s disclosure and encourage the client to engage in a dialogue with the pet about the client’s sexual orientation. Initially, some clients may feel embarrassed or silly for coming out to a pet, and these feelings should be explored and validated as normal. After the client has disclosed, the counselor should focus on the client’s verbal and nonverbal behavior during the activity and may ask questions about the client’s thoughts and feelings before, during, and after the disclosure. See the handout on page 12 for suggested questions the client should answer. The counselor should focus on the success of the client’s disclosure and offer support and encourage­ ment throughout the process. If a client is preparing to come out to significant people in their life, this activ­ ity can be repeated until the client has developed a sense of efficacy in putting together a potential comingout script. This activity can also be adapted to an out-of­ session homework assignment by providing the client with the aforementioned steps. The client can prac­ tice disclosing to the pet in the privacy and comfort of the client’s home. The client should be instructed to journal responses to the list of questions on the hand­ out. In the next session, client and counselor can pro­ cess the journal and plan for next steps. Brief Vignette

Jo seeks counseling to get support and guidance related to coming out to her family. Jo, who is thirty-seven years old, identifies as an African American cisgender lesbian. Because of her family’s strong religious back­ ground, Jo has been experiencing apprehension and anxiety about coming out to her parents. Although Jo has come out to one close friend, the fear of rejec­ tion that she has been experiencing related to dis­ closing to her parents has immobilized her. She comes to therapy motivated to get “unstuck” regarding coming

out to her parents. After a few sessions of rapport building, goal setting, and information gathering, it becomes apparent that a major source of emotional support for Jo is her German shepherd rescue dog, Callie. With this information, the counselor presents Jo with the option to bring Callie to the next session to engage in a simulated coming-out role-play. With­ out hesitation, Jo agrees. After the counselor provides Jo with explicit instructions and obtains her consent, in the next session Jo practices coming out, using Callie as a surrogate family member. Following the simulated coming out, the counselor explores with Jo her thoughts and feelings during the exercise. Callie is brought in for one more session, in which Jo is again able to practice coming out. Throughout the process, Jo’s counselor provides support, validation, and con­ structive feedback. When Jo eventually comes out to her parents, they are not as supportive as she had hoped, but because of the rehearsals with her counselor and Callie, and because she knew what the potential reactions could be, she feels prepared to cope with the experience in a healthy way, and she seeks support through a local support group. Jo continues to main­ tain a relationship with her parents, and they are begin­ ning to show support and acceptance in small ways. Suggestions for Follow-up

Therapists should follow up with the client across ses­ sions, as meanings found in the activity or homework assignment may be realized at a later time, after selfreflection. Counselor and client should contemplate how meaning gathered through the activity may trans­ late into relationships with friends and family and also how the activity relates to plans for future disclo­ sure. Further, counselor and client may work toward a plan of action for disclosure to safe, supportive oth­ ers. Additionally, if the client found the incorporation of the pet in the session to be valuable and effective, further sessions allowing for the inclusion of the pet may be discussed. Contraindications for Use

The decision to involve a client’s pet in a counseling session to facilitate the coming-out experience belongs to the client. As always, affirming counselors must

meet the clients where they are in their coming-out journey. Therefore, counselors should never encour­ age a client to come out if coming out would lead to high-risk situations (e.g., being kicked out of the house, interpersonal violence, etc.). An additional con­ sideration pertains to the demeanor of the pet. If the counselor is integrating a pet into a session, the ani­ mal should be socialized well. Moreover, potential animal allergies or fears of anyone who may come in contact with the animal must being taken into con­ sideration. Last, though coming out to a beloved pet can be therapeutic and offer the opportunity for behav­ ioral rehearsals, coming out to significant people in a client’s life can be much more intense, and the client should have a clear understanding of the differences. Professional Readings and Resources Association for LGBT Issues in Counseling. LGBT resources. www.algbtic.org/l-g-b-t-resources.html. DeBord, K. A., Fischer, A. R., Bieschke, K. J., & Perez, R. M. (2017). Handbook of sexual orientation and gender diversity in counseling and psychotherapy. Washington, DC: Amer­ ican Psychological Association. Fine, A. H. (2010). Handbook on animal-assisted therapy: Foun­ dations and guidelines for animal-assisted interventions, 3rd edition. San Diego: Academic Press. Fine, A. H., & Eisen, C. J. (2008). Afternoons with puppy: Inspi­ rations from a therapist and his animals. West Lafayette, IN: Purdue University Press. Olmert, M. D. (2010). Made for each other: The biology of the human-animal bond. Cambridge, MA: Da Capo Press. Parents and Friends of Lesbians and Gays (PFLAG). www. pflag.org.

Resources for Clients Boykin, K. (2012). For colored boys who have considered suicide when the rainbow is still not enough: Coming of age, coming out, and coming home. New York: Magnus Books. Downs, A. (2012). The velvet rage: Overcoming the pain of grow­ ing up gay in a straight man’s world, 2nd edition. Boston: Da Capo Press. Human Rights Campaign. (2014). Coming out resource guides. https://www.hrc.org/resources/coming-out-resource­ guides. Olmert, M. D. (2010). Made for each other: The biology of the human-animal bond. Cambridge, MA: Da Capo Press. Stevens, T. (2002). How to be a happy lesbian: A coming out guide. Asheville, NC: Amazing Dreams Publishing. Trevor Helpline. 1-866-4-U-Trevor (488-7386). www.thetrevor project.org.

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References American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. https://www.counseling .org/resources/aca-code-of-ethics.pdf. Aranda, F., Matthews, A. K., Hughes, T. L., Muramatsu, N., Wilsnack, S. C., Johnson, T. P., & Riley, B. B. (2015). Com­ ing out in color: Racial/ethnic differences in the relation­ ship between level of sexual identity disclosure and depression among lesbians. Cultural Diversity and Ethnic Minority Psychology, 21 (2), 247–257. doi:10.1037/a003 7644. Aronoff, U., & Gilboa, A. (2015). Music and the closet: The roles music plays for gay men in the “coming out” process. Psychology of Music, 43 (3), 423–437. doi:10.1177/03057 3561351943. Bao, K., & Schreer, G. (2016). Pets and happiness: Examining the association between pet ownership and wellbeing. Anthrozoös, 29 (2), 283–296. doi:10.1080/08927936.2016. 1152721. Berget, B., Ekeberg, Ø., & Braastad, B. O. (2008). Animalassisted therapy with farm animals for persons with psy­ chiatric disorders: Effects on self-efficacy, coping ability and quality of life, a randomized controlled trial. Clinical Practice and Epidemiology in Mental Health, 4 (1), 9. doi: 10.1186/1745-0179-4-9. Budge, S. L. (2014). Navigating the balance between positivity and minority stress for LGBTQ clients who are coming out. Psychology of Sexual Orientation and Gender Diversity, 1 (4), 350–352. Carnelley, K. B., Hepper, E. G., Hicks, C., & Turner, W. (2011). Perceived parental reactions to coming out, attachment, and romantic relationship views. Attachment and Human Development, 13 (3), 217–236. doi:10.1080/14616734.201 1.563828. Chaney, M. P., Filmore, J. M., & Goodrich, K. M. (2011, May). No more sitting on the sidelines. Counseling Today, 53 (11), 34–37. http://ct.counseling.org/2011/05/no-more-sitting-on­ the-sidelines/. Charbonnier, E., & Graziani, P. (2016). The stress associated with the coming out process in the young adult popula­ tion. Journal of Gay and Lesbian Mental Health, 20 (4), 319–328. doi:10.1080/19359705.2016.1182957. Chitic, V., Rusu, A. S., & Szamoskozi, S. (2012). The effects of animal assisted therapy on communication and social skills: A meta-analysis. Transylvanian Journal of Psychology, 13 (1), 1–17. D’Amico, E., & Julien, D. (2012). Disclosure of sexual orienta­ tion and gay, lesbian, and bisexual youths’ adjustment: Associations with past and current parental acceptance and rejection. Journal of GLBT Family Studies, 8, 215–242. doi:10.1080/1550428X.2012.677232.

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Dunlap, A. (2016). Changes in coming out milestones across five age cohorts. Journal of Gay and Lesbian Social Services, 28 (1), 20–38. doi:10.1080/10538720.2016.1124351. Fung, S., & Leung, A. S. (2014). Pilot study investigating the role of therapy dogs in facilitating social interaction among children with autism. Journal of Contemporary Psycho­ therapy, 44 (4), 253–262. https://doi.org/10.1007/s10879 -014-9274-z. Gee, N. R., Church, M. T., & Altobelli, C. L. (2010). Preschool­ ers make fewer errors on an object categorization task in the presence of a dog. Anthrozoös, 23 (3), 223–230. https://doi.org/10.2752/175303710x12750451258896. Gee, N. R., Gould, J. K., Swanson, C. C., & Wagner, A. K. (2012). Preschoolers categorize animate objects better in the presence of a dog. Anthrozoös, 25 (2), 187–198. https://doi.org/10.2752/175303712X13316289505387. Grov, C., Bimbi, D. S., Nanin, J. E., & Parsons, J. T. (2006). Race, ethnicity, gender, and generational factors associated with the coming-out process among gay, lesbian, and bisexual individuals. Journal of Sex Research, 43 (2), 115–121. Halpin, S. A., & Allen, M. W. (2004). Changes in psychosocial well-being during stages of gay identity development. Journal of Homosexuality, 47 (2), 109–129. Headey, B., Grabka, M., Kelley, J., Reddy, P., & Tseng, Y. P. (2002). Pet ownership is good for your health and saves public expenditure too: Australian and German longitudinal evi­ dence. Australian Social Monitor, 5 (4), 93–99. Hill, N. L. (2009). Affirmative practice and alternative sexual orientations: Helping clients navigate the coming out pro­ cess. Clinical Social Work Journal, 37 (4), 346–356. doi: 10.1007/s10615-009-0240-2. Kirnan, J., Siminerio, S., & Wong, Z. (2016). The impact of a therapy dog program on children’s reading skills and atti­ tudes toward reading. Early Childhood Education Journal, 44 (6), 637–651. https://doi.org/10.1007/s10643-015-07 47-9. Menna, L. F., Fontanella, M., Santaniello, A., Ammendola, E., Travaglino, M., Mugnai, F., & Fioretti, A. (2012). Evalua­ tion of social relationships in elderly by animal-assisted activity. International Psychogeriatrics, 24 (6), 1019–1020. Pelton-Sweet, L. M., & Sherry, A. (2008). Coming out through art: A review of art therapy with LGBT clients. Art Therapy: Journal of the American Art Therapy Association, 25 (4), 170–176. Riley, B. H. (2010). GLB adolescents’ “coming out.” Journal of Child and Adolescent Psychiatric Nursing, 23, 3–10. Rosario, M., Schrimshaw, E. W., & Hunter, J. (2004). Ethnic/ racial differences in the coming-out process of lesbian, gay, and bisexual youths: A comparison of sexual identity devel­ opment over time. Cultural Diversity and Ethnic Minority Psychology, 10 (3), 215–228. doi:10.1037/1099-9809.10.3. 215.

Rothman, E. F., Sullivan, M., Keyes, S., & Boehmer, U. (2012). Parents’ supportive reactions to sexual orientation dis­ closure associated with better health: Results from a population-based survey of LGB adults in Massachusetts. Journal of Homosexuality, 59, 186–200. doi:10.1080/0091 8369.2012.648878. Russell, G. M., & Hawkey, C. G. (2017). Context, stigma, and therapeutic practice. In K. A. DeBord, A. R. Fischer, K. J. Bieschke, & R. M. Perez (eds.), Handbook of sexual orienta­ tion and gender diversity in counseling and psychotherapy, 75–104. Washington, DC: American Psychological Association. Ryan, C., Huebner, D., Diaz, R. M., & Sanchez, J. (2009). Fam­ ily rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics 123, 346–352. Ryan, C., Russell, S. T., Huebner, D., & Diaz, R. (2010). Family acceptance in adolescence and the health of LGBT young adults. Journal of Child and Adolescent Psychiatric Nursing, 23 (4), 205–213.

Ryan, W. S., Legate, N., & Weinstein, N. (2015). Coming out as lesbian, gay, or bisexual: The lasting impact of initial dis­ closure experiences. Self and Identity, 14 (5), 549–569. doi:10.1080/15298868.2015.1029516. Saltzburg, S. (2007). Narrative therapy pathways for re-author­ ing with parents of adolescents coming-out as lesbian, gay, and bisexual. Contemporary Family Therapy, 29, 57–69. Sand, S. (2015). Coming out, being out: Reconciling loss and hatred in becoming whole. Psychoanalysis, Culture, and Society, 20 (3), 250–266. Schope, R. D. (2004). Practitioners need to ask: Culturally com­ petent practice requires knowing where the gay male client is in the coming out process. Smith College Studies in Social Work, 74 (2), 257–270. doi:10.1080/003773104095 17715. Woolf, A., & Brown, A. (2013). Man’s best friend: The thera­ peutic impact of emotional relationships with animals. In C. Mohiyeddini (ed.), Emotional relationships: Types, challenges, and physical/mental health impacts, 161–178. Hauppauge, NY: Nova Science Publishers.

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H A NDO UT

1. What feelings did you experience before, during, and after you disclosed?

2. If (pet’s name) was (name of a friend of family member), how do you think they would have reacted to your coming out?

3. If (pet’s name) could respond to you, what do you think they would say?

4. How accepted did you feel by (pet’s name) after your disclosure, and if you were to come out to people in your life, what kind of support would you need from them?

5. What would you do the same or differently if you were coming out to (name of a friend of family member)?

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Michael P. Chaney and Kathryn L. Pozniak

2 ASSISTING INDIVIDUALS IN COMING OUT IN LATER LIFE AS LESBIAN, GAY, OR BISEXUAL Vincent M. Marasco and Randall L. Astramovich Suggested Use: Homework Objective

This homework activity will help clients who are com­ ing out as lesbian, gay, or bisexual (LGB) during middle and later adulthood reflect on advantages and disad­ vantages of coming out to partners, children, extended family, friends, and coworkers. Rationale for Use

The coming-out process for LGB people during middle and later adulthood often involves developmental experiences similar to those involved in coming out during adolescence and early adulthood. Although the sequencing and timing may vary depending on indi­ vidual development, coming out generally involves milestones that include the recognition of same-sex attraction; identity confusion and experimentation in same-sex sexual relations; self-identification as lesbian, gay, or bisexual; and coming out to others (Calzo, Antonucci, Mays, & Cochran, 2011; Floyd & Bakeman, 2006). However, people coming out in middle and later adulthood often experience these milestones after identifying as a heterosexual for many years, and possibly being involved in opposite-sex romantic relationships before recognizing and accepting their same-sex attraction. As a result, they may experience significant changes in established relationships with partners, children, extended family, friends, and co­ workers (Johnston & Jenkins, 2004). Research also suggests that LGB people coming out in middle and later adulthood may experience ageism from within the LGB community, which may limit access to sup­ port and acceptance as an LGB person (Kimmel,

Rose, Orel, & Greene, 2006). Other struggles often experienced by individuals coming out in middle and later adulthood include grief over not having experi­ enced a typical adolescence, engaging in unhealthy behaviors as a mechanism for coping with homopho­ bia, coping with religious belief systems that margin­ alize LGB people (Johnston & Jenkins, 2004), and career development concerns (Chung, Chang, & Rose, 2015). Consequently, the coming-out process may lead to increased risk for depression and decreased self-esteem (Ryan, Legate, & Weinstein, 2015). Research on coming out later in life is limited; however, studies with younger LGB populations sug­ gest that coming out may have psychological advan­ tages, including decreasing depression and improving self-esteem (Kosciw, Palmer, & Kull, 2015). In addi­ tion, older clients coming out as LGB may experience increased authenticity and intimacy in their relation­ ships (Johnston & Jenkins, 2004). Identity intersec­ tionality undoubtedly affects the coming-out process, and older clients, especially those from multiply oppressed populations, may have heightened struggles, particularly related to family issues (Goodrich & Ginicola, 2017). Because of the significant relationship changes, disruptions, and renegotiations that may occur as a result of coming out in middle and later adulthood, this homework activity will help clients assess the advantages and disadvantages of coming out to various individuals in their social systems, including partners, children, extended family, friends, and coworkers. Intersectionality and intersectional approaches have been used within feminist theory and scholar­ ship, as well as sociology (Davis, 2008; Valentine,

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

14

2007). The foundational tenets of intersectionality are that each individual holds various identities that inter­ sect (Jones, Misra, & McCurley, 2013). Common examples of intersecting identities are race, class, and gender. However, a number of others exist and vary from person to person. Other examples include reli­ gious identity, physical or mental disability, and sexual identity or orientation. The influence of age and sex­ ual orientation has been found to be important. King and Richardson (2017) discussed mental health dis­ tress for older LGB persons, which includes substance use, depression, and an increased risk of suicide. Because of the intersecting nature of these identities, they must be examined together. When assisting clients in the coming-out process, it is important to address intersecting identities and how each identity affects the individual, their interactions with the self, and interactions within their interpersonal relationships. The American Counseling Association’s (2014) ACA Code of Ethics compels counselors to respect cli­ ent rights (B.1) and to consider multicultural factors when counseling clients from diverse backgrounds (B.1.a). Counselors working with adults coming out during middle and later adulthood should refrain from pressuring clients to come out and should honor the client’s readiness for the coming-out process. In addition, counselors should carefully consider the cul­ tural implications of coming out for clients from diverse ethnic and religious backgrounds. Furthermore, counselors are compelled to receive training and super­ vision in LGB-affirmative counseling interventions. Affirmative counseling with LGB clients emphasizes client empowerment and advocacy to help clients recognize and proactively respond to the negative effects of heterosexism in their lives (Finnerty, Kocet, Lutes, & Yates, 2017). This homework activity pro­ motes LGB-affirmative counseling practices by empow­ ering older clients in the coming-out process to explore advantages and disadvantages to coming out to spe­ cific individuals in their lives and to develop strate­ gies for addressing heterosexism, marginalization, and discrimination as they come out to others. Instructions

To assist a client in coming out to family, friends, and coworkers, instruct the client to complete a cost-benefit

analysis (CBA). A CBA is a method of assessing and examining potential benefits and disadvantages of alternative choices (David, Ngulube, & Dube, 2013) and has been incorporated into cognitive-behavioral therapy. Within the realm of counseling, a CBA can help a client visualize and better comprehend alterna­ tive decisions and potential outcomes of their choices. A client can complete a CBA to evaluate the var­ ious potential outcomes of coming out. In doing so, a client will evaluate the potential benefits of coming out, the potential disadvantages of coming out, the potential benefits of not coming out, and the potential disadvantages of not coming out. The possible outcomes of a CBA can cover a range of areas. In part, the counselor’s responsibility is to encourage the client to consider as many potential outcomes as possible. The example CBA will provide the counselor with prompts for the client to consider when completing it. Additionally, a CBA can be tai­ lored to be specific or general to meet the needs of the client. For example, the CBA can address coming out to one specific person or a group of individuals, and it can be modified at various points within the coun­ seling relationship in order to assess comfort and read­ iness. Completing the CBA multiple times through­ out counseling can help generate salient themes, assess changing outcomes, and evaluate with the client points of safety within each of the different areas of the CBA. When the client and counselor have decided to complete a CBA, they should consider various points and aspects of the coming-out process. The counselor and the client can brainstorm considerations and questions whose answers might affect the decision to come out. Such questions can include: Are there safety concerns related to the coming-out process? Will there be financial repercussions to coming out? Would coming out impair job security or benefits (if the cli­ ent is coming out within the work setting)? How would coming out affect the family system in the long term? Does the client wish to pursue a same-sex rela­ tionship after coming out? Are there spiritual or reli­ gious concerns? Considerations include meeting clients where they are, recognizing the intersection­ ality of identities, and readiness to come out. These questions and considerations are intended to be broad and to examine the coming-out process more Assisting Individuals in Coming Out in Later Life

15

holistically, and to assist the client in thinking about more than the emotional aspects of coming out. Concerns specific to each client will be addressed by completing the CBA. Brief Vignette

Alex is a fifty-three-year-old black cisgender male who presents in session with anxiety, fear, and shame. He has been married for twenty-seven years to a woman and has two children, ages twenty and twenty-three. He is involved in his local faith-based organization with his family. Alex’s anxiety, fear, and shame have had negative effects on his marriage, including increased fighting, lack of sexual intercourse, and decreased communication with his wife. Additionally, he has been scaling back his role within his faith-based orga­ nization with his wife and children. After a few weeks of meeting with his counselor, Alex discloses that he has been aware of his same-sex attractions “since I can remember”; Alex does not initially self-identify as gay or bisexual. Upon further inquiry and discussion, Alex discloses that he has limited experience in samesex relationships; he engaged in exploratory sexual behaviors when he was younger and occasionally engages in same-sex fantasy while masturbating. Over a span of roughly four months in counseling, Alex has accepted his same-sex attractions and desires as part of his sexual interests, and he has decided to explore disclosing and discussing his same-sex attrac­ tions with his wife. He maintains his sexual and roman­ tic attraction to his wife. As the counseling relation ship continues, Alex comes to recognize that sameand opposite-sex attractions fit within the bisexual identity, and he is comfortable assuming that identity. As Alex has moved through his own acceptance of his same-sex desires and attractions, he continues to experience anxiety and fear about coming out about having same-sex desires. He reports anxiety about coming out to his wife, fear of her rejection, and shame about potentially ruining his marriage and family. He also reports fear of being shamed for his desires. The use of a CBA will help Alex consider the potential costs and benefits of disclosing to his wife. The coun­ selor explains to Alex the purpose and aspects of the CBA that will allow Alex to explore the costs and benefits that are most applicable to him, his family, and 16

Marasco & Astramovich

his current sexual identity development. The coun­ selor explains that Alex is to consider all the potential benefits and disadvantages of coming out. Further, Alex is to take into consideration the various inter­ secting roles and identities he embodies, such as his involvement in a faith-based organization, his racial and ethnic identity, and his current relationships. Alex is struggling to accept or assume a nonhet­ erosexual identity. He and the counselor can explore resistance and disparities between his identities. Although Alex does not conceptualize the relationship between his current sexual identity and his past expe­ riences, he and the counselor can discuss and explore how behaviors and identity often interact with each other but are not synonymous. That is, although Alex has had same-sex attractions and experiences, he is not required to identify with a certain sexual identity on the sole basis of his sexual behaviors or attractions. Exploring the relationship between behaviors and iden­ tity is an important part of this counseling relation­ ship, and it allows Alex to self-identify without pres­ sure to assume an ill-fitting identity. Alex is then able to assume an identity that is appropriate and fitting for him. Suggestions for Follow-up

Completing a CBA can be done over the period of one to two weeks, or however long a client needs. Upon completion, meet with the client and review the CBA. Explore the various potential outcomes, their effect on the client’s choice to come out, and process with them any emotions they may have experienced while completing the CBA and those they are currently experiencing about coming out. Through exploring and processing, the client can decide, on the basis of the completed CBA, which route to take. The role of the counselor at this point is to offer support for their decisions and assistance with skills development and coping strategies. Examples of follow-up questions are: How are your interactions with others influenced by completing and reviewing your CBA? What do you hope will change as a result of having completed the CBA? The counselor can help the client reflect on how their different and intersecting identities affected its completion. The counselor can also assist in providing

alternative perspectives or help the client include more advantages or disadvantages for each category. Contraindications for Use

This activity is designed for clients who have selfidentified and self-accepted an LGB identity and who are interested in beginning the coming-out process with others in their lives. Therefore, clients who con­ tinue to struggle with same-sex attractions or who experience heightened emotions related to an LGB identity may not benefit from this activity until they have a more established sense of their sexual identity and a readiness to share this with others. Professional Readings and Resources Floyd, F. J., & Bakeman, R. (2006). Coming-out across the life course: Implications of age and historical context. Archives of Sexual Behavior, 35, 287–296. doi:10.1007/s10508-006­ 9022-x. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H. C., Loos, B., . . . & Hammer, T. R. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Coun­ seling competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individu­ als. Journal of LGBT Issues in Counseling, 7, 2–43. doi:10. 1080/15538605.2013.755444. Johnston, L. B., & Jenkins, D. (2004). Coming out in midadulthood: Building a new identity. Journal of Gay & Lesbian Social Services, 16, 19–42. doi:10.1300/J041v 16n02_02. Kimmel, D., Rose, T., & David, S. (eds.). (2006). Lesbian, gay, bisexual, and transgender aging: Research and clinical perspectives. New York: Columbia University Press.

Resources for Clients Berzon, B. (2004). Permanent partners: Building gay and les­ bian relationships that last. New York: Penguin Group. Gay Life after 40. www.gaylifeafter40.com. Pride Foundation. www.pridefoundation.org. Services and Advocacy for Gay, Lesbian, Bisexual, and Transgender Elders. www.sageusa.org. Signorile, M. (1995) Outing yourself: How to come out as les­ bian or gay to your family, friends, and coworkers. New York: Random House.

References American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. Calzo, J. P., Antonucci, T. C., Mays, V. M., & Cochran, S. D. (2011). Retrospective recall of sexual orientation identity development among gay, lesbian, and bisexual adults.

Developmental Psychology, 47, 1658–1673. doi:10.1037/ a0025508. Chung, Y. B., Chang, T. K., & Rose, C. S. (2015). Managing and coping with sexual identity at work. Psychologist, 28, 212–215. David, R., Ngulube, P., & Dube, A. (2013). A cost-benefit anal­ ysis of document management strategies used at a finan­ cial institution in Zimbabwe: A case study. SA Journal of Information Management, 15 (2). Davis, K. (2008). Intersectionality as buzzword: A sociology of science perspective on what makes a feminist theory successful. Feminist Theory, 9, 67–85. doi:10.1177/1464 70008086364. Finnerty, P., Kocet, M. M., Lutes, J., & Yates, C. (2017). Affir­ mative, strengths-based counseling with LGBTQI+ people. In M. M. Ginicola, C. Smith, & J. M. Filmore (eds.), Affirmative counseling with LGBTQI+ people, 109–125. Alexandria, VA: American Counseling Association. Floyd, F. J., & Bakeman, R. (2006). Coming-out across the life course: Implications of age and historical context. Archives of Sexual Behavior, 35, 287–296. doi:10.1007/s10508-006­ 9022-x. Goodrich, K. M., & Ginicola, M. M. (2017). Identity develop­ ment, coming out, and family adjustment. In M. M. Ginicola, C. Smith, & J. M. Filmore (eds.), Affirmative counseling with LGBTQI+ people, 61–73. Alexandria, VA: American Counseling Association. Johnston, L. B., & Jenkins, D. (2004). Coming out in midadulthood: Building a new identity. Journal of Gay & Lesbian Social Services, 16, 19–42. doi:10.1300/J041v 16n02_02. Jones, K. C., Misra, J., & McCurley, K. (2013). Intersectionality in sociology. Sociologists for Women in Society. https:// socwomen.org/wp-content/uploads/2018/03/swsfact sheet_intersectionality.pdf. Kimmel, D., Rose, T., & David, S. (eds.). (2006). Lesbian, gay, bisexual, and transgender aging: Research and clinical perspectives. New York: Columbia University Press. Kimmel, D., Rose, T., Orel, N., & Greene, B. (2006). Historical context for research on lesbian, gay, bisexual, and transgender aging. In D. Kimmel, T. Rose, & S. David (eds.), Lesbian, gay, bisexual, and transgender aging: Research and clinical perspectives, 1–19. New York: Columbia Uni­ versity Press. King, S. D., & Richardson, V. E. (2017). Mental health for older adults. Annual Review of Gerontology and Geriatrics, 37 (1), 59–75. doi:10.1891/0198-8794.37.59. Kosciw, J., Palmer, N., & Kull, R. (2015). Reflecting resiliency: Openness about sexual orientation and/or gender iden­ tity and its relationship to well-being and educational outcomes for LGBT students. American Journal of Com­ munity Psychology, 55, 167–178. doi:10.1007/s10464-014­ 9642-6.

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Ryan, W. S., Legate, N., & Weinstein, N. (2015). Coming out as lesbian, gay, or bisexual: The lasting impact of initial disclosure experiences. Self and Identity, 14, 549–569. doi:10.1080/15298868.2015.1029516.

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Valentine, G. (2007). Theorizing and researching intersec­ tionality: A challenge for feminist geography. Professional Geographer, 59, 10–21. doi:10.1111/j.1467-9272.2007. 00587.x.

COMMEN TS O N THE HAN D O UT To be most effective and beneficial for a client completing a CBA, it is important to identify to whom the CBA is directed. Answering the question “Whom am I considering coming out to?” will help guide the client in completing the homework. Additionally, the counselor should discuss with clients how their different identities and roles can influence the Benefits and Disadvantages categories. Below is an example of what Alex’s completed CBA may look like as he contemplates coming out to his wife. It includes different identities that are intertwined with his identity as a husband.

BENEFITS Coming Out

DISADVANTAGES

• Being open with my wife and self

• That she will judge me for my attractions and desires

• Not being ashamed of who I am anymore • Increased communication and honesty and authenticity • Potentially less stress, anxiety, fighting • Potentially more intimacy between us

Coming Out

• That she’ll leave me • That she’ll tell the children or others before I do, which could affect my relationship with them or my faith-based organization

• Living authentically

• Dealing with questions about my sexual orientation or people challenging my relationship with my wife

• Will be accepted by her and will be supported

• What does it mean to be a bisexual black man?

• Feeling better

• Demonstrating trust within a relationship with my wife for our kids

BENEFITS

Not Coming Out

DISADVANTAGES

Not Coming Out

• I can’t be judged for what she doesn’t know about me

• I remain anxious, fearful, ashamed

• No one questions my relationship or challenges my sexual orientation

• How does or will this affect our children? What am I teaching them about relationships?

• Relationship remains intact and we continue our marriage

• I continue to fight with my wife

• Potential divorce because of hiding who I am • Continued lack of emotional and physical intimacy • Continued decreased involvement in my faith-based organization owing to anxiety and stress • Lying to my wife and family about who I am

Vincent M. Marasco and Randall L. Astramovich

19

HA NDO U T

COST-BENEFIT ANALYSIS

BENEFITS

Coming Out

DISADVANTAGES

Coming Out

BENEFITS

Not Coming Out

DISADVANTAGES

Not Coming Out

20

Vincent M. Marasco and Randall L. Astramovich

3 TRANSGENDER TEENS AND GENDER-IDENTITY DISCLOSURE Laura R. Haddock

Suggested Uses: Activity, homework Objective

This activity is designed for use with adolescents who identify as transgender or gender nonconforming and are contemplating disclosing their gender identity to friends or family. Disclosing as trans or genderqueer to parents, caregivers, guardians, or loved ones is an important step toward empowering youth to feel confident in their gender identity. This activity was designed to be used with individuals who have not completed a gen­ der role transition. The exercise can be used in indi­ vidual or group therapy or can be assigned as home­ work for clients to engage in privately. Clients will be asked to articulate and explore their feelings related to changing gender identity during a letter-writing exercise to allow them to practice finding the words they would like to use to deliver this message, as well as explore any fears or concerns that may need to be addressed in the therapeutic process before initiating the disclosure process. Rationale for Use

Much of the literature related to the coming-out pro­ cess that aims to be inclusive of transgender experi­ ences treats sexual orientation and gender identity disclosures as parallel (Liang, 1997; Wood, 1997). How­ ever, Zimman (2009) challenges the assumption that the coming-out processes for those who identify as trans are analogous to the coming-out process for sex­ ual identity. For those who identify with a gender that does not match their natal sex assignment, there is frequently great societal pushback related to failure

to “enact gender in socially prescribed ways” (Gagné, Tewksbury, & McGaughey, 1997, p. 479). Any varia­ tion from traditional male and female gender roles, gender identity or expression, and heterosexuality is met with condemnation, control, modification, pun­ ishment, or efforts of behavioral extinction (ChenHayes, 2001). It is important to note that researchers have identified critical differences between the com­ ing-out processes for gender identity and those for sexual identity, which emphasizes the need to consider all individuals on their own terms and not make assumptions of commonalities with other queer groups (Zimman, 2009). Beals, Peplau, and Gable (2009) found that indi­ viduals reported lower psychological well-being (self­ esteem, positive affect, and satisfaction with life) on days when they concealed rather than disclosed their gender identity. Research has shown that negative reactions from close friends and family following dis­ closure happened less frequently than anticipated (Gagné et al., 1997), findings that offer a positive per­ spective on the benefits of disclosure. However, ther­ apists cannot discount the reality that hate violence is a prevalent and deadly issue faced by transgender com­ munities. The 2013 report on hate violence (NCAVP, 2014) highlights the incidence of hate violence against trans individuals at disturbingly high rates. In addition, trans people are frequently targets for fatal hate vio­ lence. For example, the report indicates that transgen­ der people of color are six times more likely to expe­ rience physical violence from the police than white cisgender survivors and victims. Transgender women are 1.8 times more likely to experience sexual violence when compared with other survivors. Additionally,

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

22

transgender women are more likely to experience police violence, discrimination, harassment, threats, and intimidation. These startling statistics demon­ strate the pervasive violence and harassment that those in the trans community face from both the police and overall society. According to FBI statistics, in 2014 there were 218 reported hate crimes in the United States related to gender identity and gender noncon­ formity (U.S. Department of Justice, 2014). Aggres­ sion such as verbal harassment can be pretty terrify­ ing under certain conditions. Thus, incorporating a therapeutic exercise designed to facilitate thorough exploration of the coming-out process allows clients to express themselves without interruption, choose and revise their words until they feel comfortable with them, and explore potential reactions within the safety of the therapeutic environment before initiating a formal disclosure. According to Erikson (1963), identity formation is the most significant developmental task during ado­ lescence. For gender-nonconforming adolescents, an additional task is developing a positive gender iden­ tity (Dispenza & O’Hara, 2016). Gender identity for­ mation is complicated for many adolescents who feel pressures to conform to an assigned gender identity and societal gender norms. This pressure to conform often conflicts with an internal need to express authen­ tic feelings of self (Gagné et al., 1997). When youth disclose their nonconforming identity to parents, they know they must deal with their parents’ immediate and long-term reactions (D’Amico, Julien, Tremblay, & Chartrand, 2015). Managing the transition into a minority identity status can be stressful, especially if adolescents fear potential change in significant fam­ ily relationships or relationships with friends and other caring adults (Russell, 2003). Because trans ado­ lescents often lack access to identity-affirming resources (dickey, Singh, Chang, & Rehrig, 2017), many of them feel alienated. Klein, Holtby, Cook, and Travers (2015) have captured themes common in counseling litera­ ture for adolescents struggling with identity develop­ ment. These themes include feeling different from peers and experiencing a need to disclose these dif­ ferences. Additionally, the process of gender-identity

development typically includes a rejection of societal norms, which may include shocking acting-out behavior before becoming comfortable in their own identity (Maguen, Shipherd, Harris, & Welch, 2007). The professional counselor’s role includes advocat­ ing for social justice and challenging oppression and violence (Chen-Hayes, 2001). Affirmative practice includes advocating against oppression and violence that targets gender-nonconforming and transgender youth. Clinicians are ethically bound to promote envi­ ronments that affirm all gender identities. Although the American Counseling Association’s (ACA, 2014) Code of Ethics (C.5) states that counselors must pro­ vide nondiscriminatory services that are based on variables inclusive of gender identity, the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) (2009) competencies for counseling transgender clients offer a comprehensive guide for use in counseling transgender clients. Coming out or disclosing a nonconforming gender identity is one indicator that identity development is crystalizing (Bussey, 2011). In accordance with the ALGBTIC (2009) competency A.1, counselors should affirm that all persons “have the potential to live full functioning and emotionally healthy lives through­ out their lifespan while embracing the full spectrum of gender identity expression, gender presentation, and gender diversity beyond the male-female binary” (p. 4). While disclosing nonconforming gender iden­ tity to parents is considered a difficult process, there can be many psychological benefits (dickey et al., 2017). However, it is critical for clinicians to recognize and understand the importance of using appropriate language (e.g., correct name and pronouns) with transgender clients; be aware that language in the transgender community is constantly evolving and varies from person to person; seek to be aware of new terms and definitions within the transgender community; honor clients’ definitions of their own gender; seek to use language that is the least restrictive in terms of gender (e.g., using clients’ names as opposed to assum­ ing which pronouns the clients assert are gender affirm­ ing); recognize that language has historically been used to oppress and discriminate against transgender

Transgender Teens and Gender-Identity Disclosure

23

people; understand that the counselor is in a position of power and should model respect for the client’s declared vocabulary (ALGBITIC, 2009, B.1, p. 15). Unfortunately, unlike gender-nonconforming peo­ ple, whose developmental experience emerges from an intrinsic need for identity authenticity, family mem­ bers are often unwilling participants on this journey (Gagné, Tewksbury, & McGaughey, 1997). Supporting adolescents who choose to disclose gender nonconformity to their caregivers promotes the emotional well-being of these youth. Identity dis­ closure allows adolescents to acknowledge a noncon­ forming identity to others. According to the American Psychological Association (APA, 2011), though devel­ opment, expression, and disclosure often occur sequen­ tially, others may display nonconforming identity behavior but not identify themselves as transgender or genderqueer. APA (2011) further suggests that others may define and disclose their gender identity but choose not to express it. Adolescents often choose not to reveal a gender-nonconforming identity, opt­ ing instead to withdraw from friends and family and withhold sharing their true identity. This withdrawal is often grounded in fear of parental rejection and abuse and a desire to avoid hurting or disappointing parents (D’Amico et al., 2015). Disclosing one’s gender identity to those closely connected (or not so closely) is rarely a onetime event. It is a process that clients often find continues throughout their life, as they dis­ close to many people over time. Coming out refers to the lifelong process of the development of a positive transgender identity or gender-nonconforming iden­ tity. Unfortunately, some young people perceive this as an isolated event that is characterized by simply say­ ing the words out loud and setting the record straight (Morrow, 2006). For some, it is a very long and diffi­ cult struggle because they often have to confront many transphobic attitudes and discriminatory practices along the way. Before initiating the process of informing others, clients need to explore any of their own existing nega­ tive stereotypes and feelings of transphobia that they learned growing up. To learn to feel good about who they are, individuals ideally need to feel movement away from repulsion and pity, and tolerance toward feelings of appreciation and admiration (Corrigan & 24

Haddock

Matthews, 2003). However, therapists must remem­ ber that because the adolescent is identified as the cli­ ent, they should carefully adhere to ACA (2014) ethics code B.5.b. and remain sensitive to the “cultural diver­ sity of families and respect the inherent rights and responsibilities of parents/guardians regarding the wel­ fare of their children/charges according to law” (p. 7). Counselors will ideally work to establish, as appro­ priate, “collaborative relationships with parents/guard­ ians to best serve clients” (p. 7). There are multiple issues counselors should be aware of that have the potential to create barriers to disclosure to parents or to complicate the emotional well-being of trans or genderqueer clients. For exam­ ple, friends or family could demonstrate transphobia such as emotional disgust, fear, anger, or discomfort felt or expressed toward people who do not conform to society’s gender expectations (Fisher et al., 2016). Negative reactions can include a variety of behaviors that range from disapproval to criticism for not com­ ing out sooner. If, after disclosing gender identity, an individual is accused of not coming out sooner as a result of a perceived gain acquired by continuing to hide the nonconforming identity, the result is a loselose situation for the client (Corrigan & Matthews, 2003). Under this logic, courageously opening up about personal identity constitutes evidence of dishon­ esty. “People come out when they are ready to do so, and shaming them for not doing so sooner constitutes a rejection of their own experience with their iden­ tity” (Ford, 2014, p. 1). If deemed appropriate, the following activity is designed to promote an explora­ tion of thoughts, feelings, and potential fears related to coming out as gender nonconforming, the initial act of disclosure, and life following initial disclosure. Instructions

This exercise can be used in individual or group ther­ apy or can be assigned as homework for clients to engage in privately. The two main purposes of the exer­ cise are to empower clients to articulate their identity in their own words and to illuminate any unresolved fears related to the coming-out process. The exercise of writing the letter is broken into three primary top­ ics: self-awareness, self-affirmation, and action steps. Suggestion 1 facilitates exploration of the client’s self-

awareness and offers an opportunity to reflect on child­ hood memories that are meaningful in relation to gender-identity development. Suggestion 2 provides an opportunity for clients to build confidence related to their gender identity and offer reassurance to oth­ ers, if appropriate, that a shift in gender identity does not mean an end to the person they have known. Suggestion 3 invites clients to determine which actions they would like to see occur following the disclosure, including name and pronoun changes. Finally, Suggestion 4 gives clients the opportunity to set boundaries with regard to those with whom they are comfortable having the information shared. If the exercise is used in session, the client may be given the questions one at a time or all at once. Ideally, allow the client to read all the questions in the session before completing the exercise so they can give thoughtful consideration to the topics before for­ mally answering the questions. When executing the exercise, the client should be provided with the exer­ cise in printed form and allowed some quiet time to complete the answers. Because most sessions are lim­ ited to roughly an hour, that is probably not enough time to fully answer and explore all four parts of the draft of the letter. Thus, one session may be devoted to having the client draft the letter and another to explor­ ing the content. Alternatively, administer the ques­ tions and explore the answers one at a time over the course of several sessions. If the exercise is assigned as homework, give consideration to the same conditions for administration, determining whether to offer all questions at once or to administer them independently in a series of assignments. Brief Vignette

Jessica is a sixteen-year-old white adolescent who was assigned female at birth. She currently resides with her paternal grandmother, who became Jessica’s pri­ mary caregiver after the death of Jessica’s mother and the incarceration of her father. Jessica and her grand­ mother reside in a rural area and are part of the white racial majority that appears to have little tolerance for racial diversity. Jessica reports she holds conservative Christian views, and she is currently living in depressed socioeconomic conditions: the primary income is provided by government assistance. Jessica is an only

child, and Jessica’s parents married when they were teenagers after her mother became pregnant. Neither parent completed high school. Jessica is very assertive about her Christian beliefs; her grandmother has not expressed any indication of assigning the same mean­ ing to her own spiritual beliefs, which she defines only as “believing in God.” Jessica reports that her mother also identified as Christian when she was alive, though she displays distress when reporting that her father claims he has converted to Islam while in prison. Jessica was referred to outpatient individual counseling as aftercare following a brief inpatient hospitaliza­ tion for depression and suicidal ideation. Jessica has a history of cutting herself on multiple occasions and withdrawing from friends and family, and she has a deteriorating relationship with her grandmother. Through the course of therapy, Jessica shares the information that for several months she has strug­ gled with feeling that she does not fit in at school and that her family does not understand her. It proves to be fairly easy to establish a therapeutic rapport with Jessica, as she seems to desire genuine connection and acceptance. During the therapeutic process, she is increasingly open about her interests and identity. She reports that she is interested in trying out for the power-lifting team, which has been met with confu­ sion by her school because she is the only girl who has expressed a desire to participate. Her grandmother, who has allowed her to pursue the sport, expresses confusion over why she wants to participate in a “sport for boys.” Jessica also mentions being sexually attracted to a girl whom she identifies as her best friend. Ulti­ mately, as Jessica begins to explore her sexual identity, she reports that she does not identify as gay. This report is somewhat incongruent with her sexual inter­ est in her female friend. At this point, Jessica reveals that she identifies as male. She goes on to explain that her pronouns are male and asks to be called Jesse. During exploration of his gender-identity devel­ opment, Jesse reveals that his depression and isolation are primarily a result of the assumed rejection and reprimand he has felt from his grandmother related to his interests and identity, which do not align with traditional female gender norms. He reports making an effort to introduce his grandmother to the concept of transgenderism by making vague references and Transgender Teens and Gender-Identity Disclosure

25

comments. He reports that his grandmother’s response was passive, and he perceived her attitude to be one of disdain and disapproval, although her attitude was not entirely clear because she refused to be open to any discussion. She assertively responded that being transgender was a “sin” and that Jesse is simply “con­ fused.” She now insists that Jesse wear makeup and nail polish, “like girls are supposed to,” which offends Jesse’s sense of self. Jesse verbalizes a desire to commu­ nicate with his grandmother about his gender identity. Jesse and his therapist determine that writing a letter will be the first step toward articulating his thoughts about his identity and the steps he would like to take moving forward. He has specifically expressed a desire to secure a binder and investigate the option of hor­ mone blockers. The therapist asks Jesse to write the letter as a homework assignment after establishing that he has a secure and confidential way to do so and does not feel that his private writing is at risk of being discovered. Jesse reports that he has a password-pro­ tected tablet and that he is comfortable completing the exercise at home. He is motivated to complete the exercise, as he is determined to “accept myself and move forward.” Jesse returns to his next therapy appointment in two weeks and has completed all four components of the letter. He describes those two weeks as “two of the most agonizing weeks of my life.” He describes the activity as simultaneously painful and liberating. He admits that he did not expect giving words to thoughts that had lived only in his head would be so challenging. He reports having difficulty even reading his own words without crying. The focus of therapy for several weeks following the exercise is exploring Jesse’s thoughts and feelings as articulated in the letter and subsequently addressing his grief and fear about what will happen after disclosing his identity to his grandmother and other family members. He worries what his aunts and cousins might say; however, he is convinced that his school peer group will be accepting, which leaves him feeling more confident that he will have a solid support system. Ultimately, he expresses a desire and willingness to give the letter to his grand­ mother and formally come out to her as transgender.

26

Haddock

Suggestions for Follow-up

The exercise of writing the letter may unleash a flood of emotion for the client. Following the creation of the client’s disclosure script, you may want to follow up with an exploration of the client’s thoughts and feel­ ings, discussing the client’s authentic self as an affir­ mative practice that facilitates client empowerment. The process of writing the letter may be quite pain­ ful, and you should follow up and allow the client to spend time processing their thoughts and feelings before determining readiness to deliver the letter to the intended recipients. After crafting the disclosure letter and evaluating the timing for coming out, an additional follow-up could include facilitating an opportunity to prepare for various types of responses to the disclosure. It is impos­ sible to predict how others will respond to it. Thus, consideration for the reactions anyone could have, as well as how the client might plan to deal with them, are a good follow-up to the activity. Cultural norms inform belief systems, frames, perceptions, under­ standings, and behaviors, which can result in a com­ plex challenge for even the most culturally sensitive counselor. Explore the client’s feelings and potential responses if someone reacts with hate, unconditional love, or apathy. Contraindications for Use

Because of the sensitive and confidential nature of the exercise, it is important to carefully weigh the risk of discovery with the benefit of the exercise. Carefully exploring the client’s vulnerability to discovery is crit­ ical before assigning this exercise as homework. In addition, this exercise can be deeply emotional; thus, it is important to weigh the potential for activating a powerful emotional response that would be better managed in the presence of the therapist before assign­ ing this exercise as homework. Every therapist should thoroughly consider whether there is a risk for the parent or caregiver to discontinue treatment or respond violently if the letter is discovered. If therapists are concerned that the client’s emotional or physical safety would be at risk in any way, this exercise may not be appropriate for use as homework.

Professional Readings and Resources D’Amico, E., Julien, D., Tremblay, N., & Chartrand, E. (2015). Gay, lesbian, and bisexual youths coming out to their parents: Parental reactions and youths’ outcomes. Jour­ nal of GLBT Studies, 11, 411–437. doi:10.1080/1550428 X.2014. 981627. dickey, l., Singh A., Chang, S., & Rehrig, M. (2017). Advocacy and social justice: The next generation of counseling and psychological practice with transgender and gender non­ conforming clients. In A. Singh & l. dickey (eds.), Affirma­ tive counseling and psychological practice with transgender and gender nonconforming clients. Washington, DC: American Psychological Association. Dispenza, F., & O’Hara, C. (2016). Correlates of transgender and gender nonconforming counseling competencies among psychologists and mental health practitioners. Psychology of Sexual Orientation and Gender Identity, 3 (2), 156–194. doi:10.1037/sgd0000151. Jia, L., Strachan, S., Griffin, S., & Easton, A. (n.d.). Coming out: A coming out guide for trans young people. LGBT Youth Scotland. www.teni.ie/attachments/664c0589-3011-46a5­ a6a3-28269015b71b.PDF. Lev, A. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. Binghamton, NY: Haworth Press. Safe Schools Coalition. (n.d.). A public-private partnership in support of gay, lesbian, bisexual, and transgender queer and questioning youth. www.safeschoolscoalition.org/. TransPulse. (2017). Transgender resources. http://transgender pulse.com/. True Colors. (2016). Sexual minority youth and family services. www.ourtruecolors.org. Winch, G. (2014). Emotional first aid: Healing rejection, guilt, failure, and other everyday hurts. New York: Hudson Street Press.

Resources for Clients Brown, M. (2003). True selves: Understanding transsexualism— For families, friends, coworkers, and helping professionals. San Francisco: Jossey-Bass. Evelyn, J. (2007). Mom, I need to be a girl, 2nd edition. Long­ mont, CO: Just Evelyn. Herman, J. (2009). Transgender explained to those who are not. Bloomington, IN: Authorhouse. International Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Youth and Student Organisation. (2017). www. iglyo.com/. The International Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Youth & Student Organisation (IGLYO) is a pan-European network, working with over ninety-five LGBTQI youth and student organizations. It is run for and by young people. Krieger, E. (2011). Helping your transgender teen: A guide for parents. New Haven, CT: Genderwise Press.

Kuklin, S. (2014). Beyond magenta: Transgender teens speak out. Somerville, MA: Candlewick Press. Tando, D. (2016). The conscious parent’s guide to gender identity: A mindful approach to embracing your child’s authentic self. Avon, MA: Adams Media. Trans Youth Equality Foundation. (n.d.). Education, advocacy, and support for transgender youth and their families. www.transyouthequality.org. Wipe Out Transphobia. (2015). www.wipeouttransphobia. com/. Wipe Out Transphobia (WOT) is an international volunteer-led project with the sole aim of reducing and wiping out the transphobia in society that regularly affects anyone who strays from the traditional binary idea of gender as assigned at birth.

References American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. https://www.counseling. org/resources/aca-code-of-ethics.pdf. American Psychological Association (APA). (2011). Answers to your questions about transgender people, gender iden­ tity, and gender expression. www.apa.org/topics/lgbt/ transgender.aspx. Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC). (2009). Competencies for coun­ seling with transgender clients. Alexandria, VA: Author. Beals, K. P., Peplau, L. A., & Gable, S. L. (2009). Stigma man­ agement and well-being: The role of perceived social sup­ port, emotional processing, and suppression. Personality and Social Psychology Bulletin, 35, 867–879. doi:10.1177/ 0146167209334783. Bussey, K. (2011). Gender identity development. In S. J. Schwartz, K. Luykcx, & V. L. Vignoles (eds.), Handbook of identity theory and research. New York: Springer. California State University at Long Beach. (n.d.). The coming out process. http://web.csulb.edu/colleges/chhs/safe-zone/ coming-out/. Chen-Hayes, S. (2001). Counseling and advocacy with trans­ gendered and gender-variant persons in schools and fam­ ilies. Journal of Humanistic Counseling, Education, and Development, 40 (1), 34–49. Corrigan, P., & Matthews, A. (2003). Stigma and disclosure: Implications for coming out of the closet. Journal of Mental Health, 12, 235–248. D’Amico, E., Julien, D., Tremblay, N., & Chartrand, E. (2015). Gay, lesbian, and bisexual youths coming out to their parents: Parental reactions and youths’ outcomes. Journal of GLBT Studies, 11, 411–437. doi:10.1080/1550428X.2014. 981627. dickey, l., Singh A., Chang, S., & Rehrig, M. (2017). Advocacy and social justice: The next generation of counseling and psychological practice with transgender and gender noncon­ forming clients. In A. Singh & l. dickey (eds.), Affirmative

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counseling and psychological practice with transgender and gender nonconforming clients. Washington, DC: Ameri­ can Psychological Association. Dispenza, F., & O’Hara, C. (2016). Correlates of transgender and gender nonconforming counseling competencies among psychologists and mental health practitioners. Psychology of Sexual Orientation and Gender Identity, 3 (2), 156–194. doi:10.1037/sgd0000151. Erikson, E. (1963). Childhood and society. New York: Norton. Fisher, A., Castellini, E., Casale, H., Tagliagambe, M., Benni, L., Vittoria, L., Giovanardi, G., Ricca, V., & Maggi, M. (2016). Transphobia and homophobia levels in gender dysphoric individuals, general population, and health care providers. Journal of Sexual Medicine, 13 (5), S124. doi:10.1016/j.jsxm.2016.03.118. Ford, Z. (2014, April 2). Why coming out is a question of safety, not honesty. Think Progress. https://thinkprogress.org/why­ coming-out-is-a-question-of-safety-not-honesty-269d37 ca46d4#.w95tmgjl4. Gagné, P., Tewksbury, R., & McGaughey, D. (1997). Coming out and crossing over: Identity formation and proclama­ tion in a transgender community. Gender and Society, 11 (4), 478–508. Klein, K., Holtby, A., Cook, K., & Travers, R. (2015). Compli­ cating the coming out narrative: Becoming oneself in a heterosexist and cissexist world. Journal of Homosexual­ ity, 62 (3), 297–326. doi:10.1080/00918369.2014.970829. Liang, A. C. (1997). The creation of coherence in coming-out stories. In A. Livia and K. Hall (eds.), Queerly phrased: Lan­ guage, gender, and sexuality, 287–309. New York: Oxford University Press.

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Maguen, S., Shipherd, J., Harris, H., & Welch, L. (2007). Prev­ alence and predictors of disclosure of transgender identity. International Journal of Sexual Health, 19 (1), 3–13. doi:10. Prevalence19n01_02. Morrow, D. (2006). Coming out as gay, lesbian, bisexual, and transgender. In D. Morrow & L. Messinger (eds.), Sexual orientation and gender expression in social work practice: Working with gay, lesbian, bisexual, and transgender peo­ ple. New York: Columbia University Press. National Coalition of Anti-Violence Programs (NCAVP). (2014). Lesbian, gay, bisexual, transgender, queer, and HIV-affected hate violence in 2013. http://avp.org/wp-content/uploads/ 2017/04/2013_ncavp_hvreport_final.pdf. Russell, S. T. (2003). Minority youth and suicide risk. American Behavioral Scientist, 46, 1241–1257. doi:10.1177/000276420 2250667. U.S. Department of Justice. (2014). Uniform Crime Reporting Program: Hate crime statistics. https://ucr.fbi.gov/hate­ crime/2014. Winch, G. (2014). Emotional first aid: Healing rejection, guilt, failure, and other everyday hurts. New York: Hudson Street Press. Wood, Kathleen M. (1997) Narrative iconicity in electronicmail: Lesbian coming-out stories. In A. Livia and K. Hall (eds.), Queerly phrased: Language, gender, and sexuality, 257–273. New York: Oxford University Press. Zimman, L. (2009). “The other kind of coming out”: Transgender people and the coming out narrative. Gender and Language, 3 (1), 53–80. doi:10.1558/genl.v3i1.53.

GUIDELINES FOR THE LET TER Making the decision to come out as trans or genderqueer to your friends and family is an important first step toward embracing your authentic self. Here are some suggestions to get you started: 1. Describe how long you’ve known you were different and how you came to realize that trans/gender­ queer/etc. is the term that best communicates your identity. This can help others understand this is not a stage, an impulsive decision, or an act of teenage rebellion. 2. Reassure family and friends that you are and will always be the same person inside. Tell them that you will be okay and know you can still have a happy life that includes your future goals, such as going to college, having a career and a family, travel. Anything you want for your future is still possible! 3. End your letter with “action steps.” • What do you want or need from your family? • You may also want them to start using a different name or pronouns for yourself. Let them know

what they are and why these things are important to you.

4. Be specific about whom you do or do not want them sharing this information with. Here are some helpful hints to remember as you are writing: a. Your goal is to share this aspect of your identity with your loved ones, not ask for their permission to be who you are. b. Keep a respectful tone. You are looking for respect and support, so show the same toward those you are writing to. c. This information or even the concept might be new to them, and they may have a lot to learn about gender identity before they fully understand. Be simple. Transgender identities can seem completely foreign to many people. Stick to the basics as you begin. d. Your family loves you and, consequently, they worry about you. Negative reactions often come from their being worried about you, your future, and your safety. e. Be yourself. The most important thing is to relax and just tell your story! Keep it personal and about you. f. Your loved ones will also need emotional support, so it’s unfair to ask them not ever to tell anyone at all. It is appropriate to ask that they let you have your own conversation with a sibling, other parent, or family member first. Try not to wait too long, though, because withholding information about something important and emotional can be quite stressful. g. Finally, remember that this will not be a “one and done” conversation. Think of this as your “opening monologue.”

Laura R. Haddock

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4 ASSISTING YOUTH WITH DISCLOSING THEIR SEXUAL ORIENTATION AND/OR GENDER IDENTITY USING AN ECOMAP Richard A. Brandon-Friedman and M. Killian Kinney Suggested Uses: Activity, homework Objective

This activity is designed to help youth visualize their social environment in order to assist them with man­ aging the disclosure of their sexual orientation and/ or gender identity to others. Through this exercise, youth and therapists will be able to identify individ­ uals within youth’s environments to whom youth would like to come out and to whom they do not feel comfortable doing so. It will also assist youth and ther­ apists with understanding the interactions between the myriad parties involved in youth’s lives. Rationale for Use

Ecomaps are a way for individuals to diagram the systems and people within those systems that are involved in their lives. Through dynamic representa­ tion, individuals can picture themselves as the center of a complex web of relationships, each of which is unique yet interdependent on the others (Hartman, 1978; Ray & Street, 2005). Ecomaps can also demon­ strate the strength or conflict-ladenness of relation­ ships and interactions, allowing individuals and pro­ fessionals to explore relationship patterns (Hartman, 1978). As cocreated products, ecomaps enhance col­ laboration between clients and therapists and provide clients with feelings of empowerment because they are able to depict their social environments as they experience them (Hartman, 1978; Ray & Street, 2005). Ecomaps can also be used to monitor changes in rela­

tionships over time, thereby allowing for exploration of these changes (Ray & Street, 2005). When used with sexual and/or gender minority individuals, ecomaps provide a baseline for discus­ sion of relational processes, disruptions in family and social relationships, experiences of homophobia and discrimination tied to specific individuals, and the relationship individuals and their families have with other social systems (Grafsky & Nguyen, 2015). Eco­ maps also provide a greater understanding of the con­ text of sexual and/or gender minority youth’s lives and thus allow for a multilevel assessment of the sup­ ports available to the individuals and the areas in which intervention may be desired (Nguyen, Grafsky, & Munoz, 2016). Perhaps most important, the feel­ ings of empowerment can be beneficial to youth nav­ igating the complex coming-out process because they can translate this therapeutic experience to feeling con­ trol over disclosing their sexual and/or gender minority identities to others (Matthews & Salazar, 2012). With the number of interacting systems and the myriad people involved in youth’s lives, it can be diffi­ cult for the youth and professionals working with them to determine which individuals know the youth’s sex­ ual orientation and/or gender identity. To reduce the confusion that can occur and to help both the youth and professionals manage this situation, this activity involves the completion of an ecomap that can be used as a reference during discussion of the youth’s sexual orientation and/or gender identity. The activity will also help youth to systematically examine their

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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relationships with others and how their sexual ori­ entation and/or gender identity may be affecting those relationships. Within this exercise, additional information regard­ ing the degree to which youth have disclosed their sexual orientation and/or gender identity will also be collected. This is a novel extension of ecomap use, intentionally taking advantage of the ecomap’s ability to assess where interventions or changes may be best directed. With this information, the youth and their therapists will be able to examine patterns in the youth’s disclosure of their sexual orientation and/or gender identity, the youth’s desires regarding disclosure in the future, and the youth’s relationships that may be signifi­ cantly affected by others’ reactions to this disclosure. The healthy development of youth’s sexual and/ or gender minority identities is crucial for their wellbeing. Positive development of these identities has been closely tied to the amount and quality of social, familial, and professional supports that youth receive, and both are related to improved psychosocial func­ tioning, increased school attendance and perfor­ mance, reduced self-harm, reduced risk behaviors, and enhanced overall well-being (Brandon-Friedman & Kim, 2016; Higa et al., 2014; Roe, 2015). Alternatively, hiding these identities has been linked with increased mental health issues, substance abuse, and risky-behav­ ior concerns (Rosario, Schrimshaw, & Hunter, 2011). These supports may be especially important to sexual and/or gender minority youth who are also racial or ethnic minorities. Beliefs about and support for sexual and/or gender minority individuals vary sig­ nificantly among racial and ethnic groups, and research has suggested variations in participation in gay-re­ lated social activities, level of disclosure of sexual ori­ entation, mental health concerns, familial and peer acceptance, and prevalence of bullying, assault, and homelessness among youth from different racial and ethnic groups (Bostwick et al., 2014; Kosciw, Greytak, Palmer, & Boesen, 2014; Rosario, Schrimshaw, & Hunter, 2004). Racial and ethnic minorities may also feel excluded from the predominantly white main­ stream gay culture while also being stigmatized by others within the same racial or ethnic category owing to their sexual orientation and/or gender identity, which can lead to further feelings of isolation (Gray,

Mendelsohn, & Omoto, 2015; Han, 2006; Hunter, 2010). To work with these youth effectively, profes­ sionals must be attuned to how individuals experience the intersectionality of their identities and how these experiences affect their relationships with others. Another essential area to consider is the degree to which religion and spirituality play a role in youth’s lives or the lives of those with whom they have close relationships. Conflict between youth’s sexual orienta­ tion and/or gender identity and their religious or spiritual convictions, or between their identities and the religious or spiritual convictions of others in their lives, is related to heightened psychosocial diffi­ culties and relationship dysfunction and increased prevalence of running away and entrance into the child welfare system (Bozard & Sanders, 2014; Super & Jacobson, 2011). Alternatively, youth who are able to integrate their religious or spiritual beliefs with their sexual orientation and/or gender identity may experience improved overall well-being (Page, Lindahl, & Malik, 2013). Thus, professionals should inquire about the place of religion and spirituality in the lives of these youths and others with whom they are close and how religion or spirituality affects their relationships and their level of disclosure. Given the complex interactions among youth’s disclosure of their sexual orientation and/or gender identity, their psychosocial functioning, and their interpersonal relationships, professionals must encour­ age youth to determine the extent to which they wish to reveal their sexual orientation and/or gender iden­ tity to others, and they should work with youth to ensure this disclosure occurs in a safe and healthy man­ ner (Matthews & Salazar, 2012). Doing so not only involves assessing the various environments in which youth live, but also the youth’s relationships with oth­ ers and the effects that their racial or ethnic identity and their religious or spiritual beliefs may have on their experiences. Using an ecomap to assist with this process is consistent with ethical practice as delineated by the National Association of Social Workers (NASW), the American Association for Marriage and Family Therapy (AAMFT), and the American Mental Health Counseling Association (AMHCA). The Code of Eth­ ics of the NASW (2017) emphasizes the importance Assisting Youth with Disclosing Using an Ecomap

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of human relationships and obligates social workers to seek to enhance relationships among individuals and their surrounding social systems. Youth’s role in the construction of the ecomap and their determina­ tion of the relationships on which to focus enhance their self- determination (NASW, 2017, 1.02) and ensures them autonomy in decision making (AAMFT, 2015, 1.8; AMHCA, 2015, A1a), while the use of eco­ maps to monitor progress assists with practice evalu­ ation (AMHCA, 2015, B1b; NASW, 2017, 5.02). Instructions

Part 1: This activity can be completed using the pro­ vided template (see page 39) or on a separate sheet of paper. When using the template, have youth follow these steps to develop the ecomap: 1. Write their name in the middle circle. 2. Identify relevant individuals within each of the cat­ egories noted in the four quadrants (family, peers, professionals, and others). Professionals can include service providers, teachers, mentors, or others with whom the youth interacts within a formal relationship. 3. Write the names of these individuals within an oval in the appropriate quadrant. The names of those who have a closer relationship with the youth should be written in the ovals closer to the center, whereas the names of those with more distant relationships should be written in the outer ovals. There may be some left­ over ovals, depending on the number of relationships the youth currently has. If additional ovals are needed, they can be drawn in. 4. Identify which individuals are already aware of the youth’s sexual orientation and/or gender identity. The ovals containing these individuals’ names should be colored green. The ovals containing the names of indi­ viduals who do not know the youth’s sexual orienta­ tion and/or gender identity should be colored red. If the youth is unsure if an individual knows or not, that circle should be colored yellow. 5. Using a scale from 1 (extremely important) to 5 (not very important), the youth should rate how important it is to disclose their sexual orientation and/or gender identity to each individual whose name appears in a red or yellow oval. 32

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6. Using the simplified ecomap key shown below, indicate the direction of communication between the youth and each individual and the strength of that relationship. Bidirectional communication Unidirectional communication Strong relationship Weak relationship Stressful relationship

Ensure that there is a line connecting the youth to each oval, that the direction of communication is noted for each relationship, and that all individuals in a yellow or red oval have a number on the scale of importance of disclosure associated with them. Note: If there is a desire not to use the provided tem­ plate, the same steps should be followed, with an oval drawn for each person noted. There are two advan­ tages to drawing an individualized ecomap: there can be additional variance in the distance between the youth’s center circle and the ovals that contain indi­ viduals’ names, and there will not be any empty circles. Part 2: Once the ecomap is complete, open a dialogue with the youth regarding what has been drawn, in the following order: 1. Ask the youth to describe the emotions experi­ enced while constructing the ecomap. Questions to consider include: a. What was it like to write out the names of those important to you and then classify your relationship with them? b. Is the number of individuals in each quadrant approximately equal? If not, where do the majority of individuals cluster? What might be the reasons for this? c. Did you find yourself questioning who knows your sexual orientation and/or gender identity and who does not? If so, how do you feel about that? If not, what made it so easy to know who is aware of your sexual orientation and/or gender identity?

d. Are there more people who know your sexual ori­ entation and/or gender identity or more people who do not know? What does the level of your disclosure mean to you? e. What are your relationships with the people who fall into each category? Is there a connection be­ tween those who know and the type of relationship you have with them? 2. Focus the youth on those who are aware of the youth’s sexual orientation and/or gender identity (shaded green). Ask the youth to consider how the individuals learned about the youth’s sexual orienta­ tion and/or gender identity, whether this disclosure had been desired, and what effects, if any, the disclo­ sure had on the relationship between the youth and those individuals. Pay particular attention to the ways in which the relationship between the youth and the individuals discussed are classified and the direc­ tion of communication between them. If most of these relationships are distant, weak, or strenuous, this may be an indication of conflict regarding the youth’s sexual orientation and/or gender identity. Those who know about the youth’s sexual orien­ tation and/or gender identity and with whom the youth has a strong bidirectional relationship are supports that can be used during future disclosures, while the characteristics of the individuals or relationship types of those who had a negative reaction can guide future decision making. Those with whom the youth has strong relationships but to whom they have not dis­ closed their sexual orientation and/or gender identity are ideal targets to consider for future disclosure, as they may become important supports as the youth comes to further understand their sexual orientation and/or gender identity. Similarly, identifying those with whom the youth has tenuous relationships may provide guidance regarding the people to whom the youth may not wish to disclose their sexual orienta­ tion and/or gender identity. Finally, by comparing eco­ maps created over several months, youth will be able to see how the disclosure of their sexual orientation and/or gender identity affects their relationships, which can provide further guidance in determining with whom they wish to build relationships as they age and gain more control over their environment.

3. Focus the youth on those who are not aware of their sexual orientation and/or gender identity (shaded red). Ask them to describe these relationships. Are they mostly tenuous, distant relationships of minor importance to the youth (labeled 4 or 5)? Are there some located nearer to the youth and with whom they have a strong relationship? If so, did the youth indi­ cate a desire to disclose to these individuals or not? Those who are near the youth but whose ovals are shaded red should be noted for the next step regard­ less of the level of desire to disclose. Also note any individuals whose ovals are shaded red but to whom the youth wants to disclose sexual orientation and/or gender identity. Part 3: Explain to the youth that in this part of the exercise, the discussion will focus on those noted as important in the previous step. This may be the most therapeutically intense part of the activity, as the youth will be challenged to articulate the reasons the noted individuals were labeled as they were and what the classifications of various individuals reveal about the youth’s relationships with others. 1. Ask the youth to consider those labeled 1 or 2. What makes disclosure of the youth’s sexual orienta­ tion and/or gender identity to each of these individ­ uals so important? What does the youth see as the likely outcome of disclosure to each individual? Are the relationships likely to be affected in a positive or negative manner? 2. Prompt the youth to consider any individuals who are close to the center of the ecomap but to whom the youth does not wish to disclose. Work with the youth to explore the reasons behind this desire. What emo­ tions are raised when considering these relationships? Is the youth fearful of the possible response? Are there indications that disclosure may lead to an unsafe situation? Is the youth reacting to a previous situa­ tion with the individual and making decisions based on those interactions? 3. Are there any individuals to whom the youth feels it is not safe to disclose sexual orientation and/or gender identity? If so, the youth must determine how to prevent them from learning this information. This

Assisting Youth with Disclosing Using an Ecomap

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may include discussion with others of the importance of not disclosing to these individuals. A safety plan may need to be written in case disclosure does occur. 4. Ask the youth to consider how individuals in the different quadrants are classified. Is there a pattern regarding the people to whom the youth wishes to dis­ close sexual orientation and/or gender identity? Is the youth avoiding more intimate, personal relationships and focusing only on those that are more temporary? If so, what are the reasons behind such decisions? 5. Ask the youth if this discussion has changed their mind regarding how the relationships with individuals were labeled or if changes to the level of importance of disclosure to any individuals are needed. Adjust­ ments should be made before moving on to Part 4. Part 4: At this time, the youth should develop a plan for the disclosure of sexual orientation and/or gender identity to those identified as people to whom it is important to disclose. 1. On the basis of the previous discussion, develop a list of those to whom the youth wishes to disclose. The list should be ordered in terms of importance of the disclosure to the youth. If the youth is unsure and does not feel ready to fully disclose to anyone who does not know, this should be explored theraputically to understand and process the youth's reasoning. It may be useful to begin with those who were shaded yellow, as communicating the youth’s sexual orienta­ tion and/or gender identity to these individuals may be easier. 2. Once the list has been created, work with the youth to develop a plan for disclosing sexual orientation and/ or gender identity to each individual. If the youth works best with well-defined plans, help identify a specific time, location, and method of disclosure for each individual. Setting a deadline may be useful if the youth is feeling pressure to make a disclosure to a spe­ cific individual, but the youth should not be admon­ ished for not meeting the deadline. Instead, the reasons for the delay should be explored with the youth. 3. Work with the youth to implement the plan one step at a time. Disclosure of sexual orientation and/or gender identity can be a difficult step, and the youth may need support during the process. 34

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While the youth should initially begin speaking with those who will probably be supportive, the youth must be prepared to deal with any possible reaction. Individuals may react to the youth’s disclosure in unexpected ways, and the youth needs to understand this. Strategies should be developed for how to deal with poor reactions, should they occur. Brief Vignette

Chris, a fourteen-year-old white, able-bodied, cisgender male, began therapy nine months ago as part of his placement into treatment foster care as a result of legal difficulties. Chris has been in foster care since age twelve, when he was removed from his mother’s cus­ tody because of substantiated physical abuse. At the time of his removal, Chris’s father was unable to care for Chris owing to financial struggles. Chris main­ tains a strong, positive relationship with his father, but he has a strained and problematic relationship with his mother. He has a positive but more distant relation­ ship with his foster parents, with whom he has been living for two years. Chris’s father is working to regain custody of Chris, which will probably happen within the next six months. Chris disclosed his sexual orientation to his ther­ apist and Department of Child Services (DCS) case manager three weeks ago and has since expressed concerns about who knows that he is gay and how he should proceed with telling others. He noted that he has told some friends and family, but he is worried about how others will react. Given the number of peo­ ple in Chris’s life and the complexity of his relation­ ships with those individuals, his therapist felt an eco­ map would help him visualize his relationships with others and determine how to proceed. Working with his therapist, Chris developed an ecomap. He described strong positive relationships with his sister, Rachel; two friends, Alisha and Robert; his therapist; his father; and a neighbor, James. To denote the strength of these relationships, he drew bold lines to these individuals. He described positive but weak relationships with his foster parents, his men­ tor, and Robert’s mother. He drew a thin line between himself and these individuals to represent these rela­ tionships. Because all these relationships were posi­ tive and bidirectional, he added arrows to both ends of the connecting lines. Chris then listed strained

relationships with his grandma, his biological mother, and his DCS worker. He indicated these difficulties with slashed lines and added arrows to represent the direction of the conflict. Chris’s therapist asked him to consider who he knew was aware of his sexual orientation, those who might be aware, and those he felt did not know. Those he knew were aware were shaded green (shown in the sample ecomap as diagonal lines running down­ ward left to right), those who possibly knew, yellow (shown in the sample as diagonal lines running down­ ward right to left), and those who did not know, red (shown in the sample as dotted with asterisks). Chris also indicated how important it felt to tell each of the people listed using a scale from 1 to 5. Chris’s therapist noted that those close to Chris were mostly shaded green or yellow, indicating that there has been some disclosure by him directly or that he felt that they may know his sexual orientation. Those who are close to him and shaded yellow were categorized as 1s or 2s, showing that he has a desire to ensure those with whom he has a close relationship know his sexual orientation. The therapist also recog­ nized that the individuals shaded red were mostly on the periphery and labeled with higher numbers. The one exception to this pattern was Chris’s rela­ tionship with Robert. Chris marked this relationship as strong and bidirectional, but he shaded the oval red and labeled his desire to disclose to Robert a 5. The therapist prompted Chris to consider the reasons for not wanting to disclose his sexual orientation to Robert given the strength of their relationship. As Chris con­ sidered this, the therapist also observed that Chris had indicated that he did want to disclose his sexual orientation to Robert’s mother. Chris reported that he and Robert had grown up together, and Robert is his best friend. He stated that he would like to tell Robert, but he has heard Robert make disparaging comments about gay peo­ ple before, and he does not want to lose his friend­ ship as a result of disclosing his sexual orientation. He noted this is his biggest struggle, but he had not mentioned it to the therapist before out of concern that the therapist would focus on that relationship only. He reported he wanted to tell Robert’s mother first, as she might be able to assist him with talking to Robert.

Respecting Chris’s desires to focus on other rela­ tionships first, the therapist worked with him to develop a plan for disclosing his sexual orientation to those identified as important to him. When ranking the desired time frame of disclosure to others, Chris listed his biological father, his foster parents, and Robert’s mother, in that order. His therapist noted that, given that Chris’s sister is already aware of his sexual orientation, she may be able to assist him with dis­ closing to his father. Chris and his therapist also devel­ oped a plan to speak with Chris’s DCS caseworker together to ask for her help in facilitating the disclo­ sure to Chris’s foster parents. Chris indicated that once this plan was completed, he would consider if and how to disclose to Robert. Suggestions for Follow-up

As therapy progresses, the ecomap should be used to guide interventions relating to the disclosure of the youth’s sexual orientation and/or gender identity. As disclosure plans are completed, the ecomap should be updated. Additional individuals may be added to the ecomap over time, and relationships between the youth and others may change, which would require a revision. Given that the ecomap also provides a snapshot of the youth’s interpretations of their relationships with others, it can also be used to guide therapeutic interventions focused on improving tenuous or stress­ ful relationships, regardless of their connection to the youth’s sexual orientation and/or gender identity. Because the ecomap will change over time, it can be used to monitor the stability of the youth’s relation­ ships with others and to note when significant changes occur. The meanings of these changes can be addressed in therapy. The ecomap can also be used as a reference docu­ ment by professionals working with the youth to mon­ itor who knows the youth’s sexual orientation and/or gender identity and who does not. Those who know should be made aware of who does not so that they can safeguard the youth’s privacy. If the youth has a goal of disclosing sexual orientation and/or gender identity to everyone listed, the ecomap can serve as a checklist to track progress toward that goal.

Assisting Youth with Disclosing Using an Ecomap

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Contraindications for Use

This activity has no specific contraindications. For youth who have a disability, the therapist can make accommodations such as reading or writing for them. One caution is that this activity foregrounds youth’s sexual orientations and/or gender identities and their disclosure to others. Many youth who present for therapy may be there for concerns completely unrelated to their sexual orientation and/or gender identity. While the professional literature suggests that disclosing individuals’ sexual orientation and/or gender identity to others is beneficial to psychosocial functioning, it must also be recognized that sexual orientation and/or gender identity is but one aspect of an individual’s global identity and should not be a primary focus of therapeutic services if there are no indications of concerns regarding this aspect of their lives. It is also imperative that therapists work with the youth to realistically appraise the likely conse­ quences of disclosing their sexual orientation and/or gender identity to others. Negative reactions to this kind of disclosure are one of the largest contributors to youth homelessness, and many youth report suf­ fering abuse after disclosures (Choi, Wilson, Shelton, & Gates, 2015). Unfortunately, these negative experi­ ences also occur within professional systems (Mountz, 2011), which highlights the all too real concerns that sexual and/or gender minority youth have. Both therapists and youth should be aware of the possible repercussions of disclosure, and plans should be made accordingly. Therapists should also ensure that any reports of abuse or harassment by individuals that are revealed during this exercise are reported to the appropriate authorities. Professional Readings and Resources Bilodeau, B. L., & Renn, K. A. (2005). Analysis of LGBT iden­ tity development models and implications for practice. New Directions for Student Services, 2005 (111), 25–39. doi:10.1002/ss.171. Fostering Transitions: A CWLA/Lambda Legal Joint Initiative. (2012). Getting down to basics: Tools to support LGBTQ youth in care. New York: Lambda Legal and Child Welfare League of America. Legate, N., Ryan, R. M., & Weinstein, N. (2011). Is coming out always a “good thing”? Exploring the relations of auton­

36

Brandon-Friedman & Kinney

omy support, outness, and wellness for lesbian, gay, and bisexual individuals. Social Psychological and Personality Science, 3 (2), 145–152. doi:10.1177/1948550611411929. Mallon, G. P. (ed.). (2017). Social work practice with lesbian, gay, bisexual, and transgender people, 3rd edition. New York: Routledge. Shilo, G., & Savaya, R. (2011). Effects of family and friend sup­ port on LGB youths’ mental health and sexual orientation milestones. Family Relations, 60 (3), 318–330. doi:10.1111/ j.1741-3729.2011.00648.x.

Resources for Clients Belge, K., & Bieschke, M. (2019). Queer: The ultimate LGBT guide for teens, 2nd edition. San Francisco: Zest Books. Genogram Analytics, LLC. (2014). Standard ecomap symbols. http://genogramanalytics.com/ecomap_symbols.html. Huegel, K. (2018). GLBTQ: The survival guide for gay, lesbian, bisexual, transgender, and questioning teens, 3rd edition. Minneapolis: Free Spirit Publishing. Owens-Reid, D., & Russo, K. (2014). This is a book for parents of gay kids: A question and answer guide to everyday life. San Francisco: Chronicle Books.

References American Association for Marriage and Family Therapy (AAMFT). (2015). Code of ethics. Alexandria, VA: Author. American Mental Health Counselors Association (AMHCA). (2015). AMHCA code of ethics. Alexandria, VA: Author. Bostwick, W. B., Meyer, I., Aranda, F., Russell, S., Hughes, T., Birkett, M., & Mustanski, B. S. (2014). Mental health and suicidality among racially/ethnically diverse sexual minority youths. American Journal of Public Health, 104 (6), 1129–1136. doi:10.2105/AJPH.2013.301749. Bozard, R. L., Jr., & Sanders, C. J. (2014). When out in church means out of church: Religious rejection and resilience as wellness factors among Christian sexual minority youth. In M. T. Garret (ed.), Youth and adversity: Psychology and influences of child and adolescent resilience and coping, 27–46. Hauppauge, NY: Nova Science Publishers. Brandon-Friedman, R. A., & Kim, H.-W. (2016). Using social support levels to predict sexual identity development among college students who identify as a sexual minority. Journal of Gay and Lesbian Social Services, 28 (4), 1–25. doi:10.1080/10538720.2016.1221784. Choi, S. K., Wilson, B. D. M., Shelton, J., & Gates, G. J. (2015). Serving our youth 2015: The needs and experience of lesbian, gay, bisexual, transgender, and questioning youth experi­ encing homelessness. Los Angeles: Williams Institute, UCLA School of Law, and True Colors Fund. Grafsky, E. L., & Nguyen, H. N. (2015). Affirmative therapy with LGBTQ+ families. In S. Browning & K. Pasley (eds.), Contemporary families: Translating research into practice, 196–212. New York: Routledge.

Gray, N. N., Mendelsohn, D. M., & Omoto, A. M. (2015). Community connectedness, challenges, and resilience among gay Latino immigrants. American Journal of Community Psychology, 55 (1–2), 202–214. doi:10.1007/ s10464-014-9697-4. Han, C.-S. (2006). Being an Oriental, I could never be com­ pletely a man: Gay Asian men and the intersection of race, gender, sexuality and class. Race, Gender, and Class, 13 (3–4), 82–97. Hartman, A. (1978). Diagrammatic assessment of family rela­ tionships. Social Casework, 59 (8), 465–476. Higa, D., Hoppe, M. J., Lindhorst, T., Mincer, S., Beadnell, B., Morrison, D. M., . . . & Mountz, S. (2014). Negative and positive factors associated with the well-being of lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth. Youth and Society, 46 (5), 663–687. doi:10.1177/0 044118X12449630. Hunter, M. A. (2010). All the gays are white and all the blacks are straight: Black gay men, identity, and community. Sexuality Research and Social Policy, 7 (2), 81–92. doi:10. 1007/s13178-010-0011-4. Kosciw, J. G., Greytak, E. A., Palmer, N. A., & Boesen, M. J. (2014). The 2013 National School Climate Survey: The experiences of lesbian, gay, bisexual, and transgender youth in our nation’s schools. New York: Gay, Lesbian, & Straight Education Network (GLSEN). Matthews, C. H., & Salazar, C. F. (2012). An integrative, empow­ erment model for helping lesbian, gay, and bisexual youth negotiate the coming-out process. Journal of LGBT Issues in Counseling, 6 (2), 96–117. doi:10.1080/15538605.2012. 678176. Mountz, S. (2011). Revolving doors: LGBTQ youth at the inter­ face of the child welfare and juvenile justice systems. LGBTQ Policy Journal at the Harvard Kennedy School, 1, 29–45.

National Association of Social Workers (NASW). (2017). Code of ethics of the National Association of Social Workers. https://www.socialworkers.org/About/Ethics/Code-of­ Ethics/Code-of-Ethics-English. Nguyen, H. N., Grafsky, E. L., & Munoz, M. (2016). The use of ecomaps to explore sexual and gender diversity in couples. Journal of Family Psychotherapy, 27 (4), 308–314. doi:10. 1080/08975353.2016.1235433. Page, M. J., Lindahl, K. M., & Malik, N. M. (2013). The role of religion and stress in sexual identity and mental health among lesbian, gay, and bisexual youth. Journal of Research on Adolescence, 23 (4), 665–677. doi:10.1111/jora.12025. Ray, R. A., & Street, A. F. (2005). Ecomapping: An innovative research tool for nurses. Journal of Advanced Nursing, 50 (5), 545–552. doi:10.1111/j.1365-2648.2005.03434.x. Roe, S. L. (2015). Examining the role of peer relationships in the lives of gay and bisexual adolescents. Children & Schools, 37 (2), 117–124. doi:10.1093/cs/cdv001. Rosario, M., Schrimshaw, E. W., & Hunter, J. (2004). Ethnic/ racial differences in the coming-out process of lesbian, gay, and bisexual youths: A comparison of sexual identity development over time. Cultural Diversity and Ethnic Minority Psychology, 10 (3), 215–228. doi:10.1037/1099­ 9809.10.3.215. Rosario, M., Schrimshaw, E. W., & Hunter, J. (2011). Different patterns of sexual identity development over time: Impli­ cations for the psychological adjustment of lesbian, gay, and bisexual youth. Journal of Sex Research, 48 (1), 3–15. doi:10.1080/00224490903331067. Super, J. T., & Jacobson, L. (2011). Religious abuse: Implica­ tions for counseling lesbian, gay, bisexual, and transgen­ der individuals. Journal of LGBT Issues in Counseling, 5 (3–4), 180–196. doi:10.1080/15538605.2011.632739.

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VIGNET TE ECOMAP WORKSHEET

FA MI LY

PE E R S Sam (mother) 5 Carsen 1

Pat (grandma) 3 Rachel (sister)

Robert 5

Jeffrey (father) 1

Alisha

Foster parents 2 Chris (15)

Karen (Robert's mom) 2

Ry (therapist)

Sarah (DCS)

James (neighbor) 2

David (mentor) 3

PROFESSIO N ALS

OTH E R S

Bidirectional communication

Important to disclose

1 = extremely important

Unidirectional communication

their sexual orientation

2 = very important

and/or gender identity

Strong relationship

3 = moderately important

Weak relationship

4 = slightly important

Stressful relationship

5 = not very important

Awareness of sexual orientation and/or gender identity Not aware Unsure if aware Aware

Designed by R. A. Brandon-Friedman, MSW. LCSW, LCAC and M. K. Kinney, MSW, LSW (2017)

38

Richard A. Brandon-Friedman and M. Killian Kinney

ECOMAP WORKSHEET

FA MI LY

PE E R S

PROFESSIO N ALS

O TH E R S

Bidirectional communication

Important to disclose

1 = extremely important

Unidirectional communication

their sexual orientation

2 = very important

and/or gender identity

Strong relationship

3 = moderately important

Weak relationship

4 = slightly important

Stressful relationship

5 = not very important

Awareness of sexual orientation and/or gender identity Not aware Unsure if aware Aware

Designed by R. A. Brandon-Friedman, MSW. LCSW, LCAC and M. K. Kinney, MSW, LSW (2017)

Richard A. Brandon-Friedman and M. Killian Kinney

39

5 MUST BE THE MUSIC: MUSICAL AUTOBIOGRAPHY AND CRITICAL LYRIC ANALYSIS Kiahni Nakai Suggested Uses: Activity, homework Objective

This musical autobiography assessment activity and critical lyric analysis homework assignment are created for practitioners who would like to build rapport and process emotions with LGBTQ (lesbian, gay, bisexual, transgender, questioning) clients. The musical auto­ biography assessment activity assesses psychological coping strategies through musical interests and pref­ erences. The critical lyric analysis homework assign­ ment engages the client in dialogue about the lyrics of a song in order to build therapeutic rapport. These activities can be especially helpful for clients who have difficulty expressing their feelings through traditional talk therapy or for clients who have not come out to family and friends. They can also be help­ ful when the therapist and client have hit a communi­ cation roadblock. These activities are applicable for use with teens and young adult LGBTQ clients. They can also be used for multiple-minority clients who come from cultural backgrounds where music is a central component of self-expression and a coping mechanism of their culture. Rationale for Use

Music has been used for centuries to express sorrow, joy, love, and shared life experiences. Music can lower anxiety by decreasing levels of the stress hormone cortisol and improving the body’s immune system function. New studies are using music to treat pain and manage a host of mental and physical health ailments (Novotney, 2013). Chanting, clapping, and singing in unison have been used by many cultures as traditional

methods of healing, managing grief, and bolstering group cohesion (Armstrong, 2016). Music and the arts in general can also provide a safe space for the LGBTQ community. Aronoff and Gilboa (2015) note that gay, lesbian, bisexual, and transgender Americans have been keen participants in choirs, where music provides a sense of unity and community. Using music within counseling and ther­ apy sessions can provide an outlet for LGBTQ clients, regardless of culture, who identify music as a central component of their identity. According to Gonzalez and Hayes (2009), music can also be useful for building rapport with clients who are resistant to traditional counseling interventions. Music can also offer an alter­ native for those who may have difficulty expressing their emotions through casual conversation, as music may convey the complexity of a person’s feelings better than words can (Armstrong, 2016). A musical autobiography assessment is an effective method to gain a holistic picture of a client’s needs and can assist in the development of an intervention plan (Bain, Grzanka, & Crowe, 2016). By analyzing the lyrics of songs, a critical lyric analysis can help facilitate dialogue and engage clients in conversations about their identity and experiences of prejudice and discrimination (Bain et al., 2016). As a result, clients can discuss their opinions on whether the song lyrics are irrelevant, helpful, or empowering. The client can share how important, or unimportant, the song is as it relates to processing feelings, healing, and moving forward throughout the counseling process. Lesbian, gay, bisexual, transgender, and ques­ tioning clients can benefit from the use of music in counseling sessions especially to express opinions,

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

40

experiences, and identities that may be difficult to dis­ cuss in their friend and family circles, as many LGBTQ clients struggle with being accepted within their com­ munities. LGBTQ clients still receive negative criticism and messages and are vulnerable to social exclusion, physical harassment, and verbal harassment, which cause many clients to struggle with opening up and sharing with others (Bain et al., 2016). Integrating music into therapeutic sessions can also provide clients with an alternative way to share their personal narra­ tive and to support practitioner-client communication (Lenes, Swank, & Nash, 2015). Therapists must be aware of their own attitudes toward LGBTQ clients in order to avoid any issues with countertransference throughout the therapeutic process. Counselors respect the diversity of clients and seek training in areas in which they are at risk of imposing their values on clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory (ACA, 2014). Best prac­ tices with clients should emphasize inclusivity, cre­ ation of safe space, use of preferred language, knowl­ edge of LGBTQ culture and music, and affirmative therapy (Whitehead-Pleaux et al., 2012). According to Bain and colleagues (2016), queer music therapy suggests that when working with LGBTQ clients to combat heteronormativity by emphasizing the complexity and fluidity of sexual orientation, therapists should support expression of unique personal and social conflicts that result from oppression. Therapists should also empower queer individuals to find strength in differences by freely expressing and performing their gender and sexual identity. Queer music therapy can also be used to positively affect interpersonal relationships, to counteract neg­ ative social pressures, and to emphasize common cause rather than commonality of identity (Bain et al., 2016). Music therapy provides a unique and engaging way to discuss clients’ presenting concerns and brain­ storm constructive interventions. When music ther­ apy is coupled with queer theory, the intricacies of sex­ ual orientation can be discussed in a way that affirms LGBTQ clients’ experiences, addresses heterosexism, and explores oppression in a way that music therapy

does not address alone (Bain et al., 2016). It is important that psychologists and counselors maintain objectivity when listening to the musical selection chosen by their client and not impose their own beliefs, personal tastes, and values on their client, especially with musical genres that may be stereo­ typed as controversial or negative (e.g., rap and heavy metal music) (Kimbel & Protivnak, 2010). Psycholo­ gists must be aware of and respect cultural, individual, and role differences and should avoid imposing their values on their clients (APA, 2013; ACA, 2014). Instructions

This worksheet can be used with individuals, groups, couples, and families. This activity can also be used in school counseling settings. Print the first handout, “Musical Autobiography Assessment Activity” (page 44), and use it in session only after confirming that music is important or useful to the client. Provide cli­ ents with enough time to complete the handout and to share their responses with the counselor, social worker, or psychologist while in session. Print the second handout, “Critical Lyric Analysis Homework Assignment” (page 45), and give it to the client to take home and complete. Ask the client to return to the following session with the completed handout and a piece of music to share with the therapist (e.g., on a CD, on a mobile device, on a musical instrument, or by singing). Begin the session by reading over the lyrics written on the worksheet. Then listen to the song brought to the session by the client without inter­ ruptions or distractions. Provide enough time to review the lyrics with the client after the song is played and ensure that there is enough time for the client to share their interpretation of the music and/ or lyrics. Ask the client to complete the “Review/ Comments” section at the end of the therapeutic ses­ sion. Repeat this activity when needed and if requested in the “Review/ Comments” section. Brief Vignette

Kendrick has recently come out to his family and friends, but he can see that his sexuality makes them feel uncomfortable, and he has been unable to discuss his feelings with them. Kendrick sought therapy

Musical Autobiography and Critical Lyric Analysis

41

because he feels alone. The people he used to rely on for support and guidance have become distant and quiet. The counselor explored questions with Kendrick about his musical preferences, and Kendrick noted in session that when he is sad, he is able to seek refuge in the soul and blues songs that his parents and grand­ parents played in the home. He observed that he is able to remember the times when he was a child and felt comforted by his family members. With the assis­ tance of the “Must Be the Music” activity and home­ work assignment, Kendrick was able to identify his feelings, how he uses music to cope with his current feelings, and how he uses music to improve his mood and outlook. This understanding helped Kendrick identify the musicians and genres that provide themes of comfort, positivity, and LGBTQ empowerment. By using the autobiography assessment activity and the critical lyric homework assignment with Kendrick, the therapist received more information about the client’s family dynamics and coping mechanisms. Kendrick was able to share themes of love, motivation, confidence, and pride that may have been difficult to share with his family and friends. The music ther­ apy exercise helped build client-practitioner rapport and understanding. Suggestions for Follow-up

These worksheets can be useful for LGBTQ clients who are resistant to counseling or have difficulty express­ ing their emotions. If clients continue to have difficulty sharing their thoughts throughout later sessions, or if the client and counselor have reached an impasse, repeat this exercise and ask the client to share addi­ tional songs. Therapists should plan time to read the lyrics provided at the beginning of the session and should also plan time for clients to share their inter­ pretation of the musical piece provided. Contraindications for Use

Before presenting these worksheets, it is important that the therapist understands that music is an impor­ tant part of the client’s life, coping mechanisms, selfexpression, and/or identity. Music may not be relevant to all LGBTQ clients and may not be a central factor in their lives. Instead, some clients may cite the Inter­ net, books, television, and movies as central to their 42

Nakai

identity formation (Aronoff & Gilboa, 2015). Last, any indications of threats to self or others should be assessed before beginning this activity. If musical themes of self-harm or harm to others are pres­ ent during this activity, it is important to follow proper ethical guidelines and local legal steps to ensure the client is safe from harm. Professional Readings and Resources American Counseling Association (ACA). (2014). American Counseling Association code of ethics. Alexandria, VA: Author. American Psychological Association (APA). (2013). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/index.aspx. Armstrong, C. (2016, February 29). Music: A powerful ally in your counseling sessions. Counseling Today. http://ct. counseling.org/2016/02/music-a-powerful-ally-in-your­ counseling-sessions/. Aronoff, U., & Gilboa, A. (2015). Music and the closet: The roles music plays for gay men in the “coming out” process. Psychology of Music, 43 (3), 423–437. https://doi.org/10. 1177/0305735613515943. Bain, C. L., Grzanka, P. R., & Crowe, B. J. (2016). Toward a queer music therapy: The implications of queer theory for radically inclusive music therapy. Arts in Psychotherapy, 50, 22–33. https://doi.org/10.1016/j.aip.2016.03.004. Gonzalez, T., & Hayes, G. (2009). Rap music in school coun­ seling based on Don Elligan’s rap therapy. Journal of Cre­ ativity in Mental Health, 4 (2), 161–172. https://doi.org/ 10.1080/1540138092945293. Kimbel, T. M., & Protivnak, J. J. (2010). For those about to rock (with your high school students), we salute you: School counselors using music interventions. Journal of Creativity in Mental Health, 5 (1), 25–38. Lenes, E., Swank, J. M., & Nash, S. (2015). A qualitative explo­ ration of a music experience within a counselor educa­ tion sexuality course. Journal of Creativity in Mental Health, 10 (2), 216–231. https://doi.org/10.1080/15401383.2014. 983255. National Association of Social Workers (NASW). (2017). National Association of Social Workers code of ethics. https://www.socialworkers.org/About/Ethics/Code-of­ Ethics/Code-of-Ethics-English. Novotney, A. (2013, November). Music as medicine. https:// www.apa.org/monitor/2013/11/music.aspx. Ocean, F. (2012). “Forrest Gump.” On Channel Orange. Warner/ Chapel Music. Ross, S. (2016). Utilizing rhythm-based strategies to enhance self-expression and participation in students with emo­ tional behavioral issues: A pilot study. Music Therapy Per­ spectives, 34 (1), 99–105. https://doi.org/10.1093/mtp/ miv021.

Secret Weapon. (1982). Must Be the Music. New York: Prelude Records. Thaut, M. H. (2015). Music as therapy in early history. Progress in Brain Research, 217, 143–158. https://doi.org/10.1016/ bs.pbr.2014.11.025. Whitehead-Pleaux, A., Donnenwerth, A., Robinson, B., Hardy, S., Oswanski, L., Forinash, M., . . . & York, E. (2012). Les­ bian, gay, bisexual, transgender, and questioning: Best prac­ tices in music therapy. Music Therapy Perspectives, 30 (2), 158–166. https://doi.org/10.1093/mtp/30.2.158.

Resources for Clients American Psychological Association (APA). (n.d.). Answers to your questions for a better understanding of sexual orientation and homosexuality. https://www.apa.org/ topics/lgbt/orientation.aspx. American Psychological Association (APA). (n.d.). Lesbian, gay, bisexual, and transgender health. https://www.apa. org/pi/lgbt/resources/lgbt-health.aspx. American Psychological Association (APA). (n.d.). Reducing sexual prejudice: The role of coming out. https://www. apa.org/pi/lgbt/resources/reducing-sexual-prejudice.aspx. Boylan, J. F. (2003). She’s not there: A life in two genders. New York: Broadway Books. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., . . . & Zucker, K. (2012). Stan­ dards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism, 13 (4), 165–232. https://doi. org/10.1080/15532739.2011.700873. Dasgupta, R. K., & Gokulsing, K. M. (2014). Masculinity and its challenges in India: Essays on changing perceptions. Jefferson, NC: McFarland. Mishima, Y. (1958). Confessions of a mask. Translated by M. Weatherby. Norfolk, CT: New Directions. Mock, J. (2014). Redefining realness: My path to womanhood, identity, love, and so much more. New York: Atria Books. Morris, B. J. (n.d.). History of lesbian, gay, and bisexual social movements. https://www.apa.org/pi/lgbt/resources/his tory.aspx. Moskowitz, H. (2015). Not otherwise specified. New York: Simon Pulse. Okparanta, C. (2015). Under the udala trees. New York: Houghton Mifflin Harcourt. Pai, H.-Y. (1993). Crystal boys. San Francisco: Gay Sunshine Press. Pitman, G. (2014). This day in June. Washington, DC: Magination Press.

Plett, C. (2015). A safe girl to love. New York: Topside Press. Rivera, G. (2016). Juliet takes a breath. Riverdale, NY: Riverdale Avenue Books. Roy, S. (2015). Don’t let him know. New York: Bloomsbury USA. Ryan, C. (2009). Helping families support their lesbian, gay, bisexual, and transgender (LGBT) children. https://docs. google.com/viewer?url=http://nccc.georgetown.edu/ documents/LGBT_Brief.pdf.

References American Counseling Association (ACA). (2014). American Counseling Association code of ethics. Alexandria, VA: Author. American Psychological Association (APA). (2013). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/index.aspx. Armstrong, C. (2016, February 29). Music: A powerful ally in your counseling sessions. Counseling Today. http://ct. counseling.org/2016/02/music-a-powerful-ally-in-your­ counseling-sessions/. Aronoff, U., & Gilboa, A. (2015). Music and the closet: The roles music plays for gay men in the “coming out” process. Psychology of Music, 43 (3), 423–437. https://doi.org/10. 1177/0305735613515943. Bain, C. L., Grzanka, P. R., & Crowe, B. J. (2016). Toward a queer music therapy: The implications of queer theory for radically inclusive music therapy. Arts in Psychotherapy, 50, 22–33. https://doi.org/10.1016/j.aip.2016.03.004. Gonzalez, T., & Hayes, G. (2009). Rap music in school coun­ seling based on Don Elligan’s rap therapy. Journal of Cre­ ativity in Mental Health, 4 (2), 161–172. https://doi.org/10. 1080/1540138092945293. Kimbel, T. M., & Protivnak, J. J. (2010). For those about to rock (with your high school students), we salute you: School counselors using music interventions. Journal of Creativity in Mental Health, 5 (1), 25–38. Lenes, E., Swank, J. M., & Nash, S. (2015). A qualitative explo­ ration of a music experience within a counselor education sexuality course. Journal of Creativity in Mental Health, 10 (2), 216–231. https://doi.org/10.1080/15401383.2014. 983255. Novotney, A. (2013, November). Music as medicine. https:// www.apa.org/monitor/2013/11/music.aspx. Whitehead-Pleaux, A., Donnenwerth, A., Robinson, B., Hardy, S., Oswanski, L., Forinash, M., . . . & York, E. (2012). Les­ bian, gay, bisexual, transgender, and questioning: Best practices in music therapy. Music Therapy Perspectives, 30 (2), 158–166. https://doi.org/10.1093/mtp/30.2.158.

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“M US T BE T H E M US IC”:

M U SIC AL AU TO BIO GRA P H Y A S S ES S M ENT ACT IVIT Y

Answer the following questions. Which musical artists, songs, or genres do you listen to when you are feeling sad and are struggling with issues related to your sexual orientation and/or gender identity?

What do you enjoy the most about these songs and artists?

Which musical artists, songs, or genres do you listen to when you want to feel empowered about your sexual orientation and/or gender identity?

What do you enjoy the most about these songs and artists?

Which musical artists, songs, or genres do you listen to when you are in love?

What do you enjoy the most about these songs and artists?

Which musical artists or songs do you listen to when you want to feel energized (e.g., work out or dance) to manage any stress related to your sexual orientation and/or gender identity?

What do you enjoy the most about these songs and artists?

Which LGBTQ artists do you enjoy listening to?

What do you enjoy about these LGBTQ songs and artists?

Does your social class, ethnicity, religion, nationality, ability, or age influence the music that you enjoy or identify with? If so, how?

Which artists, genres, or songs do you avoid listening to that may be harmful or oppressive?

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Kiahni Nakai

“M US T BE T H E M US IC”:

C RITIC AL LYRIC A NA LYS IS H O M EWO RK A S S IGNM ENT

Step 1: Select a song to share with your counselor, social worker, or psychologist that reflects your identity, current feelings, a difficult time in your life, or your hopes for the future. Your song can also reflect any experiences you’ve had with prejudice or discrimination. Musical artist: Song and album: Genre: Step 2: Include the lyrics or notes to this song below. (If you run out of space, use the back of this sheet.)

I like this song/artist because

This song makes me feel

I would recommend this song to another person because

What would you like your therapist to understand about this song and how it relates to your identities, thoughts, beliefs, or experiences?

Kiahni Nakai

45

“M US T BE T H E M US IC”:

REVIEW/ CO M M ENT S

Did you like this exercise? n YES

n NO

n MAYBE

n NOT SURE

Would you like to bring in another song to share during your next session? n YES

n NO

n MAYBE

n NOT SURE

Would you like to use this exercise again sometime in the future? n YES

n NO

n MAYBE

Comments:

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Kiahni Nakai

n NOT SURE

“MU ST BE TH E M US IC”: S A M P L E CO M P L ET ED

AC TIVIT Y MU SIC AL AUT O BIO GRA P H Y A S S ES S M ENT ACT IVIT Y

Answer the following questions. Which musical artists, songs, or genres do you listen to when you are feeling sad and are struggling with issues related to your sexual orientation and/or gender identity? I like to listen to Aretha Franklin or old blues songs from the 1960s. What do you enjoy the most about these songs and artists? I like that these songs talk about loss, sadness, or how difficult love and life can be. It makes me feel like I am not alone in my sadness when I am going through a tough time. I heard these songs played at home when I was a little boy. Which musical artists, songs, or genres do you listen to when you want to feel empowered about your sexual orientation and/or gender identity? I like to listen to rap, hip-hop, and mid-tempo to upbeat R&B songs. I especially like Curtis Mayfield “Move on Up” whenever I feel like I need a boost of confidence or motivation. I also like “Formation” by Beyoncé. Even though these songs aren’t about my sexuality, they make me feel uplifted. What do you enjoy the most about these songs and artists? I like rap and hip-hop because many artists discuss having pride in themselves, their families, and the places that they come from. I also like the R&B songs where singers speak about hav­ ing fun and staying motivated. Which musical artists, songs, or genres do you listen to when you are in love? Why? I like to listen to Corinne Bailey Rae, Beres Hammond, Jhene Aiko, and Chaka Khan when I am in love. What do you enjoy the most about these songs and artists? I like that these artists talk generally about love, but they also discuss their expectations of rela­ tionships and how they want to love and be loved.

PAGE 1

Kiahni Nakai

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“MU ST BE TH E M US IC”: S A M P L E CO M P L ET ED

AC TIVIT Y M U SIC AL AUT O BIO GRA P H Y A S S ES S M ENT ACT IVIT Y

Answer the following questions. Which musical artists or songs do you listen to when you want to feel energized (e.g., work out or dance) to manage any stress related to your sexual orientation and/or gender identity? I listen to Afrobeats, danceball, rap, and electronic dance music when I want to dance. I like Yemi Alade, Calvin Harris, Davido, and Drake. What do you enjoy the most about these songs and artists? I like that these songs make me feel like dancing, or they motivate me to complete a workout that helps me feel better and more confident. Which LGBTQ artists or songs do you enjoy listening to? I like listening to Frank Ocean, Sam Smith, and the Internet. What do you enjoy about these LGBTQ songs and artists? I enjoy that these artists make great music and talk about relationships that I identify with. I like that they are there and that there are more LGBTQ artists coming out, making music about their relationships and perspectives, and becoming popular and successful. Does your social class, ethnicity, religion, nationality, ability, or age influence the music that you enjoy or identify with? If so, how? I feel like my age and my ethnicity both influence the music that I enjoy and identify with. Music has been a big part of African American culture. I grew up seeing it used as a way to express feelings, have a good time, and manage sorrow. I also usually enjoy listening to artists that are closer to my age group, but not always. Which artists, genres, or songs do you avoid listening to that may be harmful or oppressive? Although I do like hip-hop and reggae, I avoid listening to certain artists that may say negative things. I prefer the love songs or songs about partying, pride, and motivation instead from these genres.

PAGE 2

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Kiahni Nakai

“M U ST BE TH E M US IC”: S A M P L E CO M P L ET ED

A SSIGN ME N T C RITIC AL LY RIC A NA LYS IS H O M EWO RK A S S IGNM E N T

Step 1: Select a song to share with your counselor, social worker, or psychologist that reflects your identity, current feelings, a difficult time in your life, or your hopes for the future. Your song can also reflect any experiences you’ve had with prejudice or discrimination. Musical Artist: Frank Ocean Song and Album: “Forrest Gump”—Channel Orange Genre: R&B

Step 2: Include the lyrics or notes to this song below. (If you run out of space, use the back of this sheet.) (Lyrics)

I like this song/artist because I like this song because it talks about being in love and about how exciting it is to root for someone that you are in love with. This song makes me feel Happy I would recommend this song to another person because It’s nice to have R&B songs written by men and sung by a man about his love for another man. There aren’t a lot of songs out there like this one. It’s also a fun positive song and I like Frank Ocean’s voice. What would you like your therapist to understand about this song and how it relates to your identity, thoughts, beliefs, or experiences? This song reminds me of my first love and how I felt being in love. This song reminds me of the butterflies I felt and makes me eager to discuss my past and current relationships in session. I am not used to discussing them at all because I can’t talk about these things with my friends and family. It makes them uncomfortable.

Kiahni Nakai

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“MU ST BE TH E M US IC”: CO M P L ET ED S A M P L E

REVIEW/ CO M M ENT S

Did you like this exercise?

n YES ü

n NO

n MAYBE

n NOT SURE

Would you like to bring in another song to share during your next session? n YES ü

n NO

n MAYBE

n NOT SURE

Would you like to use this exercise again sometime in the future? n YES ü

n NO

n MAYBE

n NOT SURE

Comments: I enjoyed this exercise. It made me think about how much music is a part of my life. It helped me to share a lot of things that I’ve thought about even though I didn’t exactly have the right words to share them with my counselor.

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Kiahni Nakai

6 CINEMATHERAPY FOR LGBT CLIENTS Jennifer Lancaster and Angelica Terepka Suggested Uses: Homework, activity Objective

The purpose of this activity is to provide a safe space for LGBT persons to explore their identity through the use of a popular medium (film). Films and related media may provide a means of normalization of sexual and gender-identity development. Rationale for Use

This intervention is intended for clinical use with indi­ viduals seeking to explore their sexual identity through the lens of popular media and may provide a means to generate dialogue about sexual identity in thera­ peutic work. Lesbian, gay, and bisexual individuals have less access to visible role models than their het­ erosexual counterparts (Grossman & D’Augelli, 2004). Further, minority stress theory suggests that those clients who belong to minority groups (including sex­ ual minorities) experience unique stressors that may increase the experience of mental health issues (Meyer, 2003). These stressors are particularly evident when clients experience the social discrimination and stigma that often accompany membership in these groups (Bridges, Selvidge, & Matthews, 2003; Hatzenbuehler, 2009). Furthermore, individuals who identify as multi­ ple minorities may be subjected to varying types of discrimination. Balsam and colleagues (2011) found that individuals of color who identify as LGBT expe­ rience (a) racism within their LGBT communities, (b) heterosexism within their racial or ethnic com­ munities, and (c) racial or ethnic discrimination in dating and close relationships. These unique combi­ nations of stressors are likely to negatively affect psy­ chological and mental health, particularly for LGBT

people of color who are more likely to rely on their racial or ethnic communities for support (Balsam et al., 2011). Clients who identify in multiple minority groups may be further marginalized and, as a result, may have trouble envisioning a positive life path that incorporates these aspects of their identity. Research examining the influence of LGBT-rep­ resentative media on LGBT identity suggests that LGBT individuals connect with the experience of LGBT-identified characters and celebrities (Gomillion, & Giuliano, 2011). Additionally, visibility of LGBTidentified persons in the media provides a sense of social support for LGBT youth (Gomillion & Giuliano, 2011). Members of marginalized groups who experi­ ence stigma and discrimination on the basis of sex­ ual and racial minority membership may be in further need of characters with whom they can identify in film (Bostwick et al., 2014). Films depicting characters identifying as LGBT individuals of color may be particularly powerful given the research highlighting multiple stressors experienced by individuals who identify as both sexual and racial minorities. Clients can come to understand themselves and gain new insights into their own concerns by view­ ing characters in a film who are experiencing similar circumstances (Egeci & Gencoz, 2017). While a movie is not likely to be a replica of the client’s life and cur­ rent circumstances, it can serve as a metaphor for some relevant aspect. Metaphor is often used in psycho­ therapy (particularly in CBT interventions) to aid cli­ ents in processing issues significant to them (Sharp, Smith, & Cole, 2002). Kuriansky, Vallarelli, DelBuono, and Ortman (2010) suggest that “film presents an opportunity for change by revealing issues in a non­ threatening way within the safety of distance so that

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

52

difficult material and alternate ideas and behaviors can be processed indirectly at first, and then more directly processed” (p. 91). In addition to some empirical support for the technique as part of the therapeutic toolkit (e.g., Egeci & Gencoz, 2017; Gramaglia et al., 2011; Heston & Kottman, 1997; Kuriansky et al., 2010), movies can also provide an experience that is shared between thera­ pist and client and can help improve or solidify the therapeutic alliance (Berg-Cross, Jennings, & Baruch, 1990). The process of cinematherapy is similar to other psychotherapeutic interventions, with some important distinctions. Ulus (2003) states that viewers of films engage in three phases while viewing: pro­ jection, identification, and introjection. Projection is a process in which the viewer’s thoughts and affect are activated by the film’s plot or characters. Identifica­ tion allows the viewer to relate to the experiences of the film’s characters. Introjection is the process in which viewers apply the lessons learned from the film to their personal experiences. Therapists are encour­ aged to work through each of these processes with clients, addressing the emotions evoked in the projec­ tion phase, helping the client identify with the film and make meaning of the film as it relates to the client’s life. The proposed activity requires review of several ethical codes included in the American Psychological Association’s (APA) ethical principles of psychologists (2017). Specifically, codes pertaining to clinician competence (2.01) and informed consent (10.01) are relevant. APA’s guidelines for psychotherapy with lesbian, gay, and bisexual clients include special atten­ tion to recognizing risk factors associated with this population, including those related to identity devel­ opment (APA, 2017, 2.01). These guidelines mandate that therapists recognize and respect the special chal­ lenges faced by LGBTQIA youth and older adults, as well as the life challenges that may be encountered when clients experience conflicting cultural norms (APA, 2000). Those with less experience working with this population are encouraged (according to APA guideline 2.01 and Division 44 guideline 15) to seek supervision. Additionally, therapists must consider obtaining informed consent throughout the process of therapy (APA, 2017, 10.01). For this activity it is suggested that therapists be intimately familiar with

the suggested film, its content, its themes, and the official Motion Picture Association of America film rating (e.g., PG-13, R). The therapist’s knowledge of the film will allow for a more accurate procurement of informed consent: therapists can discuss themes within the movie to help clients decide if they want to partake in the activity. Instructions

Therapists should choose a few films that they feel are likely to resonate with the client. The client chooses from this list, watches the film between sessions, and completes the film analysis worksheet. This work­ sheet is designed to elicit reactions to the film and can be modified to meet the client’s needs. The client should bring this worksheet to the next session for processing with the therapist. Film selection is an important component of this process. Caron (2005) suggests that the practitioner consider the assessment of clients and their goals in therapy before implementing the assignment. Some more specific areas to consider include age-appropri­ ateness, MPAA rating, language, and relatedness to the client’s treatment goals (e.g., identity, coming-out process, relationships). Therapists should also con­ sider the ways in which the film’s characters may or may not mirror the client’s multiple and, at times per­ haps, conflicting identities. A list of suggested films can be found at the end of this chapter or by consult­ ing the Suggested Reading section below. Clinicians should be thoroughly familiar with the film’s content before assigning a viewing activity. Following the view­ ing of the film, debriefing should be specific to the individual, and the issues and emotions associated with viewing the film should be thoroughly discussed. The discussions might include identification with the characters, the issues presented, or any other aspect that the client determines is significant. Choosing a film in which the features of the main characters (e.g., race, age, and gender) closely resemble the client’s would be ideal; however, finding such films may be difficult. Clients may thus be exposed to films featur­ ing characters with different (possibly more privi­ leged) identities than their own. Clinicians should speak with their clients about discrepancies in the rela­ tive experiences of the client and the film’s protagonist, Cinematherapy for LGBT Clients

53

focusing particularly on aspects of the film that evoke feelings of further marginalization of certain identities. It may be equally beneficial for the client to view characters with varying demographics and in vari­ ous cultural contexts in order to better identify dif­ ferences and similarities in the session. In fact, pro­ moting the use of “film as metaphor” will often allow for sufficient identification to meet clients’ needs. It should be noted that therapeutic discussion following film viewing, rather than simply watching a movie, is thought to be the active component promoting the effectiveness of cinematherapy interventions (Egeci & Gencoz, 2017). Therefore, clinicians are expected to thoroughly process the client’s experience of viewing the film by focusing on these matters along with other pertinent issues relevant to individual clients. When viewing the film, clients should make notes, which may help in the recollection of specific aspects of the film to which they had an emotional reaction. It is also recommended that clients process the movie on their own immediately after viewing the film and before completing the worksheet. Some relevant prompts for clients in completing this processing are included in the worksheet at the end of this chapter and can be customized for each client and film. Brief Vignette

Sara is a twenty-seven-year-old Latina American cisgender lesbian seeking therapy for symptoms of anx­ iety. She is currently in a serious relationship with a woman. Her parents believe that Sara lives with her “roommate.” Sara is preparing to come out to her par­ ents about her sexuality and the nature of her rela­ tionship with her partner but fears rejection from her parents. After several sessions of speaking to her ther­ apist about her anxiety, Sara continues to feel alone in her struggle and unsure of how to tell her parents about her sexuality. After assessing Sara’s relative interest in and not­ ing a hobby of watching movies, the therapist sug­ gests that she view a film in which the main character is a young Asian American male whose traditional Chi­ nese mother moves in with him following a divorce. Once the mother moves in, the character is forced to come out about his sexuality, and the remainder of

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the film presents the relationship dynamics between mother and son who eventually come to accept one another despite initial struggles within their relation­ ship. In the post-viewing therapy session, Sara and the therapist process her experience of watching the film. Sara describes feeling anxious before viewing the movie; she believes part of her anxiety arose from knowing that the plot of the movie involves an LGBT character. She also reports having felt intrigued by the movie because she has had little exposure to films that openly present LGBT issues. Sara is also able to identify anger she felt toward the character of the mother in the film but feels dis­ tressed by the fact that she did not know why she was angry with the character; through discussion with the therapist, she acknowledges that some of the anger she felt toward the mother character in the film early in the viewing was derived from her feelings toward her own mother (i.e., the projection phase). Sara admits that she identified strongly with the main character in sev­ eral respects, including feeling the need to keep her sexuality a secret from her parents, and empathizing with the cross-cultural aspects that made it difficult for the main character to come out to his mother. She discusses the anxiety she felt for the character when he first disclosed his sexuality to his mother as well as the relief she felt toward the end of the movie when mother and son were able to come to a place of accep­ tance of each other (i.e., the identification phase). Sara also tells her therapist that after viewing the film, she was finally able to visualize a future relationship with her parents after she discloses her sexuality to them. In addition, Sara discloses connecting to the char­ acter’s identity as a first-generation American. In particular, she recognized the experience of being a child of immigrant parents, whose conservative cul­ tural values are not necessarily in line with her current social context. Though Sara recognizes differences between her experiences and that of the character depicted in the film (i.e., gender, family structure), sim­ ilarities in the identity-development process resonate with her. Therapy ensued with steps toward helping Sara come out to her parents and adjust to new or changing dynamics in her parental relationship (i.e., the introjection phase).

Suggestions for Follow-up

Professional Readings and Resources

If this intervention proves useful for the client, this exercise can be used to address additional client con­ cerns as they arise, using films depicting related topics. Therapists may wish to have clients choose a movie for themselves and repeat the exercise. In addition, in the context of this intervention, clients may view favorite films and discuss in session the messages about sexuality and gender that are conveyed in these films and make comparisons.

American Psychological Association (APA). (2000). Guide­ lines for psychotherapy with lesbian, gay, and bisexual clients. American Psychologist, 55, 1440–1451. doi:10.1037//0003-066X.55.12.144. Bridges, S. K., Selvidge, M. M. D., & Matthews, C. R. (2003). Lesbian women of color: Therapeutic issues and chal­ lenges. Journal of Multicultural Counseling and Develop­ ment, 31, 113–130. Dermer, S. B., & Hutchings, J. B. (2000). Utilizing movies in family therapy: Applications for individuals, couples, and families. American Journal of Family Therapy, 28, 163–180. Niemiec, R. M., & Wedding, D. (2014). Positive psychology at the movies: Using films to build character strengths and well-being, 2nd edition. Boston: Hogrefe Publishing. Wedding, D., & Niemiec, R. M. (2014). Movies and mental illness: Using films to understand psychopathology, 4th edition. Boston: Hogrefe Publishing.

Contraindications for Use

This exercise is appropriate for clients of all educa­ tional levels and may be used as an alternative to bib­ liotherapy for clients who have poorer reading skills or disabilities preventing them from engaging in bib­ liotherapy. Special attention should be paid to film selection so that the film is appropriate to the client’s level of maturity and reflects the client’s values, reli­ giosity, and similar characteristics. Clinicians should also be aware of a client’s access to films and the equipment necessary to view a film; professionals working with certain populations should be sensitive to client financial concerns that inhibit their film-viewing ability. Last, use of cinematherapy may be inappropriate for clients with certain present­ ing problems such as trauma or sexual abuse, as view­ ing films relating to these issues may result in retrau­ matization. Therapists should keep in mind that some films may have themes that evoke difficult emotions in clients (e.g., depression, anger, anxiety). Therefore, clinicians are urged to have a thorough understand­ ing of the history of their clients and where they are in the processing and healing of previous traumatic experiences and use caution in recommending certain types of films. Therapists should avoid assigning films that have the potential to cause harm to clients. If clinicians choose to pursue an intervention based in cinematherapy for a client with a past trauma history, they are encouraged to discuss the choice of inter­ vention, details of the film, and potential discomfort the client may feel to fully assess the appropriateness of the intervention and obtain informed consent from the client to continue with the therapeutic intervention.

Resources for Clients Advocate. (2014, June 23). The top 175 essential films of all time for LGBT viewers. www.advocate.com/arts­ entertainment/film/2014/06/23/top-175-essential-films-all­ time-lgbt-viewers. Letterboxd. Your life in film. https://letterboxd.com/. Niemiec, R. M., & Wedding, D. (2014). Positive psychology at the movies: Using films to build character strengths and well-being, 2nd edition. Boston: Hogrefe Publishing.

References American Psychological Association (APA). (2000). Guide­ lines for psychotherapy with lesbian, gay, and bisexual clients. American Psychologist, 55, 1440–1451. doi:10. 1037//0003-066X.55.12.144. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/index.aspx. Balsam, K. F., Molina, Y., Beadnell, B., Simoni, J., & Walters, K. (2011). Measuring multiple minority stress: The LGBT People of Color Microaggressions Scale. Cultural Diver­ sity and Ethnic Minority Psychology, 17 (2), 163–174. Berg-Cross, L., Jennings, P., & Baruch, R. (1990). Cinematherapy: Theory and application. Psychotherapy in Private Practice, 8, 135–157. Bostwick, W. B., Meyer, I., Aranda, F., Russell, S., Hughes, T., Birkett, M., & Mustanski, B. (2014). Mental health and sui­ cidality among racially/ethnically diverse sexual minority youths. American Journal of Public Health, 104 (6), 1129–1136. https://ajph.aphapublications.org/doi/abs/ 10.2105/AJPH.2013.301749.

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Bridges, S. K., Selvidge, M. M. D., & Matthews, C. R. (2003). Lesbian women of color: Therapeutic issues and chal­ lenges. Journal of Multicultural Counseling and Develop­ ment, 31, 113–130. Caron, J. J. (2005). DSM at the movies: Use of media in clini­ cal and educational settings. https://www.counseling.org/ docs/default-source/vistas/vistas_2005_vistas05-art38. pdf?sfvrsn=e67177d9_11. Egeci, S., & Gencoz, F. (2017). Use of cinematherapy in deal­ ing with relationship problems. Arts in Psychotherapy, 53, 64–71. Gomillion, S. C., & Giuliano, T. A. (2011) The influence of media role models on gay, lesbian, and bisexual identity. Journal of Homosexuality, 58 (3), 330–354. doi:10.1080/0 0918369.2011.546729. Gramaglia, C., Abbate-Daga, G., Amianto, F., Brustolin, A., Campisi, S., De-Bacco, C., & Fassino, S. (2011). Cinematherapy in the day hospital treatment of patients with eating disorders: Case study and clinical considerations. Arts in Psychotherapy, 38 (4), 261–266. Grossman, A. H., & D’Augelli, A. R. (2004). The socialization of lesbian, gay, and bisexual youth: Celebrity and person­ ally known role models. In E. Kennedy & A. Thornton (eds.), Leisure, media, and visual culture: Representations and contestations. Eastbourne, UK: Leisure Studies Asso­ ciation Publications.

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Hatzenbuehler, M. L. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation frame­ work. Psychological Bulletin, 135, 707–730. Heston, M. L., & Kottman, T. (1997). Movies as metaphors: A counseling intervention. Journal of Humanistic Education and Development, 36, 92–99. Kuriansky, J., Vallarelli, A., DelBuono, J., & Ortman, J. (2010). Cinematherapy: Using movie metaphors to explore real relationships in counseling and coaching. In M. B. Gre­ gerson (ed.), The cinematic mirror for psychology and life coaching. New York: Springer. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674–697. Newton, A. K. (1995). Silver screens and silver linings: Using theatre to explore feelings and issues. Gifted Child Today, 18 (2), 14–19. Schulenberg, S. E. (2003). Psychotherapy and movies: On using films in clinical practice. Journal of Contemporary Psycho­ therapy, 33, 35–48. Sharp, C., Smith, J. V., & Cole, A. (2002). Cinematherapy: Metaphorically promoting therapeutic change. Counseling Psychology Quarterly, 15, 269–276. Ulus, F. (2003). Movie therapy, moving therapy! The healing power of film clips in therapy settings. Victoria, BC: Traf­ ford Publishing.

F IL M DEBRIEF ING

WO RKS H EET

Did my breathing change during the viewing? If so, when and how?

What were the major themes of the movie?

Which of these themes were most important to me? Why? Do these themes relate to my life in any way?

With which character(s) did I identify? In what ways? Do any of these characters face what I face?

What did I like about the film? What did I dislike?

Did I notice any change in my emotions? What types of emotions came up for me while watching the film? Which aspects of the film brought these emotions up?

What would I tell someone watching this film for the first time?

Which issues would I like to explore further?

Jennifer Lancaster and Angelica Terepka

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L I S T OF SU GGE STE D M OVIE S BY CAT EGO RY

It is strongly recommended that clinicians be thoroughly familiar with the chosen film before assigning viewing of the film to clients.

Family

LGB Elders

The Kids are All Right (2010)

The Birdcage (1996)

The Family Stone (2005)

Beginners (2010)

Philomena (2013)

Eat with Me (2014)

Fried Green Tomatoes (1991)

Jenny’s Wedding (2015)

The Beginners (2010)

Grace & Frankie (TV Series, 2015)

Cloudburst (2011)

Love Is Strange (2014)

Desert Hearts (1985)

Relationships

Brokeback Mountain (2005)

Blue Is the Warmest Color (2013)

Weekend (2011)

Fried Green Tomatoes (1991)

Happy Together (1997)

Freeheld (2015)

The Girl King (2015)

Carol (2015)

Now and Then (1995)

Coming Out

Kissing Jessica Stein (2001)

Pariah (2011)

The Way He Looks (2014)

Eat with Me (2014)

The Imitation Game (2014)

Wish Me Away (2011)

I Love Her (2013)

The Out List (2013)

Out in the Line-Up (2014)

Jenny’s Wedding (2015)

Bend It Like Beckham (2002)

Transgender and Gender Identity

Special Concerns

The Falls (2012)

Latter Days (2003)

Pariah (2011)

Eat with Me (2014)

Paris Is Burning (1990)

Rent (2005)

LGB Youth

Transparent (TV, 2014) Boys Don’t Cry (1999) Women in Revolt (1971) Paris Is Burning (1990) 52 Tuesdays (2013) The Crying Game (1992) The Danish Girl (2015) Tomboy (2011) Transamerica (2005)

The Edge of Seventeen (2016)

Tomboy (2011)

But I’m a Cheerleader (1999)

Beautiful Thing (1996)

Pariah (2011)

Perks of Being a Wallflower (2012)

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7 HOW DOES GOD SEE ME? A REFLECTIVE EXERCISE Hannah B. Bayne and Anita A. Neuer Colburn Suggested Uses: Activity, homework Objective

This activity facilitates clients’ self-exploration of per­ sonal faith as well as traditional religious teachings as they apply to clients’ sexual identity. It assists clients in progressing through stages of faith development by encouraging critical analysis of religious texts, reflection on personal beliefs, and discussion of how values and religious communities interact to inform clients’ views of the intersectionality of their spiritual or religious self and sexual identity. Through broach­ ing religious themes, assigning the worksheet as home­ work, and then processing the experience with the client, a counselor can use this activity to address important elements of the client’s religious and sexual identities. The activity is helpful for clients identify­ ing with a theistic spirituality or religion, including Protestantism, Catholicism, Judaism, and Islam. Because of our own understanding of the extant liter­ ature, we refer to “God” in this chapter, although some clients may use different nomenclature (e.g., “Allah”). Rationale for Use

Scholarly research, affirmative-practice competency documents, and ethical codes provide a solid rationale for the use of this activity, which is designed to address the intersectionality of clients’ spiritual or religious and LGBTQ identities. Researchers at the Pew Forum (2015) found that 89 percent of Americans claim a belief in God. The World Values Survey (2011) showed that 67.9 percent of people in the United States iden­ tify as religious, and 66.3 percent belong to a particular religious denomination. For many clients who are religious, faith is often an integral part of their per­

sonal and social identity, and counselors are encour­ aged to integrate religion and spirituality into the counseling process when it is appropriate for clients (ASERVIC, 2009, no. 12; Bayne & Neuer Colburn, 2012; Bayne, Neuer Colburn, & Conley, 2016; Hartwig Moorhead & Neuer Colburn, 2016; Kyle, 2013; Snow & Neuer Colburn, 2015; Wood & Conley, 2014). How­ ever, most religious groups have traditionally and historically upheld nonheterosexual identities as sinful and abhorrent, which leaves LGBTQ clients without much support to wrestle with questions of sexuality, morality, and their place within their religion (Beagan & Hattie, 2015; Frame, 2003; Love, Bock, Jannarone, & Richardson, 2005; Wood & Conley, 2014). In fact, many LGBTQ adults have reported experiencing sig­ nificant psychological and emotional harm from organized religions (Beagan & Hattie, 2015; Wood & Conley, 2014). Thus, clients who identify as LGBTQ may internalize negative messages from their religious communities. This conflict of doctrine with personal beliefs and experiences can leave clients feeling torn between parts of themselves and can lead to internal­ ized homophobia, self-hatred, or abandonment of their religious faith and community (Abu-Raiya, Par­ gament, Krause, & Ironson, 2015; Barret & Logan, 2002; Bayne, 2016; Frame, 2003). Wood and Conley (2014) suggested that sexual microaggressions are a form of religious or spiritual abuse leading to loss of religious or spiritual identity among LGBT people, and Abu-Raiya and colleagues (2015) found that all types of religious or spiritual struggles were positively associated with depressive symptoms and generalized anxiety and negatively associated with satisfaction with life and happiness (p. 571). Conversely, an integrated faith that allows for an affirming view of sexual iden-

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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tity can connect clients with the positive benefits of a faith community and the personal wellness resources associated with spiritual and religious foundations (Barret & Logan, 2002; Bayne, 2016; Frame, 2003; Hartwig Moorhead & Neuer Colburn, 2016; Ivtzan, Chan, Gardner, & Prashar, 2013; Kyle, 2013; Love et al., 2005). For example, Ivtzan and colleagues (2013) reported that higher levels of spirituality and religi­ osity predicted self-actualization, meaning in life, and personal growth initiative, and Kyle (2013) found that spirituality helped increase coping among suicidal college students. Professional codes of ethics and lists of clinical com­ petencies obligate counselors to provide an accepting and affirming space for clients to explore their own beliefs of how sexuality and religion intersect. The Association for Lesbian, Gay, Bisexual, and Transgen­ der Issues in Counseling (Harper et al., 2013) com­ petencies call for counselors to develop relationships with clients that foster self-acceptance, based on the understanding that normative developmental tasks of LGBQQ persons are often “complicated or com­ promised by social isolation and invisibility” (A.8). Specifically, standards A.16, A.17, and B.8 point to the importance of intentionally tending to the multi­ ple identity statuses of LGBQQ individuals and inte­ grating coming-out identity development with other areas of development, including race, gender, and spirituality. Cultural communities, defined through common racial or ethnic identities, can hold similar beliefs of homosexuality as counter-normative, thereby compounding a client’s experience of judg­ ment and fear of losing social supports (Barret & Logan, 2002, Harper et al., 2013). Clients who are already affected by racial discrimination and preju­ dice may find that an LGBQQ identity further adds to their experience of discrimination and oppression (Barret & Logan, 2002; Wood & Conley, 2014), and counselors should therefore consider how these inter­ secting identities influence the coming-out process. Regarding spirituality, ALGBTIC (Harper et al., 2013) standard C.5 states that competent counselors will acknowledge the spiritual stressors that may interfere with LGBQQ individuals’ ability to achieve their goals. The ASERVIC (2009) competencies also apply, as they stress the importance of acknowledg­

ing the centrality of clients’ beliefs regarding spiritual­ ity and religion to overall worldview and psychosocial functioning (no. 2), the ability of professional coun­ selors to describe and apply various models of spiri­ tual or religious development (no. 6), and the clinical skill of therapeutically applying theory and current research supporting the inclusion of a client’s spiritual or religious perspectives and practices (no. 14). Further, the ACA (2014) Code of Ethics compels practitioners to protect client welfare (A.1) and, spe­ cifically, to adjust their style of communication in a manner that is developmentally and culturally appro­ priate for clients (A.2.c). Counselors should thus engage in assessment of client development, under­ stand clients within their cultural context, and adjust interventions accordingly. Affirmative counseling practices for LGBTQ clients also stress this need for counselors to first have knowledge and awareness of clients’ multiple identities (racial, ethnic, gender, sex­ ual, religious, and spiritual, to name a few), and then to affirm these identities in practice through respect­ ing the unique ways clients experience both their sex­ uality and their religion as part of their whole sense of self (APA, 2012; Beagan & Hattie, 2015; Frame, 2003; Johnson, 2012). This means understanding LGBT clients in the context of faith development, sex­ ual identity development, racial identity development, experiences of micro- or macroaggressions, presence of social supports, and personal goals in order to determine how these components intersect for each client. Ignoring any part of the client’s identity (sexu­ ality or religion) would probably not be in the cli­ ent’s best interest. Counselors must be open to client definitions and conceptualizations and not impose their own expectations or agenda on the counseling process (ACA, 2014; APA, 2012; ASERVIC 2009; Johnson, 2012). Clients often do not have an avenue or model for critically examining components of their faith. Clients may feel as though sexuality and spirituality are mutu­ ally exclusive as a result of messages they have received within faith communities, and they may therefore be unaware of how these two identities can successfully intersect (Wood & Conley, 2014). Beagan and Hattie (2015) found that in response to negative messages from the church, LGBTQ participants in their study How Does God See Me? A Reflective Exercise

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“put their sexual selves and exploration of their bod­ ies on hold, and some denied or separated from whole aspects of themselves” (p. 100). However, models of faith development, such as Allport’s (1950), stress crit­ ical examination of religious texts and belief sys­ tems as important processes for continued faith mat­ uration. Allport encouraged a progression from full and unquestioning acceptance of religious doctrine to a more nuanced acceptance of faith informed by research, reflection, and personal decision making (Bayne, 2016; Love et al., 2005). Allport’s stages include raw credulity (blind acceptance from authority fig­ ures), satisfying rationalism (the process of beginning to question beliefs and being open to new meanings), and religious maturity (tolerating ambiguity and uncertainty with a critical engagement in a personal faith). In this activity we use the Allport (1950) model as a tool to support adaptive integration of clients’ religious or spiritual and LGBTQ identities. This activity, then, is designed to help clients explore key components of their faith tradition as they embrace the intersectionality of their sexual and spiri­ tual identities. Sexual and spiritual identities should also be examined through the lens of racial or ethnic identity. This activity does not require the counselor to be in a position of religious authority, or to pre­ scribe any meanings for the client. Indeed, such a posi­ tion would be inappropriate for the counselor’s role (ASERVIC, 2009; Bayne, 2016). Instead, the counselor offers a safe, affirming, and reflective space to first broach the topics of religion and spirituality, and then to invite clients to begin to identify, examine, and inte­ grate their own beliefs. Processing questions can assist clients in determining whether, and to what extent, the exercise has affected client understandings. Instructions

The activity is based on the work of Allport (1950) and uses several websites to help LGBT clients critically evaluate biblical passages that have been used to con­ demn homosexuality. Counselors should peruse these websites before advising their clients to do so. The “How does God see me?” worksheet includes refer­ ences to the websites, and the exercise could be sepa­ rated into two different activities (one for each of the two main websites). Also, while the worksheet can be 62

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used as a homework activity, it might better be initially used as an in-session tool to guide clients through the exercise, gauging their reactions. Counselors should understand Allport’s theory well enough to introduce the exercise by explaining the differences between immature faith and mature faith, and explor­ ing client reactions to this construct before moving forward. Rather than being an exhaustive list, the ques­ tions offered here can be altered for individual use, and, depending on client responses, counselors may develop further questions to help the client process the material more deeply. Brief Vignette

Jackie, a cis female, is third-generation Peruvian Amer­ ican and grew up within the Catholic church in her hometown of Washington, D.C. Jackie’s earlier attempts at relationships with men had failed, and she consis­ tently fought her attraction to women, convincing herself it would just “go away.” She’d been hoping her sexual orientation would change since she was in high school. All the while, her friends couldn’t under­ stand why she was seemingly “challenged” in the rela­ tionship department, because she was quite attrac­ tive and intelligent, and men seemed drawn to her. Her parents frequently lamented that they just wanted her to find a nice young man and settle down, partic­ ularly because she had just turned thirty and the other women in her community were typically mar­ ried by then. Jackie was very active at her church. As a teen, she had participated in the youth group, and her family stressed the importance of weekly atten­ dance at church. However, as her sexual attraction to women increased, she became more and more uncom­ fortable at church. Whenever the topic of dating or mating came up at church, the priest talked about the sinfulness of homosexuality and the importance of honoring God in personal relationships by avoid­ ing sex before marriage. Ultimately, Jackie resigned from her volunteer job as the youth group adviser, and she started skipping worship services whenever she could come up with an excuse. But it didn’t seem to help. Jackie felt isolated without the familiarity of her church community, and even though she was no longer attending the church, she still wrestled internally with her attraction to women. Furthermore, many of

her friends and neighbors attended her church, and they had begun to notice her absence. She prayed to God to take away her feelings and began to wonder if she had done something wrong, and if perhaps this attraction to women was some kind of punishment. She began to feel distant from God, convinced she could not be loved or accepted, and felt powerless to change. Within a few months she had developed low self-esteem, become isolated from some of the most important people in her life, and was depressed with thoughts of suicide. Finally, the continued struggle was too much, and Jackie went to counseling to address her attraction to other women and her discomfort with the conser­ vative biblical teachings of her family and church. She reported her desire to be able to be in a relationship with another woman but also continue to be a Chris­ tian, though she did not know a way that could be possible. After viewing the video excerpt on the Reli­ gious Tolerance website, she wept from the pain and confusion she had endured that the video seemed to affirm. The woman in the video whose religious belief system was ultimately changed after her own exam­ ination of biblical passages especially affected her. Jackie said she was open to trying to learn something new about the Bible. When she read the Introduction section from the Whosoever site, she appreciated the possibility that some of the terms used in the Bible had different connotations (based on the context and culture within which they were written) from those that she had been taught all her life. Still, she expressed some discomfort with the thought of critically exam­ ining and potentially disagreeing with concepts rooted in her past and present understanding of her faith. After reading the material and responding to the ques­ tions, Jackie felt hopeful that there could be a way for her to still be loved by God, even if she allowed her­ self to date and possibly fall in love with a woman. After several sessions, Jackie decided to start attending a different, more inclusive church whose members promoted and modeled different concep­ tualizations of same-sex relationships within the con­ text of a religious community. While she still was not out to her parents or the people she worked with, she had embarked on a journey of self-acceptance, and she began dating women. Through a process of self-

discovery and affirmation, then, Jackie was able to progress in both areas of identity that had been in con­ flict. Her sexual-identity development progressed through the counselor’s creation of an accepting and affirming space to process her feelings, hopes, and desires. Likewise, by allowing her spiritual and reli­ gious identity to be seen as an equally important and nonmutually exclusive part of herself, Jackie was able to feel safe examining her faith and pursuing a contin­ ued relationship with God. Her own faith developed as a result. She still maintained some distrust of others in her faith community, knowing they still adhered to judgments against LGBTQ individuals, and the loss of these relationships was still painful for her. Her new faith community, however, offered her the oppor­ tunity to be in relationship with others and continue to grow in her own personal faith. Suggestions for Follow-up

For some clients who grew up in conservative religious environments, this may be the first time they are read­ ing these passages through a different lens. We rec­ ommend that the counselors facilitate the client’s jour­ ney at a pace that is best for the client. Some may need to process only one of the passages per week, while others may want to read all the passages and consider them in their entirety. Also, the resolution of spiri­ tual and sexual identities can lead some clients to a new issue: that of coming out to parents or other loved ones. As with any other client considering coming out, we suggest counselors help clients strengthen their support systems while they help their clients plan when, how, and to whom they want to come out. For clients who are already out, this exercise could lead them to make changes to their worship attendance, which might also influence their current relationships in a variety of ways. For many people from conser­ vative backgrounds, reading and accepting new inter­ pretations of familiar scriptures can take a good bit of time and introspection. Counselors and/or clients may consider consultation with community clergy representing inclusive churches. Contraindications for Use

Counselors should refrain from moving into this exer­ cise too quickly, before a trusting therapeutic workHow Does God See Me? A Reflective Exercise

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ing alliance with the client has been built. If a client is self-injuring or suicidal, those issues should obviously be dealt with first and foremost. This exercise is best recommended following a thorough assessment of the client’s religious or spiritual history. Professional Readings and Resources Barret, B., & Logan, C. (2002). Counseling gay men and lesbi­ ans: A practice primer. Belmont, CA: Brooks/Cole Thomson Learning. Bayne, H. (2016). Helping gay and lesbian students integrate sexual and religious identities. Journal of College Coun­ seling, 19, 61–75. Fallon, K., Dobmeier, R., Reiner, S., Casquarelli, E., Giglia, L., & Goodwin, E. (2013). Reconciling spiritual values con­ flicts for counselors and lesbian and gay clients. ADULTSPAN Journal, 12, 38–53. Lemoire, S. J., & Chen, C. P. (2005). Applying person-cen­ tered counseling to sexual minority adolescents. Journal of Counseling & Development, 83, 146–154.

Resources for Clients: Books Bawer, B. (1993). A place at the table: The gay individual in American society. New York: Poseidon. Brown, A. (ed.). (2004). Mentsh: On being Jewish and queer. Los Angeles: Alyson Books. Chellew-Hodge, C. (2008). Bulletproof faith: A spiritual sur­ vival guide for gay and lesbian Christians. San Francisco: Jossey-Bass. Kugle, S. (2010). Homosexuality in Islam: Islamic reflections on gay, lesbian, and transgender Muslims. Oxford, UK: Oneworld Publications. Miner, J., & Connoley, J. T. (2002). The children are free: Reexamining the biblical evidence on same-sex relation­ ships. Indianapolis: Jesus Metropolitan Community Church. White, M. (1995). Stranger at the gate: To be gay and Chris­ tian in America. New York: Plume.

Resources for Clients: Websites Christian

Directory of Gay-Affirming Churches. (2017). Gaychurch. org. Ministering to LGBTQI Christians and our allies around the globe. https://www.gaychurch.org. Metropolitan Community Churches. (2013). Transforming ourselves as we transform the world. www.mccchurch.org. Q Christian Fellowship. (n.d.). https://www.qchristian.org. Religious Tolerance. (2017). Ontario Consultants on Religious Tolerance. www.religioustolerance.org. Whosoever. (n.d.). An online magazine for gay, lesbian, bisex­ ual, and transgender Christians. www.whosoever.org.

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Catholic

DignityUSA. (2017). Gay, lesbian, bisexual, and transgender Catholics. www.dignityusa.org. Jewish

Institute for Judaism and Sexual Orientation. (n.d.). Jewish LGBT organizations. www.huc.edu/ijso/SynOrg/Jewish LGBT/. World Congress: Keshet Ga’avah. (2017). www.glbtjews.org. Muslim

Queer Jihad. (2005). https://people.well.com/user/queerjhd/.

References Abu-Raiya, H., Pargament, K. I., Krause, N., & Ironson, G. (2015). Robust links between religious/spiritual struggles, psychological distress, and well-being in a national sample of American adults. American Journal of Orthopsychiatry, 85, 565–575. doi:10.1037/ort0000084. Allport, G. W. (1950). The individual and his religion. New York: Macmillan. American Counseling Association (ACA). (2014). ACA Code of Ethics. Alexandria, VA: Author. American Psychological Association (APA). (2012). Guidelines for psychological practices with lesbian, gay, and bisexual clients. American Psychologist, 67 (1), 10–42. Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC). (2009). Competencies for address­ ing spiritual and religious issues in counseling. Alexandria, VA: Author. Barret, B., & Logan, C. (2002). Counseling gay men and lesbians: A practice primer. Belmont, CA: Brooks/Cole Thomson Learning. Bayne, H. (2016). Helping gay and lesbian students integrate sexual and religious identities. Journal of College Coun­ seling, 19, 61–75. Bayne, H., & Neuer Colburn, A. A. (2012, November). Bridging the divide: Helping clients explore and integrate religious and non-heterosexual identities. Content session, Virginia Counseling Association annual conference, Fredericks­ burg, VA. Bayne, H. B., & Neuer Colburn, A. A. (2014, November). Eth­ ical supervision practices for counselors working with LGBT issues. Postconference session, Virginia Counsel­ ing Association annual conference, Williamsburg, VA. Bayne, H. B., Neuer Colburn, A. A., & Conley, A. H. (2016, October). Helping students address values conflicts through education and supervision. Content session, Southern Association for Counselor Education & Super­ vision biennial conference, New Orleans. Beagan, B. L., & Hattie, B. (2015). Religion, spirituality, and LGBTQ identity integration. Journal of LGBT Issues in Counseling, 9 (2), 92–117. doi:10.1080/155386605.2015.1 029204.

Frame, M. W. (2003). Integrating religion and spirituality into counseling: A comprehensive approach. Belmont, CA: Brooks/Cole. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H., Loos, B., . . . & Hammer, T. R. (2013). Association for Les­ bian, Gay, Bisexual, and Transgender Issues in Counseling competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individuals. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi:10.1080/15 538605.2013.755444. Hartwig Moorhead, H. J., & Neuer Colburn, A. A. (2016). Let’s get spiritual: Addressing spirituality ethically and compe­ tently in group supervision. In M. Luke & K. Goodrich (eds.), Group work experts share their favorite activities for supervision, vol. 2, 96–104. Alexandria, VA: Association for Specialists in Group Work. Ivtzan, I., Chan, C. P., Gardner, H. E., & Prashar, K. (2013). Linking religion and spirituality with psychological well­ being: Examining self-actualisation, meaning in life, and personal growth initiative. Journal of Religion and Health, 52 (3), 915–929. doi:10.1007/s10943-011-9540-2. Johnson, S. D. (2012). Gay affirmative psychotherapy with les­ bian, gay, and bisexual individuals: Implications for con­

temporary psychotherapy research. American Journal of Orthopsychiatry, 82 (4), 516–522. Kyle, J. (2013). Spirituality: Its role as a mediating protective factor in youth at risk for suicide. Journal of Spirituality in Mental Health, 15 (1), 47–67. doi:10.1080/19349637.2 012.744620. Love, P., Bock, M., Jannarone, A., & Richardson, P. (2005). Identity interaction: Exploring the spiritual experiences of lesbian and gay college students. Journal of College Student Development, 46, 193–209. Pew Forum on Religion and Public Life. (2015, November 3). U.S. becoming less religious. www.pewforum.org/2015/ 11/03/u-s-public-becoming-less-religious/. Snow, K., & Neuer Colburn, A. A. (2015, October). Spiritual competence beyond traditional definitions: A conversa­ tion on teaching inclusive spirituality. Content session, Association for Counselor Education & Supervision conference, Philadelphia. World Values Survey. (2011). www.worldvaluessurvey.org/. Wood, A. W., & Conley, A. H. (2014). Loss of religious or spiritual identities among the LGBT population. Coun­ seling and Values, 59, 95–111. doi:10.1002/j.2161-007X. 2014.00044.x.

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EX PLORIN G MY SP IRITUAL SEL F Part I Gordon Allport (1950) encouraged mature faith. Regardless of one’s belief system, this type of faith is characterized by the following attributes: • Differentiation—critically analyzing what has been taught about one’s religion; asking questions • Dynamic in character—rather than being driven by fear or impulse, embracing a stance directed more broadly outside oneself • Consistent in morality—motivated by internal, personal values • Comprehensive—accounting for matters central to all existence • Integral—all aspects of the human experience can be accounted for within the belief system • Heuristic—allowing for growth and change by tentatively holding beliefs until they can be confirmed, or until a more valid belief is introduced Overall, Allport urged people not to simply accept what is presented to them but, rather, to engage in an individual journey of self discovery. Allport’s stages of faith development include: • Raw credulity—blind acceptance of faith or doctrine from religious leaders or other authority figures • Satisfying rationalism—beginning to ask critical questions and challenge assumptions of faith; a decen­ tering process of analyzing, questioning, and exploring • Religious maturity—ability to place faith in context, tolerate ambiguity and uncertainty, and feel grounded in a personal faith Access the Religious Tolerance website (www.religioustolerance.org/introduction-to-what-the-bible­ says-and-means-about-homosexuality.htm) and view the excerpt from the 2007 documentary For the Bible Tells Me So. 1. Based on what you’ve been taught over the years, how do you think God sees you? What would God say about you? 2. As you consider this perception, what feelings come up for you? 3. What do you think about Allport’s model? How would you describe a “mature faith” for yourself? Part II Access one of these links, according to your religious tradition. Protestant: Whosoever magazine, www.whosoever.org Catholic: DignityUSA: www.dignityusa.org Jewish: Institute for Judaism and Sexual Orientation, www.huc.edu/ijso/SynOrg/JewishLGBT/, or World Congress of Gay, Lesbian, Bisexual, and Transgender Jews: www.glbtjews.org Muslim: Queer Jihad: www.well.com/user/queerjhd/ 1. What thoughts and feelings came up for you when reading through content on the site? 2. How, if at all, do these passages affect the way you think God sees you? 3. How, if at all, do these passages affect the way you see yourself? 4. Review your responses to these question. As you reflect on the exercise, how are you now feeling about your own faith journey? What would you like to do differently at this point in your development?

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Hannah B. Bayne and Anita A. Neuer Colburn

SECTION II

HOMEWORK, HANDOUTS,

AND ACTIVITIES FOR

MANAGING OPPRESSION AND

BUILDING RESILIENCE

How Does God See Me? A Reflective Exercise

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Oppression and marginalization of sexual and gender minority individuals are unfortunately very prevalent (Gattis & Larson, 2017), and these problems are com­ pounded for those who have multiple, intersecting marginalized identities (Sarno, Mohr, Jackson, & Fassinger, 2015). The destructive effects of such treat­ ment are well documented and include severe emo­ tional distress (Liao, Kashubeck-West, Weng, & Deitz, 2015). The contributors in this section highlight numerous ways to transform the internalization of injustices into resilience through a focus on self-care, advocacy, social support, and validation. Many of the chapters focus specifically on helping clients externalize the source of the oppression they are enduring. Jessica Chavez addresses the gap between structural failures in society and individual resilience in her chapter, “Survival in an Unjust World: A Tool for Coping with Multiple Forms of Oppression” (Chap­ ter 8). She provides a well-considered handout for clients to use in their efforts to hold the calm pres­ ence of the therapist between sessions as they work through the emotional effects of discrimination. In another approach, Jayleen Galarza notes in “Managing the Intersections: A Narrative Approach to Guiding Queer People of Color in Navigating Multiple Oppres­ sions” (Chapter 9) that LGBTQ people of color often experience within-group oppression in their various social identity groups. Given the complexity of work­ ing through the trauma of being marginalized within one’s own community, she advocates the use of cre­ ative storytelling to empower clients to re-author their narratives of their experiences. Kathleen M. Collins, Meredith R. Maroney, Tangela S. Roberts, Brianna M. Wadler, and Heidi M. Levitt also centralize the client’s narrative in their expressive writing exercise, “Healing from Heterosexism: An Empirically Based Exercise for Processing Heterosexist Experiences” (Chapter 17). In this exercise, the act of labeling events as hetero­ sexist and understanding the painful influence of heterosexism are the vehicles for empowerment. In “Exploring Multiple Marginalized Identities in LGBT Clients of Color” (Chapter 12), Vanessa Dabel also explores the ways in which clients are affected by the intersecting forms of oppression they experi­ ence. Using a relational approach in which she high­ lights therapists’ need to be aware of how their own 68

sociocultural experiences affect the therapeutic rela­ tionship, she provides a helpful set of questions for therapists to use as they embark on this journey of healing with their clients. In a similar vein, Zully A. Rivera Ramos, Amanda Lawson-Ross, and Carlos Hernández use liberation psychology to tease apart the influence on identity of both traditional cultural values in the Latinx community and those reflected in the LGBTQ community (Chapter 13, “Somos Latinx: Exploring Cultural Values of Sexual and GenderDiverse Latinx Clients”). Their exercise is designed to help clients integrate their various and sometimes con­ flicting cultural values, facilitating self-acceptance and thereby enhancing resilience. Other contributors stress the importance of incor­ porating supportive community in developing resil­ ience. Caroline Carter and Diane Sobel endeavor to increase social support with the group activity in “From Stress to Strength: A Group Intervention for Process­ ing Minority Stress Experiences with Transgender and Gender-Nonconforming Individuals” (Chapter 11). They strongly encourage in-group identification with the LGBT community as a source of empower­ ment, using minority stress theory as a means of pro­ viding psychoeducation for the group members. The power of community is also emphasized in Kristin N. Bertsch’s chapter, “Building Resilience with Clients Who Face Multiple Forms of Oppression” (Chapter 14). Her exercise, designed for use with individual clients, capitalizes on clients’ strengths and values for use in collective action, because the construction of a strong social network is key to decreasing the deep isolation of oppression. Because many organized religions have historically viewed nonheterosexual relationships as sinful (Bea­ gan & Hattie, 2015), the intersection of faith or spiri­ tuality and gender and sexual identities can be fraught with pain, isolation, and confusion for many LGBTQ clients. Chapter 20, “Value-Driven Exploration of Intersections between Sexual and Religious Identity,” by Angela Terepka and Jennifer Lancaster, helps cli­ ents work through some of this distress so that they can more fully access the wealth of positive benefits inherent in connecting both to their personal faith and perhaps to a larger faith community. Building on the tenets of Acceptance and Commitment Therapy

(ACT), their activity is designed to assist clients in clar­ ifying their own values and identifying negative mes­ sages that in some cases can come from within the LGBTQ community. Issues of emotional and physical safety are para­ mount, insofar as clients cannot thrive until their sense of security is enhanced. As Wendy Ashley, Allen Lipscomb, and Sarah Mountz point out in “A Toolkit for Collaborative Safety and Treatment Planning with Transgender Youth of Color” (Chapter 16), clients with these intersecting identities experience great stigma, oppression, and violence. They make a strong case for attending to safety issues as a top priority, and they have created the outstanding “Inclusive Safety Plan of Care” for use in therapy with clients who do not feel safe in this world. In “Building a Stronger Advocacy Role for Older LGBT+ Adults in Nursing Home Settings” (Chapter 15), Angela Schubert dis­ cusses the ways in which vulnerable older LGBT+ adults face ageism as well as other forms of discrimi­ nation that prevent them from receiving the level of care that they need in nursing homes. She uses rela­ tional cultural theory as a framework to understand both the context of the client’s social identities and the culture of the nursing home as she guides therapists to strengthen advocacy for older adults in these settings. Brianna M. Wadler, Meredith R. Maroney, and Sharon G. Horne guide readers through the complex cultural and clinical considerations for working with political refugees in Chapter 19, “Clinical Work with LGBTQ Asylum Seekers.” Their activity aids therapists in determining any areas of their competency that need further development and clients in setting goals for the work ahead. Given that these clients have often experi­ enced persecution related to their social identities or political beliefs (or both), understanding their unique experiences of trauma and learning how to effectively build trust are essential to helping this population. Using another powerful and evidence-based form of self-care, Eve M. Adams, Tracie L. Hitter, and Virginia Longoria outline the importance of a selfcompassionate stance in “A Lovingkindness Meditation to Heal from Heterosexism, Transphobia, and Other Forms of Oppression” (Chapter 10). They explain that perceived discrimination is associated with increased psychic distress when individuals feel personally

rejected. Using a beautiful guided meditation tailored to the LGBT community, their activity promotes a greater sense of internal safety and ease. This activity is grounded in the research on mindfulness, which has shown that a shift in perspective to a more selfcompassionate stance is yet another meaningful way to externalize painful experiences and gain some distance (Shapiro & Carlson, 2009). Finally, Eva Mendes and Meredith R. Maroney’s “At the Intersection of the Autism Spectrum and Sex­ ual and Gender Diversity: Case Studies for Use with Clinicians and Clients” addresses another intersec­ tion of identities that are often marginalized. In this chapter (Chapter 18), the authors provide therapists with vital information regarding the issues faced by sexual and gender minorities who are on the autism spectrum in order to enhance their competency and generate therapeutic dialogues with clients. They sug­ gest that therapists should invite clients to explore the intersections of their sexual and gender identities with their autistic identities. References Beagan, B. L., & Hattie, B. (2015). Religion, spirituality, and LGBTQ identity integration. Journal of LGBT Issues in Counseling, 9 (2), 92–117. doi:10.1080/155386605.2015.1 029204. Gattis, M. N., & Larson, A. (2017). Perceived microaggressions and mental health in a sample of black youths experiencing homelessness. Social Work Research, 41, 7–17. doi:10. 1093/swr/svw030. Liao, K. Y., Kashubeck-West, S., Weng, C., & Deitz, C. (2015). Testing a mediation framework for the link between per­ ceived discrimination and psychological distress among sexual minority individuals. Journal of Counseling Psychol­ ogy, 62 (2), 226–241. doi:10.1037/cou0000064. Sarno, E. L., Mohr, J. J., Jackson, S. D., & Fassinger, R. E. (2015). When identities collide: Conflicts in allegiances among LGB people of color. Cultural Diversity and Ethnic Minority Psychology, 21 (4), 550–559. doi:10.1037/cdp0000026. Shapiro, S. L., & Carlson, L. (2009). The art and science of mind­ fulness: Integrating mindfulness into psychology and the helping professions. Washington, DC: American Psycho­ logical Association.

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8 SURVIVAL IN AN UNJUST WORLD: A TOOL FOR COPING WITH MULTIPLE FORMS OF OPPRESSION Jessica Chavez Suggested Use: Handout Objective

This handout provides a tool to help clients regulate the emotional effects of discrimination and reminders of structural violence. It was created in response to the needs of gender-diverse people of color, but it can be modified for use with any client who experiences one or more forms of systematic oppression. Rationale for Use

This chapter introduces a clinical tool that was devel­ oped using intersectionality and structural compe­ tency frameworks and designed to help people cope with the negative effects of multiple oppressions. The American Psychological Association’s (APA) “Guide­ lines for Psychological Practice with Transgender and Gender Nonconforming People” recommends that clinicians take an “interdisciplinary approach” (APA, 2015, p. 850) by collaborating with medical and social service providers (e.g., surgeons and caseworkers), and this chapter expands this definition of interdisci­ plinary practice by presenting a novel intervention that is informed by interdisciplinary social science research as well as clinical science. There is extensive evidence documenting the influ­ ence of racism on economic, health-care, legal, and educational systems in the United States (Alexander, 2012; Washington, 2006). Research on racialized health and health-care disparities indicates that people of color tend to receive inadequate care and are dis­ proportionately burdened by poorer health and pre­ mature death (Gravlee, 2009; Roberts, 2013; Williams

& Mohammed, 2013). Research has also documented the specific ill effects of racism on mental health (Paradies et al., 2015). For gender-nonconforming and trans people, transphobia and cisgenderism also lead to physical health problems, exposure to violence, and negative mental health outcomes (Bockting et al., 2013; Grant et al., 2011). Activists and scholars, particularly black feminists, have long offered the insight that any sufficient anal­ ysis of oppression must account for multiple intersect­ ing identities (e.g., Collins, 2000; Crenshaw, 1989; Truth, 1851). As intersectionality theory predicts, gen­ der-diverse people of color face uniquely detrimental intersections of oppression, as well as unique oppor­ tunities for resilience (Singh & McKleroy, 2011). The field of public health, however, has been slow to adopt intersectional frameworks to study the social deter­ minants of health (Bowleg, 2012). Research on the health effects of transphobia and cisgenderism still forms a limited, albeit growing, body of work (APA, 2015), and the field has yet to thoroughly document the specific combined influence of transphobia, cis­ genderism, and racism. Unfortunately, when trans and gender-nonconforming people of color seek mental health treatment, they too often enter systems that are simultaneously shaped by transphobia, cisgenderism, and racism, and emerging research indicates that trans and gender-nonconforming people of color can be particularly vulnerable in health-care settings (Ansara & Hegarty, 2012; Grant et al., 2011). Mental health providers can help clients address the psychological, physiological, and social effects of structural injustices. To help clinicians conceptualize

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the relationship between individual-level interven­ tions and structural racism, the psychiatrist and social scientist Jonathan Metzl (2009) introduced the notion of structural competency. Structural competency addresses the shortcomings of cultural competency models, which tend to assume that, if health-care practitioners acquire enough knowledge about the cul­ ture of the Other, then they can adequately treat patients from diverse backgrounds (Metzl, 2009; Metzl & Hansen, 2014). Metzl’s concept of structural com­ petency, expanded by Metzl and Hansen (2014), asserts that good clinical practice requires that clinicians understand how social structures perpetuate social inequalities and shape one-on-one interactions in health-care settings. Metzl and Hansen (2014) also argue that clinicians ought to be trained in imagining and implementing structural interventions that change the social practices that create harm. Therapists are uniquely positioned to help trans and gender-nonconforming clients of color regulate their emotional responses, thereby mitigating stress, which is one of the factors that links structural-level racism to individual health outcomes (Dressler, Oths, & Gravlee, 2005; Williams & Mohammed, 2013). It is important for clinicians to be cautious, however, about promoting individual adaptation or resilience without acknowledging that widespread social change is necessary. For example, scholars have documented how some stereotypical representations of black women emphasize their resilience (e.g., Collins, 2000). While being perceived as resilient or experiencing resilience does not necessarily lead to oppression, these stereotypes have been used to justify policies that harm black women and create conditions that sideline the needs of black cisgender women who are sexually assaulted (Donovan & Williams, 2002). Thus, focus­ ing on the individual and on adaptation while ignor­ ing a structural analysis can perpetuate oppression. Evidence suggests that engagement with activist communities and social movements supports mental health for trans and gender-nonconforming people (Pflum et al., 2015; Singh & McKleroy, 2011), and the work we do in therapy can support clients in their fights for justice by helping them cope with the emo­ tional toll of structural violence. Additionally, the APA’s “Guidelines for Psychological Practice with Trans-

gender and Gender Nonconforming People” (2015) and the American Counseling Association’s (ACA) Competencies for Counseling with Transgender Clients (ALGBTIC, 2009) both suggest that clinicians have an ethical obligation to act not just as clinicians, but also as advocates for trans and gender-nonbinary people. For many clinicians, particularly those who identify as trans or gender-nonbinary people of color, this kind of advocacy may already be an important part of their lives. Nevertheless, clinicians using this handout, particularly those who experience multi­ ple forms of privilege in relation to their clients, would benefit from asking themselves the following questions before using this handout: Is my work lim­ ited to helping this person adapt to an unjust world? What am I doing to make my community a place where this person can experience justice, support, and well­ being? Indeed, individual-level interventions made in our offices alone are not likely to dismantle larger structures of racism, transphobia, and cisgenderism, so it is also our responsibility to do what we can to help change social contexts that perpetuate systematic oppression. This handout was created to help bridge this gap between clients’ individual-level emotional regulation and structural-level factors that perpetu­ ate oppression. Instructions

This handout should be used in the context of a strong therapeutic alliance that supports collaboration and open communication. It is most useful as an addi­ tion to treatment with clients who routinely become overwhelmed with intense emotion when faced with experiences or reminders of oppression, including those who tend to act on these emotions with impul­ sive self-harm or by lashing out at others. The therapist should explain that this handout is a tool to help reg­ ulate emotions and remember strategies for self-care, as well as a resource to help remind clients of the broader struggle for social change. It is recommended that the therapist introduce the handout and have clients complete each section collaboratively in ses­ sion. This will allow clients to discuss any reactions or thoughts they have in response to the handout and allow the therapist to offer support, encouragement, and even humor (when appropriate). The therapist and

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the client may also work together to make any neces­ sary adaptations to the handout on the basis of the client’s specific experience or identity. Allow ample time to debrief with the client before the end of the session. Brief Vignette

K. is a twenty-seven-year-old graduate student. They identify as queer, gender nonbinary (and use they, them, and their as pronouns), and Asian American. They were assigned female at birth. K. identified as a lesbian for much of their adult life and began to iden­ tify as queer and nonbinary while in graduate school. K. was born and grew up on the West Coast but moved to the Northeast to attend a small liberal arts college. Following their first year of graduate school, K. sought therapy for the first time to address difficulty con­ centrating, disappointment with their caregivers, and pervasive feelings of anger and distrust. At home, K. was often in spaces where Asian peo­ ple made up the majority, but in the Northeast, K. struggled to adjust to living among so many white people. In therapy K. talked about missing the West Coast because they felt that Asian American history “meant something” there. They felt that, on the West Coast, Asian people held positions of power, and Asian culture had a visible influence on the mainstream. In the Northeast, K. often felt tokenized or found them­ selves among white people who seemed to be made nervous by K.’s willingness to openly address racism. K. often felt angry after interactions with white cisgen­ der men. They felt that white cis men treated them in a condescending manner and belittled them, especially in professional settings. These encounters brought back early memories of K.’s first encounters with rac­ ist, objectifying portrayals of Asian women, depicted as sexualized, submissive, and weak in television shows and movies. Their anger at these moments felt unbear­ able, and K. would notice their heart rate rise, feel sweaty, and have difficulty focusing on anything but the rage. K. often worried that their anger would lead them to lose control and “cause a scene” that would lead them to lose their part-time job, become embar­ rassed, or damage relationships. In therapy sessions, K. would frequently tell stories about these encounters, and they would become overwhelmed with angry thoughts about the combined effects of cisgenderism 72

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and racism in their life. At these times, K.’s therapist would help them slow down and reflect on the anger that had become overwhelming, thereby offering scaf­ folding to help K. regulate their emotions. To help K. regulate these intense feelings on their own between sessions, however, the therapist presented the idea of using this handout in their tenth session. K. and their therapist had built a strong working alliance, and they used humor to explore K.’s initially skeptical reaction to the idea of a handout, which K. associated with their desire to be seen as strong and invulnerable. K. and their therapist laughed together while exploring how using a worksheet made K. feel that their therapist was playing the “teacher” role and reminded K. of being a powerless grade-school stu­ dent. This provided an opportunity for K. and their therapist to explore the emotions connected to these memories, and K. decided that accepting the role of “student” and using the handout would help them achieve greater independence and agency over power­ ful negative emotions. K. completed the handout in session in collaboration with their therapist and took a picture of it with their phone so that they could easily access it in moments of distress. The handout provided an opportunity for K. and their therapist to closely examine K.’s most difficult emotions and accept them in the context of a supportive therapeutic rela­ tionship. Accepting these emotions and learning to manage them outside of session allowed K. to become more aware and accepting of their anger—not just as a potentially destructive part of their experience as a person of color facing multiple oppressions, but also as a productive, creative emotion that bound K. to other queer people of color in their work as an activist and scholar. Suggestions for Follow-up

After presenting this handout in session, therapists should check in with clients to determine whether they used it to manage difficult feelings between sessions. The handout can be useful, not just for emotional regulation between sessions, but also as a starting point for in-session therapeutic metacommunication, or here-and-now explorations that help the client and therapist develop a mutual understanding of the ther­ apeutic relationship (Safran & Muran, 2000). As thera­

pists elicit feedback from clients about the handout’s utility, they may also encourage clients to modify its contents when necessary. For example, while attempt­ ing to complete the section of the handout that asks clients to identify people they can call or text who understand their perspective on oppression, a client may tell their therapist that they do not feel they are able to reach out for help at the times they feel most vulnerable. The client may be too ashamed to share difficult feelings with others or find that reaching out when they are feeling angry inevitably leads to dis­ appointing interactions with people close to them. In this example, the therapist using the handout might work collaboratively with the client to alter this section and, instead of listing people to call or text for sup­ port, the client may make a list of the people who care about their well-being and validate their pain. Rather than calling or texting for help, the client might, for example, decide to spend time recalling one or more memories of times when they felt supported and loved by others. In therapy sessions, the therapist and client can work on understanding the feelings and patterns of relating that make it difficult to find social support and reach out for help, but in the meantime, altering the handout offers a way for clients to be a coauthor of their individualized treatment plan. Contraindications for Use

This handout is intended for use with clients who believe that racism, cisgenderism, and transphobia are factors contributing to their presenting problems. For clients who are not consciously aware of the structurallevel factors affecting their experience, this handout will probably not be a useful clinical tool. For suicidal clients, clients who engage in self-harm, and clients with thoughts of harming others, this protocol is not intended to be a substitute for safety planning. Professional Readings and Resources Cole, E. R. (2009). Intersectionality and research in psychology. American Psychologist, 64 (3), 170. Gravlee, C. C. (2009). How race becomes biology: Embodiment of social inequality. American Journal of Physical Anthro­ pology, 139 (1), 47–57. Metzl, J. M. (2009). The protest psychosis: How schizophrenia became a black disease. Boston: Beacon Press.

Metzl, J. M., & Hansen, H. (2014). Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science and Medicine, 103, 126–133. Roberts, D. (2013). Fatal invention: How science, politics, and big business re-create race in the twenty-first century. New York: New Press. Washington, H. A. (2006). Medical apartheid: The dark history of medical experimentation on black Americans from colo­ nial times to the present. New York: Doubleday.

Resources for Clients Bornstein, K. (2006). Hello, cruel world: 101 alternatives to suicide for teens, freaks, and other outlaws. New York: Seven Stories Press. Downs, K. (2016, July 22). When black death goes viral, it can trigger PTSD-like trauma. PBS News Hour: The Rundown. https://www.pbs.org/newshour/rundown/ black-pain-gone-viral-racism-graphic-videos-can-cre ate-ptsd-like-trauma/. Icarus Project. http://theicarusproject.net/. Lorde, A. (1988). A burst of light: Essays. Ithaca, NY: Fire­ brand Books. Romero, F. (2013). Self care list: How to take care of your self while learning about oppression (with unaware people). https://fabianswriting.tumblr.com/post/69798253522/ self-care-list-how-to-take-care-of-your-self. Walker, I. (2016, July 8). Tips for self-care: When police bru­ tality has you questioning humanity and social media is enough. Root. www.theroot.com/articles/cuture/2016/07/ tips-for-self-care-when-police-brutality-has-you­ questioning-humanity-and-social-media-is-enough/.

References Alexander, M. (2012). The new Jim Crow: Mass incarceration in the age of colorblindness. New York: New Press. American Psychological Association (APA). (2015). APA guide­ lines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70, 832–864. Ansara, Y. G., & Hegarty, P. (2012). Cisgenderism in psychol­ ogy: Pathologising and misgendering children from 1999 to 2008. Psychology and Sexuality, 3 (2), 137–160. doi:10. 1080/19419899.2011.576696. Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC). (2009). Competencies for coun­ seling with transgender clients. Alexandria, VA: Author. https://www.counseling.org/Resources/Competencies/ ALGBTIC_Competencies.pdf. Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Ham­ ilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender popu­ lation. American Journal of Public Health, 103 (5), 943– 951. doi:10.2105/AJPH.2013.301241.

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Bowleg, L. (2012). The problem with the phrase women and minorities: Intersectionality—an important theoretical framework for public health. American Journal of Public Health, 102 (7), 1267–1273. Collins, P. H. (2000). Black feminist thought: Knowledge, con­ sciousness, and the politics of empowerment. New York: Routledge. Crenshaw, K. (1989). Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago Legal Forum, 1, 139–168. Donovan, R., & Williams, M. (2002). Living at the intersection: The effects of racism and sexism on black rape survivors. Women and Therapy, 25 (3–4), 95–105. Dressler, W. W., Oths, K. S., & Gravlee, C. C. (2005). Race and ethnicity in public health research: Models to explain health disparities. Annual Review of Anthropology, 34, 231–252. Grant, J. M., Mottet, L. A., Tanis, J., Herman, J. L., Harrison, J., & Keisling, M. (2011). National transgender discrimina­ tion survey report on health and health care. Washington, DC: National Center for Transgender Equality and the National Gay and Lesbian Task Force. Gravlee, C. C. (2009). How race becomes biology: Embodi­ ment of social inequality. American Journal of Physical Anthropology, 139 (1), 47–57. doi:10.1002/ajpa.20983. Metzl, J. M. (2009). The protest psychosis: How schizophrenia became a black disease. Boston: Beacon Press. Metzl, J. M., & Hansen, H. (2014). Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science and Medicine, 103, 126–133.

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Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., Gupta, A., Kelaher, M., & Gee, G. (2015). Racism as a determinant of health: A systematic review and meta-anal­ ysis. PLoS One, 10 (9), 1–48. doi:doi.org/10.1371/journal. pone.0138511. Pflum, S. R., Testa, R. J., Balsam, K. F., Goldblum, P. B., & Bongar, B. (2015). Social support, trans community con­ nectedness, and mental health symptoms among transgender and gender nonconforming adults. Psychology of Sexual Orientation and Gender Diversity, 2 (3), 281–286. doi:10.1037/sgd0000122. Roberts, D. (2013). Fatal invention: How science, politics, and big business re-create race in the twenty-first century. New York: New Press. Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. New York: Guilford Press. Singh, A. A., & McKleroy, V. S. (2011). “Just getting out of bed is a revolutionary act”: The resilience of transgender peo­ ple of color who have survived traumatic life events. Traumatology, 17 (2), 34–44. https://doi.org/10.1177/ 1534765610369261. Truth, S. (1851). Ain’t I a woman? https://sourcebooks.ford ham.edu/mod/sojtruth-woman.asp. Washington, H. A. (2006). Medical apartheid: The dark history of medical experimentation on black Americans from colonial times to the present. New York: Doubleday. Williams, D. R., & Mohammed, S. A. (2013). Racism and health I: Pathways and scientific evidence. American Behavioral Scientist, 57 (8), 1152–1173.

H A NDO UT

We can survive in an unjust world, and we can cope without giving in. Oppression harms our health and well-being. Ending oppression is a long and difficult struggle. This worksheet is designed to help people cope with injustice without losing sight of the fact that the problem does not actually lie with us, but with a system that causes us harm. Triggers (e.g., situations, people, etc.) that lead me to feel distressed (i.e., situations that might lead me to use this handout):

Changes I notice when I am feeling overwhelmed by experiences and reminders of oppression (e.g., feelings, sensations, emotions, thoughts):

Things I can do to help me change the way I feel (e.g., what helps calm me when I’m anxious? What helps lift me up when I’m down?):

People I can call or text who understand my perspective on oppression:

People in my life who are unable to understand my perspective (i.e., people to avoid):

Quotes, book passages, or poems that remind me of values that are important to me:

People who fight injustice and inspire me to cope and to continue speaking my truth:

Reminders of why it is important to take time to care for myself:

Triggers or reminders of oppression that I should avoid right now so that I can care for myself:

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9 MANAGING THE INTERSECTIONS: A NARRATIVE APPROACH TO GUIDING QUEER PEOPLE OF COLOR IN NAVIGATING MULTIPLE OPPRESSIONS Jayleen Galarza Suggested Use: Activity Objective

By engaging in this activity, clients will be able to explore and process the influence of multiple oppres­ sions on their lived experience as well as to identify ways to actively resist internalizing oppression. This activity is appropriate for working with individual clients who relay experiences related to various layers of discrimination, such as those rooted in heterosex­ ism, racism, and sexism. This activity could also be adapted to work in a group setting with clients encoun­ tering similar experiences. Rationale for Use

In facing oppression, especially multiple oppressions, it can be a daunting and challenging task for a client to feel fully empowered, regain strength, and resist societal narratives that have been and continue to be imposed. Research has demonstrated that queer people of color often contend with multiple oppressions, including enduring racism within predominantly white LGBTQ spaces (Balsam et al., 2011; Bridges, Selvidge, & Matthews, 2003; Sarno, Mohr, Jackson, & Fassinger, 2015). At times, these oppressions include encounters with silence, invisibility, aggression, and violence in the various spaces they navigate (Balsam et al., 2011; Bridges et al., 2003; Singh & McKleroy, 2011). For some individuals, the silencing of either their racial/ ethnic identity within predominantly white LGBTQ spaces or their sexual/gender identities among fam­

ily, neighborhood, or other important communities may produce unique challenges to fully expressing their authentic selves (Balsam et al., 2011; Bridges et al., 2003; Sarno et al., 2015). For transgender people of color in particular, the additional layer of transphobia often leads to higher rates of trauma because of increased experiences of violence and abuse (Singh & McKleroy, 2011). This activity is designed to help guide clients who identify as queer people of color through the process of navigating multiple oppressions. The desired outcome of engaging in this collaborative process is to help clients reclaim their resiliency and resist the narratives that have dominated their stories throughout development, as well as to create more preferred narratives that honor their intersectional experiences (Galarza, 2013). Affirmative practice with queer-identified clients requires that therapists be mindful of their attitudes toward their clients and gain knowledge, awareness, and training about relevant cultural influences (Alessi, Dillon, & Kim, 2015; APA, 2012). Therefore, thera­ pists cannot neglect the significance and effects of clients’ experiences of multiple intersecting identities within the therapeutic relationship (Bridges et al., 2003; Ritter & Terndrup, 2002). To ensure affirmative prac­ tice with clients who may identify as queer people of color, therapists must increase their understanding of the intersecting oppressions, such as the dynamics of experiencing racism and heterosexism within daily life, that may pertain to the client. It is important to understand the effects of oppression on their world-

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view, wellness, and development (Bridges et al., 2003; Ritter & Terndrup, 2002). In addition, they must adopt practices and interventions that intentionally make space for relevant discussions about power, oppression, and discrimination at multiple levels (Galarza, 2013). The use of narrative techniques in clinical prac­ tice may offer the therapist an opportunity to affirm clients’ experiences and bear witness as they make further meaning of navigating the world as queer peo­ ple of color (Galarza, 2013). One of the key compo­ nents of narrative practice is awareness of the fluidity and social construction of realities (Madigan, 2011; Saltzburg, 2007), and an essential task of this approach is to collaborate with clients in re-authoring prob­ lem-saturated stories (Besley, 2002; Saltzburg, 2007). Within this process, clients are invited to reflect on and process the social, political, and cultural influ­ ences, as well as their own influence, on the life of the story (Madigan, 2011; Saltzburg, 2007). By using an activity rooted in narrative therapy techniques, ther­ apists thus bring the issues of power and marginaliza­ tion into focus (Galarza, 2013; Madigan, 2011). An important concept in narrative therapy is externalization. This process of externalization seeks to distinguish the identified problem as the problem, separate from the individual, which builds a founda­ tion for an alternative story line (Madigan, 2011). By externalizing and personifying the problem, such as identifying racism as a separate entity rather than inter­ nalizing it within the person, the therapist attempts to relieve the individual of internalized shame and oppression (Galarza, 2013; Madigan, 2011). As Saltz­ burg (2007) found in her practice, such externaliza­ tion and re-authoring offered individuals the ability to process the reactions of their families to their sex­ ual orientation and/or gender identities and expres­ sions as a product of heterosexist norms and values; therefore, they were able to situate themselves out­ side this problematic narrative to better understand that this was not a reflection of who they are as a per­ son. Saltzburg (2007) stated, “By engaging in this pro­ cess of self-reflection, we are able to join with clients in more authentic, collaborative ways” (p. 58). The incorporation of a writing activity comple­ ments this therapeutic process and integrates creativity and storytelling that are often culturally rooted (An­

zaldúa, 2012; Comas-Díaz, 2006; Galarza, 2013; Rodri­ guez, 2010). In addition, the use of expressive tech­ niques as an intervention assists in honoring the intersections of identity and navigating the multiple oppressions that are often encountered (Galarza, 2013). Writing, storytelling, and the collective expe­ rience are central to the experiences and cultures of many communities of color, including queer-identified people of color (Anzaldúa, 2012; Moraga & Anzaldúa, 2015). As this activity demonstrates, clients are encouraged to reclaim the rights to their story and col­ laborate in a process of re-authoring with the thera­ pist; in effect, clients are engaged in the process of dismantling the societal narratives of marginalization, including the intersections of racism, sexism, and heterosexism, that have been ingrained throughout their development. This dismantling is particularly important for queer-identified people of color, who often must contend with and navigate several forms of stigma and discrimination throughout their lives, including experiences of racism within LGBTQ com­ munities themselves (Balsam et al., 2011; Bridges et al., 2003; Sarno et al., 2015). For many queer people of color, such life events are significant to their under­ standing of identity (Bridges et al., 2003; Galarza, 2013) and therefore require particular attention within the therapeutic process (Bridges et al., 2003; Galarza, 2013; Ritter & Terndrup, 2002). These practices uphold the principles and ethics that guide the work of clinical social workers. Accord­ ing to the National Association of Social Workers’ “Code of Ethics” (2017), the mission of social work­ ers is to address the needs of vulnerable and diverse populations with particular attention to understand­ ing and intervening on issues of social injustice. By engaging in a collaborative, narrative approach with clients, clinical social workers will consistently meet the ethical foundations of the profession by helping individuals subvert the negative social, cultural, and political influences that have dominated their lives. Instructions

This activity can be used over the course of multiple sessions. The goal is to engage clients in reflecting on the ways each of their identities intersects and affects their lives. Managing the Intersections

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In preparation for this activity, the clinician should provide the client with a writing utensil and piece of paper. Begin this activity by asking the client to label each identity they find integral to their lived experi­ ence and to write each one on the piece of paper pro­ vided—for example, black, queer, woman, college educated, middle class. If the client has difficulty with this task, it may be useful to list some examples and brainstorm with them. As they continue to share, encourage them to continue writing down their various identities on the sheet of paper. Then ask the client: “If you could give a title to your life story so far (like a title given to the book of your life), one that integrates all these identities, what would it be?” Ask the client to write down the title on the same sheet of paper. If the client is struggling to identify a title that integrates all these identities, help the client construct a title that reflects each separate identity. Process the title that the client developed and use processing questions to further explore the mean­ ing. Also begin to map the life of the problem and the various influences. See the handout of related pro­ cessing questions (page 81). As you work with the client to explore these var­ ious questions, ask them to map out their responses on the same sheet of paper containing the title. The following are suggested subheadings: a. Characters: Who are the main characters? b. Plot: What’s important to influencing the life of the story? What path has it taken so far? Where do you see the plot headed? c. Chapters: How many have you accumulated? How would you title them? As you collaborate with the client on this activity, encourage them to observe and reflect on what they’ve written. Then ask: How do you feel about your story so far? What do you hope to be different as each chap­ ter progresses? In asking these questions, the thera­ pist opens the door for exploration within future sessions. For example, the therapist can follow a par­ ticular plot offered by the client to highlight oppres­ sion as a key character in the story. The client may not have initially thought to identify oppression, such as racism, sexism, heterosexism, or transphobia, as a character in the story; however, the therapist can sug­ 78

Galarza

gest this possibility by further exploring its influence on the life of the problem. In doing so, the therapist could ask, “How did racism present an additional bar­ rier to reaching your goal?” or “How did heterosexism convince you of your limited self-worth?” While engaging in this process with the client, it is important for the therapist to consistently tune in to the client’s language and accurately reflect what is heard. The purpose is to validate the client’s experi­ ences while deconstructing the dominant story pre­ sented within session without the therapist’s impos­ ing their own desires, belief systems, or influences on the client’s story. Therefore, the therapist must always use the language reflected by the client and periodically check to be sure the client feels heard and affirmed. Brief Vignette

Nina is a thirty-three-year-old Puerto Rican, lesbian, gender-nonconforming woman who originally sought individual counseling after a recent job loss and break­ up with her female partner of eight years. During the initial assessment, Nina reported difficulties sharing her experience with others, especially family, because they were not accepting of her relationship during this time and pressured Nina to date men. In addition, Nina reported that she has routinely experienced harassment from others because of her masculine appearance. She even shared an experience at her most recent job, the one she lost, in which her employer suggested that she try to dress “more feminine,” like the other Latinas employed at the agency. Nina reported, “I guess this just comes with the territory,” referring to her identity as a butch lesbian woman. To affirm the client’s story relating multiple chal­ lenges associated with her experience as a gendernonconforming, Puerto Rican lesbian, the therapist gauged the client’s interest in participating in a narra­ tive activity. The client agreed, stating, “I think it’d be cool to think of this as a story.” For the next few ses­ sions, the therapist helped Nina map the life of the problem, which was significantly tied to her experi­ ences of multiple oppressions. The various reflective, processing questions opened up opportunities for Nina to think about the larger societal, oppressive structures at play, which allowed for the externalization of the problem. The therapist was able to collaborate

with Nina to identify a larger story line, external to her personal experience, that might have influenced her understanding of self in different contexts. The therapist was able to achieve this result by asking Nina to think about how racism, sexism, and heterosexism could have possibly played a role in these situations. Through the processing of this activity, Nina was able to re-author her story and better understand these experiences as external to herself and not a product of her various identities. For example, she was able to let go of internalized shame associated with her gender expression, as she had blamed herself for los­ ing her job, and she understood that there was noth­ ing wrong with her masculinity. The story was found in her employer’s prejudice toward masculine-present­ ing Latina women, which was reflective of a larger societal discourse. Suggestions for Follow-up

Clients can find it difficult to re-author and change relationships with a dominant narrative; therefore, it is important to revisit the client’s role in the story throughout sessions. In doing so, the therapist may want to ask the client, “How do you see your role in this story evolving?” and “How has racism or sexism or heterosexism continued to influence this story?” In doing so, the therapist is better able to track the pro­ gression of the narrative and better understand how the client’s experiences with multiple oppressions are shifting. Furthermore, in using a narrative approach, it’s important to culminate therapy with the presen­ tation of the new or preferred story that has been revealed over the course of treatment (Madigan, 2011). In collecting new chapters, the therapist can ask clients to share their new story, and the therapist can adopt the role of bearing witness to this sharing. Contraindications for Use

Before implementing this activity, assess the client’s comfort with and ability to write. If an alternative format is needed, make necessary adjustments and offer additional assistance, such as the use of a com­ puter or dictation. The client may choose to speak while the therapist writes out the client’s responses. This activity is designed for queer-identified people of color who are struggling with the ways intersectional

oppression influences their life and who want to regain strength and power by developing a more preferred story. If clients do not struggle with these concerns, then this activity can be used to further validate their resiliency. Professional Readings and Resources American Psychological Association (APA). (2017). Practice guidelines for LGB clients. https://www.apa.org/pi/lgbt/ resources/guidelines.aspx. Anzaldúa, G. (2012). Borderlands/La frontera: The new mestiza. San Francisco: Aunt Lute Books. Balsam, K. F., Molina, Y., Beadnell, B., Simoni, J., & Walters, K. (2011). Measuring multiple minority stress: The LGBT People of Color Microaggressions Scale. Culturally Diverse Ethnic Minority Psychology, 17 (2), 163–174. doi:10. 1037/a0023244. Besley, A. C. (2002). Foucault and the turn to narrative therapy. British Journal of Guidance and Counselling, 30 (2), 125– 143. doi:10.1080/03069880220128010. Campus Pride. (2013, July 29). Being an ally to queer people of color. https://www.campuspride.org/resources/being­ an-ally-to-queer-people-of-color/. Dulwich Centre. (n.d.). A gateway to narrative therapy and community work. http://dulwichcentre.com.au/. Galarza, J. (2013). Borderland queer: Narrative approaches in clinical work with Latina women who have sex with women (WSW). Journal of LGBT Issues in Counseling, 7 (3), 274–291. doi:10.1080/15538605.2013.812931. Gremillion, H. (2004). Unpacking essentialisms in therapy: Lessons for feminist approaches from narrative work. Journal of Constructivist Psychology, 17, 173–200. doi:10. 1080/10720530490447112. Madigan, S. (2011). Narrative therapy. Washington, DC: American Psychological Association. Moraga, C., & Anzaldúa, G. (eds.). (2015). This bridge called my back: Writings by radical women of color, 4th edition. Albany: State University of New York Press. Saltzburg, S. (2007). Narrative therapy pathways for re-author­ ing with parents of adolescents coming-out as lesbian, gay, and bisexual. Contemporary Family Therapy, 29, 57–69. doi:10.1007/s10591-007-9035-1. White, M., & Epston, D. (1990). Narrative means to therapeutic ends. Adelaide, Australia: Dulwich Centre.

Resources for Clients Audre Lorde Project. (n.d.). About ALP. http://alp.org/about. Crossroads Initiative at the University of Wisconsin–Madison. (n.d.). Queer people of color (QPOC) resource guide. https://www.uwec.edu/files/3195/QPOC-Crossroads­ Resource-Guide.pdf. National Queer Asian Pacific Islander Alliance. (n.d.) About. http://www.nqapia.org/wpp/home/. Managing the Intersections

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Sylvia Rivera Law Project. (2017). Resources. http://srlp.org/ resources/. Zuna Institute. (2014). National advocacy organization for black lesbians. www.zunainstitute.org/.

References Alessi, E. J., Dillon, F. R., & Kim, H. M. (2015). Determinants of lesbian and gay affirmative practice among heterosexual therapists. Psychotherapy, 52 (3), 298–307. doi:10.1037/ a0038580. American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67 (1), 10–42. doi:10.1037/a0024659. Anzaldúa, G. (2012). Borderlands/La frontera: The new mestiza. San Francisco: Aunt Lute Books. Balsam, K. F., Molina, Y., Beadnell, B., Simoni, J., & Walters, K. (2011). Measuring multiple minority stress: The LGBT People of Color Microaggressions Scale. Culturally Diverse Ethnic Minority Psychology, 17 (2), 163–174. doi:10.1037/a0023244. Besley, A. C. (2002). Foucault and the turn to narrative therapy. British Journal of Guidance and Counselling, 30 (2), 125– 143. doi:10.1080/03069880220128010. Bridges, S. K., Selvidge, M. M. D., & Matthews, C. R. (2003). Lesbian women of color: Therapeutic issues and chal­ lenges. Journal of Multicultural Counseling and Develop­ ment, 31, 113–130. Comas-Díaz, L. (2006). Latino healing: The integration of ethnic psychology into psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 43 (4), 436–453. doi:10.1037/0033-3204.43.4.436.

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Galarza

Galarza, J. (2013). Borderland queer: Narrative approaches in clinical work with Latina women who have sex with women (WSW). Journal of LGBT Issues in Counseling, 7 (3), 274–291. doi:10.1080/15538605.2013.812931. Madigan, S. (2011). Narrative therapy. Washington, DC: American Psychological Association. Moraga, C., & Anzaldúa, G. (eds.). (2015). This bridge called my back: Writings by radical women of color, 4th edition. Albany: State University of New York Press. National Association of Social Workers. (2017). Code of ethics of the National Association of Social Workers. https:// www.socialworkers.org/about/ethics/code-of-ethics. Ritter, K. Y., & Terndrup, A. I. (2002). Handbook of affirmative psychotherapy with lesbians and gay men. New York: Guilford Press. Rodriguez, D. (2010). Storytelling in the field: Race, method, and the empowerment of Latina college students. Cul­ tural Studies, Critical Methodologies, 10 (6), 491–507. doi:10.1177/1532708610365481. Saltzburg, S. (2007). Narrative therapy pathways for re-author­ ing with parents of adolescents coming-out as lesbian, gay, and bisexual. Contemporary Family Therapy, 29, 57–69. doi:10.1007/s10591-007-9035-1. Sarno, E. L., Mohr, J. J., Jackson, S. D., & Fassinger, R. E. (2015). When identities collide: Conflicts in allegiances among LGB people of color. Cultural Diversity and Ethnic Minority Psychology, 21 (4), 1–10. doi:10.1037/cdp0000026. Singh, A. A., & McKleroy, V. S. (2011). “Just getting out of bed is a revolutionary act”: The resilience of transgender peo­ ple of color who have survived traumatic life events. Trau­ matology, 17 (2), 34–44. doi:10.1177/1534765610369261.

H A NDO UT

P RO C E SSIN G QU E ST IO NS : M A NAGING T H E INT ERS ECT IO NS

Title: If you could give a title to your life story so far (like a title given to the book of your life), one that integrates all of these identities, what would it be?

a. In which ways have marginalization and oppression played a role in influencing the title of this story?

b. How do racism, sexism, and heterosexism each play their parts?

c. What’s your role in this story?

d. How do you wish to see that role change in your story?

e. In which ways have you attempted to change the story in the past?

Suggested Subheadings a. Characters: Who are the main characters?

b. Plot: What’s important to influencing the life of the story? What path has it taken so far? Where do you see the plot headed?

c. Chapters: How many have you accumulated? How would you title them?

Reflection a. How do you feel about your story so far?

b. What do you hope to be different as each chapter progresses?

Jayleen Galarza

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10 A LOVINGKINDNESS MEDITATION TO HEAL FROM HETEROSEXISM, TRANSPHOBIA, AND OTHER FORMS OF OPPRESSION Eve M. Adams, Tracie L. Hitter, and Virginia Longoria Suggested Uses: Activity, homework, handout Objective

The goal of this activity is to help lesbian, gay, bisex­ ual, and transgender (LGBT) individuals, including those who have intersecting oppressed identities (e.g., ethnic and religious minorities, women), heal from oppression-based trauma. Healing occurs by helping individuals attend compassionately to themselves through the acts of noticing the effects of oppressive experiences on themselves and offering kind wishes for themselves and for others who have experienced similar difficulties. Rationale for Use

Despite recent gains in civil rights for sexual minori­ ties (e.g., gay marriage), heterosexism is still a con­ sistent aspect of the lives of many LGB individuals. Anti-LGB attitudes and behaviors have shifted from more overt acts of discrimination to more subtle forms of devaluation (Walls, 2008), which may cause peo­ ple to minimize the influence of heterosexist discrim­ ination in their lives. Heterosexism is defined as the beliefs and attitudes held by dominant groups that stig­ matize nonheterosexuality (Herek and Berrill, 1992). There are five different dimensions of heterosexism, and each serves to deny, stigmatize, and devalue nonheterosexual relationships (Walls, 2008). Hostile het­ erosexism is what was historically called homophobia and refers to attitudes of disgust, judgment of nonheterosexuality as immoral, and avoidance (Walls,

2008). Aversive heterosexism is a set of attitudes that seek to minimize the negative effect of stigmatization and oppression experienced by LGB individuals (Walls, 2008). Amnestic heterosexism refers to the belief that while LGB individuals once experienced discrimina­ tion, such prejudicial behavior no longer occurs (Walls, 2008). Paternalistic heterosexism is a more neutral attitude of viewing LGB individuals positively, but it includes an attitude of concern for the well-being and safety of LGB individuals and a desire for these indi­ viduals to be heterosexual to protect them from prej­ udice. Positive stereotypic heterosexism is an attitude of support and acceptance, along with an appreciation for stereotypic characteristics (e.g., lesbians are skilled at auto repair). Internalized heterosexism is the intro­ jection of these attitudes by those who are the target of these attitudes, which results in negative attitudes about being a sexual minority, which Herek (2007) calls internalized stigma. Similarly, prejudice against transgender individ­ uals is conceptualized as having affective, cognitive, and behavioral aspects (Hill & Willoughby, 2005). Transphobia refers to an attitude of disgust, fear, and/ or hatred toward transgender individuals (Hill & Willoughby, 2005). Genderism, similar to heterosex­ ism, is a cultural ideology that reinforces a negative evaluation of gender nonconformity, and it may be imposed on others or an internalized belief (Hill & Willoughby, 2005). Gender-bashing refers to physical or emotional assault (or both) against individuals who are gender nonconforming (Hill & Willoughby, 2005).

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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The stress associated with being a sexual or gen­ der minority is associated with increased risk of psy­ chological distress (Levitt et al., 2009), including depression, anxiety, suicidal behavior, and substance use (Bazargan & Galvan, 2012; Budge, Adelson, & Howard, 2013; Frost & Meyer, 2009; Moradi, Van den Berg, & Epting, 2009; Reisner, Gamarel, Nemoto, & Operario, 2014; Smith & Ingram, 2004). Furthermore, experiences of heterosexist discrimination among ethnic-minority sexual minorities have been found to be associated with increased psychological stress (Szymanski & Sung, 2010). Thus, the pernicious effects of heterosexism are amplified by its effect on individu­ als’ mental health, as well its commonality with other forms of oppression (e.g., racism). More specifically, perceived discrimination results in feelings of rejection, which may lead to psycho­ logical distress. In a sample of sexual minority individ­ uals, perceived discrimination was predictive of lower levels of self-compassion and increased psychologi­ cal distress (Liao, Kashubeck-West, Weng, & Deitz, 2015). Perceived rejection was associated with nega­ tive internal feelings, self-judgment, and a decrease in self-compassion (Liao et al., 2015). Stigma aware­ ness was found to be associated with more psycholog­ ical distress among a sample of transgender adults (Breslow et al., 2015). Thus, it is important when work­ ing with LGBT clients to work on cultivating greater self-compassion. Self-compassion interventions are grounded in Buddhist religion and have been secularized in mind­ fulness-based psychological interventions (Shonin, Van Gordon, & Griffiths, 2014). Mindfulness is “a particular way of paying attention on purpose to the present moment, non-judgmentally” (Kabat-Zinn, 1994, p. 4). There is a growing body of research liter­ ature demonstrating how acceptance and mindful­ ness principles are helpful for addressing a variety of medical and mental health issues (Chiesa & Serretti, 2011; Eberth & Sedlmeier, 2012; Hofmann, Sawyer, Witt, & Oh, 2010; Klainin-Yobas, Cho, & Creedy, 2012; Shonin, Van Gordon, Slade, & Griffiths, 2013). Inter­ ventions based on these approaches have been imple­ mented to treat depression, anxiety, eating disorders, chronic pain, borderline personality disorder, and other issues (Baer, 2006).

A recent meta-analysis of studies involving selfcompassion demonstrates that it is predictive of psy­ chological well-being (Zessin, Dickhäuser, & Garbade, 2015). Neff and Germer (2013) studied the effective­ ness of a mindful self-compassion program and found it to be effective for increasing cognitive wellbeing. Self-compassion includes three components: (a) self-kindness, showing kindness to oneself instead of criticism during difficult moments; (b) common humanity, viewing one’s experiences as a struggle com­ mon to others, as opposed to experiences that sepa­ rate and isolate one from others; and (c) mindfulness, approaching painful thoughts and emotions with awareness rather than overidentification (Neff, 2003). Research demonstrates that self-compassion can help people temper emotional reactions to events such as rejection, failure, and embarrassment, and it may provide more benefit than self-esteem does (Leary et al., 2007). Self-compassion helps strengthen resilience against difficulties and helps people accept undesir­ able outcomes (Leary et al., 2007), which may help them cope with experiences of discrimination related to their sexual orientation. While there is a great deal of evidence about the efficacy of self-compassion and mindfulness inter­ ventions in general (e.g., Neff & Germer, 2013), cur­ rently there is no clear evidence of such interventions for minority populations. Given the humanistic nature of mindfulness, self-compassion, and lovingkindness interventions, such activities are inherently affirming of LGBT individuals. The relevance of mindfulness and self-compassion to oppression-based suffering is just beginning to be examined, and results so far are promising (Brown-Iannuzzi et al., 2014; Lyons, 2016; Toomey & Anhalt, 2016). The shift in the last ten years is to explore the con­ struct of mindfulness with minority populations. A study of African Americans found that trait mindful­ ness (i.e., a characteristic of those whose personali­ ties are naturally mindful) was negatively correlated with both general anxiety and anxiety arousal (Gra­ ham, West, & Roemer, 2013). Brown-Iannuzzi and colleagues (2014) examined how trait mindfulness was a protective factor for individuals who were tar­ gets of discrimination that was based on race, gender, age, and other factors. Findings indicated that the A Lovingkindness Meditation to Heal from Oppression

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relationship between depressive symptoms and per­ ceived discrimination was reduced for individuals who exhibited higher levels of trait mindfulness (BrownIannuzzi et al., 2014). Similarly, in a sample of mid­ dle-aged and older gay men in Australia, another study found that trait mindfulness appeared to reduce the relationship between distress and discrimination that was based on age and sexual orientation (Lyons, 2016). Finally, a study of LGBT Latino youth’s expe­ riences of school victimization owing to their ethnic­ ity and sexual orientation found that trait mindfulness was protective in reducing the relationships between sexual orientation–based victimization and higher depressive symptoms and lower self-esteem (Toomey & Anhalt, 2016). Though trait mindfulness seems to be useful for minority populations, there are very few studies exam­ ining the effectiveness of mindfulness-based interven­ tions with minority populations. An adaptation of cognitive-behavioral treatment for traumatized refu­ gees and ethnic minorities was adapted to include a lovingkindness practice (Hinton et al., 2013). This case study illustrated how the inclusion of a lovingkindness practice could increase psychological flexi­ bility and improve efficacy with regard to affect regulation (Hinton et al., 2013). Findings from a qualitative study demonstrate how mindfulness practice facilitates a broadening of worldview and cultivates an ability to re-perceive social and cultural identities while simultaneously honoring them (Longoria, 2014). Participants in this study, all members of oppressed groups and teach­ ers of mindfulness, offered important insights about how mindfulness-based and -informed therapies can be delivered in culturally relevant ways and how they may help people manage the psychological con­ sequences of oppression (Longoria, 2014). Shapiro and Carlson (2009) propose that the healing effects of mindfulness are the result of a shift in perspective. This shift allows for a broadening of views that expands one’s view of the self, a shift that may be heal­ ing for individuals coping with the negative effects of heterosexism and genderism. Because there are limited studies on the effective­ ness of mindfulness-based interventions with minor­ ity populations, it is important to provide adequate 84

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informed consent to clients that these techniques are in development for use with various minority popu­ lations (APA, 2010, 10.01[b]). The other APA ethical code that is particularly relevant to therapists provid­ ing mindfulness interventions to LGBT populations is 2.01(b) Boundaries of Competence. Psychologists are expected to have competence when dealing with issues of diversity in clinical work (Bieschke & Mintz, 2012). In addition, it is essential to gain sufficient training in mindfulness interventions, which would include therapists practicing these interventions in their own lives. Instructions

Therapists can use the lovingkindness meditation as an antidote to heterosexist and transphobic experi­ ences initially as an in-session activity, although it can later be given as homework. It is best to allow at least fifteen minutes for the activity and at least another fifteen minutes to process the experience. The thera­ pist can give a general introduction that this is a medi­ tation that allows clients to attend to themselves when they have felt fundamentally devalued because of their gender identity or sexual orientation. This activity works best if the therapist and client have already engaged in other mindfulness activities, including mindful breathing or other similarly ground­ ing practices. In addition, if the client has already engaged in lovingkindness or self-compassion prac­ tices, then applying these practices to specific hetero­ sexist or transphobic experiences will be more famil­ iar. Thus, it is recommended that one or two sessions be spent in these more general mindfulness practices first. We also suggest that therapists engage in these practices in their own lives so that they have personal familiarity with the experiential learning that can occur with these practices. We advise that therapists engage in mindful breathing with the client, then guide the self-compassion meditation, so that both are expe­ riencing present-moment awareness. Thus, we recom­ mend that therapists explore the resources at the end of the chapter for themselves as well as for their clients. The signal for introducing this practice occurs when the client describes an experience of heterosex­ ist, transphobic, or intersectionality discrimination. It certainly is appropriate for the therapist to empathize

and express compassion for the client, but at some point it will be important for the therapist to help the client practice some self-compassion. Such a focus is needed particularly when clients are minimizing their pain, internalizing the oppression, or focused exclu­ sively on externalizing their experience. This guided meditation combines two mindful­ ness practices. The first is based on a mindful selfcompassion practice developed by Neff and Germer (2013), and the second is based on a lovingkindness practice developed by the Buddha over 2,500 years ago (Kornfield, 2008). At the end of the chapter, both an English version and a Spanish version of the sam­ ple wording for the guided meditation are included. Brief Vignette

Alex is an Asian American cisgender male client who identifies as gay. He reports feelings of low self-worth, distressing levels of anxiety, feelings of isolation, and experiences of ethnic discrimination within the gay community and heterosexism from the larger commu­ nity. Alex has no experience with any meditation prac­ tice and is open to learning something that would help him manage the distressing emotions he experiences. The intervention begins with the therapist asking Alex to close his eyes and focus his attention on his breath. After a minute or so, the therapist asks Alex to recall a recent experience in which he was devalued because of his sexual orientation and asks him to notice the emo­ tions and physical sensations that emerge as he recalls the experience. The therapist asks him to notice if there is any resistance that emerges, and encourages him to breathe into that feeling, supporting him in observing any thoughts, feelings, or sensations that arise. Next, the therapist walks him through the steps of the guided meditation. Note that Alex is asked not to verbally respond to any of the prompts during the meditation, but instead to reflect on them internally. After the meditation is completed, the therapist asks Alex again to focus on his breath to help him become more grounded in the present moment. Suggestions for Follow-up

When the practice is completed, the therapist should come back to a grounding meditation focused on the breath and the here-and-now experience. To process

the experience with the client, we recommend using the SIFT acronym as a framework to engage in a reflective dialogue with the client (Siegel, 2010). Here the therapist will first have the client describe the physical Sensations they noticed, followed by Images, Feelings, and then Thoughts. See the sample script of how to lead the SIFT discussion. Grounding in physical sensations is an important foundation to developing greater feelings of safety. We also recommend revisiting the questions posed during the guided meditation, such as how it might have felt different when offering the lovingkindness wishes to oneself versus the large demographic group. Then the therapist can explore any other insights. Finally, the therapist can discuss with clients how and when they might practice this meditation on their own. Contraindications

Though this is a secular activity of building self-com­ passion, it may not be appropriate for individuals who adhere to a religious belief that is inconsistent or incompatible with mindfulness activities. For some people, offering lovingkindness phrases feels very sim­ ilar to praying, which may not feel congruent with their values. However, extending lovingkindness phrases is not the same thing as praying, and it is not neces­ sary for someone to be spiritually focused in order to engage in and benefit from it, as meditation is not inherently spiritual (Kabat-Zinn, 1994). Additionally, this activity may be challenging for sexual abuse sur­ vivors as it does require that the clients focus on their bodily sensations. It may also be challenging for transgender clients who are not feeling connected to their bodies. Thus, it would be important not to introduce this activity until a great deal of safety and trust have been established and the client feels ready to focus on bodily sensations. Professional Readings and Resources American Psychological Association (APA). (2010). Ethical standards of psychologists. Washington, DC: Author. Baer, R. A. (ed.). (2006). Mindfulness-based treatment approaches: Clinician’s guide to evidence base and appli­ cations. Boston: Elsevier Associated Press. Germer, C. K., & Siegel, R. D. (eds.). (2012). Wisdom and compassion in psychotherapy: Deepening mindfulness in clinical practice. New York: Guilford Press. A Lovingkindness Meditation to Heal from Oppression

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Germer, C. K., Siegel, R. D., & Fulton, P. R. (eds.). (2013). Mindfulness and psychotherapy, 2nd edition. New York: Guilford Press. Longoria, V. (2014). Contemplating culture: Exploring the use of mindfulness therapies with diverse groups. New Mexico State University, ProQuest Dissertations Publishing, 3582299.

Resources for Clients Dresser, M. (ed.). (1996). Buddhist women on the edge: Contemporary perspectives from the Western frontier. Berkeley, CA: North Atlantic Books. Germer, C. K. (2009). The mindful path to self-compassion: Freeing yourself from destructive thoughts and emotions. New York: Guilford Press. Germer, C., & Neff, K. (2017). Self-compassion break. San Diego: Center for Mindful Self-Compassion. https:// chrisgermer.com/wp-content/uploads/2017/02/MSC­ Self-Compassion-Break.pdf. Gutiérrez-Baldoquín, H. (ed.). (2004). Dharma, color, and culture: New voices in Western Buddhism. Berkeley, CA: Parallax Press. Kornfield, J. (2008). The wise heart: A guide to the universal teachings of Buddhist psychology. New York: Bantam Books. Neff, K. (2011). Self-compassion: The proven power of being kind to yourself. New York: William Morrow. Neff, K. (2018). Self-compassion mediations. http://self-com passion.org/. Nicole, C. (2017). Black Lives Matter meditation for healing racial trauma. http://drcandicenicole.com/2016/07/ black-lives-matter-meditation/. Salzberg, S., and Das, K. (2018). Power of the loving heart. www.sharonsalzberg.com/. Siegel, D. (2018). Dr. Dan Siegel. http://www.drdansiegel.com/. Siegel, D. J., and Bryson, T. P. (n.d.). Refrigerator sheet: The whole-brain child. https://www.drdansiegel.com/pdf/ Refrigerator%20Sheet--WBC.pdf. Yang, L. (n.d.). Awakening together. www.larryyang.org/.

References American Psychological Association (APA). (2010). Ethical standards of psychologists. Washington, DC: Author. Baer, R. A. (2006). Mindfulness training as a clinical inter­ vention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10, 125–143. doi:10. 1093/clipsy.bpg015. Bazargan, M., & Galvan, F. (2012). Perceived discrimination and depression among low-income Latina male-to-female transgender women. BMC Public Health, 12, 663. doi:10. 1186/1471-2458-12-663. Bieschke, K. J., & Mintz, L. B. (2012). Counseling psychology model training values statement addressing diversity: History, current use, and future directions. Training and 86

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Education in Professional Psychology, 6 (4), 196–203. doi: 10.1037/a0030810. Breslow, A. S., Brewster, M. E., Velez, B. L., Wong, S., Geiger, E., & Soderstrom, B. (2015). Resilience and collective action: Exploring buffers against minority stress for transgender individuals. Psychology of Sexual Orientation and Gender Diversity, 2 (3), 253–265. doi:10.1037/sgd 0000117. Brown-Iannuzzi, J. L., Adair, K. C., Payne, B. K., Richman, L. S., & Fredrickson, B. L. (2014). Discrimination hurts, but mindfulness may help: Trait mindfulness moderates the relationship between perceived discrimination and depressive symptoms. Personality and Individual Differ­ ences, 56, 201–205. doi:10.1016/j.paid.2013.09.015. Budge, S. L., Adelson, J. L., & Howard, K. A. (2013). Anxiety and depression in transgender individuals: The roles of transition status, loss, social support, and coping. Journal of Consulting and Clinical Psychology, 81, 545–557. doi:10.1037/a0031774. Chiesa, A., & Serretti, A. (2011). Mindfulness based cognitive therapy for psychiatric disorders: A systematic review and meta-analysis. Psychiatry Research, 187 (3), 441–453. doi:10.1016/j.psychres.2010.08.011. Eberth, J., & Sedlmeier, P. (2012). The effects of mindfulness meditation: A meta-analysis. Mindfulness, 3 (3), 174–189. doi:10.1007/s12671-012-0101-x. Frost, D. M., & Meyer, I. H. (2009). Internalized homophobia and relationship quality among lesbians, gay men, and bisexuals. Journal of Counseling Psychology, 56 (1), 97–109. doi:10.1037/a0012844. Graham, J. R., West, L. M., & Roemer, L. (2013). The experi­ ence of racism and anxiety symptoms in an AfricanAmerican sample: Moderating effects of trait mindfulness: Erratum. Mindfulness, 4 (4), 342. doi:10.1007/s12671­ 012-0152-z. Herek, G. M. (2007). Confronting sexual stigma and prejudice: Theory and practice. Journal of Social Issues, 63 (4), 905– 925. doi:10.1111/j.1540-4560.2007.00544.x. Herek, G. M., & Berrill, K. (eds.). (1992). Hate crimes: Con­ fronting violence against lesbians and gay men. Thousand Oaks, CA: Sage. Hill, D. B., & Willoughby, B. B. (2005). The development and validation of the Genderism and Transphobia Scale. Sex Roles, 53 (7–8), 531–544. doi:10.1007/s11199-005-71 40-x. Hinton, D. E., Ojserkis, R. A., Jalal, B., Peou, S., & Hofmann, S. G. (2013). Loving-kindness in the treatment of trauma­ tized refugees and minority groups: A typology of mind­ fulness and the Nodal Network Model of affect and affect regulation. Journal of Clinical Psychology, 69 (8), 817–828. doi:10.1002/jclp.22017. Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and

depression: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78, 169–183. doi:10.1037/a0018 555. Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness and meditation in everyday life. New York: Hyperion. Klainin-Yobas, P., Cho, M. A. A., & Creedy, D. (2012). Efficacy of mindfulness-based interventions on depressive symp­ toms among people with mental disorders: A meta-anal­ ysis. International Journal of Nursing Studies, 49, 109–121. doi:10.1016/j.ijnurstu.2011.08.014. Kornfield, J. (2008). The wise heart: A guide to the universal teachings of Buddhist psychology. New York: Bantam Books. Leary, M. R., Tate, E. B., Adams, C. E., Batts Allen, A., & Hancock, J. (2007). Self-compassion and reactions to unpleasant self-relevant events: The implications of treat­ ing oneself kindly. Journal of Personality and Social Psy­ chology, 92 (5), 887–904. doi:10.1037/0022-3514. 92.5.887. Levitt, H. M., Ovrebo, E., Anderson-Cleveland, M. B., Leone, C., Jeong, J. Y., Arm, J. R., . . . & Horne, S. G. (2009). Bal­ ancing dangers: GLBT experience in a time of anti-GLBT legislation. Journal of Counseling Psychology, 56 (1), 67–81. Liao, K. Y., Kashubeck-West, S., Weng, C., & Deitz, C. (2015). Testing a mediation framework for the link between per­ ceived discrimination and psychological distress among sexual minority individuals. Journal of Counseling Psychol­ ogy, 62 (2), 226–241. doi:10.1037/cou0000064. Longoria, V. (2014). Contemplating culture: Exploring the use of mindfulness therapies with diverse groups. New Mexico State University, ProQuest Dissertations Pub­ lishing, 3582299. Lyons, A. (2016). Mindfulness attenuates the impact of dis­ crimination on the mental health of middle-aged and older gay men. Psychology of Sexual Orientation and Gender Diversity, 3 (2), 227–235. doi:10.1037/sgd0000164. Moradi, B., Van den Berg, J. J., & Epting, F. R. (2009). Threat and guilt aspects of internalized anti-lesbian and gay prej­ udice: An application of personal construct theory. Journal of Counseling Psychology, 56 (1), 119–131. doi:10.1037/ a0014571. Neff, K. D. (2003). Development and validation of a scale to measure self-compassion. Self and Identity, 2, 223–250. doi:10.1080/15298860390209035. Neff, K. D., & Germer, C. K. (2013). A pilot study and random­

ized controlled trial of the mindful self-compassion pro­ gram. Journal of Clinical Psychology, 69 (1), 28–44. doi:10. 1002/jclp.21923. Reisner, S. L., Gamarel, K. E., Nemoto, T., & Operario, D. (2014). Dyadic effects of gender minority stressors in sub­ stance use behaviors among transgender women and their non-transgender male partners. Psychology of Sexual Orientation and Gender Diversity, 1, 63–71. doi:10.10 37/0000013. Shapiro, S. L., & Carlson, L. (2009). The art and science of mindfulness: Integrating mindfulness into psychology and the helping professions. Washington, DC: American Psy­ chological Association. Shonin, E., Van Gordon, W., & Griffiths, M. D. (2014). The emerging role of Buddhism in clinical psychology: Toward effective integration. Psychology of Religion and Spiritual­ ity, 6 (2), 123–137. doi:10.1037/a0035859. Shonin, E., Van Gordon, W., Slade, K., & Griffiths, M. D. (2013). Mindfulness and other Buddhist-derived interventions in correctional settings: A systematic review. Aggression and Violent Behavior, 18, 365–372. doi:10.1016/j.avb. 2013.01.002. Siegel, D. (2010). Mindsight: The new science of personal trans­ formation. New York: Bantam. Smith, N. G., & Ingram, K. M. (2004). Workplace heterosexism and adjustment among lesbian, gay, and bisexual individ­ uals: The role of unsupportive social interactions. Journal of Counseling Psychology, 51 (1), 57–67. doi:1037/0022 0167.51.1.57. Szymanski, D. M., & Sung, M. R. (2010). Minority stress and psychological distress among Asian American sexual minority persons. Counseling Psychologist, 38 (6), 848– 872. doi:10.1177/0011000010366167. Toomey, R. B., & Anhalt, K. (2016). Mindfulness as a coping strategy for bias-based school victimization among Lati­ na/o sexual minority youth. Psychology of Sexual Orien­ tation and Gender Diversity, 3 (4), 432–441. doi:10.1037/ sgd0000192. Walls, N. E. (2008). Toward a multidimensional understand­ ing of heterosexism: The changing nature of prejudice. Journal of Homosexuality, 55 (1), 20–70. doi:10.1080/009 18360802129287. Zessin, U., Dickhäuser, O., & Garbade, S. (2015). The relation­ ship between self-compassion and well-being: A meta­ analysis. Applied Psychology: Health and Well-Being, 7 (3), 340–364. doi:10.1111/aphw.12051.

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LOVINGKINDNESS MEDITATION FOR HETEROSEXIST AND TRANSPHOBIC EXPERIENCES (ENGLISH)

“May we feel worthiness even when others devalue us.”

Allow yourself to recall, in some detail, a situation in which you were devalued by another, not because of something you did or didn’t do, but because of your sexual orientation or gender identity. Were there other aspects of your identity that you were also aware of (religion, ethnicity, etc.)? Check in with your body right now and focus your awareness on your physical sensations. Perhaps there is a feeling of resistance, of not wanting to go to such a place. Try just breathing into that feeling. Notice if any emotions, thoughts, or other physical sensations emerge.

What other comforting wishes do you want to send to this larger group? Notice how it feels to say these phrases for the LGBT community as compared to just yourself.

• Say to yourself: “This is a moment of difficulty, of

suffering.” Notice how your body responds to this acknowledgment. “There are others who are like me who have had similar experiences.” “I am not alone in having this experience.”

• Then place your hand over your heart, and feel the warmth of your hand comforting your heart. How does your body respond? Breathe in the following phrases:

“May I find some sense of safety in this moment.”

“May I feel strong in this moment.”

“May I feel worthiness even as I am devalued by

others.” “May I find some breathing space when I feel con­ strained by inequality so that I can respond creatively.” What other comforting wishes do you have for yourself in this situation? Repeat these phrases and notice how your being responds to each one.

• Now bring to mind another LGBT individual you know who has also experienced heterosexism, and picture the two of you standing together. And sur­ rounding you, try picturing all the many LGBT individuals who have faced discrimination.

“May we feel safe when we have such challenging experiences.” “May we feel strong in the face of adversity.” 88

“May we find some space to respond creatively when we feel constrained.”

• Bring your awareness back to your breath right now and check in with how your body is feeling at this moment. Which sensations have shifted? Which sensations have remained? Are there additional thoughts or feelings you are experiencing now?

MEDITACIÓN DE LA BONDAD PARA EXPERIENCIAS DE HETEROSEXISMO O TRANSFOBIA (ESPAÑOL)

Permítase recordar, con algún detalle, esta situación donde fue usted desvalorado/a por otra persona, no por algo que usted hizo o que no hizo sino por su orient­ ación sexual o su identidad de género. ¿Habían otros aspectos de su ser o de su identidad (religión, etnici­ dad, etc.) de los que también estaba usted consciente? Tome una observación de su cuerpo en este momento y traiga su atención a cualquier sensación que note. Tal vez hay una sensación de resistencia, de no querer ir a tal lugar. Trate simplemente de respirar hacia esa sensación. Sigua observando, viendo a ver si surgen emociones, pensamientos u otras sensaciones físicas.

• Dígase a sí mismo:

“ Este es un momento de dificultad, de sufrimiento.” Fíjese cómo responde su cuerpo a este recono­ cimiento. “Hay otras personas que son como yo que han tenido experiencias similares.” “No estoy solo/a en tener esta experiencia.”

• Ahora ponga su mano sobre su corazón, y sienta el

calor de su mano consolando a su corazón. ¿Cómo responde su cuerpo? Respire hacia adentro las siguientes frases:

“ Que pueda yo encontrar algún sentido de seguri­ dad en este momento.” “ Que pueda sentirme fuerte en este momento.” “Que pueda sentir que soy digno/a aun al ser des­ valorado por otros.”

“Que pueda yo encontrar un espacio para respirar cuando me sienta restringido/a por la injusticia para así poder responder creativamente.” ¿Qué otros deseos consoladores tiene para usted mismo/a en esta situación? Repita estas frases de nuevo y fíjese en cómo responde su ser a cada una de ellas. •Ahora, traiga a la mente una imagen de otra per­ sona LGBT quien usted conoce que también ha experimentado heterosexismo e imagínese que están los dos parados juntos. Y rodeándolos, trate de imaginar a todas las personas LGBT quienes han experimentado discriminación. “Que podamos sentirnos seguros cuando tengamos estas experiencias desafiantes.” “Que podamos sentirnos fuertes al frente de la adversidad.” “Que podamos sentirnos valorados y dignos aun cuando otros nos desvaloran.” “Que podamos encontrar un espacio para responder creativamente cuando nos sentimos restringidos/ as.” ¿Qué otros deseos consoladores le gustaría mandarle a este grupo más grande? Fíjese en cómo se siente el decir estas frases a todo el grupo en comparación con deseárselas a usted solo/a. • Ahora dirija de nuevo su atención a su respiración y tome una observación de cómo se siente su cuerpo en este momento. ¿Qué sensaciones han cambiado? ¿Cuáles han permanecido? ¿Hay otros pensamientos o sentimientos que está experi­ mentando ahora? Adapted from Germer, C., & Neff, K. (2017), Self-compassion break (San Diego: Center for Mindful Self-Compassion), https://=chrisgermer.com/wp-content/uploads/2017/02/ MSC-Self-Compassion-Break.pdf.

REFLECTIVE DIALOGUE USING SIFT (SIEGEL, 2010)

After completing the lovingkindness, self-compassion exercise, you will want to help the client move from having the internal experience to processing this expe­

rience through a reflective dialogue. This relational experience allows for another level of processing and possible healing. Allow a few moments of silence to occur between you and the client as the client shifts from the internal world to the relational space (use this as a time to take a few breaths and check into your own internal experience in the moment). You can spend a moment letting clients know that you will ask them to reflect on four aspects of their experience. It is very common for clients to have some difficulty identifying certain aspects of their experience, as they often move more quickly to their thoughts. It is important to ask clients to pause before expressing their thoughts until the other aspects of their experi­ ence have been explored. You can provide the ratio­ nale that many of our initial reactions to oppression are experienced in the nonverbal and nonconceptual part of the brain (the amygdala), so we need to listen to those reactions first. Then use some of the follow­ ing questions to prompt the client (we recommend that you ask only one or two questions for each level). 1. What were the physical Sensations you were aware of? Where in your body did you feel them? Describe the sensation (e.g., tightness, constric­ tion, warmth, shakiness). What are you feeling in your body right now? 2. Describe any visual Images, pictures or symbols you noticed. Were there other situations that popped into your awareness? Are any other images arising now? 3. What emotions did you feel at different moments? What might the physical sensations or images tell you about your Feelings? Did any feeling shift over time (including shifting from one bodily sensation to another) or change in intensity? Did you have any reactions to your feelings (feelings about your feelings)? Did any feeling surprise you? What are you feeling now? 4. What Thoughts did you have? Did you have any reactions to your thoughts (feelings about your thoughts)? Did any thoughts surprise you? As we are talking about it now, are there any insights (new ideas) you have about the oppressive experience?

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11 FROM STRESS TO STRENGTH: A GROUP INTERVENTION FOR PROCESSING MINORITY STRESS EXPERIENCES WITH TRANSGENDER AND GENDER-NONCONFORMING INDIVIDUALS Caroline Carter and Diane Sobel

Suggested Use: Group activity Objective

This two-part activity is designed to help transgender and gender-nonconforming (TGNC) clients learn about the harmful effects of minority stress on psycho­ logical functioning and overall mental health. Spe­ cifically, it teaches TGNC clients to use the minority stress model to identify the ways in which minority stress is present in their lives and its effects on them. Rationale for Use

This activity aims to help clients practice identifying their personal resilience within minority stress expe­ riences, including ways they are positively navigating and coping with minority stress. This activity also encourages TGNC community members to connect with one another by providing a space for them to receive validation from others about their experiences of distress, recognize and acknowledge their own and others’ signs of resilience, and increase their own abil­ ity to cope by further identifying ways to navigate specific minority stress experiences together. A nat­ ural outcome of this activity is increased in-group identification within the TGNC community, an ele­ ment that increases resiliency in the face of minority stress experiences. There is more and more documentation that TGNC individuals commonly experience gender-based

stigmatization, discrimination, and victimization (Beemyn & Rankin, 2011; Bradford et al., 2007; Clements-Nolle, Marx, & Katz, 2006; Paul, 2015). It has also been well documented that TGNC individuals demonstrate high prevalence rates of many mental health concerns, including clinical depression, anxiety, and substance abuse (Bockting et al., 2013; ClementsNolle et al., 2006). Suicidal ideation and suicide rates are also much higher among TGNC individuals than among the general population (Clements-Nolle et al., 2006; Moscicki, 1995; Weissman et al., 1999). Fur­ thermore, there is a need for increased understanding and research on higher rates of stress experienced among those who hold additional marginalized iden­ tities intersecting with a TGNC identity. The initial research on intersectionality among TGNC individ­ uals has been on those who hold an intersecting ethnic identity (Bazargan & Galvan, 2012; Kattari, Walls, Whitfield, & Langenderfer-Magruder, 2016; Whitfield, Langenderfer-Magruder, Walls, & Clark, 2014). This research has found that unlike individuals with a sin­ gular minority identity, TGNC individuals holding an additional intersecting racial or ethnic identity must navigate multiple and interacting marginaliza­ tions and thus undergo increased discriminatory experiences and stress. In recent years, theorists have built on Meyer’s (2003) minority stress model (Hatzenbuehler, 2009), and researchers and theorists have proposed extend-

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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ing Meyer’s minority stress model to include the experiences of TGNC individuals. These theorists and researchers shed light on the distinct stress experienced by the TGNC community owing to cultural transphobia (Bockting et al., 2013; Breslow et al., 2015; Hendricks & Testa, 2012; Levitt & Ippolito, 2014; Rood et al., 2016). The minority stress model was originally developed to understand the relation­ ship between the high incidence of mental health disorders among lesbian, gay, and bisexual (LGB) individuals and the high rates of discrimination, prejudice, and victimization that were due to LGB individuals’ minority status. We are using Hatzen­ buehler’s (2009) expansion of Meyer’s (2003) min­ ority stress model, additionally following Breslow and colleagues (2015), who have applied Hatzen­ buehler’s theory to TGNC individuals. This model suggests that stressful events experienced by TGNC minorities (external stressors) can be internalized (internal stressors), in such a way that the internal­ ization of them can lead to psychopathology (psy­ chological distress). External stressors, also known as distal stressors (Breslow et al., 2015; Meyer, 2003), are the initial envi­ ronmental events one experiences because of minority status membership, including direct and indirect experiences of discrimination and prejudice. Internal stressors, also known as proximal stressors (Breslow et al., 2015; Meyer, 2003), result from the “emotional and cognitive appraisals” or the meaning making of discriminatory events (Breslow et al., 2015, p. 254). Two key proximal stressors identified by Meyer (2003) are expectation or anticipation of stressful events and the internalization of negative attitudes and preju­ dices from society (Hendricks & Testa, 2012; Meyer, 2003). Anticipation of discriminatory events can lead to anxiety and vigilance, whereas internalization can result in internalized transphobia for TGNC individ­ uals, which is then directed at the self. Finally, psy­ chological distress is the result of external and internal stressors (Breslow et al., 2015). This distress can include depression, anxiety, trauma, and panic. Following this distress, individuals may turn to forms of coping in an attempt to reduce the distress (e.g., negative coping—increased substance use, self-harm, or sui­

cidality—and positive coping—reaching out for support, journaling). Several recent studies have suggested not only that TGNC individuals are negatively affected by discrimination and victimization, but also that resil­ ience can develop in response to these events (Bock­ ting et al., 2013; Breslow et al., 2015; Hendricks & Testa, 2012; Riggle, Rostosky, McCants, & PascaleHague, 2011). Resilience can be understood as the internal emotional and cognitive resources one has when one finds oneself in stressful situations (Harvey, 2007). Current research shows a number of resiliency factors that can be developed as a result of minority stress. These include taking strength from resisting discrimination, finding safe and accepting places and connection within a supportive community, being able to define one’s own gender identity, seeing gender diversity as a natural part of the world, embracing one’s self-worth, building awareness of oppression and identifying it when it occurs, and cultivating hope for the future (Scourfield, Roen, & McDermott, 2008; Singh, Hays, & Watson, 2011). The proposed activity involves several steps designed to build resiliency in TGNC clients. Psychoeducation is provided about the minority stress model in order to normalize the participants’ experiences. Peer support and pride in one’s transgender identity are cultivated by encouraging members of the group to connect with one another through sharing experi­ ences of discrimination and prejudice, expectations of rejection, internalized transphobia, and the psychologi­ cal distress that results. Individual resilience further increases through interventions, which invite mem­ bers to share successful ways of managing minority stress and to brainstorm new ways to manage minority stress experiences together. These self-disclosures instinctively draw on the social support of other members, which increases participants’ sense of belonging and inhibits feelings of thwarted belongingness and felt burdensomeness. Thwarted belongingness and felt burdensomeness often are the key drivers of social isolation, which can leave TGNC people at much higher risk of suicidal ideation and suicidality (Hendricks & Testa, 2012; Joiner, 2010). Expressions of strength and pride in one’s

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own and in one another’s ability to navigate stressful situations can both foster connection and lead to the development of pride in one’s minority identity, which has been shown to buffer the negative effects of minority stress on mental health in other minority groups (Kessler, Price, & Wortman, 1985; Meyer, 1995). The ethical guidelines for both counselors and psychologists require that these professionals provide culturally competent services to all clients (American Counseling Association [ACA], 2014; APA, 2017). APA’s “Ethical Principles of Psychologists and Code of Conduct,” for example, requires that psychologists have respect for the “Rights and Dignity” of all people (APA, 2017). Principle E states that “psychologists are aware of and respect cultural, individual, and role dif­ ferences, including those based on . . . gender identity, . . . and consider these factors when working with members of such groups” (APA, 2017). Therefore, psy­ chologists and counselors are to consider the effects of the experiences of TGNC people, including stigma and minority stress, when providing services to them. Furthermore, therapists’ involvement in assist­ ing clients to process incidents of stigma and minority stress experiences aligns with the APA’s “Guidelines for Psychological Practice with Transgender and Gen­ der Nonconforming People” (dickey et al., 2015). These guidelines give further guidance on ethical practice with TGNC clients. Guideline 10 states, “Psychologists strive to understand how mental health concerns may or may not be related to a TGNC person’s gender identity and the psychologi­ cal effects of minority stress” (dickey et al., 2015, p. 845). These guidelines additionally highlight the benefits of therapists’ facilitating peer support, which can allow TGNC individuals to provide support to one another. Guideline 11 states, “Psychologists rec­ ognize that TGNC people are more likely to experi­ ence positive life outcomes when they receive social support or trans-affirmative care” (dickey et al., 2015, p. 846). Instructions

This activity has been developed for application in a group setting. Groups should consist of gender-diverse individuals (i.e., transgender, gender-nonconforming, nonbinary, and genderfluid individuals). Leaders can 92

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use the specific prompt provided with the minority stress group exercise template at the end of the chap­ ter, which provides psychoeducation on minority stress for the group and will then prepare the group for application of the theory in the exercise. Leaders may find it beneficial to provide group members with a copy of the prompt so that they can follow along. Brief Vignette

Sarah is a trans-feminine Latina college student who identifies as female and uses she/her pronouns. She came out to her family during the summer. In this scenario (see the chart on p. 93), many of the members in the group identified with Sarah’s experience, and all of them previously had had simi­ lar experiences with one or more of their family members. Many of them shared their common expe­ riences and had thoughts (i.e., internal stressors) sim­ ilar to those that Sarah described. These included try­ ing to become invisible, remaining silent, and feeling bad about themselves. Group participants also shared experiences of wanting to escape these situations. Sharing similar feelings and experiences allowed the group’s participants to feel connected and understood by one another. As a result, the conversation was able to shift into a stance of empathic support for Sarah, who was in the situation currently. Prompting members to talk about other ways that they had responded to similar situations led to brainstorming ideas of other responses they had had in the past or that they might have in the future. These ideas included those listed in the accompany­ ing chart, as well as ideas like moving to another city and never being in touch with any family again. Group leaders validated ideas, but they also helped group members see additional choices they were not currently recognizing, but which they were empow­ ered to make (for example, instead of moving, telling family members they will not engage with them until they respect their identity). Group leaders invited members to discuss their additional intersecting identities and how these affect their experiences as TGNC people. In this situation, leaders validated the unique cultural tensions shared by Sarah as a trans Latina woman. Leaders modeled respectfulness of Sarah’s cultural identity for other members who were

FROM STRESS TO STRENGTH CHART: SARAH

External Stressor

1. Minority Stress Experience

Internal Stressor

Psychological Distress

Identify what happened. (This can be a direct or indirect experience.)

Identify what you told Identify your mood, yourself afterward. feelings, or behaviors that (For example, identify followed. internalized transphobia or anticipatory stress.)

I went home for the holiday break and was continually misgendered by grandparents after telling them my correct name and pronouns.

1. I will never be affirmed in my true gender. 2. Others will continue to never see me as female.

Depression, sadness, anger, hopelessness, shame, wanting to selfharm

3. If I speak up to my grandparents again, it will be seen as disrespectful in my culture. 3. I hate myself. 4. I am not normal.

Identify the ways you were resilient during or following this experience. Identifying Resilience

1. The best I could do was remain silent.

My personal strengths that Additional ways other the group notices. members have coped with similar experiences.

1. I am internally clear that my grandparents’ behavior was wrong, 2. I allowed myself to leave disrespectful, and the situation and go unkind. home early. 2. I am aware of my 3. I reached out to a friend feelings and have had who accepts me and the courage to share genders me correctly. them with the group.

1. Decide not to interact with those who do not respect who I am and do not make an honest effort to gender me correctly. 2. Set boundaries about whom I choose to spend time with. 3. Excuse myself from going to family gatherings that include unaccepting family members.

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struggling to see that it would be difficult for Sarah to implement certain suggestions (for example, com­ pletely cutting off ties to family because of the impor­ tance of family in Latina culture). Following the group discussion about Sarah’s experience, some par­ ticipants shared their contact information with her, inviting her to ask them for support should she find herself in a similar situation again. Suggestions for Follow-up

Following the discussion of the specific responses to the items in the chart, the leaders may invite the group members to reflect on what it was like to talk about these experiences with one another. The fol­ lowing questions can help facilitate this discussion: 1. What is it like to talk about these experiences with one another? 2. What is it like to hear that others have had some of the same experiences? 3. What is it like to hear suggestions from others? 4. What is it like to make suggestions to others? 5. What is it like to hear others talk about the posi­ tives in what others are doing to navigate very dif­ ficult circumstances? Contraindications for Use

Participants should be invited to share only what they would like to share with the group about their expe­ riences. Research has shown not only that members of the TGNC community have experienced rejection and discrimination from those within the cisgender community, but also that they have been surprised to have experiences of invalidation and rejection from those within the LGB community (Levitt & Ippolito, 2014). This can result in TGNC members being under­ standably reticent to come out and be vulnerable within a larger LGBTQ group, regardless of their antic­ ipated shared group membership with the other par­ ticipants in the group (Levitt & Ippolito, 2014). Addi­ tionally, some group participants will encourage others to get involved in the community faster than all the participants may be ready to. When this occurs, facilitators need to give permission to members to par­ ticipate, come out, or join with other members in community activities at a rate that is comfortable for them (Breslow et al., 2015). 94

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Professional Readings and Resources Erickson-Schroth, L. (2014). Trans bodies, trans selves: A resource for the transgender community. New York: Oxford University Press. Lev, A. I. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. New York: Haworth Clinical Practice Press. Makadon, H. J., & American College of Physicians. (2008). The Fenway guide to lesbian, gay, bisexual, and transgender health. Philadelphia: American College of Physicians. Meyer, I. H., & Northridge, M. E. (eds.). (2007). The health of sexual minorities: Public health perspectives on lesbian, gay, bisexual, and transgender populations. New York: Springer. Stryker, S., & Whittle, S. (2006). The transgender studies reader. New York: Routledge.

Resources for Clients Gender Spectrum. https://www.genderspectrum.org/. An

organization based in Oakland, CA, that provides educa­ tion, training, and support to help create a gender-sensi­ tive and inclusive environment for all children and teens. Kuklin, S. (2014). Beyond magenta: Transgender teens speak out. Somerville, MA: Candlewick Press. Mock, J. (2014). Redefining realness: My path to womanhood, identity, love & so much more. New York: Atria. Transgender Law Center. http://transgenderlawcenter.org/. The Transgender Law Center works to change law, policy, and attitudes so that all people can live safely, authentically, and free from discrimination regardless of their gender identity or expression. Trevor Project. http://www.thetrevorproject.org/. The Trevor Project is the leading national organization providing cri­ sis intervention and suicide prevention services to lesbian, gay, bisexual, transgender, and questioning (LGBTQ) young people ages thirteen to twenty-four. Williams Institute. http://williamsinstitute.law.ucla.edu/mis sion/#sthash.0oS5ZjZ5.dpuf. An independent think tank at the University of California Los Angeles focused on providing rigorous, independent research on sexual ori­ entation and gender-identity law and public policy.

References American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/. Bazargan, M., & Galvan, F. (2012). Perceived discrimination and depression among low-income Latina male-to-female transgender women. BMC Public Health, 12 (1), 1. Beemyn, G., & Rankin, S. (2011). The lives of transgender peo­ ple. New York: Columbia University Press. Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Ham­

ilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103 (5), 943–951. doi:10.2105/AJPH.2013.301241. Bradford, J., Xavier, J., Hendricks, M., Rives, M. E., & Honnold, J. A. (2007). The health, health-related needs, and lifecourse experiences of transgender Virginians. Virginia Transgender Health Initiative Study Statewide Survey Report. www.vdh.virginia.gov/content/uploads/sites/ 10/2016/01/THISFINALREPORTVol1.pdf. Breslow, A. S., Brewster, M. E., Velez, B. L., Wong, S., Geiger, E., & Soderstrom, B. (2015). Resilience and collective action: Exploring buffers against minority stress for transgender individuals. Psychology of Sexual Orientation and Gender Diversity, 2 (3), 253–265. doi:10.1037/sgd0000117. Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. Journal of Homosexuality, 51, 53–69. doi:10.1300/J082v51n03_04. dickey, l. m., et al. (2015). Guidelines for psychological prac­ tice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. Harvey, M. R. (2007). Towards an ecological understanding of resilience in trauma survivors: Implications for theory, research, and practice. In M. R. Harvey & P. TummalaNarra (eds.), Sources and expressions of resiliency in trauma survivors: Ecological theory, multicultural practice, 9–35. Binghamton, NY: Haworth. doi:10.1300/J146vl4n01_02. Hatzenbuehler, M. L. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation frame­ work. Psychological Bulletin, 135 (5), 707. doi:10.1037/ a0016441.

Hendricks, M. L., & Testa, R. T. (2012). A conceptual frame­ work for clinical work with transgender and gender nonconforming clients: An adaptation of the minority stress model. Professional Psychology: Research and Practice, 5 (43), 460–467. doi:10.1037/a0029597.

Herman, J. L. (2013, June). Gendered restrooms and minority stress: The public regulation of gender and its impact on transgender people’s lives. Journal of Public Management and Social Policy, 65–80. Retrieved from http://williams institute.law.ucla.edu/research/ ransgender-issues/ herman-jpmss-june-2013/. Jew, C. L., Green, K. E., & Kroger, J. (1999). Development and validation of a measure of resiliency. Measurement and Evaluation in Counseling and Development, 32, 75–90. Joiner, T. (2010). Myths about suicide. Cambridge: Harvard University Press. Kattari, S. K., Walls, N. E., Whitfield, D. L., & LangenderferMagruder, L. (2016). Racial and ethnic differences in experiences of discrimination in accessing social services among transgender/gender-nonconforming people. J ournal of Ethnic & Cultural Diversity in Social Work, 1–19. doi:10.1080/15313204.2016.1242102.

Kessler, R. C., Price, R. H., & Wortman, C. B. (1985). Social factors in psychopathology: Stress, social support, and coping processes. Annual Review of Psychology, 36, 531–572. doi:10.1146/annurev.ps.36.020185.002531. Levitt, H. M., & Ippolito, M. R. (2014). Being transgender: Navigating minority stressors and developing authentic self-presentation. Psychology of Women Quarterly, 38 (1), 46–64. doi:10.1177/0361684313501644. Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36, 38–56. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129 (5), 674–697. doi:10.1037/0033-2909.129.5.674. Moscicki, E. K. (1995). Epidemiology of suicide. Internatio­ nal Psychogeriatrics, 7, 137–148.

Paul, J. C. (2015, January). School-related victimization across subgroups of transgender individuals: Implica­ tions for psychological wellbeing and educational attain­ ment. In Society for Social Work and Research, Society for Social Work and Research 19th Annual Conference: The Social and Behavioral Importance of Increased Longevity. https://sswr.confex.com/sswr/2015/webpro gram/Paper22543.html. Riggle, E .D., Rostosky, S. S., McCants, L. E., & PascaleHague, D. (2011). The positive aspects of a transgender self-identification. Psychology and Sexuality, 2, 147–158. doi:10.1080/19419899.2010.534490. Rood, B. A., Reisner, S. L., Surace, F. I., Puckett, J. A., Maroney, M. R., & Pantalone, D. W. (2016). Expecting rejection: Understanding the minority stress experiences of transgender and gender-nonconforming individuals. Transgender Health, 1 (1), 151–164. doi:10.1089/trgh.2016.

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Scourfield, J., Roen, K., & McDermott, L. (2008). Lesbian, gay,

bisexual and transgender young people’s experiences of distress: Resilience, ambivalence, and self-destructive behaviour. Health and Social Care in the Community, 16 (3), 329–336. doi:10.1111/j.1365-2524.2008. 00769. Singh, A. A., Hays, D. G., & Watson, L. S. (2011). Strength in the face of adversity: Resilience strategies of transgender individuals. Journal of Counseling and Devel­ opment: JCD, 89 (1), 20. doi:10.1002/j.1556-6678. 2011. tb00057.x.

Weissman, M. M., Bland, R. C., Canino, G. J., Greenwald, S., Hwu, H.-G., Joyce, P. R., Karam, E. G., & Lee, C.-K. (1999). Prevalence of suicide ideation and suicide attempts in nine countries. Psychological Medicine, 29 (1), 9–17.

Whitfield, D. L., Langenderfer-Magruder, L., Walls, N. E., & Clark, B. (2014). Queer is the new black? Not so much: Racial disparities in anti-LGBTQ discrimination. Journal of Gay and Lesbian Social Services, 26 (4), 426– 440. doi:10.1080/10538720.2014.955556. From Stress to Strength: A Group Intervention

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PART 1: GROUP PSYCHOEDUCATION ON MINORIT Y STRESS Leader prompt: Today we are going to talk about the term minority stress and its role in the TGNC community. We believe that many of you in the room have experienced or are experienc­ ing minority stress as a result of your gender identity or gender expression. Our hope is that this exercise will provide you with an understanding of minority stress, while also providing the opportunity to discuss your experiences with your peers, thereby offering some relief of its burden. Minority stress can be understood as the very high levels of stress experienced by members of the TGNC community. These elevated levels of stress come from distinct and increasing amounts of prejudice and discrimination experienced by your community. Minority stress is composed of 3 parts: 1. External stressors: These are experiences of prejudice, violence/victimization, or discrimina­ tion that one directly experiences. Example: Someone refuses to serve you or treats you unfairly because of your TGNC status or presentation. External stressors can also come from indirect experiences. Example: You witness friends being harassed at a party because of their TGNC status, or you learn about a recent hate crime involving a TGNC person in an online news story. 2. Internal stressors: These can be understood as the meaning you make of the external stress­ ors. Another way of thinking of internal stressors is as negative mental filters. These filters are shaped by your thoughts and feelings about yourself and the world. When you experience the external stressor, it can go through a negative mental filter, which results in your drawing con­ clusions about yourself and the world. An example of a specific internal stressor is internalized transphobia, or the personalization of negative messages conveyed in your environment about TGNC people. Another example of an internal stressor is stigma awareness or anticipatory stress. This is the expectation or anticipation of future experiences of prejudice and/or discrimi­ nation that results in a current experience of fear, anger, vigilance, and increased stress. Antici­ patory stress can also result in the hiding of one’s identity, which can add to one’s distress. Example: Internalized transphobia: Because you read news blogs, which use demonizing words about transgender individuals (e.g., “predator,” “mentally ill”), you may tell yourself, “Others think I’m disgusting. Maybe they’re right” or “Who am I fooling? I just have a mental illness.” Example: Anticipatory stress: Because you read about an anti-transgender law passing in a nearby state, you worry: “The world will never be accepting of me.” “I will never be safe.” “I’m sure other states will pass a similar law.” “My friend lives in this neighboring state. Maybe he has friends or family who agree with this law.” “If I visit my friend I may be unsafe. I could be victimized.”

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3. Psychological distress: These are the effects, including symptoms, negative feelings moods, and behaviors, that arise as a result of the external and internal stressors. Psychological distress can often be followed by negative or positive forms of coping (ways of managing or attempt­ ing to reduce the distress). Examples: Psychological distress can include anxiety, depression, racing thoughts, worry, social isolation, increased substance use, loneliness, hopelessness, decreased motivation, suicidality, somatic symptoms (for example, stomach ache or loss of appetite). This distress may then be coped with in negative ways: substance use, self-harming, avoidance, isolation. Individuals may also use positive coping: reaching out to a friend or loved one, journaling, exercising, taking social action, and so on. PART 2: GROUP ACTIVIT Y A. Individual preparation: Identifying minority stress experiences a. Hand out a chart to all the members. b. Prompt: Everyone will work individually for five to ten minutes. Think about examples of your own personal experiences of minority stress and write them in your chart. c. Prompt: Write examples of how you have navigated some of these experiences in the chart. B. Group sharing: Building resilience a. Ask participants to share examples of external stressors (discriminatory or prejudicial events) and how they navigated them. Invite participants to join with one another in listening to the stories. b. Invite participants to share strengths that they hear in one another’s stories of how they navigated these difficult external events. c. Invite participants to brainstorm other ways they might navigate the others’ experiences of minority stress. Invite participants to reflect on the experience of talking about these experiences together using the follow-up questions.

Caroline Carter and Diane Sobel

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FROM STRESS TO STRENGTH CHART

External Stressor

Internal Stressor

Psychological Distress

Identify what happened. (This can be a direct or indirect experience.)

Identify what you told yourself afterward. (For example, identify internalized transphobia or anticipatory stress.)

Identify your mood, feelings, or behaviors that followed.

Identify the ways you were resilient during or following this experience.

My personal strengths that Additional ways other the group notices. members have coped with similar experiences.

External Stressor

Internal Stressor

Psychological Distress

Identify what happened.

Identify what you told yourself afterward.

Identify your mood, feelings, or behaviors that followed.

Identify the ways you were resilient during or following this experience.

My personal strengths that Additional ways other the group notices. members have coped with similar experiences.

1. Minority Stress Experience

Identifying Resilience

2. Minority Stress Experience

Identifying Resilience

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12 EXPLORING MULTIPLE MARGINALIZED IDENTITIES IN LGBT CLIENTS OF COLOR Vanessa Dabel Suggested Use: Activity Objective

The activity included in this chapter will help LGBT clients of color explore their intersecting minority identities and process experiences of oppression and marginalization in a clinical setting. Rationale for Use

As of 2016, about 7.3 percent of individuals aged eigh­ teen to thirty-six in the United States identified as a member of the lesbian, gay, bisexual, and transgender (LGBT) community (Gates, 2017). Also noteworthy is that higher rates of racial minorities than white individuals in the United States reported being LGBT in 2016: about 3.6 percent of whites, 4.9 percent of Asians, 5.4 percent of Hispanics, 4.6 percent of blacks, and 6.3 percent of “Other” minorities identified as LGBT (Gates, 2017). Further, about 40 percent of the overall U.S. LGBT population identified as members of racial and ethnic minorities in 2016 (Gates, 2017). These findings suggest the importance of understand­ ing the experiences of adults who hold multiple mar­ ginalized identities, specifically pertaining to their sex­ ual, gender, and racial or ethnic statuses. Researchers have found that racial, gender, and sexual minority individuals often experience oppres­ sion, marginalization, and microaggressions because of their minority statuses (Balsam et al., 2011; Gattis & Larson, 2017; Nadal et al., 2016; Sutter & Perrin, 2016). Microaggressions refer to seemingly subtle and unintentional assaults toward minority individuals. These assaults may be verbal or nonverbal and expe­ rienced as discriminatory (Balsam et al., 2011; Nadal,

2011; Nadal et al., 2016; Sue et al., 2007). Microag­ gressions may lead to distress for the person toward whom they are directed and negatively affect mental health and sense of self (Balsam et al., 2011; Gattis & Larson, 2017; Nadal, 2011; Sue et al., 2007). Respond­ ing to issues of racism, sexism, heterosexism, and overall oppression can have deleterious effects on LGBT individuals of color, leading them to experience issues such as depression, anxiety, substance abuse, and trauma, among other negative outcomes (Cochran et al., 2007; Díaz et al., 2001; Gattis & Larson, 2017; Hughes, Johnson, & Matthews, 2008; Meyer, Dietrich, & Schwartz, 2008; Sutter & Perrin, 2016; Zamboni & Crawford, 2007). LGBT individuals of color may feel ostracized and unaccepted by their heterosexual counterparts in their racial or ethnic community, while also experi­ encing racism and heterosexism in other settings (Fields et al., 2015; Malebranche, Fields, Bryant, & Harper, 2009; Nadal & Corpus, 2013; Sutter & Perrin, 2016). This is especially the case for gender-noncon­ forming individuals of color, who are often the target of violence, maltreatment, and victimization owing to their sexual identity and gender expression (Huffaker & Kwon, 2016; Singh & McKleroy, 2011). Addi­ tionally, the intersection of various identities can bring up feelings of inner turmoil for LGBT individuals of color, especially in the face of oppression. For these individuals, there may be an ongoing internal battle of attributing more value or higher priority to one par­ ticular identity, depending on which issues arise at a given moment (Nadal & Corpus, 2013; Santos & VanDaalen, 2016). Lesbian women of color, for example, may have to negotiate their various identities daily

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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when navigating family dynamics and issues in the workplace, and in instances of activism for social causes (e.g., racial inequality, women’s rights, LGBT rights). When working with LGBT clients of color in therapy, mental health professionals should consider possible within-group and cultural differences. For instance, information presented in this chapter high­ lights mainly the experiences of individuals in the United States, though some studies have also focused on non-U.S. cultures and societies (Dunn et al., 2014; Gates, 2011). It is also important for therapists to be mindful of the various sociocultural identities that can affect a client’s experiences, such as immigrant status, disability, class, and religion or spirituality (Nadal, 2008). The activity presented in this chapter contains open-ended questions specifically to allow clients to explore their individual cultural experiences with the therapist. Therapists must also consider the daily stress that LGBT individuals of color may experience given their multiple minority identities. Therefore, the activ­ ity provided here is based on the multicultural model of the stress process proposed by Slavin, Rainer, McCreary, and Gowda (1991) and adapted from Lazarus and Folkman’s (1984) stress model. This model highlights the cognitive and behavioral processes that minorities may experience following events of discrim­ ination and oppression. These individuals appraise the situation to determine level of danger, apply a relevant cultural frame to understand what they are experiencing, assess whether they can and should respond (considering aspects of their cultural identity and beliefs about systemic oppression), choose to cope through problem-focused or emotion-focused efforts, and as a result may experience a range of out­ comes (for example, somatic changes, changes in behavior or sense of self; Balsam et al., 2011; Gattis & Larson, 2017; Nadal et al., 2016; Sutter & Perrin, 2016). Individuals with multiple minority identities may constantly cycle through this process of evaluat­ ing experiences of oppression, and different aspects of their identity can be affected at different times (Nadal & Corpus, 2013; Santos & VanDaalen, 2016). Though there is no current research using the model proposed by Slavin and colleagues (1991), several researchers have emphasized the importance of under­

standing the influence of minority stress on individ­ uals with multiple minority identities, particularly LGBT people of color (Balsam et al., 2011; Gattis & Larson, 2017; Nadal et al., 2016; Sutter & Perrin, 2016). Therefore, use of the activity in this chapter can help LGBT clients of color better understand their internal processes and responses to these chal­ lenging experiences. The American Psychological Association (APA) has outlined specific guidelines for therapeutic work with lesbian, gay, and bisexual (LGB) individuals (APA, 2012), transgender and gender-nonconforming (TGNC) individuals (APA, 2015), and racial or ethnic minorities (APA, 1993). In the case of treating TGNC individuals, guideline 3 states, “Psychologists seek to understand how gender identity intersects with the other cultural identities of TGNC people” (APA, 2015). Similarly, guideline 11 for working with LGB clients states, “Psychologists strive to recognize the challenges related to multiple and often conflicting norms, values, and beliefs faced by lesbian, gay, and bisexual mem­ bers of racial and ethnic minority groups” (APA, 2012). These guidelines encourage practicing clinicians to acknowledge the role of multiple minority identities on the psychological and socioemotional functioning of clients (APA, 2012, 2015). Clinicians treating LGBT clients of color should be familiar with the guide­ lines so that they might better support these clients. Before completing this activity with clients, thera­ pists are encouraged to seek consultation and addi­ tional training if necessary to ensure delivery of cultur­ ally competent and appropriate services (APA, 1993, 2b, 2c). Professionals treating these clients must also understand the influence of their own intersecting identities and biases on their work with their clients (APA, 1993, 3a). This can be done through self-explo­ ration and using methods such as the ADDRESSING framework (Hays, 2001). This framework allows ther­ apists to examine their own cultural identities, power, and privilege across various categories, including age, disability, religion, ethnicity, social class, sexual orien­ tation, indigenous background, national origin, and gender (Hays, 2001). When considering use of the ADDRESSING framework in therapy with clients, therapists should consider their own level of comfort with self-disclosure regarding different aspects of their Exploring Multiple Marginalized Identities 101

identity and the potential effect of their disclosure on the therapeutic alliance (Hanson, 2005). Instructions

The activity presented in this chapter contains ques­ tions that can help generate discussion between ther­ apists and their clients regarding experiences with marginalization and oppression. This activity can be completed in about thirty minutes with clients in an individual or group therapy setting. By completing this exercise, clients will be able to process experiences of oppression and marginalization and explore ways that they negotiate their multiple minority identities on a daily basis. The goal is to help clients address and acknowledge these painful experiences so that they may ultimately experience healing and growth. To introduce this activity to clients, therapists may begin by saying, “I will be asking you some ques­ tions about your experience with marginalization and oppression. While I know that these questions may bring up difficult and painful experiences, my hope is that they may also lead to healing.” In addition, therapists can orient clients to ideas about oppres­ sion, marginalization, and microaggressions, though they must be sure that they themselves are familiar with these terms before discussing them with clients. Then therapists can assess clients’ understanding of these terms and offer psychoeducation if necessary. Therapists may then invite clients to reflect on their own experiences with these concepts and share aspects of these experiences in the therapy setting. After introducing the activity and relevant con­ cepts, therapists can focus on helping clients explore significant events in their journey (e.g., the comingout process) and ideas about the client’s own sexual, gender, racial or ethnic, and other social identities (e.g., socioeconomic status, religious or spiritual beliefs, nationality). Therapists can then discuss how the cli­ ents’ intersecting identities might influence their views about being LGBT (e.g., explore neighborhood demo­ graphics, stigma in their racial or ethnic community, family dynamics, religious or spiritual and sociocul­ tural experiences, possible internalized racism and homophobia). The following vignette provides an example of how a therapist might use the activity with a client. 102 Dabel

Brief Vignette

Joel is a twenty-year-old black, gay, cisgender male and a junior in college (a sociology major). He comes to the counseling center because of his concerns regarding academic stress and anxiety. He reports feeling worried about the upcoming midterms and is experiencing symptoms such as racing heartbeat, shortness of breath, and sweaty palms. He states that these symptoms have persisted for the past two weeks and he has not had much relief despite efforts to “relax.” Joel reports that he would like to learn strate­ gies for anxiety management and improved concen­ tration when studying for exams. At intake, Joel also reports that he came out to his family a couple of weeks before and has received mixed reactions. He decided that he wanted to come out to them before going home for Thanksgiving break next month, as a close friend on campus encour­ aged him to do so. His mother and father both have expressed anger and disappointment, indicating that he has “betrayed” his family and Christian upbringing. Joel has received support from his eighteen-year-old sister, while his twenty-three-year-old brother has been supportive though not completely understanding of his experience. Joel is worried about how things will go when he returns home for break. He indicates that he wants to come up with a plan for navigating his relationship with his parents, and he is wondering whether to disclose his sexuality to friends back home. Before completing the activity, the therapist spends time reflecting on her own social identities and biases that could affect her work with Joel. She and Joel both then openly share aspects of their various identities. After doing so, the therapist notices the Joel appears more relaxed, and he reports feeling more comfortable during the session. She then asks the following questions: • If you feel comfortable doing so, tell me more about your experience. Specifically, tell me about a time when you felt marginalized, discriminated against, or attacked because of who you are. • How did this experience make you feel? • How did you respond? Was that how you hoped you would respond? If not, how would you want to respond in the future?

• How do you feel that this experience has influ­ enced the way you see others, yourself, and the world? • Have you found any strategies helpful in coping with this experience? If so, what are those strategies? • What other coping strategies can you use to deal with the stress of these hurtful experiences? (Ther­ apists and client can collaboratively explore addi­ tional coping strategies.) Joel recalls feeling ostracized by his parents after com­ ing out, and he discusses his experiences with hetero­ sexism on campus. Joel also indicates undergoing psychological and psychosomatic acute trauma responses after the experiences with his family and friends, including feeling “frozen” and that his heart was “racing so fast” days after these events. Joel and the therapist collaboratively explore additional cop­ ing strategies, such as mindfulness practices, guided meditation, journaling, and continuing to process experiences in session. Joel expresses some motiva­ tion to begin implementing some of these practices, including bringing in a journal entry to his next therapy session. Suggestions for Follow-up

When following up, therapists can help clients reflect on ways to incorporate their various intersecting iden­ tities into their own sense of self. They can also help clients strengthen existing coping strategies and iden­ tify new adaptive strategies to cope with their expe­ riences. Therapists can also take time to process with clients what it was like to complete the activity and reflect on any insights gained from doing so. Contraindications for Use

When helping LGBT clients of color process experi­ ences of marginalization through this activity, thera­ pists must note that inquiries made regarding these experiences may lead clients to become retraumatized and retriggered. Therefore, therapists’ attunement to clients’ responses and body language is essential (Hanson, 2005; Levitt, Pomerville, & Surace, 2016). Clients who exhibit great discomfort or anxiety, for example, may not be ready to engage in the activity. It is also

important that therapists focus on establishing solid therapeutic rapport and fostering a sense of relative safety before asking potentially triggering questions. Professional Readings and Resources Davidson, M. M., & Hauser, C. T. (2015). Multicultural coun­ seling meets potentially harmful therapy: The complexity of bridging two discourses. Counseling Psychologist, 43 (3), 370–379. doi:10.1177/001100001456714. Ferguson, A. D., Carr, G., & Snitman, A. (2014). Intersections of race-ethnicity, gender, and sexual minority communi­ ties. In M. L. Miville & A. D. Ferguson (eds.), Handbook of race- ethnicity and gender in psychology, 45–63. New York: Springer. Hendricks, M. L., & Testa, R. J. (2012). A conceptual frame­ work for clinical work with transgender and gender non­ conforming clients: An adaptation of the minority stress model. Professional Psychology: Research and Practice, 43, 460–467. doi:10.1037/a0029597. Miville, M. L., & Ferguson, A. D. (eds.). (2014). Handbook of race-ethnicity and gender in psychology. New York: Springer. Wendt, D. C., Gone, J. P., & Nagata, D. K. (2015). Potentially harmful therapy and multicultural counseling: Bridging two disciplinary discourses. Counseling Psychologist, 43 (3), 334–358. doi:10.1177/0011000014548280.

Resources for Clients APA Division 44, Society for the Psychological Study of Lesbian, Gay, Bisexual, and Transgender Issues. (2018). https:// www.apa.org/about/division/div44.aspx. APA Office on Sexual Orientation and Gender Diversity (2018). Programs and services. https://www.apa.org/pi/lgbt/. Audre Lorde Project. (n.d.). http://alp.org. Chin, S. (2009). The other side of paradise: A memoir. New York: Simon and Schuster. Consortium of Higher Education LGBT Resource Professionals. (2017). https://www.lgbtcampus.org/. Human Rights Campaign. (2017). https://www.hrc.org. National LGBTQ Task Force. (2018). www.thetaskforce.org. Trans People of Color Coalition. (2013). https://www.glaad. org/tags/trans-people-color-coalition.

References American Psychological Association (APA). (1993). Guidelines for providers of psychological services to ethnic, linguistic, and culturally diverse populations. American Psychologist, 48, 45–48. American Psychological Association (APA). (2012). Guidelines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67, 10–42. American Psychological Association (APA). (2015). Guidelines for psychological practice with transgender and gender Exploring Multiple Marginalized Identities 103

nonconforming people. American Psychologist, 70, 832– 864. doi:10.1037//a0039906. Balsam, K. F., Molina, Y., Beadnell, B., Simoni, J., & Walters, K. (2011). Measuring multiple minority stress: The LGBT People of Color Microaggressions Scale. Cultural Diversity and Ethnic Minority Psychology, 17 (2), 163–174. doi:10.1037/a0023244. Cochran, S. D., Mays, V. M., Alegria, M., Ortega, A. N., & Takeuchi, D. (2007). Mental health and substance use dis­ orders among Latina/o and Asian American lesbian, gay, and bisexual adults. Journal of Counseling and Clinical Psychology, 75, 785–794. doi:10.1037/0022-006X.75. 5.785. Díaz, R. M., Ayala, E. B., Bein, E., Henne, J., & Marin, B. V. (2001). The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: Findings from 3 US cities. American Journal of Public Health, 91 (6), 927–932. Dunn, T. L., Gonzalez, C. A., Costa, A. B., Nardi, H. C., & Iantaffi, A. (2014). Does the minority stress model gen­ eralize to a non-U.S. sample? An examination of minority stress and resilience on depressive symptomatology among sexual minority men in two urban areas of Brazil. Psychology of Sexual Orientation and Gender Diversity, 1 (2), 117–131. doi:10.1037/sgd0000032. Fields, E. L., Bogart, L. M., Smith, K. C., Malebranche, D. J., Ellen, J., & Schuster, M. A. (2015). “I always felt I had to prove my manhood”: Homosexuality, masculinity, gender role strain, and HIV risk among young black men who have sex with men. American Journal of Public Health, 105 (1), 122–131. doi:10.2105/AJPH.2013.301866. Gates, G. J. (2011). How many people are lesbian, gay, bisex­ ual, and transgender? Williams Institute, 1–8. http://wil liamsinstitute.law.ucla.edu/wp-content/uploads/Gates­ How-Many-People-LGBT-Apr-2011.pdf. Gates, G. J. (2017). In U.S., more adults identifying as LGBT. Washington, DC: Gallup. http://www.gallup.com/poll/ 201731/lgbt-identification-rises.aspx. Gattis, M. N., & Larson, A. (2017). Perceived microaggressions and mental health in a sample of black youths experi­ encing homelessness. Social Work Research, 41, 7–17. doi:10.1093/swr/svw030. Hanson, J. (2005). Should your lips be zipped? How therapist self-disclosure and non-disclosure affects clients. Coun­ selling and Psychotherapy Research, 5 (2), 96–104. doi:10. 1080/17441690500226658. Hays, P. A. (2001). Addressing cultural complexities in practice: A framework for clinicians and counselors. Washington, DC: American Psychological Association. Huffaker, L., & Kwon, P. (2016). A comprehensive approach to sexual and transgender prejudice. Journal of Gay and Lesbian Social Services, 28, 195–213. doi:10.1080/105387 20.2016.1191405.

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Hughes, T. L., Johnson, T. P., & Matthews, A. K. (2008). Sexual orientation and smoking: Results from a multisite wom­ en’s health study. Substance Use and Misuse, 43, 1218–1239. doi:10.1080/10826080801914170. Lazarus, R., & Folkman, S. (1984), Stress, appraisal, and coping. New York: Springer. Levitt, H. M., Pomerville, A., & Surace, F. I. (2016). A qualita­ tive meta-analysis examining clients’ experiences of psy­ chotherapy: A new agenda. Psychological Bulletin, 142, 801–830. doi:10.1037/bul0000057. Malebranche, D. J., Fields, E. L., Bryant, L. O., & Harper, S. R. (2009). Masculine socialization and sexual risk behaviors among black men who have sex with men: A qualitative exploration. Men and Masculinities, 12, 90–112. doi:10. 1177/1097184X07309504. Meyer, I., Dietrich, J., & Schwartz, S. (2008, June). Lifetime prevalence of mental disorders and suicide attempts in divers lesbian, gay, and bisexual populations. American Journal of Public Health, 98 (6), 1004–1006. Nadal, K. L. (2008). Preventing racial, ethnic, gender, sexual minority, disability, and religious microaggressions: Rec­ ommendations for promoting positive mental health. Prevention in Counseling Psychology: Theory, Research, Practice, and Training, 2, 22–27. Nadal, K. L. (2011). The Racial and Ethnic Microaggressions Scale (REMS): Construction, reliability, and validity. Jour­ nal of Counseling Psychology, 58 (4), 470. doi:10.1037/ a0025193. Nadal, K. L., & Corpus, M. J. (2013). “Tomboys” and “bak­ las”: Experiences of lesbian and gay Filipino Americans. Asian American Journal of Psychology, 4 (3), 166–175. doi:10.1037/a0030168. Nadal, K. L., Whitman, C. N., Davis, L. S., Erazo, T., & Davidoff, K. C. (2016). Microaggressions toward lesbian, gay, bisex­ ual, transgender, queer, and genderqueer people: A review of the literature. Journal of Sex Research, 53, 488–508. doi :10.1080/00224499.2016.1142495. Santos, C. E., & VanDaalen, R. A. (2016). The associations of sexual and ethnic-racial identity commitment, conflicts in allegiances, and mental health among lesbian, gay, and bisexual racial and ethnic minority adults. Journal of Coun­ seling Psychology, 63, 668–676. doi:10.1037/cou0000170. Singh, A. A., & McKleroy, V. S. (2011). “Just getting out of bed is a revolutionary act”: The resilience of transgender people of color who have survived traumatic life events. Traumatology, 17, 34–44. doi:10.1177/1534765610369261. Slavin, L. A., Rainer, K. L., McCreary, M. L., & Gowda, K. K. (1991). Toward a multicultural model of the stress process. Journal of Counseling and Development, 70 (1), 156–163. doi:10.1002/j.1556-6676.1991.tb01578.x. Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B., Nadal, K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life: Implications

for clinical practice. American Psychologist, 62, 271–286. doi:10.1037/0003-066X.62.4.271. Sutter, M., & Perrin, P. B. (2016). Discrimination, mental health, and suicidal ideation among LGBTQ people of color. Journal of Counseling Psychology, 63, 98–105. doi:10. 1037/cou0000126.

Zamboni, B. D., & Crawford, I. (2007). Minority stress and sexual problems among African- American gay and bisexual men. Archives of Sexual Behavior, 36, 569–578. doi:10. 1007/s10508-006-9081-z.

Exploring Multiple Marginalized Identities 105

ACTIVIT Y The following guided questions will help clients process and cope with their experiences of marginalization and oppression. Please discuss the activity, along with related concepts, with clients before asking these questions, as they may be triggering. • If you feel comfortable doing so, tell me more about your experience. Specifically, tell me about a time when you felt marginalized, discriminated against, or attacked because of who you are.

• How did this experience make you feel?

• How did you respond? Was that how you hoped you would respond? If not, how would you want to respond in the future?

• How do you feel that this experience has influenced the way you see others, yourself, and the world?

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• Have you found any strategies helpful in coping with this experience? If so, what are those strategies?

• What other coping strategies can you use to deal with the stress of these hurtful experiences? (Therapists and clients can collaboratively explore additional coping strategies.)

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13 SOMOS LATINX: EXPLORING CULTURAL VALUES OF SEXUALLY AND GENDER-DIVERSE LATINX CLIENTS Zully A. Rivera Ramos, Amanda Lawson-Ross, and Carlos Hernández Suggested Use: Handout Objective

The objective of this handout is to support sexually and gender-diverse Latinx clients in exploring the influence of traditional cultural values (Edwards & Cardemil, 2015; Marin & Marin, 1991) on their sexual, gender, and Latinx identities. Doing so may facilitate their process of integrating and affirming these intersecting identities. Clients may be able to identify, process, and communicate their experi­ ences at personal, interpersonal, structural, and cultural levels. Rationale for Use

Historically, underrepresented sexually and genderdiverse individuals have suffered from marginaliza­ tion and oppression, which is further complicated by their intersection with other marginalized identities, such as Latinx (González & Espín, 1996; Manalansan, 1996; Rivera-Ramos, Oswald, & Buki, 2015). We use the term Latinx as a gender-inclusive way of referring to people of Latin American descent (Padilla, 2016). The use of Latino marginalizes women, transgender, and genderqueer individuals. By replacing the use of “o/a” at the end of “Latin” with an “x,” we acknowl­ edge the intersectionality of sexual, gender, and Latinx identities (Padilla, 2016). In the United States, under­ represented sexually and gender-diverse Latinx indi­ viduals probably experience heterosexism or cisgen­ derism (or both) within their Latinx community and racism within the primarily white underrepresented sexually and gender-diverse community, which may lead them to have to choose between these commu­

nities (González & Espín, 1996; Manalansan, 1996; Rivera-Ramos et al., 2015). Individuals who self-identify with their Latinx community have unique challenges in how they expe­ rience and internalize oppression (Manalansan, 1996; Muñoz-Laboy et al., 2009; Rivera-Ramos et al., 2015; Velez, Moradi, & DeBlaere, 2014; Zea, Reisen, & Poppen, 1999). The Pulse massacre is a tragic example of the complexity of these challenges. Pulse is a night­ club located in Orlando, Florida, serving primarily underrepresented sexually and gender-diverse individ­ uals. One June 12, 2016, a large mass shooting occurred at Pulse during Latinx night (Vazquez, 2016). Many Latinx families learned about their children’s sexually and gender-diverse identities in the aftermath of the shooting. Much of the media coverage was focused on the sexually and gender-diverse identities of the victims or the attacker’s Muslim identity without not­ ing the intersectionality of Latinx, sexual, and gender identities. This chapter attempts to address the com­ plexity of these intersecting experiences to promote culturally responsive interventions. Liberation psychology is a culturally appropriate theoretical orientation in working with underrepre­ sented sexually and gender-diverse Latinx individuals, as it was developed by Ignacio Martín-Baró (1983a, 1983b), a social psychologist from El Salvador who served and advocated for socially marginalized groups. He suggested that it is critical to examine the oftenpathologized subjective experiences of marginalized groups who have had few opportunities to tell their story from their perspective because of the dominant discourse established by oppressive social structures. This theory facilitates giving voice to those often

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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silenced by oppression and marginalization and advo­ cates for a social justice approach addressing systemic, cultural, and sociopolitical factors influencing individ­ ual experiences (Chávez, Torres Fernandez, HipólitoDelgado, & Torres Rivera, 2016; Martín-Baró, 1983a, 1983b). The theory includes three main processes: consci­ entization, empowerment, and problematization (Chávez et al., 2016). Conscientization entails assisting clients in becoming aware of the structural factors influencing their distress (Chávez et al., 2016). With underrepresented sexually and gender-diverse Latinx clients, this involves becoming aware of the effects of oppression that are due to their race or ethnicity, sex­ ual orientation, gender identity, social class, and doc­ umentation status, among others. Through promoting empowerment we instill hope and support, recognize clients’ strength and resiliency, and identify support­ ive resources that have helped them survive in the midst of systemic oppression. We can support clients by normalizing their experiences and recognizing that they can reclaim and redefine Latinx cultural values. This leads to the process of problematization, where we facilitate an understanding of how the interaction of personal, interpersonal, structural, and cultural factors have perpetuated the cycle of oppression in which they live (Chávez et al., 2016). Problematization entails questioning how these cultural values affect the integration of their marginalized identities. Liberation psychology aligns itself with affirmative practices because it goes beyond the individual and focuses on sociocultural factors. This theory can be easily integrated with multicultural and feminist the­ ories (Crethar, Torres-Rivera, & Nash, 2008; Funder­ burk & Fukuyama, 2001; Gonzalez, Biever, & Gardner, 1994; Negy & McKinney, 2006) because they also focus on social justice advocacy and structural inequalities, as well as power dynamics between the client-counselor relationship and the influence of cultural values on individuals’ psychological well-being. Multiculturalism assumes that people construct the meaning of their world through their cultural and sociohistorical experi­ ences, and there are thus multiple perspectives that should be equally valued (Funderburk & Fukuyama, 2001). Feminist counseling has been found to enhance resiliency and emotional well-being among under­

represented sexually and gender-diverse individuals and families (Negy & McKinney, 2006). Latinx sexu­ ally and gender-diverse individuals often have to navi­ gate hostile sociopolitical and familial environments (Manalansan, 1996; Muñoz-Laboy et al., 2009; RiveraRamos et al., 2015; Velez et al., 2014; Zea et al., 1999). Thus, it is critical to address resiliency in dealing with oppression and negative biases. Through integrating these theories with the hand­ out in this chapter, clients may explore their Latinx cultural values in relation to their sexual orientation and gender identity. The assumption is that clients are experts on their own lives and counselors are col­ laborators. This is key as we support clients’ develop­ ment of autonomy and sense of control in order to facilitate taking action to change the oppressive struc­ tural system affecting their distress. Ethical codes for counselors (ACA, 2014, F.11.c) and psychologists (APA, 2017, 2.01b) encourage the development of awareness, knowledge, and skills in serving culturally diverse individuals in regard to eth­ nicity, gender identity, race, sexual orientation, and other cultural identities. Understanding the influence of these identities is critical for providing services and making appropriate referrals (ACA, 2014, A.11.b). Awareness about our role as service providers, as well as our limitations, is critical as we engage in social justice–oriented work (ACA, 2014, A.4.b). To be con­ sistent with ACA and APA ethics codes, it is also important to be aware of the biases that we hold and how these affect our understanding of cultural values that may be salient for underrepresented sexually and gender-diverse Latinx clients (ACA, 2014, C.5; APA, 2017, 3.01, 3.03). Instructions

After rapport-building and information-gathering sessions are completed, the handout may be intro­ duced. Give the handout to clients to be completed in session or at home and process it in session. Read the instructions on the sheet and explain the exam­ ple to facilitate understanding. The aim is to identify cultural values that may be affecting clients both negatively and positively, as a way to support them in integrating and affirming their intersecting gender, sexual, and Latinx identities. Somos Latinx: Exploring Cultural Values 109

Brief Vignette

Alex (pronouns: they, them, theirs) is a twenty-year­ old college junior majoring in engineering. They came to the counseling center to explore feelings of depression and sadness related to school and family. On the intake form, they indicated “questioning” on sexual orientation and “other” on gender identity. They self-identified as multiracial and of Cuban, Mexican, and Puerto Rican descent and disclosed having fam­ ily members of mixed documentation status. Alex appeared nervous and was tearful. They are from a “traditional loving and chaotic” working-class family where both of their parents and their older brother (twenty-two) contribute financially. Alex has a younger sister (seventeen). The family is Catholic and attends church regularly. Alex completed the first two years at a junior college close to home, and it has been difficult for them to adjust to a primarily European American, white university. Alex expressed feeling homesick and not really connecting with other students on cam­ pus. They feel they have no time to socialize because of the amount of work required in their major. They started questioning their sexual and gender identities in high school, and it has continued in col­ lege. They reported having gone to a sexually and gender-diverse student club meeting once, but left shortly after arriving because they did not feel they belonged and felt nervous and scared someone might recognize them. They had not spoken to anyone about this at the beginning of counseling and expressed feeling sad and disgusted; they also mentioned pray­ ing to God to help them “change.” Alex expressed struggling with their family’s cultural values and how their family may react; Alex worried that they may have to choose between being themselves and adhering to their Latinx culture’s norms, values, and expectations. Alex completed the handout at home. During the following session, we processed the results, and they had marked that respeto had a moderate and positive effect on their Latinx identity, while it had a greater and negative influence on their sexual and gender identities (i.e., conscientization). This suggested that the effect of this value is conflicted and potentially contributing to their distress. Helping Alex recog­ nize their strength and resiliency in navigating the value of respeto instilled hope and empowerment in 110 Rivera Ramos, Lawson-Ross, & Hernández

their decision to uphold their parents’ wishes not to come out to others in the family, while seeking sup­ port and affirmation in exploring their sexual ori­ entation and gender identity (i.e., empowerment). This led to the question of how respeto is affecting the integration of their Latinx, sexual, and gender identities, as well as understanding their concerns within a larger sociocultural context (i.e., prob­ lematization). Thus, the counseling process pro­ moted an understanding of their intra- and inter­ personal challenges, in conjunction with the psychosocial and sociopolitical implications related to Alex’s distress. In the following sessions, we con­ tinued to deepen exploration of respeto and other salient cultural values. We also addressed how their views of the cultural values compared to their fami­ ly’s views. This counseling process helped Alex depathologize their concerns, feel more connected to their intersecting identities, accept certain aspects of their culture, and improve their relationships. Suggestions for Follow-up

Processing the responses on the handout may take several sessions. Refer to the list of follow-up questions for further exploration. It is important to challenge irrational thinking and myths, reconstruct positive and affirming characteristics, and empower clients as you support them in integrating and valuing their sexual, gender, and Latinx identities. Contraindications for Use

This handout is based on our experience working with sexually and gender-diverse Latinx college students at predominantly white institutions. Given the variety of resources available at institutions of higher educa­ tion, working with community members (e.g., mar­ ried with children or elderly) may present additional challenges related to language barriers, documenta­ tion status, and finances. The handout may work with other age ranges and may need to be adapted for the client’s developmental stage. The handout may not be useful with elementary- and middle-school children because they may not have a clear understanding of Latinx cultural values and how these may intersect with sexual orientation and gender identity. It may be

also contraindicated for use with individuals who reject or do not identify with their Latinx culture and related values. Professional Readings and Resources Edwards, L. M., & Cardemil, E. V. (2015). Clinical approaches to assessing cultural values among Latinos. In K. F. Geisinger (ed.), Psychological testing of Hispanics: Clinical and intellectual issues, 215–236. Washington, DC: Ameri­ can Psychological Association. doi:10.1037/14668-012. Estrada, F., Rigali-Oiler, M., Arciniega, G. M., & Tracey, T. J. G. (2011). Machismo and Mexican American men: An empirical understanding using a gay sample. Journal of Counseling Psychology, 58 (3), 358–367. doi:10.1037/ a0023122. Hames-García, M., & Martínez, E. J. (2011). Gay Latino studies: A critical reader. Durham, NC: Duke University Press. Muñoz-Laboy, M., Leau, C. J., Sriram, V., Weinstein, H. J., del Aquila, E. V., & Parker, R. (2009). Bisexual desire and familism: Latino/a bisexual young men and women in New York City. Culture, Health, and Sexuality, 11, 331–344. doi:10.1080/13691050802710634. Rivera-Ramos, Z. A., Oswald, R. F., & Buki, L. P. (2015). A Latina/o campus community’s readiness to address les­ bian, gay, and bisexual concerns. Journal of Diversity in Higher Education, 8 (2), 88. doi:10.1037/a0038563. Sager, J. B., Schlimmer, E. A., & Hellmann, J. A. (2001). Latin American lesbian, gay, and bisexual clients: Implications for counseling. Journal of Humanistic Counseling, Educa­ tion, and Development, 40 (1), 21–34. doi:10.1002/j.21 64-490X.2001.tb00099.x. Velez, B. L., Moradi, B., & DeBlaere, C. (2014). Multiple oppres­ sions and the mental health of sexual minority Latina/o individuals. Counseling Psychologist, 43 (1), 7–38. doi:10. 1177/0011000014542836. Zea, M. C., Reisen, C. A., & Poppen, P. J. (1999). Psychological well-being among Latino lesbians and gay men. Cultural Diversity and Ethnic Minority Psychology, 5, 371–379. doi:10.1037/1099-9809.5.4.371.

Resources for Clients: Print and Online American Psychological Association (APA). (2011). Respues­ tas a sus preguntas sobre las personas trans, la identidad de género y la expresión de género. https://www.apa.org/ topics/lgbt/brochure-personas-trans.pdf. American Psychological Association (APA). (2012). Respues­ tas a sus preguntas para una mejor comprensión de la ori­ entación sexual y la homosexualidad. https://www.apa. org/topics/lgbt/answers-questions-so-spanish.pdf. Asociación de Psicología de Puerto Rico, Comité de Asuntos de la Comunidad LGBT. (2014). Estándares para el tra­ bajo e intervención en comunidades lesbianas, gay, bisex­

uales e identidades trans. http://docs.wixstatic.com/ ugd/0522af_89334b8cc3904582841b58dcce2ca374.pdf. DeColores Queer Orange County. (n.d.). https://dcqoc.wee bly.com/. De la Torre, M., Castuera, I., & Meléndez Rivera, L. (n.d.). A la familia: Una conversación sobre nuestras familias, la biblia, la orientación sexual y la identidad de género. http://www.thetaskforce.org/static_html/downloads/ release_materials/tf_a_la_familia.pdf. Familia: Trans Queer Liberation Movement. (n.d.). http:// familiatqlm.org/. Familia es familia. (2017). http://familiaesfamilia.org/. Harrison-Quintana, J., Pérez, D., & Grant, J. (2012). Injustice at every turn: A look at Latino/a respondents in the National Transgender Discrimination Survey. www. transequality.org/sites/default/files/docs/resources/ntds_ latino_english_2.pdf. Human Rights Campaign. (2013). Guía de recursos para salir del closet: Para personas lesbianas, gais, bisexuals y trans­ géneros. http://assets.hrc.org//files/assets/resources/ GuiaParaSalirDelCloset_2013_final.pdf. Latino Outreach and Understanding Division: LOUD. (n.d.). http://somosloud.org/. PFLAG San Juan, PR. (n.d.). https://www.facebook.com/ PFLAG.SanJuan.PR. Somos Orlando. (n.d.). http://somosorlando.info/. TransLatin@ Coalition. (n.d.). https://www.translatinacoali tion.org/. University of Washington Q Center. (2008). Guide to Latin American LGBT communities. http://depts.washington. edu/qcenter/sites/default/files/downloads/Latin%20 Am%20LGBT%20Guide.pdf. Vásquez-Rivera, M., Martínez-Taboas, A., Francia-Martínez, M., & Toro-Alfonso, J. (2016). LGBT 101: Una mirada introductoria al colectivo. San Juan, PR: Publicaciones Puertorriqueñas.

Resources for Clients: Films Barbosa, P., & Lenoir, G. (directors). (2001). De colores (doc­ umentary). Oakland, CA: Eyebite Productions & Woman Vision Productions. Barrón, E. (producer), & Tovar Velarde, S. (director). (2014). Cuatro lunas. Mexico City: Atko Films, Los Gueros, Kinomada, Color Space, & Skyflak Studio. Castro-Bojorquez, M. (producer & director), & Alfaro, J. (direc­ tor). (2011). Tres gotas de agua (documentary). Oakland, CA: Somos Familia. Castro-Bojorquez, M. (producer & director), Alfaro, J. Cruz, K., & Salinas, L. (producers). (2015). El canto del colibrí (documentary). San Francisco: Somos Familia & Bayview Hunters Point Center for Arts and Technology. Gutiérrez A. T., & Tabío, J. C. (directors). (1993). Fresa y choc-

Somos Latinx: Exploring Cultural Values 111

olate. Havana: Instituto Cubano del Arte e Industrias Cinematográficos. McCray, J. (producer & director). (2007). Tal como somos (documentary). Chicago: Juneteenth Productions & University of Illinois at Chicago.

References American Counseling Association (ACA). (2014). ACA code of ethics. https://www.counseling.org/resources/aca-code­ of-ethics.pdf. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/. Anastasia, E. A., & Bridges, A. J. (2015). Understanding ser­ vice utilization disparities and depression in Latinos: The role of fatalismo. Journal of Immigrant and Minority Health, 17, 1758–1764. doi:10.1007/s10903-015-0196-y. Arciniega, G. M., Anderson, T. C., Tovar-Blank, Z. G., & Tracey, T. J. G. (2008). Toward a fuller conception of machismo: Development of a traditional machismo and caballerismo scale. Journal of Counseling Psychology, 55 (1), 19–33. doi:10.1037/0022-0167.55.1.19. Bryant-Davis, T., & Comas-Díaz, L. (2016). Womanist and mujerista psychologies: Voices of fire, acts of courage. Wash­ ington, DC: American Psychological Association. Chávez, T. A., Torres Fernandez, I., Hipólito-Delgado, C. P., & Torres Rivera, E. (2016). Unifying liberation psychol­ ogy and humanistic values to promote social justice in counseling. Journal of Humanistic Counseling, 55 (3), 166–182. doi:10.1002/johc.12032. Crethar, H. C., Torres-Rivera, E., & Nash, S. (2008). In search of common threads: Linking multicultural, feminist, and social justice counseling paradigms. Journal of Counseling and Development, 86, 269–278. doi:10.1002/j.1556-6678. 2008.tb00509.x. Edwards, L. M., & Cardemil, E. V. (2015). Clinical approaches to assessing cultural values among Latinos. In K. F. Geisinger (ed.), Psychological testing of Hispanics: Clini­ cal and intellectual issues, 215–236. Washington, DC: American Psychological Association. doi:10.1037/14668 -012. Funderburk, J. R., & Fukuyama, M. A. (2001). Feminism, multiculturalism, and spirituality: Convergent and divergent forces in psychotherapy. Women & Therapy, 24 (3–4), 1–18. doi:10.1300/J015v24n03_01. González, F. J., & Espín, O. M. (1996). Latino men, Latina women, and homosexuality. In R. P. Cabaj & T. S. Stein (eds.), Textbook of homosexuality and mental health, 583–602. Washington, DC: American Psychiatric Press. Gonzalez, R. C., Biever, J. L., & Gardner, G. T. (1994). The multicultural perspective in therapy: A social construc­ tionist approach. Psychotherapy, 31, 515–524. doi:10.1037/0033-3204.31.3.515.

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Manalansan, M. F., IV. (1996). Double minorities: Latino, Black, and Asian men who have sex with men. In R. C. Sav­ in-Williams & K. M. Cohen (eds.), The lives of lesbians, gays, and bisexuals, 393–415. Orlando, FL: Harcourt Brace. Marin, G., & Marin, B. V. (1991). Research with Hispanics. Newbury Park, CA: Sage. Martín-Baró, I. (1983a). Las estructuras sociales y su impacto psicológico. In Martín-Baró, Acción e ideología, 71–109. San Salvador: UCA Editores. Martín-Baró, I. (1983b). La interacción personal contexto y percepción. In Martín-Baró, Acción e ideología, 183–240. San Salvador: UCA Editores. Muñoz-Laboy, M., Leau, C. J., Sriram, V., Weinstein, H. J., del Aquila, E. V., & Parker, R. (2009). Bisexual desire and familism: Latino/a bisexual young men and women in New York City. Culture, Health and Sexuality, 11, 331– 344. doi:10.1080/13691050802710634. Negy, C., & McKinney, C. (2006). Application of feminist therapy: Promoting resiliency among lesbian and gay families. Journal of Feminist Family Therapy, 18, 67–83. doi:10.1300/J08v18n01_03. Ojeda, L., Pina-Watson, B., & Gonzalez, G. (2016). The role of social class, ethnocultural adaptation, and masculinity ideology on Mexican American college men’s well-being. Psychology of Men and Masculinity, 17 (4), 373–379. doi:10.1037/men0000023. Padilla, Y. (2016, April 18). What does “Latinx” mean? A look at the term that’s challenging gender norms. Complex. https://www.complex.com/life/2016/04/latinx/. Piña-Watson, B., & Abraído-Lanza, A. (2016). The intersection of fatalismo and pessimism on depressive symptoms and suicidality of Mexican descent adolescents: An attribution perspective. Cultural Diversity and Ethnic Minority Psy­ chology, 23 (1), 93–101. doi:10.1037/cdp0000115. Piña-Watson, B., Ojeda, L., Castellon, N., & Dornhecker, M. (2013). Familismo, ethnic identity, and bicultural stress as predictors of Mexican American adolescents’ positive psychological functioning. Journal of Latina/o Psychology, 1 (4), 204–217. doi:10.1037/lat0000006. Rivera-Ramos, Z. A., Oswald, R. F., & Buki, L. P. (2015). A Latina/o campus community’s readiness to address lesbian, gay, and bisexual concerns. Journal of Diversity in Higher Education, 8 (2), 88–103. doi:10.1037/a0038563. Stevens, E. P. (1973). Marianismo: The other face of machismo in Latin America. In A. Pescatello (ed.), Female and male in Latin America: Essays, 89–100. Pittsburgh: University of Pittsburgh Press. Tropp, L., Erkut, S., García Coll, C., Alarcón, O., & Vazquez García, H. (1999). Psychological acculturation: Develop­ ment of a new measure for Puerto Ricans on the U.S. mainland. Educational Psychological Measurement, 59 (2), 351–367. doi:10.1177/00131649921969794.

Vasquez, R. (2016, June 19). The Point podcast episode 1: Covering the Pulse shooting. The Point @ WUFT Podcast. https://www.wuft.org/news/2016/06/19/the-point­ podcast-episode-1-covering-the-pulse-shooting/. Velez, B. L., Moradi, B., & DeBlaere, C. (2014). Multiple oppressions and the mental health of sexual minority

Latina/o individuals. Counseling Psychologist, 43 (1), 7–38. doi:10.1177/0011000014542836. Zea, M. C., Reisen, C. A., & Poppen, P. J. (1999). Psychologi­ cal well-being among Latino lesbians and gay men. Cul­ tural Diversity and Ethnic Minority Psychology, 5, 371–379. doi:10.1037/1099-9809.5.4.371

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FOLLOW-UP QUESTIONS The questions below can be used as a follow-up to the cultural values activity over several sessions. Make sure to process clients’ reactions to the activity. The goal is for clients to reflect on the effects of the intersections of their Latinx, gender, and sexual identities. 1. How does your gender, and what this means for you, affect your Latinx and sexual identities?

2. How was your coming-out process, given your multiple oppressed identities?

3. How does your family’s documentation status influence your experiences as a sexually or genderdiverse Latinx individual?

4. Which sociopolitical events, such as the Pulse massacre, have affected your experiences as a sexually or gender-diverse Latinx individual?

5. If you speak Spanish or Portuguese with your family, how does language relate to your comingout process?

6. Who are people within your Latinx family and community who can act as potential allies in your coming-out process and who may help you cope with the fear of rejection?

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7. What have you heard about sexually or gender-diverse individuals within your Latinx family and community?

8. What biases do you have in relation to sexual orientation or gender identity?

9. How have you navigated your Latinx, gender, and sexual identities?

10. What other intersecting identities have affected you?

11. What do you need to feel truly integrated as a sexually or gender-diverse Latinx individual?

12. How does your experience as a sexually or gender-diverse Latinx individual within the Latinx community compare to your experience within the European American white dominant society?

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14 BUILDING RESILIENCE WITH CLIENTS WHO FACE MULTIPLE FORMS OF OPPRESSION Kristin N. Bertsch

Suggested Uses: Activity, homework Objective

This activity is designed for clients who face multiple intersecting minority identities (e.g., race, sexual ori­ entation, and gender). Clients will be encouraged to explore the multiple identities they hold and how experiences of oppression affect them in their every­ day life. Additionally, clients will be invited to assess their individual strengths and values and be guided in how to use these strengths and values to partici­ pate in collective action that is meaningful to them to build resilience against incidents of discrimina­ tion. For the purposes of this exercise, collective action has been defined as an individual of a particu­ lar group “acting as a representative of the group” and participating in action that “is directed at improving the condition of the entire group” (Wright, Taylor, & Moghaddam, 1990, p. 995). Rationale for Use

An increasing amount of research conducted with pop­ ulations with multiple marginalized identities (e.g., race, sexual orientation, and gender) suggests that experiences of discrimination are related to negative mental health concerns (DeBlaere et al., 2014, Ghab­ rial, 2017). Specifically, individuals who identify with these intersecting marginalized identities have unique experiences apart from those of their white sexualminoritized counterparts and their heterosexual eth­ nic-minoritized counterparts. For instance, in a quali­ tative study with eleven lesbian, gay, bisexual, trans, and queer people of color (LGBTQ-POC), Ghabrial (2017) sought to examine how respondents described

the relationships between their identities and com­ munities, to explore how underresearched microag­ gressions may affect LGBT-POC, and to learn more about how multiple marginalization and discrimina­ tion affect stress and health in the LGBTQ-POC community. Four common themes emerged. Some respondents reported feeling disconnected from their racial or ethnic community because of their sexual orientation and/or disconnected from the mainstream LGBTQ community owing to their racial or ethnic identity. In terms of identity relationships, some par­ ticipants felt they had to conceal their sexual orien­ tation because of their racial identity, often referring to cultural expectations as one of the reasons, whereas other participants felt that a sexual-minority and racialized identity was a source of pride. In terms of coming out, some participants concealed their sexual identity because of cultural homophobia, threat to safety, and stress, noting the importance of awareness of one’s basic needs and safety. Stress and anxiety, the last theme, were centered on negative psychological and physical symptoms (e.g., hair loss) that result from having these multiple minoritized identities. For all these reasons, it is important that therapists hold a unique, nuanced understanding of the variety of chal­ lenges faced by this population and use culturally appropriate interventions. Although research has been conducted to assess therapist competencies when working with sexualminority populations, fewer studies have examined the efficacy of affirmative psychotherapy practices when working with these populations (Berke, Maples-Keller, & Richards, 2016). However, scholars agree that there are a few central behaviors that are critical to affirmative

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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counseling. For instance, important LGBQ-affirmative behaviors include building a strong therapeutic alli­ ance, advocacy skills (e.g., knowledge of community resources for LGBQ individuals), therapist knowledge of LGBQ-nuanced concerns, self-awareness of atti­ tudes toward one’s own and others’ sexual-identity development, and assessment of underlying concerns of LGBQ clients (Dillon, Worthington, Soth-McNett, & Schwartz, 2008). Additionally, affirmative counsel­ ors work from a nonpathological framework when conceptualizing an LGBQ person’s presenting concerns (APA, 2012). It is important that affirmative interven­ tions match the client’s developmental level, culture, stage of identity, and level of self-acceptance. Affir­ mative therapists are also aware that this population is resilient and knowledgeable about interventions that will build on that resilience to help thwart the negative effects of discriminatory experiences. The minority stress framework posits that grouplevel coping strategies may build further resilience and thus lessen the negative mental health conse­ quences associated with oppression for sexual-minor­ ity persons (Meyer, 2003; Szymanski & Owens, 2009). DeBlaere and colleagues (2014) investigated the protective power of collective action for sexual-minority women of color in the context of multiple discrimi­ nation experiences (e.g., racism, sexism, and hetero­ sexism) and psychological distress. Several findings were telling in the experiences of sexual-minority women of color. Experiences of racism, sexism, and heterosexism were each positively and significantly related to psychological distress. When examined together, only heterosexism accounted for significant and unique variance in psychological distress with this sample of sexual-minority women of color. These findings suggest that participants in this sample may have developed coping strategies related to gender and race because of the visibility of these identities. Because sexual identity is often invisible, women in this sample may have been more likely to encounter heterosexual discrimination as a result of having developed fewer coping strategies for discrimination that was based on this identity. It is evident that hav­ ing multiple marginalized identities is complex and important to explore. In accordance with affirmative counseling practices, the ability to integrate ways to

explore collective-action interventions in the therapy room requires a strong therapeutic alliance, a deep understanding of the client’s presenting concerns, and accurate perception of the client’s development level. Finally, the American Psychological Association provides “Guidelines for Psychological Practice with LGB Clients” (APA, 2012). These codes can be helpful in guiding and informing work with clients. In particu­ lar, guideline 1 states, “Psychologists strive to under­ stand the effects of stigma (i.e., prejudice, discrimina­ tion, and violence) and its various contextual manifest­ ations in the lives of lesbian, gay, and bisexual people” (APA, 2012, p. 12). In terms of application, APA notes that a safe therapeutic relationship is of primary importance. Additionally, this guideline also under­ scores the importance of understanding “the different combinations of contextual factors related to gender, race, ethnicity, cultural background, social class, reli­ gious background, disability, geographic region, and other sources of identity that can result in dramatically different stigmatizing pressures and coping styles” (APA, 2012, pp. 12–13). Along with increasing a cli­ ent’s sense of safety and decreasing stress, APA urges psychologists to assist clients in developing social resources and to empower clients to confront social stigma and discrimination when appropriate. APA distinguishes between clients who are more comfortable with their sexual orientation and those who are not as comfortable when referring clients to social resources. For those who are more comfort­ able, referring to local support groups or other com­ munity resources may be appropriate. For those who are less comfortable with their sexual orientation, online discussion groups or community groups may better meet the client’s level of identity development. Taken together, APA recognizes the importance of building social networks and community as a way to protect against the negative psychological effects of discrimination. Therefore, psychologists who are knowledgeable about a range of collective-action activi­ ties that are aimed at decreasing isolation and build­ ing resilience are also adhering to APA guidelines and recommendations. The “Guidelines for Psychological Practice with LGB Clients” (APA, 2012) pay particular attention to cli­ ents with multiple minoritized identities. For instance, Building Resilience with Clients Who Face Oppression 125

guideline 11 states, “Psychologists strive to recognize the challenges related to multiple and often conflicting norms, values, and beliefs faced by lesbian, gay, and bi­ sexual members of racial and ethnic minority groups” (APA, 2012, p. 20). APA encourages psychologists to work with clients in identifying protective factors and coping skills that may have developed as a result of their multiple minoritized identities. Additionally, psy­ chologists should be aware of additional protective factors that have been demonstrated to be helpful in decreasing the amount of psychological distress (e.g., collective action; DeBlaere et al., 2014). These pro­ tective factors can help clients build on their already existing coping strategies to strengthen resilience against stigma and discrimination that are based on their sexual, racial, and ethnic identities. Instructions

This exercise would best be used after the therapist has a conceptual understanding of the client’s sexualidentity development level and presenting concerns and has created a strong therapeutic relationship. This activity may range over a number of sessions depending on the clients and where they are in terms of readiness to take action steps. In terms of intro­ ducing the activity, it is important for the therapist to use everyday language to communicate psychoedu­ cation about the potential benefit of participating in collective action to thwart the negative psychological consequences of discriminatory experiences. First, it is important to use the Identity Prompts Worksheet to explore aspects of identity that are salient to the client. The prompts provided (which are not exhaustive) are important for therapists to use whether or not they engage further in the activity, as doing so gives them a nuanced understanding of their clients’ particular identities. The identity exploration may take place in the beginning sessions (e.g., session three or four, depending on the nature of the therapeutic alli­ ance) and may take an entire session or multiple ses­ sions, depending on the client and the content dis­ closed. As therapists learn more about their clients, their level of knowledge will inform the types of collec­ tive-action activities that may be suggested. It is important to emphasize that collective action can take different forms and can be shaped in ways 126 Bertsch

that align with an individual’s strengths, values, inter­ ests, and time constraints. It can be particularly help­ ful to explain to clients that participating in collec­ tive action can help people feel empowered by “doing something.” To assist clients in exploring and identi­ fying which type of collective action may align most with their strengths and interests, therapists may use the Homework Assignment (on page 130) for sug­ gested exploration questions that clients can think about and answer between sessions. Clients can com­ plete the assignment at home as they reflect on their answers, or they can complete it in session, depending on the wishes of the clients or therapists. In the explanation of the Homework Assignment, therapists should invite clients to think more in depth about their values and strengths and which collectiveaction activity may be the best fit. Additionally, depend­ ing on the clients’ preferences and strengths, thera­ pists may benefit from spending time between sessions finding local community organizations that support LGBQ persons of color and also researching upcom­ ing events. In the following session, therapists should invite clients to discuss their progress or lack thereof and process the experience of doing the homework— or what prevented them from exploring their inter­ ests. In this session, therapists may present the Collec­ tive-Action Activity sheet and work with clients to determine if one or more of the activities listed seem like an appropriate fit. Therapists should note to the clients that the list is not exhaustive and that clients are welcome to try other activities that are not listed. Brief Vignette

Kia identified as a twenty-one-year-old African Amer­ ican, cisgender, queer woman in her senior year at a four-year university. She said she had come out to her parents about a year before, and her mother continues to imply that “this is just a phase,” and her father “does not acknowledge that part of my life.” Kia said that before she came out, she had a close relationship with her parents and would go home often for family and church events, as she was always active in her family, church, and black community (the three often inter­ sected). After coming out, Kia reported visiting home less frequently and feeling like an outsider in her fam­ ily and in church. Kia noted that she has a girlfriend,

but her mother refers to Kia’s girlfriend as “her friend” and her father does not acknowledge her girlfriend “at all.” Kia said she has limited social support other than that from her girlfriend and often felt that she “didn’t fit in anywhere.” Kia reported that she knew of spaces on campus that might be “safe” and identified the women’s center, the LGBT center, and the Black Cultural Center, but she also acknowledged feeling that she could talk about only one identity that cor­ responded with that particular center, and when she attempted to talk about the intersection of her minori­ tized identities, the room often fell silent. It became clear that Kia began to internalize these reactions, as she perceived them to be invalidating and silencing. The therapist worked to create a strong thera­ peutic rapport that allowed Kia to share all her iden­ tities. It was during session three that Kia and her therapist were able to explore Kia’s multiple identities in greater depth. Simultaneously, the therapist nor­ malized Kia’s experience. For example, the therapist commended and highlighted the coping skills Kia had developed as a way of dealing with feelings of rejection from her community (e.g., writing poetry) and empathized with the challenges she faced (e.g., isolation). Approximately five sessions into therapy, the therapist provided psychoeducation on collective action and how it may be helpful to find community with people with similar identities and experiences. The therapist explained that collective action can take many forms. Kia was invited to take home the Home­ work Assignment and either write in or reflect on activities that she found meaningful or fun (or both). In session six and after some discussion of Kia’s inter­ ests and strengths, the therapist presented Kia with the Collective-Action Activity sheet, which provides a number of examples of what collective action could look like. Working with Kia, the therapist identified several activities that could be beneficial. After some discussion, Kia decided to join the Queer Students Group, where she’d heard that there were other black and brown members. Additionally, Kia started read­ ing memoirs of black lesbians, which helped her feel empowered, validated, and less isolated in her expe­ riences. After a few months of therapy, she had formed a network of people on whom she could rely for sup­ port, and she did not feel the need to censor any of

her identities in these spaces. At the end of therapy, Kia still struggled with integration of her identities in terms of her family but felt more at ease with herself and her ability to cope with negative experiences. Suggestions for Follow-up

After the exercise has been completed, it is important for therapists to continually follow up in sessions on how collective-action activities are going between session meetings. Over time, clients may begin to see positive effects in collective-action engagement (e.g., stronger ability to cope with external experiences of discrimination, less isolation, increased social con­ nection). However, if the collective-action activities are not helpful, it is important that therapists be aware of this so they can work with clients to find out what may be hindering the benefits (e.g., lack of Internet access or transportation to meetings, conflict with work schedule) and to strategize other collective-action activities that may be easier to access or more reward­ ing. In addition, exploration of if and how clients’ involvement in collective-action activities changes their ability to cope over time with experiences of oppression is important. Contraindications for Use

The exercise may not be useful for those clients who are not developmentally ready to take action and are in the beginning stages of identity exploration. There­ fore, it is important to assess clients’ stage of identity development and their readiness for being involved with collective action. For instance, clients who are closeted and do not feel physically or emotionally safe to come out may not want to join a group in which they would feel pressure to out themselves. Further, clients who are questioning their sexual identity and would like more time to explore this in individual sessions may not want to engage in this type of collec­ tive action. In the cases of early stages of exploration or physical and safety concerns with coming out, it is recommended that therapists share resources (e.g., online resources, books) that clients can read on their own, as this activity would also be considered collective action. The clients’ presentation may shift over the course of therapy, in which case this exercise’s appro­ priateness can be reevaluated. Building Resilience with Clients Who Face Oppression 127

Professional Readings and Resources Bowleg, L., Craig, M. L., & Burkholder, G. (2004). Rising and surviving: A conceptual model of active coping among black lesbians. Cultural Diversity and Ethnic Minority Psychology, 10, 229–240. doi:10.1037/1099-9809.10.3.229. DeBlaere, C., & Bertsch, K. N. (2013). Perceived sexist events and psychological distress of sexual minority women of color: The moderating role of womanism. Psychology of Women Quarterly, 37, 167–178. doi:10.1177/03616843124 70436. Friedman, C., & Leaper, C. (2010). Sexual-minority college women’s experiences with discrimination: Relations with identity and collective action. Psychology of Women Quarterly, 34, 152–164. doi:10.1111/j.1471-6402.2010. 01558.x.

Resource for Clients Grant, S. J. (2016, November 11). A guide to QTPoC organi­ zations in the U.S. Huffington Post. https://www.huffing tonpost.com/entry/a-guide-to-queer-qtpoc-organizations­ in-the-us_us_5824b64ee4b0e89dd9ee7e8f.

References American Psychological Association (APA). (2012). Guidelines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67, 10–42. doi:10.1037/ a0024659. Berke, D. S., Maples-Keller, J. L., & Richards, P. (2016). LGBTQ perceptions of psychotherapy: A consensual qualitative analysis. Professional Psychology: Research and Practice, 47, 373–382. doi:10.1037/pro0000099.

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DeBlaere, C., Brewster, M. E., Bertsch, K., DeCarlo, A., Kegel, K., & Presseau, C. (2014). The protective power of collec­ tive action for sexual minority women of color: An inves­ tigation of multiple discrimination experiences and psy­ chological distress. Psychology of Women Quarterly, 38, 20–32. doi:10.1177/03616843-13493252. Dillon, F. R., Worthington, R. L., Soth-McNett, A. M., & Schwartz, S. J. (2008). Gender and sexual identity–based predictors of lesbian, gay, and bisexual affirmative coun­ seling self-efficacy. Professional Psychology: Research and Practice, 39, 353–360. doi:10.1037/0735-7028.39.3.353. Ghabrial, M. A. (2017). “Trying to figure out where we belong”: Narratives of racialized sexual minorities on community, identity, discrimination, and health. Sex Research Social Policy, 14, 42–55. doi:10.1007/s13178-016-0229-x. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674–697. doi:10.1037/0033-2909.129.5.674. Szymanski, D. M., & Owens, G. P. (2009). Group-level coping as a moderator between heterosexism and sexism and psychological distress in sexual minority women. Psychol­ ogy of Women Quarterly, 33, 197–205. doi:10.1111/j.1471 -6402.2009.01489.x. Wright S. C., Taylor D. M., & Moghaddam, F. M. (1990). Responding to membership in a disadvantaged group: From acceptance to collective protest. Journal of Person­ ality and Social Psychology, 58, 994–1003. doi:10.1037/ 0022-3514.58.6.994.

IDENT IT Y P RO M P T S

WO RKS H EET

1. What identities feel most salient to you?

2. When did you first discover these identities?

3. What were your first messages about race, gender, and sexual orientation?

4. Was there anyone in particular who helped you in this process?

5. Who were your role models in helping you realize your multiple identities?

6. What types of messages in the media, family, and/or religion did you receive about your identities?

Examples: What did you hear about racial or ethnic minorities in the sexual minority community? What did you hear about sexual minorities in your racial or ethnic community? Which ideas about gender did you hear, and where did you hear them (racial or ethnic community, family, religious affiliation)?

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HOMEWORK ASSIGNMENT

1. What are your hobbies?

2. What do you like to do in your free time?

3. What are some of your skills (e.g., public speaking, writing)?

4. Do you like to work and play independently, or do you prefer working and playing in groups?

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COLLECTIVE-ACTION ACTIVITIES (Not an exhaustive list)

1. Join a listerv, discussion group, or Facebook group to read and share experiences of oppression and gain support. 2. Volunteer to call or write to local politicians on behalf of the client’s group(s). 3. Attend a local rally. 4. Attend a local poetry- or book-reading event that showcases the identities salient to the client. 5. Research different meet-up groups in the area (meetup.org); this can be helpful in finding others who are also looking for community. 6. Attend a Pride parade. (Caveat: because of the parades’ history of excluding voices of color, this activity may not be appropriate, as the mainstream LGBT community does not resonate with many individuals. If someone is interested in attending a Pride parade, it may be important to provide some psychoeducation and also be aware of your own community’s efforts, or lack thereof, to include communities of color in their Pride events.) 7. Read literature related to a client’s particular identities. 8. Attend conferences or local presentations. 9. Join a local support group (in person or online).

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15 BUILDING A STRONGER ADVOCACY ROLE FOR OLDER LGBT+ ADULTS IN NURSING HOME SETTINGS Angela Schubert Suggested Use: Activity Objective

The objectives of this activity are to (a) help LGBT+ clients examine their own assumptions and biases related to their minority status(es) and other social identities; (b) challenge internalized prejudice through curious intentionality and empathy; (c) explore the pros and cons of coming out in the nursing home; (d) educate older LGBT+ clients of their rights in the nursing home; and (e) assist LGBT+ clients to effec­ tively communicate and advocate for themselves and their personal needs when choosing a nursing home. Rationale for Use

Research suggests that residential experiences of older LGBT+ adults are often overwhelmingly negative (Stein, Beckerman, & Sherman, 2010). Although the federal 1987 Nursing Home Reform Act (2002; Resi­ dent Rights, 42 C.F.R. §483.10) explicitly requires nursing homes to protect and promote the lives of each resident, countless anecdotal claims of discrim­ ination, isolation, and abuse are reported by residents in nursing home facilities (Hovey, 2009; Pope, Wier­ zalis, Barret, & Rankins, 2007; Schubert, 2015; Stein, Beckerman, & Sherman, 2010). Older LGBT+ adults often face aging alone or with a different version of “family” and, therefore, may be afraid to approach the nursing home staff regarding personal needs related to their sexual orientation, sexual expression, gender identity, and/or gender expression (Hovey, 2009; Schubert, 2015; Stein, Beckerman, & Sherman, 2010). Relentless homophobic attitudes continue to discour­

age the LGBT+ older adult population from coming out in the nursing home (Hunter, 2007), and this response is further complicated when LGBT+ older adults negatively internalize their own sexual orien­ tation and/or gender. Counselors have a unique opportunity to support their older clients through the process of coming out in the nursing home. Because of the possibly sensitive and complex nature of the presenting issues, counselors would benefit from a the­ ory that offers an affirming, exploratory approach to a client’s social identities. An understanding of how those identities affect the experience of coming out is essential for client growth and counselor advocacy (Singh & Moss, 2016). Relational cultural theory (RCT) is an ideal approach for the very reason that it is founded in the context of mutual understanding, empathy, and radi­ cal respect (Comstock et al., 2008). Using a contextual approach, RCT emphasizes connectedness, emotional well-being, and improving the “adverse impact of various forms of cultural oppression, marginalization, and social injustice” (Comstock et al., 2008, p. 280). These specific activities are inspired by RCT, the aim being to transform a client’s perspective from a place of self-exploration and reflection to a state of con­ nection, action, and advocacy (Singh & Moss, 2016). As clients explore their comfort and safety in address­ ing their sexual orientation and gender identity to themselves and, later, to the nursing home facility, cli­ ents may become better at advocating for themselves and their basic human needs. The use of intersectionality theory in practice cre­ ates the opportunity to discuss the relationship among

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aging, sexuality, and gender (Krekula, 2007). Lesbians and gay men of different age cohorts have experienced varying levels of exposure to social changes that have, in turn, influenced personal awareness of and attitudes about sexual orientation. This activity engages the client and counselor in a dialogue about what it means to be an older adult who identifies as LGBT+, and how sexual and gender identification are influenced by the client’s age and other intersecting identities. As a result, affirming and empowering the client’s inter­ secting identities, including nontraditional gender and sexual identities, can decrease possible shame, fear, isolation, and secrecy (Hall, Barden, & Conley, 2014). Affirmative practice includes addressing and explor­ ing several American Counseling Association (ACA) (2014) and American Psychological Association (APA) (2012) codes and guidelines related to client’s rights and readiness to explore topics related to stigma surrounding contextual factors regarding intersecting identities. Most important, it is therapeutically effi­ cacious and ethically competent to understand that the multilayered process is not the same for all LGBT+ individuals, and therapists therefore require a thor­ ough exploration of what it means to come out for each LGBT+ client (Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling [ALGBTIC], 2009, A.18, A.19). Ethically competent clinicians are charged with respecting the client’s rights (ACA, 2014, B.1.a; ALG­ BTIC, 2009, A.13) and helping identify any personal safety concerns related to disclosing orientation and gender identity to the nursing home. To strengthen ethically affirming therapeutic practice, the ACA established the ALGBTIC Competencies Taskforce (ALGBTIC, 2009) to identify, examine, and approach the intersecting identities of clinicians and clients in order to better understand power, privilege, and ther­ apeutic development. In these guidelines, contextual factors related to intersecting identities associated with LGBT+ individuals include important and crit­ ically unique reasons to refrain from sharing their orientation with others, or not, across the life span (ALGBTIC, 2009, A.13, A.14). Individuals who identify as LGBT+ experience oppression both systemically and interpersonally as a result of heterosexism (Singh & Moss, 2016), discrim­

ination (Mereish & Poteat, 2015), sexism (Singh & Moss, 2016), ageism (Schubert, 2015), internalized heterosexism (Kashubeck-West, Szymanski, & Meyer, 2008), transphobia (Ward, Sutherland, & Rivers, 2012), and racism (Balsam et al., 2011; Szymanski & Gupta, 2009). Such layered experiences of oppression mag­ nify stigma and increase risk of mental health issues for LGBT+ individuals (Mereish & Poteat, 2015; Singh & Moss, 2016). To challenge the negative conversa­ tions presented to and/or internalized by the LGBT+ older adult, the RCT approach emphasizes relation­ ships and contextual factors associated with the inter­ secting identities and experiences of the person (Hall, Barden, & Conley, 2014). The APA guidelines address the ways in which cli­ nicians may assist LGB needs from the client’s per­ spective. These guidelines include the obligation of ethically competent clinicians to identify and examine the effect of contextual factors or intersecting identi­ ties that may increase social stigma when LGB individ­ uals come out (APA, 2012). Similarly, as part of the therapeutic process, the ACA ALGBTIC Competencies Taskforce advises clinicians to incorporate comingout identity models of development as a means to val­ idate the multicontextual identity of clients, and to assist the client with the development of an integrated sense of self as a result (ALGBTIC, 2009, A.16, A.17). Instructions

In this activity, the counselor and client engage in a collaborative four-step intervention consisting of (a) a reflection of lived social identities (see “Examining Intersectionality: A Self-Reflection Survey,” on page 138); (b) an exploration of perceived beliefs and knowledge of nursing homes (see the same survey); (c) an identification of any personal safety concerns related to coming out to the nursing home; and (d) an engagement in self-advocacy through experiential role-playing with the counselor (see “Nursing Home Affirming Policies and Practices Questionnaire,” on page 139). One way to protect LGBT+ older adults from negative experiences is to educate them (and their families) on specific questions to ask when select­ ing a nursing home. Clients may use this question­ naire to inquire about specific policies and practices at potential nursing homes. Clients are tasked with Building a Stronger Advocacy Role for Older LGBT+ Adults 133

identifying their own fears or hesitations regarding the nursing home experience. More specifically, with the assistance of counselors, clients will write out their perceived beliefs and knowledge of nursing homes and identify any personal safety concerns related to coming out to the nursing home. Simply put, the counselor helps clients make a list of pros and cons of relocating to a nursing home. Once the list is made, clients are asked to identify their rights as a nursing home resident with the counselor. The counselor can assist them with identifying a local ombudsman to assist in answering questions related to nursing home resident rights. Note that this process requires counselors to first identify and explore their own individual prejudices and biases regarding sexual orientation, gender, abil­ ities, and ageism, and to understand the ways in which minority social identities are oppressed and discrimi­ nated against in society (Corey & Corey, 2016). By consciously addressing personal prejudices in a pro­ active way, clinicians are better able to assist their LGBT+ clients in examining their own assumptions and biases related to their minority status(es) and other social identities (Bigner & Wetchler, 2012).

man living under someone else’s roof. He discloses his coming-out story and what it meant for him to be a man who was gay, biracial, alone, and in need of others’ help. He explores his own internalized hetero­ sexism, his disconnect with others in previous social circles, and his fears of coming out to staff at the nursing home; he also reveals his trepidation about disclosing at all. With much chagrin, he comes to the conclusion that he does not desire to spend his life hiding anymore. During the next session, Bernard is able to witness his own strength in response to the reflective ques­ tioning. He addresses his need to feel connected to others. He then explores what he needs in order to feel connected to others at the nursing home. He recog­ nizes he has some concerns for his personal safety and seeks advice on how to select an LGBT+-affirming nursing home. The counselor then explores Bernard’s comfort by role-playing the interview between him and a hypothetical nursing home. Bernard has diffi­ culty at first with the questioning and wonders how he would handle the conversation. After several roleplays, Bernard identifies his own adaptation of the questions and requests the counselor be present during the call.

Brief Vignette

Bernard is a seventy-five-year-old biracial, cisgender male of African American and Puerto Rican descent. Bernard recently fell at his apartment. His partner of twenty years, Rodrigo, passed away last year and Bernard has lived alone ever since. Bernard sought counseling eight months after Rodrigo died to address his grief and loneliness. The hospital staff wanted him to temporarily relocate to a nursing home because of his need to use a wheelchair, but Bernard refused. Since leaving the hospital, it has become more diffi­ cult for him to move around his apartment. It is not wheelchair accessible, and the amount of energy he uses to move from one room to another exhausts him. Still, he is able to use not-for-profit rural bus trans­ portation to attend counseling sessions. Bernard anx­ iously addresses the possibility of relocating to an assisted-living facility permanently. Using “Examining Intersectionality: A Self-Reflection Survey” (p. 138), Bernard spends the rest of the time in session exam­ ining his own fears of what it means to be a gay, biracial 134 Schubert

Suggestions for Follow-up

The reflective process of exploring interpersonal rela­ tionships, connectedness, and disconnectedness can be quite challenging for both the client and the coun­ selor. Clients may initially experience some discom­ fort and hesitation as they examine the social systems they navigate. According to McCauley (2013), the most effective RCT approach requires a conscious effort to address the originating system of resistance. This process involves naming the problem by thera­ peutically shifting the conversation from verbalizing grievances to making a conscious choice to move toward a system that promotes relational values (McCauley, 2013). The process by which a system of resistance is identified may be strengthened through continued reflective questioning related to connection. It would be beneficial to follow up with clients to explore to what degree their conceptualization of con­ nection and disconnection has changed. As a result of identifying a system of resilience, the client may

identify a supportive community that can assist in resisting oppressive forces and disconnection. Contraindications for Use

RCT emphasizes the importance of establishing ther­ apeutic rapport as a means to cultivate a deeper under­ standing of the client’s connection to self and others (McCauley, 2013). One way to establish rapport is to engage clients in discourse regarding their worldview through culturally relevant questioning. Bernard communicated several identities but identified his role as a man as his primary identification. This identifi­ cation influenced his conceptualization of his other identities, including his second identification as a gay man. Clients may not consider sexual orientation as the central issue with regard to their needs in the nurs­ ing home. A thorough conversation is therefore nec­ essary between client and clinician before engaging in advocacy. More important, careful inspection of the client’s social identities will assist the clinician in understand­ ing how such identities may affect the experience of coming out in the nursing home. RCT’s contextual nature offers this very opportunity. For example, con­ sider Bernard’s racial and ethnic identities—African American and Puerto Rican descent. Both African American and Latino communities tend to hold strong views toward family, religion, and heritage (Lemelle, 2010). As a result, minority sexual orientation within these communities may be considered a sin (Lemelle, 2010), and disclosure of LGBT+ orientation can be viewed as an act against the family and the heritage (Trahan & Goodrich, 2015). Regardless of the known homophobia and heterosexism in both communi­ ties, individuals who identify as LGBT+ may choose silence about their sexual orientation for the sake of their families and their heritage (Lemelle, 2010; Tra­ han & Goodrich, 2015). Although Bernard did not specifically address his biracial identity as a primary identity, his racial and ethnic heritage must be taken into consideration. Another intersectional layer may include gener­ ational differences in attitude toward coming out and age. Internalized ageism is psychologically inter­ twined with one’s sense of self-worth and core iden­ tity as a human (Schubert, 2015): “Lesbians and gay

men of different age cohorts have experienced varying levels of exposure to these social changes that have, in turn, influenced personal awareness of and attitudes about sexual orientation” (Parks, Hughes, & Matthews, 2004, p. 243). Although humans are sexual beings, society often dismisses the sexual desires and needs of the older adult population, and older adults are not exempt from thinking of aging sexuality in this way. As a result, older LGBT+ adults may not give their sexual orientation or their identity as a sexual being high priority and may dismiss their own feelings and desires altogether. Counselors would benefit from exploring whether publicly addressing the sexual orientation of their clients is a concern. Counselors might need to first work with clients to explore their internalized ageism before clients consider coming out to a nursing home. Professional Readings and Resources Brick, P., Lunquist, J., Sandak, A., & Planned Parenthood of Greater Northern New Jersey. (2009). Older, wiser, sexually smarter: 30 sex ed lessons for adults only. Morristown, NJ: Planned Parenthood of Greater Northern New Jersey. Day-Vines, N. L., Wood, S. M., Grothaus, T., Craigen, L., Hol­ man, A., & Dotson-Blake, K. (2007). Broaching the sub­ jects of race, ethnicity, and culture during the counseling process. Journal of Counseling and Development, 85 (4), 401–409. doi:10.1002/j.1556-6678.2007.tb00608.x. Fox, R. C. (2007). Gay grows up: An interpretive study on aging metaphors and queer identity. Journal of Homosexuality, 52 (3–4), 33–61. Frank, D. A., & Cannon, E. P. (2010). Queer theory as pedagogy in counselor education: A framework for diversity training. Journal of LGBT Issues in Counseling, 4 (1), 18–31. Hall, K. G., Barden, S., & Conley, A. (2014). A relational-cul­ tural framework: Emphasizing relational dynamics and multicultural skill development. Professional Counselor, 4 (1), 71–83. Hill, R. J. (2004). Activism as practice: Some queer consider­ ations. New Directions for Adult and Continuing Educa­ tion, 102, 85–94. Misawa, M. (2010). Queer race pedagogy for educators in higher education: Dealing with power dynamics and positionality of LGBTQ students of color. International Journal of Critical Pedagogy, 3 (1), 26–35. Stone, C. B. (2003). Counselors as advocates for gay, lesbian, and bisexual youth: A call for equity and action. Journal of Multicultural Counseling and Development, 31 (2), 43–155.

Resources for Clients

Building a Stronger Advocacy Role for Older LGBT+ Adults 135

Adult Protective Services (APS). To locate APS services in your area, visit www.napsa-now.org/get-help/help-in-your­ area/. Lambda Legal Help Desk. Discrimination against a nursing home resident who identifies as LGBT+ is illegal. Contact for information and lawyer referrals: 1-866-542-8336 or https://www.lambdalegal.org. Long-term care ombudsman (LTCO). For information about the ombudsman program and to locate your LTCO pro­ gram, visit https://www.ltcombudsman.org/about/about­ ombudsman. National Resource Center on LGBT Aging. Locate a variety of resources related to long-term care services at www. lgbtagingcenter.org/resources/resources.cfm?s=15.

References American Counseling Association (ACA). (2014). ACA Code of Ethics. Alexandria, VA: Author. American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67 (1), 10–42. doi:10.1037/a0024659. Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC). (2009). Competencies for counseling with transgender clients. Alexandria, VA: Author. Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC). (2012). ALGBTIC competen­ cies for counseling with lesbian, gay, bisexual, transgender, queer, questioning, intersex, and ally individuals. https:// www.counseling.org/docs/ethics/algbtic-2012-07.pdf? sfvrsn=2. Balsam, K. F., Molina, Y., Beadnell, B., Simoni, J., & Walters, K. (2011). Measuring multiple minority stress: The LGBT People of Color Microaggressions Scale. Cultural Diversity and Ethnic Minority Psychology, 17 (2), 163–174. doi:10. 1037/a0023244. Bigner, J. J., & Wetchler, J. L. (2012). Handbook of LGBT- affir­ mative couple and family therapy. New York: Routledge. Comstock, D. L., Hammer, T. R., Strentzch, J., Cannon, K., Parsons, J., & Salazar, G., II. (2008). Relational-cultural theory: A framework for bridging relational, multicultural, and social justice competencies. Journal of Counseling & Development, 86 (3), 279–287. Corey, M. S., & Corey, G. (2016). Becoming a helper. Belmont, CA: Brooks/Cole, Cengage Learning. Grzanka, P. R., & Miles, J. R. (2016). The problem with the phrase “intersecting identities”: LGBT affirmative therapy, intersectionality, and neoliberalism. Sexuality Research and Social Policy, 13 (4), 371–389. doi:10.1007/s13178­ 016-0240-2.

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Hall, K. G., Barden, S., & Conley, A. (2014). A relational-cul­ tural framework: Emphasizing relational dynamics and multicultural skill development. Professional Counselor, 4 (1), 71–83. Hovey, J. E. (2009). Nursing wounds: Why LGBT elders need protection from discrimination and abuse based on sex­ ual orientation and gender identity. Elder Law Journal, 17 (1), 95. Hunter, S. (2007). Coming out and disclosure: LGBT persons across the lifespan. Binghamton, NY: Haworth Press. Kashubeck-West, S., Szymanski, D., & Meyer, J. (2008). Inter­ nalized heterosexism: Clinical implications and training considerations. Counseling Psychologist, 36 (4), 615–630. doi:10.1177/0011000007309634. Krekula, C. (2007). The intersection of age and gender: Rework­ ing gender theory and social gerontology. Current Sociol­ ogy, 55 (2), 155–171. doi: 0.1177/0011392107073299. Lemelle, A. J. (2010). Black masculinity and sexual politics. New York: Routledge. McCauley, M. (2013, March). Relational-cultural theory: Fostering healthy coexistence through a relational lens. In G. Burgess & H. Burgess (eds.), Beyond intractability. Boulder: Conflict Information Consortium, University of Colorado, Boulder. https://www.beyondintractability. org/essay/relational-cultural-theory. Mereish, E. H., & Poteat, V. P. (2015). A relational model of sexual minority mental and physical health: The negative effects of shame on relationships, loneliness, and health. Journal of Counseling Psychology, 62 (3), 425–437. doi: 10.1037/cou0000088. Montagu, A. (1986). Touching: The human significance of the skin, 3rd edition. New York: Harper & Row. Muzacz, A. K., & Akinsulure-Smith, A. M. (2013). Older adults and sexuality: Implications for counseling ethnic and sexual minority clients. Journal of Mental Health Counseling, 35 (1), 1–14. doi:10.17744/mehc.35.1.534385 v3r0876235. Parks, C. A., Hughes, T. L., & Matthews, A. K. (2004). Race/ ethnicity and sexual orientation: Intersecting identities. Cultural Diversity and Ethnic Minority Psychology, 10, 241–254. Pope, M., Wierzalis, E. A., Barret, B., & Rankins, M. (2007). Sexual and intimacy issues for aging gay men. Adultspan Journal, 6 (2), 68–82. doi:10.1002/j.2161-0029.2007. tb00033.x. Resident Rights. (1987). Nursing Home Reform Act of 1987, 42 C.F.R. §483.10, Omnibus Budget Reconciliation Act. Schubert, A. M. (2015). Attitudes toward aging sexual expres­ sion in nursing homes: An exploration of the older adult resident phenomenon. PhD diss., University of Missouri– Saint Louis.

Singh, A. A., & Moss, L. (2016). Using relational-cultural theory in LGBTQQ counseling: Addressing heterosexism and enhancing relational competencies. Journal of Coun­ seling and Development, 94 (4), 398–404. doi:10.1002/ jcad.12098. Stein, G. L., Beckerman, N. L., & Sherman, P. A. (2010). Les­ bian and gay elders and long-term care: Identifying the unique psychosocial perspectives and challenges. Jour­ nal of Gerontological Social Work, 53 (5), 421–435. doi:10 .1080/01634372.2010.496478. Szymanski, D. M., & Gupta, A. (2009). Examining the rela­ tionship between multiple internalized oppressions and

African American lesbian, gay, bisexual, and questioning persons’ self-esteem and psychological distress: Correction. Journal of Counseling Psychology, 56 (2), 300. doi:10.103 7/a0015407. Trahan, D. P., Jr., & Goodrich, K. M. (2015, March). You think you know me, but you have no idea. Family Journal, 23 (2), 147–157. doi:10.1177/1066480715573423. Ward, R., Sutherland, M., & Rivers, I. (2012). Lesbian, gay, bisexual, and transgender ageing: Biographical approaches for inclusive care and support. London: Jessica Kingsley.

Building a Stronger Advocacy Role for Older LGBT+ Adults 137

E XAM INING INT ERS ECT IO NA L IT Y:

A SEL F-REF L ECT IO N S URVEY

Neurologically, humans are wired to connect in meaningful ways, and social structures can either foster healthy relational development and growth or oppress socialized relationships and identities. To better understand when and how your problems occurred within the social framework, identify the source of your pain. 1. Describe your coming-out process across your life span.

2. How was your coming-out process received by others?

3. How did you experience your coming-out process?

4. What is your understanding of what it means to be a man or a woman? To be a man or woman of color?

5. What is your understanding of what it means to be a man or woman and in need of others’ support?

6. What has been your experience asking others for support?

7. What does connection mean to you in relation to your desire to connect with others and for those to connect with you?

8. Describe your social relationships. What has allowed you to remain connected with them? If not, what has gotten in the way of staying connected?

9. What are your concerns regarding the nursing home and nursing home staff?

10. How important is it to disclose your sexual orientation and/or gender expression to the nursing home?

11. What do you feel you need in order to feel safe at the nursing home?

138

Angela Schubert

N U RSIN G HO M E A F F IRM ING P O L ICIES A ND

P RACT ICES Q UES T IO NNA IRE

1. Which policies are in place to honor and protect privacy of the residents?

2. Does your nursing home explicitly address nondiscrimination policies related to LGBT+ identity and gender expression?

3. How are staff members trained to address nontraditional gender identities and LGBT+ orientations?

4. Are any staff currently employed openly LGBT+?

5. Does the nursing home currently care for LGBT+ residents?

6. Are residents expected to seek out assistance related to privacy for intimacy issues related to gender expression?

7. Is there an LGBT+ resident advocate on staff?

8. Which policies are in place to honor same-sex couples and gender-variant partners?

9. Are there any community events held to celebrate LGBT+ persons or issues?

10. Are same-sex couples allowed to live in the same room?

11. Does the nursing home support nonbiological families in its policies?

12. Are same-sex partners honored as medical powers of attorney?

13. How is gender and sexual inclusivity marketed in this nursing home?

Angela Schubert

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16 A TOOLKIT FOR COLLABORATIVE SAFETY AND TREATMENT PLANNING WITH TRANSGENDER YOUTH OF COLOR Wendy Ashley, Allen Eugene Lipscomb, and Sarah Mountz Suggested Use: Collaborative activity Objective

The objective is to create an Inclusive Safety Plan of Care (ISPOC) for transgender youth of color. This tool­ kit was developed to assist clients and therapists in cocreating a plan to bring together concerns, ideas, strengths, and members of support to help transgen­ der youth of color meet their basic needs and achieve their goals. Note that this activity can be generalized for use with clients who hold a variety of marginalized identities. Rationale for Use

Transgender (including transsexual, gender-variant, genderqueer, genderfluid, agender, Two-Spirit, and gender-nonconforming) youth of color face stigma related both to race or ethnicity and gender identity. The rejection, harassment, and violence they experi­ ence are significantly more severe than those experi­ enced by their lesbian, gay, and bisexual counterparts (Norton & Herek, 2013). Surviving racial or ethnic discrimination requires strong connections to family and ethnic community. However, transgender youth of color seldom receive the support of their larger com­ munity regarding their transgender identity (Ryan, 2009). Unlike racial stereotypes that a family or ethnic community positively reframes, many communities reject a child’s gender nonconformity, unwittingly reinforcing negative cultural perceptions regarding gender identity (Ryan, Russell, Huebner, & Diaz,

2010). Stigma places these young people at greater risk for homelessness, substance use, violence, suicidal ideation, and risky sexual behaviors at a rate twentyfive times higher than that for the general population (Grant et al., 2011). Transgender youth face safety challenges where gender-conforming (or congruent) youth frequently do not; contexts such as home, school, communities, foster care, and juvenile justice systems are often the backdrop for bullying and victimization. Disrespect for their identity or punishment for iden­ tity expression can result in denial of public restrooms, exclusion from activities, disproportionate discipline, and ongoing marginalization. Additional consequences of harassment and discrimination include depres­ sion, substance abuse, suicide, and being the victim of hate crimes (Ryan et al., 2010). Thus, safety is a critical element in treatment planning with this population. An unfortunate result in the clinical environment is that youth’s identities, rather than their presenting problems or safety concerns, become the focus of intervention (Lev, 2004). Additional barriers to safety for transgender youth of color include the sex-segregated nature of many residential services (homeless shelters, substance abuse treatment centers, group homes) and a dearth of pro­ viders of gender-affirming medical services, as well as inconsistent insurance coverage for such services (Lyons et al., 2015). In the face of institutional dis­ crimination and systemic oppression, family support may serve as a protective factor against the multitude of threats to safety and well-being (Bockting, 2014;

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Grant et al., 2011). This ISPOC facilitates practitioners’ and family members’ support for the safety and wellbeing of transgender clients without pathologizing their identities. Although there is minimal material regarding eth­ ical and affirming clinical practice with transgender youth, a small body of work has begun to emerge (Bernal & Coolhart, 2012). If a youth has disclosed a gender identity to family members, and family has been mildly to moderately rejecting, use of the Family Acceptance Project model may be appropriate (Ryan, Huebner, Diaz, & Sanchez, 2009; Ryan et al., 2010; Snapp et al., 2015). The Family Acceptance Project is congruent with the ISPOC framework in that it pro­ vides an opportunity for dialogue and psychoeducation with parents or other caretakers regarding rejecting parental behaviors (blaming, shaming, excluding, name-calling) and accepting parental behaviors (requiring respect, supporting, advocating, expressing affection), the latter being positively correlated with healthy outcomes, higher self-esteem, closer family relationships, and better overall health. This model is also appropriate for use with foster parents, an impor­ tant consideration given that LGBTQ youth of color are nearly twice as likely to be placed in foster care (Ryan, 2013). By acknowledging legitimate health challenges facing the transgender community, the ISPOC will affirm transgender mental and medical health care (e.g., hormone therapies, gender-confirmation surgery, safe and trans-positive general medical services) through the entire life span, not just during the initial assessment process or during transition. Using this plan affirms mental and medical health care by asking specific questions about current mental health status and medical care (i.e., both past and present history). The plan serves as a guide to support therapists, col­ laborating professionals, family members, and other involved persons to inquire about needs rather than making assumptions. As clinicians, it is our ethical responsibility to engage in practices that promote and demonstrate respect for differences, supporting the expansion of cultural knowledge and resources safe­ guarding the rights of and confirming equity for trans individuals (Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling [ALGBTIC],

2009). In addition, the ISPOC can be used to under­ stand the biological, familial, social, cultural, socio­ economic, and psychological factors that influence the course of development of transgender identities to expand choice and opportunity. Ethically speak­ ing, clinicians must be equipped to provide their clients with education and resources on gender experiences, gender expression, and sexuality (ALGBTIC, 2009). In using the ISPOC, clinicians must identify the gen­ der-normative assumptions present in current life­ span development theories and address these biases in assessment and counseling practices. It is ethically incumbent on the clinician when completing the ISPOC to understand how stigma and pressures to be gender conforming may affect personality develop­ ment even in the face of the resiliency and strengths of transgender individuals (ALGBTIC, 2009). Further, understanding how these factors influence decision making in regard to employment, housing, and health care is essential when constructing the ISPOC. Cli­ nicians must also understand how psychological dis­ orders manifest themselves in transgender clients. The ISPOC is designed to motivate clinicians to recognize the influence of other contextual factors and social determinants of health (race, education, ethnicity, religion and spirituality, socioeconomic sta­ tus, sexual orientation, role in the family, peer group, geographical region, and so on) that may be of impor­ tance to clinical treatment. Clinicians should be informed on the various ways of living consistently with one’s gender identity, which may or may not include physical or social gender transition, and how these options may affect transgender individuals throughout their treatment; these matters should be discussed when developing the ISPOC (Bernal & Coolhart, 2012). Ethically, clinicians must be aware of the sociopolitical influences that affect the lives of transgender individuals, and that stereotyping, dis­ crimination, and marginalization may shape the client’s treatment processes, self-esteem, self-concept, and willingness to access the resources identified on the ISPOC (Bernal & Coolhart, 2012). Finally, when clinicians are collaborating with clients in developing their ISPOC, they must be pro­ active in identifying additional barriers and challenges faced by transgender individuals (e.g., ethnic identity Treatment Planning with Transgender Youth of Color 141

and/or sexuality; anxiety and depression; suicidal ideation and behavior; nonsuicidal self-injury; sub­ stance abuse; academic failure; homelessness; inter­ nalized transphobia; STD/HIV infection; addiction). According to a survey conducted by Haas, Rodgers, and Herman (2014), suicide attempts are 50 percent higher among those who openly disclose they are transgender or gender nonconforming. In particular, 65 percent of the transgender population with a men­ tal health condition that substantially affects a major life activity reported attempting suicide. The research clearly reflects the fact that multiple marginalized identities increase risk for transgender youth. Transgender youth of color experience higher rates of homelessness, sexual violence, substance use or abuse, and mental health challenges than their white transgender youth counterparts (Bockting, 2014). Instructions

The therapist will collaborate with the client to create an ISPOC. It is recommended that the therapist sit with the client when creating this plan in a session. The therapist and client should work together over an average of four to six sessions to cocreate the plan. The duration of each session should be fifty to seventyfive minutes. The therapist should begin the session by discussing expectations and the purpose of the plan (i.e., to meet the client’s individual needs, to promote safety, and to support ongoing well-being). It is impor­ tant for both the therapist and the client to know that this plan is a working document that is meant to evolve and change over time to continue meeting the client’s needs. It is recommended that the therapist reassess the client every three months (or sooner, as needed) to ensure that the plan is relevant and up-to­ date. In addition, the therapist should consider the following points to guide the planning session: • Use language that is inclusive and nonpejorative with regard to sexual orientation and gender identity. • Focus on the client’s strengths, irrespective of gen­ der identity. • Address the needs of the whole person (i.e., inter­ secting identities). • Ask the client how they self-identify and use these terms and pronouns. 142 Ashley, Lipscomb, & Mountz

• The therapist and client should identify safer places, peers, and allies of support for times of need (e.g., shelters). • Assess youth disclosure to family and level of fam­ ily acceptance, engaging family where indicated and appropriate. • The therapist and client should identify kinship net­ works, mentors, sources of support, and permanency resources (those that promote long-term support) outside family of origin, where appropriate. • The therapist and client should identify safety pro­ tocols if the client is in the process of transitioning, referring to appropriate medical services where indicated (e.g., youth-serving clinics that provide gender-affirming treatments). • The therapist should work with the client regarding health insurance options for pursuing gender-affirm­ ing treatment (depending on jurisdiction, public insurance may or may not cover treatment). • The therapist should employ a harm-reduction approach to engaging youth in terms of current substance use and/or use of street hormones and participation in a street economy related to pro­ curing gender-affirming treatment (e.g., sex work). • The therapist should acknowledge, validate, and affirm the client’s intersectional values, attitudes, and beliefs. • The therapist and client should work together to identify triggers for suicidal ideation and risk factors. Brief Vignette

Shay is a seventeen-year-old African American transgender youth. She self-identifies as queer and uses the pronouns she, her, and hers. Shay shared with her therapist during the assessment that “things have hap­ pened” to her in her life. She also noted that when she turns eighteen she is going to another country to have a procedure done. Shay is currently homeless and is staying on the streets. She was kicked out of her devoutly Christian mother’s home when she was found wearing women’s clothing. Shay occasionally stays with her grandmother, who says, “I don’t agree with that spirit or why you choose to wear women’s clothing, but I love you and will pray for you. I just

want you to be safe.” When asked if she would be interested in staying in a shelter she replies, “Hell no! They’re all fucked up in the shelter and I don’t have time for their bullshit!” She tells her therapist, “I just want to be independent, have my own things, and not have everyone telling me how they want me to be all the time.” The therapist replies by validating Shay’s feelings of frustration and disappointment with past experi­ ences residing in a shelter. The therapist also affirms and praises Shay for wanting to be independent and self-sufficient. In addition, the therapist invites Shay to work in collaboration on a plan that would assist her in working toward her goals. The therapist says, “I would like to work with you on developing a plan that will increase your independence, based on your goals. You have shared with me some challenges you’ve experi­ enced based on your gender identity, so I would like to identify trans-affirming resources, services, and sup­ port to assist you with meeting your needs. Please keep in mind that this plan is a working document that can be changed or modified at any time to accommodate your day-to-day and future needs as they change. You are the one guiding this plan, and if something does not sound right or work for you, it can be changed. As your therapist, I am here to provide support, to offer assistance in locating trans-affirming resources, and to ensure that you are safe. What do you think about working with me to create this plan to help you reach your goals?” Shay appeares hesitant but agrees to work with her therapist to cocreate the plan. Once completed, the plan illuminates many of Shay’s strengths as well as multiple challenges that she may face in moving toward independence. Further, the plan provides a framework for Shay and her ther­ apist to collaboratively identify resources and services to mitigate some of the barriers she faces. The pro­ cess of completing the plan has allowed Shay and her therapist to engage in authentic dialogue about cul­ turally relevant concerns, which supports the therapeu­ tic relationship. Additionally, Shay’s senses of empow­ erment, motivation, and agency have increased. Suggestions for Follow-up

It is the therapist’s responsibility to continue to follow up and check in with the client regarding the appli­

cability of the current ISPOC. The therapist should continue to assess and collaborate on an ongoing basis with the client to ensure the plan is up-to-date in addressing the client’s needs. Contraindications for Use

The ISPOC is advisable for transgender youth of color, as well as many other populations; there are minimal contraindications for use. The most effective use of the ISPOC requires clients to be vulnerable in disclos­ ing their needs and desires; thus, a therapeutic rap­ port is critical. Practitioners should anticipate guarded presentations initially and be prepared to pace them­ selves in fully completing the document. In cases in which clients present with acute psychosis, severe depression, mania, traumatic brain injury, or eating disorders, consultation with a psychiatrist and/or med­ ical doctor should be included in the plan. In addi­ tion, if the therapist does not have any awareness of local resources before starting this plan, constructing this plan may be of less benefit to the client and family. Professional Readings and Resources Conron, K., Wilson, J., Cahill, S., Flaherty, J., Tamanaha, M., & Bradford, J. (2015, November). Our health matters: Mental health, risk, and resilience among LGBTQ youth of color who live, work, or play in Boston. Fenway Insti­ tute, Boston. https://fenwayhealth.org/wp-content/ uploads/our-health-matters.pdf. Dank, M., Yu, L., Yahner, J., Pelletier, E., Mora, M., & Conner, B. M. (2015, September). Locked in: Interactions with the criminal justice and child welfare systems for LGBTQ youth, YMSM, and YWSW who engage in survival sex. Urban Institute, Research Report. www.urban.org/sites/ default/files/publication/71446/2000424-Locked-In-In teractions-with-the-Criminal-Justice-and-Child-WelfareSystems-for-LGBTQ-Youth-YMSM-and-YWSW-Who­ Engage-in-Survival-Sex.pdf. Klein, A., & Golub, S. A. (2016). Family rejection as a predic­ tor of suicide attempts and substance misuse among transgender and gender nonconforming adults. LGBT Health, 3 (3), 193–199. Ryan, C. (2009). Helping families with lesbian, gay, bisexual and transgender (LGBT) children. San Francisco: Marian Wright Edelman Institute, Family Acceptance Project, San Francisco State University. http://nccc.georgetown. edu/documents/LGBT_Brief.pdf. Ryan, C., Russell, S. T., Huebner, D., & Diaz, R. (2010). Family acceptance in adolescence and the health of LGBT young adults. Journal of Child and Adolescent Psychiatric Nursing, 23 (4), 205–213. Treatment Planning with Transgender Youth of Color 143

Substance Abuse and Mental Health Services Administration. (2014). A practitioner’s resource guide: Helping families to support their LGBT children. HHS Publication No. PEP14­ LGBTKIDS. Rockville, MD: Substance Abuse and Mental Health Services Administration. Toomey, R. B., Ryan, C., Diaz, R. M., Card, N. A., & Russell, S. T. (2010). Gender-nonconforming lesbian, gay, bisexual, and transgender youth: School victimization and youth adult psychosocial adjustment. Developmental Psychology, 46 (6), 1580–1589.

Resources for Clients Beemyn, G. (2014). Transgender history. In L. Erickson Schroth (ed.), Trans bodies, trans selves. New York: Oxford Uni­ versity Press. Fierce. Building the leadership & power of LGBTQ youth of color. http://fiercenyc.org/. Ryan, C., et al. (2009). Family Acceptance Project publica­ tions. http://familyproject.sfsu.edu/publications. Simmons, H., & White, F. (2014), Our many selves. In L. Erickson Schroth (ed.), Trans bodies, trans selves. New York: Oxford University Press. Trans bodies. A resource guide for the transgender commu­ nity. http://transbodies.com/. Trans lifeline: (877) 565-8860 Transsexual Road Map. Transsexual & transgender road map. http://www.tsroadmap.com/index.html. World Professional Association for Transgender Health. Standards of care. https://www.wpath.org/publications/ soc.

References Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC). (2009). Competencies for counseling with transgender clients. Alexandria, VA: Author. Bernal, A. T., & Coolhart, D. (2012). Treatment and ethical considerations with transgender children and youth in family therapy. Journal of Family Psychotherapy, 23 (4), 287–303. Bockting, W. (2014). The impact of stigma on transgender iden­ tity development and mental health. In B. P. C. Kruekels, T. D. Steensma, & A. L. C. de Vries (eds.), Gender dys­ phoria and disorders of sex development, 319–330. New York: Springer.

144 Ashley, Lipscomb, & Mountz

Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Keisling, M. (2011). Injustice at every turn: A report of the national transgender discrimination survey, executive summary. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force. Haas, A., Rodgers, P., & Herman, J. (2014). Suicide attempts among transgender and gender non-conforming adults: Findings of the National Transgender Discrimination Survey. American Foundation for Suicide Prevention and Williams Institute, UCLA School of Law. https:// williamsinstitute.law.ucla.edu/wp-content/uploads/AFSP­ Williams-Suicide-Report-Final.pdf. Lev, A. I. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. New York: Haworth Clinical Practice Press. Lyons, T., Shannon, K., Pierre, L., Small, W., Krüsi, A., & Kerr, T. (2015). A qualitative study of transgender individuals’ experiences in residential addiction treatment settings: Stigma and inclusivity. Substance Abuse Treatment, Pre­ vention, and Policy, 10, 17. http://doi.org/10.1186/s13011­ 015-0015-4. Norton, A. T., & Herek, G. M. (2013). Heterosexuals’ attitudes toward transgender people: Findings from a national probability sample of U.S. adults. Sex Roles: A Journal of Research, 68 (11), 738–753. Ryan, C. (2009). Helping families with lesbian, gay, bisexual, and transgender (LGBT) children. San Francisco: Marian Wright Edelman Institute, Family Acceptance Project, San Francisco State University. http://nccc.georgetown. edu/documents/LGBT_Brief.pdf. Ryan, C. (2013). Generating a revolution in prevention, well­ ness, and care for LGBT children and youth. Temple Polit­ ical and Civil Rights Law Review, 23, 331. Ryan, C., Huebner, D., Diaz, R. M., & Sanchez, J. (2009). Fam­ ily rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics, 123 (1), 346–352. Ryan, C., Russell, S. T., Huebner, D., & Diaz, R. (2010). Family acceptance in adolescence and the health of LGBT young adults. Journal of Child and Adolescent Psychiatric Nursing, 23 (4), 205–213. Snapp, S. D., Watson, R. J., Russell, S. T., Diaz, R. M., & Ryan, C. (2015). Social support networks for LGBT young adults: Low-cost strategies for positive adjustment. Family Rela­ tions, 64 (3), 420–430.

INCLUSIVE SAFET Y PL AN OF CARE (ISPOC) Name of client: Pronouns used: Additional previously used names: Date of birth: Date of plan: Phase of treatment Assessment Treatment planning/middle phase Termination Crisis Other Permanency plan/long-term goal (written in client’s own words):

Team members involved in developing, creating, building, and supporting this plan: Name

Relationship

Phone number

Available 24/7?

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Wendy Ashley, Allen Eugene Lipscomb, and Sarah Mountz

145

Client strengths and needs (considering trauma)—check as many as apply: Safety Suicide

Homicide

Abuse (child or elder)

Substance use/abuse

Domestic violence

Grave disability

Notes: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Family School/education Work/vocational Social Sex work Money Emotional Behavioral Mentorship

Health/medical Cultural Fun/recreational Spiritual Legal Street hormones/ hormones Housing Mental health Insurance

Notes: ______________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Family strengths and needs—check as many as apply: Safety

Family

School/educational

Work/vocational

Social

Sex work

Money

Emotional

Behavioral

Mentorship

Health/medical

Cultural

Fun/recreational

Spiritual

Legal

Street hormones/ hormones

Housing

Mental health

Insurance

Notes: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

146

Wendy Ashley, Allen Eugene Lipscomb, and Sarah Mountz

SHORT- AND LONG-TERM RESOURCES

1.

2.

3.

4.

5.

6.

Name

Phone Number Location Hours Service

COURT/LEGAL CONSIDERATIONS

Need

Strengths

Strategy(ies)

Person Responsible

Cost/Resource

Other

1.

2.

3.

4.

5.

Plan Progress: The team will revisit this plan two weeks after its creation. Wendy Ashley, Allen Eugene Lipscomb, and Sarah Mountz

147

INCLUSIVE SAFET Y PL AN AGREEMENT We, the Inclusive Safety Plan members, agree to the planning, implementation, and success of this plan. Together we will work with (client name)____________________________ to meet (pronoun)_____________ goals and vision.

Vision statement:

Name

Signature

Date Signed

Copy Received? n Yes n No n Yes n No n Yes n No n Yes n No n Yes n No n Yes n No n Yes n No n Yes n No n Yes n No n Yes n No

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Wendy Ashley, Allen Eugene Lipscomb, and Sarah Mountz

17 HEALING FROM HETEROSEXISM: AN EMPIRICALLY BASED EXERCISE FOR PROCESSING HETEROSEXIST EXPERIENCES Kathleen M. Collins, Meredith R. Maroney, Tangela S. Roberts, Brianna M. Wadler, and Heidi M. Levitt Suggested Use: Homework Objective

This activity entails an expressive writing exercise intended to help clients process experiences of hetero­ sexism that they have had. Objectives of the exercise include permitting clients (1) to focus on these expe­ riences in order to more fully process their effects or regulate emotions connected to them; (2) to develop insights about themselves, interpersonal dynamics, or societal systems that contributed to heterosexist events; and (3) to develop strategies for coping with these events, relationships, or systems. This exercise is appropriate for lesbian, gay, bisexual, queer-identi­ fied, and other nonheterosexual (LGBQ) clients as well as transgender clients who identify as LGBQ. Rationale for Use

Heterosexism refers to the pervasive attitude in West­ ern culture concerning the superiority of heterosexual orientations, relationships, and behaviors, and the resulting systemic oppression of all nonheterosexual identities (Herek, 2004). Heterosexism is a nuanced concept that can be understood in relation to, and is often used interchangeably with, related terms such as homophobia, homonegativity, and heteronormativ­ ity (Russell & Bohan, 2007). However, heterosexism does not imply only an aversion to homosexuality; it also describes how society tacitly and repeatedly com­ municates the message that heterosexual orientations

and behaviors are superior to any nonheterosexual orientations and behaviors. Heterosexism is perpetuated through both indi­ vidual factors, such as attitudes and behaviors, and systemic factors, such as policies and actions that dis­ criminate against nonheterosexuals (Meyer, 2003). These factors create stressors for LGBTQ people that range from distal, such as stressful events and hypervigilance stemming from expectation of such events, to proximal, including internalization of heterosexist attitudes that cause individual psychological distress (Herek, 2017; Meyer, 2003). Heterosexism is trans­ mitted not only through overt acts of discrimination, such as acts of violence or the lack of equal civil rights; subtle microaggressive acts and comments that endorse heterosexism can be just as harmful because of their insidious nature (Nadal et al., 2011). Because these communications are often implicit and routine, the stress caused by them may accumulate slowly without prompting the same self-protective responses that other stressors might (e.g., Herek, 2004; Russell & Bohan, 2007). Expressive writing is an intervention aimed at helping people cope with difficult emotions or situa­ tions through personal disclosure. In this interven­ tion, people typically write about their thoughts and feelings regarding traumatic or challenging experi­ ences. The original paradigm (Pennebaker & Beall, 1986) has been used with various populations and methodological adaptations. A meta-analysis of 146

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

150

expressive writing studies, examining how these exer­ cises influence traumatic experiences, found that they demonstrate positive effects (Frattaroli, 2006), with an average effect size of r = .075. Completing at least three sessions that last at least fifteen minutes each was found to yield larger effect sizes in psychological health, physical health, and subjective effect, as well as a positive overall effect size (r = .08), compared to adaptations with shorter or fewer writing sessions. These documented psychological benefits are especially promising considering the low-cost (inexpensive, lowrisk) nature of engaging in expressive writing. Expressive writing exercises have been used to help people process a variety of psychological issues, including depression (Baikie, Geerligs, & Wilhelm, 2011), trauma (Smyth, Hockemeyer, & Tulloch, 2008), and life transitions (Booker & Dunsmore, 2017). Expressive writing also has been used to address minority-specific issues and their psychological cor­ relates, including internalized racism (Kaufka, 2009), trauma-related distress in Hispanic individuals (Hirai, Skidmore, Clum, & Dolma, 2012), gay-related stress in men (Pachankis & Goldfried, 2010) and women (Lewis et al., 2005), and coping with hate speech (Crowley, 2014). These studies indicate that expressive writing appears to be effective for LGBQ clients, and they suggest that it also may be helpful for LGBQ cli­ ents who also hold other oppressed identities, although none of these studies directly focused on intersec­ tional identities. These exercises have reliably led to psychological improvement, as measured by scales assessing depres­ sion (Henry et al., 2010), anxiety (Hirai et al., 2012), positive and negative affect (Pachankis & Goldfried, 2010), self-esteem (Pennebaker, Colder, & Sharp, 1990), and avoidance behaviors (Swanbon, Boyce, & Greenberg, 2008), as well as reduced physiological measures (e.g., cortisol in response to traumatic mem­ ories; Smyth et al., 2008). Studies testing the effective­ ness of expressive writing typically use a pen-and­ paper method, but online formats are also effective in yielding positive psychological change (Baikie et al., 2011; Lange et al., 2000). The exercise being presented here is in the process of being developed as part of an empirical assessment of a set of expressive writing exercises for LGBTQ

clients. Preliminary research (Collins et al., 2017) has shown that LGBTQ individuals who completed the expressive writing exercise described in this chapter, or either of two additional online exercises, experi­ enced a reduction in negative affect, symptoms of depression, and subjective distress caused by hetero­ sexist events. The term heterosexist events in this exer­ cise includes discrimination, harassment, microag­ gressions, and violence toward LGBTQ clients because of their sexual orientations or beliefs about their sex­ ual orientations. These reductions in psychological distress were seen immediately after completing the exercise as well as at a two-month follow-up. Partici­ pants also experienced subjective benefits in addi­ tion to the empirical reductions in psychological dis­ tress; just over 90 percent of participants reported that the exercises helped them make progress in dealing with their heterosexist event. LGBTQ participants who engaged in these expres­ sive writing exercises in the context of the online study also were asked to reflect on their participation and growth. Participants identified multiple aspects of the exercises that were helpful to them (Maroney, Levitt, Roberts, & Wadler, 2016). For instance, some participants noted that the structured parts of the study—such as the guided questions, revisiting the heterosexist event on three days, and time guidelines— were helpful for them, whereas others reported that these exercises promoted internal reflection by desig­ nating a space for them to better understand their experiences by putting their thoughts and feelings into words. Other gains that participants noted included an increased awareness of their emotions, new per­ spectives and understanding of the event, and more action-oriented changes, such as bringing new reali­ zations to therapy or recognizing future goals. This exercise can be used to support therapists in providing responsive treatments tailored to LGBTQ clients. Ethically, therapists should have the compe­ tence and awareness to provide affirming care to LGBTQ clients (American Psychological Association [APA], 2010, 2012, 2015). The first of the Guidelines for Practice with Lesbian, Gay, and Bisexual Clients (APA, 2012, p. 12) specifically states, “Psychologists strive to understand the effects of stigma (i.e., preju­ dice, discrimination, and violence) and its various Healing from Heterosexism 151

contextual manifestations in the lives of gay, lesbian, and bisexual people,” which speaks to the relevance of recognizing heterosexism and openness to process­ ing heterosexist experiences in therapy. Therapists who are not as familiar with the influence of heterosexism on LGBTQ clients will wish to consider seeking out additional education on how best to serve LGBTQ clients (APA, 2010, standard 2; APA, 2012, guideline 20; see the Professional Readings and Resources later in this chapter). Referring clients to the following exercise can support them in further processing het­ erosexist experiences. By inviting them to discuss their experience in writing, therapists can allow clients a space to reflect and develop their thoughts about these experiences and then continue processing them in therapy. Instructions

Not all LGBTQ clients have experienced heterosexist events that they want to process. Clients may come to therapy for a variety of reasons and have varying issues they would like to discuss; however, LGBTQ clients often use therapy to discuss events that have happened in their lives that are, or were, driven by heterosexist sentiments (Russell & Bohan, 2007). Cli­ ents may be upset about these events, may be unsure if an event was heterosexist, or may feel uncertain how deeply it has affected them. In any of these cases, this activity can be offered to clients as a homework exercise to enable them to further process that expe­ rience. However, clients may or may not wish to engage in this exercise or may wish to discuss the event with their therapist in order to decide. The following pointers can help during these conversations. This exercise can be introduced by explaining that it involves twenty minutes of writing per day for three days with the aim of further processing and healing from heterosexism. The exercise was created as part of a research study to develop treatments for distress caused by heterosexism, which has permitted the assessment of its effectiveness, and the exercise has been found to be helpful to the vast majority of the people who have completed it so far (just over 90 per­ cent; Collins et al., 2017). Clients who engage in this homework exercise between sessions can develop insights about the events or about how they would like 152 Collins, Maroney, Roberts, Wadler, & Levitt

to respond to those events that they can bring into session to discuss further. They can complete the exer­ cise on paper or can visit the link to the online study to complete either the same exercise or one of two others. Clients who opt to complete the exercise online will be randomly sorted into one of the three writing exercises about heterosexism, so those who want to be sure to complete the exercise included in this chap­ ter are encouraged to complete the exercise on paper. Identifying a heterosexist event. The heterosexist event might have occurred recently or a long time ago. It might be a onetime event or a long-standing or continuing event. The central feature of the event is that it is something that is still troubling to the client and that the client wishes to resolve, develop insight into, or learn to cope with better. Some clients are very clear on when they have experienced heterosex­ ist events, but others may be unsure if an event was driven by heterosexist sentiments or not. They may not be familiar with terms like heterosexism, homopho­ bia, and biphobia. Labeling an experience by saying that it sounds like a heterosexist event, and hearing the therapist define those words, however, can be very empowering. Recognizing that an event or experi­ ence is characterized by heterosexist dynamics allows clients to externalize responsibility or blame that they may be internalizing. This appropriate externalization can help alleviate distress or shift problematic inter­ personal dynamics. Even if an event is recognized as heterosexist, time to process it can help lead to new options and possibilities for how to respond to that event in a healthier manner. 1) Introducing the exercise. Once the client and ther­ apist identify a heterosexist experience that is trou­ bling for the client, the homework exercise can be suggested to the client toward the end of the ses­ sion. The suggestion might sound like this: “I have a homework exercise that you might find benefi­ cial. It can help you process this experience more and make progress in how you are thinking about it. The writing exercise takes about twenty minutes, which you should try to do three days in a row to help you process your heterosexist experience. You can do this exercise on a handout that I can give you, or you can do this or another exercise focused on heterosexist events that is included in an online

research study. You can read about the online ver­ sion at the link on the handout, if you’d like to learn more. If you’d like to try this, it is completely up to you which version you select. The important point is that most of the people who have com­ pleted these exercises have found them to be help­ ful, and so I am curious to see if it would be help­ ful for you. If you would like to talk about your experience doing the exercises, I’d be glad to hear about how they went in our next session.” (See the instructions for follow-up on page 154 for more details on leading a discussion after this exercise.) 2) Additional information about the exercises. The following information is provided in case clients decide to engage in the online version and discuss it in session. Suggestions are made to help thera­ pists consider which version might be appropriate to recommend, and distinctions between the for­ mats are noted. Clients may prefer to engage in the written exercise if they are less comfortable with computers or cannot access them. Clients may pre­ fer to engage in the online study if they would ben­ efit from emailed reminders each day to complete the writing exercise. Additionally, it can empower clients to make a contribution to LGBTQ research and the development of interventions that not only may help them but can also assist other people who have had heterosexist events. There are two main differences between the exercise in this chapter and the online study. The first is that on the first day of the online study and at a one month follow-up, clients complete ques­ tionnaires to assess demographics, psychological distress, and event-related distress. These questions allow researchers to see how these exercises are most helpful and continue to shape these exercises to benefit LGBTQ clients. The second difference is in the online study, after reviewing a consent form with a detailed description of the study and con­ senting, clients are randomly assigned to one of three exercises. Preliminary results suggest that they all are effective in helping the majority of clients make gains and have not suggested significant dif­ ferences among the exercises (Collins et al., 2017). The following are brief descriptions of the three different types of writing exercise in the online

format. The written exercise presented in this chap­ ter is an open-ended writing exercise modeled after a typical expressive writing exercise, in which clients are asked to write about their thoughts and emotions surrounding their heterosexist experi­ ence. A second exercise is a focused-attention exer­ cise, in which participants are prompted to describe the event and then write objective descriptions of their actions over the past twenty-four hours in order to notice how they can decide to focus their thinking. It is reflective of mindfulness-based prac­ tices that have been found effective in helping gay men deal with discrimination (Lyons, 2016). The final format is a more structured exploration that guides clients to focus on their feelings, their needs based on these feelings, and the actions they would like to take to meet those needs. It is based on principles tied to emotion-focused therapy, a therapy that has been found to be well adapted for LGBTQ populations (Greenberg, 2002; Hardtke, Armstrong, & Johnson, 2010). Clients are welcome to try a new format of exercise online or to engage in one writing exercise format multiple times; how­ ever, we encourage them to complete the first set of writing exercises and the follow-up before they try a new exercise. Some clients find that progress occurs on the third writing day. Brief Vignette

Maria is a thirty-two-year-old Mexican American, cisgender woman who identifies as a lesbian. Maria described having a conversation with her mother about her fiancée and having her mother sigh and express her wish that Maria could still back out of the wedding. The following dialogue occurred while Maria discussed this event with her therapist: T: It sounds like planning your wedding is very troubling. It is a joyful event, but also there are lots of other emotions that are more worrisome. M: Yeah. I wish this could go more smoothly. I feel really worried about upsetting my family and that I might regret doing this later. Maybe I shouldn’t be getting married and we should just live together. T: It seems to me that this heterosexist or homophobic reaction from your mother is having quite an effect Healing from Heterosexism 153

on you and really stripping a lot of the happiness from your wedding. I wonder if the ways that her feelings have affected you would be good to explore? It can be easy to internalize attitudes like this, especially from our families, and it’s sometimes hard to figure out how to respond. Do you think you would be inter­ ested in exploring your feelings and reactions about this event further?

suggest that clients continue to engage in these sets of exercises if or when they wish and can express a will­ ingness to process the event in session. If clients indicate that they are interested in dis­ cussing their experience, the following are potential prompts for talking about the homework in session:

M: Definitely!

2. How has your understanding of the event changed since last week?

T: There is an exercise that you might want to try that other LGBTQ people have found helpful. It is a writing exercise aimed at helping people process heterosexist experiences, like the one we’ve been discussing. I can give you a handout that contains the exercise instruc­ tions. You can use the handout instructions with a piece of paper or go online to the link on the handout. The links leads to a research study that has this exer­ cise and two others embedded within it and contrib­ utes to the development of interventions for LGBTQ therapy. If you would like to try this exercise, it is up to you which format you select. In both cases, the exercise guides you to engage in writing for twenty minutes a day for three consecutive days about your experience. If you do decide to complete this exercise, we can talk more about your experience next week. I’d be glad to hear what you discover. M: OK. I’ll check that out. Suggestions for Follow-up

Upon completing the homework, clients may or may not want to discuss their experience of engaging in the writing exercise. Because therapists may not know what clients will prefer (and this preference might shift), therapists will want to tentatively ask clients if they engaged in the writing exercise and if they would like to discuss their experience of doing this. For some, the process of writing extensively about a heterosexist event may bring up painful and intensely personal thoughts and emotions that they may not be ready to address in session, but for many this opportunity for support will be welcomed. Indeed, a number of partic­ ipants in the research study indicated that they would like to find a therapist to discuss their insights from the exercise or reported that they spoke with their ther­ apist about their writing. In this case, therapists can 154 Collins, Maroney, Roberts, Wadler, & Levitt

1. What was it like to sit down and write on three consecutive days?

3. Did any new emotions come forward while you wrote? 4. What did the exercise make you realize? About yourself? About others? 5. Did you discover any new ways of thinking about your relationship? 6. What, if anything, was difficult about writing? 7. What, if anything, did you find most powerful about the exercise? 8. Did you notice any new thoughts about how to get your needs met in the world? Therapists can explore clients’ responses, examining how the emotions, behaviors, and ideas that emerge relate to other patterns that have been identified in the course of therapy. Therapists who are not as familiar with leading conversations on heterosexist experiences may find that this structure aids them in facilitating exploration. At the same time, it will be important that therapists seek education on LGBTQ therapy and ethics (see APA, 2012, 2015). Therapists should take care to affirm clients’ experiences and recognize that microaggressions that can seem subtle on the surface can be distressing, especially as they reoccur in clients’ lives and reinforce negative messages with which they have had to contend across their lifetimes. Contraindications for Use

This homework exercise may not work for everybody. Clients come to therapy for a variety of reasons, and clinical judgment should be used when assessing whether this exercise would be well received by a cli­ ent. Because of the nature of the exercise, this home­ work may not be suitable for clients who are not com­

fortable expressing themselves through writing. This exercise may not be appropriate for clients who are currently in crisis, as they might need extra support and may benefit from processing the event with their therapist in session and creating safe boundaries together rather than on their own. All clients conduct­ ing this exercise would need a safe place to engage in the exercise. Clients considering the online exercises also must have access to a computer connected to the Internet and would need to be able to write fluently in English and be over eighteen years of age. Professional Readings and Resources American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67, 10–42. doi:10. 1037/a0024659. American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70, 832–864. doi:10.1037/a0039906. Puckett, J. A., & Levitt, H. M. (2015). Internalized stigma within sexual and gender minorities: Change strategies and clinical implications. Journal of LGBT Issues in Coun­ seling, 9, 329–349. doi:10.1080/15538605.2015.1112336. Russell, G. M., & Bohan, J. S. (2007). Liberating psychotherapy: Liberation psychology and psychotherapy with LGBT clients. Journal of Gay and Lesbian Psychotherapy, 11, 59–75. doi:10.1300/J236v11n03_04. Spengler, E. S., Miller, D. J., & Spengler, P. M. (2016). Microaggressions: Clinical errors with sexual minority clients. Psychotherapy, 53, 360. doi:10.1037/pst0000073. Szymanski, D. M., & Mikorski, R. (2016). External and inter­ nalized heterosexism, meaning in life, and psychological distress. Psychology of Sexual Orientation and Gender Diversity, 3, 265. doi:10.1037/sgd0000182.

Resources for Clients GLBT National Hotline. https://www.glbthotline.org/national hotline.html; hotline: 1-888-843-4564. Heterosexism Healing Study. http://tinyurl.com/HetHealing. LGBTQ Mental Health. (n.d.). Resources and exercises to sup­ port healing from heterosexism. https://LGBTQMental­ Health.com. Singh, A. (2018). The queer and transgender resilience work­ book: Skills for navigating sexual orientation and gender expression. Oakland, CA: New Harbinger. Trans Lifeline. www.translifeline.org; hotline: 1-877-565-8860. Trevor Project. Crisis intervention for LGBTQ+ youth. www. thetrevorproject.org; hotline: 1-866-488-7386.

References American Psychological Association (APA). (2010). Ethical principles of psychologists and code of conduct. http:// apa.org/ethics/code/index.aspx. American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67 (1), 10–42. doi:10.1037/a0024659. American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gen­ der nonconforming people. American Psychologist, 70 (9), 832–864. doi:10.1037/a0039906. Baikie, K. A., Geerligs, L., & Wilhelm, K. (2011). Expressive writing and positive writing for participants with mood disorders: An online randomized controlled trial. Journal of Affective Disorders, 136 (3), 310–319. doi:10.1016/j. jad.2011.11.032. Booker, J. A., & Dunsmore, J. C. (2017). Expressive writing and well-being during the transition to college: Compar­ ison of emotion-disclosing and gratitude-focused writing. Journal of Social and Clinical Psychology, 36, 580–606. doi:10.1521/jscp.2017.36.7.580. Braun, V., & Clarke, V. (2006). Using thematic analysis in psy­ chology. Qualitative Research in Psychology, 3, 77–101. doi:10.1191/1478088706qp063oa. Collins, K. M., Levitt, H. M., Maroney, M. R., Roberts, T. S., Wadler, B. M., & Minami, T. (2017, June). Healing from heterosexism through expressive writing interventions. In H. M. Levitt (chair), Psychotherapeutic responses to het­ erosexist injuries: Research toward recovery. Symposium conducted at the forty-eighth international annual meet­ ing of the Society for Psychotherapy Research, Toronto, Canada. Crowley, J. P. (2014). Expressive writing to cope with hate speech: Assessing psychobiological stress recovery and forgiveness promotion for lesbian, gay, bisexual, or queer victims of hate speech. Human Communication Research, 40, 238–261. doi:10.1111/hcre.12020. Frattaroli, J. (2006). Experimental disclosure and its modera­ tors: A meta-analysis. Psychological Bulletin, 132, 823. doi:10.1037/0033-2909.132.6.823. Greenberg, L. S. (2002). Emotion-focused therapy: Coaching clients to work through their feelings, 2nd edition. Wash­ ington, DC: American Psychological Association. Hardtke, K. K., Armstrong, M. S., & Johnson, S. (2010). Emo­ tionally focused couple therapy: A full-treatment model well-suited to the specific needs of lesbian couples. Jour­ nal of Couple & Relationship Therapy, 9 (4), 312–326. doi :10.1080/15332691.2010.515532. Henry, E. A., Schlegel, R. J., Talley, A. E., Molix, L. A., & Bet­ tencourt, B. A. (2010). The feasibility and effectiveness of expressive writing for rural and urban breast cancer sur-

Healing from Heterosexism 155

vivors. Oncology Nursing Forum, 37, 749–757. doi:10. 1188/10.ONF.749-757. Herek, G. M. (2004). Beyond “homophobia”: Thinking about sexual prejudice and stigma in the twenty-first century. Sexuality Research and Social Policy, 1, 6–24. doi:10.15 25/srsp.2004.1.2.6. Herek, G. M. (2017). Documenting hate crimes in the United States: Some considerations on data sources. Psychology of Sexual Orientation and Gender Diversity, 4, 143–151. doi:10.1037/sgd/0000227. Hirai, M., Skidmore, S. T., Clum, G. A., & Dolma, S. (2012). An investigation of the efficacy of online expressive writ­ ing for trauma-related psychological distress in Hispanic individuals. Behavior Therapy, 43, 812–824. doi:10.1016/ j.beth.2012.04.006. Kaufka (2009). The shadows within: Internalized racism and reflective writing. Reflective Practice: International and Multidisciplinary Perspectives, 10, 137–148. doi:10.10 80/14623940902786115. Lange, A., van de Ven, J. P., Schrieken, B. A., Bredeweg, B., & Emmelkamp, P. M. G. (2000) Internet-mediated, proto­ col-driven treatment of psychological dysfunction. Jour­ nal of Telemedicine and Telecare, 6 (1), 15–21. http:// journals.sagepub.com/doi/abs/10.1258/1357633001 933880. Lewis, R. J., Derlega, V. J., Clarke, E. G., Kuang, J. C., Jacobs, A. M., & McElligott, M. D. (2005). An expressive writing intervention to cope with lesbian-related stress: The mod­ erating effects of openness about sexual orientation. Psy­ chology of Women Quarterly, 29, 149–157. doi:10.1111/ j.1471-6402.2005.00177.x. Lyons, A. (2016). Mindfulness attenuates the impact of dis­ crimination on the mental health of middle-aged and older gay men. Psychology of Sexual Orientation and Gender Diversity, 3, 227–235. doi:10.1037/sgd0000164. Maroney, M. R., Levitt, H. M., Roberts, T. R., & Wadler, B. M. (2016, October). Using an online writing intervention to process experiences of heterosexism in LGBTQ individ­ uals. Presentation at the Sixteenthth Annual Diversity Challenge at Boston College, Chestnut Hill, MA. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Concep­ tual issues and research evidence. Psychological Bulletin, 129, 674–697. doi:10.1037/0033-2909.129.5.674.

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Nadal, K. L., Issa, M. A., Leon, J., Meterko, V., Wideman, M., & Wong, Y. (2011). Sexual orientation microaggressions: “Death by a thousand cuts” for lesbian, gay, and bisexual individuals. Journal of LGBT Youth, 8, 234–259. doi:10.1 080/19361653.2011.584204. Pachankis, J. E., & Goldfried, M. R. (2010). Expressive writing for gay-related stress: Psychosocial benefits and mecha­ nisms underlying improvement. Journal of Consulting and Clinical Psychology, 78 (1), 98–110. doi:10.1037/a0017580. Pennebaker, J. W., & Beall, S. K. (1986). Confronting a trau­ matic event: Toward an understanding of inhibition and disease. Journal of Abnormal Psychology, 95, 274–281. doi:10.1037/0021-843X.95.3.274. Pennebaker, J. W., Colder, M., & Sharp, L. K. (1990). Acceler­ ating the coping process. Journal of Personality and Social Psychology, 58, 528–537. doi:10.1037/0022-3514.58.3. 528. Puckett, J. A., & Levitt, H. M. (2015). Internalized stigma within sexual and gender minorities: Change strategies and clinical implications. Journal of LGBT Issues in Counseling, 9, 329–349. doi:10.1080/15538605.2015.1112336. Remer, L. (2013). Feminist therapy. In J. Frew & M. D. Spiegler (eds.), Contemporary psychotherapies for a diverse world, 373–414. New York: Routledge. Russell, G. M., & Bohan, J. S. (2007). Liberating psychotherapy: Liberation psychology and psychotherapy with LGBT clients. Journal of Gay and Lesbian Psychotherapy, 11, 59–75. doi:10.1300/J236v11n03_04. Smyth, J. M., Hockemeyer, J. R., & Tulloch, H. (2008). Expres­ sive writing and post‐traumatic stress disorder: Effects on trauma symptoms, mood states, and cortisol reactivity. British Journal of Health Psychology, 13, 85–93. doi:10. 1348/135910707X250866. Spengler, E. S., Miller, D. J., & Spengler, P. M. (2016). Microaggressions: Clinical errors with sexual minority clients. Psychotherapy, 53, 360. doi:10.1037/pst0000073. Swanbon, T., Boyce, L., & Greenberg, M. A. (2008). Expres­ sive writing reduces avoidance and somatic complaints in a community sample with constraints on expression. British Journal of Health Psychology, 13 (1), 53–56. doi:10. 1348/135910707X251180. Szymanski, D. M., & Mikorski, R. (2016). External and inter­ nalized heterosexism, meaning in life, and psychological distress. Psychology of Sexual Orientation and Gender Diversity, 3, 265. doi:10.1037/sgd0000182.

EXPRESSIVE WRITING EXERCISE

This exercise is one of three that were found to be helpful to most clients in a research study that contributes to the development of therapy interventions to help LGBTQ people. If you prefer to participate in that study online, you can visit http://tinyurl.com/HetHealing to learn more. Please complete this exercise when you are alone in a quiet space where you can reflect without distractions. You will need a blank sheet of paper, a notebook, or something similar on which to write your thoughts. Don’t worry about spelling and grammar for this exercise—just focus on the exercise instructions. 1. First, take five minutes to write a description of the heterosexist experience that you are focusing on for this exercise. Please describe what happened, what was upsetting for you at the time, and what remains upsetting for you now. (Examples: being insulted or bullied, being harassed, being denied services.)

2. Now use the next fifteen minutes to really explore your deepest feelings and thoughts about this experience.

3. Repeat this exercise three days in a row. Even if one day doesn’t seem particularly helpful, the next day might lead you to a new place. Be curious about your experience and see what comes as you write.

Kathleen M. Collins, Meredith R. Maroney, Tangela S. Roberts, Brianna M. Wadler, and Heidi M. Levitt

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18 AT THE INTERSECTION OF THE AUTISM SPECTRUM AND SEXUAL AND GENDER DIVERSITY: CASE STUDIES FOR USE WITH CLINICIANS AND CLIENTS Eva Mendes and Meredith R. Maroney Suggested Uses: Activity, handout Objectives

We aim to provide an overview of the autism spectrum and to highlight some ways autism may present among individuals who identify as LGBTQ. This exercise is designed to facilitate a conversation between clients and clinicians regarding intersecting identities, includ­ ing those related to autism, gender identity, and sex­ ual orientation. A list of autism spectrum disorder (ASD) traits, case studies of individuals identifying with these intersecting identities, and questions for use in therapy are also included; these may be useful for counselors working with clients of LGBTQ+ and autistic identities. Rationale for Use

The current CDC figures for the prevalence of ASD in children are currently one in sixty-eight (Christensen et al., 2016). There is emerging evidence that there is greater diversity of sexual orientation and gender identity among children, adolescents, and adults on the autism spectrum than in the general population (Glidden, Bouman, Jones & Arcelus, 2016; May, Pang, & Williams, 2017; Mendes & Bush, 2015; Van Der Miesen, Hurley, & De Vries, 2016; van Schalkwyk, Klingensmith, & Volkmar, 2015). Thus, there is grow­ ing recognition in both the research and clinical com­ munities of the intersection of sexual orientation and gender diversity among individuals on the autism spectrum. There is limited clinical knowledge about

adults on the autism spectrum, especially those who are diagnosed with Asperger’s syndrome/ASD Level 1 (the high-functioning variety of ASD), and few inter­ ventions for working with their neurological differ­ ences and unique social, communication, and emo­ tional challenges (Mendes, 2015). There is even less information about and understanding of those who identify as autistic and LGBTQ+ (Bennett & Goodall, 2016). This understanding is important in promoting acceptance and sensitivity among family, friends, and providers toward those who identify as autistic (Mendes & Bush, 2015). Providers’ expertise tends to come from working either with those on the autism spectrum or with LGBTQ+ individuals, which can make it challenging for clients to seek out support from providers who are affirming of both identities. There now seems to be a very small group of pioneering men­ tal health providers who understand how to include both identities in an affirming way (Strang et al., 2018). Those who identify as LGBTQ and autistic may face unique challenges as a result of their intersecting identities, which are important to consider in the context of clinical work. For instance, individuals with autism may face invalidation of their sexual orienta­ tion or gender identity because their capacity to under­ stand their identities is considered to be dubious, or because their identity has been mislabeled as a fixa­ tion on gender identity or sexual orientation (Burke, 2016). A lack of acceptance and understanding of LGBTQ identities can have major implications for autistic clients in their gender expression, their ability

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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to make medical decisions and access care that is affirming, and their ability or willingness to seek out social and legal recognition (ASAN, NCTE, and National LGBTQ Task Force, 2016). Clients who are LGBTQ and autistic may also struggle with social isolation or finding spaces that are affirming of their multiple identities (Strang et al., 2018). Finally, autistic individuals and transgender individuals have been shown to have more difficulties related to employment and navigating their identities at work and school; these difficulties may be exacerbated for those who are both gender diverse and autistic (Budge, Tebbe, & Howard, 2010; Hendricks, 2010; Strang et al., 2018). Given the growing recognition of the prevalence of the ASD and LGBTQ+ spectrum overlap (Van Der Miesen et al., 2016), it is important that there be increased discussion of this intersection in the clinical community. Clinicians run the risk of undertreating their clients or invalidating their clients’ identities if they do not understand the diversity of sexual orien­ tation and gender identity and how it may be manifest among autistic individuals (Glidden et al., 2016). Clinicians must seek out appropriate training around areas beyond their own competence (American Psycho­ logical Association [APA], 2017), which is increas­ ingly important given that there are few who are knowl­ edgeable about sexual orientation, gender identity, and autism. Because of the lack of services available for autistic adults and the lack of consensus on evi­ dence-based treatments with this population (Murphy et al., 2016), clinicians may have to seek out educa­ tion independently to ensure that they achieve the necessary competence to serve clients (APA, 2017, standard 2). As stated in the “Guidelines for Psycho­ logical Practice with Transgender and Gender Non­ conforming [TGNC] People” (APA, 2015), providers should strive to understand the complexity of the mul­ tiple identities of TGNC individuals and how intersec­ tionality may affect gender identity and access to affirmative care. Recently released clinical guidelines on working with clients who present with co-occur­ ring gender dysphoria and autism spectrum disorder highlight the importance of treatment that addresses both gender and autism concurrently; such treatment may require a collaborative approach from profession­

als who specialize in each area (Strang et al., 2018). As stated in the American Psychological Association’s ethics code (APA, 2017, principle E), psychologists are urged to eliminate the effect of biases in their work. By exploring their own attitudes and the knowledge they may hold about clients’ diverse identities, clini­ cians are better able to assess their ability to provide affirmative treatment (APA, 2010, 2015). It is essential that counselors educate themselves on working with this population and deepen their understanding, sensi­ tivities, and strategies for working with individuals who identify on the dual spectrums of ASD and LGBTQ+. Instructions

The following case studies can be used as a tool in exploring identity with clients who are on the autism spectrum and are LGBTQ+, serving as a means of facilitating discussion about similarities to and differ­ ences from the cases provided. Clinicians may wish to bring these narratives into the therapy room when they perceive that clients are questioning their sexual orientation or gender identity, exploring or present­ ing with ASD, or experiencing challenges regarding family or couples work. This activity could be intro­ duced if the client reports being unsure of how to start a session, to normalize the experience a client is having, or for clients with more difficulty naming what is happening to them. Clinicians should introduce this activity by stating something similar to the follow­ ing: “I sometimes have my clients read something in therapy to be able to facilitate a conversation. Would you be open to that?” Clinicians can give clients the option to read independently or together. It may be useful to have the case studies and questions available for clients to refer to as a visual, should they choose. The table of traits could be brought into session inde­ pendently to initiate a conversation about the ways the client’s autistic identity may be affecting different facets of life. Clinicians may wish to talk through guided questions or refer to them after reading through the case study with clients. Materials Included

Handout A: A handout listing common ASD traits and how they may manifest themselves in clients

Intersection of Autism Spectrum and Sexual and Gender Diversity 159

Handout B: Two case studies with clients who hold intersecting LGBTQ and autistic identities Handout C: Guided questions for clinicians to use in therapy with clients who identify as autistic or ASD and diverse in gender identity or sexual orientation Brief Vignette

Lex is a twenty-five-year-old nonbinary, bisexual Asian American individual with work and family challenges. Lex’s pronouns are they, them, and their, and they were assigned female at birth. They are currently seeing a counselor because they are working as a part-time cashier at a ski-sports shop, but they are trained and educated as a musician and would like to work in their field. They also recently broke up with their girl­ friend and are wondering if they are on the autism spectrum because of their recurrent social challenges with work and relationships. In session Lex recently disclosed, “I’m also not out to my family as nonbinary and could use some help with that.” Handout A: When Lex glances at the list of ASD traits and features, they ask for a pencil and put checkmarks against most of the traits on the list. They focus on the first core area of ASD differences and features, under the heading Social. They began talking about how working with a theater group as a pianist was so chal­ lenging for them because they were unable to interpret what the music director wanted. They got so stressed out from the confusing messages and wanting to do a good job that they quit the job after just two weeks. Then they moved on to the features listed under Emo­ tional and spoke about how their girlfriend broke up with them because they couldn’t emotionally support her while she was going through a bout of depres­ sion and a fight with her father. Lex had already been researching if they were on the autism spectrum before all this happened, but their girlfriend’s telling them that she had been secretly reading books about ASD before the breakup confirmed their suspicions. They said, “Until then, I would just randomly look up ASD traits on the Internet, but wasn’t motivated to do enough to go speak to a specialist or anything. How­ ever, when Shelby broke up with me, I realized that I really needed to look into this.”

160 Mendes & Maroney

After Lex completed Handout A, the counselor examined the traits that Lex had checked. A profile of traits began to form that pointed toward major socialcommunication and emotional challenges. Employ­ ment and relationship challenges related to these traits became very apparent. After a few sessions processing Lex’s ASD traits and working through coping strate­ gies for work-related social-communication challenges, the counselor presented Lex with Handout B—Case Study 2. Reading the case study helped the counselor and Lex examine and process the challenges with Shelby, their ex-girlfriend. Suggestions for Follow-up

Clinicians may wish to check in with their clients as a way of continuing the conversation about the inter­ section of autistic and sexual orientation and gender identities. It may be helpful for clinicians to refer to the handout of common ASD traits as they appear relevant to their clients’ experiences and presentation, exploring the ways these traits manifest themselves in different situations (e.g., in the workplace, among family, in friendships and romantic relationships). Referring to the list of traits and case studies may be useful when setting goals in treatment, as well as when reflecting on client growth. Contraindications for Use

Clinicians should be aware of their own comfort level discussing autistic and LGBTQ identities. Those who are newer to working with autistic clients, or clients at the intersection of autistic and LGBTQ identities, may wish to seek out support, consultation, or addi­ tional resources. Clinicians should be aware of where clients are in understanding their identities, and they should note their clients’ reactions to the case studies. For instance, some clients may relate but may not be ready to explore, while others may explicitly state they are not interested in discussing this topic as part of treatment. Clinicians should note that there is large variability across the autism spectrum, as illustrated by a quote from Stephen Shore, an autistic advocate, professor, and author: “If you’ve met one person with Asperger’s, you’ve met one person with Asperg­ er’s” (quoted in Mendes, 2015, p. 230). Therefore, the included case studies may not resonate with all clients.

Professional Readings and Resources American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender nonconforming people. https://www.apa.org/ practice/guidelines/transgender.pdf. Attwood, T. (2008). The complete guide to Asperger’s syn­ drome. Philadelphia: Jessica Kingsley Publishers. Burke, C. (2016, January 26). Gender dysphoria and autism with Aron Janssen MD. Ackerman Podcast. http://acker man.podbean.com/e/the-ackerman-podcast-22-gender­ dysphoria-autism-with-aron-janssen-md/. Glidden, D., Bouman, W. P., Jones, B. A., & Arcelus, J. (2016). Gender dysphoria and autism spectrum disorder: A sys­ tematic review of the literature. Sexual Medicine Reviews, 4 (1), 3–14. doi:10.1016/j.sxmr.2015.10.003. Mendes, E. A. (2015). Marriage and lasting relationships: Suc­ cessful strategies for couples and counselors. Philadelphia: Jessica Kingsley Publishers. Mendes, E., & Bush, H. H. (2015). “Labels do not describe me”: Gender identity and sexual orientation among women with Asperger’s and autism. www.evmendes.com/wpcontent/uploads/2015/04/Labels-do-not-final.pdf. Strang, J. F., Meagher, H., Kenworthy, L., de Vries, A. L., Menvielle, E., Leibowitz, S., . . . & Pleak, R. R. (2018). Ini­ tial clinical guidelines for co-occurring autism spectrum disorder and gender dysphoria or incongruence in ado­ lescents. Journal of Clinical Child & Adolescent Psychology, 47 (1), 105–115. doi:10.1080/15374416.2016.1228462.

Resources for Clients Attwood, T. (2008). The complete guide to Asperger’s syndrome. Philadelphia: Jessica Kingsley Publishers. Decker, J. S. (2014). The invisible orientation: An introduction to asexuality. New York: Carrel Books. Mendes, E. A. (2015). Marriage and lasting relationships: Suc­ cessful strategies for couples and counselors. Philadelphia: Jessica Kingsley Publishers. Sickels, C. (2015). Untangling the knot: Queer voices on mar­ riage, relationships, and identity. Portland, OR: Ooligan Press. Tammet, D. (2007). Born on a blue day: Inside the extraordi­ nary mind of an autistic savant: A memoir. New York: Free Press. Testa, R. J., Coolhart, D., & Peta, J. (2016). The gender quest workbook: A guide for teens and young adults exploring gender identity. Oakland, CA: Instant Help Books.

References American Psychiatric Association. (2013). Diagnostic and sta­ tistical manual of mental disorders, 5th edition. Arlington, VA: American Psychiatric Publishing. American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and

bisexual clients. American Psychologist, 67 (1), 10–42. doi:10.1037/a0024659. American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. doi:10.1037/a0039906. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/index.aspx. ASAN, NCTE, and National LGBTQ Task Force. (2016, June). Joint statement on the rights of transgender and gender non-conforming autistic people. (Press release). http:// autisticadvocacy.org/wp-content/uploads/2016/06/ joint_statement_trans_autistic_GNC_people.pdf. Bennett, M., & Goodall, E. (2016). Towards an agenda for research for lesbian, gay, bisexual, transgendered and/or intersexed people with an autism spectrum diagnosis. Journal of Autism and Developmental Disorders, 46 (9), 3190–3192. Budge, S. L., Tebbe, E. N., & Howard, K. A. (2010). The work experiences of transgender individuals: Negotiating the transition and career decision-making processes. Journal of Counseling Psychology, 57 (4), 377–393. Burke, C. (2016, January 26). Gender dysphoria and autism with Aron Janssen MD. Ackerman Podcast. http:// ackerman.podbean.com/e/the-ackerman-podcast-22-gender­ dysphoria-autism-with-aron-janssen-md/. Christensen, D. L., et al. (2016). Prevalence and characteristics of autism spectrum disorder among children aged 8 years—autism and developmental disabilities monitoring network, 11 sites, United States, 2012. CDC Morbidity and Mortality Weekly Report. Surveillance Summaries, 65 (3), 1–23. doi:10.15585/mmwr.ss6503a1. De Vries, A. L., Noens, I. L., Cohen-Kettenis, P. T., van Berckelaer-Onnes, I. A., & Doreleijers, T. A. (2010). Autism spectrum disorders in gender dysphoric children and adolescents. Journal of Autism and Developmental Disor­ ders, 40 (8), 930–936. doi:10.1007/s10803-010-0935-9. Glidden, D., Bouman, W. P., Jones, B. A., & Arcelus, J. (2016). Gender dysphoria and autism spectrum disorder: A sys­ tematic review of the literature. Sexual Medicine Reviews, 4 (1), 3–14. doi:10.1016/j.sxmr.2015.10.003. Hendricks, D. (2010). Employment and adults with autism spectrum disorders: Challenges and strategies for success. Journal of Vocational Rehabilitation, 32 (2), 125–134. May, T., Pang, K. C., & Williams, K. (2017). Brief report: Sexual attraction and relationships in adolescents with autism. Journal of Autism and Developmental Disorders, 47 (6), 1–7. doi:10.1007/s10803-017-3092-6. Mendes, E. A. (2015). Marriage and lasting relationships: Suc­ cessful strategies for couples and counselors. Philadelphia: Jessica Kingsley Publishers. Mendes, E., & Bush, H. H. (2015). “Labels do not describe me”:

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Gender identity and sexual orientation among women with Asperger’s and autism. www.evmendes.com/wpcontent/uploads/2015/04/Labels-do-not-final.pdf. Murphy, C. M., Wilson, C. E., Robertson, D. M., Ecker, C., Daly, E. M., Hammond, N., . . . & McAlonan, G. M. (2016). Autism spectrum disorder in adults: Diagnosis, manage­ ment, and health services development. Neuropsychiatric Disease and Treatment, 12, 1669–1686. doi:10.2147/NDT. S65455. National Institute for Health and Care Excellence (NICE). (2012, June). Autism spectrum disorder in adults: Diag­ nosis and management. www.nice.org.uk/guidance/cg142. Shumer, D. E., Reisner, S. L., Edwards-Leeper, L., & Tishelman, A. (2015). Evaluation of Asperger syndrome in youth presenting to a gender dysphoria clinic. LGBT Health, 3 (5), 387–390. doi:10.1089/lgbt.2015.0070.

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Strang, J. F., Meagher, H., Kenworthy, L., de Vries, A. L., Men­ vielle, E., Leibowitz, S., . . . & Pleak, R. R. (2018). Initial clinical guidelines for co-occurring autism spectrum dis­ order and gender dysphoria or incongruence in adoles­ cents. Journal of Clinical Child & Adolescent Psychology, 47 (1), 105–115. doi:10.1080/15374416.2016.1228462. Van Der Miesen, A. I., Hurley, H., & De Vries, A. L. (2016). Gender dysphoria and autism spectrum disorder: A nar­ rative review. International Review of Psychiatry, 28 (1), 70–80. doi:10.3109/09540261.2015.1111199. van Schalkwyk, G. I., Klingensmith, K., & Volkmar, F. R. (2015). Gender identity and autism spectrum disorders. Yale Journal of Biology and Medicine, 88 (1), 81–83.

HANDOUT A: CORE DIFFERENCES AND TRAITS In the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), Asperger’s syndrome was collapsed under the umbrella of Autism Spectrum Disorder. This table in not intended to be diagnostic or comprehensive. Diagnosing someone on the autism spectrum is a longer and much more complicated process. This table is a summary of the common manifestation of traits for people on the ASD spectrum. Please refer to the DSM-5 (APA, 2013) for specific diagnostic criteria.

Core Areas of Differences and Features 1. Social

Traits May Be Manifest in This Way n Deficits in social reciprocity n Reduced sharing of interests n Struggling to navigate social situations n Black-and-white thinking (all or nothing) n Rigid thinking and inflexible point of view n Lack of perspective taking or theory of mind, i.e., the ability to understand another’s point of view or to understand that others have their own thoughts and feelings n Inconsistent eye contact n Trouble adjusting behavior to suit social context

2. Communication

n Verbal, nonverbal communication challenges n Inappropriate body language and expression n Echolalia (i.e., repeating odd phrases or sentences) n Lack of initiation n Trouble with back-and-forth conversation flow n Communicating to inform rather than connect n Slow processing n Tendency to focus on details or the negative n Highly logical; can make insensitive comments n Unusually loud or monotonous voice n Struggling to hear/understand tone (dismissive, angry) of voice n Taking things literally n Trouble understanding what is said n Linear thinking patterns and speech

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3. Emotional

n Challenges with emotion regulation n Escalation from zero to sixty n Extreme emotions: up or down n Even-keel emotions: never up or down n Lacking in emotional reciprocity n Anger issues n Poor emotional self-awareness n Alexithymia (no words for emotions) n Vulnerability to stress n Low emotional intelligence quotient (EIQ) n Inability to understand another’s point of view n Lack of awareness or understanding of others’ feelings

4. Physical

n Unusual physicality or repetitive motor movements n Rigid body or unusual body movements n Rocking, flapping, tapping, or shaking legs n Unusual, awkward gait n Odd hand gestures

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5. Need for Structure and Routine

n Attachment to routines, objects, or structure n Hard time changing schedules n Needing structure n Adhering to routines n Sitting in the same chair or spot n Insisting on sameness n Needing to have things neat and organized n Needing to know exactly when things start and end n Always punctual or arrives way ahead of time

6. Executive Functioning Deficits

n Trouble organizing space n Extremely messy n Hoarding n Time-management issues n Chronically late

7. Obsessive Special Interests

n Obsessive, narrow interests n Ritualized behaviors n Highly restricted, fixated interests n Intense special interest in a particular subject or subjects (interests can change over time) n Hyper- or hypo-sensitivity

8. Sensory Issues

n Hyper- or hypo- sensitivity (for example, does not feel cold or is always cold) n Needing to sleep with a weighted blanket Eva Mendes and Meredith R. Maroney

HANDOUT B: T WO CASE STUDIES Case Study 1: Kat Kat, twenty-five, an asexual, nonbinary, European American individual, comes in for counseling at her parents’ behest after her recent autism diagnosis. She is dressed in black leggings and a hooded, long-sleeved sweatshirt dress. One side of her head is shaved, the other dyed blue. Her lip and eye­ brows are pierced. She arrives looking disheveled and as though she hasn’t showered in a couple of days and mildly smelling of body odor. Kat is also thirty minutes late to the session because she took the wrong route to get to the therapist’s office. Once she arrives at the door marked with the therapist’s name, she opens it without knocking. Not even giving a chance for the therapist to invite her in, she barges in and plops herself down on the couch. Appearing to be visibly upset, she keeps her gaze fixed on the floor. After a long pause, she say looks up briefly and says, “I’m sorry, I’m just trying to gather myself. I couldn’t find your office and kept going around in circles! Why is there no sign on this building?” The therapist thinks to herself, “There is a big sign marking the building right in front, but she probably missed it in her anxiety to get here.” Kat says, “I don’t know how this works. What do I say?” “I understand that your parents wanted to you to come see me. Usually in a therapy session, cli­ ents start by telling me why they came in and what things they want to work on.” Kat seems to take the information in and ponders aloud, “Yes, I’m here because my parents want me to.” She rolls her eyes. “They keep saying that I need to see someone to work on my social skills. Do you help with that? I’m not so sure I need help with social skills. But I could use some help finding a job. I just lost my job recently because I was rude to a customer. Is that something you can help me with?” “Sure, we can definitely discuss that.” Kat abruptly changes topic and says, “Did they tell you that I recently told them that I’m asexual?” The therapist replies, “No, they didn’t. Can you tell me more about that?” “I don’t know!” Kat suddenly snaps. “Will you judge me for it? My last therapist tried to tell me that I would grow out of it! She said that people with autism develop later in life and that I might become attracted to people as I grow older. She said it was a developmental thing. She wouldn’t lis­ ten to me!” The therapist gently reassures her, “No, I won’t judge you. Or at least I’ll try not to. I’m so sorry that your last therapist was so unsupportive.” “Thank you. That’s helpful and I don’t want to write off all therapists just because of one.” Case Study 2: Sunee Sunee, thirty, is a gay, cisgender, Turkish immigrant male with ASD who entered therapy along with his partner, Enrique, a cisgender, gay, Hispanic male for couples counseling. Sunee recalls: “Enrique first mentioned that I might have ASD, but I had a hard time being con­ vinced at first. In fact, our first couples counselor also had a hard time seeing my ASD traits.” Speaking about his family of origin, and why he had not previously sought an ASD diagnosis, Sunee says, “I was born and raised in Turkey in a really quirky family of intellectuals. My parents were medical doctors, and so I always had a very out-of-the-box upbringing. In the quirky family, I wasn’t considered odd at all. I started speaking in full sentences when I was two and a half years old, for example, and was reading books on astronomy by the time I was six years old. No one told Eva Mendes and Meredith R. Maroney

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me that was weird or unusual. Also, I only wore black in my teen years, kind of like goth! Even though growing up in Turkey made it hard for me to socially isolate myself, I didn’t have any friends outside the family in the true sense of the word.” Describing his childhood and school years in the context of his autistic behaviors, Sunee explains, “My teachers and classmates probably thought I was strange not only because of the way I dressed, but how I acted in school. I challenged authority a lot, but my parents were prominent in the community, and things were somehow smoothed over for me. In hindsight, I do wish I were less protected. I might have learned more social skills that way. But I also have to say that I was too accomplished to be diagnosed with a disability. I was a published photographer and poet by the time I was ten! I might have also not thought of myself as strange or different because I was always in my own little world. “When I met Enrique, it took a while for us to find a balance that worked for us in terms of spending time together. When we were dating, it was fine, but now that we live together it has become much harder. Enrique really enjoys going out late at night to dance with our friends, and I have a really hard time with the loud music, the crowds, and don’t get why he wants to do this so often. It feels like there’s nothing I can do to fix it—it ends in a fight if I don’t go, and if I do, it always triggers a meltdown. “Most problematic about my ASD are my anger issues and meltdowns, which have become more and more frequent lately, largely before or after social situations. This has been really damag­ ing to our relationship.” Enrique adds, “It’s not like I go out every night or even every weekend. I’ll go out like once a month maybe, but the problem is that Sunee is always coding. He has his own start-up. When he’s not working, he’s composing music, so it’s really hard to get any quality time with him. Also, he smokes pot a lot to help him relax. But then he’s not in a place to really engage with me in a mean­ ingful way.”

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HAN D O U T C : Q UES T IO NS F O R EXP LO RAT IO N O F

IDENT IT IES WIT H CL IENT S

1. Did you relate to anything in Sunee’s story? In Kat’s? What resonated with you?

2. When did you first become aware of your autism and your sexual orientation or gender identity? What was that like for you?

3. How do you identify in terms of your autism? How do you identify your sexual orientation or gender identity? Have these labels shifted or changed for you?

4. How do you see yourself as someone who is autistic and LGBTQ?

5. What comes to mind, academically, culturally, socially, and in terms of your family and upbringing?

6. How have your identities affected your socioeconomic status, if at all?

7. Have you come out to a therapist before? What was that experience like?

8. What would you hope to see from mental health providers who want to support your sexual orientation, gender identity, and autism?

9. Do you see any obstacles to your ability to live authentically and feel at peace with and accepting of your identity? What are those thoughts? Can we look at them?

10. Write down things that you like about your ASD/LGBTQ identities

11. How can we help you combat the obstacles you’ve identified? What helps you feel better?

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19 CLINICAL WORK WITH LGBTQ ASYLUM SEEKERS Brianna M. Wadler, Meredith R. Maroney, and Sharon G. Horne Suggested Use: Activity Objective

The purpose of this activity is to provide clinicians with an overview of the unique challenges faced by sexual and gender minority individuals who are seek­ ing asylum. In this activity, we aim to facilitate dis­ cussion about the client’s potential concerns and cur­ rent needs. To further assist clinicians, two additional questionnaires that have been beneficial in exploring sources of support and resilience for people success­ fully resettling are provided to frame the discussion (Alessi, 2016). Rationale for Use

LGBTQ individuals seeking asylum status tend to have a specific set of experiences and needs about which clinicians should be aware when working with these individuals (Hopkinson et al., 2017). People seeking asylum often have a history of trauma (Heller, 2009). This history, combined with the process of leaving their home country and pleading their asylum cases, can create high levels of additional stress that can ham­ per their successful adjustment to the new country (Portman & Weyl, 2013). As defined by the United Nations High Commis­ sioner for Refugees (UNHCR), refugees are individ­ uals who flee their countries of origin “owing to a well founded fear of being persecuted for reasons of race, religion, nationality, membership of a particu­ lar social group or political opinion” (UNHCR, 2011, p. 10). As Heller (2009) explains, fear of persecution applies to both asylum seekers and refugees. The pri­ mary difference is that refugees are granted legal sanctuary status before arriving in the new country,

whereas asylum seekers go to another country to seek sanctuary and then apply for refugee status. As a part of seeking asylum, individuals undergo immigration proceedings in the new country. Exact numbers of LGBTQ people seeking or granted asylum in the United States are hard to determine (Heller, 2009) because sexual orientation and gender identity infor­ mation is not regularly recorded as part of U.S. data collection (McGuirk, Niedzwiecki, Oke, & Volkova, 2015). Portman and Weyl (2013) estimated that fewer than five hundred people were granted asylum in the United States for sexual orientation or gender identity. In Stronger Together: Best Practice Guide for Support­ ing LGBT Asylum Seekers in the U.S., the Human Rights Campaign Foundation, the National LGBTQ Task Force, and the LGBT Freedom Asylum Network esti­ mated that approximately 5 percent of all asylum claims in the United States are for sexual orientation or gender identity (Brodie, Craig, & Amaro, 2015; McGuirk et al., 2015). Affirmative asylum claims in 2017 were approximately 139,801 (DHS-OIS, 2019); 5 percent of those claims would be about 6,990 people whose asylum claims involved sexual orientation or gender identity. Individuals request asylum through a series of steps particular to the host country, which generally include the process of explaining their personal expe­ riences through a narrative and providing evidence of persecution, which may include testimony from wit­ nesses (Berg & Millbank, 2009). In the United States, asylum seekers must request asylum status within one year of arriving (Piwowarczyk, Fernandez, & Sharma, 2017). As part of the asylum process, LGBTQ asylum seekers must demonstrate that they have experienced persecution because of their membership in a “social

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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group,” that is, a sexual or gender minority group, and that they will face persecution if they return (Berg & Millbank, 2009; Piwowarczyk et al., 2017; Reading & Rubin, 2011). The evidence provided is then judged by officials who either grant or deny asylum status. The process of sharing their personal narratives with immigration officials is extremely stressful for people seeking asylum, but particularly so for people seeking asylum on the basis of minority sexual ori­ entation or gender identity because they may never have shared these experiences with others (Reading & Rubin, 2011). In their countries of origin, LGBTQ asylum seekers may have experienced shame about their identities and feared sharing them, and they often have expended a great deal of energy trying to con­ ceal their identities (Berg & Millbank, 2009). In giving their narrative, however, asylum seekers are expected to recount the personal details of their own sexual ori­ entation or gender identity, despite any shame and fear they may feel in disclosing (Reading & Rubin, 2011) and any retraumatizing that may occur in the process (Shidlo & Ahola, 2013). This narrative may include intimate information such as their first sexual experiences (Berg & Millbank, 2009), and it often is recounted while asylum seekers are fighting their own internalized homophobia (Piwowarczyk et al., 2017). In addition, asylum seekers carry tremendous risk if they are denied asylum and are required to return to their countries of origin. Heller (2009) discusses asylum seekers’ experience as one of covering and reverse-covering. Covering is the process of covering up one’s identity, and reversecovering is the process of accentuating aspects of one’s identity. To be granted asylum, LGBTQ asylum seekers may feel compelled to prove their identity by conform­ ing to LGBTQ stereotypes, hoping to be more con­ vincing to the decision makers. Heller (2009) argues that both covering and reverse-covering are oppressive and potentially harmful to the asylum seeker. Refugees and asylum seekers face many challenges in their journeys from their countries of origin to the host country. They may express distrust toward offi­ cials that is the result of past experiences of persecu­ tion at the hands of people holding power, which may then extend to host-country government officials, law enforcement officers, and medical and mental health

providers (Reading & Rubin, 2011; Renner, 2009). For example, in a sample of LGBT asylum seekers, Hop­ kinson and colleagues (2017) found that 65 percent identified government authorities as one of the groups that persecuted them. In a study of transgender Mexi­ can asylum seekers, participants frequently mentioned experiencing violence by police (Cheney et al., 2017). Refugees and asylum seekers also face challenges of acculturation as they adapt to their new environments (Reading & Rubin, 2011; Renner, 2009). Their efforts to obtain housing, food, and transportation may be hampered by language barriers and the extreme stress of fleeing their countries of origin. Complicating matters is the high burden of dis­ tress asylum seekers carry with them, in the forms of depression, post-traumatic stress disorder (PTSD), anxiety, grief (Slobodin & de Jong, 2015), loneliness and isolation (Hopkinson et al., 2017; Reading & Rubin, 2011), and significant trauma histories (Heller, 2009; Piwowarczyk et al., 2017; Renner, 2009). In gen­ eral, asylum seekers and refugees regularly report experiencing many atrocities in their countries of ori­ gin, such as threats, arrests and detainment, physical assaults, sexual assaults, withholding of food or med­ ical care, witnessing the harming or killing of loved ones, and being forced to move repeatedly (Alessi, 2016; Hopkinson et al., 2017; Piwowarczyk et al., 2017). LGBTQ asylum seekers in particular also report expe­ riencing forced heterosexual marriage, forced con­ version therapy, “corrective rape” (Alessi, 2016, p. 203), losing their jobs, and being evicted (Piwowarczyk et al., 2017). Hopkinson and colleagues (2017) found that LGBT asylum seekers reported higher rates of sexual trauma and suicidality when compared to nonLGBT asylum seekers. In addition to living with these traumas and their effects, asylum seekers face the possibility of becoming retraumatized when having to recount these experiences of persecution in their narrative testimony (Reading & Rubin, 2011). Whereas some refugees and asylum seekers find social support within local immigrant communities in their host countries, LGBTQ asylum seekers may encounter anti-LGBTQ attitudes from residents coming from their countries of origin (Hopkinson et al., 2017; Portman & Weyl, 2013; Shidlo & Ahola, 2013). Unlike others seeking asylum, LGBTQ people Clinical Work with LGBTQ Asylum Seekers 169

usually cannot depend on their own families for sup­ port because their families often were part of the antiLGBTQ abuse they experienced in their home coun­ try (Hopkinson et al., 2017; Shidlo & Ahola, 2013). LGBTQ asylum seekers have reported either not disclosing their identities to local immigrant commu­ nities or avoiding local communities so as not to be retraumatized (Alessi, 2016; Piwowarczyk et al., 2017). Asylum seekers may find it challenging to access quality mental health care because of differences in expectations about care and difficulties communicat­ ing that are due to language barriers (Slobodin & de Jong, 2015). Asylum seekers may not trust Western practices such as psychotherapy and may perceive seeking assistance for mental health from a stranger to be stigmatizing (Reading & Rubin, 2011). Even with many barriers to treatment, LGBTQ asylum seekers can benefit from engaging in therapy. Creating a safe space for the client is paramount, given the client’s traumatic experiences and the generally unsettled life of an asylum seeker (Alessi, 2016; Piwo­ warczyk et al., 2017; Reading & Rubin, 2011). Cul­ tural sensitivity is also a priority in any interventions with asylum seekers and should be the foundation regardless of techniques used (Slobodin & de Jong, 2015). Social service and legal agencies may refer asy­ lum seekers to mental health services to help them cope with the distressing nature of the asylum-seeking process (Reading & Rubin, 2011). Asylum seekers may also look for therapy to cope with symptoms of PTSD, depression, and anxiety (Renner, 2009). Slobodin and de Jong (2015) conducted a review of mental health interventions for refugees and asy­ lum seekers. The two types of interventions with most empirical support were trauma-focused cognitive behavioral therapy (CBT) and narrative exposure ther­ apy (NET) (Slobodin & de Jong, 2015). In one study cited, a culturally sensitive CBT treatment was devel­ oped on the basis of somatic symptoms experienced by Cambodian refugees (Hinton et al., 2005). In a repeated-measures crossover design, all participants were randomly assigned to immediate or delayed treat­ ment with the culturally sensitive CBT. The authors found that participants in the immediate treatment showed significant improvement in PTSD and anxiety symptoms (Hinton et al., 2005). 170 Wadler, Maroney, & Horne

Studies that included NET in clinical work were also effective in reducing PTSD symptoms (Slobodin & de Jong, 2015). In one study, asylum seekers were assigned to receive either treatment as usual or NET; after treatment, those who had received NET experi­ enced a decrease in PTSD symptoms (Neuner et al., 2010). In another study, refugees and asylum seekers received either NET or stress inoculation training (SIT), and researchers found that NET was more effec­ tive in reducing PTSD symptoms (Hensel-Dittmann et al., 2011). Overall, Slobodin and de Jong (2015) argued that NET was helpful in reducing PTSD symp­ toms among refugees and asylum seekers, but that NET was not necessarily more effective than usual treatment for depression and anxiety. Although research has supported CBT and NET, there is limited ability to generalize from this research because the sample sizes tend to be small or the study is specific to a certain group (Slobodin & de Jong, 2015). Slobodin and de Jong (2015) also discussed the assertion that group therapy can improve the mental health of refugees and asylum seekers. Reading and Rubin (2011) found that group therapy was especially beneficial because it can address asylum seekers’ isola­ tion, shame, and need for social support by increasing universality and sharing of experiences. Much work with asylum seekers and refugees focuses on their symptoms, deficits, and challenges (e.g., Cheney et al., 2017). However, in the face of immense challenges, asylum seekers have shown great resilience (Hopkinson et al., 2017). In a study of resil­ ience among minority sexual and gender identity refugees and asylum seekers, Alessi (2016) provided a definition of resilience as “positive adaptation within the context of significant adversity” (p. 204). In his study, Alessi (2016) identified six themes of resilience: staying hopeful and positive; relying on support from significant others and friends; doing whatever it takes; giving back; spiritual upkeep (for African and Carib­ bean people); and, the most critical, using commu­ nity and legal services. He found that lower symptoms of depression, anxiety, PTSD, stress, and somatic ail­ ments are associated with resilience. Therapists can help clients recognize and foster this resilience, which can have long-term benefits for asylum seekers as they settle in their new country. In clinical practice,

Alessi (2016) suggests that clinicians find ways to help connect LGBTQ clients to community services so that their basic needs can be met, they can find assis­ tance with the asylum process, and they can start to build a supportive community, which will boost their resilience. Therapists who are working with asylum seekers and refugees need to be aware of and examine their own assumptions about therapy, asylum seekers, and forced migration experiences (Reading & Rubin, 2011). Asylum seekers may express different ideas about mental health, sexuality, and gender that are specific to their cultural background; therefore, gaining aware­ ness of what may contribute to their cultural context can benefit therapeutic work (Reading & Rubin, 2011). Clinicians may find it challenging to hear asylum seek­ ers’ violent narratives, as Brice (2011) described when sharing his internal reactions to his client’s narrative. Understanding what LGBTQ asylum seekers have experienced can help clinicians build a therapeutic relationship with these clients. Therapists should have a good understanding of internalized homophobia and internalized transphobia because many asylum seekers have internalized the negative messages from their countries of origin (Reading & Rubin, 2011). Therapists also should familiarize themselves with the clients’ countries of origin and current events there to the degree possible (Renner, 2009). In addition, a trauma-informed approach can shift the focus of ther­ apy from symptoms to understanding how the symp­ toms are attempts to cope with trauma (Alessi, 2016). Asylum seekers and refugees are entitled to ethical treatment and rights as set forth by the United Nations’ Universal Declaration of Human Rights (UN Gen­ eral Assembly, 1948) and other international ethical guidelines (International Panel of Experts, 2017; Inter­ national Union of Psychological Science, 2008). In the American Psychological Association’s (APA) “Ethical Principles of Psychologists and Code of Conduct,” the general principles of beneficence and nonmaleficence, fidelity and responsibility, integrity, justice, and respect for people’s rights and dignity are all applicable to work with LGBTQ asylees (APA, 2017). Clinicians should be aware of their own com­ petence and its limits and work to maintain their com­ petence about LGBTQ asylum seekers (APA, 2017,

standard 2). The activity in this chapter can help clini­ cians identify areas in which clients need additional assistance, which may be beyond clinicians’ compe­ tence. In their work with this population, clinicians also should be especially aware of nationality- or lan­ guage-based discrimination that asylees may face and cooperate with their many other care providers (APA, 2017, standard 3). This activity can help clini­ cians learn about clients’ other needs and other pro­ viders working with the clients. Assessment of asy­ lum clients should be conducted, interpreted, and used thoughtfully, and the clients’ cultural back­ grounds and the limitations of the assessments should be kept in mind (APA, 2017, standard 9). Especially important is that clinicians provide informed con­ sent in a language clients understand well (APA, 2017, standard 10). The following activity should not be used unless the client is comfortable using English or the activity has been correctly translated into the client’s language. Instructions

The following exercise can be used either as a handout for clients to complete, allowing them an opportu­ nity to share experiences that may be challenging for them to disclose in therapy, or as a guide for thera­ pists in sessions with asylum-seeking clients or recent asylum grantees. Therapists can use the exercise during intake, once a relationship has been established, or at multiple points during therapy. Questions can be clini­ cian-administered or self-administered. Clients can respond to questions using the 0–4 scale or a yes/no response, if the latter is more comfortable or easier because of language differences. Open-ended questions include question prompts in parentheses, which are optional. The resources may be adapted to share with clients, as appropriate. Therapists are encouraged to speak with an immigration attorney experienced in LGBTQ asylum cases for the most accurate and up-to­ date legal information. Brief Vignette

Sam, age twenty-six, is an asylum seeker from Somalia who identifies as a cisgender gay man and a Muslim. He fled his refugee camp several months before, after receiving multiple death threats because of rumors Clinical Work with LGBTQ Asylum Seekers 171

about his sexual encounters with other men. Sam has been experiencing nightmares, fatigue, and insomnia that his primary doctor could not explain, so he has been referred to Joan, a counselor at the community health center. As part of building rap­ port in the second session, Joan asks Sam, “What have been your experiences so far with housing?” Through this process she learns that Sam is having trouble finding safe and stable housing. With this information, Joan refers Sam to the case manager at the local resettlement agency, who is able to help resolve the housing concerns. After exploring his experiences finding a welcoming religious or spiri­ tual community, Joan also learns the importance of Islam in Sam’s life, and how he is missing this source of strength and support in the United States. Joan con­ nects Sam to a local LGBTQ- affirming Muslim com­ munity, which he later reports is very helpful and comforting to him. Through listening to and working to address Sam’s immediate concerns, Joan builds enough trust with Sam that he feels comfortable answering questions from the first page of the activ­ ity (e.g., How often do you have trouble sleeping?). Joan and Sam then start to address his nightmares, insomnia, and fatigue. Suggestions for Follow-up

The exercise as a handout can be repeated at the con­ clusion of therapy or at the beginning and conclusion of a therapy group. It can then be used to set goals for post-treatment or to realign goals for continued work. Contraindications for Use

This exercise should not be used with clients who cannot read English with understanding, unless it has been professionally translated into a language the client can understand. Professional Readings and Resources Center for Victims of Torture. (n.d.). Heal torture. https:// www.healtorture.org/content/mental-health-resources. Heartland Alliance. (n.d.). Rainbow response: A practical guide to resettling LGBT refugees and asylees. Chicago: Heart­ land Alliance. http://www.rainbowwelcome.org/uploads/ pdfs/Rainbow%20Response_Heartland%20Alliance%20 Field%20Manual.pdf.

172 Wadler, Maroney, & Horne

Heartland Alliance International. (n.d.). Rainbow Welcome Initiative. www.rainbowwelcome.org. LGBT Freedom Asylum Network (FAN). (n.d.). http://www. lgbt-fan.org/. McGuirk, S., Niedzwiecki, M., Oke, T., & Volkova, A. (2015). Stronger together: A guide to supporting LBGT asylum seekers in the US. Washington, DC: LGBT Freedom Asy­ lum Network. http://www.lgbt-fan.org/wp-content/ uploads/2015/06/Stronger_Together_FINAL.pdf. Mulé, N. J., & Gates-Gasse, E. (2012). Envisioning LGBT ref­ ugee rights in Canada: Exploring asylum issues. http:// www.ocasi.org/downloads/Envisioning_Exploring_ Asylum_Issues.pdf. Muller, R. T. (2015, September 10). LGBTQ refugees lack mental healthcare. Psychology Today. https://www. psychologytoday.com/blog/talking-about-trauma/ 201509/lgbtq-refugees-lack-mental-healthcare. Organization for Refuge, Asylum and Migration (ORAM). (n.d.). http://oramrefugee.org/. Organization for Refuge, Asylum & Migration (ORAM). (2012). Rainbow bridges: A community guide to rebuilding the lives of LGBTI refugees and asylees. http://www.refugee legalaidinformation.org/sites/srlan/files/fileuploads/ oram-rainbow-bridges-2012.pdf.

Resources for Clients Okparanta, C. (2015). Under the udala trees. Boston: Hough­ ton Mifflin Harcourt. Papalexandris, J. (2016). Five bells: Being LGBT in Australia. New York: New Press. Quesada, U., Gomez, L., & Vidal-Ortiz, S. (eds.). (2015). Queer brown voices: Personal narratives of Latino/a LGBT activ­ ism. Austin: University of Texas Press. Spijkerboer, T. (ed.). (2013). Fleeing homophobia: Sexual ori­ entation, gender identity, and asylum. New York: Routledge.

References Alessi, E. J. (2016). Resilience in sexual and gender minority forced migrants: A qualitative exploration. Traumatology, 22 (3), 203–213. doi:10.1037/trm0000077. American Psychological Association (APA). (2017). American Psychological Association ethical principles of psycholo­ gists and code of conduct. https://www.apa.org/ethics/ code/. Berg, L., & Millbank, J. (2009). Constructing the personal narratives of lesbian, gay, and bisexual asylum claimants. Journal of Refugee Studies, 22 (2), 195–223. doi:10.1093/ jrs/fep010. Brice, A. (2011). “If I go back, they’ll kill me . . .”: Personcentered therapy with lesbian and gay clients. PersonCentered & Experiential Psychotherapies, 10 (4), 248–259. doi:10.1080/14779757.2011.626624.

Brodie, K., Craig, A., & Amaro, J. (2015, October 15). Report to support LGBT asylum seekers released by HRC, LGBT FAN, and National LGBTQ Task Force. https://www.hrc. org/press/groundbreaking-report-to-support-lgbt­ asylum-seekers-released-today-by-hrc. Cheney, M. K., Gowin, M. J., Taylor, E. L., Frey, M., Dunnington, J., Alshuwaiyer, G., . . . Wray, G. C. (2017). Living out­ side the gender box in Mexico: Testimony of transgender Mexican asylum seekers. American Journal of Public Health, 107, 1646–1652. doi:10.2105/AJPH.2017.303961. Department of Homeland Security Office of Immigration Statistics (DHS-OIS). (2019). Annual flow report: Refugees and asylees: 2017. https://www.dhs.gov/sites/default/files/ publications/Refugees_Asylees_2017.pdf. Heller, P. (2009). Challenges facing LGBT asylum-seekers: The role of social work in correcting oppressive immigration processes. Journal of Gay & Lesbian Social Services, 21 (2–3), 294–308. doi:10.1080/10538720902772246. Hensel-Dittmann, D., Schauer, M., Ruf, M., Catani, C., Oden­ wald, M., Elbert, T., & Neuner, F. (2011). The treatment of victims of war and torture: A randomized controlled com­ parison of narrative exposure therapy and stress inocu­ lation training. Psychotherapy and Psychosomatics, 80, 345–352. doi:10.1159/000327253. Hinton, D. E., Chean, D., Pich, V., Safren, S. A., Hofmann, S. G., & Pollack, M. H. (2005). A randomized controlled trial of cognitive-behavior therapy for Cambodian refugees with treatment-resistant PTSD and panic attacks: A cross-over design. Journal of Traumatic Stress, 18, 617– 629. doi:10.1002/jts.20070. Hopkinson, R. A., Keatley, E., Glaeser, E., Erickson-Schroth, L., Fattal, O., & Nicholson Sullivan, M. (2017). Persecution experiences and mental health of LGBT asylum seekers. Journal of Homosexuality, 64 (12), 1650–1666. doi:10.108 0/00918369.2016.1253392. International Panel of Experts (2017). The Yogyakarta principles: Additional principles and state obligations on the applica­ tion of international human rights law in relation to sex­ ual orientation, gender identity, gender expression and sex characteristics to complement the Yogyakarta principles. www.yogyakartaprinciples.org/principles-en/yp10. International Union of Psychological Science (2008). Univer­ sal declaration of ethical principles for psychologists.

http://www.iupsys.net/about/governance/universal­ declaration-of-ethical-principles-for-psychologists.html. McGuirk, S., Niedzwiecki, M., Oke, T., & Volkova, A. (2015). Stronger together: A guide to supporting LBGT asylum seekers in the US. Washington, DC: LGBT Freedom Asy­ lum Network. http://www.lgbt-fan.org/wp-content/ uploads/2015/06/Stronger_Together_FINAL.pdf. Neuner, F., Kurreck, S., Ruf, M., Odenwald, M., Elbert, T., & Schauer, M. (2010). Can asylum seekers with posttrau­ matic stress disorder be successfully treated? A random­ ized controlled pilot study. Cognitive Behavioral Therapy, 39, 81–91. doi:10.1080/16506070903121042. Piwowarczyk, L., Fernandez, P., & Sharma, A. (2017). Seeking asylum: Challenges faced by the LGB community. Jour­ nal of Immigrant and Minority Health, 19 (3), 723–732. doi:10.1007/s10903-016-0363-9. Portman, S., & Weyl, D. (2013). LGBT refugee resettlement in the US: Emerging best practices. Forced Migration Review, 1 (42), 44–47. Reading, R., & Rubin, L. R. (2011). Advocacy and empower­ ment: Group therapy for LGBT asylum seekers. Trauma­ tology, 17 (2), 86–98. doi:10.1177/1534765610395622. Renner, W. (2009). The effectiveness of psychotherapy with refugees and asylum seekers: Preliminary results from an Austrian study. Journal of Immigrant and Minority Health, 11, 41–45. doi:10.1177/0020764014535752. Shidlo, A., & Ahola, J. (2013). Mental health challenges of LGBT forced migrants. Forced Migration Review, 1 (42), 9–11. Slobodin, O., & de Jong, J. T. V. M. (2015). Mental health inter­ ventions for traumatized asylum seekers and refugees: What do we know about their efficacy? International Journal of Social Psychiatry, 61 (1), 17–26. doi:10.1177/ 0020764014535752. United Nations (UN) General Assembly. (1948). Universal declaration of human rights. https://www.ohchr.org/EN/ UDHR/Documents/UDHR_Translations/eng.pdf. United Nations High Commissioner for Refugees (UNHCR). (2011). Handbook and guidelines on procedures and crite­ ria for determining refugee status: Under the 1951 conven­ tion and the 1967 protocol relating to the status of refugees. Geneva: United Nations. http://www.unhcr.org/3d58e13b4. pdf.

Clinical Work with LGBTQ Asylum Seekers 173

HOW I FEEL: EXPERIENCES OF ASYLUM SEEKERS Please answer the following questions thinking about how you have felt over the past seven days. Use the following scale to respond by writing the number that corresponds to how you feel. 0 Not at all

1 A little

2 Sometimes

3 Quite a bit

4 Extremely

1. How often have you had repeated thoughts about hurtful things that happened to you in the past? 2. How often do you feel connected to your new country? 3. How often do you avoid things that remind you of hurtful things that happened in the past? 4. How often do you have trouble sleeping? 5. How often have you felt accepted as an LGBTQ person in this community? 6. How often do you lose interest in daily activities? 7. How often have you felt unsure about who it is safe to come out to in your new country? 8. How often do you have angry outbursts? 9. How often have you felt that it is easier to be an LGBTQ person here in this country? 10. How often do you feel disconnected from other people? 11. How often have you gotten to know people in your new country? 12. How often is it hard to concentrate? 13. How often have you felt relief that you are in your new country? 14. How often do you have trouble with your memory?

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Brianna M. Wadler, Meredith R. Maroney, and Sharon G. Horne

What have been your experiences since arrival in your host country? Please answer the questions about your experiences in the following parts of your life. 1. Housing? (Have you found safe, stable housing? Are you having any trouble with your living situation? What are the current challenges, if any?)

2. Food? (Do you have enough food? Are you able to find food you like?)

3. Religion or spirituality? (If this is important to you, have you been able to find a welcoming place of worship or a religious or spiritual community?)

4. Employment or volunteer work? (Have you obtained an employment authorization document? Do you need English language classes to prepare for employment?)

5. The asylum process? (What is the status of your asylum claim? Have you connected with immigration legal counsel?)

6. Being an LGBTQ person living here? (Are you able to be open about your LGBTQ identity? What has it been like with new friends? Where you live?)

7. In your transition to the United States, who has been helpful? (What people, resources, organizations are helpful? Whom can you count on?)

8. What helps you keep going? (What things specific to you as a person have helped you overcome so many barriers so far? What are your strengths?)

9. What else do you think I should know about you? What will help me understand your experience?

Brianna M. Wadler, Meredith R. Maroney, and Sharon G. Horne

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20 VALUE-DRIVEN EXPLORATION OF INTERSECTIONS BETWEEN SEXUAL AND RELIGIOUS IDENTITY Angelica Terepka and Jennifer Lancaster Suggested Use: Activity Objective:

This activity is designed to facilitate integration of sexual and religious identities through a valuesexploration process. Rationale for Use

Individuals who both are religious and identify as a sexual minority member must navigate the complex terrain of integrating their sexual identity with reli­ gious messages (both affirming and nonaffirming) about sexual orientation. Because of the potential con­ flict between these identities, individuals may be tempted to deny one aspect of themselves and uphold the other; doing so may result in a sense of loss and a lack of integration of the individual as a whole (Shea, 2005). Additionally, research suggests that cultural factors affect the integration of religious and sexual identities (Akerlund & Cheung, 2000; Sremac & Ganzevoort, 2015). For example, Caucasian American religious LGBT individuals are more likely than eth­ nic minorities to leave one affiliation and opt for a more LGBT-affirming religion (Marin, 2016). It would seem that white individuals experience more freedom to explore other religious options as a means of decreasing conflict between their religious and sexual identities, whereas members of minority populations feel a sense of responsibility to family and communi­ ties of fellowship, which decreases their likelihood of leaving their religious community (Marin, 2016). Thus, the path to integration of religious and sexual identi­ ties may look different across people of varying racial

groups and cultures (Adamczyk & Pitt, 2009; Lease, Horne, & Noffsinger-Frazier, 2005). Assisting clients who identify as both a sexual minority and religious in an exploration of their values pertaining to both aspects of identity may help them experience growth and integration in these domains rather than feeling they must choose one over the other (Bozard & Sanders, 2011). The ethical code states that psychologists must be aware of and respect diver­ sity, including religious and sexual identity domains (American Psychological Association [APA], 2017, principle E); professionals should thus aim to help clients identify and integrate values derived from both identities in a manner that upholds both aspects of client diversity. For example, Bozard and Sanders (2011) developed a counseling model aimed at assess­ ment of the salience of religious identity and sexual identity as well as determination of potential conflict between these domains. The authors further propose interventions aimed at integration of these identities in an effort to recover religion as a source of strength for LGB clientele. Although the current activity does not specifically use Bozard and Sanders’s (2011) model, it does offer a way of exploring these meaningful identities in an effort to move toward a successful inte­ gration for individuals who identify as both religious and LGBT. Furthermore, research has shown that self-acceptance and increased knowledge are instru­ mental in successful integration of LGBT and religious identities (Dahl & Galliher, 2009); identification of values related to both identities may contribute to the increased knowledge and self-awareness necessary for healthy integration.

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

176

The American Psychological Association urges psychologists to understand how multiple minority statuses may complicate and exacerbate the oppres­ sion and discrimination that clients experience (APA, 2017, principle E, standard 2.01). Further, integration of multiple identities may be challenging for some individuals who identify with two or more commu­ nities that have conflicting views. For example, people who identify with the Mormon religion may feel pro­ hibited from expressing their sexual orientation as gay or lesbian (Goodwill, 2008). Psychologists are there­ fore encouraged to help clients explore the domains of diverse identities in an effort to find commonali­ ties and compatible intersections between identities, while recognizing and working to reduce conflicting values in these domains of identity (APA, 2008). In accordance with this effort, models for assessment and integration of religious and sexual identity in coun­ seling have been developed (Bozard & Sanders, 2011). The manner in which LGBT individuals are viewed in a religious milieu varies among religious denominations and cultural contexts (Adamczyk & Pitt, 2009; Lease et al., 2005). Some individuals may find their religion affirming of their sexual orienta­ tion and, as a result, experience little to no conflict in expressing both aspects of their identity. However, the majority of individuals find religious traditions to be nonaffirming of sexual minorities (Gibbs, 2015); there­ fore, religious LGBT people may fear rejection from family, clergy, and their congregation. Another diffi­ culty religious LGBT individuals may experience involves discrimination by nonreligious LGBT people. O’Brien (2004) suggests that a “double stigma” (p. 181) exists for LGBT Christians who feel rejected by their religious community and also feel rejected by other LGBT persons, who may be contemptuous of Christi­ anity, for being openly religious. Such circumstances increase the psychological distress religious LGBT indi­ viduals may experience when attempting to integrate and express both religious and sexual identities (e.g., Rodriguez & Ouellette, 2000; Wood & Conley, 2014). The varying stance of LGBT individuals among reli­ gious traditions in combination with the individual’s own religious inclination leads to several ways in which LGBT people may express religious identities. MacDonald (2006) describes the following five cate­

gories of religious expression by LGBT individuals: • Religion is personally irrelevant: Individuals identify as atheists or nonfaithful. They do not experience a need to express themselves through religious means. Persons in this category do not typically experience a personal conflict between religious beliefs and sexual orientation. • Religious moratorium: Notions of religion and spir­ ituality are actively rejected. Negative emotional energy such as anger and resentment may be directed toward religion. This type of religious expression by LGBT people may be reactionary following rejec­ tion by a specific religious institution or protection from future potential rejection by a religion. • Adoption of alternative spiritualities: Individuals may foster their spiritual life through adoption of new religious beliefs. Some individuals may leave their original place or community of worship for another, more affirming congregation or faith tradition. As a result, individuals may experience loss of relation­ ships associated with their religious community and a change in their religious identity. • Assimilation within a traditional religion while affirming one’s sexual identity: LGBT individuals may acknowledge their sexual orientation and decide to continue associating with their religious community despite negative responses from that community. Some individuals in this position may feel obligated to continue engaging in their religious traditions or may lack awareness of more affirming religious traditions. Others may find that the religious tenets of their faith tradition continue to play a large role in their lives regardless of the rejection of their sex­ ual orientation (Pietkiewicz & KołodziejczykSkrzypek, 2016). • Accommodation of the moral tenets of traditional religions by rejection or suppression of personal sex­ ual identity: Individuals in this position may keep their sexual orientation a secret and denounce this aspect of their identity; they may even seek more religiously orientated conversion-type therapies. This position is both psychologically and spiritually damaging (Kelliher, 2012). The following activity aims to help clinicians and clients Value-Driven Exploration of Sexual and Religious Identity 177

explore values related to two different domains of identity (sexuality and religiosity) and find ways in which clients can integrate these domains in a healthy manner. The activity is based on components of Accep­ tance and Commitment Therapy (ACT; Hayes, 2013). One of the key components of ACT is to help the cli­ ent choose to focus on thoughts and behaviors that are consistent with the values held by the client (Robb, 2007). The aim of values clarification in ACT is to help clients identify what is important in their lives. Val­ ues can be defined as principles chosen by individuals as important standards of behavior, which become the predominant reinforcer of behavior. These values may be innate or socially derived from the construc­ tions of religion, family, education, and other areas. Many people experience difficulty when one or more of these value systems are inconsistent or perceived to be in conflict (Hayes et al., 2013). When faced with this dissonance, it is common for clients to attempt to “decide” between the two values or sys­ tems, rather than try to integrate them. This activity centers on the goal of helping psychologists carry out their ethical responsibility to acknowledge and respect aspects of diversity (including those based on religion and sexual identity) (APA, 2017, principle E; standard 2.01) and aid clients with the integration of their distinct identities. Additionally, the foundation of this activity in ACT allows for the exploration of values in an affirmative and inclusive manner (Hays, 2009), one in which clients can embrace their sexual identity and religious identity simultaneously within the context of their values. Further, the purpose of the activity is in line with the ethical guidelines for multicultural education, training, research, and practice devised by the APA (2008). Specifically, guideline 2 notes the importance of multicultural sensitivity, responsiveness, knowledge, and understanding of factors contributing to the diversity of individuals (APA, 2008). Inherent in the proposed activity is the identification of client values related to two specific identities that clients may hold. Additionally, the activity will allow mental health pro­ viders to better implement guideline 5, which encour­ ages the application of culturally appropriate skills in clinical practice (APA, 2008). The exercise can help

178 Terepka & Lancaster

therapists develop the skill of exploring the client’s val­ ues and identifying possible conflicts among those values to help preserve the unique multicultural iden­ tities held by the client. Instructions

This exercise is best used in individual settings but could be easily adapted for group treatment. Addition­ ally, this activity can be completed during sessions in collaboration with a therapist, or it can be assigned as homework for the client to complete independently. The main purpose of the activity is to stimulate explo­ ration and discussion of values (religious and social) pertinent to the client. Questions to prompt consideration of values in general, as well as values specific to religion and sex­ uality, are provided. Following initial consideration, clients are encouraged to complete the activity (specific instructions are provided on the worksheet). Last, collaborative review of the worksheet should take place with specific emphasis on identification of val­ ues that appear to be inconsistent with the integration of religious and sexual identities. Brief Vignettes

Jenna is an eighteen-year-old cisgender Arab Ameri­ can woman who identifies as Muslim and bisexual. She is heavily involved in her religious community and an active member of her Saudi Arabian cultural center. She has not disclosed her sexual orientation to her family or religious community. Jenna also vol­ unteers at a local LGBTQ center, where she is out and provides support for individuals who identify as members of sexual minorities. Jenna presents for ther­ apy with anxiety and depression, stating that she feels as though she is “leading a double life.” The clinician engages in the values-driven exploration activity, and Jenna is able to realize that her work in all social con­ texts derives from her core values of community, car­ ing, and compassion. Once Jenna recognizes the sim­ ilarities among her work in her religious community, cultural center, and the LGBTQ center, she is able to consider other possible values that are relevant to her religious and sexual identities (e.g., importance of relationships and intimacy). Furthermore, Jenna’s ther­

apeutic exploration and integration of her own val­ ues help her understand how others around her may also begin to view her as both bisexual and religious. James is a thirty-two-year-old gay cisgender Polish American male presenting for treatment with symp­ toms of depression. He was raised in a strict Catholic household and was very much involved with his church as an adolescent. In his early twenties, he explored his sexual orientation and recognized his identity as gay; at this time, he also became distant from his church and religious beliefs. Although he has disclosed his sexual orientation to his family and is currently in a healthy, committed same-sex relationship, he reports experiencing symptoms of depression and the feel­ ing that “something is missing from [his] life.” While working with James, his clinician encourages him to consider his life journey as a religious man and his life journey as gay separately; in session, James and his clinician compare his experiences, and James realizes that his coming out coincided with his loss of reli­ gious identity. He notes his childhood assumption that his Catholic faith completely denounced homosexu­ ality, which resulted in uncomfortable cognitive dis­ sonance. James completes the values-driven activity to explore both his religious and sexual identities. He is able to identify the Catholic virtue of an all-loving and accepting God along with his own value of accept­ ing his sexual identity. He also finds correlations between his identities on values such as relationships, respect, love, compassion, and connection; James even recalls biblical stories of same-sex individuals who were depicted as loving and caring for each other deeply. Exploring similarities among values supporting both identities helps James integrate his self-under­ standing as a gay Catholic man. Suggestions for Follow-up

This is a values-identification exercise. The next step is to examine consistencies and inconsistencies between clients’ religious and sexual identities and determine a value-driven plan of action for identity integration. For example, clients may consider ways in which they may fulfill their religious or spiritual growth needs in the context of an LGBT sexual identity. Clients may also consider finding a supportive religious commu­ nity or engaging in bibliotherapy offering affirmative interpretations of religious scripture.

Contraindications for Use

Clients who are just beginning to explore their sexual identity or their religious identity may find that this exercise is too involved. Integrations of values assess­ ment are more easily accessible for clients who have more thoroughly explored each individual aspect of their identity. Readings for the Professional American Psychological Association (APA) (2009). Report of the APA’s Task Force on Appropriate Therapeutic Responses to Sexual Orientation. Washington, DC: APA. Beagan, B. L., & Hattie, B. (2015). Religion, spirituality, and LGBTQ identity integration. Journal of LGBT Issues in Counseling, 9 (2), 92–117. doi:10.1080/15538605.2015.10 29204. Bozard, R. L., & Sanders, C. J. (2011). Helping Christian les­ bian, gay, and bisexual clients recover religion as a source of strength: Developing a model for assessment and inte­ gration of religious identity in counseling. Journal of LGBT Issues in Counseling, 5 (1), 47–74. Faulkner, S. L., & Hecht, M. L. (2011). The negotiation of closetable identities: A narrative analysis of lesbian, gay, bisexual, transgendered queer Jewish identity. Journal of Social and Personal Relationships, 28 (6), 829–847. Pietkiewicz, I. J., & Kołodziejczyk-Skrzypek, M. (2016). Living in sin? How gay Catholics manage their conflicting sex­ ual and religious identities. Archives of Sexual Behavior, 45 (6), 1573–1585. Shah, S. (2016). Constructing an alternative pedagogy of Islam: The experiences of lesbian, gay, bisexual and transgender Muslims. Journal of Beliefs & Values: Studies in Religion & Education, 37 (3), 308–319.

Resources for Clients Human Rights Campaign. (2019). Resources: Religion and faith. https://www.hrc.org/resources/topic/religion-faith. Marin, A. (2016). Us versus us: The untold story of religion and the LGBT community. Colorado Springs, CO: NavPress. Michaelson, J. (2011). God vs. gay? The religious case for equal­ ity. Boston: Beacon Press. Siraj al-Haqq Kugle, S. (2010). Sexual diversity in Islam: Is there room in Islam for lesbian, gay, bisexual and transgender Muslims? www.mpvusa.org/sexuality-diversity/.

References Adamczyk, A., & Pitt, C. (2009). Shaping attitudes about homo­ sexuality: The role of religion and cultural context. Social Science Research, 38 (2), 338–351. Akerlund, M., & Cheung, M. (2000). Teaching beyond the defi­ cit model: Gay and lesbian issues among African Ameri­ cans, Latinos, and Asian Americans. Journal of Social Work Education, 36 (2), 279–292. Value-Driven Exploration of Sexual and Religious Identity 179

American Psychological Association (APA). (2008). Report of the Task Force on the Implementation of the Multicultural Guidelines. Washington, DC: Author. https://www.apa. org/about/policy/multicultural.aspx. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/index.aspx. Bozard, R. L., & Sanders, C. J. (2011). Helping Christian les­ bian, gay, and bisexual clients recover religion as a source of strength: Developing a model for assessment and inte­ gration of religious identity in counseling. Journal of LGBT Issues in Counseling, 5 (1), 47–74. Dahl, A. L., & Galliher, G. V. (2009). LGBQQ young adult experiences of religious and sexual identity integration. Journal of LGBT Issues in Counseling, 9 (2), 92–112. Gibbs, J. J. (2015). Religious conflict, sexual identity, and sui­ cidal behaviors among LGBT young adults. Archives of Suicide Research, 19 (4), 472–488. Goodwill, K. A. (2008). Religion and the spiritual needs of gay Mormon men. Journal of Gay and Lesbian Social Services, 11 (4), 23–37. Hayes, S. C., Levin, M. E., Plumb-Vilardaga, J., Villatte, J. L., & Pistorello, J. (2013). Acceptance and commitment ther­ apy and contextual behavioral science: Examining the progress of a distinctive model of behavioral and cogni­ tive therapy. Behavior Therapy, 44 (2), 180–198. http:// doi.org/10.1016/j.beth.2009.08.002. Hays, P. A. (2009). Integrating evidence-based practice, cog­ nitive-behavior therapy, and multicultural therapy: Ten steps for culturally competent practice. Professional Psy­ chology: Research and Practice, 40 (4), 354–360. Kelliher, A. (2012). The challenges of supporting the spiritual and religious journey of lesbian, gay, bisexual and transgender clients. Inside Out, 68. http://iahip.org/inside-out/ issue-68-autumn-2012/the-challenges-of-supporting-the­ spiritual-and-religious-journey-of-lesbian-gay-bisexualand-transgender-clients.

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Lease, S. H., Horne, S. G., & Noffsinger-Frazier, N. (2005). Affirming faith experiences and psychological health for Caucasian lesbian, gay, and bisexual individuals. Journal of Counseling Psychology, 52 (3), 378–388. MacDonald, S. V. (2006). Spiritual journey mapping with les­ bian, gay, and bisexual clients. In K. B. Helmeke & C. F. Sori (eds.), The therapist’s notebook for integrating spiri­ tuality in counseling II: More homework, handouts, and activities for use in psychotherapy, 177–188. Binghamton, NY: Haworth Press. Marin, A. (2016). Us versus us: The untold story of religion and the LGBT community. Colorado Springs, CO: NavPress. O’Brien, J. (2004). Wrestling the angel of contradiction: Queer Christian identities. Culture and Religion, 5, 179–202. Pietkiewicz, I. J., & Kołodziejczyk-Skrzypek, M. (2016). Living in sin? How gay Catholics manage their conflicting sex­ ual and religious identities. Archives of Sexual Behavior, 45 (6), 1573–1585. Robb, H. (2007). Values as leading principles in acceptance and commitment therapy. International Journal of Behavioral Consultation and Therapy, 3 (1), 118–122. Rodriguez, E. M., & Ouellette, S. C. (2000). Gay and lesbian Christians: Homosexual and religious identity integration in the members and participants of a gay-positive church. Journal for the Scientific Study of Religion, 39 (3), 333–347. Shea, J. J. (2005). Finding God again: Spirituality for adults. Lanham, MD: Rowman and Littlefield. Sremac, S., & Ganzevoort, R. R. (eds.). (2015). Religious and sexual nationalisms in central and eastern Europe: Gods, gays, and governments. Leiden: Brill. Stitt, A. L. (2014). The cat and the cloud: ACT for LGBT locus of control, responsibility, and acceptance. Journal of LGBT Issues in Counseling, 8 (3), 282–297. Wood, A. W., & Conley, A. H. (2014). Loss of religious or spir­ itual identities among the LGBT population. Counseling and Values, 59, 95–111.

QUESTIONS TO AID THE PROCESS OF GENERAL VALUES EXPLORATION Consider your personal values. Think of the different domains of your life, including relationships (friendships, romantic connections, family), spirituality, work or education, and leisure time. What really matters to you? What do you want to accomplish with your time? What type of person do you want to be? Which personal qualities do you admire in others? Which qualities do you want to develop? Questions to aid the process of exploring values related specifically to religion and sexuality: • Can you tell me about the religious life in your family when you were young?

• How did you know religion was important for your relatives?

• How did you know religion was important to you?

• How do you experience your religion? (e.g., uplifting, hopeful, encouraging, harsh, punishing, shaming)

• When and how did you realize you were LGBT?

• How did you experience and interpret your attraction to same-sex individuals?

• What changes in your behavior have you noticed since you identified as LGBT?

• What experiences have you had in the coming-out process? Were there times when what happened was different from your expectations? What was that like?

• How did your relatives and religious community refer to sexuality?

• What did your family and religious community think about homosexuality? How did that affect you?

• How do religious beliefs affect you as an LGBT person?

• How does being LGBT affect your spiritual or religious practice?

• Which of your religious beliefs uphold respect for your sexuality or gender identity? Angelica Terepka and Jennifer Lancaster

181

ACTIVIT Y: CL ARIF Y YOUR VALUES Here is a list of some common values people may find important. Please read through the list and determine how important each value is to you, on a scale of 1 to 4 (1 = not at all important; 2 = not very important; 3 = somewhat important; 4 = very important). Once you have identified which values are important to you, consider if the values that are important to you affirm your religious identity and your sexual orientation. Value

Importance

Religious identity

Acceptance/self-acceptance Adventure Authenticity Caring/self-care Community Compassion/self-compassion Connection Courage Encouragement Fairness and justice Forgiveness/self-forgiveness Freedom and independence Gratitude Honesty Intimacy Kindness Love Relationships Respect/self-respect Sexuality Supportiveness Trust Other: Other: 182

Angelica Terepka and Jennifer Lancaster

Sexual orientation

SECTION III

HOMEWORK, HANDOUTS,

AND ACTIVITIES FOR

RELATIONSHIPS

Value-Driven Exploration of Sexual and Religious Identity 183

There are many facets to relationships that are unique to individuals who identify as LGBTQ+. Differences in levels of being out, management of oppression and stigma, and internalized homonegativity, heterosex­ ism, and transphobia can all play significant roles in relational dynamics (Meladze & Brown, 2015). This section provides activities and handouts to help clients navigate these themes as well as issues related to inter­ secting religious, racial, ethnic, and social-class iden­ tities. They address social media, sexuality, eroticism, intimacy, violence, and power in innovative and pow­ erful ways. Group therapy is particularly useful for learning and practicing relationship skills. Luke R. Allen shares a group activity for trans youth about creating safe and positive connections in “Transgender Youth and Healthy Relational Skills” (Chapter 23). Because trans youth receive too little relationship skill development that is designed specifically for their experiences, this exercise seeks to answer important questions for these youth and provides essential modeling of healthy relat­ ing. In “Two Stars and a Wish: Termination Activities for Groups with Sexual- and Gender-Identity Diverse Clients” (Chapter 24), Theodore R. Burnes introduces a group therapy exercise to work on an often-avoided skill: the ability to say a meaningful good-bye. Burnes points out that it can be especially disappointing for sexual and gender minorities to leave supportive relationships when they face so much oppression outside the therapeutic group. Assisting them in processing the relationships in the group helps them use termination as a way to deepen the connections they have formed and empowers them to internalize what they have gained to use in current and future relationships. With regard to sexuality in relationships, two chapters focus specifically on open communication about desire and needs. In “Exploring and Navigating Sexual Desire in Relationships” (Chapter 21), Sara K. Bridges outlines the ways in which societal and cul­ tural messages regarding gender roles, sexual iden­ tity, and sexuality come into play when communicating and experiencing sexual desire. In her exercises, cli­ ents are guided through deep exploration of the per­ sonal meanings they have constructed regarding sexual desire so that they can more effectively communicate 184

these preferences and wants with their partners. Kandice H. van Beerschoten introduces another way to help clients explore their sexual desires in “BDSM Exploration and Communication within LGBT Rela­ tionships” (Chapter 27). Van Beerschoten notes that LGBT clients often face more judgment about BDSM practices than do cisgender and heterosexual indi­ viduals, which makes it harder for them to find sup­ portive spaces within which to explore their interests. Because safety and excellent communication are crit­ ical to the practice of BDSM, it is important for cli­ ents to have an affirming place and methods to dis­ cuss their issues of safety, fears, and health concerns. Theodore R. Burnes offer another way of helping clients explore their needs and the messages they have received about relationships in Chapter 25, “The Quadrant Exercise of Relationship Exploration for Sexual- and Gender-Identity Diverse Clients.” This handout can be used with groups or in individual ther­ apy. It provides clients with a nonjudgmental stance by which they can clarify their own values and needs while also identifying negative societal messages that they don’t want to endorse. It is crucial for therapists to address violence of any kind in romantic relationships. As Sabina de Vries notes in “Intimate Partner Violence: Initial Interven­ tions for LGBTQ Clients” (Chapter 22), there are sim­ ilar or higher rates of interpersonal violence among sexual minorities than among heterosexual women, yet there are fewer services available for battered part­ ners in same-sex relationships. These statistics make the need for LGBTQ-affirming therapists even more pressing in this area. Taking into account the ways in which clients may be isolated because of both their sexual identity and their status as a survivor of intimate partner violence, the author helps therapists provide extensive psychoeducation and create an appropriate safety plan for their clients. No discussion of relationships would be complete without exploring the role of social media. Nathaniel Amos addresses the client’s well-being as well as the nuances of the therapeutic relationship in the age of technology in Chapter 26, “Negotiating Information and Communication Technologies with Sexual and Gender Minority Youth and Young Adults.” Use of social media and online resources is salient for LGBTQ

youth because many turn to the Internet for connec­ tion when they experience rejection at home or school. As a result, clients may be having negative experiences online that are important to process. It is also possi­ ble for boundaries between the therapist and client to be blurred when there is more information available about both parties in cyberspace than is being shared in the room. Amos provides therapists with effective

strategies to assess the client’s “digital footprint” as well as the therapist’s use of technology and its influ­ ence on the therapeutic relationship. Reference Meladze, P., & Brown, J. (2015). Religion, sexuality, and inter­ nalized homonegativity: Confronting cognitive dissonance in the Abrahamic religions. Journal of Religion and Health, 54 (5), 1950–1962. doi:10.1007/s10943-015-0018-5.s.

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21 EXPLORING AND NAVIGATING SEXUAL DESIRE IN RELATIONSHIPS Sara K. Bridges Suggested Uses: Homework, handout Objective

The aim of these activities and the corresponding homework is to help couples explore their individual and relational experiences of sexual desire and its fluc­ tuations. In particular, these exercises are designed to help dispel implicit adherence to societal assumptions about desire and desire discrepancy in relationships by expanding awareness of personal and relational sexual desire independent of societal expectations. Rationale for Use

Sexual relationships are complex, and the assumption of mutual pleasure and desire that ultimately result in synchronized mutual orgasms is a myth maintained by popular culture. This myth perpetuates both a notion of how good sex should look and feel (McCarthy & Wald, 2015) and how much partners should desire each other, which often results in feelings of inadequacy or failure. In reality, couples routinely expe­ rience different degrees of desire, and the presence or absence of desire fluctuates over time. Additionally, over the course of a relationship, sexual desire often changes because of contextual issues such as relation­ ship satisfaction, stress, health, and the simple fatigue that comes from responding to the tasks of daily living (McCarthy & Wald, 2015). However, the recent trend toward the medicalization of sexuality (Meixel, Yan­ char, & Fugh-Berman, 2015; Tiefer, 2012) has high­ lighted the issue of desire difficulties and has prob­ lematized these normal fluctuations even further. Thus, what could formerly be perceived as a common ebb and flow of sexual desire within a relationship

despite cultural norms is frequently seen, owing in part to societal expectations and media representation, as pathological or necessarily problematic. Conversely, other research has shown that for many lesbian cou­ ples, sexual desire discrepancies are problematic only if the couple themselves view the discrepancies as a problem (Bridges & Horne, 2007), and shifts in desire for same-sex couples are not necessarily an indication of a change in love or affection (Diamond, 2013). For same-sex partners, issues related to level of “outness,” internalized homonegativity, stigma, and gender-based stereotypes (e.g., gay male couples have copious amounts of sex and are open about casual extrarelational sex, and lesbian couples have a sex life that dwindles over time) can all play a role in the experience and expression of sexual desire (Diamond, 2013; Meladze & Brown, 2015). Additionally, the underlying assumption of sexual similarity is particu­ larly tempting for same-sex couples who often feel that they should at least have a general idea about their partner’s likes and desires that is based on their shared gender background (Felmlee, Orzechowicz, & Fortes, 2010). Yet often these assumptions are errone­ ous and lead to misunderstanding, confusion, and hurt. Further, to assume that gender is a constant con­ struct that is not shaped by gender identity, gender expression, or the internal sense of conformity or nonconformity to gender norms is to chance missing essential components of desire that are connected to some degree to one’s own unique experience of gender (Diamond, 2004). Culture and ethnicity also can play a significant role in how sexual desire is experienced or expressed (Hatfield, Rapson, & Martel, 2007; Hatfield & Rapson,

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

186

1993) because of the multiple ways culture often influ­ ences the expression of sexuality. How conservative or liberal someone is sexually, the degree to which desire can or should be displayed, the role of sexual­ ity within a relationship, and even the amount of guilt one feels owing to one’s sexuality can all be influ­ enced by culture and ethnicity to some degree (Tol­ man et al., 2014). Likewise, age, ability status, and reli­ gion can influence the experience of sexuality in multiple ways and add to the complexity inherent in understanding sexual desire (see Meladze & Brown, 2015; Sowe, Brown, & Taylor, 2014). Clearly, understanding sexual desire and its mean­ ings is complicated and multifaceted (Holmberg & Blair, 2009). Therefore, it becomes necessary to under­ stand individual desire and its fluctuations as well as the role of desire in the unique sexual lives of a couple. The exercises in this chapter are designed to help individuals and couples explore their own desire, the meanings behind the presence or absence of desire, and the ways in which desire is or is not problematic on the basis of a couple’s own understandings of desire—all in cooperation with the multitude of iden­ tity influences (e.g., orientation, gender expression and gender identity, religion, culture, ethnicity, age, ability). Constructivist therapeutic techniques are uniquely situated to help elaborate the meanings of sexual desire both individually and relationally (Brickell, 2006; Butt, 2005). Looking at core understandings or con­ structs of sexual desire can help individuals under­ stand the origins and functions of their desire while also understanding the origins and functions of their partners’ sexual desire (Zumaya, Bridges, & Rubio, 1999). The ability to understand the constructions of the other allows the couple to enter into a role rela­ tionship (Kelly, 1963). Role relationships (Leitner & Thomas, 2003) are relationships that emphasize both understanding one’s own constructions and under­ standing the construing processes of the other. These relationships require advanced perspective taking and empathic understanding—both qualities that lead to better communication and connection. The use of constructivist methodologies for the elaboration and exploration of personal meaning struc­ tures is well documented (see Hardison & Neimeyer, 2012). The pursuit of true understanding of one’s own

formation of sexual meanings and the facilitation of communicating these meanings with a significant other can lead to a deeper affirmation of desire, sex­ uality, and satisfaction within a relationship. Of course, any exploration of core meanings and constructs could uncover uncomfortable feelings or experiences, so it is necessary to obtain explicit permission from clients that is based on their complete understanding that looking for underlying meanings and experience could come with strong emotions (Tolman et al., 2014). Moreover, as clinicians, we are all held to a standard of ethics that requires us to engage in affirming prac­ tice and to be very clear whom we are treating and what our relationship with each client will be, espe­ cially when working with couples (American Psy­ chological Association, 2017). Therefore, although we may be working more directly with one member of a couple and that person’s unique personal meanings related to sexual desire, this is always done in the con­ text of the couple and with an understanding that personal meanings are intertwined and connected to the meanings of the other (Bridges & Neimeyer, 2005; Neimeyer & Neimeyer, 1994). Instructions

Before implementing these exercises, clinicians are bound by an ethical responsibility to ensure that they are not working outside their scope of practice and that the clients are emotionally and relationally ready to explore the sexual aspects of their relationship. Further, assessment of physical or emotional abuse or coercion within the relationship should be conducted to ensure that neither partner is completing these exercises under duress. Exploring and navigating sexual desire can be facilitated through two core exercises: self-character­ ization sketch and holonic mapping of sexual desire. These exercises can be initiated in session and also carried out in more detail in a written homework exer­ cise. Initially it is best to explore meanings associ­ ated with sexual desire in session in the presence of the therapist rather than attempting to deepen and elaborate sexual meanings relationally at home. In the first exercise clients are instructed to write or speak in the third person as a way of establishing a nonthreatening and nonevaluative setting (CrittenExploring and Navigating Sexual Desire in Relationships 187

den & Ashkar, 2012). In the second exercise, the cli­ ents are asked first to explore their own personal holonic structure of sexual desire and then to look at how their structures interact and combine to form a couple’s holonic structure. Exercise 1: Self-Characterization Sketch of Sexual Desire

In this exercise clients are asked to write a self-charac­ terization of their sexual desire from the perspective of someone who knows them very well, “better than anyone ever could really know you” (Kelly, 1955/1991, p. 241). This sketch is a technique of personal con­ struct therapy and an adaptation of George Kelly’s selfcharacterization sketch (Crittenden & Ashkar, 2012). Kelly believed that phrasing the prompt in this way moved clients away from trying to guess what the per­ spective of someone close to them might be and toward a fuller examination of themselves independent of societal expectations or norms. In the current adap­ tation of the original self-characterization sketch (which was more generally about the whole person), clients are asked to focus on one aspect of themselves— their sexual desire: I want you to write a character sketch about [client name] and [identified possessive pronoun] sexual desire, just as if [identified personal pronoun] were the principal character in a play. Write it as it might be written by a friend who knew [identified pronoun] very intimately and very sympathetically, perhaps bet­ ter than anyone ever really could know [identified pronoun]. Be sure to write it in the third person. For example, start out by saying, “[client name] is . . .” (adapted from Kelly, 1955/1991, p. 241). Kelly then advised clinicians and partners to take a credulous approach in attempting to understand the sketch and the clients’ sexual desire through the cli­ ents’ eyes. True empathic understanding (the ability to understand the construing processes of the other) is a vital step to entering into a role relationship and forming deeper connections. These connections and understandings can alleviate hurt feelings and mis­ understandings regarding the absence or presence of sexual desire and its many relational and nonrela­ tional influences. 188 Bridges

Exercise 2: Holonic Structure of Sexual Desire

This exercise is a variation of the “Exploring and Negotiating Sexual Meanings” (Bridges & Neimeyer, 2003) exercise in The Therapist’s Notebook for Lesbian, Gay, and Bisexual Clients: Homework, Handouts, and Activities for Use in Psychotherapy (Whitman & Boyd, 2003). Though the initial exercise was designed to look at sexual meaning making in general, this varia­ tion is focused specifically on understanding the per­ sonal meanings and understandings of sexual desire. Thus, this exercise includes a full exploration of sex­ ual desire based on holonic mapping. A holon is a part of a larger meaning system that has sufficient inter­ nal complexity to be considered a whole meaning sys­ tem in and of itself. Therefore, a holonic map is an elaborate exploration of four subcomponents of sexual desire: eroticism, interpersonal bonding, reproduc­ tion/children, and gender. To construct the map, ques­ tions are asked of clients in session, and they are given a handout that can be used as a way of discovering and elaborating on their own understanding of sexual desire and its many components (see the “Holonic System of Sexual Desire Meanings” handout on page 192). Each member of the couple completes the map individually, and then the two people work together to find ways their maps overlap and depart, allowing for deeper understanding and collaborative navigation. Brief Vignette

Dewaine and Paul have been together as a couple for ten years, married for the last four years, and have three-year-old twin girls. Dewaine is African Ameri­ can and Paul is Caucasian, and both men identify as cisgender. Dewaine was raised in a strict Baptist house­ hold, whereas Paul reported that his family would celebrate the “big holidays” but was not particularly religious. They presented for therapy because of a marked decrease in sexual activity and a feeling that there might be something wrong with their relation­ ship because they have gay male friends who are still “sexual maniacs” later in life. Both men said they felt sexually satisfied when they did have sex, but the spon­ taneous flairs of sexual desire that used to be a big part of their relationship had diminished over the past several years. In creating the self-characterization sketches about their sexual desire, it became clear that

Dewaine had created meanings regarding sexual desire from his first feelings of same-sex desire as an adolescent that necessitated secrecy. He never fully exhibited his desire out in the open, even though he was very comfortable with his sexual orientation. Dewaine reported that this comfort took a long time to achieve as an African American man from a reli­ gious family. His family had eventually come to accept his relationship with Paul over the last few years; however, he knew there would always be an underlying disapproval of his sexual orientation that resulted from his family’s religious beliefs. Paul, on the other hand, had always felt free to disclose his sexual orientation because he came from a very open and accepting family. He reported that for his family, family always came first, and they would do anything for him. Through the self-characterization sketch he revealed that he really felt desire only at the end of the day, when all tasks and chores had been attended to and their kids had been put to bed. For Paul, desire was a reward for getting all things done and for being the kind of parent his own par­ ents were to him. For Dewaine, desire was some­ thing to be carefully managed and revealed only when he could do so in private. Taking these fuller understandings of the meanings of their sexual desire into consideration, it became clear that Dewaine was consistently constricting the erotic holon, whereas Paul was dilating the reproduction/children holon. In navigating their maps and meanings, the couple dis­ covered that their sexual activity and desire were not necessarily problematic or indicative of deeper prob­ lems at this point in their relationship. Instead, they realized that spontaneous, earth-moving desire was a product of societal and gender norm–based expec­ tations rather than a representation of their own attraction, love, and commitment to each other. They both agreed that, eventually, they would like to have sex more often, but for now they were not concerned about their relationship, sexually or otherwise. Fur­ ther, they began to examine ways that societal pressures and “shoulds” were infiltrating their relationship, and they agreed that regular monthly sessions would help keep their relationship on track as they raised their girls.

Suggestions for Follow-up

Often, exploring sexual desire in this in-depth way can be surprising to clients and their therapists. The pressure to be sexual in certain ways or even at cer­ tain times (celebrations, weekends, etc.) can be both implicit and pervasive in a culture inundated with sex but deprived of accurate sexuality information or edu­ cation. Helping clients understand their own thoughts, feelings, and meanings about sexual desire can be very freeing for them, while also highlighting how different these feelings may be when compared to a societal or media-based norm. Continued discussions about desire as it shows up in day-to-day life will deepen their individual and couple understanding of desire and how to navigate discrepancies in desire. Contraindications for Use

Speaking about sexuality can be uncomfortable for many clients. Therefore, building rapport and an empathic alliance is crucial before delving into these topics. Assessment of interpersonal violence, medi­ cal concerns, or hidden extrarelational partnering is necessary and would need to be addressed before work on sexual desire. Additionally, some clients may be uncomfortable with writing or speaking about themselves in the third person and do not feel threat­ ened by first-person exploration. It is still advisable for the clients to initially attempt to write or speak in the third person as an avenue for deeper understand­ ing of underlying constructs. These constructs may not be as readily available if writing in the first per­ son. Finally, these exercises require openness to selfexploration, partner communication, and both self and partner understanding. It may be necessary to do some initial work on communication and empathy before initiating the exercises. Professional Resources and References American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/index.aspx. Brickell, C. (2006). The sociological construction of gender and sexuality. Sociological Review, 54 (1), 87–113. doi:10. 1111/j.1467-954X.2006.00603.x. Bridges, S. K., & Horne, S. G. (2007). Sexual satisfaction and desire discrepancy in same-sex women’s relationships.

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Journal of Sex and Marital Therapy, 33 (1), 41–53. doi:10. 1080/00926230600998466. Bridges, S. K., & Neimeyer, R. A. (2003). Exploring and nego­ tiating sexual meanings. In J. S. Whitman & C. J. Boyd (eds.), The therapist’s notebook for lesbian, gay, and bisexual clients, 145–149. Binghamton, NY: Haworth Press. Bridges, S. K., & Neimeyer, R. A. (2005). The relationship between eroticism, gender, and interpersonal bonding: A clinical illustration of sexual holonic mapping. Journal of Constructivist Psychology, 18 (1), 15–24. doi:10.1080/107 20530590523008. Brown, J. D., & Bobkowski, P. S. (2011). Older and newer media: Patterns of use and effects on adolescents’ health and well-being. Journal of Research on Adolescence, 21 (1), 95–113. doi:10.1111/j.1532-7795.2010.00717.x. Butt, T. (2005). Editorial foreword: The construction of sexu­ alities. Journal of Constructivist Psychology, 18 (1), 1–2. doi:10.1080/10720530590522955. Crittenden, N., & Ashkar, C. (2012). The self-characterization technique: Uses, analysis, and elaboration. In P. Caputi, L. L. Viney, B. M. Walker, & N. Crittenden (eds.), Personal construct methodology, 109–128. Hoboken, NJ: John Wiley & Sons. Diamond, L. M. (2004). Emerging perspectives on distinctions between romantic love and sexual desire. Current Direc­ tions in Psychological Science, 13 (3), 116–119. doi:10.1111/ j.0963-7214.2004.00287.x. Diamond, L. M. (2006). The intimate same-sex relationships of sexual minorities. In A. L. Vangelisti & D. Perlman (eds.), The Cambridge handbook of personal relationships, 293–312. New York: Cambridge University Press. doi:10.1017/CBO9780511606632.017. Diamond, L. M. (2013). Links and distinctions between love and desire: Implications for same-sex sexuality. In C. Hazan & M. I. Campa (eds.), Human bonding: The science of affectional ties, 226–250. New York: Guilford Press. Felmlee, D., Orzechowicz, D., & Fortes, C. (2010). Fairy tales: Attraction and stereotypes in same-gender relationships. Sex Roles, 62 (3–4), 226–240. doi:10.1007/s11199-009 -9701-x. Hardison, H. G., & Neimeyer, R. A. (2012). Assessment of personal constructs: Features and functions of construc­ tivist techniques. In P. Caputi, L. L. Viney, B. M. Walker, & N. Crittenden (eds.), Personal construct methodology, 3–51. Hoboken, NJ: John Wiley & Sons. Hatfield, E., & Rapson, R. L. (1993). Historical and cross-cul­ tural perspectives on passionate love and sexual desire. Annual Review of Sex Research, 467–497. Hatfield, E., Rapson, R. L., & Martel, L. D. (2007). Passionate love and sexual desire. In S. Kitayama & D. Cohen (eds.), Handbook of cultural psychology, 760–779. New York: Guilford Press.

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Holmberg, D., & Blair, K. L. (2009). Sexual desire, communi­ cation, satisfaction, and preferences of men and women in same-sex versus mixed-sex relationships. Journal of Sex Research, 46 (1), 57–66. doi:10.1080/002244908026 45294. Kelly, G. A. (1955/1991) The psychology of personal constructs, vol. 1. New York: Routledge. Kelly, G. A. (1963). A theory of personality: The psychology of personal constructs. New York: W. W. Norton. Leitner, L., & Thomas, J. (2003). Experiential personal con­ struct psychotherapy. In F. Fransella (ed.), International handbook of personal construct psychology, 257–264. Hoboken, NJ: John Wiley & Sons. doi:10.1002/04700 1337.ch25. McCarthy, B., & Wald, L. M. (2015). Strategies and techniques to directly address sexual desire problems. Journal of Family Psychotherapy, 26 (4), 286–298. doi:10.1080/0897 5353.2015.1097282. Meixel, A., Yanchar, E., & Fugh-Berman, A. (2015). Hypoac­ tive sexual desire disorder: Inventing a disease to sell low libido. Journal of Medical Ethics: Journal of the Institute of Medical Ethics, 41 (10), 859–862. doi:10.1136/medethics­ 2014-102596. Meladze, P., & Brown, J. (2015). Religion, sexuality, and inter­ nalized homonegativity: Confronting cognitive dissonance in the Abrahamic religions. Journal of Religion and Health, 54 (5), 1950–1962. doi:10.1007/s10943-015-0018-5. Neimeyer, G., & Neimeyer, R. A. (1994). Constructivist meth­ ods of marital and family therapy: A practical precis. Jour­ nal of Mental Health Counseling, 16 (1), 85–104. Sowe, B. J., Brown, J., & Taylor, A. J. (2014). Sex and the sinner: Comparing religious and nonreligious same-sex attracted adults on internalized homonegativity and distress. Amer­ ican Journal of Orthopsychiatry, 84 (5), 530–544. doi:10. 1037/ort0000021. Tiefer, L. (2012). Medicalizations and demedicalizations of sexuality therapies. Journal of Sex Research, 49 (4), 311– 318. doi:10.1080/00224499.2012.678948. Tolman, D. L., Diamond, L. M., Bauermeister, J. A., George, W. H., Pfaus, J. G., & Ward, L. M. (2014). APA handbook of sexuality and psychology, vol. 1, Person-based approaches. Washington, DC: American Psychological Association. doi:10.1037/14193-000. Whitman, J. S., & Boyd, C. J. (eds.). (2003). The therapist’s note­ book for lesbian, gay, and bisexual clients: Homework, hand­ outs, and activities for use in psychotherapy. Binghamton, NY: Haworth Clinical Practice Press. Zumaya, M., Bridges, S. K., & Rubio, E. (1999). A constructivist approach to sex therapy with couples. Journal of Construc­ tivist Psychology, 12 (3), 185–201. doi:10.1080/10720539 9266064.

Resources for Clients American Association of Sexuality Educators. (n.d.). Coun­ selors and Therapists referral directory. https://www. aasect.org/referral-directory. Diamond, L. (2009). Sexual fluidity: Understanding women’s love and desire. Cambridge: Harvard University Press.

National Coalition for Sexual Freedom. (n.d.). Kink Aware Professionals Directory. https://ncsfreedom.org/key-pro grams/kink-aware-professionals-59776. Sexuality Information and Education Council of the United States. (2018). https://www.siecus.org/.

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HOLONIC SYSTEM OF SEXUAL DESIRE MEANINGS (adapted from Bridges & Neimeyer, 2003)

GENDER

EROTICISM

REPRODUCTION

INTERPERSONAL BONDING

Our sexual identity, and consequently our sexual desire, is made up of four interrelated systems of meanings. These systems differ from one person or relationship to another. Because it can be confusing to sort through these meanings with a partner (or even on one’s own), it is often helpful to reflect on each of these areas in turn, as they bear on your thoughts, feelings, and preferences about issues related to gender, erotic pleasure, interpersonal bonding, and reproduction. As a guide, you might find it helpful to try to answer some of the following questions for yourself, before discussing similar questions with your partner. A few suggestions for exploring each of these systems follows, as well as some questions that focus on their interaction. Other topics related to these areas might occur to you as you reflect on each, so the following prompts should be considered only a general guide to how your exploration might evolve. 1. Gender holon: the way we see ourselves as female, male, lesbian, gay, bisexual, transgender, or heterosexual within society and all the implications this has for our lives. Sample questions: • How does your personal conception of your gender identity shape your sexual desire? What aspects of your gender identity do you value? • Are the gender roles adopted by you and your partner compatible, complementary, or conflictual in their implications for sexual desire within your relationship? How flexible or fixed are your respective roles in the relationship? 2. Eroticism holon: our desire for sexual excitement, pleasure, and orgasm. Sample questions: • What forms of sexual activity give you pleasure? Are there times your desire for these activities changes? What influences your desire for different kinds of sexual activity? • What meanings or fantasies enhance or intensify your excitement and erotic potential? What mean­ ings inhibit it? How comfortable are you sharing these meanings and fantasies with your partner?

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• How compatible are your erotic preferences with your partner’s erotic preferences? Which aspects of your erotic preferences are most difficult to speak about? Which are easily misunderstood? • How does your ability to be open about your erotic preferences affect your sexual desire? 3. Interpersonal Bonding holon: our capacity to develop intense feelings in regard to the pres­ ence or absence, availability or unavailability of another specific human being. Sample questions: • To what extent does your sexual desire influence how you seek versus retreat from meaningful attachment relationships? How are these forms of drawing close or distancing expressed in words or actions? • Is the form of closeness sought by both of you similar or dissimilar? How might you signal your need for greater connection or space in a way that is constructive for you both? How are you able to be connected and close with or without the presence of sexual desire? 4. Reproduction holon: the human potential to create or foster the development of individuals. Sample questions: • What role, if any, does having or raising children play in your sexual desire? Has this changed over time, and if so, how? • How compatible are your hopes or wishes concerning the desirability or timing of raising chil­ dren with those of your partner? How might such wishes be navigated? Holonic interactions: the subtle interplay among your four systems of sexual desire meanings, or between your meanings and those of your partner. Sample questions: • Are some of your holons isolated from the others, so that it is not clear that they connect with other domains of your sexual desire? How would your sense of your sexual desire change if they were more completely integrated? • Are some of your holons “bigger” or more important than others? What would this map look like if you drew them to scale? How would your map compare with your partner’s holonic structure? • Is there a distinctive “firing order” of your holons? That is, does the activation of one (for exam­ ple, interpersonal bonding) tend to trigger the activation of another (such as eroticism)? Is the sequencing of your activation similar to or different from that of your partner? This handout can also be found online at the Constructivist Sexuality Research Lab website: https://skbridges.wixsite.com/csrl.

Sara K. Bridges

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22 INTIMATE PARTNER VIOLENCE: INITIAL

INTERVENTIONS FOR LGBTQ CLIENTS

Sabina de Vries

Suggested Uses: Activity, homework Objective

This activity is designed for clients who find them­ selves in an abusive relationship and want to leave their partners. Safety and psychoeducation are of utmost importance when working with clients strug­ gling to leave an abusive relationship. The goal of this activity is to provide initial tools to help LGBTQ cli­ ents increase safety and gain greater understanding of abusive relationship patterns that are found in intimate relationships and those that are specific to same-sex relationships. Rationale for Use

Intimate partner violence (IPV) is a wide-ranging problem in the United States, and LGBTQ commu­ nities are not immune. It can be defined as violence that occurs in romantic relationships and may include emotional, physical, and sexual abuse (Kubicek, McNeeley, & Collins, 2016). Prevalence of IPV among sexual minorities was found to be similar to or higher than that of heterosexual women (Kubicek et al., 2016). The National Violence Against Women survey found that 21.5 percent of men and 35.4 percent of women living with a same-sex partner had experienced physi­ cal violence, as opposed to those in heterosexual relationships, which were reported as 7.1 percent and 20.4 percent, respectively. In addition, the Centers for Disease Control and Prevention found that 41 per­ cent of lesbians, 61 percent of bisexual women, and 35 percent of heterosexual women had experienced rape, physical violence, or stalking by an intimate

partner. It was also found that 26 percent of gay men, 37 percent of bisexual men, and 29 percent of hetero­ sexual men had experienced rape, physical violence, or stalking by an intimate partner. Intimate partner violence can have deadly consequences. For example, in 2000, 1,247 women and 440 men were killed by a partner; 33 percent of female victims and 4 percent of male victims were murdered by an intimate partner (American Bar Association, n.d.). These data do not account for those who commit suicide because of intimate partner violence. Though concrete data are difficult to obtain, it is speculated that of the roughly 6,000 women who commit suicide each year, a signif­ icant number were abused by an intimate male partner (Websdale, 2003). Currently, about 2,000 agencies provide services to survivors of IPV (Hines & Malley-Morrison, 2005). According to feminist-based philosophies, most domestic violence services are geared toward young, heterosexual women (Hines & Douglas, 2011). Today most domestic violence agencies also provide services to underserved populations such as LGBTQ clients; however, it was found that overall services and out­ reach were still lacking for these domestic violence survivors (Hines & Douglas, 2011). Adolescents as well as men receive the least amount of services (Hines & Douglas, 2011). Research indicates that those in sexual minority relationships may be at a higher risk for dating violence when compared to their heterosexual counterparts (Dank, Lachman, Zweig, & Yahner, 2014). Factors such as discrimination, internalized homophobia, and general victimization may contrib­ ute to increased risk of IPV (Lewis, Milletich, Kelley, & Woody, 2012).

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

194

Before moving on to specific interventions, we need to highlight unique aspects of working with LGBTQ clients who are experiencing IPV. For exam­ ple, counselors should practice only in accordance with their competencies. The American Counseling Association (ACA) Code of Ethics, section C.2, Pro­ fessional Competence (ACA, 2014), indicates that counselors need to possess multicultural counseling competencies to work with a variety of clients, which includes those from LGBTQ backgrounds. In addi­ tion, the ACA Code of Ethics stipulates that counsel­ ors need to possess or acquire skills and competencies in order to provide effective and affirmative counsel­ ing interventions. Counselors working with clients in IPV relationships in general, and from an LGBTQ background specifically, need to obtain crucial knowl­ edge and skills. For example, counselors should have a working knowledge of processes involved in trau­ matic bonding and the Stockholm syndrome (Wallace, 2007). Counselors should also understand and accept that survivors of IPV frequently return to the abusive partner. Leaving an abusive relationship is usually a long, intricate, painful, and frustrating journey for the survivor. Counselors working with this population need to provide services in accordance with the Asso­ ciation for LGBT Issues in Counseling (ALGBTIC) competencies and understand the implications of the intersectionality of IPV, sexual minority status, and multiple-minority status (Harper et al., 2013). IPV presents an additional viewpoint to intersectionality. Many sexual minority victims are double-closeted (Stephenson, Khosropour, & Sullivan, 2010), meaning they have not come out or not completely come out and they are also hiding the abuse. To date, no targeted prevention or interventions have been developed for underserved populations such as sexual minorities (Kubicek et al., 2016). The lim­ ited literature that addresses IPV concerns of sexual minorities has focused primarily on lesbian relation­ ships (Stephenson et al., 2010). One of the few studies focusing on IVP in gay male relationships found rel­ atively high levels of IPV among gay and bisexual men (Stephenson et al., 2010). The ALGBTIC compe­ tencies stipulate that practitioners have awareness, a solid knowledge base, and skills when working with LGBTQ clients (Harper et al., 2013). Therefore, it is

important for LGBTQ-affirming counselors to be aware of and keep track of these trends in populations they serve. It is important for survivors of IPV to be exposed to the concept of the cycle of violence. The cycle of vio­ lence consists of a repeating pattern of tension build­ ing, explosion, and honeymoon phases. Frequently, survivors are only vaguely aware of the existence of such patterns, and processing this information can help the victim understand that the abuser and the abusive relationship are similar to those others have experienced (Walker, 1979). The inability to recog­ nize abusive patterns might stem from “gaslighting” (Salerno & Garro, 2016), which refers to the abuser’s attempt to manipulate the victim into doubting their memories, perceptions, and sanity. The abuser’s goal is to confuse, control, and keep the victim off bal­ ance. It can be helpful for the survivor to know that they are not crazy (Bancroft, 2003, p. 136) and that many others have suffered through abusive relation­ ships and, in the end, were able to leave (Bancroft, 2003). Finally, it is imperative to explore the strategies that abusive partners may use to overpower and con­ trol their victims. Counselors working with LGBT clients need to understand how abusive patterns unfold in order to offer affirmative counseling services and to be in compliance with ALGBTIC counseling com­ petencies (Harper et al., 2013). For example, threats, coercion, intimidation, and violence are used to instill fear in the partner. Among other things, the abuser may be using emotional, economic, physical, or sexual abuse to control the victim (Walker, 1979). The abuser may also use children or pets to manipulate or to instill fear. The GLBT Power and Control Wheel (see page 200) is similar to the heterosexual power and control wheel; however, the LGBT version also high­ lights the fact that same-sex couples are also nega­ tively affected by heterosexism and by homo-, trans-, and biphobia (Chavis & Hill, 2008). For example, the abuser may threaten to out the victim as an LGBTQ person if the victim has not come out, not come out completely, or come out only to specific individuals (Kulkin et al., 2007). The abuser may insist that no one is willing to help because of the victim’s sexual iden­ tity, or may insist that the victim deserves being abused Intimate Partner Violence: Interventions for LGBTQ Clients 195

owing to sexual orientation (National Domestic Vio­ lence Hotline, n.d.). Another tactic used in LGBTQ battering is to question the victim’s LGBTQ status as defined by the abuser; this tactic serves as an emotional battering tool as well as an attempt to isolate the victim from com­ munity support (National Domestic Violence Hotline, n.d.). LGBTQ batterers also may try to monopolize and manipulate supportive family and friends to cut vic­ tims off from their support system (National Domes­ tic Violence Hotline, n.d.). Last, the abuser may attempt to portray the violence as consensual, espe­ cially in gay battering relationships (National Domes­ tic Violence Hotline, n.d.). Instructions

There is a paucity of research on interventions for sexual-minority IPV victims or IPV perpetrators (Edwards, Sylaska, & Neal, 2015). However, the follow­ ing widely accepted IPV interventions can be adapted to suit the needs of LGBTQ clients. These exercises can be used as initial tools to help individual LGBTQ clients understand and make sense of abusive relation­ ship patterns. They are best used in the safety of the counselor’s office. The activities presented here consist of an initial Safety First activity, followed by the Cycle of Violence and GLBT Power and Control Wheel. Safety First. It is of utmost importance that the survivor of IPV has a structured plan in place to stay safe. To fit the needs of abused LGBTQ clients and to promote safety, one option is to adapt safety plans developed to serve women leaving an abusive hetero­ sexual relationship. Such a safety plan should address safety during an IPV situation, safety when preparing to leave, safety in a personal residence (possibly obtain­ ing protective orders), safety in public places or at work, safety involving alcohol and drug abuse, and emotional safety. It is also vital to stash away impor­ tant items such as money, critical paperwork, identi­ fication documents, and the like. A comprehensive personalized safety plan form can be obtained from the National Center on Domestic and Sexual Violence and can be tailored to fit the individual needs of cli­ ents wanting to leave abusive relationships. Time in the counselor’s office can be spent on helping the survivor work on and process a personal safety plan. 196 de Vries

In accordance with the ACA Code of Ethics (ACA, 2014, A.4.a, Avoiding Harm), it is imperative that the personalized safety plan is kept in a secure location and out of the abuser’s reach so as not to invite more abuse and harm. Cycle of Violence and GLBT Power and Control Wheel. Counselors should spend some time process­ ing the Cycle of Violence and GLBT Power and Con­ trol Wheel with their clients: many survivors of IPV are not completely aware of the patterns involved in abusive relationships. In addition, these tools can help correct mistaken beliefs frequently held by vic­ tims, such as their having any measure of control over abusive patterns. Understanding the Cycle of Violence and GLBT Power and Control Wheel can provide much-needed information about abusive relationship patterns. For example, the Cycle of Violence can be used to guide the relationship narrative as the client and counselor work on creating a cohesive story line regarding how the client arrived at this particular and distressing point. The client and counselor can work through each of the eight sections that contain the power and con­ trol strategies. The client will be asked to examine how the abuser uses each strategy to assert power and control in the current relationship. The main purpose is to identify and gain clarity regarding abusive strat­ egies and how these affect the victim. Brief Vignette

Maria, a young cisgender lesbian Latina, came to see Joann, a counselor in private practice, because she was concerned about her relationship with Julie. She reported that Julie had been abusive toward her at an ever-increasing level. She felt confused by the fact that Julie at times would be the way she used to be when the couple first fell in love, but the good times would never last. Joann used the Cycle of Violence handout to help Maria understand the cyclical nature of abusive relationships, and to emphasize that Maria was not to blame for the periodic violent eruptions. Maria reported that she had become afraid for her life because the most recent incident caused her to need stitches. In a violent outburst, Julie had pushed her through a glass door in the couple’s dining room. Maria stated that she had left the abusive relationship before.

She had even gone to a local battered women’s shelter; however, Julie followed her there, claiming that she was also a victim of IPV. Out of fear and because she viewed Julie as all-powerful, Maria returned to the relationship, but things got increasingly worse. Maria felt that she could not call on her family for help. She stated that her parents didn’t know that she was in a same-sex relationship. Maria told them that she and Julie were just roommates. She reported that her family had come to the U.S. as undocu­ mented immigrants from a Latin American country. Maria described her family as very traditional and noted that they viewed a gay or lesbian identity as a violation of divine and natural law. She feared that her family would reject her for being in a lesbian relationship. In the past, Julie had threatened to out Maria to her family. Julie had also threatened to report Maria to the local immigration authorities if she were to leave her. Maria stated that for these rea­ sons she had stayed in the relationship far too long, but she also felt that she couldn’t endure the abuse any longer. Joann spent some time developing a personalized safety plan with Maria, including identifying safe places and safe people to whom to reach out for help. Joann and Maria also reviewed the GLBT Power and Control Wheel handout. They discussed how Julie took advantage of Maria’s illegal immigrant status and her not being out to her parents. Julie had used these vulnerabilities to bully Maria into submission. Maria found it empowering to move from confusion about her relationship struggles and self-blame to under­ standing that there are clear and predictable abusive patterns in her relationship with Julie. She requested to leave the handouts and her personalized safety plan at Joann’s office until she was able to find safer living arrangements. Maria feared that Julie would find them if she were to take them home, and that this would escalate the violence. Suggestions for Follow-up

These activities can be revisited in subsequent sessions for further processing and discussions. Leaving an abusive relationship is frequently a developmental pro­ cess, and insights and resolve to leave develop over time. Also, it is important to note that insight created

by working through these exercises can lead to emo­ tional distress and anxiety, as well as produce a height­ ened sense of urgency in clients to leave the abusive relationship. It may be prudent to remind clients that it might be safer to have a suitable escape plan in place instead of acting on impulse. It is important to remem­ ber that clients caught up in abusive relationships are at increased danger when attempting to leave. It is essential for counselors to have a list of resources avail­ able, such as LGBTQ-friendly shelter information and other vital assistance available in the community. Contraindications for Use

The above resources should not be used if they put the LGBTQ client who is experiencing IPV at increased risk of abuse. Also, clients who are experiencing heightening stress responsivity and emotional reactiv­ ity because of the abuse they are experiencing may have to work on emotional stabilization first. Professional Resources Domestic Abuse Intervention Programs. (n.d.). Home of the Duluth model: What is the Duluth model? https://www. theduluthmodel.org/about/index.html. Herman, J. L. (1992). Trauma and recovery: The aftermath of violence—from domestic abuse to political terrorism. New York: Guilford. Kulkin, H. S., Williams, J., Borne, H. F., de la Bretonne, D., & Laurendine, J. (2007). A review of research on violence in same-gender couples: A resource for clinicians. Journal of Homosexuality, 53 (4), 71–87. doi:10.1080/009183608 02101385. Merrill, G. S., & Wolfe, V. A. (2000). Battered gay men: An exploration of abuse, help seeking, and why they stay. Journal of Homosexuality, 39 (2), 1–30. Stiles-Shields, C., & Carroll, R. A. (2015). Same-sex domestic violence: Prevalence, unique aspects, and clinical impli­ cations. Journal of Sex and Marital Therapy, 41 (6), 636– 648. doi:10.1080/0092623X.2014.958792.

Resources for Clients Fontes, L. A. (2015). Invisible chains: Overcoming coercive control in your intimate relationship. New York: Guilford. Gay, Lesbian, Bisexual and Transgender Power and Control Wheel. (n.d). http://www.ncdsv.org/images/TCFV_glbt_ wheel.pdf. National Center on Domestic and Sexual Violence. (n.d.). Domestic Violence Personalized Safety Plan. http:// www.ncdsv.org/images/DV_Safety_Plan.pdf.

Intimate Partner Violence: Interventions for LGBTQ Clients 197

National Coalition Against Domestic Violence. http://www. ncadv.org/. National Domestic Violence Hotline. https://www.thehotline. org/.

References American Bar Association. (n.d.). Domestic violence statis­ tics. https://www.americanbar.org/groups/domestic_vio­ lence/ initiatives/resources/statistics/. American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. Bancroft, L. (2003). Why does he do that? Inside the minds of angry and controlling men. New York: Berkley. Chavis, A. Z., & Hill, M. S. (2008). Integrating multiple inter­ secting identities: A multicultural conceptualization of the power and control wheel. Women and Therapy, 32 (1), 121–149. doi:10.1080/02703140802384552. Dank, M., Lachman, P., Zweig, J. M., & Yahner, J. (2014). Dat­ ing violence experiences of lesbian, gay, bisexual, and transgender youth. Journal of Youth and Adolescence, 43 (5), 846–857. doi:10.1007/s10964-013-9975-8. Dutton, D., & Golant, S. (1995). The batterer: A psychological profile. New York: Basic Books. Edwards, K. M., Sylaska, K. M., & Neal, A. M. (2015). Intimate partner violence among sexual minority populations: A critical review of the literature and agenda for future research. Psychology of Violence, 5 (2), 112–121. doi:10. 1037/a0038656. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H., Loos, B., & Lambert, S. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individu­ als. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi :10.1080/15538605.2013.755444. Hines, D. A., & Douglas, E. M. (2011). The reported availabil­ ity of US domestic violence services to victims who vary by age, sexual orientation, and gender. Partner Abuse, 2 (1), 3–30. doi:10.1891/1946-6560.2.1.3. Hines, D., & Malley-Morrison, K. (2005). Family violence in the United States: Defining, understanding, and combat­ ing abuse. Thousand Oaks, CA: Sage.

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Kaschak, E. (2001). Intimate betrayal: Domestic violence in lesbian relationships. Women and Therapy, 23 (3), 1–5. doi:10.1300/J015v23n03_01. Kubicek, K., McNeeley, M., & Collins, S. (2016). Young men who have sex with men’s experiences with intimate part­ ner violence. Journal of Adolescent Research, 31 (2), 143– 175. doi:10.1177/0743558415584011. Kulkin, H. S., Williams, J., Borne, H. F., de la Bretonne, D., & Laurendine, J. (2007). A review of research on violence in same-gender couples: A resource for clinicians. Journal of Homosexuality, 53 (4), 71–87. doi:10.1080/0091836 0802101385. Lewis, R. J., Milletich, R. J., Kelley, M. L., & Woody, A. (2012). Minority stress, substance use, and intimate partner vio­ lence among sexual minority women. Aggression and Violent Behavior, 17 (3), 247–256. McClennen, J. C. (2005). Domestic violence between samegender partners: Recent findings and future research. Jour­ nal of Interpersonal Violence, 20 (2), 149–154. doi:10. 1177/0886260504268762. National Domestic Violence Hotline. (n.d.). https://www.the hotline.org/is-this-abuse/lgbt-abuse/. Salerno, A., & Garro, M. (2016). Relational dynamics in samesex couples with intimate partner violence: Coming out as a protective factor. International Journal of Humanities and Cultural Studies, 1 (2), 131–140. Stephenson, R., Khosropour, C., & Sullivan, P. (2010). Report­ ing of intimate partner violence among men who have sex with men in an on-line survey. Western Journal of Emer­ gency Medicine, 11 (3), 242–246. http://escholarship.org/ uc/item/2gb740tj. Walker, L. E. (1979). The battered woman. New York: Harper & Row. Wallace, P. (2007). How can she still love him? Domestic vio­ lence and the Stockholm syndrome. Community Practi­ tioner, 80 (10), 32–34. Walters, M. L., Chen, J., & Breiding, M. J. (2013). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 findings on victimization by sexual orientation. Atlanta: National Center for Injury Prevention and Control, Cen­ ters for Disease Control and Prevention. Websdale, N. (2003). Reviewing domestic violence deaths. National Institute of Justice Journal, 250, 26–31.

THE CYCLE OF VIOLENCE

DENIAL

O

N

BATTERER I’m sorry / begs forgiveness / promises HER RESPONSE to get counseling / goes to church/AA • Agrees to stay, sends flowers / brings presents / return, or take “I’ll never do it again” / wants to him back make love / declares love / • Attempts to stop legal proceedings enlists family support / • Sets up counseling cries appointments for him • Feels happy, hopeful

O

G

TE

Rape Use of weapons Beating

ON

ON BU I LD I S N IN

PL

SI

BATTERER Hitting Choking Humiliation Imprisonment

EX

HER RESPONSE • Protects herself any way she can • Police called by her her kids, neighbor • Tries to calm him • Tries to reason • Leaves • Fights back

O

HER RESPONSE • Attempts to calm him • Nurturing • Silent / talkative BATTERER • Stays away from Moody family, friends Nitpicking • Keeps kids Isolates her quiet Withdraws affection • Agrees Puts down • Withdraws Yelling • Cooks his Drinking or drugs favorite Threatens dinner Destroys property • General feeling Criticizes of walking Sullen on eggshells Crazy making

ACUT E

HON

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M Y E

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GAY, LE S BIA N, BIS EXUA L , A ND T RA NS P OWER A ND CO NT RO L WH EEL

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DOMES TIC VIO LE N C E P E RSONA L IZED S A F ET Y P L A N Name: __________________________________________________ Date:_____________________________ The following steps represent my plan for increasing my safety and preparing in advance for the possi­ bility for further violence. Although I do not have control over my partner’s violence, I do have a choice about how to respond to him/her and how to best get myself and my children to safety. STEP 1: Safety during a violent incident. People cannot always avoid violent incidents. In order to increase safety, battered persons may use a variety of strategies. I can use some of the following strategies: A. If I decide to leave, I will _____________________________________________________________________. (Practice how to get out safely. What doors, windows, elevators, stairwells, or fire escapes would you use?) B. I can keep my purse or wallet and car keys ready and put them (location) _______________________________ in order to leave quickly. C. I can tell ___________________________________ about the violence and request that she or he call the police if she or he hears suspicious noises coming from my house. D. I can teach my children how to use the telephone to call 911. E. I will use _________________________________________ as my code with my children or my friends so they can call for help. F. If I have to leave my home, I will go to _____________________________________________. (Decide this even if you don’t think there will be a next time.) G. I can also teach some of these strategies to some or all of my children. H. When I expect we’re going to have an argument, I’ll try to move to a place that is low risk, such as ___________________________________. (Try to avoid arguments in the bathroom, garage, kitchen, near weapons, or in rooms without access to an outside door.) I. I will use my judgment and intuition. If the situation is very serious, I can give my partner what he/she wants to calm him/her down. I have to protect myself until I/we _________________________________. STEP 2: Safety when preparing to leave. Battered persons frequently leave the residence they share with the battering partner. Leaving must be done with a careful plan in order to increase safety. Batterers often strike back when they believe that a battered partner is leaving a relationship. I can use some or all of the following strategies: A. I will leave money and an extra set of keys with ____________________________ so I can leave quickly. B. I will keep copies of important documents or keys at _____________________________. C. I will open a savings account by _____________________________, to increase my independence. D. Other things I can do to increase my independence include: ____________________________________ ________________________________________________________________________________________ E. I can keep my phone with me at all times. I understand that if my batterer and I share a cellphone account, he or she my be able to track my phone calls, and I should leave a disposable phone with _____________________________. F. I will check with ______________________________ and _____________________________ to see who would be able to let me stay with them or lend me some money. Sabina de Vries

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G. I can leave extra clothes or money with _____________________________________. H. I will sit down and review my safety plan every __________________ in order to plan the safest way to leave the residence. _______________________ (domestic violence advocate or friend’s name) has agreed to help me review this plan. I. I will rehearse my escape plan and, as appropriate, practice it with my children. STEP 3: Safety in my own residence. There are many things that a person can do to increase his or her safety in her own residence. It may be impossible to do everything at once, but safety measures can be added step by step. Safety measures I can use: A. I can change the locks on my doors and windows as soon as possible. B. I can replace wooden doors with steel or metal doors. C. I can install security systems, including additional locks, window bars, poles to wedge against doors, an electronic system, etc. D. I can purchase rope ladders to be used for escape from second-floor windows. E. I can install smoke detectors and fire extinguishers for each floor of my house or apartment. F. I can install an outside lighting system that is activated when a person is close to the house. G. I will teach my children how to call me or __________________ (name of friend, etc.) in the event that my partner takes the children. H. I will tell the people who take care of my children which people have permission to pick up my chil­ dren and that my partner is not permitted to do so. The people I will inform about pick-up permission include: _____________________________________ (name of school)

_____________________________________ (name of babysitter)

_____________________________________ (name of teacher)

_____________________________________ (name of Sunday-school teacher)

_____________________________________ (name[s] of others)

I. I can inform _____________________________________ (neighbor) and ____________________________ (friend) that my partner no longer resides with me and that they should call the police if he or she is observed near my residence. STEP 4: Safety with an Order of Protection. Many batterers obey protection orders, but one can never be sure which violent partner will obey and which will violate protective orders. I recognize that I may need to ask the police and the courts to enforce my protective order. The following are some steps I can take to help the enforcement of my protection order: A. I will keep my protection order _______________________ (location). Always keep it on or near your person. If you change wallets or purses, that’s the first thing that should go in the new one. B. I will give my protection order to police departments in the community where I work, in those com­ munities where I visit friends or family, and in the community where I live. C. There should be county and state registries of protection orders that all police departments can call to confirm a protection order. I can check to make sure that my order is on the registry. The telephone numbers for the county and state registries of protection orders are: _______________________ (county) and _______________________ (state). D. I will inform my employer; my minister, rabbi, etc.; my closest friend; and ___________________ that I have a protection order in effect. 202

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E. If my partner destroys my protection order, I can get another copy from the clerk’s office. F. If the police do not help, I can contact an advocate or an attorney and file a complaint with the chief of the police department or the sheriff. G. If my partner violates the protection order, I can call the police and report the violation, and/or contact _____________________________. STEP 5: Safety on the job and in public. Each battered person must decide if and when she or he will tell others that her or his partner has battered her or him and that she or he may be at continued risk. Friends, family, and coworkers can help protect such a person. Each woman or man should carefully consider which people to invite to help secure her or his safety. I might do any or all of the following: A. I can inform my boss, the security supervisor, and_____________________________ at work. B. I can ask _____________________________ to help me screen my telephone calls at work. C. When leaving work, I can ________________________________________________________________. D. If I have a problem while driving home, I can _______________________________________________. E. If I use public transit, I can ________________________________________________________________. F. I will go to different grocery stores and shopping malls to conduct my business and shop at hours that are different from those I kept when residing with my battering partner. G. I can use a different bank and go at hours that are different from those I kept when residing with my battering partner. STEP 6: Safety and drug or alcohol use. Most people in this culture use alcohol. Many use mood-altering drugs. Much of this is legal, although some is not. The legal outcomes of using illegal drugs can be very hard on a battered person, may hurt his or her relationship with his or her children, and can put him or her at a disadvantage in other legal actions with the battering partner. Therefore, battered persons should carefully consider the potential cost of the use of illegal drugs. Beyond this, the use of alcohol or other drugs can reduce a person’s awareness and ability to act quickly to protect himself or herself from the battering partner. Furthermore, the use of alcohol or other drugs by the batterer may give him or her an excuse to use violence. Specific safety plans must be made concerning drugs or alcohol use. If drug or alcohol use has occurred in my relationship with my battering partner, I can enhance my safety by some or all of the following: A. If I am going to use, I can do so in a safe place and with people who understand the risk of violence and are committed to my safety. B. If my partner is using, I can ______________________________________________________________ and/or ________________________________________________________________________________. C. To safeguard my children I might _________________________________________________________. STEP 7: Safety and my emotional health. The experience of being battered and verbally degraded by partners is usually exhausting and emotionally draining. The process of building a new life takes much courage and incredible energy. To conserve my emotional energy and resources and to avoid hard emotional times, I can do some of the following:

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A. If I feel down and am returning to a potentially abusive situation, I can _____________________________ ___________________________________________________________________________________________. B. When I have to communicate with my partner in person or by telephone, I can _____________________ ____________________________________________________________________. C. I will try to use “I can . . .” statements with myself and be assertive with others. D. I can tell myself, “______________________________________________________________” whenever I feel others are trying to control or abuse me. E. I can read __________________________________________________________ to help me feel stronger. F. I can call ____________________________________ and ________________________________ for support. G. I can attend workshops and support groups at the domestic violence program or __________________ _____________________ to gain support and strengthen relationships. STEP 8: Items to take when leaving. When battered persons leave partners, it is important to take certain items. Beyond this, they sometimes give an extra copy of papers and an extra set of clothing to a friend just in case they have to leave quickly. Money: Even if I never worked, I can take money from jointly held savings and checking accounts. If I do not take this money, my partner can legally take the money and close the accounts. Items on the following lists with asterisks by them are the most important to take with me. If there is time, the other items might be taken, or stored outside the home. These items might best be placed in one location, so that if we have to leave in a hurry, I can grab them quickly. When I leave, I should take: • Identification for myself • Children’s birth certificates • My birth certificate • Social Security cards • School and vaccination records • Money • Cellphone • Checkbook, ATM card • Credit cards • Keys—house, car, office • Driver’s license and registration • Medications • Copy of protection order • Welfare identification, work permits, green cards • Passport(s), divorce papers • Medical records—for all family members • Lease/rental agreement, house deed, mortgage payment book • Bank books, insurance papers • Address book • Pictures, jewelry • Children’s favorite toys and/or blankets • Items of special sentimental value

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Telephone numbers I need to know: Police/sheriff’s department (local)—911 or _________________________________ Police/sheriff’s department (work _________________________________________ Police/sheriff’s department (school )_______________________________________ Prosecutor’s office ______________________________________________________ Battered women’s program (local) ________________________________________ National Domestic Violence Hotline: 800-799-SAFE (7233) 800-787-3224 (TTY) www.ndvh.org County registry of protection orders ______________________________________ State registry of protection orders_________________________________________ Work number __________________________________________________________ Supervisor’s home number _______________________________________________ I will keep this document in a safe place and out of the reach of my potential attacker. Review date: _______________________________

Source: Adapted from National Center on Domestic and Sexual Violence.

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23 TRANSGENDER YOUTH AND HEALTHY RELATIONAL SKILLS Luke R. Allen

Suggested Use: Group activity, workshop Objective

In this group activity, participants are able to engage in an interactive discussion that provides a way of com­ municating about relationships. The goal is to offer transgender and gender-diverse youth a semi-anony­ mous, safe space in which they can ask questions about relationships in a supportive peer group. Through this collaborative group activity, participants can come to think more concretely and define more clearly their expectations for creating, participating in, and main­ taining healthy, safe relationships; they also expand their personal knowledge as they explore new intimate relationships. Rationale for Use

Transgender youth receive little to no relationship or sexual health education designed uniquely for them (Magee, Bigelow, DeHaan, & Mustanski, 2012). Rather, youth often see widespread negative media presen­ tation of transgender identities and relationships (McInroy & Craig, 2015; Ringo, 2002). If genderdiverse young persons are not exposed to what healthy and safe intimate relationships look like (through edu­ cational efforts, positive media representation, or per­ sonal life), then they might lack information on how healthy and safe relationships are established, operate, or are maintained. Because of this lack of education, poor media representation, and other societal and institutional stressors (Capous-Desyllas & Barron, 2017), the conditions might be such that genderdiverse youth encounter difficulties in communicat­ ing about sex and gender, which is an essential

aspect of successful intimate relationships (Levitt & Ippolito, 2014). They may face additional obstacles in navigating the formation of romantic relationships owing to their marginalized identities of sexuality and/ or gender (Greene et al., 2015). Gender-diverse youth can face more challenges than their cisgender counterparts encounter. These challenges include more extreme and pervasive soci­ etal stressors, discrimination, and interpersonal vio­ lence (Dank, Lachman, Zweig, & Yahner, 2014). Those who transition with the aid of gender-affirming medi­ cal interventions may experience more drastic shifts in the social aspect of their identities, such as the loss or gain of perceived gender privilege (American Coun­ seling Association [ACA], 2010). Identities are fluid (Shields, 2008; Singh, 2013), and even the understand­ ing of one’s sexual orientation can change during or after transition (Auer et al., 2014; Bockting, Benner, & Coleman, 2009; Katz-Wise, Reisner, Hughto, & KeoMeier, 2016; Meier, Pardo, Labuski, & Babcock, 2013). Trans youth can also encounter intersecting forms of oppression in response to their other held margin­ alized identities and aspects of self (e.g., age, sexual orientation, nationality, race, political beliefs, ability status, socioeconomic status) from individuals as well as systems and institutions of power in society (Crenshaw, 1991; Daley, Solomon, Newman, & Mishna, 2007; Warner & Shields, 2013; see also American Psychological Association [APA], 2015, guideline 3). In 2013, for instance, transgender survivors of inti­ mate partner violence who were persons of color were 2.6 times more likely than the overall population of lesbian, gay, bisexual, transgender, and queer (LGBTQ) survivors to experience discrimination within inti-

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mate partner relationships (National Coalition of Anti-Violence Programs [NCAVP], 2014). In 2014 transgender people of color were twice as likely to experience threats and intimidation than the overall LGBTQ population (NCAVP, 2015). Young persons (ages fourteen to twenty-four) are particularly at risk; in 2015 they were three times more likely to experience hate violence from relatives and acquaintances compared to those twenty-four or older (NCAVP, 2016). Nonetheless, transgender youth can display tremendous resilience (DiFulvio, 2015; Singh, Hays, & Watson, 2011). Peer contact and support and seeking out and cultivating meaningful relationships are important aspects of this resilience for sexually and gender-diverse youth (Asakura, 2015; Riley, Sithar­ than, Clemson, & Diamond, 2013; Singh et al., 2011). Bockting and colleagues (2013) found that enhancing peer support is also an important aspect of developing resilience for the transgender population. Because this is a group activity, there is potential for participants to develop new connections and facili­ tate peer support, creating friendships that can carry over outside the activity. Singh and dickey (2017) identify some of the theo­ retical perspectives that mental health professionals may use in their work with transgender clients, includ­ ing the minority-stress model (Meyer, 2003), strengthsbased and resilience approaches (ACA, 2010; APA, 2015), and multicultural and social justice advocacy approaches (Ratts et al., 2015). The minority-stress theory posits that sexual, gender, and racial minorities are at greater risk for mental and physical health prob­ lems by way of increased psychological distress result­ ing from the regular exposure to prejudice, discrimi­ nation, and stigma to which they are subject (Meyer, 2003). Through the theory lens of minority stress, the therapist would not view such observed health dis­ parities in transgender and gender-diverse clients as reflecting inherent pathology, but rather as the sequelae of persistent stigma directed toward them (Hatzen­ buehler & Pachankis, 2016; Meyer, 2003). From the strength-based perspective, the counselor would assess and maintain an awareness of the clients’ strengths and sources of support, and whether they are internal, such as personality characteristics, or external, such as community support (Chang & Singh, 2016).

The application of social justice advocacy approaches may take a variety of forms, depending on context and the individual, and should integrate a systemic, multicultural approach to wellness (ACA, 2010; Ratts, DeKruyf, & Chen-Hayes, 2007). At a foundational level, counselors should seek to understand how their own cultural background and experiences influence their beliefs about gender, gender identity, and how we conceptualize the coun­ seling needs of gender-diverse clients (ACA, 2010; Singh & dickey, 2017). Social justice and advocacy efforts on the counselor’s part may range from teach­ ing clients self-advocacy skills to advocating that gender-inclusive restrooms are available in our work­ places, to working directly with school administrators when necessary, and beyond (dickey & Loewy, 2010; dickey, Singh, Chang, & Rehrig, 2017; Holman & Goldberg, 2006; Ratts et al., 2007). Guidelines for working with transgender and gender-nonconforming persons emphasize that when gender-diverse persons receive social support and trans-affirmative care, they tend to experience more positive life outcomes (APA, 2015, guideline 11). Ethical principles and guidelines direct us to work with our clients in a way that is respectful of their gender, gender identity, and sexual orientation, among other aspects of cultural and individual differences (ACA, 2010, competencies B.1 & D.7; ACA, 2014; APA, 2017, principle E). We must also be able to recognize that gender is a nonbinary construct (ACA, 2010, compe­ tencies A.1 & B.6; APA, 2015, guideline 1). Such affirmative work may aid in counteracting the wide range of societal, personal, and environmental dis­ crimination transgender youth can face. Clinicians have observed that transgender adoles­ cents have questions related to sexual health that are often left unanswered (Bungener, Steensma, CohenKettenis, & de Vries, 2017). In a qualitative study exploring preferred sexual health interventions for sexually and gender-diverse youth, the strongest pref­ erences were for group-type interventions whose con­ tent focuses on communication and relationship vio­ lence (Greene et al., 2015). Thus, informed by the literature, this collaborative intervention invites transgender youth to ask the questions that are most salient to their own lives and intimate relationships in a group Transgender Youth and Healthy Relational Skills 207

setting. Subsequently, the activity allows for the impor­ tant benefit of learning from others who may be navi­ gating, or have already experienced, similar concerns. The activity also creates psychoeducational opportu­ nities for the mental health professional facilitator. Instructions

Materials required: note cards and pens or pencils (all of the same color). Optional: white board, chalk­ board, or easel pad. This activity could be conducted within a time frame of forty-five to ninety minutes, and the number of participants can range from six to eighteen. The summary of the event to be included in programming event materials should encourage participants to come prepared to engage in hands-on activities and begin to uncover what is important to them in main­ taining healthy intimate relationships. To set up this activity, provide note cards and writing utensils to attendees. Instruct participants to write a question they have regarding how to navigate their relationships on the card. Collect the cards, shuffle, and redistrib­ ute them to participants. Ask attendees to read out loud the question on the card they have received. Facil­ itate dialogue and provide psychoeducation when appropriate. Give sufficient time for the group to dis­ cuss the question. Then have another participant read the next question. Continue this process until no questions remain. A facilitator instructional sheet (to be used when running the group) is provided at the end of this chapter; it contains more detailed sugges­ tions, typical occurrences, and commonly asked par­ ticipant questions (see page 211). Successful facilitation of group activities requires that the therapist maintain an awareness of potential critical incidents to exploit as a learning opportunity. As in group therapy, confidentiality cannot be guar­ anteed by the workshop facilitator, and the limitation of confidentiality should be explained (ACA, 2014, B.4.a.; APA, 2017, 10.03). However, the therapist can help promote confidentiality by asking participants not to share any identifying information about other participants in the workshop group. This request for confidentiality serves the important function of help­ ing participants feel safe to share.

208 Allen

Brief Vignette

Avien is a fifteen-year-old nonbinary biracial adoles­ cent of Latino and English ethnicity living in a group home. Avien uses they, them, and their. They were one of seventeen group attendees of various gender identities, at different stages of exploring their gender and sexual identities, and of varying backgrounds and resources, ages fourteen to seventeen. During the activity (after cards had been collected, shuffled, and redistributed), in response to one question asked, Avien described experiencing anticipatory anxiety about disclosing their transgender identity to potential partners and friends. At this time, the leader seized on this critical incident and posed a question to the group as a whole: “Have any of you had similar wor­ ries, either in the past or present, and how did you navigate that corresponding anxiety and fear?” Other participants indeed had gone through similar experi­ ences and were able to share what it had been like for them. One participant shared the recollection that they had also been scared about disclosing and sharing their true self with others; however, once they had, they felt great relief. “I did lose some friends,” the par­ ticipant told Avien during the discussion, “but the friends that stayed are the greatest I’ve ever had.” Here the facilitator acknowledged the difficulty of coming out and the myriad contextual intersecting consider­ ations (e.g., privilege and oppression, cultural beliefs about sex and gender, perceptions of potential future negative feedback and reactions, coping strategies, and available local sources of social support) to keep in mind when weighing the costs and benefits of dis­ closing identities. In participant workshop feedback, Avien and several others later mentioned the impor­ tance of being open and honest in relationships and with partners as a takeaway from this workshop that will affect their own life in a positive way. Suggestions for Follow-up

Because this is a workshop activity, follow-up may not be appropriate. However, attendees may benefit from a list of both national and local resources for transgen­ der youth that includes hotline numbers, transgender­ affirmative doctors, and mental health professionals.

Contraindications for Use

This activity was originally designed for gender-expan­ sive youth from ages thirteen to seventeen who were attending the workshop with the consent of their guardians. Though the workshop may be delivered to a slightly younger or older group, it might not be appro­ priate to include children under thirteen. If there is too broad an age range, questions may not be develop­ mentally relevant enough to all participants, which could potentially make common themes harder to iden­ tify in the given time constraints. Facilitators should be mindful of the potential for the focus of the group to be about how to educate the cisgender community, rather than focusing on other salient needs of the par­ ticular group at hand. Moreover, the geographical location, culture, and climate of where this activity is conducted should be taken into account. For instance, youth living in more progressive or resource-abun­ dant areas may be more likely to find peers, friends, and partners who are supportive of their relevant iden­ tities than those participants who live in less progres­ sive areas with fewer resources. Professional Readings and Resources Brill, S., & Kenney, L. (2016). The transgender teen: A hand­ book for parents and professionals supporting transgender and non-binary teens. Jersey City, NJ: Cleis Press. Kuklin, S. (2014). Beyond magenta: Transgender teens speak out. Somerville, MA: Candlewick Press. Yalom, I. D., & Leszcz, M. (2005). Theory and practice of group psychotherapy, 5th edition. New York: Basic Books.

Resources for Clients Gender Spectrum Lounge. Provides a space for gender-expan­ sive teens, their parents, and affirmative professionals to connect with one another. https://genderspectrum.org/ lounge. Testa, R. J., Coolhart, D., & Peta, J. (2015). The gender quest workbook: A guide for teens and young adults exploring gender identity. Oakland, CA: New Harbinger. TrevorSpace. Social networking site for LGBTQ youth (ages thirteen to twenty-four), their friends, and their allies. https://www.trevorspace.org.

References American Counseling Association (ACA). (2010). Compe­ tencies for counseling with transgender clients. Journal of LGBT Issues in Counseling, 4, 135–159. doi:10.1080/15 538605.2010.524839.

American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. American Psychological Association (APA). (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70, 832– 864. doi:10.1037/a0039906. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/index.aspx. Asakura, K. (2015). Theorizing pathways to resilience among LGBTQ youth: A grounded theory study. PhD diss., University of Toronto. Auer, M. K., Fuss, J., Höhne, N., Stalla, G. K., & Sievers, C. (2014). Transgender transitioning and change of self-re­ ported sexual orientation. PloS One, 9 (10), 1–11. doi:10.1371/journal.pone.0110016. Bockting, W., Benner, A., & Coleman, E. (2009). Gay and bisexual identity development among female-to-male transsexuals in North America: Emergence of a transgender sexuality. Archives of Sexual Behavior, 38 (5), 688–701. doi:10.1007/s10508-009-9489-3. Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Hamilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103 (5), 943–951. doi:10.2105/AJPH.2013.301241. Bungener, S. L., Steensma, T. D., Cohen-Kettenis, P. T., & de Vries, A. L. C. (2017). Sexual and romantic experiences of transgender youth before gender-affirmative treatment. Pediatrics, 139 (3), 1–9. doi:10.1542/peds.2016-2283. Capous-Desyllas, M., & Barron, C. (2017). Identifying and navigating social and institutional challenges of transgender children and families. Child and Adolescent Social Work Journal, 34 (6), 527–542. doi:10.1007/s10560-017­ 0491-7. Chang, S. C., & Singh, A. A. (2016). Affirming psychological practice with transgender and gender nonconforming people of color. Psychology of Sexual Orientation and Gender Diversity, 3 (2), 140–147. doi:10.1037/sgd0000153. Crenshaw, K. (1991). Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Review, 43 (6), 1241–1299. Daley, A., Solomon, S., Newman, P. A., & Mishna, F. (2007). Traversing the margins: Intersectionalities in the bullying of lesbian, gay, bisexual and transgender youth. Journal of Gay and Lesbian Social Services, 19 (3–4), 9–29. doi:10. 1080/10538720802161474. Dank, M., Lachman, P., Zweig, J. M., & Yahner, J. (2014). Dat­ ing violence experiences of lesbian, gay, bisexual, and transgender youth. Journal of Youth and Adolescence, 43 (5), 846–857. doi:10.1007/s10964-013-9975-8. dickey, l. m., & Loewy, M. I. (2010). Group work with transgender clients. Journal for Specialists in Group Work, 35

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(3), 236–245. doi:10.1080/01933922.2010.492904. dickey, l. m., Singh, A. A., Chang, S. C., & Rehrig, M. (2017). Advocacy and social justice: The next generation of counseling and psychological practice with transgender and gender nonconforming clients. In A. A. Singh & l. m. dickey (eds.), Affirmative counseling and psychologi­ cal practice with transgender and gender nonconforming clients, 247–262. Washington, DC: American Psycholog­ ical Association. DiFulvio, G. T. (2015). Experiencing violence and enacting resilience: The case story of a transgender youth. Violence against Women, 21 (11), 1385–1405. doi:10.1177/107780 1214545022. Greene, G. J., Fisher, K. A., Kuper, L., Andrews, R., & Mus­ tanski, B. (2015). “Is this normal? Is this not normal? There is no set example”: Sexual health intervention pref­ erences of LGBT youth in romantic relationships. Sexu­ ality Research and Social Policy, 12 (1), 1–14. doi:10.10 07/s13178-014-0169-2. Hatzenbuehler, M. L., & Pachankis, J. E. (2016). Stigma and minority stress as social determinants of health among lesbian, gay, bisexual, and transgender youth. Pediatric Clinics of North America, 63 (6), 985–997. doi:10.1016/j. pcl.2016.07.003. Holman, C. W., & Goldberg, J. M. (2006). Ethical, legal, and psychosocial issues in care of transgender adolescents. International Journal of Transgenderism, 9 (3–4), 95–110. doi:10.1300/J485v09n03_05. Katz-Wise, S. L., Reisner, S. L., Hughto, J. W., & Keo-Meier, C. L. (2016). Differences in sexual orientation diversity and sexual fluidity in attractions among gender minority adults in Massachusetts. Journal of Sex Research, 53 (1), 74–84. doi:10.1080/00224499.2014.1003028. Levitt, H. M., & Ippolito, M. R. (2014). Being transgender: Navigating minority stressors and developing authentic self-presentation. Psychology of Women Quarterly, 38 (1), 46–64. doi:10.1177/0361684313501644. Magee, J. C., Bigelow, L., DeHaan, S., & Mustanski, B. S. (2012). Sexual health information seeking online: A mixed-meth­ ods study among lesbian, gay, bisexual, and transgender young people. Health Education and Behavior, 39 (3), 276–289. doi:10.1177/1090198111401384. McInroy, L. B., & Craig, S. L. (2015). Transgender representa­ tion in offline and online media: LGBTQ youth perspec­ tives. Journal of Human Behavior in the Social Environment, 25 (6), 606–617. doi:10.1080/10911359.2014.995392. Meier, S. C., Pardo, S. T., Labuski, C., & Babcock, J. (2013). Measures of clinical health among female-to-male transgender persons as a function of sexual orientation. Archives of Sexual Behavior, 42 (3), 463–474. doi:10.1007/s10508­ 012-0052-2.

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Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129 (5), 674–697. doi:10.1037/0033-2909.129.5.674. National Coalition of Anti-Violence Programs (NCAVP). (2014). Lesbian, gay, bisexual, transgender, queer, and HIVaffected intimate partner violence in 2013. https://avp. org/resources/reports/. National Coalition of Anti-Violence Programs (NCAVP). (2015). Lesbian, gay, bisexual, transgender, queer, and HIVaffected hate violence in 2014. https://avp.org/resources/ reports/. National Coalition of Anti-Violence Programs (NCAVP). (2016). Lesbian, gay, bisexual, transgender, queer, and HIVaffected hate violence in 2015. https://avp.org/resources/ reports/. Ratts, M., DeKruyf, L., & Chen-Hayes, S. (2007). The ACA advocacy competencies: A social justice advocacy frame­ work for professional school counselors. Professional School Counseling, 11 (2), 90–97. Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2015). Multicultural and social justice counseling competencies. http://www.counseling.org/ docs/default-source/competencies/multicultural-and-so cial-justice-counseling-competencies.pdf?sfvrsn=20. Riley, E. A., Sitharthan, G., Clemson, L., & Diamond, M. (2013). Recognising the needs of gender-variant children and their parents. Sex Education, 13 (6), 644–659. doi:10. 1080/14681811.2013.796287. Ringo, P. (2002). Media roles in female-to-male transsexual and transgender identity formation. International Journal of Transgenderism, 6 (3), 1–22. Shields, S. A. (2008). Gender: An intersectionality perspective. Sex Roles, 59 (5), 301–311. doi:10.1007/s11199-008­ 9501-8. Singh, A. A. (2013). Transgender youth of color and resilience: Negotiating oppression and finding support. Sex Roles, 68 (11), 690–702. doi:10.1007/s11199-012-0149-z. Singh, A., & dickey, l. (2017). Introduction. In A. Singh & l. dickey (eds.), Affirmative counseling and psychological practice with transgender and gender nonconforming cli­ ents, 3–18. Washington, DC: American Psychological Association. doi:10.1037/14957-001. Singh, A. A., Hays, D. G., & Watson, L. S. (2011). Strength in the face of adversity: Resilience strategies of transgender individuals. Journal of Counseling and Development, 89 (1), 20–27. doi:10.1002/j.1556-6678.2011.tb00057.x. Warner, L. R., & Shields, S. A. (2013). The intersections of sexuality, gender, and race: Identity research at the cross­ roads. Sex Roles, 68 (11), 803–810. doi:10.1007/s11199­ 013-0281-4.

FACILITATOR INSTRUCTION SHEET After a short discussion on confidentiality, intro­ ductions, and an optional ice breaker, the facilitator distributes pens or pencils and note cards to partici­ pants. Participants are instructed to write on one side of the card a question they have regarding how to navigate their relationships. The facilitator should explain that the purpose of using identical note cards and writing only on one side is to help create some degree of anonymity. After attendees have written their questions, the facilitator collects the cards, shuffles them, and then redistributes them to partici­ pants. The facilitator then asks the attendees to read out loud the question on the card they have received. Cards are read one at a time, and the group does not move forward to the next card until the first question has been discussed. When there are very similar questions, the redundant questions may be skipped (as the substance of the question would have already been discussed). Cards are read until no questions remain. Note cards provide an easy format for sharing and discussing. This is where the interactivity and dialogue begin. The time attendees spend on each question can range from thirty seconds to eight minutes, although it is more common for the group to devote four to six minutes on average. Naturally for this type of activity, common discussion themes may become apparent. For example, attendees may mention characteristics of what they believe to be healthy and unhealthy relationships. The facilitator can choose to use a writing board or paper easel to compose a list of these characteristics for visual representation or to track the group’s ideas. New perspectives and advice from peers, as well as the normalizing experience often accompanying these ideas, can be tremen­ dously beneficial. Facilitators are encouraged to pro­ vide psychoeducation when appropriate. In this activ­ ity, psychoeducation may include themes related to relationship cycles, communication, knowing one’s own boundaries, information about the effects of medical interventions, safe-sex practices, knowledge of legal rights for transgender persons, and local resources. Because of the challenge of being transgender in a cisgender-normative world, the lived experience of transgender youth can be highly complex as they navigate the stigma to which they will be subject. Understanding of one’s sexual orientation can change

during or after transition, and there can be difficul­ ties in trusting cisgender persons. Some may use avoidance as a means of coping with their con­ cerns about relational dynamics. The questions they ask during the exercise reflect their experi­ ence. Common questions include the following: Handling Disclosure • “ When would be an appropriate time to come out to a partner?” • “ Does anyone else feel uncomfortable or unsure about what to do when cisgender heterosexual people are attracted to you?” • “ How do you come out or talk about being trans to a straight partner? What do you do when your partner says they’re straight while dating someone of the same gender?” Creating Relationships and Meeting Others • “How do I approach someone I like? Do I start off by telling them I’m [trans]?” • “How do you approach men for dating as a gay (trans) man?” • “I really like this guy from work. My parents don’t want me dating (at all, no matter what). How do I convince them? Should I even try?” • “How do you go about finding a non-straight relationship in a heterocentric world?” Partner Struggles and Navigation • “ How do I handle my partner transitioning?” • “ How will it be different [from normal dating]?” • “ How do you navigate intimacy with cisgen­ der people while dating? Sex, etc.” • “How do I help my partner feel comfortable talking about his sexuality with me?” • “How do I get her to believe that she is truly beautiful and special to me?” • “Is a relationship healthy if my partner is struggling with my gender identity?” Intimacy • “ Is it okay not to want vaginal sex (when dating a guy, for someone who identifies as FTM)?” • “ Would a lesbian not be comfortable with being intimate with a person with a vagina but no boobs?” • “How the hell do you know if you’re attracted to someone in a romantic or platonic way?” 211

24 TWO STARS AND A WISH: TERMINATION ACTIVITIES

FOR GROUPS WITH SEXUAL- AND GENDER-IDENTITY

DIVERSE CLIENTS Theodore R. Burnes Suggested Use: Activity Objective

The objective of this activity is to increase clients’ comfort with the ending of a counseling group and to decrease feelings of anxiety and sadness with the ending of a group. Rationale for Use

Clients in a counseling group (e.g., a long-term therapy group, interpersonal process group, support group, or psychoeducation group) who have experienced systemic oppression and marginalization because of their sexual and/or gender identities may often expe­ rience difficulty in navigating healthy intimate rela­ tionships (Burnes & Ross, 2010). They may also have difficulty navigating the shift in these relationships that comes with the termination of a counseling group. Termination in any group setting has proven to be a tricky stage of group development to navigate for cli­ ents and therapists alike (Fehr, 2003; Shapiro, 2017); however, for clients with diverse sexual and gender identities, such difficulty may, in part, stem from hav­ ing formed a bond with other group members who have also endured various forms of societal homopho­ bia and oppression (Burnes & Ross, 2010). For groups that are focused on topics related to diverse sexual and gender identities (e.g., a support group for lesbian, bisexual, and queer-identified women; a psychoeducation group for transgender youth on changing one’s identity documents such as driver’s licenses and passports), such termination can

pose additional challenges, as the social support fos­ tered in the group may be difficult for clients to find in other areas of their lives (Burnes & Hovanesian, 2017). In addition, many therapists who have worked with sexual- and gender-identity diverse clients may not have specific competence in conducting group therapy (Horne, Levitt, Reeves, & Wheeler, 2014) or in having to induce termination and thereby shift rela­ tional intimacy (Burnes & Hovanesian, 2017). Further, as all groups are by definition multicultural (DeLu­ cia-Waack, Kalodner, & Riva, 2013), the need for cli­ ents to address how various clients in the group may have different rituals, meaning, and cultural under­ standings of saying good-bye is of paramount impor­ tance when inducing termination in a counseling group. Thus, the need for therapists to have interven­ tions that are specific to working with termination in groups that are focused on working with LGBTQ clients is paramount. Various sets of guidelines from professional orga­ nizations in mental health disciplines have noted the importance of group counseling and psychological practices in group settings for sexually and genderdiverse clients. The American Psychological Associa­ tion (APA) (2011) notes the importance of psycholo­ gists’ attention to relationships for LGB individuals in various domains of psychological practice, includ­ ing group work; this importance is also stressed in guidelines for psychological practice with transgender and gender-nonconforming individuals (APA, 2015). Further, the American Group Psychotherapy Associ­ ation (AGPA) (2007) has published guidelines that

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note the specific competencies needed for effective group work in a variety of settings and with a variety of different populations to attend to various group members’ respective constellations of privileged and oppressed identities. Despite these standards, there are data to support the idea that sexual- and gender-identity diverse cli­ ents may use group psychotherapy and psychoedu­ cational outreach workshops in ways that are different from those of clients outside these groups, in part because of their need for social support from and con­ nection to individuals who have endured similar experiences of discrimination and oppression (Burnes & Hovanesian, 2017; Paul, 2016). Therapists may not be able to understand the specific needs and parame­ ters that occur within a group context in which one or more members have a sexually and/or genderdiverse identity, and they thus may not ask the right questions or implement the right interventions (Paul, 2016). Such skills are part of the ethical mandates of various mental health professions (e.g., ACA, 2014; APA, 2011) to engage with the different facets of mul­ ticultural competence. Therefore, therapists need to consider how their clients’ gender and sexual identi­ ties may affect the termination process within a psy­ chotherapy group. Group workers may face chal­ lenges in termination with clients, including setting appropriate boundaries during termination, helping make appropriate referrals for some clients’ ongoing mental health issues, and ensuring confidentiality about the group’s process. Instructions

Clients can complete this activity, called “Two Stars and a Wish,” as the final activity in a group counseling session. Therapists should introduce the activity by alerting clients that this activity is designed to help them think about their relationships with group mem­ bers as they close and also to provide one another feedback for growth. Group members should sit in a circle. The therapist should begin by identifying this session as a time in which clients have come together and formed a community that is built in part on their sexually and gender-diverse identities. The therapist should then alert group members that they are going to do an activity that allows for information to be

shared as the group prepares to end and members pre­ pare to say good-bye. The therapist should then ask for a volunteer to go first. Once a client (e.g., client no. 1) volunteers to go first, each of the other clients will provide “two stars” for client no. 1 and one “wish” for client no. 1 (see page 216). Each client should have one turn to give their feedback to client no. 1. (It is better and more time effective, for example, for cli­ ent no. 2 to give both stars and a wish to client no. 1 in one turn than for every client to give one star to client no. 1, then every client give a second star, etc.) Clients completing the activity in a small group (five to six clients) counseling session should be given at least forty-five minutes in the session to complete this activity. If there are more than six clients, the group facilitators should allow an additional fifteen minutes. After completion of the activity, therapists should ask clients a series of questions to help them process the activity. Specifically, questions that can be helpful to propel such a process include: (a) What was completing this activity like for you? (b) What are the ways that you might stay connected after the group has ended? (c) What was it like to receive such feedback? (d) What will it be like not to come to group next week? How are we feeling as our time together ends? The facilitator should explicitly address the possibility of connection between members after the group has ended, especially because this group may have pro­ vided members with valued social support and insight into their own identity development. Some members may not want such a connection, and some members may want varied types of connections with other members (e.g., client no. 1 only wants to be friends on Facebook with other group members, whereas client no. 2 hopes that members can get together for coffee once a month). Therapists should be able to process these intricate group interactions with an attention to how members’ reflections have built a community for people of diverse sexual and gender identities within the group. This activity can be helpful to clients in a range of settings. In a psychoeducation group format, this activity can help sexually and gender-diverse clients identify their own future goals for personal growth Two Stars and a Wish 213

that have emerged from their work in the group. This activity can also help members recognize the ways that the group has addressed issues of societal homo­ phobia and oppression (Burnes & Hovanesian, 2017). This activity is best used through interactive, small group work across different age ranges (e.g., high school students, college students, individuals in mid­ dle adulthood, older adults). Brief Vignette

The last session (session twelve of a twelve-session closed support group) of the nonbinary gender sup­ port group had five members: Guadalupe, Cole, Max, Stuart, and Keenan. The group facilitator, Theo, decided to use the “Two Stars and a Wish” activity during the group’s final therapy session. Cole, a thirty­ five-year-old African American, heterosexual client, decided to engage in the activity first. Each group member went around and gave Cole two stars and a wish. In one interaction, Guadalupe, a twenty-nine­ year-old Mexican American, lesbian-identified group member, shared how she found Cole’s coming out as nonbinary as “really instrumental and a good example for me as I chose to share my own identity with my families.” In another interaction, Max, a forty-one-year­ old Caucasian heterosexual client, shared a hope that he had for Cole: for Cole to be able to share their nonbinary gender identity with their coworkers. After each client took a turn as the center of the group’s process, Theo went over the activity with the group. The clients found that, as the group was ending, there were similar feelings among members: sadness about ending the group and wanting connection out­ side the group. Theo was then able to help facilitate the discussion about termination, whether or not they would like to stay connected after the group disbanded, and the differing ways that various members could stay connected. This activity can be used in individual sessions (in which the therapist and client do a modified version of this activity). Depending on the type of group ses­ sion, clinicians can have clients complete the activity as a whole group, or cluster the individuals into small groups (five to six people per small group), have each small group complete the activity, and then process the activity with the whole group. 214 Burnes

Suggestions for Follow-up

At the end of the activity, facilitators should ensure that participants in the group are okay with terminat­ ing. If there are clients who are at risk for harming themselves or others, facilitators should make appro­ priate referrals to individual counselors or to outside providers (and follow up to ensure that attendees have connected with these providers) to ensure that all risk is handled ethically and properly. Facilitators working in various settings should consult with the policies and procedures of their set­ ting to inquire about follow-up with clients after the clients have terminated from group counseling and are no longer clients. If follow-up is appropriate and clini­ cally indicated, facilitators may want to do a survey check-in that assesses participants’ experiences of the group and directly assesses their experience of the termination activity. Specifically, counselors can ask an open-ended question such as, “How did you expe­ rience the termination activity during the last group session? Did you feel as though it was helpful, and do you have any ideas for improving this activity?” Contraindications for Use

This activity should not be used with children who have not yet reached a cognitive capacity to engage in abstract reasoning (Broderick & Blewitt, 2010). Fur­ ther, individuals who may have had difficulty process­ ing loss and/or saying good-bye to one another in a group setting may need additional time or a more emotion-focused activity. Professional Readings and Resources American Group Psychotherapy Association (AGPA). (2007). Practice guidelines for group psychotherapy. https:// www.agpa.org/docs/default-source/practice-resources/ download-full-guidelines-(pdf-format)-group-works!ev idence-on-the-effectiveness-of-group-therapy. pdf?sfvrsn=2. Craig, S. L., Austin, A., & McInroy, L. B. (2014). School-based groups to support multiethnic sexual minority youth resiliency: Preliminary effectiveness. Child and Adoles­ cent Social Work Journal, 31 (1), 87–106. doi:10.1007/ s10560-013-0311-7. Heck, N. C., Croot, L. C., & Robohm, J. S. (2015). Piloting a psychotherapy group for transgender clients: Descrip­ tion and clinical considerations for practitioners. Profes­ sional Psychology: Research and Practice, 46 (1), 30–36. doi:10.1037/a0033134.

Lindsay, T., & Orton, S. (2014). Groupwork practice in social

work. Thousand Oaks, CA: Sage/Learning Matters.

Smith, N. G., Hart, T. A., Moody, C., Willis, A. C., Andersen,

M. F., Blais, M., & Adam, B. (2016). Project PRIDE: A cognitive-behavioral group intervention to reduce HIV risk behaviors among HIV-negative young gay and bisexual men. Cognitive and Behavioral Practice, 23 (3), 398–411. doi:10.1016/j.cbpra.2015.08.006. Travers, J. C., Tincani, M. J., & Lang, R. (2014). Facilitated communication denies people with disabilities their voice. Research and Practice for Persons with Severe Disabilities, 39 (3), 195–202. doi:10.1177/15407969 4556778.

Resources for Clients CenterLink. (2017). Local, state, and national LGBT organiza­ tions and groups. https://www.lgbtcenters.org. Cook, J. T. (2016). Group glue: The connective power of how simple questions lead to great conversations. Oklahoma City: Redinals Publishing. Drebing, C. (2016). Leading peer support and self-help groups: A pocket resource for peer specialists and support group facilitators. Holliston, MA: Alderson Press. Gibson, S. (2017). Relationship help: How to say goodbye to a group. Conflict to Peace in Relationships. www.conflict topeaceinrelationships.com/relationship-help-how-to-say­ goodbye-to-a-group/. Smith, J. (2016). Psychotherapy: A practical guide. New York: Routledge.

References American Counseling Association (ACA). (2014). 2014 ACA code of ethics. Alexandria, VA: American Counseling Association. American Group Psychotherapy Association (AGPA). (2007). Practice guidelines for group psychotherapy. https:// www.agpa.org/docs/default-source/practice-resources/ download-full-guidelines-(pdf-format)-group-works!­ evidence-on-the-effectiveness-of-group-therapy.pdf?s fvrsn=2. American Psychological Association (APA). (2011). Guide­ lines for psychological practice with gay, lesbian, and bisexual clients. American Psychologist, 67 (1), 10–42. doi:10.1037/a0024659.

American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. doi:10.1037/a0039906. Broderick, P. C., & Blewitt, P. (2010). The life span: Human development for helping professionals, 3rd edition. New York: Pearson/Prentice Hall. Burnes, T. R., & Hovanesian, P. N. T. (2017). Psychoeducation groups in LGBTQ psychology. In T. R. Burnes & J. L. Stanley (eds.), Teaching LGBTQ psychology: Queering innovative pedagogy and practice, 117–138. Thousand Oaks, CA: Sage. Burnes, T. R., & Ross, K. (2010). Applying social justice to oppression and marginalization in group process: Inter­ ventions and strategies for group counselors. Journal for Specialists in Group Work, 35 (2), 169–176. doi:10.1080/0 1933921003706014. DeLucia-Waack, J. L., Kalodner, C. R., & Riva, M. (eds.). (2013). Handbook of group counseling and psychotherapy. Thou­ sand Oaks, CA: Sage. Fehr, S. S. (2003). Introduction to group therapy: A practical guide, 2nd edition. New York: Routledge. Frost, D. M., & Meyer, I. H. (2009). Internalized homophobia and relationship quality among lesbians, gay men, and bisexuals. Journal of Counseling Psychology, 56 (1), 97. doi:10.1037/a0012844. Horne, S., Levitt, H. M., Reeves, T., & Wheeler, E. (2014). Group work with gay, lesbian, bisexual, and transgender clients: Discussing invisible differences. In J. L. DeLuciaWaack, D. A. Gerrity, C. R. Kalodner, & M. T. Riva (eds.), Handbook of group counseling and psychotherapy. Thou­ sand Oaks, CA: Sage. Nerses, M., Kleinplatz, P. J., & Moser, C. (2015). Group ther­ apy with international LGBTQ+ clients at the intersec­ tion of multiple minority status. Psychology of Sexualities Review, 6 (1), 99–109. Paul, P. L. (2016). Affirmative therapy with sexual minority clients. In K. A. DeBord, A. R. Fischer, K. J. Bieschke, & R. M. Perez (eds.), Handbook of sexual orientation and gender diversity in counseling and psychotherapy, 131–156. Washington, DC: American Psychological Association. Shapiro, J. L. (2017). A five-stage technique to enhance ter­ mination in group therapy. In S. S. Fehr (ed.), 101 inter­ ventions in group therapy, 2nd edition, 86–89. New York: Routledge.

Two Stars and a Wish 215

T WO STARS AND A WISH For each of the two stars, clients should provide one of the following: a. a strength that they have seen in client no. 1

b. a way that client no. 1 has grown in their sexually and gender-diverse community during the duration of the group

c. an attribute related to their sexually and/or gender-diverse identity/identities that they admire in client no. 1

d. one aspect of client no. 1 that they will miss

For each wish, clients should provide one of the following: a. a goal for client no. 1 to continue growing as a sexually or gender-diverse person after the group ends

b. an area for client no. 1 to continue working on that is relevant to the client’s group goals (or the overall goals of the group)

c. a positive hope for client no. 1’s future

216

Luke R. Allen

25 THE QUADRANT EXERCISE OF RELATIONSHIP EXPLORATION FOR SEXUAL- AND GENDER-IDENTITY DIVERSE CLIENTS Theodore R. Burnes Suggested Use: Activity Objective

The goal of this activity is to increase sexual- and gender-identity diverse individuals’ knowledge about what they desire in a relationship with one or more individuals. Rationale for Use

Individuals who have experienced systemic oppression and marginalization on the basis of their sexual and/ or gender identities may often experience difficulty in beginning or maintaining healthy intimate relation­ ships (Frost & Meyer, 2009). Such difficulty stems, in part, from a variety of factors related to societal homophobia and oppression (Frost, 2013). However, many therapists who have experience working with sexual- and gender-identity diverse clients may not have experience working with issues of sexual expres­ sion and relational intimacy (Burnes, 2016; Burnes, Singh, & Witherspoon, 2017). Thus, therapists need to plan specific interventions to increase sexual- and gender-identity diverse clients’ self-awareness and knowledge about their desires and needs for their intimate relationships. In addition, it is important for therapists to be aware that sexual- and gender-identity diverse clients may transcend the boundaries of traditional monog­ amous relationships. Specifically, some individuals may engage in polyamorous relationships, or sexual and relational practices in which there may be multi­

ple concurrent partners and various structures of sexual relationships (Burnes et al., 2017). Thus, a client want­ ing a relationship may be one member of a polyam­ orous relationship who wants specific relational needs to be filled that are either partially being filled by another partner or not being filled at all. Therefore, it’s important for therapists to fully investigate rela­ tional needs and desires with a sensitivity to diverse relational structures. Various sets of guidelines from professional orga­ nizations in mental health disciplines have noted the importance of intimate relationships for sexually and gender-diverse clients. The American Psychologi­ cal Association (APA) (2011) noted the importance of psychologists’ attention to relationships for LGB individuals. Further, the APA (2015) has recently noted the importance of psychologists’ acquisition of knowl­ edge, attitudes, and skills for transgender and gendernonconforming (TGNC) clients; the authors of this document note the importance of having an overall understanding of healthy intimate relationships and partnerships for TGNC people. Despite these standards, there are data to support the conclusion that sexual- and gender-identity diverse clients may have difficulty determining their needs and desires for intimate relationships, specifically within a therapeutic context (Patterson, 2016). Therapists may not be able to understand the needs and parameters that are specific to relationships in which one or more members have a sexually and/or gender-diverse iden­ tity, and they thus do not ask the right questions or

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

218

implement the right interventions (Patterson, 2016). Therefore, therapists need to consider how their cli­ ents’ gender and sexual identities may influence which factors they look for in starting and maintaining a healthy relationship. Further, because therapists may not be adequately trained in areas of sexuality and intimate relationships for these clients (Burnes et al., 2017), they risk engaging in unethical practice related to working with sexual- and gender-identity diverse clients, including (a) making relationship issues a focal point of therapy when they don’t need to be, (b) avoid­ ing relationship topics when clients with a sexual- and/ or gender-diverse identity want to talk about their relationships in therapy, and (c) not seeking appropri­ ate consultation or supervision related to relationship issues for sexual- and/or gender-identity diverse cli­ ents (APA, 2011; Haldeman, 2012). Further, given that sexual- and gender-identity diverse clients form and maintain intimate relationships within a unique con­ text of oppression that includes homophobia, bipho­ bia, cissexism, and transphobia, the need for therapists to consider unique relationship issues is paramount (Burnes, 2017).

After completion of the activity, therapists should ask clients a series of questions to help them process it. Specific questions that can be helpful to stimulate such a process include: (a) What was completing this activity like for you? (b) What were the similarities in your four lists? How do you understand those similarities? (c) What were the differences in your four lists? How do you understand those differences? (d) What were the three most important things that you learned about yourself by completing this activity? (e) As you reflect on this activity, what do you think are messages from LGBTQ communities that you have received about an ideal relationship? (f) As you reflect on this activity, what do you think are messages from your various communities (e.g., your family of origin, your racial or ethnic community) that you have received about an ideal relationship?

Instructions

(g) How do you think that having identities that are culturally and/or systemically oppressed has affected your ability to find a relationship?

Clients can complete this activity, called the Quadrant Exercise (see page 222), as homework or in a counsel­ ing session. Therapists should tell clients that this activity is designed to help them think about and identify what they might be looking for in a relation­ ship. They should provide clients with a copy of the Quadrant handout and a writing instrument and ask them to complete each of the four lists. Therapists should tell clients to answer the questions in each of the four boxes by creating four separate lists. Thera­ pists should tell clients that they can write down qual­ ities on multiple lists (i.e., the same quality can appear in more than one quadrant). Clients completing the activity in an individual or a group counseling session should be given ten minutes to complete this activity (clients in a group counseling session should each complete the Quadrant activity individually). If clients are completing the activity outside session, therapists should ask clients to time themselves for ten minutes to complete the activity and bring the completed activity to the next session.

This activity can be used in individual sessions (in which the therapist and client process the activity after it’s completed) or in a group counseling session. If used in a group session, clinicians can (a) have clients complete the activity individually and then pro­ cess the activity with the whole group, (b) have cli­ ents complete the activity individually, cluster the indi­ viduals into small groups (two or three people per small group), have small groups each process the activ­ ity, and then process the activity with the whole group, or (c) cluster the individuals into small groups (two to three people per small group) and have small groups each complete the activity together, and then process the activity with the whole group. This activity can be helpful with clients in a range of settings. In a psychoeducation group format, this activity can help sexual- and gender-identity diverse clients recognize symptoms of societal homophobia and oppression (Burnes & Hovanesian, 2017) through interactive, small-group work across different age The Quadrant Exercise of Relationship Exploration 219

ranges (e.g., high school students, college students, individuals in middle adulthood, older adults). Fur­ ther, this is a good activity to also use with youth and young adults who may “want a relationship” but do not know how to articulate what they need in a rela­ tionship. This activity may also be a good topic for a particular session of a support group provided for sexual- and gender-identity diverse clients (e.g., an empowerment group for queer women). Brief Vignette

Maria is a thirty-year-old Mexican American woman who came out as a transgender-identified, lesbianidentified female. She and her therapist have been working together for almost three years (in which Maria worked on therapy goals related to strengthen­ ing her transgender identity), and Maria has recently identified wanting to be in an intimate partnership. Maria’s therapist provided Maria with a copy of the Quadrant Exercise and asked Maria to complete the activity as homework. Maria came back to session the next week. She had completed the four lists. She and her therapist noted the similarities between her List 1 and her List 3, and Maria was able to gain the insight that what she was looking for in a relationship was also what she would be able and willing to offer in a relationship. For example, Maria noted that she was out as transgender and had worked to develop her sense of self in terms of both her ethnic and her gender identities. Maria also noted that she wanted “someone who was out,” and that “level of outness is a deal breaker for me. I can’t date someone who’s not out as being a queer woman or who wants me to go into the closet about my transgender identity.” Maria was able to recognize that her desires related to a potential partner’s out­ ness mirrored her own values about her own outness. Maria also recognized that her shortest list was the list of qualities that she was willing to compromise on in another person, and she was able to have a subse­ quent conversation with her therapist about how she often had difficulty compromising in her relationships. She and her therapist articulated the idea that learn­ ing ways to compromise would be a good goal for her next phase of counseling.

220 Burnes

Suggestions for Follow-up

Given the objective of this learning activity, it is help­ ful to think about accurately assessing individuals’ knowledge gained from this activity as a two-step model. First, clinicians using this activity in an individ­ ual therapeutic context can use subsequent sessions to ask clients about insights gained from this activity and assess clients’ self-report. In addition, it would be helpful for clients to use behavioral indicators as a measure for follow-up. Specifically, if clients indicate explicit criteria that they are looking for in a rela­ tionship, they may exhibit ways that they are looking for those criteria in possible partners and thus indi­ cate ways that the activity has had a positive outcome on their well-being. For example, clients may com­ plete this activity and gain the insight that they want a partner who is open to the prospect of having chil­ dren. Thus, the client may use subsequent therapy ses­ sions to craft ways of bringing this desire into con­ versations (e.g., role-playing with the therapist different ways of bringing up the topic of children with possi­ ble partners) and eventually implement these ways in conversations with potential partners. Contraindications for Use

Clinicians using this activity should reflect on the range of sexual expression that exists for clients, including individuals who are not sexually attracted to anyone and who may want a relationship that consists exclu­ sively of romantic and emotional connection. Specif­ ically, asexual people may not identify with or define themselves by their sexuality. Asexual identities reflect a range of experiences (including wanting to engage in romantic, affectional relationships) and often do not include a focus on sexuality (Burnes, 2017; Scott, McDonnell, & Dawson, 2016). Thus, clinicians can use modified versions of this activity to ensure well­ being for those clients. In addition, individuals who have survived phys­ ical or emotional abuse or domestic violence in a relationship may have difficulty completing this activ­ ity. Individuals who have survived emotional and/or physical abuse in same-sex relationships may find it difficult to engage in their communities to find other partners for fear of stigma and rejection (Renzetti &

Miley, 2014). Clinicians should thoroughly assess clients’ emotional well-being after such abuse-related incidents, and they may wait to engage in this activity until clients have thoroughly processed such abuse and its clinical implications on their lives. Professional Resources Easton, D., & Hardy J. W. (2009). The ethical slut: A practical guide to polyamory, open relationships, and other adven­ tures. New York: Celestial Arts. Gamarel, K. E., Reisner, S. L., Laurenceau, J. P., Nemoto, T., & Operario, D. (2014). Gender minority stress, mental health, and relationship quality: A dyadic investigation of transgender women and their cisgender male partners. Journal of Family Psychology, 28 (4), 437. doi:10.1037/ a0037171. Macapagal, K., Greene, G. J., Rivera, Z., & Mustanski, B. (2015). “The best is always yet to come”: Relationship stages and processes among young LGBT couples. Journal of Family Psychology, 29 (3), 309. doi:10.1037/fam0000094. Reuter, T. R., Newcomb, M. E., Whitton, S. W., & Mustanski, B. (2017). Intimate partner violence victimization in LGBT young adults: Demographic differences and asso­ ciations with health behaviors. Psychology of Violence, 7 (1), 101. doi:10.1037/vio0000031. Whitton, S. W., & Kuryluk, A. D. (2014). Associations between relationship quality and depressive symptoms in samesex couples. Journal of Family Psychology, 28 (4), 571– 576. doi:10.1037/fam0000011.

Resources for Clients Chapman, G. D. (1995). The five love languages: The secret to love that lasts. Chicago: Northfield Publishing. Clunis, M. D., & Green, G. D. (2004). Lesbian couples: A guide to creating healthy relationships. Chicago: Northfield Publishing. Easton, D., & Hardy, J. W. (2009). The ethical slut: A practical guide to polyamory, open relationships, and other adven­ tures. New York: Celestial Arts. Niedra, A. How to find real, lasting love without looking for it. Tiny Buddha. http://tinybuddha.com/blog/how-to­ find-real-lasting-love-without-looking-for-it. Proud, B., & Windsor, B. (2014). First comes love: Portraits of enduring LGBTQ relationships. New York: Soleil. Scott, S., McDonnell, L., & Dawson, M. (2016). Stories of non‐ becoming: Non‐issues, non‐events and non‐identities in asexual lives. Symbolic Interaction, 39 (2), 268–286. doi:10.1002/symb.215. Travis, R. L. (2013). Gay men’s guide to love and relationships. Boston: RLT Publishing.

References American Psychological Association (APA). (2011). Guidelines for psychological practice with gay, lesbian, and bisexual clients. American Psychologist, 67 (1), 10–42. doi:10.1037/ a0024659. American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. doi:10.1037/a0039906. Burnes, T. R (2016). Working with gay, lesbian, bisexual, and queer students. In H. S. Hamlet (ed.), School counseling practicum and internship: 30 essential lessons, 96–103. Thousand Oaks, CA: Sage. Burnes, T. R. (2017). Flying faster than the birds and the bees: Toward a sex-positive theory and practice in multicultural education. In R. K. Gordon, T. Akutsu, J. C. McDermott, & J. W. Lalas (eds.), Challenges associated with cross-cul­ tural and at-risk student engagement, 171–189. Hershey, PA: IGI Global Publishing. Burnes, T. R , & Hovanesian, P. T. (2017). Psychoeducation groups in LGBTQ psychology. In T. R. Burnes & J. L. Stanley (eds.), Teaching LGBTQ psychology: Queering innovative pedagogy and practice, 117–138. Thousand Oaks, CA: Sage. Burnes, T. R., Singh, A. A., & Witherspoon, R. G. A. (2017). Sex-positivity training in counseling psychology: An exploratory analysis. Counseling Psychologist, 45 (4), 470–486. doi:10.1177/0011000017710216. Frost, D. M. (2013). Stigma and intimacy in same-sex relation­ ships: A narrative approach. Journal of Family Psychology, 25 (1), 1–10. doi:10.1037/a0022374. Frost, D. M., & Meyer, I. H. (2009). Internalized homophobia and relationship quality among lesbians, gay men, and bisexuals. Journal of Counseling Psychology, 56 (1), 97–109. Haldeman, D. (2012). Guidelines for psychological practice with lesbian, gay, and bisexual clients. American Psychol­ ogist, 67 (1), 10–42. doi:10.1037/a0024659. Patterson, C. J. (2016). Lesbian, gay, bisexual, and transgender family issues in the context of changing legal and social policy environments. In K. A. DeBord, A. R. Fischer, K. J. Bieschke, & R. M. Perez (eds.), Handbook of sexual ori­ entation and gender diversity in counseling and psycho­ therapy, 313–332. Washington, DC: American Psycho­ logical Association. Renzetti, C. M., & Miley, C. H. (2014). Violence in gay and lesbian domestic partnerships. New York: Routledge. Scott, S., McDonnell, L., & Dawson, M. (2016). Stories of non-becoming: Non‐issues, non‐events and non‐identities in asexual lives. Symbolic Interaction, 39 (2), 268–286. doi:10.1002/symb.215. Veaux, F., & Rickert, E. (2014). More than two: An ethical guide to polyamory. Seattle: Thorntree Press.

The Quadrant Exercise of Relationship Exploration 221

THE Q UA DRA NT EXERCIS E

LIST 1. What are qualities that you believe you are looking for in a relationship?

LIST 2. What are qualities that you believe you don’t want in a relationship, but would be willing to compromise on if a potential partner possessed these qualities?

LIST 3. What are qualities that you believe you would provide to others in a relationship?

LIST 4. What are deal breakers (qualities that, if a potential partner had them, would be reason not to continue to engage with that person)?

222

Theodore R. Burnes

26 NEGOTIATING INFORMATION AND COMMUNICATION TECHNOLOGIES WITH SEXUAL AND GENDER MINORITY YOUTH AND YOUNG ADULTS Nathaniel Amos Suggested Uses: Activity, homework Objective

The goal of this chapter is twofold. First, it aims to sup­ port the clinician and client in developing a shared language regarding how clients use information and communication technologies (ICTs) in their lives. The shared language supports the clinician and client in better understanding the role of technology as it affects a client’s overall well-being. Second, the chapter aims to proactively address discovery of the clinician’s per­ sonal information online and includes recommenda­ tions on how to assess potential boundary violations (e.g., if a client “friends” a clinician on Facebook). Rationale for Use

This activity is designed for use with sexual and gen­ der minority youth (SGMY). Sexual and gender minority is used to refer to people identifying along the LGBTQIAA spectrum, whereas youth is a fluidly defined category. Generally, researchers frame youth as the period of psychological transition between childhood and adulthood, yet no universally accepted age range exists. For the purposes of this chapter, youth is referred to in keeping with the United Nations definition and refers to people between fifteen and twenty-four years old (United Nations, n.d.). SGMY are at risk of experiencing an increased amount of social isolation and, so, often turn to digital means to achieve social connectedness, decreased isolation, and an improved sense of well-being (GLSEN, CiPHR, &

CCRC, 2013; Hillier & Harrison, 2007; Kosciw et al., 2012; Tao, 2014). Multiple population-based studies have documented use rates among youth broadly and the ways in which SGMY use ICTs. Information and communication technologies is a comprehensive term designed to capture the wide variety of technology SGMY might be using. It includes, but is not limited to, social media networks, the Internet (broadly), video game consoles, and cell phones (Craig et al., 2015), which SGMY use differently from their non-SGMY peers (GLSEN et al., 2013; Lenhart, 2015). Most nota­ bly, the Gay, Lesbian, and Straight Education Network (GLSEN) documented that SGMY spend an average of five hours per day online, which is approximately forty-five minutes more than non-SGMY (GLSEN et al., 2013). GLSEN’s study documented four modes of ICT use among SGMY, including seeking safer social spaces, information seeking regarding identity devel­ opment and sexual health, accessing peer supports, and civic participation (GLSEN et al., 2013). Recent research has also demonstrated that the Internet and ICTs function as a haven for SGMY (Ybarra, Mitchell, Palmer, & Reisner, 2015). Compared to their non-SGMY peers, SGMY face an increased risk of rejection and verbal, physical, and sexual vic­ timization at home and school, which contributes to clinical concerns such as substance use, depression, post-traumatic stress, and elevated suicidality (Craig et al., 2015; GLSEN et al., 2013). SGMY thus may seek supportive social spaces online because they do not have access to such spaces in person (Ybarra et

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al., 2015). Online resources also support SGMY in researching identity development, seeking access to sexual health information, and participating in social activism (Craig & McInroy, 2014; GLSEN et al., 2013). Having access to such online resources is strongly correlated to improved quality of life for SGMY (Craig & McInroy, 2014; Craig et al., 2015; Ybarra et al., 2015). Given that SGMY are using ICTs in such varied modes, clinicians in a variety of contexts could ben­ efit from having a frame established regarding the various ways in which SGMY might be engaging with ICTs (Ybarra et al., 2015). There are multiple gains to be made from doing so, including (but not limited to) an improved understanding of clients in their social environment, an improved understanding of how peer support functions for a client, and improved therapeutic rapport by demonstrating empathic curi­ osity regarding a client’s social world (Craig & McIn­ roy, 2014). In an increasingly interconnected world, clinicians working with SGMY must be ready to directly con­ front the ethical conflicts inherent when interfacing with technology (Duncan-Daston, Hunter-Sloan, & Fullmer, 2013; Judd & Johnston, 2012; Kays, 2011; Tunick, Mednick, & Conroy, 2011). Ethical standards regarding technology usage vary across therapeutic disciplines and training (ACA, 2014; APA, 2017; NASW, 2017). The American Counseling Association (ACA) has developed a thorough listing of ethical practices. At its core, the ACA advocates that “coun­ selors understand the additional concerns related to the use of distance counseling, technology, and social media and make every attempt to protect confidenti­ ality and meet any legal and ethical requirements for the use of such resources” (ACA, 2014, p. 3). Ethicists argue that clinicians across all disciplines are individu­ ally responsible for addressing ethical issues involved in ICT use with their clients, unless otherwise directed by workplace leadership (Halabuza, 2014). Two broad dilemmas are associated with working with clients in terms of ICT usage. First, potential risks of increased ICT usage among SGMY might include cyberbullying and sexual predation (Giffords, 2009; Ybarra et al., 2015). Second, the relationship between clinician and client might become blurred by the avail­ ability of more information available online or if a

clinician has a website or social media presence (Hal­ abuza, 2014). Specific concerns might include (but are not limited to) confidentiality concerns, privacy breaches, and establishment of dual relationships (Halabuza, 2014; Kolmes & Taube, 2016). With an increase in ICT use, SGMY may be tar­ geted by cyberbullies and potential sexual predators (Giffords, 2009; Ybarra et al., 2015). Caretakers have historically expressed concerns about online sexual victimization of SGMY as well as exposure to sexually explicit material made more easily available on the Internet (Jones, Mitchell, & Finkelhor, 2012). These concerns continue to remain a key component of policy debates; however, research conducted over a five-year period from 2005 to 2010 found that sexual victimization might be on the decline (Jones et al., 2012). Researchers cite such improvements as result­ ing from increased rates of online literacy as well as increased parental involvement (Guan & Subrah­ manyam, 2009). Despite gains made, researchers con­ tinue to call for improved methods of understanding and preventing sexual victimization of SGMY using ICTs (Jones et al., 2012). The etiology and development of cyberbullying presents a complex research question (Ybarra et al., 2015). In the non-cyber world, researchers estimate that about 82 percent of SGMY report being ver­ bally taunted and 38 percent report being physically harassed in school settings, and online rates are correspondingly high (Kosciw et al., 2012). Newer research has suggested, however, that online com­ munities may support SGMY in feeling safer, thus decreasing the deleterious effects of cyberbullying (Ybarra et al., 2015). Researchers continue to call for an improved understanding of cyberbullying gener­ ally and to study more effective methods of bullying prevention (Ybarra et al., 2015). As with any new resources, clinicians must be mindful of risks inherent in using ICTs. Ethics researchers recommend that clinicians review pros and cons with clients to improve understanding of potential risks involved in using ICTs (Giffords, 2009). This includes reviewing privacy policies of social media and networking websites as well as monitoring client ICT use (Giffords, 2009). If a SGMY’s family is supportive, clinicians may also consider working

Negotiating Information and Communication Technologies 225

with parents to review online “tip sheets” developed by government and nonprofit agencies to ensure that SGMY are supported (Ybarra et al., 2015). Ethics researchers highly recommend that clini­ cians themselves, in addition to monitoring client use, continue to monitor their own social media use (Zur & Zur, 2011). Potential boundary violations might occur if a clinician unknowingly or, in some cases, intentionally invites clients to participate in a clinician’s personal social media network (Halabuza, 2014; Judd & Johnston, 2012; Zur & Zur, 2011). Along with potential privacy violations, clinicians should also monitor potential dual relationships unintentionally developed through social media networking sites (Zur & Zur, 2011). Ethicists thus recommend that clinicians review the privacy settings on their social media accounts and carefully monitor the information made available online through periodic Internet searches (e.g., using a Google search to identify what informa­ tion a clinician might have available over the Inter­ net) (Halabuza, 2014; Kolmes & Taube, 2016). Ethics researchers also recommend that clinicians review the privacy limitations on electronic communication (email or phone text messages) and set clear guidelines with clients regarding the use of electronic commu­ nication (Halabuza, 2014; Kolmes & Taube, 2016). Instructions

Activity 1: Assessing a Client’s Digital Footprint The first activity provided here is designed for use in therapy. It can be used with the standard clinical assessment a clinician may use when first meeting a client. It can also be used at any point where social media use becomes indicated in the clinical relation­ ship, such as when a client discloses experiencing cyberbullying. A clinician may introduce the activity by presenting copies of the activity to the client. The clinician can clarify that the activity is designed to support the client and clinician in developing a shared language that furthers cohesion in the therapeutic relationship and helps the client invite the clinician into the client’s technological world. The activity itself is a brief, semi-structured ques­ tionnaire. In it clinicians will find space for client name, preferred pronouns, and date of birth; questions dedicated to identifying a client’s digital footprint, 226 Amos

which includes subsections for identifying what kinds of technology a client uses (e.g., the Internet, social media), frequency of usage, and current level of privacy settings; and questions dedicated to understanding a client’s motivation to use ICTs. Questions are adapted from GLSEN and colleagues’ 2013 report, Out Online, as well as research from the Pew Research Center’s 2015 report on teens, social media, and technology (Lenhart, 2015). Activity 2: Clinician Self-Assessment The second activity is a self-assessment. A clinician may choose to take the self-assessment at any point. The self-assessment might also be useful for training settings and in supervisory relationships to help new clinicians clarify their use of technology and the ways in which it might affect the therapeutic relationship. The assessment is a brief, semi-structured ques­ tionnaire. It is a self-report instrument for clinicians. It asks similar questions regarding a clinician’s digital footprint and is also adapted from the GLSEN and Pew reports. The activity supports clinicians in differ­ entiating appropriate curiosity from potential cyberstalking behavior. The latter subsection is adapted from ethics-focused literature aimed at supporting cli­ nicians in maintaining appropriate clinical boundaries in an increasingly digitized age (Zur, 2008). Activity 3: Assessing a Client’s Search for Information This activity is designed to be used when a client attempts to contact a clinician by technological means. It can be used at any point in which it becomes indi­ cated in the clinical relationship. It can be introduced when a boundary has been crossed or preventatively after a clinician has assessed a client’s technology use (after Activity 1). The levels of boundary violations are provided below as a brief framework to introduce a sample framework to a client. Level 1: Curiosity. This level encapsulates an appropri­ ate search for a clinician using a search engine (Zur, 2008). This search may produce information about the clinician’s professional life (including training, professional memberships, highest degree obtained, and the clinician’s professional website). Level 2: Thorough search/due diligence. This level includes a simple search (producing results similar

to Level 1) as well as contacting the state licensing board, inquiring after ethical investigations, or reading information provided about the clinician written by former clients or professional colleagues (Zur, 2008). Level 3: Intrusive search. This level includes seeking out a clinician’s personal information, such as inves­ tigating public records (e.g., marriage certificates, divorce proceedings, personal address), joining social media networks under a disguised name, and paying for a service that would conduct a legal investigation into a clinician’s life (Zur, 2008). Level 4: Illegal search/cyberstalking. At this juncture, a clinician should consider consulting an attorney and/or law enforcement. Cyberstalking, as defined by the National Institute of Justice, is defined as “the use of technology to stalk victims” and “involves the pur­ suit, harassment, or contact of others in an unsolic­ ited fashion . . . via the Internet or e-mail” (National Institute of Justice, 2007). This can include gathering information such as credit reports, banking informa­ tion, cell phone records, tax records, and other highly private information through illegal means (Zur, 2008). Brief Vignette

You are a therapist working in a small, communitybased nonprofit that provides after-school program­ ming (including clinical services) for self-identified SGMY and allies in a major urban area. NG is a six­ teen-year-old African American, gay-identified, cisgender male (using he, him, and his pronouns) with whom you have been working for four sessions. He presented to treatment reporting wanting to build a more supportive peer network and to address symp­ toms of anxiety and depression. At the start of your fifth session, he shares the facts that he uses Instagram and that he has been experiencing online bullying from peers at his school. He reports that peers have been leaving derogatory and hate-filled comments on his pictures. He is very tearful and reports that he is angry. He reports that Instagram was a safe space for him and that he could make meaningful connec­ tions with people outside his immediate peer group at school. He does not want to leave Instagram because it provides him a sense of community outside his school-based environment. Using the worksheets pro­

vided in this chapter, you help NG clarify that he wants to continue to maintain his safe space and that he can change his privacy settings to “private” on Instagram so that he can avoid receiving derogatory comments in the future. In completing the activity, he begins to ask you about your own Instagram profile. He admits that he looked for you on Instagram and found a profile that seemed to be yours. You know that your privacy set­ tings were on “private” and that you maintain an Instagram profile to stay connected to a group of friends. You navigate a conversation where you assess his level of interest as being developmentally appro­ priate and you his acknowledge his desire to be con­ nected, but you clarify that you cannot accept his request to be connected on Instagram because you want to maintain a professional relationship. He expresses understanding. Your session continues to address his ability to develop satisfying relationships with age-appropriate peers. Suggestions for Follow-up

As clients continue in treatment and as they age, it is suggested that clinicians continually assess a client’s involvement in ICT use and continue to assess for cyberbullying. Consider following up at various, clin­ ically appropriate junctures—for example, when a client transitions to a new school environment or when a client meets a new partner (GLSEN et al., 2013). Contraindications for Use

The information available about ICT use in nonurban areas is comparatively nascent (Craig & McInroy, 2014; Ybarra et al., 2015). Available research acknowl­ edges that ICT use is necessarily bounded by region, socioeconomic status (SES), and associated class or wealth privilege, despite the growing use of ICTs and improved availability of the necessary technologies (smartphones, computers, the Internet) in locations where ICT and necessary technologies were not avail­ able (Mustanski, Lyons, & Garcia, 2011). Clinicians in rural areas and clinicians working with clients who might not have access to the latest technologies should take caution when implementing the activities to anticipate and respond to microaggressions related to regional, class, and wealth privileges (Craig & McIn-

Negotiating Information and Communication Technologies 227

roy, 2014; Mustanski et al., 2011; Ybarra et al., 2015). Clinicians should also pay close attention to the ways in which access to and use of ICTs might differ across racial and ethnic boundaries as they intersect with a client’s stated gender and sexual orientation identity (Craig & McInroy, 2014; Mustanski et al., 2011; Ybar­ ra et al., 2015). The activities in this chapter were designed for clients who are within the specified age range of fifteen to twenty-four. However, the activities are assessment-based and thus not necessarily limited to that specific age range. The activities were designed in service of empowering a client demographic that is arguably more at risk for cyber-victimization than clients who might be outside that specific age range (GLSEN et al., 2013; Hillier & Harrison, 2007; Kosciw et al., 2012; Tao, 2014). Finally, the activities are con­ traindicated for clients who may have learning dif­ ferences or who might be experiencing symptoms of psychosis, as their involvement with ICT may be influenced by differences in perception and/or reality testing (GLSEN et al., 2013; Lenhart, 2015). Professional Resources Anti-Defamation League. (2012). What to do if your child exhibits bullying behavior. https://www.adl.org/assets/ pdf/education-outreach/What-to-Do-if-Your-Child-Ex hibits-Bullying-Behavior.pdf. Centers for Disease Control and Prevention. (2016). Technol­ ogy and youth: Protecting your child from electronic aggression. https://www.cdc.gov/violenceprevention/ pdf/ea-tipsheet-a.pdf. Edgington, S. M. (2011). The parent’s guide to texting, Facebook, and social media. Dallas: Brown Books. GLSEN, CiPHR, & CCRC. (2013). Out online: The experiences of lesbian, gay, bisexual and transgender youth on the Internet. New York: GLSEN. https://www.glsen.org/sites/ default/files/Out Online FINAL.pdf. Lenhart, A. (2015). Teens, social media, and technology over­ view 2015. Pew Research Center. www.pewinternet. org/2015/04/09/teens-social-media-technology-2015/#.

Client Resources Human Rights Campaign. (2017). Resources on cyber-bully­ ing. https://www.hrc.org/resources/resources-on-cyber­ bullying. i-Safe Ventures Digital Learning. (2018). www.isafe.org/. Trevor Project. (2017). Saving young LGBTQ lives. https:// www.thetrevorproject.org/.

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US Department of Health and Human Services. (2017). What is cyberbullying. https://www.stopbullying.gov/cyber­ bullying/index.html.

References American Counseling Association (ACA). 2014. ACA code of ethics. https://www.counseling.org/resources/aca-code­ of-ethics.pdf. American Psychological Association (APA). 2017. Ethical prin­ ciples of psychologists and code of conduct. https://www. apa.org/ethics/code/. Behnke, S. (2008). Ethics in the age of the Internet. Monitor on Psychology, 39 (7), 74. Brown, J. D., & Bobkowski, P. S. (2011). Older and newer media: Patterns of use and effects on adolescents’ health and well-being. Journal of Research on Adolescence, 21 (1), 95–113. Craig, S. L., & McInroy, L. (2014). You can form a part of your­ self online: The influence of new media on identity devel­ opment and coming out for LGBTQ youth. Journal of Gay and Lesbian Mental Health, 18 (1), 95–109. Craig, S. L., McInroy, L., McCready, L. T., Di Cesare, D. M., & Pettaway, L. D. (2015). Connecting without fear: Clinician implications of the consumption of information and communication technologies by sexual minority youth and young adults. Clinical Social Work Journal, 43, 159–168. Duncan-Daston, R., Hunter-Sloan, M., & Fullmer, E. (2013). Considering the ethical implications of social media in social work education. Ethics Information Technology, 15, 35–43. Garner, J., & O’Sullivan, H. (2010). Facebook and the profes­ sional behaviours of undergraduate medical students. Clinical Teacher, 7, 112–115. Giffords, E. D. (2009). The Internet and social work: The next generation. Families in Society, 90 (4), 413–418. GLSEN, CiPHR, & CCRC. (2013). Out online: The experiences of lesbian, gay, bisexual, and transgender youth on the Internet. New York: GLSEN. https://www.glsen.org/sites/ default/files/Out Online FINAL.pdf. Guan, S. A., & Subrahmanyam, K. (2009). Youth Internet use: Risks and opportunities. Current Opinion in Psychiatry, 22, 351–356. Halabuza, D. (2014). Guidelines for social workers’ use of social networking websites. Journal of Social Work Values and Ethics, 11 (1), 23–32. Hillier, L., & Harrison, L. (2007). Building realities less limited than their own: Young people practising same-sex attrac­ tion on the Internet. Sexualities, 10 (1), 82–100. Jones, L. M., Mitchell, K. J., & Finkelhor, D. (2012). Trends in youth Internet victimization: Findings from three youth Internet safety surveys, 2000–2010. Journal of Adolescent Health, 50, 179–186.

Judd, R. G., & Johnston, L. B. (2012). Ethical consequences of using social network sites for students in professional social work programs. Journal of Social Work Values and Ethics, 9 (1), 5–11. Kays, L. (2011, July 4). Must I un-friend Facebook? Exploring the ethics of social media. New Social Worker. https:// www.socialworker.com/feature_articles/ethics-articles/ Must_I_Un-Friend_Facebook%3F_Exploring_the_ Ethics_of_Social_Media/. Kolmes, K., & Taube, D.O. (2016). Client discovery of psycho­ therapist personal information online. Professional Psy­ chology: Research and Practice, 47 (2), 147–154. Kosciw, J. G., Greytak, E. A., Bartkiewicz, M. J., Boesen, M. J., & Palmer, N. A. (2012). The 2011 National School Climate Survey: The experiences of lesbian, gay, bisexual and transgender youth in our nation’s schools. New York: GLSEN. https://glsen.org/sites/default/files/2011%20National%20 School%20Climate%20Survey%20Full%20Report.pdf. Lenhart, A. (2015). Teens, social media, and technology over­ view 2015. Pew Research Center. www.pewinternet. org/2015/04/09/teens-social-media-technology-2015/#. Lusk, B. (2010). Digital natives and social media behaviors: An overview. Prevention Researcher, 17, 3–6. Mitchell, K. J., Finkelhor, D., Wolak, J., Ybarra, M., and Turner, H. (2011). Youth Internet victimization in a broader vic­ timization context. Journal of Adolescent Health, 48 (2), 128–134. Mustanski, B., Lyons, T., & Garcia, S. C. (2011). Internet use and sexual health of young men who have sex with men: A mixed-methods study. Archives of Sexual Behavior, 40, 289–300. National Association of Social Workers (NASW). (2017). Code of ethics. Washington, DC: Author. https://www.social workers.org/About/Ethics/Code-of-Ethics/Code-of­ Ethics-English.

National Institute of Justice. (2007). Stalking. https://www. nij.gov/topics/crime/stalking/pages/welcome.aspx. Rietmeijer, C., Bull, S., McFarlane, M., Patnaik, J., & Douglas, J. (2003). Risks and benefits of the Internet for populations at risk for sexually transmitted infections (STIs): Results of an STI clinic survey. Sexually Transmitted Diseases, 30, 15–19. Subrahmanyam, K., & Greenfield, P. M. (2008). Communicat­ ing online: Adolescent relationships and the media. Future of Children, 18 (1), 119–146. Tao, K. (2014). Too close and too far: Counseling emerging adults in a technological age. Psychotherapy, 51 (1), 123–127. Taylor, L., McMinn, M. R., Bufford, R. K., & Chang, K. B. T. (2010). Psychologists’ attitudes and ethical concerns regarding the use of social networking web sites. Profes­ sional Psychology: Research and Practice, 41, 153–159. Tunick, R. A., Mednick, L., & Conroy, C. (2011). A snapshot of child psychologists’ social media activity: Professional and ethical practice implications and recommendations. Professional Psychology: Research and Practice, 42 (6), 440–447. United Nations. (n.d.). Definition of youth. https://www. un.org/esa/socdev/documents/youth/fact-sheets/youth­ definition.pdf. Ybarra, M. L., Mitchell, K. J., Palmer, N. A., & Reisner, S. L. (2015). Online social support as a buffer against online and offline peer and sexual victimization among US LGBT and non-LGBT youth. Child Abuse and Neglect, 39, 123–136. Zur, O. (2008). The Google factor: Therapists’ unwitting selfdisclosure on the net. New Therapist, 57, 16–22. Zur, O., & Zur, A. (2011). The Facebook dilemma: To accept or not accept? Responding to clients’ “friend requests” on psychotherapists’ social networking sites. Independent Practitioner, 31 (1), 12–17.

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ACT IVIT Y 1 WO RKS H EET

Demographics Client Name: ________________________________________ Date of Birth: _______________ Pronouns: ___________________________ Do you have a cell phone? n Yes n No If yes: Is it a smartphone? n Yes n No

Do you text? n Yes n No

Whom do you text? Please list: __________________________________________________

Do you have access to a computer at home?

n Yes n No

Do you have access to an Internet connection at home?

n Yes n No

Do you have access to a computer at school?

n Yes n No

Do you have access to an Internet connection at school?

n Yes n No

Do you use any electronic video game consoles?

n Yes n No

If yes:

Is it a portable game console? n Yes n No Do you participate in any community-based or multiplayer games that use an Internet

connection? n Yes n No If yes, please list: _______________________________________________________________

For which of the following activities do you use the Internet? n Schoolwork

n Social media

n Romantic/sexual connections

n Browsing n Online communities

n Sexual health research n Activism participation

n Other: _____________________________________________________________________ If you participate in social media, which social media platforms do you participate in? n Facebook

n Twitter

n Instagram

n Snapchat

n Tumblr

n Dating applications (please list): ______________________________________________

How often do you participate in activities involving technology (including texting, the Internet,

and social media)? Circle the most accurate frequency.

Less than 1 hour

1–3 hours/day

9–15 hours/day

15+ hours/day

4–8 hours/day

PAGE 1

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ACT IVIT Y 1 WO RKS H EET

Are you aware of the privacy settings on your social media accounts? n Yes n No Have you ever Googled yourself? n Yes n No If yes, did you find anything surprising? n Yes n No If yes, please describe: _______________________________________________________________________________ _______________________________________________________________________________ If you participate in online communities (including social media), can you describe the quality of those communities? _______________________________________________________________________________ _______________________________________________________________________________ If you participate in online communities (including social media), what do you like about those communities? _______________________________________________________________________________ _______________________________________________________________________________ If you participate in online communities (including social media), what do you dislike about those communities?_________________________________________________________ _________________________________________________________________________________ Have you ever been a target of cyberbullying? n Yes n No If yes, please describe: _________________________________________________________________________________ _________________________________________________________________________________ Have you ever targeted anyone else as an act of cyberbullying?

n Yes n No

If yes, please describe: _______________________________________________________________________________ _______________________________________________________________________________ How do you keep yourself safe online? _______________________________________________________________________________ _______________________________________________________________________________

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ACT IVIT Y 2 WO RKS H EET

Are you aware of the HIPAA policies governing electronic communication? n Yes n No Do you have a cellphone? n Yes n No If yes: Is it a smartphone?

n Yes n No

Do you text?

n Yes n No

Whom do you text? Please list: __________________________________________________ Do you have access to a computer at home?

n Yes n No

Do you have access to an Internet connection at home?

n Yes n No

Do you have access to a computer at work?

n Yes n No

Do you have access to an Internet connection at work?

n Yes n No

Do you communicate with clients via email or text?

n Yes n No

Do you use any electronic video game consoles?

n Yes n No

If yes: Is it a portable game console? n Yes n No Do you participate in any community-based or multiplayer games that use an Internet connection ? n Yes n No.

If yes, please list: _________________________________________

For which of the following activities do you use the Internet? n Professional activities

n Social media

n Browsing

n Sexual health research

n Romantic/sexual connections

n Online communities

n Activism participation

n Other: ______________________________________________________________________

If you participate in social media, which social media platforms do you participate in? n Facebook

n Twitter

n Instagram

n Snapchat

n Tumblr

n Dating applications (please list): _______________________________________________

How often do you participate in activities involving technology (including texting, the

Internet, and social media)? Circle the most accurate frequency

Less than 1 hour

1–3 hours/day

9–15 hours/day

15+ hours/day

4–8 hours/day

Are you aware of the privacy settings on your social media accounts? n Yes n No Have you ever Googled yourself? n Yes n No If yes, did you find anything surprising? n Yes n No If yes, please describe: __________________________________________________________

_______________________________________________________________________________

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27 BDSM EXPLORATION AND COMMUNICATION WITHIN LGBT RELATIONSHIPS Kandice H. van Beerschoten Suggested Uses: Homework, activity Objective

The objective of this activity is to facilitate or increase open, healthy, and positive communication within relational constellations (monogamous, nonmonoga­ mous, polyamorous relationships) wherein individuals wish to consensually participate in bondage and disci­ pline/dominance and submission/sadism and masoch­ ism, or BDSM. It may also be used with individuals who are curious to explore BDSM activities but are unsure about their interests and limits. This question­ naire serves as a starting point for both therapeutic and relational dialogue about safe, healthy exploration. Rationale for Use

As both populations may be judged as nonnormative within our heteronormative society, the LGBT and BDSM communities alike struggle for acceptance (Freeburg & McNaughton, 2017). When these sexual identifications overlap within an individual, clients may face additional difficulties, both internally and within their respective sexuality peer group (Goldberg, 2016). Also, clients may fear being judged by their therapist when disclosing their interest in or curios­ ity about BDSM (Kolmes, Stock, & Moser, 2006; Nichols, 2006). With the recent introduction of BDSM-themed books and movies, there has been an increase in peo­ ple expressing their curiosity about BDSM and explor­ ing some of those activities in the privacy of their homes (Berrill, 2012). The Fifty Shades trilogy was “credited with spurring a rise in sales of furry hand­

cuffs and wooden paddles” (Deller & Smith, 2013, p. 934). Additionally, in a small survey of fifty-one women who read the Fifty Shades books, 86 percent said that the books had influenced their sexual attitudes (Del­ ler & Smith, 2013). However, there may be confusion about how to get started, the wide range of activities, and the depth of communication that is necessary for successful BDSM play. It is important that quality conversations take place before play in order to ensure safety (Williams et al., 2017; Williams, Thomas, Prior, & Christensen, 2014). It is also inevitable that some of this material will make its way into the therapeutic space. However, for the therapist who is unfamiliar with the intricacies of BDSM, power dynamics, and the various activities that take place in these relationships, the prospect of guiding clients through how to engage safely in these interactions may seem daunting (Cannon-Gibbs, 2016). Some therapists may feel uncertain or insecure about BDSM because of a lack of education and infor­ mation about the subject (Cannon-Gibbs, 2016), but others may cross the line, causing their clients to have a negative experience (Kolmes et al., 2006; Nichols, 2006; Wright, 2008). When a survey of kink-identi­ fied people explored discrimination by professionals, 39.3 percent of respondents reported feeling discrimi­ nated against by mental health professionals (Wright, 2008). Additionally, some BDSM practitioners have had negative experiences in which they felt their ther­ apist judged them on the basis of their kinky identifi­ cation (Kolmes et al., 2006; Nichols, 2006). Not only do these experiences contradict the core of affirmative practice, but they also present an ethical

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issue. The National Association of Social Workers (NASW) “Code of Ethics,” as well as the ethical codes of other major mental health organizations, specifi­ cally address the issue of discriminating against clients on the basis of sexual orientation (NASW, 2017; see also AAMFT, 2015; ACA, 2014; AMHCA, 2015; APA, 2013; American Psychological Association, 2017). There is an emerging belief that kink within the LGB community may also be seen through the lens of sexual orientation (Gemberling, Cramer, & Miller, 2015). According to Gemberling and colleagues (2015), sexual orientation is composed of sexual behavior, sexual attraction, and sexual identity (among other components), and those who identify as kinky close­ ly resemble people with an LGB orientation. Each group has a specific set of behaviors it prefers, peo­ ple to whom they are attracted, and an identity that they feel represents their true self (Gemberling et al., 2015). Within BDSM, people are viewed as being oriented toward the power exchange that occurs between partners (Gemberling et al., 2015). Thus, the NASW Code of Ethics advises that “social workers treat each person in a caring and respectful fashion, mindful of individual differences and cultural and ethnic diversity. Social workers promote clients’ socially responsible self-determination” (NASW, 2017, 3.4). Whether clients view their participation in BDSM as their orientation, one of many sexual practices, or a form of sexual leisure (Williams & Prior, 2015), therapists have the ethical responsibility to work in their clients’ best interests, withhold judg­ ment, and be respectful of them as unique individuals. The intersection between BDSM and other minority identifications can contribute to further stig­ matization. A 2008 study of BDSM participants found that 22 percent of respondents identified as gay or lesbian, 35 percent as bisexual, and 7 percent as “other.” Additionally, 5 percent identified as transgender and 1 percent as intersex (Wright, 2008). A person identi­ fying as LGBT or polyamorous “would be more likely to experience stigma and pathologisation for being kinky than someone who is cisgender, monogamous, and heterosexual” (Richards & Barker, 2013, p. 92). Particularly because this dual identification may put clients at risk of being additionally stigmatized, it is important that therapists practice with them in an

affirmative manner. This requires not only valuing the kinky LGBT client as much as the nonkinky hetero­ sexual cisgender client, but also working to “counter the effects of heterosexism” (British Psychological Society, 2012, p. 70). Williams et al. (2014) outlined the most important elements in establishing a healthy BDSM dynamic, called the Four Cs. These are identified as caring, con­ sent, caution, and communication. It is this model that I considered in the formulation of the BDSM Commu­ nication Tool (page 239), rather than the more out­ dated Safe, Sane, and Consensual (SSC) or Risk-Aware Consensual Kink (RACK). These two acronyms have historically been used by the BDSM community as guidelines for behavior within play and interactions, the goals ultimately being safety and accountability (Williams et al., 2014). The BDSM Communication Tool encourages individuality, self-expression, and assertiveness, and it gives clients an avenue for sharing information with their partner that may be challeng­ ing to broach in conversation. By using the BDSM Communication Tool with a person who wants to explore kink, the therapist is actively validating the cli­ ent as a whole person while also being sensitive to the sexual culture. Most important, the client’s gender and sexual identity, sexual and psychological limits, and consent are also clearly addressed with the aim of establishing a healthy communication foundation. Instructions

The BDSM Communication Tool should be used when clients appear to be stuck or uncertain regarding their specific interests in or the practical application of kink, as well as how to proceed with a partner. By asking directly, the therapist should ascertain if cli­ ents know which activities interest them, how to safely engage in those activities, and how to have discus­ sions with new or current partners about the aspects of BDSM relevant to them. For example, when some­ one is new to BDSM experimentation, do they know specifically what they want to try? Has the couple established a safe word, which is used to bring a halt to all activity if needed? Have medical conditions been discussed, as well as what to do if an emergency occurs? These are all questions the therapist should ask and areas that should be explored for those new BDSM Exploration and Communication 235

to this type of sexual experimentation. If clients appear confused, hesitant, or overwhelmed, or expresses uncertainty regarding how to broach the subject with their partner, this is a good indication that the BDSM Communication Tool would serve as a valuable source of assistance. Explain to clients that the tool may help them define their interests, boundaries, needs, and expectations for healthy kinky sexuality. Clients in individual therapy should be instructed to fill out the BDSM Communication Tool and bring it with them to the next session for review. If clients plan to share their BDSM exploration with a partner outside therapy, each person should complete the questionnaire individually and then exchange forms. After reviewing their partner’s form, both members of the couple should thoroughly discuss the answers provided. Ideally, this conversation will allow the cou­ ple to begin exploring BDSM in a healthy manner. Likewise, if the tool is being used within couples coun­ seling, each person should fill out a questionnaire, exchange and discuss the forms with the other, and then bring the completed questionnaires with them to the next session for processing. When discussing the results with clients, it is important to talk about each aspect of the form. What is appealing about the desired activities? Why are oth­ ers designated as hard limits? Is the hard limit attached to a trigger of which the client and partner need to be aware? Have adverse life events been properly pro­ cessed, and how might these affect desired types of play? Does the client, or the partner, have concerns about any types of activities? Do couples seem comfort­ able and respectful talking to each other? Are each person’s needs and expectations realistic? It is impor­ tant for the therapist to be supportive and nonjudg­ mental, yet also to challenge issues that could prove problematic. To assist clients and partners with con­ tinuing to learn and be prepared to explore sexually, therapists should recommend books that place empha­ sis on beginner protocol and safety (see Resources for Clients). Brief Vignette

Mike is forty-two years old and Caucasian. He iden­ tifies as a gay cisgender male. He began therapy after ending a long-term relationship in which there had 236 Beerschoten

been little sex. Mike expressed the desire for a fully satisfying sex life, which he felt probably included some aspect of BDSM. However, having never exper­ imented with BDSM before, he could not identify his specific interests, nor did he know the range of options. Mike was given the BDSM Communication Tool to fill out as homework, and then several sessions were dedicated to processing his responses. Mike dated occasionally, though he did not feel comfortable enough to experiment with BDSM. How­ ever, approximately eighteen months into treatment, he began a serious relationship. Mike’s new partner was also interested in sexual exploration and had some limited experience with BDSM. Once they were far enough into the relationship that trust was estab­ lished, Mike used the BDSM Communication Tool by asking his partner to fill it out as well. Mike then brought his partner into a session, and we explored their similar interests together. For exam­ ple, flogging was a shared curiosity. We discussed spe­ cifically both persons’ thoughts and feelings, what they hoped to gain from the experience, what their fanta­ sies about flogging entailed, how they each expected to feel from flogging and being flogged, and how they hoped the other person would feel. Also, safety was discussed, which included the need to learn about proper technique, as well as communication during the scene. The couple had established a safe word that they each would remember and recognize, if used. Recommendations for both books and online resources were provided for Mike and his partner to use as addi­ tional preparation tools. Each person seemed comfort­ able in his respective role as dominant or submissive, and the couple as a unit appeared to be excited about introducing this new aspect into their intimate life. Suggestions for Follow-up

Once clients fill out the BDSM Communication Tool, they should bring their answers into session for pro­ cessing. Given that the questionnaire asks about trauma, fears, and other issues that may present chal­ lenges within BDSM, therapists should continuously evaluate to ensure that a healthy dynamic has, in fact, been established. This can be accomplished by asking questions that explore the quality of the dynamic, such as:

1. Has a safe word been established? If not, why? 2. Have limits been established and discussed? If not, why not? If the client is a dominant, how will the submissive partner be kept safe if the dominant is unaware of the submissive’s limits? If the client is a submissive, why has this information not been communicated to the partner? For both, how can this communication be improved? Are there other areas in which communication is an issue? 3. How do they feel during the scene? Negative emotions, such as guilt and shame, will need to be processed. 4. Do they feel safe before, during, and after playing? 5. Do they feel free to stop, if necessary? Able to say no? 6. Is the right amount of aftercare being provided? 7. Is BDSM adding to the client’s sexuality in the desired way? Contraindications for Use

This tool would be neither helpful nor necessary for individuals who have identified as kinky for a long time, are comfortable with this part of their sexuality, and know what their interests are. However, when entering a new relationship, it could be useful to com­ municate desires, limits, and needs, particularly if the client’s partner has relatively little experience with BDSM. This tool is not meant to be used in relationships where there is any history, suspicion, or disclosure of domestic violence or other types of relational abuse. In these situations, enthusiastic consent cannot be guaranteed, and the practice of BDSM would be a safety concern. Additionally, those who have experi­ enced a recent trauma may not be able to engage com­ fortably and safely in many BDSM activities. Professional Resources Goldberg, A. (2016). The Sage encyclopedia of LGBTQ studies. Los Angeles: Sage. Kleinplatz, P. J., & Moser, C. (2006). Sadomasochism: Powerful pleasures. Binghamton, NY: Harrington Park Press. Langdridge, D., & Barker, M. (2007). Safe, sane and consensual: Contemporary perspectives on sadomasochism. New York: Palgrave Macmillan.

National Coalition for Sexual Freedom. (2017). www. ncsfreedom.org. Weinberg, T. S. (1995). S&M: Studies in dominance and sub­ mission. Amherst, NY: Prometheus. Wright, S. (2008). 2008 Survey of Violence and Discrimina­ tion against Sexual Minorities fast facts. http://www. ncsfreedom.org/resources/bdsm-survey/2008-bdsm-survey­ fast-facts.

Resources for Clients Andrews, V. (2012). The complete leatherboy handbook. Day­ tona Beach, FL: Adynaton Publishing. Bean, J. (1994). Leathersex: A guide for the curious outsider and the serious player. Los Angeles: Daedalus Publishing. Califia, P. (1988). The lesbian S/M safety manual: Basic health and safety for woman-to-woman S/M (Lady Winston Series). Boston: Lace Publications. Eulenspiegel Society. (2017). www.tes.org. Miller, P., & Devon, M. (1995). Screw the roses, send me the thorns: The romance and sexual sorcery of sadomasoch­ ism. Fairfield, CT: Mystic Rose Books. National Coalition for Sexual Freedom. (2017). www. ncsfreedom.org National Leather Association International. (2017). www.nlainternational.com/. Rinella, J. (1994). The master’s manual: A handbook of erotic dominance. Los Angeles: Daedalus Publishing. Society of Janus. (2017). https://soj.org/. Stein, D. (2013, September 27). How to do the right kinky thing—Ethical principles for BDSM. Leatherati. https:// leatherati.com/how-to-do-the-right-kinky-thing-ethical­ principles-for-bdsm-c9a781f44a06. Warren, J. (2000). The loving dominant. Emeryville, CA: Greenery Press. Wiseman, J. (1996). SM 101: A realistic introduction. Emeryville, CA: Greenery Press.

References American Association for Marriage and Family Therapy (AAMFT). (2015). Code of ethics. http://www.aamft. org/Legal_Ethics/Code_of_Ethics.aspx. American Counseling Association (ACA). (2014). ACA code of ethics. https://www.counseling.org/docs/default-source/ ethics/2014-aca-code-of-ethics.pdf?sfvrsn=fde89426_5. American Mental Health Counselors Association (AMHCA). (2015). AMHCA code of ethics. http://connections.amhca. org/HigherLogic/System/DownloadDocumentFile.ashx? DocumentFileKey=d4e10fcb-2f3c-c701-aa1d-5d0f53b 8bc14. American Psychiatric Association (APA). (2013.) The principles of medical ethics with annotations especially applicable to psychiatry. https://www.psychiatry.org/ psychiatrists/practice/ethics.

BDSM Exploration and Communication 237

American Psychological Association. (2017). Ethical princi­ ples of psychologists and code of conduct. https://www. apa.org/ethics/code/. Berrill, A. (2012, December 10). Fifty Shades phenomenon gives Ann Summers a boost as “mummy porn” trend sends sales of handcuffs and blindfolds soaring. Daily Mail. http:// www.dailymail.co.uk/femail/article-2245788/Fifty-Shadesphenomenon-gives-Ann-Summers-boost-Mummy-Porn­ trend-sends-sales-handcuffs-blindfolds-soaring. html. British Psychological Society. (2012). Guidelines and literature review for psychologists working therapeutically with sexual and gender minority clients. Retrieved from https:// www.bps.org.uk/sites/bps.org.uk/files/Policy/Policy%20 -%20Files/Guidelines%20and%20Literature%20Review %20for%20Psychologists%20Working%20Therapeutically %20with%20Sexual%20and%20Gender%20Minority% 20Clients%20%282012%29.pdf. Cannon-Gibbs, S. (2016). The dichotomy of “them and us” thinking in counselling psychology incorporating an empirical study on BDSM. DPsych thesis, City Univer­ sity of London. http://openaccess.city.ac.uk/16215. Deller, R. A., & Smith, C. (2013). Reading the BDSM romance: Reader responses to Fifty Shades. Sexualities, 16, 932–950. doi:10.1177/1363460713508882. Freeburg, M. N., & McNaughton, M. J. (2017). Fifty shades of grey: Implications for counseling BDSM clients. Faculty, Administrator & Staff Articles. Paper 23. https://vc. bridgew.edu/fac_articles/23. Gemberling, T., Cramer, R., & Miller, R. (2015). BDSM as a sexual orientation: A comparison to lesbian, gay, and bisexual identity. Journal of Positive Sexuality, 1 (3), 37–43. http://journalofpositivesexuality.org/archive/volume-1­ feb-nov-2015/. Goldberg, A. (2016). The Sage encyclopedia of LGBTQ studies. Los Angeles: Sage.

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Kolmes, K., Stock, W., & Moser, C. (2006). Investigating bias in psychotherapy with BDSM clients. In P. J. Kleinplatz & C. Moser (eds.), Sadomasochism: Powerful pleasures, 301–324. Binghamton, NY: Harrington Park Press. National Association of Social Workers (NASW). (2017). NASW code of ethics. https://www.socialworkers.org/ About/Ethics/Code-of-Ethics/Code-of-Ethics-English. Nichols, M. (2006). Psychotherapeutic issues with “kinky” cli­ ents: Clinical problems, yours and theirs. In P. J. Klein­ platz & C. Moser (eds.), Sadomasochism: Powerful plea­ sures, 281–300. Binghamton, NY: Harrington Park Press. Richards, C., & Barker, M. (2013). Sexuality and gender for mental health professionals: A practical guide. Los Ange­ les: Sage. Williams, D. J., & Prior, E. E. (2015). “Wait, go back, I might miss something important!” Applying Leisure 101 to sim­ plify and complicate BDSM. Journal of Positive Sexuality, 1 (3), 63–69. http://journalofpositivesex uality.org/. Williams, D. J., Thomas, J. N., Prior, E. E., Amezquita, C., & Hall, D. (2017). Social work practice with clients that enjoy participation in consensual BDSM: Identifying and apply­ ing strengths. Journal of Positive Sexuality, 3 (1), 12–20. http://journalofpositivesexuality.org/wp-content/uploads/ 2017/03/Social-Work-Practice-and-Consensual-BDSM­ Applying-Strengths-Williams-Thomas-Prior-Amezquita­ Hall.pdf. Williams, D. J., Thomas, J. N., Prior, E. E., & Christensen, M. C. (2014). From “SSC” and “RACK” to the “4Cs”: Introduc­ ing a new framework for negotiating BDSM participation. Electronic Journal of Human Sexuality, 17. http://www. ejhs.org/volume17/BDSM.html. Wright, S. (2008). 2008 Survey of Violence and Discrimination against Sexual Minorities fast facts. http://www.ncsfree dom.org/resources/bdsm-survey/2008-bdsm-survey­ fast-facts.

BDSM COMMUNICATION TOOL Directions: Each person in the relationship is to fill out this form openly and honestly. Once

completed, forms are to be exchanged and discussed. Be sure to ask for clarity where needed.

This form does not constitute consent. Consent must be obtained for each activity and anew

during each encounter.

Preferred name during play:

Preferred pronouns:

Relationship status:

Preferred method of being addressed during play (title):

BDSM role identification, if known:

My definition of this is:

My safe word is:

Previous trauma(s) (including abuse, sexual violence, military experiences, motor vehicle accidents, etc.):

Health issues:

Potential trigger(s):

Hard limits (things I absolutely do not want to try):

Soft limits (things I may be willing to explore at a later time but not now):

Current areas I would like to explore:

BDSM fantasies that I have:

Pain level:

n None

Pain frequency: n Never

n Only as an accent n Occasional

n Significant pain

n About half the time

n Sadist/masochist n Most of the time

n All of the time

Circle one: I DO or DO NOT enjoy leaving/having temporary marks or bruises resulting from play. I DO or DO NOT seek to engage in a power exchange. Fears I have about BDSM are:

Questions I have about BDSM are:

1.

1.

2.

2.

3.

3.

It is important for me to give my partner and to receive from them

Aftercare needs:

Other specific needs I have:

Kandice H. van Beerschoten

239

AC TI V I TIES Instructions: Check the appropriate box that reflects your level of interest in exploring each activity. If you have already experienced the activity, indicate your preference for it.

Yes, I like this

Want to try

ANAL PLAY Anal intercourse Fisting Pegging Rimming Toys BREAST PLAY Breast binding Nipple clamps BONDAGE Blindfold Cock and ball torture (CBT) Cross Gags Handcuffs Rope Spreader bar CONTROL/RESTRAINT Chastity devices Denied masturbation Denied orgasm Forced celibacy Forced masturbation Forced orgasm Orgasm on command EDGE PLAY Choking/breath play Consensual nonconsent Scat Water sports GENERAL SEX Multiple simultaneous partners Partner exchange HUMILIATION Verbal Physical

240

Kandice H. van Beerschoten

Curious but cautious

Hard limit NO

Yes, I like this

Want to try

Curious but cautious

Hard limit NO

Sexual objectification Public IMPACT PLAY Back Breasts/chest Buttocks Feet Genitals Legs Cane Face slapping Belt Flogger Hand/spanking Paddle Riding crop Whip LEATHER MEDICAL PLAY Gynecological exam Sounding POWER EXCHANGE ROLE - PLAY SENSATION PLAY Electrical play Fire play Hot wax Ice Needle play SERVICE Cleaning Cooking Crawling Kneeling Massage VAGINAL PLAY Fisting Oral sex Toys Vaginal penetration WRESTLING

Kandice H. van Beerschoten

241

SECTION IV

HOMEWORK, HANDOUTS,

AND ACTIVITIES FOR

LGBTQ PARENTING AND

FAMILY THERAPY

running foot 243

In the chapters that this section comprises, the con­ tributors share interventions to enhance familial sup­ port and work through painful family dynamics with LGBTQ clients. The authors address affirmative par­ enting approaches, transform conventional geno­ grams to be inclusive of family of choice and other family structures, and provide activities to facilitate better understanding and communication among fam­ ily members. It is exceedingly important for LGBTQ individuals, whether they are children or parents, to be validated and respected by family members. For example, studies have demonstrated higher levels of self-esteem and less emotional distress in sexual and gender minorities who are raised in supportive envi­ ronments (Johnson, Sikorski, Savage, & Woitaszewski, 2014; Snapp et al., 2015). The chapters in this section are essential resources for helping clients get the sup­ port that they need. Transgender youth experience higher rates of abuse and discrimination than do other marginalized groups, even within their families (Grant et al., 2011). For this reason, several chapters in this section offer methods for assisting parents to validate their nonbi­ nary children’s gender identity. In Chapter 28, “Trans­ gender-Affirmative Parenting: Practicing Pronouns,” Jennifer M. Gess offers both psychoeducation and an exercise to assist parents in explicitly validating their trans or gender-nonconforming children by increas­ ing their facility with using their correct pronouns. Her innovative approach encourages parents to prac­ tice pronouns even with familiar household objects so that they can start to think outside the box in a nonshaming and effective way. Heather Kramer offers another effective strategy to help parents increase their comfort level with their children’s pronouns in Chapter 35, “An Informative Intervention for Parents and Caregivers of Transgen­ der and Gender-Nonbinary Children and Adoles­ cents.” This is a group intervention that is designed to increase the support and normalization that parents receive as they navigate this process. The activity is designed to ultimately promote the self-worth of chil­ dren and adolescents through a skillful balance of supporting and challenging their parents. Rebekah Byrd and Laura Boyd Farmer provide another activity for parents in Chapter 30, “Expanding 244

Binary Thinking: A Reflective Activity for Parents and Caregivers of Transgender and Gender-Expansive Youth.” Given that less than 43 percent of all transgender and gender-expansive (TGE) youth report having a supportive adult in their lives (Baum et al., 2014), they have created an activity that invites par­ ents to move beyond the gender binary in their think­ ing. They share a provocative worksheet to help par­ ents reflect honestly on the ways in which their more narrow views of gender may be negatively affecting their child or teen. Clients in LGBTQ-parented families too often do not see their particular family structures reflected in society. Two chapters provide therapists with geno­ gram exercises that can validate any family structure, social identity, and cultural context. Fiona Tasker, Maeve Malley, and Pedro Alexandre Costa share fam­ ily mapping exercises for adults and children to facili­ tate expression of their own definition of family in Chapter 29, “Family Mapping Exercises (FMEs) for Adults and Children in LGBTQ-Parented Families.” Anthony Zazzarino, Veronica M. Kirkland, and Jenae Thompson speak to the issues faced by parents who identify as sexual and gender minorities as well as trauma survivors through a genogram exercise in Chapter 34, “Addressing Blended Family and Trauma Issues with Sexual and Gender Minority Parents.” Both chapters incorporate elements of queer theory and intersectionality to help therapists explore the various systems of oppression and privilege experienced by the family members. In completing these activities, clients are guided to contextualize and explore their relation­ ships within their various sociocultural systems. Coming out as either a gender or a sexual minority can be fraught with pain and a range of reactions from family members. Three chapters provide excellent strategies to help families respond in supportive ways to the disclosure. In Chapter 31, “Parents of Transgender Teens and the Initial Disclosure Process,” Laura R. Haddock and Hilary Meier take a strengths-based approach to assist parents in regulating their affect and behavior toward their teens. They offer a thorough glossary of pertinent terms as a starting point for par­ ents in creating a shared vocabulary, and they pro­ vide parents with a wide range of reflective questions on all aspects of the process, including disclosure;

school, legal, and safety concerns; and physical tran­ sition. This chapter is an outstanding resource that helps transgender teens by ensuring that parents have the guidance and information that are essential for them to be affirming of their children. Taking a family therapy approach, Susannah C. Coaston, Patia Tabar, and Lori Barrett help youth mit­ igate the influence of negative family reactions to their coming-out disclosure in Chapter 32, “Maintaining the Family Unit When an Adolescent Family Mem­ ber Comes Out as a Sexual or Gender Minority.” Meet­ ing with the family as a whole allows the therapist to tailor the work to the family’s cultural background and worldviews in order to help the family respond in more adaptive ways. Using unexpected props to pro­ vide psychoeducation, their exercise also employs powerful symbolism. Another strategy to process the pain of parental rejection after coming out is outlined in Cara Herbitter and Heidi M. Levitt’s “Empty-Chair Work for Cop­ ing with Heterosexist and/or Transphobic Family Rejection” (Chapter 33). The authors guide thera­ pists to engage clients individually to empower them to appropriate assignation of blame for rejection to the parents, rather than its being internalized by the client. Effectively addressing varying levels of outness in couples can greatly enhance intimacy and reduce

tension in romantic relationships. In Chapter 36, “Cir­ cles of Outness: Systemic Exploration of Disclosure Decisions in Mixed-Orientation Relationships,” Mary R. Nedela, M. Evan Thomas, and Michelle M. Mur­ ray offer a narrative therapy approach to deepening communication and understanding regarding dis­ closure decisions in mixed-orientation couples. References Baum, J., Brill, S., Brown, J., Delpercio, A., Kahn, E., Kenney, L., & Nicoll, A. (2014). Supporting and caring for our gender expansive youth. http://hrc-assets.s3-website-us­ east-1.amazonaws.com//files/assets/resources/Genderexpansive-youth-report-final.pdf. Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Kiesling, M. (2011). Injustice at every turn: A report of the national transgender discrimination survey. Washing­ ton, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force. https://transequality. org/sites/default/files/docs/resources/NTDS_Report.pdf. Johnson, D., Sikorski, J., Savage, T. A., & Woitaszewski, S. A. (2014). Parents of youth who identify as transgender: An exploratory study. School Psychology Forum, 8 (1), 56. Snapp, S. D., Watson, R. J., Russell, S. T., Diaz, R. M., & Ryan, C. (2015). Social support networks for LGBT young adults: Low cost strategies for positive adjustment. Family Rela­ tions: An Interdisciplinary Journal of Applied Family Studies, 64 (3), 420–430.

245

28 TRANSGENDER-AFFIRMATIVE PARENTING: PRACTICING PRONOUNS Jennifer M. Gess Suggested Use: Homework Objective

This activity is for parents of transgender or genderdiverse children. The objective of the activity is to increase parents’ ability to use their child’s self-identi­ fied, gender-affirming pronoun. Rationale for Use

Transgender and gender-diverse individuals refer to those whose gender identity or expression does not align, according to Western societal standards, with their sex assigned at birth (Moe, Perera-Diltz, Sepul­ veda, & Finnerty, 2014). Transgender and genderdiverse youth often experience higher rates of harass­ ment, discrimination, and abuse in society and school and within their families than any other marginal­ ized group (Grant et al., 2011). At the societal level, many transgender and gender-diverse youth experi­ ence poverty, discrimination in health care, and barri­ ers to accessing identification documents aligning with their self-identified, affirming gender (Grant et al., 2011). According to the National Transgender Discrimination Survey, 78 percent of transgender and gender-diverse students between kindergarten and twelfth grade reported some form of harassment related to their gender identity and expression, 35 per­ cent reported incidences of physical violence, and 12 percent reported sexual violence (Grant et al., 2011). The harassment and bullying many transgender and gender-diverse youth experience are extremely severe, leading one in six students to drop out of school before the end of twelfth grade (Grant et al., 2011). Trans-

gender and gender-diverse youth of color experience greater harassment and violence (Koken, Bimbi, & Parsons, 2009; Singh, Hwahng, Chang, & White, 2017; Singh & McKleroy, 2011). Approximately 57 percent of transgender and gender-diverse individuals expe­ rience significant family rejection, which contributes to the 20–45 percent of homeless youth who identify as lesbian, gay, bisexual, transgender, queer, or other gender and sexual identities (LGBTQ+) (Grant et al., 2011; Keuroghlian, Shtasel, & Bassuk, 2014; National Alliance to End Homelessness, 2008). As a result of harassment, discrimination, and abuse in society and school and within their families, transgender and gender-diverse individuals have higher rates of negative mental health outcomes, lower academic results, and higher rates of substance abuse and suicidality than their cisgender peers (Grant et al., 2011; Grossman & D’Augelli, 2007; Singh, Hays, & Watson, 2011). Over half of transgender and gen­ der-diverse youth attempt suicide, a statistic that demonstrates the high risks vulnerable youth experi­ ence (Clements-Nolle, Marx, & Katz, 2006; Grant et al., 2011). The mistreatment many transgender and gender-diverse youth experience is highly correlated with negative outcomes, including mental health issues and suicide attempts, but these consequences can be reduced through social support. The negative outcomes dissipate when transgen­ der and gender-diverse youth are surrounded by social support (Mustanski & Liu, 2013). Transgender and gender-diverse youth in supportive environments report increased self-esteem, increased life satisfac­ tion, and higher rates of positive mental health (Sherer,

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

246

2016). Transgender and gender-diverse youth who have supportive environments have healthy development and higher self-esteem (Johnson, Sikorski, Savage, & Woitaszewski, 2014). Transgender and gender-diverse youth need social support to dissipate experiences of oppression, discrimination, and harassment. Specifically, family support has the largest posi­ tive effect on LGBTQ+ youth (Snapp et al., 2015). The psychological and emotional well-being of transgen­ der and gender-diverse youth increases with family support (Johnson et al., 2014). Family support of transgender children, including using the name and pronoun the children feel most comfortable with, leads to positive outcomes (McConnell, Birkett, & Mus­ tanski, 2016). The following activity demonstrates one method that counselors can use to help parents with a transgender or gender-diverse child show support for their child. Transgender and gender-diverse individuals often have names and pronouns assigned at birth that do not fit their identity. Many will change their assigned names and pronouns or have already done so (Deutsch & Buchholz, 2015; Thorpe, 2015). For many transgender and gender-diverse individuals, being called by their self-identified, gender-affirming names and pronouns is empowering (Denny, 2004). Transgen­ der and gender-diverse youth whose parents use their self-identified, gender-affirming pronoun experience affirmation and validation (McConnell et al., 2016). Parents and guardians have the opportunity to support their children by using their self-identified, genderaffirming names and pronouns. Counselors are ethically responsible for treating clients equitably and for honoring diversity. The Amer­ ican Counseling Association (ACA) Code of Ethics (2014) states the importance of social justice, diversity, and multiculturalism, specifically in the preamble and ethical principles. Specifically, the standard of non­ discrimination in the Code of Ethics states, “Counsel­ ors do not condone or engage in discrimination against prospective or current clients . . . based on . . . gen­ der identity, [and] sexual orientation” (p. 9). Further, the Code of Ethics requires multicultural counseling competence, defined as “counseling that recognizes diversity and embraces approaches that support the worth, dignity, potential, and uniqueness of individuals

within their historical, cultural, economic, political, and psychosocial contexts” (p. 20). Standards of the counseling profession include LGBTQ+ competency: counselors must support transgender and genderdiverse clients by using those clients’ self-identified, gender-affirming names and pronouns and helping support and facilitate families in using their children’s self-identified, gender-affirming names and pronouns (dickey & Singh, 2017). In 2009 the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC), a division of the ACA that promotes awareness and understanding of LGBTQ+ topics, published the ALGBTIC “Competencies for Counseling with Transgender Clients” (Burnes et al., 2010) to provide guide­ lines for counselors working with trans clients. The competencies provide an in-depth, affirmative framework for use by counselors, counseling students, and counselor educators. The competencies present guidelines for developing and maintaining safe and supportive counseling relationships with LGBTQ+ individuals. Specifically, the competencies state, “Com­ petent counselors will understand the importance of using appropriate language (e.g., correct name and pronouns)” (p. 8). The ALGBTIC competencies high­ light the importance of affirming clients by using their self-identified, gender-affirming names and pronouns. In 2015 the American Psychological Association (APA) published the “Guidelines for Psychological Practice with Transgender and Gender Nonconform­ ing People.” The guidelines classify “not using a per­ son’s preferred name or pronoun” as an example of discrimination (APA, 2015, p. 838). Counselors can affirm clients by using their self-identified, genderaffirming names and pronouns and educate parents on the importance of using their children’s self-iden­ tified, gender-affirming names and pronouns. Fur­ ther, the guidelines state, “Psychologists are encour­ aged to examine how their language (e.g., use of incorrect pronouns and names) may reinforce the gender binary in overt or subtle and unintentional ways” (p. 840). Counselors must be aware of the lan­ guage they use in order to use affirmative language to empower the client and educate the family. Using affirmative language is part of creating a safe, thera­ peutic space for the client. If the counselor does not Transgender-Affirming Parenting: Practicing Pronouns 247

use affirmative language and does not educate the family to use the transgender or gender-diverse child’s self-identified, gender-affirming name and pronoun, the counselor is not practicing ethical counseling. Instructions

The counseling session is a prime opportunity for fam­ ily members to begin or continue practicing their child’s self-identified, gender-affirming name and pro­ nouns. In the counseling session with the parents of the transgender or gender-diverse child, invite the parents to practice using their child’s self-identified, gender-affirming pronouns. Whether the child is pres­ ent depends on the family relationship and the child’s developmental level. Though transparency is impor­ tant, there might be situations in which, because the parents’ process takes time, hurtful discussion topics may arise. In these situations, provide an individual session exclusive to the parents. Provide a safe, nonjudgmental space for parents to practice using their child’s pronouns. Validate their experience of struggling with the new name and pro­ nouns. Many parents experience the loss of the dreams they held for their child, and it is important to acknowl­ edge the grief process (Phillips & Ancis, 2008; Saltz­ burg, 2004, 2009). Simultaneously, as an advocate for the transgender or gender-diverse child, it is just as important to correct the parents if they accidentally use their child’s old pronouns or old name (sometimes referred to as the child’s “deadname”). As appropri­ ate, it may be important to discuss the ramifications of using the child’s old name and pronouns, specifi­ cally the pain the child experiences when hearing the old name and pronouns. One suggestion to begin the session is to ask the parents to share a favorite memory of their child while using the child’s self-identified, gender-affirming pro­ nouns. Let them know you will correct them while they are sharing the memory to help them practice. Because parents may be tentative and uncomfortable using the child’s new name and pronouns, demon­ strate support through nodding, paraphrasing, and other supportive verbal and nonverbal techniques. To continue the progress, toward the end of the session invite the parents to engage in homework that will be due at the next session. The homework 248 Gess

appears at the end of the chapter, titled “TransgenderAffirming Parenting: Practicing Pronouns Homework” (page 253). The following is a detailed step-by-step process for the homework assignment. Step 1. Throughout the week, share stories out loud about your pet, car, holiday character, plants, and household objects using their pronouns. Post sticky labels around your home to remind you to engage in the activity. Verbally discussing and hearing the pro­ nouns is beneficial to this process. Invite your family to help you verbally practice sharing stories about your yellow Labrador retriever Luna (she/her), cele­ brating Santa Claus (he/him) during the Christmas holidays, and Jamie (she/her) the coffee machine. If you do not have safe people to share the activity with, verbally talk to your pet, plant, or yourself about Luna, Santa Claus, and Jamie. For example, when speaking with your spouse or partner, bring up the upcoming holidays: “Christmas is coming soon and Santa Claus is coming. He is going to fly to our home with his reindeer.” While you may feel silly during this activity, you will have the opportunity to become very proficient at changing names and pronouns. Step 2. Once you have practiced for a few days and are feeling proficient, switch pronouns for your pet, car, holiday character, plants, and household objects—but not the names. This step will help you with the pro­ cess of learning eventually to use different pronouns for your transgender or gender-diverse child. Con­ tinue referring to your Labrador retriever as Luna but begin using he/him pronouns; continue referring to Santa Claus as Santa Claus but use she/her pronouns. Again, keep sharing stories out loud to yourself, to your family, or to your pets or plants. This process pro­ vides you with the opportunity to become skillful at adapting to new pronouns while creating a supportive environment for the child. Many children use gender-neutral pronouns, such as they/them or ze/zir. Continue calling your coffee machine Jamie and use gender-neutral pronouns, such as they/them. Including nonbinary pronouns may make this activity more challenging. If your child iden­ tifies as nonbinary, this is a great place to start! Prac­ tice talking out loud about Jamie the coffee machine, who uses they/them pronouns.

Once this feels more comfortable, change the pro­ nouns again. Proceed at the pace that fits best for you, which varies from person to person. Pronouns can be difficult to change, so be gentle and kind with your­ self as you learn to use new pronouns. Recognize this as a big step that shows support for transgender or gender-diverse children, thereby reducing the nega­ tive effects of the oppression, discrimination, and harassment they experience. Step 3. The final step is changing the name. For some, changing the name is the most difficult. Some parents experience using a name different from the one they gave their child as painful and challenging. Again, making these imperative changes demonstrates sup­ port for the transgender or gender-diverse child, and support will lead to the child’s higher self-esteem and self-worth (Ryan, 2009). Brief Vignette

Thomas and Olivia Parker are parents of Zoe Parker, a twelve-year-old who was assigned female at birth. Thomas is a firefighter for the local fire department, and Olivia works part-time at a library. Thomas, a heterosexual, Caucasian cisgender man, grew up in a nonreligious household; Olivia, an African American, heterosexual cisgender woman, grew up in a Chris­ tian home. Thomas and Olivia take their daughter to church a few times a year and live in a middle-class, predominantly white neighborhood. Zoe plays for the school soccer team, and the Parkers spend their free time going to soccer games, camping, and attend­ ing events at the library where Olivia works. Thomas and Olivia describe Zoe as a playful, kind, spirited kid. When Zoe was three and four years old, she told people “My name is Ben” and “I’m a boy.” Thomas and Olivia would tell Zoe, “No, you’re a girl and your name is Zoe,” and laugh it off. Zoe would become infuri­ ated and scream whenever Thomas or Olivia would try to put a dress on her or put a hair clip in her hair. When Zoe was four years old, she found scissors in the kitchen and cut off her ponytail. Olivia was hor­ rified and yelled at Zoe for “ruining her hair.” Olivia rushed Zoe to a hairdresser to “fix” her hair. Zoe stopped telling people “My name is Ben and I’m a boy” around the age of five and began wearing dresses and hair clips. Thomas and Olivia felt relieved.

Around age ten, Zoe stopped wearing dresses and began wearing pants and baggy shirts. She became sullen and quiet. Thomas and Olivia became con­ cerned for their child. Given her previous experience at an earlier age, Zoe refused to talk to them about the change in appearance and behavior. By the time she was eleven, Thomas and Olivia decided to go to family counseling because of their concern for Zoe’s change in attitude and appearance. Audrey is a family counselor in private practice. The Parkers had a few sessions as a family with Audrey. Audrey soon discovered Zoe had seen the school counselor a few times and, after obtaining a release of information, she reached out to the school counselor. The school counselor stated that he had seen Zoe a few times over the past year, and Zoe had told him numerous times, “I’m not a girl. I’m a boy. A lot of my friends are already calling me ‘he’ and I love it.” Audrey asked to meet with Zoe individually. In the individual session, Zoe told Audrey, “I know I’m not a girl. I’ve always known I’m a boy. I’m too scared to say anything to my parents because they wouldn’t understand, but I can’t take this any longer. I need them to start calling me Ben and using he/him pro­ nouns.” After processing Zoe’s fears, Audrey and Zoe came up with a plan to come out as a transgender boy to Thomas and Olivia in the next family session. The following week, Audrey began the family ses­ sion by discussing gender as a spectrum and the oppression, discriminations, and harassment that transgender and gender-diverse individuals face. Audrey stated that the most important factor to reduce nega­ tive outcomes for transgender and gender-diverse youth is supportive family. Audrey emphasized that transgender and gender-diverse youth whose families support them have lower rates of suicide attempts, homelessness, depression, and substance abuse. If a family rejects their transgender or gender-diverse child, the child is eight times more likely to attempt suicide (Ryan, 2009). Audrey had several brochures, books, and websites to share with Thomas and Olivia on transgender and gender-diverse youth. Next, Zoe nervously stated, “I’m a boy,” and shared his story of gender, including how he never felt like a girl. Audrey supported him along the way and rec­ ommended that Thomas and Olivia listen and not Transgender-Affirming Parenting: Practicing Pronouns 249

interrupt Zoe. Thomas and Olivia appeared surprised, but they saw Zoe’s face light up with excitement and hope as their child talked about the future. Thomas and Olivia hadn’t seen their child exude happiness in years. Audrey recommended that Thomas and Olivia see another counselor who specializes in grief coun­ seling to process the potential ambiguous loss they might be experiencing. Audrey also provided educa­ tional materials for Thomas and Olivia to learn more about raising, supporting, and affirming their transgender child. After a few family sessions, Thomas and Olivia appeared ready to take the first step of the activity; therefore, Audrey discussed the importance of pro­ nouns. Audrey stated, “Using your child’s self-identi­ fied, gender-affirming name and pronouns is a way to show your child that you love and accept him. You’ve known your child for over eleven years; therefore, using his new name and pronouns can be a big change! One way to help practice using his new name and pro­ nouns is by practicing at home. For example, you have mentioned you have a family dog named Bear. Let’s try referring to Bear and Bear’s pronouns regu­ larly. Another idea is that Easter is coming up. You can try regularly referring to the Easter Bunny as he/him.” Audrey helped Thomas and Olivia come up with a few more examples. Thomas and Olivia agreed to put sticky notes around the house to remember to use their names and pronouns daily. The goal of the first part of the activity is to increase awareness of genderbinary pronouns. At the next family session, Audrey asked how the week using the names and different pronouns had gone for Thomas and Olivia. Thomas observed, “I’d never thought much about pronouns before, so this is the first time it’s really been on my mind.” Olivia noted that she was regularly discussing “the male Easter Bunny” and “our male dog, Bear” with Thomas. Thomas and Olivia demonstrated their desire to learn more about the power and influence of pronouns because of their desire to support and care for their child. Audrey decided Thomas and Olivia were ready for the second step: to switch pronouns. For the next week, Thomas and Olivia kept the same names for the dog and the Easter Bunny, but they switched the pronouns. For example, Bear, the previ­ 250 Gess

ously he/him dog, was now Bear, the she/her dog. The Easter Bunny now also had she/her pronouns. At the next family session, Thomas and Olivia reported that it was more difficult to call Bear and the Easter Bunny “she” and “her.” Thomas and Olivia kept practicing for another two weeks. The second step of the activity adds the component of increased awareness of genderbinary pronouns by forcing the participant to give careful consideration to gender and pronouns before referring to others. The third step to the activity is changing the names. Suddenly, Bear the dog became Carla (she/her) the dog and the Easter Bunny became the Leprechaun (he/him). While Thomas and Olivia reported they felt “a little silly” calling their dog Carla and the Easter Bunny “the Leprechaun,” they found the activity very helpful in making them aware of the power and sig­ nificance of names and pronouns. After the parents successfully completed the activ­ ity, Zoe felt supported and ready to share his self-iden­ tified new name, Ben, and his gender-affirming pro­ nouns, he, him, and his. After the period of practicing pronouns and names, Thomas and Olivia felt as though they understood the importance of using their child’s self-identified, gender-affirming name and pronouns to support his self-worth and identity. Thomas and Olivia were ready to begin actively calling their child Ben and using he/him pronouns. In session, Audrey gently corrected as needed, and Ben began to blossom as the kind, spirited kid he once had been. Suggestions for Follow-up

The initial process of changing pronouns and names can be a difficult one. For this reason, it is important for counselors to remain nonjudgmental when parents slip while simultaneously gently and firmly remind­ ing them to continue to use their child’s self-identified, gender-affirming pronouns. During counseling ses­ sions with parents, counselors should have parents continue practicing their child’s self-identified, genderaffirming pronouns and name. Contraindications for Use

Parents whose personal beliefs and values do not sup­ port transgender or gender-diverse people often have more difficulties supporting their transgender or gen­

der-diverse child. For example, parents who are deeply religious may struggle to accept their transgender or gender-diverse child (Higa et al., 2014). The conse­ quences for parents who do not support their transgender or gender-diverse child are the child’s higher risk for suicide attempts, higher rates of depression, and higher rates of substance abuse. Changing pro­ nouns and names may be a challenging and ongoing process. These parents may benefit from a slower, more in-depth family counseling process along with individual grief counseling. Professional Resources Brill, S. A., & Kenney, L. (2016). The transgender teen: A hand­ book for parents and professionals supporting transgender and non-binary teens. Jersey City, NJ: Cleis. Brill, S. A., & Pepper, R. (2008). The transgender child: A hand­ book for families and professionals. San Francisco: Cleis. Ginicola, M. M., Smith, C., & Filmore, J., eds. (2017). Affir­ mative counseling with LGBTQI+ People. Alexandria, VA: American Counseling Association. Kosciw, J. G., Diaz, E. M., & Gay, L. Y. (2008). Involved, invisi­ ble, ignored: The experiences of lesbian, gay, bisexual and transgender parents and their children in our nation’s K–12 schools. Gay, Lesbian and Straight Education Net­ work (GLSEN). Lev, A. I. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. Binghamton, NY: Haworth Press. Mustanski, B., & Liu, R. (2013). A longitudinal study of pre­ dictors of suicide attempts among lesbian, gay, bisexual, and transgender youth. Archives of Sexual Behavior, 42 (3), 437–448. Ryan, C. (2009). Supportive families, healthy children: Help­ ing families with lesbian, gay, bisexual, and transgender children. San Francisco: Family Acceptance Project, Marian Wright Edelman Institute, San Francisco State University. Saltzburg, S. (2009). Parents’ experience of feeling socially supported as adolescents come out as lesbian and gay: A phenomenological study. Journal of Family Social Work, 12 (4), 340–358.

Resources for Clients Brill, S. A., & Kenney, L. (2016). The transgender teen: A hand­ book for parents and professionals supporting transgender and non-binary teens. Jersey City, NJ: Cleis. Brill, S. A., & Pepper, R. (2008). The transgender child: A hand­ book for families and professionals. San Francisco: Cleis. Family Acceptance Project. (n.d.). http://familyproject.sfsu.edu/. Gender Spectrum. (n.d.). https://www.genderspectrum.org/.

Herdt, G., & Koff, B. (2000). Something to tell you: The road families travel when a child is gay. New York: Columbia University Press. Human Rights Campaign. (n.d.). Advocating for LGBTQ Equality | Human Rights Campaign. https://www.hrc.org/. Korell, S. C., & Lorah, P. (2007). An overview of affirmative psychotherapy and counseling with transgender clients. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (eds.), Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients, chap. 11. Washing­ ton, DC: American Psychological Association. Kosciw, J. G., Diaz, E. M., & Gay, L. Y. (2008). Involved, invis­ ible, ignored: The experiences of lesbian, gay, bisexual and transgender parents and their children in our nation’s K–12 schools. Gay, Lesbian and Straight Education Net­ work (GLSEN). National Federation of Parents and Friends of Lesbian and Gays (PFLAG). (n.d.). https://www.pflag.org/. Pepper, R. (2012). Transitions of the heart: Stories of love, strug­ gle, and acceptance by mothers of transgender and gender variant children. San Francisco: Cleis.

References American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. American Psychological Association (APA). (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70, 832– 864. doi:10.1037/a0039906. Burnes, T. R., Singh, A. A., Harper, A., Pickering, D. L. Moun­ das, S., Scofield, T., Maxon, W., & Harper, B. (2010). ALGBTIC competencies for counseling with transgen­ der clients. https://www.counseling.org/resources/ competencies/algbtic_competencies.pdf. Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. Journal of Homosexuality, 51, 53–69. Denny, Dallas. (2004, November/December). Pronoun trouble. Transgender Tapestry, 104 (5). http://dallasdenny.com/ Writing/2013/10/06/pronoun-trouble-2004/. Deutsch, M., & Buchholz, D. (2015). Electronic health records and transgender patients—Practical recommendations for the collection of gender identity data. Journal of Gen­ eral Internal Medicine, 30 (6), 843–847. dickey, L. M., & Singh, A. A. (2017). Social justice and advo­ cacy for transgender and gender-diverse clients. Psychi­ atric Clinic, 40, 1–13. Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Keisling, M. (2011). Injustice at every turn: A report of the National Transgender Discrimination Survey. National Center for Transgender Equality and National Gay and Lesbian Task Force.

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Grossman, A. H., & D’Augelli, A. R. (2007). Transgender youth and life-threatening behaviors. Suicide and Life-Threaten­ ing Behavior, 37 (5), 527–537. doi:10.1521/suli.2007.37.5. 527. Haas, A. P., Rodgers, P. L., & Herman, J. L. (2014). Suicide attempts among transgender and gender non-conforming adults: Findings of the national transgender discrimina­ tion survey. American Foundation for Suicide Prevention. Herdt, G., & Koff, B. (2000). Something to tell you: The road families travel when a child is gay. New York: Columbia University Press. Herman, J. (2013). Gendered restrooms and minority stress: The public regulation of gender and its impact on transgender people’s lives. Journal of Public Management and Social Policy, 19 (1), 65–80. Higa, D., Hoppe, M. J., Lindhorst, T., Mincer, S., Beadnell, B., Morrison, D. M., Wells, E. A., Todd, A., & Mountz, S. (2014). Negative and positive factors associated with the well-being of lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth. Youth and Society, 46 (5), 663–687. Johnson, D., Sikorski, J., Savage, T. A., & Woitaszewski, S. A. (2014). Parents of youth who identify as transgender: An exploratory study. School Psychology Forum, 8 (1), 56–74. Keuroghlian, A. S., Shtasel, D., & Bassuk, E. L. (2014). Out on the street: A public health and policy agenda for lesbian, gay, bisexual, and transgender youth who are homeless. American Journal of Orthopsychiatry, 84 (1), 66–72. doi:10. 1037/h0098852. Koken, J. A., Bimbi, D. S., & Parsons, J. T. (2009). Experiences of familial acceptance-rejection among transwomen of color. Journal of Family Psychology, 23, 853–860. Kosciw, J. G., Diaz, E. M., & Gay, L. Y. (2008). Involved, invis­ ible, ignored: The experiences of lesbian, gay, bisexual and transgender parents and their children in our nation’s K–12 schools. Gay, Lesbian and Straight Education Net­ work (GLSEN). McConnell, E. A., Birkett, M., & Mustanski, B. (2016). Fami­ lies matter: Social support and mental health trajectories among lesbian, gay, bisexual, and transgender youth. Jour­ nal of Adolescent Health, 59 (6), 674–680. doi:10.1016/j. jadohealth.2016.07.026. Moe, J., Perera-Diltz, D., Sepulveda, V., & Finnerty, P. (2014). Salience, valence, context, and integration: Conceptual­ izing the needs of sexually and gender diverse youth in P–12 schools. Journal of Homosexuality, 61 (3), 435–451. Mustanski, B., & Liu, R. (2013). A longitudinal study of pre­ dictors of suicide attempts among lesbian, gay, bisexual, and transgender youth. Archives of Sexual Behavior, 42 (3), 437–448.

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National Alliance to End Homelessness. (2008, December 8). Incidence and vulnerability of LGBTQ homeless youth (Brief no. 2). Youth Homelessness Series. https://b.3cdn. net/naeh/1f4df9fc5fcad14d92_vim6ivd15.pdf. Phillips, M. J., & Ancis, J. R. (2008). The process of identity development as the parent of a lesbian or gay male. Jour­ nal of LGBT Issues in Counseling, 2 (2), 126–158. Ryan, C. (2009). Supportive families, healthy children: Helping families with lesbian, gay, bisexual, and transgender children. San Francisco: Family Acceptance Project, Marian Wright Edelman Institute, San Francisco State University. Saltzburg, S. (2004). Learning that an adolescent child is gay or lesbian: The parent experience. Social Work, 49 (1), 109. Saltzburg, S. (2009). Parents’ experience of feeling socially supported as adolescents come out as lesbian and gay: A phenomenological study. Journal of Family Social Work, 12 (4), 340–358. Sherer, I. (2016). Social transition: Supporting our youngest transgender children. Pediatrics, 137 (3), 1–2. doi:10. 1542/peds.2015-4358. Singh, A. A., Hays, D. G., & Watson, L. S. (2011). Strength in the face of adversity: Resilience strategies of transgender individuals. Journal of Counseling and Development: JCD, 89 (1), 20. doi:10.1002/j.1556-6678.2011.tb00057.x. Singh, A. A., Hwahng, S. J., Chang, S. C., & White, B. (2017). Affirmative counseling with trans/gender-variant people of color. In A. A. Singh & l. m. dickey (eds.), Affirmative counseling and psychological practice with transgender and gender nonconforming clients, 41–68. Washington, DC: American Psychological Association. Singh, A. A., & McKleroy, V. S. (2011). “Just getting out of bed is a revolutionary act”: The resilience of transgender peo­ ple of color who have survived traumatic life events. Traumatology, 17 (2), 34–44. Singh, A. A., Meng, S. E., & Hansen, A. W. (2014). “I am my own gender”: Resilience strategies of trans youth. Journal of Counseling and Development, 92 (2), 208–218. doi:10.1002/j.1556-6676.2014.00150.x. Snapp, S. D., Watson, R. J., Russell, S. T., Diaz, R. M., & Ryan, C. (2015). Social support networks for LGBT young adults: Low cost strategies for positive adjustment. Family Rela­ tions: An Interdisciplinary Journal of Applied Family Stud­ ies, 64 (3), 420–430. Thorpe, A. (2015). Towards the inclusion of trans* identities: The language of gender identity in postsecondary student documentation. Antistasis, 5 (2), 81–89. Zalaznick, M. (2015). Creating inclusive climates. District Administration, 51 (7), 35–38.

TRANSGENDER-AFFIRMING PARENTING: PRACTICING PRONOUNS HOMEWORK Do you have a pet?

n Yes n No

If yes, what is your pet’s name? _________________________________

Do you have a car?

n Yes n No

If yes, do you have a name for your car? _________________________

What is a character that represents an upcoming holiday you celebrate (e.g., Santa, Easter Bunny, leprechauns) ?_________________________________ Do you have a plant?

n Yes n No If yes, do you have a name for your plant? ________________________

In addition to the above or if none of the above fit, provide a name for a household or inanimate object you use daily (e.g., the television or refrigerator): ________________________________________ Next, what is the assigned gender for the above: Pet: _____________________

Car: ______________________

Holiday character: _____________________

Plant: _____________________

Household object: _____________________

STEP 1. Post sticky labels to remind yourself to share stories out loud about your pet, car, holiday character, plant, and household objects using their pronouns.

STEP 2. Once you have practiced for a few days and are feeling proficient, switch pronouns for your pet, car, holiday character, plant, and household objects—but not their names. Once this feels more comfortable, change the pronouns again.

STEP 3. Change the names of your pet, car, holiday character, plant, and household objects.

Jennifer M. Gess

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29 FAMILY MAPPING EXERCISES (FMES) FOR ADULTS AND CHILDREN IN LGBTQ-PARENTED FAMILIES Fiona Tasker, Maeve Malley, and Pedro Alexandre Costa Suggested Use: Activity Objective

The aim of the family mapping exercises (FMEs) is to explore and then chart clients’ self-definition of their family and the strength of their emotional, social, and practical connections with others in their family network. LGBTQ-parented families are frequently complex and rarely defined simply by biological or legal parenting. Thus, mapping family connections is often a useful exercise in beginning to understand a client’s relationship context and definition of family. Two different FMEs are available, one for adults (the Family Map for adults) and one for children (the Apple Tree Family). Rationale for Use

Visual depictions of family relationships, or drawn genograms, are established techniques in the clinical assessment of individuals or families (McGoldrick, Gerson, & Petry, 2008). Genograms enable the ther­ apist to easily view family membership and the rela­ tionship between family members in a family-tree formation over three or more generations. In provid­ ing an intergenerational view of the family, the gen­ ogram connects both family of origin and families led or formed by LGBTQ clients, prompting valu­ able insights into how past family events might affect current relationship concerns. Traditional genograms, however, often have presented a view of the family bound by biological and marital connections, bypass­ ing family-of-choice connections that feature in the family formations created by LGBTQ individuals (Weston, 1997). Traditional genogram nomenclature

has been expanded to include symbols for LGBTQ individuals (McGoldrick, Garcia Preto, & Carter, 2015), but standard notation lacks the flexibility of self-cho­ sen symbols that can depict cherished and changing identifications (Callis, 2014). As FMEs do not use a standard notation for denoting identities, these provide a visual way of affirming all the family relationships of LGBTQ people and identifying supportive family connections and social resources for LGBTQ people. Genograms have spawned a number of offshoots that have widened the consideration of family relation­ ships. Socially constructed genograms have been used by Milewski-Hertlein (2001) to give greater freedom to clients to draw twenty-first-century family forms. Ecomaps, or ecograms, also have been developed to help clients place their current family relationships in relation to the major systems that contextualize them (Hartman, 1995; Limb & Hodge, 2011). Ecomaps emphasize the presence or absence of resources for clients and their families at a systemic level. The Fam­ ily Map for adults (page 258) combines both the genogram focus on family and the ecomap freedom to depict systems and resources. FMEs evolved specifically in relation to working with members of LGBTQ-led families and are parti­ cularly useful for working with LGBTQ clients because they do not necessarily constrain family relationships into heteronormative structures. For example, draw­ ing and then redrawing genograms as family maps has highlighted the importance of acceptance and affir­ mation versus heterosexism and sexual prejudice for lesbian couples when constructing a joint family map (Swainson & Tasker, 2005). The special features and complexity of the family networks created by bisexual

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mothers also have been emphasized by family map­ ping (Tasker & Delvoye, 2018). In families with donorconceived children, both the similarities and differ­ ences in the family networks of lesbian mothers and their children were highlighted in a study using the Apple Tree Family activity for children (Tasker & Granville, 2011). FMEs enable the therapist and the client to think about the family system surrounding the client and may visually emphasize on a single page previously unacknowledged relationship connections and resources that could be further explored in therapy. Visual depiction and the associated conversation prompted by the FMEs enable the therapist to high­ light salient parenting contexts and identify relation­ ships that are important in different ways to the indi­ vidual and collective well-being of different family members. For example, different FME depictions may be produced by LGBTQ parents that depend on whether they became a parent within their current same-gender relationship or within a previous or ongoing different-gender relationship (Tasker & Malley, 2012). Furthermore, a child’s FME may rep­ resent one, two, or more parental figures (Tasker & Granville, 2010, 2011). From FMEs therapists may also learn about their clients’ chosen family relation­ ships (family of choice) as well as those based on biological or legal ties (Weston, 1997). FMEs are useful in considering the effects of changing family relationships through various pro­ cesses such as coming out, partnership, birth of chil­ dren, relationship dissolution, death, migration, and poverty. LGBTQ clients’ unique intersection of their multiple social identities will probably influence their family networks and the sources of support and resources they can draw on within their networks as depicted in FMEs (Swainson & Tasker, 2005). Moore and Brainer (2013) have considered how race and ethnicity matter in the lives of African Americans, Hispanics, and Asian and Pacific Islander (API) Americans and how these crucially intersect with experiences of sexual-minority parents and their children. For example, compared to European American same-gender couples, both African Amer­ ican and Hispanic same-gender couples are more likely to experience economic disadvantage, whereas

both API American and Hispanic same-gender cou­ ples are more likely than other groups to be affected by issues connected with immigration. Added com­ plexity is introduced in LGBTQ relationships and families when differences of power or visibility in class, culture, nationality, education, or ability com­ pete for attention in particular situations (Singh & Harper, 2012). In providing a map of family relation­ ships and allegiances that can be viewed as a whole, FMEs can help clients explore assumptions about which identity is foregrounded within a particular context or relationship, while helping family mem­ bers retain a sense of family connection. According to the American Association for Marriage and Family Therapy (AAMFT) code of ethics, therapists must provide professional service free of prejudice and discrimination and adopt a culturally sensitive stance (2015). Consent and con­ fidentiality issues of adults, vulnerable adults, and children must be appropriately addressed by the therapist in relation to family work—for example, through working within the guidelines of relevant professional bodies. The British professional body— the Association for Family Therapy (AFT)—states: “When faced with an ethical dilemma members should adopt the course of action which ‘maximises the good’ and does the ‘least harm.’ They should attach particular weight to the rights of the vulnera­ ble and those with least power” (2015, p. 2). The American Psychological Association (APA) has stated that the delivery of professional services to lesbian, gay, bisexual, and transgender clients must be built on the principle that “same-sex sexual and romantic attractions, feelings, and behaviors are normal and positive variations of human sexuality regardless of sexual orientation identity” (2009, p. 121). Specifically in regard to LGBTQ families, APA (2012) further states that LGBTQ people may recog­ nize friends and other nonbiologically related peo­ ple as part of their family of choice. For many LGBTQ people, the family of origin may be rejecting of their sexual identity, and other networks of morethan-friends can provide familial and supportive relationships that their biological family may not. These support networks can be revealed by a family mapping exercise. Family Mapping Exercises for LGBTQ-Parented Families 255

Instructions

Family Map (FM) for Adults Adult clients are asked to take part in an interview con­ versation about who is in their family and their fam­ ily relationships. Key interview questions for use with the Family Map (FM) for adults are available below and at the Family Mapping Exercises website (Tasker, 2017). As part of the interview, clients are asked to draw a map or to help the therapist draw a map of their family relationships. Clients are asked to come up with their own symbols for themselves and their sexual identity. A blank sheet of white 8.5- × 11-inch paper and a selection of lead and colored pencils are made available for the activity. If an audio recording is not made, then the therapist should note the client’s description of the relationships depicted on the FM as a future memory aid. The FM can usually be adapted for use with clients with special needs and disabilities: the therapist can assist with drawing or offer (as appro­ priate) computer help, a trained assistant, or a transla­ tor. For example, for a client with visual impairment, blocks of different shapes and sizes could be posi­ tioned and a range of textural fabrics used to provide rich description. Therapist instructions to client: I’d like you to draw, or help me draw, a map of your family. Please put a mark or a symbol or a drawing (use whatever symbols you like) on the blank sheet of paper for each mem­ ber of your family, so that all these relationships and the connections between them are shown on the paper. Remember, everybody’s family is different, and some­ times it’s not easy to draw, so you’re welcome to have another go at drawing your family map if you need to. Apple Tree Family (ATF) for Children The FME for children involves children constructing a picture of their family by placing a paper apple on an apple tree to represent each member of their fam­ ily —the Apple Tree Family (ATF). The ATF was devel­ oped as an enjoyable activity for preschool and ele­ mentary-school children. The materials needed for the Apple Tree Family are a standard picture of a green tree (the Apple Tree) in the center of a plain white sheet of 8.5- × 11-inch paper and a pile of red paper apples, available below or from the FME website (Tasker, 2017). The ATF, like the FM for adults, can 256 Tasker, Malley, & Costa

often be adapted for use by children and adolescents with special needs. The therapist puts the blank Apple Tree out on a table or the floor for the child and puts a few paper apples next to the tree ready for the child to pick up and place on the tree to represent family members. A pile of individual apples can be copied from the apple under the tree, reproduced, cut out, and placed in a pile at the foot of the apple tree on the sheet of paper. A pen or a pencil is needed for nam­ ing each apple (either for the therapist or the child to write the name on), as is glue suitable for children’s use. To avoid any suggestion of the “correct” family size expected on the apple tree, the therapist makes it clear that more apples are available for the child to use if these are needed. The interview questions for use with the ATF are available from the FME website (Tasker, 2017). If an audio recording is not made, the therapist should note the child’s description of each family relationship as the child places each apple on the tree. Therapist instructions to child: We all come from different sorts of families—some are very big, and some are very small and have different people in them. I’d like you to help me find out who is in your family by putting a red apple on this green apple tree for yourself and for anybody who is in your family. Then we can see your Apple Tree Family. Would you like to do that for me? So that I can remember whose apple is whose, would you like to write a name on each apple, or would you like me to write for you? Brief Vignette

When they arrived for a therapy session, Arlette and Cathleen (a white, middle-class, able-bodied, cisgen­ der lesbian couple, ages thirty-eight and thirty, respec­ tively) had been in a monogamous relationship for two years (living together for twelve months) and resided in New Zealand. Both Arlette and Cathleen had been traveling in New Zealand when they met, although they were both U.S. citizens originally from Arizona. Arlette brought her young son, Jamie, with her from Arizona to New Zealand. Arlette and Jamie’s father (Arlette’s ex-partner) had separated acrimoniously three years before. Jamie was now five years old. The issue that brought the family into therapy was the couple’s decision to move back to Arizona. Back

in Arizona, Arlette’s mother (age sixty-five) recently had had a major operation, and so Arlette felt that she needed to return home to support her mother, her father (seventy-four years old), and her younger sister, Susan (twenty-eight years old and living at home with her parents after being diagnosed with autism as a teenager). No other members of Arlette’s family of origin were mentioned as available to help out. Arlette’s brother and his wife (both thirty-two years old) were described by Arlette as “useless.” Arlette considered herself to be “first-generation” middle class, having been the first of her family to go to college, and she was aware of how her family and siblings felt a degree of alienation in response to what they perceived as her “abandonment” of some familial norms and values. Also, Arlette was anxious about how her family would regard Cathleen and her family, who were more estab­ lished in their middle-class circumstances, but who came from a second-generation Irish American Cath­ olic background. Arlette’s family identifies as Baptists, though Arlette herself espoused no religious identity. As a consequence of these interrelated issues, histories, and identifications, Arlette had apprehensions about moving back to Arizona. In contrast to Arlette, Cathleen was an only child whose parents had been “fine about it” when she came out to them while in college in her home state. At this time Cathleen and her parents occasionally contacted each other over Skype, and she also regularly Skyped her best friend and ex-lover Phyllis (Phyl), who lived with Nino and JJ (identified as a trans man and a gender-nonconforming person, respectively) in the United States. Cathleen saw her family of origin as less crucial to her than her family of choice. Further­ more, most of Cathleen’s family-of-choice connections were now in New Zealand, including Lucille (Cath­ leen’s ex and now her best friend) and Tanya (also from the United States; she recently had settled in New Zealand with Tui, a Maori woman). Nonetheless, Cathleen felt a great longing to be regularly back in touch with Phyl and rekindle other LGBTQ contacts. This was a factor in Cathleen’s decision to return to Arizona with Arlette and Jamie, to whom she said she was attached. With the couple’s agreement, the Family Map was introduced as an activity in this initial session, as many

of the difficulties that Arlette and Cathleen identified involved their very different pattern of close relation­ ships and the potential misunderstandings or clashes they could foresee in incorporating these relation­ ships into their life together. In the first half of the session, Jamie sat quietly, saying very little, and was keen to explore the toy box in the adjacent therapy room when invited to do so. While Jamie played with some toy cars he found, Arlette and Cathleen together constructed and talked about their family map (see Figure 1). Arlette and Cathleen subsequently brought Jamie back into the room, and they stayed with him for a more child-focused session in which Jamie con­ structed his Apple Tree Family (see Figure 2). The family was encouraged to think about the FMEs they produced as preparation for the next session, but the therapist asked them not to get into heavy discussion about the FMEs with one another. At a subsequent session Arlette, Cathleen, and the therapist together identified themes that were evident to them in Figures 1 and 2 while Jamie listened, chim­ ing in occasionally, as he played again with the cars in the toy box. In Figure 1, the family connections high­ lighted by Arlette seemed very different from those highlighted by Cathleen. Each attached different mean­ ings to the biological and chosen relationships included on the map, as highlighted by several contextual fea­ tures that the therapist encouraged the clients to draw or represent. For example, Arlette drew the distance between Arlette’s parental home in Arizona and her heartfelt family with Cathleen and Jamie in New Zealand. Cathleen added the flags. Arlette gave sup­ port to a number of people but indicated a mutually supportive relationship only with Cathleen. Arlette also said the distance (represented by her as a sea of waves) meant that she avoided conflict with Jamie’s father. Cathleen gave stars to family-of-choice mem­ bers who she said had “always been there for her.” Arlette then added Nina to the Family Map and gave her a star. Arlette spoke of Nina as her best friend through school and college, although they had not been in contact for a while. In Figure 2 Jamie first put his mom’s apple on the tree and then his dad’s. After that, Jamie put an apple for himself on the tree, situated below but between these two. He seemed eager to do the activity and Family Mapping Exercises for LGBTQ-Parented Families 257

Figure 1. Arlette and Catheen’s Family Map

258

Cathleen

Granny Auntie Susan

Mom Snoopy Dog

Dad Jamie

Name

Figure 2. Jamie’s Apple Tree Family

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Name

Figure 3. Apple Tree Family activity for children (blank) Source: Fiona Tasker and Julia Granville. (2011). Children’s views of family relationships in lesbian-led families, Journal of GLBT Family Studies, 7 (1–2), 182–199. Reprinted by permission of Taylor and Francis Group, LLC (www.tandfonline.com). First published in Fiona Tasker and Julia Granville. (2010). Die Perspektive des Kindes in lesbischen Familien. In Dorett Funcke and Petra Thorn (eds.), Die gleichgeschlechtliche Familie mit Kindern. Interdisziplinäre Beiträge zu einer neuen Lebensform. Reprinted by permission of Transkript Verlag.

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quickly added further apples for his granny and Aun­ tie Susan, whom he said he spoke to when they were on the phone with Mom. After this Jamie paused, and the therapist asked him if there was anyone else in his family who could go on the tree. Jamie then put on an apple for Cathleen, who he said helped him brush his teeth and took him to his preschool. After another pause, and a similar prompt, Jamie mentioned Tanya and Tui, who had two dogs, but he then said they were not in his family. He then decided, however, to add an apple for Auntie Susan’s dog, Snoopy, next to his apple on the tree. After completion of both FMEs, the following issues were identified as potential topics for discus­ sion in a subsequent session: Were there differences in hierarchies of closeness or obligation experienced by the couple? Whom did Jamie want in his family and in what ways could this be organized in the family? Who had rights and responsibilities (legal, financial, practical, and emotional) as a parent, grandparent, aunt, uncle, family friend, or supporter for Jamie? Were these rights and responsibilities reserved for family of origin, or could these roles be filled by family of choice? How did each partner experience the incorporation, or exclusion, of various ex-partners into a shared relational network? Suggestions for Follow-up

The FMEs were initially developed as assessment tech­ niques for examining family relationships. Addition­ ally, the FMEs can be used as follow-up exercises— either in the session or as a homework activity—as a way of evaluating the effectiveness of an interven­ tion designed to combat isolation by increasing social support networks or deepen existing involvements. Contraindications for Use

Many different and difficult issues can be raised for LGBTQ clients in talking about family in terms of past experiences, current predicaments, and future hopes. Simply being presented with a blank piece of paper, or a blank apple tree, and instructions to display your family can be daunting, particularly for those with perfectionist tendencies. Furthermore, the fact of “mapping,” or indeed producing any visual depiction, can be an emotional experience even though it may

be a gateway to addressing deficits or reshaping patterns of relationship. Knowing something can be a very different experience from actually seeing it. For instance, a very sparse relational map can feel like a painful failure. Further, particular sensitivity is needed when considering how people who have died are included in the map, or in pointing out a similar patterning of difficulties across or within generations of the family, especially if clients have not noticed this before. For these reasons, we strong­ ly advise that therapists first administer FMEs within a session with the client and ensure that enough time is allowed for the activity in the session. Once the client is familiar with the FME technique, a subse­ quent administration can be either session-based or used as a homework activity. Professional Resources Ariel, J., & McPherson, D. W. (2000). Therapy with lesbian and gay parents and their children. Journal of Marital and Family Therapy, 26, 421–432. doi:10.1111/j.17520606.2000.tb00313.x. Brodzinsky, D. M., & Pertman, A. (eds.). (2012). Adoption by lesbians and gay men: A new dimension in family diversity. New York: Oxford University Press. Freeman, T., Graham, S., Ebtehaj, F., & Richards, M. (eds.). (2014). Relatedness in assisted reproduction: Families, origins, and identities. Cambridge: Cambridge University Press. Goldberg, A. E. (2010). Lesbian and gay parents and their children. Washington, DC: American Psychological Association. Goldberg, A. E., & Allen, K. R. (eds.). (2013). LGBT-parent families: Innovations in research and implications for practice. New York: Springer. Golombok, S. (2015). Modern families: Parents and children in new family forms. Cambridge: Cambridge University Press. Hicks, S. (2011). Lesbian, gay, and queer parenting: Families, intimacies, genealogies. Basingstoke, UK: Palgrave Macmillan. Tasker, F. (2017). Family mapping exercises. https://family mappingexercises.wordpress.com/. Weston, K. (1997). Families we choose: Lesbians, gays, kinship. New York: Columbia University Press.

Resources for Clients Dunne, G. A. (ed.). (1998) Living “difference”: Lesbian perspec­ tives on work and family life. Binghamton, NY: Haworth Press. Garner, A. (2004). Families like mine: Children of gay parents tell it like it is. New York: HarperCollins. Family Mapping Exercises for LGBTQ-Parented Families 261

Goldberg, A. E., Gartrell, N. K., & Gates, G. (2014). Research report on LGB-parent families. Los Angeles: Williams Institute, UCLA School of Law. http://williamsinstitute. law.ucla.edu/wp-content/uploads/lgb-parent-familiesjuly-2014.pdf. Gottlieb, A. R. (2003). Sons talk about their gay fathers: Life curves. Binghamton, NY: Harrington Park Press. Howey, N., & Samuel, E. (eds.). (2000). Out of the ordinary: Essays on growing up with gay, lesbian, and transgender parents. New York: St. Martin’s Press. Lehr, V. (1999). Queer family values: Debunking the myth of the nuclear family. Philadelphia: Temple University Press. Sarles, P. A. Gay-themed picture books for children. http:// booksforkidsingayfamilies.blogspot.co.uk/. Strah, D., & Margolis, S. (2003). Gay dads: A celebration of fatherhood. New York: Putnam. Weston, K. (1997). Families we choose: Lesbians, gays, kinship. New York: Columbia University Press.

References American Association for Marriage and Family Therapy (AAMFT). (2015). Code of ethics. https://www.aamft.org/ Documents/ Legal Ethics/AAMFT-code-of-ethics.pdf. American Psychological Association (APA). (2009). Report of the APA Task Force on Appropriate Therapeutic Responses to Sexual Orientation. https://www.apa.org/pi/lgbt/ resources/therapeutic-response.pdf. American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual Clients. American Psychologist, 67, 10–42. doi:10. 1037/a0024659. Association for Family Therapy (AFT). (2015). AFT code of ethics and practice. http://www.aft.org.uk/Springboard­ WebApp/userfiles/aft/file/Ethics/Code%20of%20 Ethics%20September%202015.pdf. Callis, A. S. (2014). Bisexual, pansexual, queer: Non-binary identities and the sexual borderlands. Sexualities, 17, 63–80. doi:10.1177/1363460713511094. Hartman, A. (1995). Diagrammatic assessment of family rela­ tionships. Families in Society: The Journal of Contemporary Human Services, 76 (2), 111–122. Limb, G. E., & Hodge, D. R. (2011). Utilizing spiritual eco­ grams with Native American families and children to promote cultural competence in family therapy. Journal

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of Marital and Family Therapy, 37, 81–94. doi:10.1111/j. 1752-0606.2009.00163.x. McGoldrick, M., Garcia Preto, N., & Carter, B. (2015). The expanding family life cycle: Individual, family, and social perspectives. London: Pearson. McGoldrick, M., Gerson, R., & Petry, S. S. (2008). Genograms: Assessment and intervention, 3rd edition. New York: W. W. Norton. Milewski-Hertlein, K. A. (2001). The use of a socially con­ structed genogram in clinical practice. American Journal of Family Therapy, 29, 23–38. doi:10.1080/019261801 25996. Moore, M. R., & Brainer, A. (2013). Race and ethnicity in the lives of sexual minority parents and their children. In A. E. Goldberg & K. R. Allen (eds.), LGBT-parent families: Innovations for research and for practice, 133–148. New York: Springer. doi:10.1007/978-I-4614-4556-2_9. Singh, A. A., & Harper, A. (2012). Intercultural issues in LGBTQQ couple and family therapy. In J. J. Bigner & J. L. Wetchler (eds.), Handbook of LGBT-affirmative couple and family therapy, 283–298. New York: Routledge. Swainson, M., & Tasker, F. (2005). Genograms redrawn: Les­ bian couples define their families. Journal of GLBT Family Studies, 1 (2), 3–27. doi:10.1300/J461v01n02_02. Tasker, F. (2017). Family mapping exercises. https://family­ mappingexercises.wordpress.com/. Tasker, F., & Delvoye, M. (2018). Maps of family relations drawn by women engaged in bisexual motherhood: Defining family membership. Journal of Family Issues, 39 (18), 4248–4274. doi:10.1177/0192513X18810958. Tasker, F., & Granville, J. (2010). Die Perspektive des Kindes in lesbischen Familien. In D. Funcke & P. Thorn (eds.), Die gleichgeschlechtliche Familie mit Kindern. Inter­ disziplinäre Beiträge zu einer neuen Lebensform, 429– 454. Frankfurt: Transkript Verlag. Tasker, F., & Granville, J. (2011). Children’s views of family relationships in lesbian-led families. Journal of GLBT Family Studies, 7, 182–199. doi:10.1080/15504 28X.2011.540201. Tasker, F., & Malley, M. (2012). Working with LGBT parents. In J. J. Bigner & J. L. Wetchler (eds.), Handbook of LGBTaffirmative couple and family therapy, 149–165. New York: Routledge. Weston, K. (1997). Families we choose: Lesbians, gays, kinship. New York: Columbia University Press.

ACTIVITIES: FAMILY MAP (FM) FOR ADULTS

Suggested Additional Interview Questions Sometimes there might be additional people who are important to you in a way a family member might be, although other people in your family would not always include them in their family definition. These might be people with whom you previously had or currently have an intimate connection in an emotional, sexual, or practical way. Do you want to include anyone like this on your map? Sometimes other aspects of your life are very much connected to the way you think about your family— for example, being part of an LGBTQ group or your local community or neighborhood. Or it may be that your home, or any animals you have living with you, are connected with your family. Would you like to include these or anything else that’s important on your family map? For additional questions, see https://familymappingexercises.wordpress.com.

ACTIVITIES: APPLE TREE FAMILY (ATF) FOR CHILDREN Suggested Additional Interview Questions Sometimes everybody in a family lives together and sometimes they don’t. Sometimes lots of different people can be like a parent to you or part of your family in different ways. Does that happen in your family? Some children have just one parent; others have two moms or two dads or a mom and a dad. Some children have more than two parents, and all of them are so special in their very own way that it might be difficult to tell other people about. What’s your family like? For additional questions, see https://familymappingexercises.wordpress.com.

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30 EXPANDING BINARY THINKING: A REFLECTIVE ACTIVITY FOR PARENTS AND CAREGIVERS OF TRANSGENDER AND GENDER-EXPANSIVE YOUTH Rebekah Byrd and Laura Boyd Farmer Suggested Uses: Activity, homework Objective

The objective of this activity is to assist parents and caregivers of transgender and gender-expansive (TGE) youth in questioning and elaborating on binary ideas of gender. This activity is intended to develop greater awareness for parents and caregivers in supporting TGE youth while also strengthening resources for advocat­ ing against oppression that stems from genderism. Rationale for Use

This activity is designed to help parents and caregivers of TGE youth understand that binary conceptualiza­ tions of gender have been used to oppress and discrim­ inate against sexual- and gender-identity diverse indi­ viduals (Farmer & Byrd, 2015). Increasingly, alarming rates of suicidal ideation specifically attributed to how one identifies is a significant risk factor for TGE youth (Grossman & D’Augelli, 2007). Support from parents and caregivers for TGE youth is essential to develop a positive self-image, to increase self-esteem, and to foster thriving (Orr & Baum, 2015), but fewer than half (43 percent) of TGE youth report having a supportive adult in their family (Baum et al., 2014). It is important to assist parents and caregivers in chal­ lenging biased thinking so that they may in turn assist their youth in combating internalized stigma related to gender identity. Understanding genderism is a key component of this task. In short, genderism is “the belief that gender is binary, and that only two gen­ ders—male and female—exist” (Sampson, 2014, p. 35).

In a much greater context, genderism affects myriad aspects of one’s life. Airton (2009) conceptualizes gen­ derism quite vividly: “Because of the reality of gender binary socialization, then, genderism not only rein­ forces the negative evaluation of gender non-confor­ mity or an incongruence between sex and gender. Genderism is more pervasively manifested as the fear­ ful anticipation of non-conformity and any incon­ gruence between biological sex, and the way these are lived and expressed through gender” (p. 230). Binary thinking may limit parents and caregivers in their ability to understand, accept, and support their child. Reflecting on the binary paradigm and questioning the subsequent genderism that pervades Western culture is an essential place to start. Though this activity focuses on expanding binary thinking, it is necessary for counselors to acknowledge the intersectionality of identities. Gender, gender iden­ tity, and gender expression intersect with many identi­ ties, including socioeconomic status, race, ethnicity, ability status, sexual or affectional orientation, religious or spiritual affiliation, and age (Parent, Deblaere & Moradi, 2013). Therefore, counselors seek to understand the multiple systems of oppression affecting each client. Because each client and each counseling situation are unique, ethical and multiculturally competent counsel­ ors think critically about the intersections present. Sexual minority and TGE youth may face signif­ icant challenges well into adulthood (Toomey et al., 2010). Some challenges may include school victimiza­ tion, depression, and poor self-concept (Toomey et al., 2010). Therefore, clinical interventions are recom-

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mended to support TGE youth as well as their parents and caregivers (Grossman & D’Augelli, 2007). Affirming TGE individuals is a legal and ethical obligation for counselors. The American Counseling Association Code of Ethics (ACA, 2014) states that ethical counselors do not discriminate “based on . . . gender, gender identity, sexual orientation . . . or any basis proscribed by law” (p. 9). Further, the code is clear that our primary role as counselors is to affirm, respect, and promote client welfare. According to the ALGBTIC “Competencies for Counseling Transgender Clients,” counselors will “affirm that all per­ sons have the potential to live full functioning and emotionally healthy lives throughout their lifespan while embracing the full spectrum of gender identity expression, gender presentation, and gender diversity beyond the male-female binary” (2009, p. 4). Support­ ing and responding in an affirming manner are imperative when clients are questioning, disclosing, and processing their identities (ALGBTIC Transgen­ der Committee, 2010; Harper et al., 2013). School counselors are uniquely positioned to pro­ vide support to TGE students. The American School Counselor Association’s (ASCA’s) ethical standards emphasize a school counselor’s role to advocate for and affirm “all students from diverse populations including but not limited to . . . gender, gender iden­ tity/expression” (2016, p. 1). Legally, federal Title IX law prohibits discrimination in schools on the basis of sex and has been applied by the U.S. Justice and Edu­ cation Departments as well as courts to include dis­ crimination of youth who identify as TGE (National Center for Transgender Equality, 2016). State and local laws protecting TGE individuals do exist (American Civil Liberties Union, 2016) but vary from state to state. Counselors should stay apprised of the laws that apply in their respective states. In sum, counselors, whether working in schools, agencies, or private prac­ tices, seek to affirm all clients in a supportive and compassionate manner. Counselors who adopt fluid, multifaceted conceptualizations of gender and affec­ tional identities are best prepared to meet the needs of TGE youth (Farmer & Byrd, 2015). Instructions

When working with families, couples, children, or adolescents, this activity may be used to assist the par­

ents and caregivers of TGE youth in questioning and expanding on binary ideas of gender. Questions for initial reflection are derived from Garfinkel’s (1967) ethnomethodological studies describing the character­ ization of gender as it is generally understood and acknowledge that viewing gender as binary, rigid, and fixed is manifest in many ways. Statements 1 through 8 in the activity are derived from Kessler and McKenna (1978, pp. 113–114), as they offer genderbinary assumptions that may be chosen, depending on presenting concerns, as a self-reflective exercise for parents and caregivers to examine and challenge their own binary beliefs. The authors have expanded on this list and added follow-up questions. The vignette below illustrates how the activity can be used in an initial session; however, this activity may be appropriate at any time during the counseling process when binary thinking emerges as a barrier in the parent-child relationship. As is true of any activ­ ity that encourages self-reflection, counselors should take care to build rapport with clients and present information in a thoughtful and compassionate man­ ner. Further, counselor self-awareness is key, and coun­ selors are asked to consider the following concepts: • In what ways could the client’s experience with racism affect the experience of genderism? • In what ways could the client’s experience with poverty affect the experience of genderism? • In what ways could the client’s experience with pov­ erty, racism, and sexual or affectional orientation affect the experience of genderism? • In what ways could the client’s experience with heterosexism affect the experience of genderism? • In what ways could experiences with multiple iden­ tities affect the client’s internalization of these “isms”? • In what ways have multiple systems of oppression affected the client? The activity could also be used in an individual session with a TGE youth to examine internalized genderism. Further, the activity is not limited to counseling sessions and can also be applied in the context of training. Counselors, teachers, administrators, and staff members could benefit from an activity that enhances understanding of TGE individuals. Expanding Binary Thinking: A Reflective Activity 265

When parents and caregivers discuss thoughts reflecting a binary view of gender, gender expression, and/or identity, the counselor can provide the parents and caregivers with a handout of this activity (see page 269). In session, the counselor can introduce specific statements related to the discussion at hand. Therefore, it would be helpful for counselors to be familiar enough with the activity that they can offer the statements that are most applicable to each unique situation. For example, if parents or caregivers are reflecting on how their child or adolescent needs to “figure out if he is a boy or a girl,” the counselor could offer mul­ tiple challenging statements from the activity for exploration. The counselor could start with the first statement, asking the parents or caregivers to con­ sider their ideas and beliefs on the following: “There are two, and only two, genders (male and female).” An attuned, nonjudgmental, and patient counselor understands that the parent or caregiver may in fact believe this statement. Depending on where the parents or caregivers are in their own process, it may be helpful to offer a sec­ ond statement for contemplation, such as, “Any excep­ tions to the two genders are not to be taken seriously. (They must be jokes, pathology, etc.)” The parents or caregivers are invited to consider their level of agree­ ment with this idea. With each step, the parents are also invited to consider the unique characteristics of their own child and contrast this knowledge of their child with the binary ideas represented in the state­ ments. The counselor understands that this is a pro­ cess that takes time and is dependent on each individ­ ual and the unique needs presented. Parents and caregivers will present at different places in their own process of understanding. This will determine how the counselor is able to move through the statements for consideration. It may be unclear where the parents and caregivers are in their own awareness until the statements and subsequent reflective questions are offered. The parent or care­ giver may be able to process only a few statements in one session; alternatively, multiple sessions may be needed to process and evaluate beliefs on a single statement. The counselor works with the parents and caregivers to meet them where they are and does not push them through the activity at a rapid pace. 266 Byrd & Farmer

Brief Vignette

You are conducting an initial session with a thirteen­ year-old child, Emma, who was referred by Emma’s parents because of recent moodiness, withdrawal, and family conflict. Emma’s gender assignment at birth was female; however, Emma does not identify as female or male. Emma prefers to be called Em and uses the pronouns they, them, and their. Em likes to wear baggy clothes, has short hair, and sometimes uses chest bind­ ing to flatten their breasts. Em is outspoken about their identity with their parents, rejecting both male and female labels. During the appointment, Em’s mother states, “I just can’t take it. You’re either a he or a she . . . but there is no such thing as an ‘it.’ If you’re an ‘it,’ you are nobody. You don’t exist.” As the counselor facilitating the session, you quickly realize that you will need to separate Em and her mother to continue gathering information. You decide to invite Em’s mother for an individual session the following week. After building rapport with Em’s mother and validating her confusion about Em’s iden­ tity, you introduce the activity as a way to explore ideas about gender. You also acknowledge that perhaps our beliefs about gender are socialized; in other words, some beliefs we develop on our own through our lived experiences, and others are handed to us and rein­ forced from a very early age. In these cases, it can be difficult to tease apart what is true for us, what is true for others, and what is true in society. This activity is thus offered as an exercise to explore assumptions about gender, sexuality, and identity. As the counselor working with Em’s mother, you begin by saying, “I would like to invite you to consider some ideas about gender. For each of the following statements, consider how much you agree or disagree with the idea presented.” Then the first binary state­ ment in the activity is offered for reflection: There are two, and only two, genders (male and female). Em’s mother considers her own beliefs associated with this statement and seems pensive. You gently facilitate a discussion with the mother about her personal beliefs and values using prompts such as: What is your ini­ tial reaction to this statement? What thoughts are coming up for you? If you agree with this statement, what if there is a possibility that more genders exist? How might this relate to Em?

Em’s mother seems to be thinking critically about the previous questions. You notice that her shoulders drop, her posture softens, and her tone lowers as she expresses a desire to be close with Em. She also states that while she does not understand, she also does not want to be disconnected from her daughter. She tells you, “I just don’t know how to understand, but I want to try.” As the counselor, you present her with the following question from the activity, asking her to consider her beliefs associated with the following: One’s gender is invariant. (If you are female/male, you always were female/male and you always will be female/male.) She reflects on this statement and how it is some­ thing she has certainly believed in the past but is not sure how it fits with Em. She notes that society, com­ munity, school, and other systems may view Em in a negative light, and she does not want that for Em. You discuss ways to affirm and support Em, and their mother seems interested in this conversation, while noting, “I have never thought of that before!” Because Em’s mother made the statement above (“You’re either a he or a she”), you decide to discuss the fourth statement in the activity: Any exceptions to the two genders are not to be taken seriously. (They must be jokes, pathology, etc.) Together, you discuss the challenges and benefits of taking Em seriously and confirming their identity. You further discuss, if there are beliefs or values that Em’s mother personally stands firm on, how might she avoid imposing them on Em and thus convey love and support. You assist Em’s mother in role-playing affirming messages and using Em’s personal pronouns. You acknowledge Em’s mother and support her in this process while noting that this will take time. You give Em’s mother a copy of the self-reflective activity for her to continue thinking about until your next session. Suggestions for Follow-up

In the sessions following distribution and facilitation of the self-reflective activity, counselors can follow up with parents and caregivers to inquire about new realizations and integration of ideas. Ideally, the activ­ ity will open the door for an ongoing dialogue between counselors and the parents and caregivers of TGE youth to increase self-awareness of biases related to gender-binary thinking. By doing their own work, parents and caregivers are better equipped to support

youth when they face challenges on their own path toward self-discovery and self-acceptance. It is possi­ ble that the process of challenging such ingrained ideas about gender may take weeks or months. To address the issue from multiple angles, counselors may question how these binaries have influenced parents and caregivers in their own lives and, in turn, how they may be affecting their child. Having a safe, sup­ portive space for such dialogue will help facilitate further growth and understanding. Contraindications for Use

This activity should not be used with parents and caregiv­ ers while youth are present in the session. It is best prac­ tice for parents and caregivers to be separated from youth while parents work through their own process of coming to understand their child’s identity, particularly in cases where the parent is experiencing emotional distress. By working with counselors separately, parents are free to do their own work and exploration without unintended, negative effects on the child. Professional Resources Budge, S. L., Rossman, H. K., & Howard, K. A. S. (2014). Cop­ ing and psychological distress among genderqueer indi­ viduals: The moderating effect of social support. Journal of LGBT Issues in Counseling, 8 (1), 95–117. doi:10.1080/155 38605.2014.853641. Davis, K. (2008). Intersectionality as a buzzword. Feminist The­ ory, 9 (1), 67–85. Elizabeth, A. (2013). Challenging the binary: Sexual identity that is not duality. Journal of Bisexuality, 13 (3), 329–337. Entrup, L., & Firestein, B. A. (2007). Developmental and spiri­ tual issues of young people and bisexuals of the next gener­ ation. In B. A. Firestein (ed.), Becoming visible: Counseling bisexuals across the lifespan, 89–107. New York: Columbia University Press. Galupo, M. P., Davis, K. S., Grynkiewicz, A. L., & Mitchell, R. C. (2014). Conceptualization of sexual orientation identity among sexual minorities: Patterns across sexual and gender identity. Journal of Bisexuality, 14 (3–4), 433– 456. doi:10.1080/15299716.2014.933466. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H. C., Loos, B., . . . Kocet, M. (2013). Association for Les­ bian, Gay, Bisexual, and Transgender Issues in Counseling competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individuals. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi:1080/15538 605.2013.755444. McDonald, M. (2006). An other space: Between and beyond lesbian-normativity and trans-normativity. Journal of Les­ bian Studies, 10 (1), 201–214. Expanding Binary Thinking: A Reflective Activity 267

Nadal, K. L., Rivera, D. P., & Corpus, M. J. (2010). Sexual ori­ entation and transgender microaggressions: Implications for mental health and counseling. In D. W. Sue (ed.), Microaggressions and marginality: Manifestation, dynamics, and impact, 217–240. Hoboken, NJ: John Wiley & Sons. Nadal, K. L., Skolnik, A., & Wong, T. (2012). Interpersonal and systemic microaggressions toward transgender people: Implications for counseling. Journal of LGBT Issues in Counseling, 6 (1), 55–82. doi:10.1080/15538605.2012.648583. Preves, S. E. (2000). Negotiating the constraints of gender bina­ rism: Intersexuals’ challenge to gender categorization. Current Sociology, 48 (3), 27–50. Tebbe, E. A., Moradi, E., & Ege, B. (2014). Revised and abbre­ viated forms of the genderism and transphobia scale: Tools for assessing anti-trans* prejudice. Journal of Coun­ seling Psychology, 6 (4), 581–592. doi:10.1037/cou0000043.

Resources for Clients Baum, J., Brill, S., Brown, J., Delpercio, A., Kahn, E., Kenney, L., & Nicoll, A. (2014). Supporting and caring for our gen­ der expansive youth. http://hrc-assets.s3-website-us-east­ 1.amazonaws.com//files/assets/resources/Gender-expan sive-youth-report-final.pdf. GLSEN. (2017). Championing LGBTQ issues in K–12 educa­ tion since 1990. www.glsen.org. Human Rights Campaign. (2017). Explore: Transgender chil­ dren and youth. https://www.hrc.org/explore/topic/ transgender-children-youth. National Center for Transgender Equality. (2019). Know your rights: Schools. https://transequality.org/know-your-rights/ schools. Orr, A., & Baum, J. (2015). Schools in transition: A guide for supporting transgender students in K–12 schools. http:// hrc-assets.s3-website-us-east-1.amazonaws.com//files/ assets/resources/Schools-In-Transition.pdf. Sylvia Rivera Law Project. (2017). Fact sheet: Transgender & gender non-conforming youth in school. http://srlp.org/ resources/fact-sheet-transgender-gender-nonconforming­ youth-school/.

References Airton, L. (2009). Untangling “gender diversity”: Genderism and its discontents (i.e., everyone). In S. R. Steinberg (ed.), Diversity and multiculturalism: A reader, 223–246. New York: Peter Lang. ALGBTIC Transgender Committee. (2010). American Coun­ seling Association: Competencies for counseling with transgender clients. Journal of LGBT Issues in Counsel­ ing, 4 (3–4), 135–159. doi:10.1080/15538605.2010.524839. American Civil Liberties Union. (2016). Know your rights: Transgender people and the law. https://www.aclu.org/ know-your-rights/transgender-people-and-law. American Counseling Association (ACA). (2014). Code of ethics and standards of practice. Alexandria, VA: Ameri­ can Counseling Association. 268 Byrd & Farmer

American School Counselor Association. (2016). Ethical stan­ dards for school counselors. https://www.schoolcounselor. org/asca/media/asca/Ethics/EthicalStandards2016.pdf. Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC). (2009). Competencies for coun­ seling with transgender clients. Alexandria, VA: Author. Baum, J., Brill, S., Brown, J., Delpercio, A., Kahn, E., Kenney, L., & Nicoll, A. (2014). Supporting and caring for our gender expansive youth. http://hrc-assets.s3-website-us­ east-1.amazonaws.com//files/assets/resources/Genderexpansive-youth-report-final.pdf. Farmer, L. B., & Byrd, R. (2015). Genderism in the LGBTQQIA community: An interpretative phenomenological analysis. Journal of Lesbian, Gay, Bisexual, and Transgender Issues in Counseling, 9 (4), 288–310. doi:10.1080/15538605.201 5.1103679. Garfinkel, H. (1967). Studies in ethnometholology. Englewood Cliffs, NJ: Prentice-Hall. Grossman, A. H., & D’Augelli, A. R. (2007). Transgender youth and life-threatening behaviors. Suicide and Life-Threatening Behavior, 37 (5), 527–537. doi:10.1521/suli.2007.37.5.527. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H. C., Loos, B., . . . Kocet, M. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling com­ petencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individuals. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi:1080/15538605.20 13.755444. Kessler, S. J., & McKenna, W. (1978). Gender: An ethnometh­ odological approach. Chicago: John Wiley & Sons. National Center for Transgender Equality. (2019). Know your rights: Schools. https://transequality.org/know-your-rights/ schools. Orr, A., & Baum, J. (2015). Schools in transition: A guide for supporting transgender students in K–12 schools. http:// hrc-assets.s3-website-us-east-1.amazonaws.com//files/ assets/resources/Schools-In-Transition.pdf. Parent, M. C., Deblaere, C., & Moradi, B. (2013). Approaches to research on intersectionality: Perspectives on gender, LGBT, and racial/ethnic identities. Sex Roles, 68 (11–12), 639–645. doi:http://dx.doi.org.iris.etsu.edu:2048/ 10.1007/s11199-013-0283-2. Sampson, I. (2014). Gender: The infinite ocean. Communities, 162, 35–38. Stone, C. (2015). Transgender and gender nonconforming students: Advocate for best practice. https://www.school counselor.org/magazine/blogs/september-october-2015/ transgender-and-gender-nonconforming-students-adv. Toomey, R. B., Ryan, C., Diaz, R. M., Card, N. A., & Russell, S. T. (2010). Gender-nonconforming lesbian, gay, bisex­ ual, and transgender youth: School victimization and young adult psychosocial adjustment. Developmental Psychology, 46 (6), 1580–1589. doi:10.1037/a0020705.

EXPANDING BINARY THINKING: A REFLECTIVE ACTIVITY FOR PARENTS AND CAREGIVERS OF TRANSGENDER AND GENDER-EXPANSIVE YOUTH 1. There are two, and only two, genders (male and female). 2. One’s gender is invariant. (If you are female/male, you always were female/male and you always will be female/male.) 3. Genitals are the essential sign of gender. (A female is a person with a vagina; a male is a person with a penis.) 4. Any exceptions to the two genders are not to be taken seriously. (They must be jokes, pathology, etc.) 5. There are no transfers from one gender to another except ceremonial ones (masquerades). 6. Everyone must be classified as a member of one gender or the other. (There are no cases where gender is not attributed.) 7. The female-male dichotomy is a “natural” one. (Males and females exist independently of scientists’ —or anyone else’s—criteria for being male or female.) 8. Membership in one gender or the other is “natural.” (Being female or male is not dependent on anyone’s deciding what you are.) 9. Gender expression should always match gender identity. Any incongruence between gender expression and gender identity should not be taken seriously and must be for entertainment purposes only. 10. There is only one sexual orientation: heterosexual. Any other sexual orientation that does not fit into this category (gay, lesbian, bisexual) should not be taken seriously and shall be considered immoral. 11. There are two and only two sexual orientations (gay/lesbian and heterosexual). Any other sexual orientation that does not fit into these two categories should not be taken seriously, shall be considered a phase, or may be understood as sexual identity confusion. 12. There are two and only two types of relationship status (single or married/partnered). A person who identifies as engaging romantically or sexually in anything other than a monogamous, committed relationship will not find true happiness in life and shall not be considered moral. After reflecting on the statements above, consider the following questions: a. Did you become aware of any personal beliefs or values that you were unaware of previously? b. What is the potential effect of your beliefs on your child? c. Would you consider expanding your views to include multiple understandings of human sexuality, affectional attraction, gender, and relationships? d. If there are beliefs or values you personally stand firmly on, how might you avoid imposing them on your child and convey love and support?

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31 PARENTS OF TRANSGENDER TEENS AND THE INITIAL DISCLOSURE PROCESS Laura R. Haddock and Hilary Meier Suggested Uses: Handout, homework Objective

The goal of this exercise is to educate caregivers on facts related to gender identity. An additional goal is to encourage caregivers to initiate an honest reflection of their own experience after their child discloses as transgender. Rationale for Use

The disclosure process for transgender adolescents can be terrifying, not only for the teenager, but also for their family and friends. It is often a time of high emo­ tions that move along a continuum from confusion, shock, disbelief, rejection, anger, and grief to accep­ tance, peace, understanding, and concern (Field & Mattson, 2016). Researchers examining the disclosure experiences of transgender teens report that the pro­ cess of coming out is frequently mediated by factors that are unique to each individual, such as fear, safety, and personal circumstances (Klein, Holtby, Cook, & Travers, 2015). For some youth, despite the potential for negative consequences, disclosing their gender identity is “pure necessity” (Klein et al., 2015, p. 308). Transgender youth who feel a sense of family acceptance report better physical, mental, and educa­ tional outcomes all around (Hunt & Moodie-Mills, 2012). Until parents understand the concept of gender identity, they may question their relationship with their children and the home environment that they fostered (Gross, 2013). Parents may grieve the loss of their expectations and the future that they imagined for themselves and their child (Field & Mattson, 2016).

This exercise is designed to help parents gain clarity, answer questions, and raise self-awareness related to gender identity. It is important at this potentially frag­ ile time for parents to be well informed and educated about gender identity, as well as to have the opportu­ nity to process their own thoughts, feelings, and beliefs related to gender identity. Therapists can provide a compassionate environment to support parents whose teens are moving through the disclosure process. These resources may be used to facilitate greater under­ standing and increased self-awareness with parents in a neutral and affirming way. Studies show that many children and adolescents from diverse backgrounds identify as transgender at an earlier age than historically recorded (Svab & Kuhar, 2014). This means that youth often disclose their identity and come out while still living with their parents (D’Augelli, Grossman, Starks, & Sinclair, 2010). Research tells us that many adolescents dis­ close gender disparity to a friend or other person close to them before coming out to their parents and family (Beals & Peplau, 2006), that motivation for coming out varies from individual to individual and by ethno­ cultural background, and that many youth long to be close to their families (Svab & Kuhar, 2014). Of impor­ tance is the reality that when youth disclose their gender identity to parents, they face both the imme­ diate and long-term reactions of their parents. For example, if a teen’s disclosure results in parental rejec­ tion, that rejection can leave the youth emotionally and physically vulnerable, particularly if they find themselves cast onto the streets with nowhere to turn for support (Hunt & Moodie-Mills, 2012). Managing

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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the transition into the awareness of a gender-minority status is stressful for both teens and caregivers as it may change the significant family relationships that structure their lives, in addition to their relationships with friends and other significant adults (Ryan et al., 2010). While it would be ideal for every parent to receive a teen’s disclosure of transgender identity with open arms and an attitude of loving acceptance, this is often not the case (Pyne, 2016). Parents may exhibit a series of hostile attitudes and feelings against transgender people, grounded in their own cultural iden­ tity (American Psychological Association, 2011). Being insulted by a parent can be hurtful to a child, and those with nonconforming gender identities are at great risk of experiencing oppression (Hebard & Hebard, 2015). Throughout history, many thriving cultures have recognized and integrated gender variance (Brill & Pepper, 2008; McKitrick, 2015). Being mindful of the cultural identity of the family system and honoring the variety of potential cultural and racial contexts of parents are critical. Therapists should orient them­ selves beyond the Western tradition of a binary percep­ tion of gender (Dea, 2016). For example, the Navajo culture recognizes an identity that integrates identity of boy and girl (“A Map of Gender Diverse Cultures,” 2015). Another example is Hawaiian culture, which recognizes a gender identity that embraces the inter­ section of both the male and female spirit (“A Map of Gender Diverse Cultures,” 2015). The therapist can use a wellness- and strengthsbased approach that employs the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) (2009) competencies for counseling with transgender clients. Creating a friendly, supportive environment that affirms people who identify as transgender will set a tone of respect in accordance with ALGBTIC competency C.9 (ALGBTIC, 2009). For all interactions that involve the family of a transgender teen, competency C.7. (ALGBTIC, 2009, p. 7) advises the therapist to “acknowledge that physical (e.g., access to health care, HIV, and other health issues), social (e.g., fam­ ily/partner relationships), emotional (e.g., anxiety, depression, substance abuse), cultural (e.g., lack of support from others in their racial/ethnic group),

spiritual (e.g., possible conflict between their spiritual values and those of their family’s), and/or other stress­ ors (e.g., financial problems as a result of employ­ ment discrimination) often interfere with transgen­ der people’s ability to achieve their goals.” Therefore, taking a proactive approach to assisting parents in regulating their affect, thoughts, and behav­ ior throughout this disclosure process ultimately has the potential to help both the transgender youth and the caregivers navigate a very complex process and, ideally, strengthen the adult-child relationship. Stud­ ies of parents of LGBT youth following the comingout process have shown that parental reactions range from feelings of cognitive dissonance related to a lack of understanding to intense love and protectiveness for their child (Conley, 2011). Cognitive-emotional dissonance causes many caregivers to disengage from routine parenting functions and to withdraw socially (Pallotta-Chiarolli, 2005). Thus, as the youth discloses a nonconforming gender identity, the parents often shut down (Svab & Kuhar, 2014) as they face learn­ ing to adapt to the new identity of being a parent of a child who belongs to a stigmatized minority group (Grafsky, 2014). This can be especially important for the adoles­ cent, as perceived caregiver attitudes toward the youth’s identity have been found to have a significant rela­ tionship to the teen’s emotional adjustment following the disclosure process (Darby-Mullins & Murdock, 2007). The perceived acceptance and support from parents has been associated with better mental, emo­ tional, and behavioral health (D’Augelli, 2003; Ryan et al., 2010). Conversely, perceived negative parental reactions have been associated with increased psy­ chological symptoms, depression, suicide attempts, illegal drug use, and sexually risky behaviors (D’Am­ ico, Julien, Tremblay, & Chartrand, 2015; Willoughby, Doty, & Malik, 2010). By guiding caregivers toward valuing their children and supporting their choice to live authentically, parents can be assisted through emotional uncertainty into a position of advocacy. Through affirmative practice, caregivers may feel that their parental rights are legitimized, gain the safety of sharing authentic feelings, and learn to be a resource and lifelong advocate for their progeny.

Parents of Transgender Teens and the Disclosure Process 271

Instructions

The glossary of terms (see page 276) is intended to be a starting point for discussion related to gender identity, and it is designed to serve as a psychoeduca­ tional resource. This handout includes definitions of a variety of terms related to gender identity, and it may be shared with parents as appropriate. It is important to remain cognizant that terms are ever-changing and that clinicians should research the most current terms, as well as terms that are familiar and used by the cli­ ent, before handing out the glossary. Therapists may choose to dedicate an entire session to reviewing the glossary and answering caregiver questions or use the glossary review as an introduction to the reflective exercise. Once the therapist is satisfied that the care­ givers have working knowledge of the glossary’s terms, they may initiate the reflective exercise. The reflec­ tive exercise can be conducted in one or multiple ses­ sions, depending on each caregiver’s individual needs, emotional state, and developmental process. This exercise can be deeply emotional, and ther­ apists should be prepared to fully support and medi­ ate parental reactions. Thus, the therapist may choose to give the caregiver the self-reflection sections one at a time or all at once. When executing the exercise, the caregiver should be provided with the questions and allowed some quiet time to complete the answers. Because most sessions are limited to roughly an hour, that is probably not enough time to fully answer and explore all sections of the exercise. Thus, the thera­ pist may opt to use one session to have the caregiver draft the answers and another session (or sessions) to explore the content. Alternatively, the therapist can administer the exercise in sections over the course of multiple sessions. There is no identified benefit to offering the questions in a particular order, and it is recommended that therapists tailor the selection of items to meet the needs of each particular client. Brief Vignette

Paul and Keisha are the biological grandparents of Misha, a fifteen-year-old who was assigned female at birth and who has recently come out as transgender and uses he, him, and his pronouns. Paul and Keisha are the legal guardians and primary caregivers for Misha and are a working-class couple who identify as 272 Haddock & Meier

African American and Seventh-Day Adventist. There are no reported physical health problems within the family. Misha was initially enrolled in therapy by his grandparents to address self-injurious behavior, and sessions have included both individual and family appointments in conjunction with Paul and Keisha. Misha, who has asked to be called Mike, expressed gender dysphoria and ultimately disclosed a transgen­ der identity to his therapist. He recently disclosed being transgender to his caregivers by writing a letter. Following the receipt of the letter, Paul and Keisha requested an appointment to meet with the therapist without Mike. Mike fully supports the therapist’s meet­ ing with his grandparents and is relieved that they are willing to discuss his disclosure as transgender. Paul and Keisha arrive for the first counseling ses­ sion independent of Mike, presenting as distraught and angry. The therapist indicates that the goal for the session is to process Keisha’s and Paul’s thoughts and feelings after receiving Mike’s disclosure letter. The therapist expresses empathy for their experience and the challenge of understanding what has happened. Keisha angrily states, “She is not a boy. She is messed up and needs help.” Paul is initially very quiet. He does not verbalize that he agrees with Keisha’s position but does not offer an alternative perspective either. The therapist initiates an inquiry to assess Paul’s and Kei­ sha’s level of understanding of the concepts of gender identity. At this point, Paul speaks up and asks if this means that Misha is gay. Keisha, maintaining her defensive position, bitterly comments that “Misha has always been a tomboy and she is just confused.” It becomes clear that education is a good starting point. Providing Keisha and Paul each a copy of the glossary of terms, the therapist asks them to review the information and to feel free to ask questions. They are gently encouraged to open themselves up to learn­ ing more about what it means to be trans or genderqueer and to gain understanding of what Mike may be going through. Paul and Keisha both articulate a desire to maintain a relationship with Mike and agree to learn more about what it means to be trans or gen­ derqueer. The remainder of the session is dedicated to answering Paul’s and Keisha’s questions related to sex­ ual and gender identity because they conflate the two concepts. The session concludes with both guardians

expressing greater understanding of gender identity and how it is separate from sexual orientation. They both present as more calm, and each actively partici­ pate in discussion. The therapist encourages Paul and Keisha to write down any questions that come up for them after the review of the glossary and asks them to bring those questions to their next session. Each expresses a willingness to assume a neutral position and an understanding of their role in preserving their relationship with Mike. They are encouraged to affirm their love and commitment to Mike, and it is deter­ mined that they will participate in a few independent sessions with the therapist to complete the reflective exercise and process their thoughts, feelings, and questions. Upon completion of the reflective exercise and any subsequent follow-up, they will reconvene for a family session.

identity. One contraindication of the reflective exercise is the potential for disrupted parent-child communi­ cation if caregivers become triggered with intense emotions or the relationship between parents and youth is particularly fragile. It may be best not to use this activity if the risk of a period of decreased com­ munication between caregiver and child outweighs the benefits of heightened self-awareness for parents. Therapists are cautioned against using the reflec­ tive exercise with caregivers who demonstrate a partic­ ularly unstable emotional state. Though it is common for parents to make comments like “it feels like my world has been flipped upside-down” and “it feels like a death in the family,” this activity requires a capacity for logic and insight, and it should not be used with caregivers who demonstrate a pervasive pattern of maladaptive cognitions or behavior.

Suggestions for Follow-up

Professional Resources

The exercise of the glossary of terms may introduce caregivers to a great deal of new information. Follow­ ing an initial review of the glossary, the therapist may want to follow up by verifying that the information is clear and that there are no questions. The therapist may choose to encourage caregivers to write down questions and bring them to the follow-up appoint­ ment to help ensure that all concerns are addressed. After completing the self-reflective exercise, an additional follow-up could include preparing the care­ givers for a family session together with the child or teen. Topics for follow-up with the teen could include a response to the disclosure about gender identity, exploration of the implications of the disclosure on the caregivers and teen’s relationship, or perceptions about what challenges the future may hold for the youth, the caregiver, or both. Remember that cultural norms inform belief systems, frames, perceptions, understandings, and behaviors. Ideally, the follow-up will facilitate affirmative exchanges between caregivers and teens. Contraindications for Use

Therapists should use the glossary of terms as needed depending on caregiver knowledge. The glossary is not necessary to use with caregivers who demonstrate working knowledge of concepts related to gender

Dea, S. (2016). Beyond the binary: Thinking about sex and gender. Peterborough, Ont.: Broadview Press. dickey, l., Singh, A., Chang, S., & Rehrig, M. (2017). Advocacy and social justice: The next generation of counseling and psychological practice with transgender and gender non­ conforming clients. In A. Singh & l. dickey (eds.), Affir­ mative counseling and psychological practice with transgender and gender nonconforming clients. Washington, DC: American Psychological Association. Dispenza, F., & O’Hara, C. (2016). Correlates of transgender and gender nonconforming counseling competencies among psychologists and mental health practitioners. Psychology of Sexual Orientation and Gender Identity, 3 (2), 156–194. doi:10.1037/sgd0000151. Erickson-Schroth, L. (ed.). (2014). Trans bodies, trans selves. New York: Oxford University Press. Gender Spectrum. (2017). Gender Spectrum helps to create gender sensitive and inclusive environments for all chil­ dren and teens. https://www.genderspectrum.org/. Lev, A. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. Binghamton, NY: Haworth Press. National Center for Transgender Equality. (2017). About us. https://www.transequality.org/about. The National Cen­ ter for Transgender Equality is the nation’s leading social justice advocacy organization winning lifesaving change for transgender people. PFLAG New York City. (2016). Questions parents ask about transgender people. www.pflagnyc.org/support/trans genderquestions. PFLAG NYC is a partnership of par­ ents, allies, and LBGT people working to make a better future for LBGT youth and adults. Parents of Transgender Teens and the Disclosure Process 273

Winch, G. (2014). Emotional first aid: Healing rejection, guilt, failure, and other everyday hurts. New York: Hudson Street Press.

Resources for Clients Brill, S., & Pepper, R. (2008). The transgender child: A handbook for parents and professionals. San Francisco: Cleis Press. Brown, M. (2003). True selves: Understanding transsexualism —For families, friends, coworkers, and helping profession­ als. San Francisco: Jossey-Bass. Evelyn, J. (2007). Mom, I need to be a girl. Longmont, CO: Just Evelyn. Herman, J. (2009). Transgender explained for those who are not. Bloomington, IN: AuthorHouse. Krieger, E. (2011). Helping your transgender teen: A guide for parents. New Haven, CT: Genderwise Press. Kuklin, S. (2014). Beyond magenta: Transgender teens speak out. Somerville, MA: Candlewick Press. Tando, D. (2016). The conscious parent’s guide to gender iden­ tity: A mindful approach to embracing your child’s authentic self. Avon, MA: Adams Media. Transparenthood. (2016). Experiences raising a transgender child. https://transparenthood.net. TransPulse. (2017). TransPulse transgender resources. https:// transgenderpulse.com/. TransPulse is a support and research site for those on the transgender spectrum and their friends, family, and support system. Trans Youth Equality Foundation. (n.d.). Education, advocacy, and support for transgender youth and their families. www.transyouthequality.org. Wipe Out Transphobia. (2015). Activism, education, sup­ port, understanding. www.wipeouttransphobia.com/.

References American Counseling Association. (2014). ACA code of ethics. Alexandria, VA: Author. American Psychological Association. (2011). Answers to your questions about transgender people, gender identity, and gender expression. https://www.apa.org/topics/lgbt/ transgender.pdf. Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC). (2009). Competencies for coun­ seling with transgender clients. Alexandria, VA: Author. Beals, K. P., & Peplau, L. A. (2006). Disclosure patterns within social networks of gay men and lesbians. Journal of Homo­ sexuality, 51, 101–120. doi:10.1300/J082v51n02_06. Bregman, H. R., Malik, N. M., Page, M. J. L., Makynen, E., & Lindahl, K. M. (2013). Identity profiles in lesbian, gay, and bisexual youth: The role of family influences. Journal of Youth and Adolescence, 42, 417–430. doi:10.1007/ s10964-012-9798-z. Brill, S., & Pepper, R. (2008). The transgender child: A handbook for families and professionals. San Francisco: Cleis Press.

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Conley, C. (2011). Learning about a child’s gay or lesbian sex­ ual orientation: Parental concerns about societal rejection, loss of loved ones, and child well-being. Journal of Homo­ sexuality, 58, 1022–1040. doi:10.1080/00918369.2011.59 8409. D’Amico, E., Julien, D., Tremblay, N., & Chartrand, E. (2015). Gay, lesbian, and bisexual youths coming out to their par­ ents: Parental reactions and youths’ outcomes. Journal of GLBT Family Studies, 11 (5), 411–437. doi:10.1080/1550 428X.2014.981627. Darby-Mullins, P., & Murdock, T. B. (2007). The influence of family environment factors on self-acceptance and emo­ tional adjustment among gay, lesbian, and bisexual ado­ lescents. Journal of GLBT Family Studies, 3, 75–91. doi:10.1300/J461v03n01_04. D’Augelli, A. R. (2003). Lesbian and bisexual female youths aged 14 to 21: Developmental challenges and victimiza­ tion experiences. Journal of Lesbian Studies, 7, 9–29. doi:10.1300/J155v07n04_02. D’Augelli, A. R., Grossman, A. H., Starks, M. T., & Sinclair, K. O. (2010). Factors associated with parents’ knowledge of lesbian, gay, and bisexual youths’ sexual orientation. Journal of GLBT Family Studies, 6, 1–21. doi:10.1080/1550 4281003705410. Dea, S. (2016). Beyond the binary: Thinking about sex and gender. Peterborough, Ont.: Broadview Press. Field, T., & Mattson, G. (2016). Parenting transgender children in PFLAG. Journal of GLBT Family Studies, 12 (5), 413– 429. doi:10.1080/1550428X.2015.1099492. Grafsky, E. L. (2014). Becoming the parent of a GLB son or daughter. Journal of GLBT Family Studies, 10, 36–57. doi: 10.1080/1550428X.2014.857240. Gross, G. (2013, August 13). Parenting advice: When your gay child comes out (blog post). http://www.huffington post.com/dr-gail-gross/when-your-gay-child-comes­ out_b_3437051.html. Hebard, S., & Hebard, A. (2015, February 26). Beyond LGB. Counseling Today. https://ct.counseling.org/2015/02/ beyond-lgb/. Hunt, J., & Moodie-Mills, A. (2012, June 29). The unfair crim­ inalization of gay and transgender youth: An overview of the experiences of LGBT youth in the juvenile justice sys­ tem. Center for American Progress. https://www.ameri canprogress.org/issues/lgbt/reports/2012/06/29/11730/ the-unfair-criminalization-of-gay-and-transgender-youth/. Klein, K., Holtby, A., Cook, K., & Travers, R. (2015). Compli­ cating the coming out narrative: Becoming oneself in a heterosexist and cissexist world. Journal of Homosexual­ ity, 62, 297–326. doi:10.1080/00918369.2014.970829. A map of gender diverse cultures. (2015, August 11). Inde­ pendent Lens. www.pbs.org/independentlens/content/ two-spirits_map-html/.

McKitrick, J. (2015). A dispositional account of gender. Phil­ osophical Studies, 172 (10), 2575–2589. doi:10.1007/ s11098-014-0425-6. Mohr, J. J., & Fassinger, R. E. (2003). Self-acceptance and selfdisclosure of sexual orientation in lesbian, gay, and bisexual adults: An attachment perspective. Journal of Counseling Psychology, 50, 482–495. doi:10.1037/0022­ 0167.50.4.482. Pallotta-Chiarolli, M. (2005). When our children come out: How to support gay, lesbian, bisexual, and transgendered young people. Sidney, Australia: Finch Publishing. Pyne, J. (2016). Parenting is not a job . . . it’s a relationship: Recognition and relational knowledge among parents of gender non-conforming children. Journal of Progressive Human Services, 27 (1), 21–48. doi:10.1080/10428232.20 16.1108139.

Ryan, C., Russell, S. T., Huebner, D., Diaz, R. M., & Sanchez, J. (2010). Family acceptance in adolescence and the health of LGBT young adults. Journal of Child and Adolescent Psychiatric Nursing, 23, 205–213. doi:10.1542/peds.2007­ 3524. Svab, A., & Kuhar, R. (2014). The transparent and family clos­ ets: Gay men and lesbians and their families of origins. Journal of GLBT Family Studies, 10, 15–35. doi:10.1080/1 550428X.2014.857553. Willoughby, B. L., Doty, N. D., & Malik, N. M. (2010). Victim­ ization, family rejection, and outcomes of gay, lesbian, and bisexual young people: The role of negative GLB identity. Journal of GLBT Family Studies, 6, 403–424. doi :10.1080/1550428X.2010.511085.

Parents of Transgender Teens and the Disclosure Process 275

GENDER IDENTITY GLOSSARY OF TERMS Agender: A person whose identity is nonbinary or who may feel as though they are genderless or do not have a gender. Androgynous: Possessing both masculine and femi­ nine traits. Presenting in a way that appears not entirely masculine or entirely feminine. Androgyny can occur in regard to fashion, gender, physical characteristics, and so on. Bigender: A person who identifies as both masculine and feminine. They may feel that they shift between a distinct feminine identity and masculine identity, or as though their gender identity encompasses a combi­ nation of their feminine and masculine identities. Cisgender: A person who is not under the transgender umbrella. Demigirl/Demiboy: A demigirl is a person who feels their gender identity is partially feminine but is not wholly binary, regardless of their assigned gender. Like­ wise, a demiboy is a person who feels their gender identity is partially masculine but is not wholly binary. Like a demigirl, a demiboy may identify this way regardless of their assigned gender. Dysphoria: A state of feeling unhappy; discomfort with oneself emotionally, mentally, or physically. Some­ one with gender dysphoria experiences significant discontent with their sex assigned at birth. Gender: The state of being male, female, or however one defines oneself on the gender spectrum. Gender dysphoria: The formal diagnosis used by counselors, psychologists, and other providers for people with significant body dysphoria. Genderfluid: A person whose gender is fluid, mean­ ing their gender can shift and change from various points on the spectrum; they may feel as though their gender is in a constant state of motion and readily shifts from one state to another. Gender nonconforming: The behavior or expression of not conforming to society’s definitions of male and female. Genderqueer: A person who identifies as neither, both, or a combination of male and female genders. Gender transition: A period during which a transgen­ der person may decide to change their physical appear­ ance and body to match their internal gender identity. 276

Intersex: A general term used for a variety of condi­ tions in which a person is born with reproductive or sexual anatomy that doesn’t fit the typical definition of male or female. Neutrois: Another identity that falls under the umbrella of gender-neutral or transgender identities. In most cases, neutrois can be understood as inter­ changeable with gender neutral. There is, however, not one singular definition for neutrois because everyone experiences gender in a different way. Nonbinary: A person who feels their gender identity does not fall within the accepted gender binary of male or female and may feel as though they are both, neither, or a mixture of the two. Sex: The biological and physiological characteristics of male and female. Sexuality: A person’s sexual preference or orienta­ tion—for example, gay, straight, bisexual, pansexual, transsensual, and so on. Transgender: A person whose self-identity does not conform unambiguously to conventional notions of male or female gender. Transfeminine: Used to describe transgender people who were assigned male at birth but who identify with femininity to a greater extent than with masculinity. Transmasculine: Used to describe transgender people who were assigned female at birth but who identify with masculinity to a greater extent than with femininity. All the terms offered here are intended as flexible, working definitions. Cultural identity, socioeconomic background, region, race, and age may all influence the understanding and interpretation of these terms. Every effort was made to use the most inclusive lan­ guage possible while also offering useful descriptions. This information was adapted from the following sources: • http://genderqueerid.com/gq-terms • https://www.hrc.org/resources/sexual-orientation­ and-gender-identity-terminology-and-definitions • https://spectrumcenter.umich.edu • https://nonbinary.org/wiki/List_of_nonbinary_ identities • https://thesafezoneproject.com/

Laura R. Haddock and Hilary Meier

REFLECTIVE QUESTIONS FOR PARENTS OF TRANSGENDER TEENS Initial Disclosure 1. What does being transgender mean to me? 2. How is my child’s gender identity a reflection of me? 3. Does knowing my teen identifies as transgender change the way I feel about them? 4. Do I believe my teen is rebelling, experimenting, or going through a phase? 5. Why do I believe my child chose this time to tell me that they are transgender? 6. Does my teen’s being transgender leave me feeling as if I am losing the child I know? 7. What do I think my child needs from me to feel safe to talk to me about being transgender? 8. How will I feel if my child asks me to call them by a different name or use different pronouns? 9. How do I feel about connecting with other parents and youth going through this process? 10. What do I need to embrace my child who identifies as a new gender? Sexual Orientation 11. Do I associate transgender with being gay or lesbian? 12. How will I feel if my teen is sexually attracted to the gender they were assigned at birth? 13. How do I feel about having a child who is gay? 14. Would I rather my son or daughter be gay than transgender? Safety 15. How worried am I that my child will be discriminated against? 16. Am I afraid for my teen’s safety? 17. Do I worry that my family will be targeted for hate crimes or stereotyping? 18. How will I feel if my child is bullied because of their gender identity? School 19. What are my concerns about my teen’s returning to school after disclosing as transgender? 20. How do I feel about my teen’s using the restroom of the gender that they identify with, either in public or at school? 21. What responsibility do I feel my school has to support my child’s gender identity?

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Religious or Spiritual Beliefs 22. What are my religious beliefs in relation to transgender identities? 23. If my religious beliefs are not affirming toward my teen’s identity shift, what does that mean for me? 24. How will I deal with a conflict between my spiritual or religious beliefs and my teen’s identity? 25. If I take an affirmative position and support my child’s transition, how important is it to me for my place of worship to support that decision? Parental Uncertainty or Guilt 26. Do I believe there is something I could have done as a parent to prevent my teen from being transgender? 27. Am I worried that I did something as a parent to contribute to my child’s being transgender? 28. Am I concerned that my child is transgender because of something I or my spouse did during my pregnancy? 29. What will I do if my teen’s other caregiver(s) doesn’t feel the same way I do? Disclosing to Others 30. Am I worried about how I will tell other people my child is transitioning or transgender? 31. Am I worried that other people will judge me, my teen, or my family when they find out that my child identifies as transgender? 32. Would I prefer to keep this information private within our family? 33. Do I have concerns that our family will be treated differently after my teen comes out publicly? Puberty and Transitioning 34. How do I feel about allowing my child to take hormones or wear a binder? 35. How would I feel if my teen began to dress as the gender opposite the one they were assigned at birth? 36. Do I feel clearly informed and educated about hormone treatment or puberty-delaying interventions? 37. How will I find the information that I need to clearly understand the implications of using hormone therapy? Surgery and Body Modification

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38. How will I feel if my child wants gender-affirmation surgery? 39. Am I feeling overwhelmed by the idea of my child’s surgically altering their body? 40. Do I feel that I know where to get information and support for reassignment surgery? 41. What is my opinion about my teen’s permanently changing their body? 42. Do I clearly understand what happens during gender-affirmation surgery? Legal Issues 43. Am I concerned that there will be negative consequences for my child if they legally change their gender and name? 44. Do I believe my child will have difficulty finding a job or attending college? 45. What will it mean to me if my child asks to change a name or gender on legal documents?

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32 MAINTAINING THE FAMILY UNIT WHEN AN ADOLESCENT FAMILY MEMBER COMES OUT AS A SEXUAL OR GENDER MINORITY Susannah C. Coaston, Patia Tabar, and Lori Barrett Suggested Use: Activity Objective

The goal of this activity is to help the family under­ stand the possible consequences of rejecting or nonaffirming statements and behaviors for the adolescent client. This activity gives the client an opportunity to share the effect of these rejecting experiences with the family and to rebuild family cohesion. Acceptance by the family ensures the integrity of the family unit, allows the client to live without the fear of rejection, and increases the overall well-being of the adolescent client. Rationale for Use

Family therapy, when combined with experiential interactions, is helpful in creating meaningful com­ munication between family members, including adolescents and their caregivers (Thompson, Bender, Cardoso, & Flynn, 2011). Additionally, clients who feel engaged in the therapeutic process participate more and are more likely to support treatment goals (Broome, Joe, & Simpson, 2001). Participation in fam­ ily therapy can help develop a greater sense of belong­ ing and connection between parents and children, which in turn enhances engagement in the therapeutic process (Thompson, Bender, Lantry, & Flynn, 2007). For sexual orientation or gender identity (SOGI) minority youth, there exists a host of unique stressors. In the Gay, Lesbian, and Straight Education Network’s (GLSEN) 2015 National School Climate Survey, 85 per­

cent of students who responded to the survey reported verbal harassment, 27 percent reported physical harass­ ment, 13 percent reported physical assault, and, alarm­ ingly, nearly 60 percent reported sexual harassment in their school during the previous year (Kosciw et al., 2016). In an earlier study based on the 2009 GLSEN data, researchers found that victimization in the school environment can result in reduced self-esteem, as well as lower grade-point averages and more absences, par­ ticularly in schools with fewer supportive educators (Kosciw, Palmer, Kull, & Greytak, 2013). Approximately 42 percent of SOGI minority youth report online harassment or bullying, which is three times the rate of heterosexual or cisgender youth bullying (GLSEN, CiPHR, & CCRC, 2013). As a result of the stresses experienced by SOGI minority youth, the chance of depression, substance use, and risky sexual behaviors increases (Centers for Disease Control and Preven­ tion, 2014; Marshal et al., 2011). In terms of substance abuse, sexual minority youth are five times more likely to use illegal drugs (Kann et al., 2016). Gender-identity minorities also have increased risk of substance use (Reisner, Greytak, Parsons, & Ybarra, 2015). For ado­ lescents, suicide is the second most common cause of death (Heron, 2016); however, sexual minority youth are two to four times more likely to attempt suicide (CDC, 2014; Kann et al., 2016). Reisner, Vetters, and colleagues (2015) found rates of depression, anxiety, suicidal ideation, suicide attempts, self-harm, and inpatient and outpatient mental health use two to three times the rates of cisgender peers. SOGI minority

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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youth are also at a greater risk of both suicidal ideation and nonsuicidal self-harm as a result of victimization (Liu & Mustanski, 2012), including a heightened risk for rural versus urban youth both online and in per­ son (GLSEN et al., 2013; Kosciw, Palmer, & Kull, 2014). Coming out or disclosing one’s identity can be a challenging task for adolescents (Legate, Ryan, & Weinstein, 2012), the challenge often being related to a fear of rejection or of damaging the relationship with the family (Potoczniak, Crosbie-Burnett, & Saltzburg, 2009). These concerns can be compounded for SOGI minority youth who are also ethnic minorities (e.g., African American, Asian American, Latin American, or American Indian). Intersectionality refers to the awareness and experience of those with multiple cate­ gories of identities (e.g., race, class, gender, nationality) and how the overlay of these distinct identities can affect the experience of any one of these identities (Gibson, Alexander, & Meem, 2014). Viewed through this lens, SOGI minority youth who are ethnic minori­ ties may experience discrimination and lack of privi­ lege as a result of how our culture views race, sexuality, and gender identity. Limited literature exists that focuses on the challenges that can exist for these youth owing to racial, ethnic community, or family values; however, adherence to traditional values and level of acculturation may play a significant role (Potoczniak et al., 2009). Further, it is important to note that there exist significant within-group differences, along with similarities and differences between groups within each culture (Ratts et al., 2015). Cultures that have a collectivist orientation, such as Asian American, African American, and Latin Amer­ ican, tend to give priority to harmony in relationships with family members, and actions and decisions are determined by a sense of duty or obligation to the fam­ ily unit (Sauceda, Paul, Gregorich, & Choi, 2016). Such cultures tend to embed the self in the relation­ ship with family (Sauceda et al., 2016). For the SOGI youth from these backgrounds with particularly strong kinship ties, the fear of losing the support of family as a result of coming out can be overwhelming (LaSala, 2010). Overall, coming out for SOGI minority youth can have significant implications for the household, so ethnic minority youth are less likely to be out to their families (Grov, Bimbi, Nanín, & Par­

sons, 2006). Thus, some researchers have concluded that the factors that determine disclosure to family for ethnic minority youth warrant further research (Potoczniak et al., 2009). Unfortunately, there is a lack of empirical infor­ mation available that specifically speaks to how having a transgender family member affects the family unit (Whitley, 2013). As a whole, however, transgender youth face high levels of family rejection and home­ lessness, and transgender youth of color experience additional challenges because of racism (Bith-Melander et al., 2010). When a SOGI minority youth comes out, the entire family unit can be affected. Studies have shown that parental rejection can lead to a decrease in ado­ lescent self-esteem and emotional well-being (Shpigel, Belsky, & Diamond, 2015). Implicit or explicit criti­ cism, rejection, shaming, and other types of emotional and physical abuse increase an adolescent’s risk for depression and suicidal ideations (Shpigel et al., 2015). This lack of tolerance or acceptance demonstrated by parents shreds the basic attachment between the par­ ents and child, and it also has the capacity to destroy the child’s self-esteem (Gutierrez & Hagedorn, 2013). Parents whose views are based on the belief that their child is “choosing” to be gay in contravention of their closely held religious beliefs are more likely to resort to sexual-orientation change efforts (SOCE) to convert their child to heterosexuality, thereby driving a wedge between themselves and the child (Diamond & Shpigel, 2014). The more the child’s sexuality or gender identity is seen as controllable, the more negative the response toward the child becomes (Armesto & Weisman, 2001). When parental acceptance is present, however, it tends to result in lower depression scores and a reduced sensitivity to discrimination, rejection sensitivity, and internalized homophobia (Feinstein, Wadsworth, Davila, & Goldfried, 2014). Often, SOGI minority youth find themselves homeless as a result of family rejection. The Lesbian, Gay, Bisexual, and Transgender (LGBT) Homeless Youth Provider Survey indicated that the top two rea­ sons for homelessness were running away following family rejection because of sexual orientation or gen­ der identity and being forced out of the home as a result of the same (Durso & Gates, 2012). Approximately

Maintaining the Family Unit When an Adolescent Comes Out 281

40 percent of all homeless youth identify as LGBTQ, and 68 percent of those youth reported that being rejected by their families was the primary cause (Durso & Gates, 2012). Anecdotal evidence suggests that emo­ tional distress caused by family rejection can have disastrous consequences. For example, a Cincinnati transgender adolescent, Leelah Alcorn, reported that her parents responded to the disclosure of her gender identity by telling her, “God doesn’t make mistakes.” Additionally, they took her to Christian therapists who reinforced their opinion that being transgender is wrong. Leelah ultimately walked four miles from her house to Interstate 71, where she completed sui­ cide by deliberately walking into the path of an oncom­ ing tractor-trailer (Fox, 2015). In recognition of the challenges that SOGI minority youth face and the critical importance of parental acceptance, counselors should work to keep up-to-date with advances in the literature to provide culturally sensitive and appropriate care. Counselors must be careful to avoid imposing their own attitudes, values, and beliefs on clients, and they must be sensi­ tive to cultural differences regarding issues of sexual orientation and gender (American Counseling Asso­ ciation [ACA], 2014). Counselors should examine potential biases and heteronormative or transnegative assumptions or beliefs that could present a barrier to providing affirmative practice and gain cultural com­ petence regarding unique challenges and experiences of SOGI minority individuals (McGeorge & Carlson, 2011; Singh & dickey, 2016). For many counselors, it can be challenging to be supportive and understand­ ing of parents who behave in ways that can be hurt­ ful to their child; however, it is important for parents to have a safe environment in which they can feel free to work through their feelings without sensing judg­ ment from the counselor (Shpigel & Diamond, 2014). The Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC), a divi­ sion of the ACA, published a list of competencies for those working with sexual minorities (Harper et al., 2013) and competencies for counseling transgender clients (Burnes et al., 2010). Among the specific rec­ ommendations are several general suggestions for cre­ ating a safe environment in a counseling setting. Coun­ selors are encouraged to continue their education 282 Coaston, Tabar, & Barrett

through workshops and conferences, but also through dialogue with SOGI minority individuals, reading about life experiences that may be similar to or differ­ ent from their own, and educating themselves on the sociopolitical climate and how it influences laws and policies that affect their clients’ lives (Harper et al., 2013). Counselors should use respectful and inclusive language and client-identified, gender-affirming pro­ nouns or names when appropriate (Burnes et al., 2010; Harper et al., 2013). Doing so may involve a measure of flexibility and accommodation, as clients may ini­ tially express one preference but change as they explore their identity and identify another that fits better. Counselors should be careful not to misgender (i.e., use the wrong gender pronoun for) their clients; how­ ever, if misgendering occurs, counselors should cor­ rect themselves but avoid drawing excessive attention to the mistake (Stringer, 2011). It is important for counselors to recognize that coming out is an individ­ ual decision wherein SOGI minorities determine the process and extent to which they come out (Harper et al., 2013). Coming out has positive effects in terms of improved well-being; however, it can also increase the chances of victimization (Kosciw et al., 2014). Finally, the concept of family can refer to family of ori­ gin (whether biological or through adoption), for which this chapter is written. That said, counselors should honor a broader definition of family, or “family of choice,” that includes others defined by the SOGI individual (Burnes et al., 2010). When working with families from privileged and marginalized backgrounds, counselors should con­ sider the multicultural and social justice counseling competencies published by the Association for Mul­ ticultural Counseling and Development (AMCD), a division of the ACA (Ratts et al., 2015). As discussed above, family reactions to coming out vary across cultures; race and ethnicity can significantly affect the experience of coming out or be a causal factor in fami­ lies’ reactions (Potoczniak et al., 2009). Therefore, coun­ selors should seek to understand the family’s worldview on issues of sexual orientation or gender identity and how this influences their perspective on their SOGI minority youth’s identity. Further, counselors should consider how the SOGI minority youth view their own intersecting identities and how this affects their experiences.

TABLE 1. STATISTICAL RATES OF EXPERIENCES FOR SOGI MINORIT Y YOUTH

Kosciw et al. (2016)

Bullying

85% reported some form of bullying at school, including 60% reporting sexual harassment

GLSEN, CiPHR, & CCRC (2013)

Cyberbullying

3x more likely to experience online harassment or bullying than heterosexual peers

Kann et al. (2016)

Substance use/abuse

5x higher rates than heterosexual peers

Reisner, Greytak, et al. (2015)

Substance use/abuse

Increased odds over cisgender adolescents

Marshal et al. (2011)

Depression

2x higher rates than heterosexual peers

Reisner, Vetters, et al. (2015)

Anxiety, depression, self-harm

2–3x increased risk than cisgender youth

Liu & Mustanski (2012)

Self-harm

Higher rates than heterosexual or cisgender peers

Suicide/suicidal ideation

2–4x more likely than heterosexual peers to attempt suicide 3x increased risk of suicidal ideation and suicide attempts

CDC (2014); Kann et al. (2016); Reisner, Vetters, et al. (2015)

Instructions

This activity is designed for use in a family therapy session. Specifically, balloons are used to demonstrate the concept of familial unity and how that unity can be affected by the coming out of a teen or young adult member. The therapist provides balloons and a twelveinch length of string for each family member. Family members are instructed to blow up their balloons, and all but the client tie their balloons with a string. The client is instructed to hold their balloon firmly between their fingers to secure the opening, without letting air out. While standing in a circle, all members of the family unit hold their own balloons and press them carefully together in the center of the circle to demonstrate that the whole is greater than the individ­ ual parts. The therapist can comment on the strengths of the family unit on the basis of information gathered in previous sessions. Then the therapist asks the client to share a state­ ment that a family member has made to or about them that resulted in feelings of isolation or disconnection from the family unit because of their SOGI minority status. The client is then asked to move away from

the family unit with their balloon. This physical sep­ aration demonstrates the breakup of the integrity of the family unit in visual form. The counselor then begins to educate the family on the effect of rejection on SOGI minority adoles­ cents using the statistics stated above (Table 1) or newer statistics if available. Depending on the emo­ tional status of each member of the family unit, the counselor should determine which option of letting the air out of the balloon is appropriate: using a pin (concealed from the family) at the end of the exer­ cise or having the adolescent slowly release the air until the balloon is empty. As each statistic is stated, from least traumatic to most traumatic, the coun­ selor will ask the client to release just a little air from the balloon. When the counselor reveals the statistic regarding teen suicide for SOGI minority adoles­ cents, the counselor will reach for the client’s balloon and pop it with the pin. After allowing a moment of startled silence follow­ ing the popping of the balloon, the counselor will process the activity with the family. Processing should focus on reactions to the activity, the meaning of the

Maintaining the Family Unit When an Adolescent Comes Out 283

lost balloon to the sum of the balloons, and how this experience relates to life outside the family therapy sessions. For counselors who feel that the shock value of popping the balloon might be too intense for the cli­ ent and family, the client can slowly let the air out of the balloon while the counselor reads the statistics, demonstrating how the air will be let out of the fam­ ily members’ lives if they force the family member out. Alternatively, the client could be seated in an office chair on wheels. With the recitation of each fact, the client can be asked to move farther and farther toward the door until the client is outside the door to the coun­ seling office. Once the separation has been achieved, the client can be brought back in and the balloons can once again be used to demonstrate the interconnect­ edness of the family. It is important that the counselor provide a safe, open environment for discussions and respond in an empathetic and validating manner. All members of the family unit should be given the opportunity to pro­ cess their responses to the exercise, with the caveat that some responses might be embarrassing or emo­ tional, and therefore it might be appropriate to remind the members that respect should be shown at all times. To further illustrate the interconnection of the family unit, all members could be given a balloon and be asked to juggle their own balloon. All members should throw their balloon into the air and catch it several times. After reflection on the ease of juggling one balloon, each member of the family unit is asked to juggle all the balloons by themselves. The family unit can then process the difficulty of being respon­ sible for juggling all the balloons. After each mem­ ber has had the chance to juggle all the balloons, the family can juggle all the balloons together, demon­ strating that balancing their challenges together as an intact family unit makes the unit stronger, and each member has more support as a whole than individu­ ally. The family members can then process the differ­ ences and the value each member brings to the whole of the family unit. Brief Vignette

Elias is a fifteen-year-old Latino cisgender boy growing up in a conservative Texas town with strict Catholic 284 Coaston, Tabar, & Barrett

parents, Carlos and Belinda. The second of five chil­ dren, Elias is the oldest son, and his father hoped that he would become a football star at the local high school, following in his father’s footsteps. Elias did not share his father’s interest in sports, favoring more cere­ bral pursuits. Additionally, he found himself attracted to a classmate, Mark, who was not Hispanic. When Elias came out to his parents, Carlos became very angry, screaming that he wouldn’t have a “faggot” liv­ ing under his roof and threatening to kick Elias out of the house. Belinda, who was more embracing of her son’s sexuality, convinced his father to go to family coun­ seling to seek an alternative to kicking Elias out of the house. After several weeks building the therapeu­ tic alliance, the counselor completed the balloon exer­ cise and chose to pop Elias’s balloon. After a stunned silence lasting nearly a minute, Carlos revealed that suicide was one of his greatest fears for his children and explained that he had lost a cousin to suicide during his childhood. This session served as a turn­ ing point for the family: each member grew more committed to healing the rift that had formed since Elias disclosed his sexual orientation. Suggestions for Follow-up

Therapists should follow up during the next session to determine whether further processing of either exercise is needed. The following questions could be used as guides for processing the activity: • What were you feeling while participating in this activity? • What thoughts did you have while participating in this activity? • What have you learned as a result of this activity? • How might you use what you have learned here in your life? • How, if at all, has the information shared today influenced the way you see the family unit? Contraindications for Use

Because of the emotional nature of these issues and the possible negative responses to the disclosure made by family members to the adolescent client, it is rec­ ommended that a stable therapeutic alliance be devel­ oped before the activity is attempted. This activity is

appropriate for all backgrounds, as long as the thera­ peutic alliance is strong. No matter what therapeutic focus the provider attempts, Shpigel and colleagues (2015) recommend the provider first demonstrate to the non-SOGI minority family members that the therapist understands the distress the family members are feeling and is not allied with the SOGI minority member in any perceived adversarial position. This activity would not be recommended for any client or family member who is actively suicidal or who has a history of suicidality that could be retriggered thereby. Professional Resources American Psychological Association (APA). (2009). Report of the American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation. https://www. apa.org/pi/lgbc/publications/therapeutic­ resp.html. American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67 (1), 10–42. doi:10.1037/a0024659. Armesto, J. C., & Weisman, A. G. (2001). Attribution and emo­ tional reactions to the identity disclosure (“coming-out”) of a homosexual child. Family Process, 40 (2), 145–161. doi:10.1111/j.1545-5300.2001.4020100145.x. Burnes, T. R., Singh, A. A., Harper, A. J., Harper, B., MaxonKann, W., Pickering, D. L., & Hosea, J. (2010). American Counseling Association: Competencies for counseling with transgender clients. Journal of LGBT Issues in Counseling, 4 (3–4), 135–159. doi:10.1080/15538605.2010.524839. Diamond, G. M., & Shpigel, M. S. (2014). Attachment-based family therapy for lesbian and gay young adults and their persistently nonaccepting parents. Professional Psychol­ ogy: Research and Practice, 45 (4), 258–268. doi:10.1037/ a0035394. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H. C., Loos, B., . . . Kocet, M. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling com­ petencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individuals. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi:10.1080/1553 8605.2013.755444. Knudson-Martin, C., & Laughlin, M. J. (2005). Gender and sexual orientation in family therapy: Toward a postgender approach. Family Relations, 54 (1), 101–115. Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., McCullough, J. R., & Hipolito-Delgado, C. (2015). Multi­ cultural and social justice counseling competencies. Alex­ andria, VA: Association for Multicultural Counseling and Development.

Stone Fish, L., & Harvey, R. G. (2005). Nurturing queer youth: Family therapy transformed. New York: W. W. Norton.

Statistical References for the Professional Bullying statistics: Anti-bullying help, facts, and more. (n.d.). http://www.bullyingstatistics.org/content/gay-bullyingstatistics.html. Centers for Disease Control and Prevention (CDC). (n.d.). LGBT youth. https://www.cdc.gov/lgbthealth/youth.htm. GLSEN. (n.d.). https://www.glsen.org. PFLAG New York City. (n.d.). Statistics you should know about gay & transgender youth. http://www.pflagnyc.org/ safeschools/statistics. SPEAK: Suicide Prevention Education Awareness for Kids. (n.d.). Suicide facts. http://www.speakforthem.org/facts. html. Trevor Project. (n.d.). Preventing suicide: Facts about suicide. http://www.thetrevorproject.org/pages/facts-about-suicide.

Resources for Clients Holman, M. (2015). Mom and Dad, I’m gay: Coming out of the closet. CreateSpace Independent Publishing Platform. Human Rights Campaign. (n.d.). Resources: Coming out. https://www.hrc.org/resources/topic/coming-out. Jennings, K., & Shapiro, P. (2003). Always my child: A parent’s guide to understanding your gay, lesbian, bisexual, trans­ gendered, or questioning son or daughter. New York: Simon & Schuster. Pandora’s Project. (n.d.). Coming out to family and friends as being GLBT. https://www.pandys.org/articles/ comingout.html. Pew Research Center. (2013). Chapter 3: The coming out expe­ rience. www.pewsocialtrends.org/2013/06/13/chapter-3­ the-coming-out-experience/. PFLAG. (n.d.). https://www.pflag.org/. Ryan, C. (2009). Helping families support their lesbian, gay, bisexual, and transgender (LGBT) children. Washington, DC: National Center for Cultural Competence, George­ town University Center for Child and Human Develop­ ment. http://nccc.georgetown.edu/documents/LGBT_ Brief.pdf. Signorile, M. (1995). Outing yourself: How to come out as les­ bian or gay to your family, friends, and coworkers. New York: Random House. Stanford, J. C. (2015). Coming out: Gay, lesbian, bisexual, trans­ gendered: The complete guide to coming out of the closet, finding support, and thriving in your new life. Amazon Digital Services.

References American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author.

Maintaining the Family Unit When an Adolescent Comes Out 285

Armesto, J. C., & Weisman, A. G. (2001). Attribution and emo­ tional reactions to the identity disclosure (“coming-out”) of a homosexual child. Family Process, 40 (2), 145–161. doi:10.1111/j.1545-5300.2001.4020100145.x. Bith-Melander, P., Sheoran, B., Sheth, L., Bermudez, C., Drone, J., Wood, W., & Schroeder, K. (2010). Understanding sociocultural and psychological factors affecting transgender people of color in San Francisco. Journal of the Association of Nurses in AIDS Care, 21 (3), 207–220. doi:10.1016/j.jana.2010.01.008. Broome, K. M., Joe, G. W., & Simpson, D. D. (2001). Engage­ ment models for adolescents in DATOS-A. Journal of Adolescent Research 16, 608–623. Burnes, T. R., Singh, A. A., Harper, A. J., Harper, B., MaxonKann, W., Pickering, D. L., & Hosea, J. (2010). American Counseling Association: Competencies for counseling with transgender clients. Journal of LGBT Issues in Counseling, 4 (3–4), 135–159. doi:10.1080/15538605.2010.524839. Centers for Disease Control and Prevention (CDC). (2014). LGBT youth. Retrieved from https://www.cdc.gov/lgb thealth/youth.htm. Diamond, G. M., & Shpigel, M. S. (2014). Attachment-based family therapy for lesbian and gay young adults and their persistently nonaccepting parents. Professional Psychol­ ogy: Research and Practice, 45 (4), 258–268. doi:10.1037/ a0035394. Durso, L. E., & Gates, G. J. (2012). Serving our youth: Findings from a national survey of service providers working with lesbian, gay, bisexual, and transgender youth who are home­ less or at risk of becoming homeless. Los Angeles: Williams Institute with True Colors Fund and the Palette Fund. Feinstein, B. A., Wadsworth, L. P., Davila, J., & Goldfried, M. R. (2014). Do parental acceptance and family sup­ port moderate associations between dimensions of minority stress and depressive symptoms among lesbi­ ans and gay men? Professional Psychology: Research and Practice, 45 (4), 239–246. doi:10.1037/a0035393. Fox, F. (2015, January 8). Leelah Alcorn’s suicide: Conversion therapy is child abuse. Time. http://time.com/3655718/ leelah-alcorn-suicide-transgender-therapy/. Gibson, M. A., Alexander, J., & Meem, D. T. (2014). Finding out: An introduction to LGBT studies, 2nd edition. Thou­ sand Oaks, CA: Sage. GLSEN, CiPHR, & CCRC. (2013). Out online: The experiences of lesbian, gay, bisexual, and transgender youth on the Internet. New York: GLSEN. https://www.glsen.org/sites/ default/files/Out Online FINAL.pdf. Grov, C., Bimbi, D. S., Nanín, J. E., & Parsons, J. T. (2006). Race, ethnicity, gender, and generational factors associated with the coming‐out process among gay, lesbian, and bisexual individuals. Journal of Sex Research, 43 (2), 115–121. doi:10. 1080/00224490609552306. Gutierrez, D., & Hagedorn, W. B. (2013). The toxicity of shame

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applications for acceptance and commitment therapy. Journal of Mental Health Counseling, 35 (1), 43–59. doi:10.17744/mehc.35.1.5n16p4x782601253. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H. C., Loos, B., . . . & Kocet, M. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Coun­ seling competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individu­ als. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi:1080/15538605.2013.755444. Heron, M. (2016). Death: Leading causes for 2014. National Vital Statistics Report, 65 (5), 1–96. Kann, L., Olsen, E. O., McManus, T., Harris, W. A., Shanklin, S. L., Flint, K. H., . . . & Zaza, S. (2016). Sexual identity, sex of sexual contacts, and health-related behaviors among students in grades 9–12—United States and selected sites, 2015. MMWR Surveillance Summaries 65 (no. SS-9). doi:10.15585/mmwr.ss6509a1. Kosciw, J. G., Greytak, E. A., Giga, N. M., Villenas, C., & Dan­ ischewski, D. J. (2016). The 2015 National School Climate Survey: The experiences of lesbian, gay, bisexual, transgen­ der, and queer youth in our nation’s schools. New York: GLSEN. Kosciw, J. G., Palmer, N. A., & Kull, R. M. (2014). Reflecting resiliency: Openness about sexual orientation and/or gender identity and its relationship to well-being and edu­ cational outcomes for LGBT students. American Journal of Community Psychology, 55 (1–2), 167–178. doi:10.10 07/s10464-014-9642-6. Kosciw, J. G., Palmer, N. A., Kull, R. M., & Greytak, E. A. (2013). The effect of negative school climate on academic out­ comes for LGBT youth and the role of in-school supports. Journal of School Violence, 12 (1), 45–63. doi:10.1080/153 88220.2012.732546. LaSala, M. C. (2010). Coming out, coming come: Helping fami­ lies adjust to a gay or lesbian child. New York: Columbia University Press. Legate, N., Ryan, R. M., & Weinstein, N. (2012). Is coming out always a “good thing”? Exploring the relations of auton­ omy support, outness, and wellness for lesbian, gay, and bisexual individuals. Social Psychological and Personality Science, 3 (2), 145–152. doi:10.1177/1948550611411929. Liu, R. T., & Mustanski, B. (2012). Suicidal ideation and selfharm in lesbian, gay, bisexual, and transgender youth. American Journal of Preventive Medicine, 42 (3), 221–228. Marshal, M. P., Dietz, L. J., Friedman, M. S., Stall, R., Smith, H. A., McGinley, J., . . . & Brent, D. A. (2011). Suicidality and depression disparities between sexual minority and heterosexual youth: A meta-analytic review. Journal of Adolescent Health, 49 (2), 115–123. doi:10.1016/j.jado health.2011.02.005. McGeorge, C. R., & Carlson, T. S. (2011). Deconstructing heterosexism: Becoming an LGB affirmative heterosexual

couple and family therapist. Journal of Marital and Family Therapy, 37 (1), 14–26. doi:10.1111/j.1752-06 06.2009.00149.x. Potoczniak, D., Crosbie-Burnett, M., & Saltzburg, N. (2009). Experiences regarding coming out to parents among Afri­ can American, Hispanic, and white gay, lesbian, bisex­ ual, transgender, and questioning adolescents. Journal of Gay and Lesbian Social Services, 21 (2–3), 189–205. doi:10.1080/10538720902772063. Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., McCullough, J. R., & Hipolito-Delgado, C. (2015). Mul­ ticultural and social justice counseling competencies. Alexandria, VA: Association for Multicultural Counsel­ ing and Development. Reisner, S. L., Greytak, E. A., Parsons, J. T., & Ybarra, M. L. (2015). Gender minority social stress in adolescence: Disparities in adolescent bullying and substance use by gender identity. Journal of Sex Research, 52 (3), 243–256. doi:10.1080/00224499.2014.886321. Reisner, S. L., Vetters, R., Leclerc, M., Zaslow, S., Wolfrum, S., Shumer, D., & Mimiaga, M. J. (2015). Mental health of transgender youth in care at an adolescent urban community health center: A matched retrospective cohort study. Journal of Adolescent Health, 56, 274–279. doi:10. 1016/j.jadohealth.2014.10.264. Sauceda, J. A., Paul, J. P., Gregorich, S. E., & Choi, K. H. (2016). Assessing collectivism in Latino, Asian/Pacific Islander, and African American men who have sex with men: A psychometric evaluation. AIDS Education and Prevention, 28 (1), 11–25. doi:10.1521/aeap.2016.28.1.11.

Shpigel, M. S., Belsky, Y., & Diamond, G. M. (2015). Clinical work with non-accepting parents of sexual minority chil­ dren: Addressing causal and controllability attributions. Professional Psychology: Research and Practice, 46 (1), 46–54. doi:10.1080/00918369.2015.1061364. Shpigel, M. S., & Diamond, G. M. (2014). Good versus poor therapeutic alliances with non-accepting parents of samesex oriented adolescents and young adults: A qualitative study. Psychotherapy Research, 24 (3), 376–391. doi:10.10 80/10503307.2013.856043. Singh, A. A., & dickey, l. m. (2016). Implementing the APA guidelines on psychological practice with transgender and gender nonconforming people: A call to action to the field of psychology. Psychology of Sexual Orientation and Gender Diversity, 3 (2), 195–200. doi:10.1037/sgd000 0179. Stringer, J. (2011). All about pronouns. http://transwellness. org/wp-content/uploads/2014/02/Pronouns-Handout.pdf. Thompson, S. J., Bender, K., Cardoso, J. B., & Flynn, P. M. (2011). Experiential activities in family therapy: Percep­ tions of caregivers and youth. Journal of Child and Fam­ ily Studies, 20, 560–568. doi:10.1007/s10826-010-9428-x. Thompson, S. J., Bender, K., Lantry, J., & Flynn, P. M. (2007). Treatment engagement: Building therapeutic alliance in home-based treatment with adolescents and their families. Contemporary Family Therapy, 29 (1–2), 39–55. doi:10. 1007/s10591-007-9030-6. Whitley, C. T. (2013). Trans-kin undoing and redoing gender negotiating relational identity among friends and family of transgender persons. Sociological Perspectives, 56 (4), 597–621.

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33 EMPTY-CHAIR WORK FOR COPING WITH HETEROSEXIST AND/OR TRANSPHOBIC FAMILY REJECTION Cara Herbitter and Heidi M. Levitt Suggested Use: Activity Objective

The objective of this exercise is to aid clients in pro­ cessing painful emotions related to heterosexist and/ or transphobic parental rejection. Additionally, it is intended to hold the parents accountable for their rejecting behavior in order to help in the child’s pro­ cess of recovering and developing resilience. Rationale for Use

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) clients who experience parental rejection related to their sexual orientation and gender identity are at increased risk for negative mental health symptoms (Bouris et al., 2010; Rothman, Sullivan, Keyes, & Boeh­ mer, 2012; Simons et al., 2013). The rejection experi­ ence can linger in clients’ minds and influence their self-esteem, mood, substance use, and interpersonal connections (Herbitter & Levitt, 2019; Rothman et al., 2012). More broadly, decreased social support has been associated with a myriad of negative mental health risks among LGBTQ people (e.g., Fredriksen-Goldsen et al., 2014; Teasdale & Bradley-Engen, 2010; Williams, Connolly, Pepler, & Craig, 2005). The presence of social support also may be protective for LGBTQ per­ sons against other sexual and gender minority stress­ ors (e.g., Button, O’Connell, & Gealt, 2012; Eisenberg & Resnick, 2006; Graham & Barnow, 2013; Trujillo et al., 2017), and the lack of this support may render LGBTQ people more vulnerable to the negative con­ sequences of other stressors they are likely to encoun­ ter. Low parental support, in particular, has been

associated with negative mental health risks among LGBTQ youth (e.g., Bouris et al., 2010; Simons et al., 2013) and LGBQ adults (e.g., Rothman et al., 2012). In a systematic review of studies of LGB youth, Bouris and colleagues (2010) found that heterosexist rejec­ tion has been associated with increased risk of maladap­ tive behaviors, including substance use and self-harm. A study of transgender youth found that increased parental support was correlated with fewer depressive symptoms and greater life satisfaction (Simons et al., 2013). In a study of LGB adults ages eighteen to sixty, a history of poor reactions by parents to their com­ ing out was associated with mental health problems and behaviors, including depression and substance use (Rothman et al., 2012). Losing family support may pose additional challenges for ethnic minority indi­ viduals, for whom family involvement may be both an important cultural value and a way of connecting to the broader community (Potoczniak, CrosbieBurnett, & Saltzburg, 2009). The American Psychological Association (APA) guidelines for working with sexual minority clients has outlined how therapists should address the effects of heterosexism as follows: “Among the interventions psychologists are urged to consider are (a) increasing the client’s sense of safety and reducing stress, (b) developing personal and social resources, (c) resolv­ ing residual trauma, and (d) empowering the client to confront social stigma and discrimination, when appropriate” (APA, 2012, p. 13). The guidelines also identified difficulties with family of origin as an impor­ tant area for therapists to potentially address, while attending to intersectionality and how cultural factors

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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may come to bear on these relationships. Similarly, when working with transgender and gender-noncon­ forming (TGNC) clients, the APA has recognized the importance of addressing challenges that may develop with family of origin as clients explore their gender identity (APA, 2015). In this vein, the activity described here aims to help clients work toward resolution with their painful experiences of familial heterosexist and/ or transphobic parental rejection. Knowing how to assist clients as they work through heterosexist and/ or transphobic experiences is part of ethical practice with LGBTQ clients. Preliminary research on LGBQ people coping with heterosexist parental rejection has suggested that clients may be seeking more experiential modes of therapy to cope with the emotional challenges of this rejection (Herbitter & Levitt, 2019). Emotion-focused therapy (EFT), or process-experiential therapy, is a humanistic and constructivist psychotherapy orien­ tation that is based in both Gestalt and client-centered modalities. It is an empirically based approach that has demonstrated equivalence to other bona fide psy­ chotherapy orientations through meta-analyses (Elliott, Watson, Goldman, & Greenberg, 2004; Elliott et al., 2013). EFT can be adapted for use with diverse clients while attending to feminist-multicultural values (e.g., Levitt, Whelton, & Iwakabe, 2019). Clinicians have adapted these experiential approaches for use with sexual minority couples in particular (e.g., Hardtke, Armstrong, & Johnson, 2010), and we believe these approaches may be well suited for use in individual therapy with LGBTQ clients, as these approaches provide an opportunity to explore difficult emotions and relationships. Empty-chair work for unfinished business, an exercise introduced by EFT practitioners, may be a particularly powerful opportunity for LGBTQ clients to address heterosexist and/or transphobic rejection from parents. Our qualitative research on heterosexist parental rejection suggests that appropriately assign­ ing blame to rejecting parents and understanding the systemic roots of rejection may enable adaptive cop­ ing (Herbitter & Levitt, 2019). Our findings identify coping mechanisms for parental rejection as including acceptance of negative emotions, self-acceptance, seeking out affirmative support, and potentially deep­

ening understanding of parents. Engaging in this exer­ cise can assist clients in developing highly individu­ alized strategies that can support them in coping with rejection. Two-chair exercises are therapeutic activities that are based in Gestalt therapy and typically used to help clients integrate divided aspects of themselves or develop new responses to interpersonal experiences (see Elliott et al., 2004). They structure a role-played dialogue between either nonintegrated parts of the self or the self and a significant other who is imagined in an empty chair (Elliott et al., 2004). The emptychair exercise presented in this chapter is a type of twochair exercise that has been adapted from EFT and often is referred to as an exercise for unfinished busi­ ness (Greenberg, Rice, & Elliott, 1993). The current application of empty-chair work for unfinished busi­ ness is an opportunity to achieve some resolution with these painful, unresolved experiences in the absence of family acceptance, or in cases when family mem­ bers have become more accepting but discussing past rejection is not feasible or safe. These exercises can help clients separate their own self-assessment from that of critical others or to develop new perspectives on others’ intentions (Elliott et al., 2004; Greenberg & Malcolm, 2002). In this exercise we refer to the stages of resolution that often are used in teaching empty-chair work for unfinished business (Elliott et al., 2004), but we apply the exercise to addressing heterosexist and/or transphobic parental rejection. While this chapter tailors this exercise to the context of parental rejection, it can also be used to process heterosexist and/or transphobic rejection from other significant figures in cli­ ents’ lives. It can be used in the context of ongoing individual therapy. Instructions

In this exercise clients have the opportunity to claim and explore unresolved emotions, such as hurt and anger, toward the rejecting parents. Clients can then articulate their unmet needs for parental support and acceptance and work to find some resolution. Because the exercise is driven by client-centered theory, the way this resolution transpires is determined by the cli­ ents, which allows them to develop coping strategies Empty-Chair Work for Coping with Family Rejection 289

and resolutions that are appropriate for their own cul­ tural contexts, family dynamics, and personal needs. For instance, for some clients the process of holding the parents accountable for their rejecting behavior and recognizing that they, the LGBTQ children, are not to blame for the rejection or any negative family interactions that followed is empowering. For others, the process of understanding their rejecting parents’ behavior as evolving from a context of heterosexism and transphobia, rather than purely a character flaw, may lead to a sense of compassion without their nec­ essarily forgiving their parents. For other clients, the exercise provides space for them to forgive their par­ ents in order to move on, without condoning the rejecting behavior. Therapists can guide clients through this exercise repeatedly over a course of therapy, and resolutions may evolve across time. We recommend that therapists do not initiate this task with a certain outcome in mind, but rather permit their clients to arrive at their own solutions that emerge from the pro­ cess of exploration. Two-chair exercises may be an especially emo­ tional experience, and therapists should enter the exer­ cises willing to slow the stages down as needed to allow clients to engage safely and work through chal­ lenging emotions. If therapists are uncertain about how clients are feeling, they can ask clients if they feel able to continue or would like to take a break to pro­ cess what has happened so far. The clients’ pace should be respected, and empty-chair work can progress slowly. Although the complete task is described in this chapter, it may be that some clients move through only a few stages in initial sessions. If therapists need to end a session and clients are between stages of the task, therapists can simply ask clients to notice how they are feeling in that moment, and then ask them to come out of the exercise and consider what would be good to continue thinking about until the next session. I. Marker Confirmation Within EFT, therapists look for client signals that they are ready to work on a particular issue; these signals are referred to as markers. This exercise is initiated in response to a client’s raising issues of unresolved hurt, sadness, pain, or anger related to rejecting parents, particularly when the issue appears to be causing the 290 Herbitter & Levitt

client distress. The client’s emotional expression can appear either restrained or charged. II. Setting Up and Starting Because empty-chair work is a very emotionally charged process, therapists typically do not engage in these exercises until after they have had three sessions of therapy with a client, in which they can establish their alliance and develop a focus for their treatment. In the case where parental rejection appears as a marker, it can be useful to spend a session exploring a client’s emotional reaction to the rejection. This initial exploration can assist a client in connecting to the emotional response once the empty-chair exercise is begun. It can help to build clients’ investment in engaging in this focused exploration by allowing them to recognize the distressing emotions that they have been carrying. Once the marker has been expressed in session, the therapist begins by reflecting on the emotions that the client has expressed as a preliminary means of setting up the exercise. Then the therapist can intro­ duce the exercise as an opportunity to further explore the emotions by imaging the rejecting parents. It usu­ ally suffices to ask the client simply, “Would you like to engage in an exercise with me to explore your reac­ tion to your parents’ rejection and see if we can under­ stand it better?” The therapist should convey this sug­ gestion with confidence. (Tentatively suggesting having a conversation with an empty chair that represents a parent is often met with skepticism!) Simple assent that the issue is important to explore is enough. Once the client consents, the therapist can initiate the exercise in the same session. From a logistical perspective, the therapist can set up the empty-chair exercise by sitting next to the client and placing an empty chair across from the client, so that both are gazing at the empty chair, which will represent the rejecting parent or relative. The client should be asked first to imagine the other in the chair. This exploration can take some time. Clients can describe the other, in particular how the parent may be seated, the par­ ent’s facial expression, and whether the client imag­ ines the parent expressing the rejection through body language. This exploration of the nonspeaking parent allows the client to enter into emotional contact with

the imagined other and evokes powerful feelings and reactions. III. Differentiating Meaning and Expressing Primary Emotions (Deeper Emotions) To stimulate the client’s emotional response to the rejection, the therapist typically will ask the client to move into the parent’s chair. After the client is seated, the therapist will ask the client to pretend they are the parent and express the rejection to the client in just the way that the parent would. (“Be your parent.” “What would she say to really reject you?” “Do what he does to make you feel really rejected.”) While it might take clients some time to readjust, most clients are able to do this for a few minutes. If a client refuses to move into the parent’s chair, this is okay; the client can remain in the client chair and describe the parent’s expected rejection. Next, clients return to their own chair, and the therapist asks them to express their feelings in response to the parent’s rejection. (“What does it feel like to hear all this anger and outrage? Tell him.”) The ther­ apist can restate the most dramatic aspects of the parental rejection to help stimulate this response. (For instance, “Your father was saying to you, ‘I never wanted a lesbian daughter. You are not the daughter that I wanted.’ How does it feel to hear him say that? Tell him.”) By asking the client to reflect inward and then to communicate the emotion to the other chair directly, the therapist can maintain contact between the two chairs and help the client maintain access to deeper emotions. By using an evocative tone and language, the therapist aids the client in going deeper into their most basic, or primary, emotions, such as hurt and anger. The therapist helps the client explore the root of emotions by focusing the client on the newest or least well-integrated emotion and asking for further descrip­ tion and elaboration of that emotion. (For instance: “You feel angry. Really angry. What does that emotion feel like? Tell him!”) For example, a client who begins the exercise angry might come to identify sad emo­ tions that require integration. A client who begins the exercise in fear of a parent might get in touch with anger. Each time the therapist asks the client to stay with and describe a less well-integrated emotion, the

client can differentiate aspects of that newer emotion and better integrate them. After staying with and exploring the new emotion for some time, the thera­ pist will notice the same new emotions emerging, which is a cue to move on. The therapist then asks the client to change chairs and imagine how the parent might respond. The imagined parent might respond with understanding and with a softer affect. Parents might explain why they were unable to meet the clients’ needs or their wish that they could have done so. In this case, the therapist can guide parents to express the wish and articulate the apology implicit in the response. While the client is in the parent chair, the therapist will align with that chair and support the parent’s emo­ tional expression. Alternatively, the parent may respond with further rejection. This rejection can also be helpful, as it allows the client to realize that the parent is not soft­ ening and that boundaries may need to be established in order to provide protection from unyielding rejec­ tion. If the parent is still alive, it may not be as useful to explore the parents’ side too extensively (because the real parent might have a different response); it may be preferable to use this expression as a way to stim­ ulate change in the client when seated in the client chair. If the parent is deceased, however, the exercise can more extensively explore both sides to help the client reach some resolution. Clients are returned to the client chair and again directed to express their feelings to the parent. These switches might occur a few times as a client comes into contact with deeper emotions. Once the client appears to be in strong contact with multiple levels of feeling, the therapist can progress to the next stage. IV. Expressing and Validating Unmet Needs In this stage clients are encouraged to express what they would have liked the parent to give them, namely, acceptance of their sexual orientation and/or gender identity, or what they still need in order to cope with the distressing feelings. It is often useful to ask the client specifically what the less well-integrated emo­ tion that was discovered in the previous stage needed or still needs. (“So alongside of the feelings of being scared or small, there is also a feeling of anger. That Empty-Chair Work for Coping with Family Rejection 291

anger is important and real. What does that anger need to feel better? Tell him.”) Clients should be encour­ aged to express what they needed and how it felt to have this need unmet, while the therapist validates the client’s right to have this need met. Therapists can ask the client how that need might be met, regardless of whether the parent is capable of fulfilling it or if it needs to be fulfilled by the client. (“What might that scared part of you need in order to feel better?” “Is there anything that the sad part of you might want to ask of your parent?” “What might you remind your­ self or say to yourself when you are feeling angry?”) During this stage, clients may worry that therapists are expecting them to ask their real parent to fulfill this need, and so therapists may want to communi­ cate that this process is meant to help clients under­ stand themselves and decide later what, if anything, they wish to communicate to their real parent. V. Shift in Representation of the Other As clients become more confident in asserting their feelings and needs, they can better claim their right to be accepted by their parents. In this imagined inter­ action, a client’s perspective of the parent shifts from a purely threatening and judgmental figure to a less powerful person who may simply be acting on their own fears and internalized stigma. The loss of power may be due to the client’s realizing that the parent is either an imperfect but well-disposed person who is sorry to have been unable to meet the client’s needs or an imperfect and hostile person who is unable to stop being rejecting. There may be a sense of compas­ sion for the parent, but this is not necessary. What is most important in this stage is that the parent’s power is diminished and vulnerabilities are revealed. In response, the client becomes more empowered and able to make decisions about how to proceed with the relationship. VI. Self-Affirmation and Letting Go of Bad Feelings In this final stage, the resolution takes place in one of two ways: the client develops a deeper understand­ ing of the parent who was unable to provide support but is apologetic or holds the hostile parent account­ able. In the first scenario, the client may recognize that the parents were raised in a very religious envi­ 292 Herbitter & Levitt

ronment and probably had to constrain their own sexual desires and simply were repeating this pattern out of fear or habituated learning. A new, deeper understanding of the parent could lead to forgiving parents for their rejecting behavior as a limitation rather than as having arisen out of maliciousness. For­ giveness is not necessary, however, nor should it be pressured, as it may be experienced as invalidating the injustice of the rejection. In the absence of understanding or forgiveness, resolution occurs through holding the parent account­ able for the rejection. This is especially important for LGBTQ people, who may perceive themselves as at fault for the rejection and may have internalized this stigma. Thus, achieving this accountability is impor­ tant regardless of how the resolution takes place, and it should be coupled with understanding and for­ giveness even if it is pursued. Finally, there may be a grieving for the unmet need for acceptance from the parent as the client realizes that the need for accep­ tance may never be met. This acceptance can allow the client to move on and develop new resources and supports that foster self-acceptance. Brief Vignette

A trans male-identified, white, European American twenty-eight-year-old client, John, presented in ther­ apy expressing unresolved feelings about his parent: “Ever since I came out as trans to my dad, he can barely look at me. He still keeps up the old pictures of me with long hair, like, pretending that’s how I still look. I get so frustrated, but I guess it’s just how things are.” In this case, the client expressed frustration and com­ municated that his tense relationship with his par­ ents, especially his father, was a critical issue for him, but he did not appear to be in touch with emotions of anger or hurt. The identification of this marker pre­ sented an opening for engaging in empty-chair work to deepen contact with his emotions. Because the marker emerged after the therapy relationship had been well established and they had spent time discussing his family, the therapist decided to propose an emptychair exercise in this session (Setting Up and Start­ ing). After reflecting the client’s emotional expression, the therapist introduced the exercise.

T: It might be helpful to have you explore your reac­ tions to your father so we can better understand them. Would you be willing to engage in an exercise with me to do this? C: Okay. I would do that.

boy who I was—even if I didn’t have words to tell you then who I was. T: You are saying, “I feel sad, Dad, for you and for me too.” Can you tell him how that sadness feels? What is it like for you to carry this sadness? Tell him.

T: Great. [Moves empty chair opposite client and moves therapist’s chair to face empty chair]. Now, what I’d like you to do is to imagine your father in the chair across from you, so that you can tell him how upset you are feeling. Can you imagine him sitting there? Can you see his face? What does he look like?

C: I feel so tired of carrying this sadness for so long. I feel scared that you will never come to accept me for who I am. I also really miss that love that I felt from you when I was little. I am scared that I won’t feel it again.

C: He is sitting sort of hunched over and scowling. He doesn’t really want to be here talking with me. He doesn’t want to look at me.

C: It is super-scary. I would hate to think that I will never have that from you again. It would be horrible to go through life missing that and feeling that you will never accept me as I am. I am terrified that this will be the rest of my life.

T: He is sort of resistant. He doesn’t want to see you. C: Yeah. He is looking away. T: Okay. Can you shift over here [patting empty chair]? Now, be your Dad. Show how you make John feel rejected. What do you say to him? Tell him. C: I don’t want to call him “John.” T: Tell him: “I don’t want to call you ‘John.’ ” C: I don’t want to call you “John.” I miss Joanie. I miss my little girl and I don’t want you to be this other person. T: Tell John what it feels like for you to miss your lit­ tle girl. What does that missing feel like? Tell him (Differentiating Meaning and Expressing Primary Emotions). C: I miss her and I feel like you have grown up so fast and then suddenly have become someone who I don’t know. What happens to all the time and energy I spent with her? All the memories I have had with her? I love her and now you are telling me that I can’t have her anymore. T: Okay, John, switch back to your chair. [Pause.] Your Dad is telling you that he misses the girl he used to have and loves and misses you. He is struggling to know how to relate to you now. Can you tell him how it makes you feel to hear what he is saying? C: I feel sad. I feel sad for you, Dad, because you did love me as a girl and I imagine that this feels painful for you. I feel sad for me too, because I still am that same person. That little girl you knew was the little

T: This is really scary. Tell him how scary it is.

T: John, tell him what that scared part of you is need­ ing. You don’t need to tell him this in real life, but just so we can understand better. Be the part of you that is so scared and tell him what you need (Expressing and Validating Unmet Needs). C: The scared part of me is needing you to tell me that you will come around someday. I understand that this is a big change for you. I just want to know that you will be on my side someday. That you will be able to see that the little girl you raised was me and that you have that same love for me as I am now. T: Yeah. That is really so scary—not knowing. “I want to know that you will come to accept and love me.” Come over here now and switch chairs [indicating the parent chair]. Now, as John’s Dad, he is asking you, “Can you tell me that one day you will work through this? Are you going to work through this so you can love me again?” How do you feel when you hear John ask this? He feels really scared. Tell him. C:I feel torn. I do feel like I will keep thinking about this. It is important to me. I want to tell John that I will work through this and come out feeling different, but I can’t tell how it will end up. I didn’t grow up in the same generation as you and I was taught to have very different reactions to things. It is hard for me to imagine this ending up either way. I am not sure that I will be able to feel the same sort of love for him— even though I wish I could. Empty-Chair Work for Coping with Family Rejection 293

T: Okay. Come back here to your chair. John, how do you feel hearing your Dad say, “I will keep thinking about this, but I am unsure how I will come to feel”? Can you tell him? C: This really hurts. I think this is what he would say, though. How can he know how he will feel? T: It’s like you see that he is struggling and is just not able to be the person you might want him to be, or that he might even want to be. Tell him, “I realize that you can’t know how you will feel, but it hurts.” (Shift in Representation of the Other) C: I realize that you can’t predict the future, but it really hurts me to hear you say this. It is hurtful to want to be close to you and not to know how this will turn out and to have you say and act hurtfully to me while you figure it out. T: Tell him what this hurt part of you needs. What do you need to take care of yourself? (Self-Affirmation and Letting Go of Bad Feelings) C: I need to have some space, I guess. I think I need to back off a while and let you figure things out while I protect myself more. I feel like eventually you might come around, but I don’t think it is good for me to sit around while you are figuring this out. Or good for our relationship. T: What can you do that would be better for you? C: I think I need to pull back a little bit and spend time with people who are able to care for me and clearly say that they love me. I’ll continue to talk with my Mom and my sister, but I’m going to take some space from my Dad while he works through this. I need to take care of myself more. The therapist then asked the client to turn back so they are face-to-face so they could process what the exercise was like for him. They talked about the insights that he achieved and how his understanding of his father had shifted as well as his own sense of what he needed to do to protect himself from the effects of the rejection. The therapist recommended that the client continue to consider ways to care for himself over the week as a homework exercise. If the session would have ended in an earlier stage of the exercise, the therapist would have asked the client to continue to think about that stage during the week as a homework exercise. 294 Herbitter & Levitt

Suggestions for Follow-up

Empty-chair work for unfinished business can be particularly emotional, and so it should begin within the first fifteen minutes of a session, and adequate time should be left at the end of a session (e.g., fifteen minutes) to briefly discuss the experience. This also helps clients return to their emotional baseline and transition back to their daily activities. The session fol­ lowing empty-chair work often is devoted to unpack­ ing those experiences. This may involve discussing how it felt to re-experience painful emotions and also any surprising emotions or needs that were uncovered or plans that were formulated. The discussion often continues to focus either on potentially developing a new understanding of family members or holding them accountable. It can be challenging to address the harms of parental rejection in the context of individual therapy, given the systematic nature of the injustice perpetu­ ated. In those sessions after the empty-chair exercise, it may be valuable to draw on feminist-multicultural approaches (e.g., Brown, 2009; Russell & Bohan, 2007) to help clients understand the systemic roots of paren­ tal rejection in societal heterosexism and transpho­ bia and how intersectional stressors can complicate these experiences. Discussing how this stigma can be internalized by parents and passed down intergenera­ tionally can help clients better understand parents’ reactions as well as notice the ways that these senti­ ments can be introjected and influence the client’s sense of self-esteem. These discussions can provide an understanding of how to resist messages of stigma and empower clients to make decisions that work for them in the context of their own lives. Contraindications for Use

Because of the emotional intensity of this exercise, it is contraindicated with clients who are in the middle of an active crisis or at high risk of suicidality, selfharm, or harm to others. If clients have experienced physical, sexual, or severe emotional childhood abuse by parents, the exercise can be adjusted so that the clients do not act out the parental rejection but instead imagine it and then respond to it. Therapists can decide whether clients will have enough ego strength to respond to the abusive parent if enacted in a role­

play. In these cases, focus should typically be on hold­ ing parents accountable and spending most or all of the time with clients seated in the client chair rather than trying to understand their parent’s perspective. Professional Resources Elliott, R., Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2004). Learning emotion-focused therapy: The processexperiential approach to change. Washington, DC: Amer­ ican Psychological Association. Greenberg, L. S., & Foerster, F. S. (1996). Task analysis exem­ plified: The process of resolving unfinished business. Jour­ nal of Consulting and Clinical Psychology, 64, 439–446. Hardtke, K. K., Armstrong, M. S., & Johnson, S. M. (2010). Emotionally focused couple therapy: A full treatment model well-suited to the specific needs of lesbian couples. Journal of Couple and Relationship Therapy, 9, 312–326. Levitt, H. M., Whelton, W. J., & Iwakabe, S. (2019). Integrating feminist-multicultural perspectives into emotion-focused therapy. In L. Greenberg & R. Goldman (eds.), Clinical handbook of emotion-focused therapy. Washington, DC: American Psychological Association. Ryan, C. (2014). A practitioner’s resource guide: Helping fam­ ilies to support their LGBT children. HHS Publication no. PEP14-LGBTKIDS. Rockville, MD: Substance Abuse and Mental Health Services Administration. https://family project.sfsu.edu/sites/default/files/FamilySupportForLGBT ChildrenGuidance.pdf.

Resources for Clients Diamond, G. M., Shahar, B., Sabo, D., & Tsvieli, N. (2016). Attachment-based family therapy and emotion-focused therapy for unresolved anger: The role of productive emo­ tional processing. Psychotherapy, 53 (1), 34–44. doi:10. 1037/pst0000025. LGBTQ Mental Health. (n.d.). Resources and exercises designed to support. http://LGBTQMentalHealth.com/ main-page. Newman, K., & Newman, A. (2015). All out: A father and son confront the hard truths that made them better men. Toronto: Random House Canada. PFLAG. (n.d.). Need support? https://pflag.org/needsupport. PFLAG. (2008). Our trans loved ones: Questions and answers for parents, families, and friends of people who are transgen­ der and gender expansive. https://pflag.org/publications. PFLAG. (2016). Our children: Questions and answers for fam­ ilies of lesbian, gay, bisexual, transgender, gender-expansive and queer youth and adults. https://pflag.org/resource/ our-children. Ryan, C. (2009). Supportive families, healthy children: Helping families with lesbian, gay, bisexual & transgender chil­ dren. San Francisco: Family Acceptance Project, Marian Wright Edelman Institute, San Francisco State Univer­

sity. https://familyproject.sfsu.edu/sites/default/files/ FAP_English Booklet_pst.pdf.

References American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67, 10–42. doi:10.1037/a0024659. American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70, 832–864. doi:10.1037/a0039906. Bouris, A., Guilamo-Ramos, V., Pickard, A., Shiu, C., Loosier, P. S., Dittus, P., . . . & Waldmiller, J. M. (2010). A system­ atic review of parental influences on the health and wellbeing of lesbian, gay, and bisexual youth: Time for a new public health research and practice agenda. Journal of Primary Prevention, 31, 273–309. doi:10.1007/s10935­ 010-0229-1. Brown, L. S. (2009). Feminist therapy. Washington, DC: American Psychological Association. Button, D. M., O’Connell, D. J., & Gealt, R. (2012). Sexual minority youth victimization and social support: The inter­ section of sexuality, gender, race, and victimization. Jour­ nal of Homosexuality, 59, 18–43. doi:10.1080/00918369.2 011.614903. Eisenberg, M. E., & Resnick, M. D. (2006). Suicidality among gay, lesbian, and bisexual youth: The role of protective factors. Journal of Adolescent Health, 39, 662–668. doi:10. 1016/j.jadohealth.2006.04.024. Elliott, R., Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2004). Learning emotion-focused therapy: The processexperiential approach to change. Washington, DC: Amer­ ican Psychological Association. Elliott, R., Watson, J., Greenberg, L. S., Timulak, L., & Freire, E. (2013). Research on humanistic-experiential psycho­ therapies. In M. J. Lambert (ed.), Bergin & Garfield’s hand­ book of psychotherapy and behavior change, 6th edition, 495–538. New York: Wiley. Fredriksen-Goldsen, K. I., Cook-Daniels, L., Kim, H.-J., Ero­ sheva, E. A., Emlet, C. A., Hoy-Ellis, C. P., . . . & Muraco, A. (2014). Physical and mental health of transgender older adults: An at-risk and underserved population. Geron­ tologist, 54, 488–500. doi:https://doi.org/10.1093/geront/ gnt021. Graham, J. M., & Barnow, Z. B. (2013). Stress and social sup­ port in gay, lesbian, and heterosexual couples: Direct effects and buffering models. Journal of Family Psychol­ ogy, 27, 569–578. doi:10.1037/a0033420. Greenberg, L. S., & Malcolm, W. (2002). Resolving unfinished business: Relating process to outcome. Journal of Consult­ ing and Clinical Psychology, 70, 406–416. doi:10.1037/00 22-006X.70.2.406.

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Greenberg, L. S., Rice, L. N., & Elliott, R. (1993). Facilitating emotional change: The moment-by-moment process. New York: Guilford Press. Hardtke, K. K., Armstrong, M. S., & Johnson, S. M. (2010). Emotionally focused couple therapy: A full treatment model well-suited to the specific needs of lesbian couples. Journal of Couple and Relationship Therapy, 9, 312–326. Herbitter, C., & Levitt, H. M. (2019). Whether or not “It gets better” . . . Coping with parental heterosexist rejection. Manuscript in preparation. Levitt, H. M., Whelton, W. J., & Iwakabe, S. (2019). Integrating feminist-multicultural perspectives into emotion-focused therapy. In L. Greenberg & R. Goldman (eds.), Clinical handbook of emotion-focused therapy. Washington, DC: American Psychological Association. Potoczniak, D., Crosbie-Burnett, M., & Saltzburg, N. (2009). Experiences regarding coming out to parents among Afri­ can American, Hispanic, and white gay, lesbian, bisexual, transgender, and questioning adolescents. Journal of Gay and Lesbian Social Services: Issues in Practice, Policy & Research, 21, 189–205. doi:10.1080/10538720902772063. Rothman, E. F., Sullivan, M., Keyes, S., & Boehmer, U. (2012). Parents’ supportive reactions to sexual orientation dis­ closure associated with better health: Results from a pop-

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ulation-based survey of LGB adults in Massachusetts. Journal of Homosexuality, 59, 186–200. doi:10.1080/0091 8369.2012.648878. Russell, G. M., & Bohan, J. S. (2007). Liberating psychotherapy: Liberation psychology and psychotherapy with LGBT cli­ ents. Journal of Gay and Lesbian Psychotherapy, 11, 59–75. Simons, L., Schrager, S. M., Clark, L. F., Belzer, M., & Olson, J. (2013). Parental support and mental health among transgender adolescents. Journal of Adolescent Health, 53 (6), 791–793. doi:10.1016/j.jadohealth.2013.07.019. Teasdale, B., & Bradley-Engen, M. (2010). Adolescent samesex attraction and mental health: The role of stress and support. Journal of Homosexuality, 57, 287–309. doi:10.1080/00918360903489127. Trujillo, M. A., Perrin, P. B., Sutter, M., Tabaac, A., & Benotsch, E. G. (2017). The buffering role of social support on the associations among discrimination, mental health, and suicidality in a transgender sample. International Journal of Transgenderism, 18, 39–52. doi:10.1080/15532739.201 6.1247405. Williams, T., Connolly, J., Pepler, D., & Craig, W. (2005). Peer victimization, social support, and psychosocial adjustment of sexual minority adolescents. Journal of Youth and Adolescence, 34, 471–482. doi:10.1007/s10964-005-7264-x.

34 ADDRESSING BLENDED FAMILY AND TRAUMA ISSUES WITH SEXUAL AND GENDER MINORITY PARENTS Anthony Zazzarino, Veronica M. Kirkland, and Jenae Thompson Suggested Uses: Activity, homework Objective

The purposes of this genogram activity are (1) to understand the multiple cultural identities of parents who identify as sexual and gender minorities and (2) to understand how past relationship and familial traumatic experiences, feelings of oppression, and priv­ ilege have shaped a parent’s development as a person and as a parent. By using the genogram, sexual and gender minority parents can further explore the rela­ tionships they have with their parents and how those relationships have shaped their current role. Addi­ tionally, to follow up the activity, the sexual and gen­ der minority parents will work on increasing their support system. Rationale for Use

Estimates indicate that 48 percent of women and 20 percent of men who identify as a sexual or gender minority are raising approximately two to three mil­ lion children under the age of eighteen (Borden, 2014; Few-Demo, Humble, Curran, & Lloyd, 2016; Oswald, 2016). Currently, there is a shift in public opinion that supports sexual minority relationships; according to one U.S. poll, 58 percent of those surveyed view gay and lesbian relationships as morally acceptable (Bor­ den, 2014). Now is a time of greater social acceptance for all aspects of sexual or gender minority couples: relationships, marriage, and parenting (Gates, 2015). Gates reported: “In 1992, polling showed that only 29 percent of Americans supported the idea that samesex couples should have the legal right to adopt chil­

dren. In a 2014 poll, that figure was 63 percent, even higher than support for marriage among same-sex couples” (p. 68). Though views of sexual and gender minority individuals may be shifting, it is clear that discrimination is still prevalent for this population (Borden, 2014). Many sexual and gender minority parents still experience social victimization, stigma­ tization, and harassment because of their nontradi­ tional family structure, as well as discrimination that affects their daily living and their careers (Chung, Szymanski, & Markle 2012; Oakley, Farr, & Scherer, 2017). The perceived discrimination continues to be a risk factor for emotional and behavioral problems across the life span, which makes it more difficult to work through parental stress (Oakley et al., 2017). Often, sexual and gender minority parents can hear criticism that they are selfish, damaging, or dangerous for children (Power et al., 2015). These traumatic experiences, as well as the comingout process and identity development, can shape a sexual and gender minority person’s relationship and parenting styles (Chung et al., 2012; Glennon, 2015). For example, sexual and gender minority individuals experience higher rates of traumatic incidents during adolescence, which can lead to many negative behav­ iors and long-term effects (Goldbach, Fisher, & Dunlap, 2015). The societal view of sexual and gender minority individuals as deviants, from adolescence through adulthood, frames how many sexual and gen­ der minorities view themselves in relation to others (Glennon, 2015). As a result, the power of the geno­ gram resides in its visual-graphic nature and pictures that allow counselors to explore information-rich data

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about individual, relationship, and family histories (Cook & Poulsen, 2011). Traumatic backgrounds, coupled with continued experiences of discrimination, make the transition to parenthood difficult for many sexual and gender minorities (Goldberg, Kinkler, Moyer, & Weber, 2014). Sexual and gender minority parents find it tough to rely on social support (Borden, 2014). Feeling connected to others is important for one’s overall well-being, self-esteem, and health (Power et al., 2015). Family relationships, friendships with other parents, and ties to a community group that encourage good parent­ ing contribute to the quality of parenting (Eggebeen, 2012). Additionally, the sense of belonging and being connected with others helps reduce many stressors and increases one’s family processes and coping skills (Power et al., 2015). Social and family support is tra­ ditionally linked with parental adjustment; therefore, sexual and gender minority parents who receive less support will experience a greater difficulty adjusting to the parental role (Chung et al., 2012). The ability to work on strengthening a couple’s support from family and friends can provide a sense of validation and external motivation (Power et al., 2015). Never­ theless, building this type of support may be difficult for sexual and gender minority parents, which ulti­ mately increases internal conflict within the family (Eggebeen, 2012). It is crucial for sexual and gender minority parents to develop a support network. The challenges that they face when deciding to become parents include less than enthusiastic family members who dredge up con­ cerns about what it would look like and the challenges the child will encounter, as well as care professionals who entrench this choice with heterosexism, hostility, and a lack of support (Boggis, 2012). Although emo­ tional support is critical during this time, sexual and gender minority parents often experience emotional distancing from family members who choose not to accept or not to be a part of the relationship, child, or family dynamic (Boggis, 2012). The emotional dis­ tance from the family of origin results in feelings of stress and isolation, as well as an overwhelming void of support, advice, and help navigating the world of parenting (Boggis, 2012). Additionally, new sexual and gender minority parents may experience the loss

of other sexual and gender minority friends and com­ munity who do not engage in kid-friendly activities and are thus unable to provide the necessary support (Boggis, 2012). These challenges, compounded by naturally occurring within-family differences, such as multicultural, multiracial, and gender variance between parent and child, both enrich and stress the family dynamic (Boggis, 2012). Developing relationships with other sexual and gender minority parent families is crucially important for the reemergence of connec­ tion and a sense of community (Goldberg, Sweeney, Black, & Moyer, 2016). Counselors need to understand the current state of sexual and gender minority parenting and the vari­ ous relationship dynamics that are affected (Gates, 2015). Once a sexual or gender minority couple have a child, it appears that they tend to experience more burdens associated with family life than heterosexual couples (Chung et al., 2012). Many sexual and gen­ der minority couples with children are twice as likely to be living in poverty as different-sex couples, despite their higher levels of education; sexual and gender minority couples also experience higher rates of unem­ ployment (Gates, 2015). Furthermore, sexual and gender minority families face struggles when advocat­ ing for their children in the school setting, seeking appropriate medical care for their children, develop­ ing and defining their roles as parents, and dividing childcare and housework responsibilities (Chung et al., 2012; Shields et al., 2012). Still, children of sexual and gender minority parents report psychological and social well-being similar to that of children of heterosexual parents (Clarke & Demetriou, 2016). A counselor working with sexual and gender minority parents can focus on coping with parental stressors and improve the relationship between the couple. A loving relationship bolstered by strong com­ munication skills can help mitigate stressors and lead to a healthier family unit (Goldberg & Smith, 2014). Additionally, counselors need to work with sexual and gender minority parents on adjusting to the shift in the parents’ use of time and energy, as well as the shift in family roles (Goldberg et al., 2014). Even if the parents are attending counseling, a counselor can encourage the parents to attend support groups or take part in activities with other sexual and gender minority Addressing Blended Family and Trauma Issues 299

parents in their community (Goldberg et al., 2014). Some of these activities include connecting with other parents through a local diversity center or using online resources that facilitate relationship-building activi­ ties with other sexual and gender minority parents in their area. When referring clients to support groups, it is helpful for the counselor to specifically refer to other sexual or gender minority groups (Goldberg et al., 2014). These support groups can provide a foun­ dation of assistance and normalize the experiences for the parents, as well as increase the parents’ support network (Goldberg et al., 2014). To guide the therapeutic process, counselors can begin to incorporate queer theory and intersection­ ality into traditional family theories to support sex­ ual and gender minority parents (Few-Demo et al., 2016). Queer theory explores the fluidity and diversity in sexual and gender identities, where human beings cannot be constrained to a binary system (Oswald, Blume, & Marks, 2005). Meanwhile, intersectionality is a framework that can help counselors understand how individuals explore and negotiate their multiple privileged and oppressed identities (Few-Demo et al., 2016)—for example, the interactions between being a sexual or gender minority and a parent. Therefore, using traditional family theories, counselors can incor­ porate the tenets of queer theory and intersectional­ ity to acknowledge cisnormativity and heteronorma­ tivity; explore the unique characteristics of sexual and gender minority parents and the family system, including aspects of race, ethnicity, socioeconomic status, and geographical location; use culturally appro­ priate interventions with a focus on building support systems, communication skills, and coping skills; and engage in a transformational approach that helps sex­ ual and gender minority parents fight through the resistance and struggles (Borden, 2014; Few-Demo et al., 2016; Power et al., 2015). The American Counseling Association (ACA) (2014) Code of Ethics encourages professional helpers to remain aware of their own personal cultural val­ ues and avoid imposing these values on clients. Spe­ cifically, the ACA indicates that counselors must “gain knowledge, personal awareness, sensitivity, disposi­ tions, and skills pertinent to being a culturally compe­

300 Zazzarino, Kirkland, & Thompson

tent counselor in working with a diverse client popu­ lation” (ACA, 2014, C.2.a). To do so, counselors must seek additional training opportunities to enhance their competence (ACA, 2014, C.2.f). Additionally, coun­ selors must be aware of the cultural aspects of the cli­ ent and respect the diverse aspects that each client brings to the counseling relationship (ACA, 2014, B.1.a). Furthermore, counselors working with sexual and gender minority parents must clearly define who the client is and discuss limitations to confidentiality within the family system (ACA, 2014, B.4.b). To address these needs, the Association for Les­ bian, Gay, Bisexual, and Transgender Issues in Coun­ seling (ALGBTIC) highlighted specific competencies for counseling sexual and gender minorities (Harper et al., 2013). The competencies align with the Council for Accreditation of Counseling and Related Educa­ tion Programs (2016) Standards: human growth and development; social and cultural foundations; helping relationships; group work; professional orientation and ethical practice; career and lifestyle development, assessment, and research; and program evaluation. According to Edwards, Robertson, Smith, and O’Brien (2014), however, the American Association of Marriage and Family Therapy (AAMFT) has not established specific guidelines for working with sexual and gender minority couples and families. Therefore, counselors must rely on the ACA (2014) Code of Ethics and the ALGBTIC’s competencies (Harper et al., 2013) when working with sexual and gender minority parents. Originally, genograms were developed to help families understand and process family membership and patterns of functioning (Goodman, 2013). To inte­ grate the needs of culturally diverse families, research­ ers revised genograms to reinforce the inclusion of intersectionality among diverse families (Goodman, 2013). Alterations to the original use and design have made genograms helpful in treatment with families experiencing substance use, substance abuse, and trauma by assessing and deconstructing maladaptive patterns of functioning to promote healing and resil­ ience among families (Goodman, 2013). Genograms are an effective tool used by counselors to help families understand relationship connections, functions, and behaviors (Tasker & Granville, 2011). Specifically, for

sexual and gender minority–led families, genogram development serves to help family members under­ stand each member’s identity, as well as understand the larger community (Tasker & Granville, 2011). This chapter provides instructions for an in-session activity, a brief vignette, suggestions for follow-up, and additional resources to support counselors in increasing their competence and providing ethical support to sexual and gender minority parents. Instructions

Materials needed for this genogram activity include pencils, ultra-fine-point markers or pens, colored pencils or markers, erasers, and an eleven-by-seven­ teen-inch poster board. The counselor will use a pencil to outline the genogram and an eraser to clear away errors. The counselor will use the ultra-fine-point marker to embolden shapes, lines, and symbols drawn within the genogram to make it more visibly appealing. The colored pencils and markers will be used to pro­ vide color to symbols and shapes as the client desires. Create a genogram covering at least three generations of the caregivers’ families of origin. Focus on sexual orientation, gender identity, traumatic experiences, and boundaries. Encourage the caregivers to bring pictures or photographs representing context and his­ tory. Additionally, focus on cultural and diversity experiences. Inform the caregivers that the genogram can take multiple sessions to complete owing to the information and processing needed to finish the proj­ ect. Symbols, colors, and pictures allow the client to communicate and process unique emotional experi­ ences that words cannot adequately express (Cook & Poulsen, 2011; Ward, 2012). Following are the steps for counselors to carry out when creating the genogram with their clients. Step 1. Please draw a picture of your family of origin beginning with you and your partner on the eleven­ by-seventeen-inch poster board. [A smaller piece of paper may be used.] Place the following symbols for the two of you about two-thirds of the way down the sheet [see genogram key on page 305 for a list of symbols]. Please write your initials and age within each symbol. Next to each of you, place the correspond­ ing symbol for your ex-partner, including that person’s initial and age in the symbol.

Step 2. On the top one-third of the paper, place the corresponding symbol for each of your parents with their initials and age, as indicated by the genogram key [see example genogram on page 305]. Step 3. On the bottom one-third of the paper, place the corresponding symbol for each of your children with their initials and ages, as indicated by the genogram key [see example genogram]. Step 4. Using the corresponding symbols, draw lines representing the type of relationship between differ­ ent members in the genogram and their interactions with one another as indicated by the genogram key [see example genogram]. Step 5. Using additional symbols, designate different multicultural issues experienced by your family. For example, were they victimized in their social locations, or did they convey discriminatory and oppressive views to others that were based on their marginalized experiences (e.g., racism, sexism, homophobia, transphobia, physical disability, mental disability)? Following the completion of the genogram, the coun­ selor can use reflective questions to engage the client and gain a deeper understanding of the situation and family dynamics regarding oppression and sexual identity. Some reflective questions counselors should be encouraged to ask include the following: a) Which aspects of your sexual and/or gender identity do you embrace or reject? b) Which biases related to your gender and/or sex­ ual identity has your family of origin transmitted to you? c) Which aspects of your sexual or gender identity are you least comfortable with? d) Which groups or people have you had a difficult time working with? e) How important is it for you to have others know about your experiences related to your gender or sexual identity? f) How do you relate to others in the sexual and gen­ der minority community? Counselors are encouraged to explore how transmis­ sion of information related to cultural issues occurs for each parent across three generations of the family Addressing Blended Family and Trauma Issues 301

history. These communication patterns can indicate the ways in which the parents feel that they are being effective or ineffective in their parenting skills with each child, and they can relate to previous experiences from their own childhood (Ward, 2012). The final aspect of the genogram involves synthe­ sis and affords parents the opportunity to discuss interlocking forms of oppression and privilege they have experienced, which is encouraged to promote critical exploration of catalytic experiences (Kosutic et al., 2009). During this part of the activity, the coun­ selor should facilitate discussion about thoughts, feel­ ings, contents, and processes, and how personal iden­ tities were shaped. The facilitator should also explore what the parents learned from completing the activity. Brief Vignette

Ryan (thirty-nine years old) and Joe (short for Jose­ phine, forty years old) are a lesbian couple who pre­ sent in the counseling office together for support with parenting. Ryan is an African American transgender woman and Joe is a Latina cisgender woman. The cou­ ple have been married for five years, and they each have a biological child from a previous heterosexual rela­ tionship and one child they recently adopted together. The children are Zane (Ryan’s fourteen-year-old son), Jason (Joe’s fifteen-year-old son), and Timothy (their fourteen-year-old adopted son). Timothy is the only white person in the family. All three children perform well academically and have not had any issues with one another since Timothy arrived two years ago. He had been placed in five foster homes before he met Ryan and Joe, who fostered him for two years before legally adopting him this year. The extent of his trauma is unknown, other than what they learned when he first arrived at their home; however, Ryan and Joe have just found out that Timothy was recently charged with sex­ ually abusing a peer at school. Timothy participates in court-ordered counseling with a Certified Sex Offender Treatment Practitioner (CSOTP) weekly, where this information was disclosed and shared with his adoptive parents. Timothy’s counselor referred Ryan and Joe to parent-education counseling sessions. The family does not have any friend or familial support, and they recently moved to the area for Joe’s employment. During the first session with both parents, the 302 Zazzarino, Kirkland, & Thompson

counselor will gather background information perti­ nent to their presentation for clinical intervention. The counselor will then describe the benefits of a geno­ gram, including having visual representation of rela­ tional patterns, communication patterns, and cultural family information for each partner. The parents will see the benefit of engaging in therapy that uses pictures and drawings that provide a framework representing familial relationships. Ryan and Joe will be asked to disclose any traumatic experiences they have under­ gone, which the children may be triggering. Coun­ selors facilitating use of the genogram with sexual and gender minority parents should also note on the poster relational patterns of contention that are based on the parents’ sexual and/or gender identity. Please refer to the genogram key and example genogram (page 305) for examples of how these patterns could be represented in the case of Ryan and Joe. Suggestions for Follow-up

Once the genogram is complete, the counselor and family must spend time conceptualizing and discuss­ ing their families of origin (Tasker & Granville, 2011). These discussions provide space and opportunity for children to ask questions and for sexual and gender minority parents to provide information. Counselors can facilitate parent-led conversations about the uniqueness of the family (Tasker & Granville, 2011). Additionally, counselors can highlight the sources of support available within the extended family and community (Tasker & Granville, 2011). Developing relationships with other sexual and gender minority parent families is crucially important for the reemergence of connection and a sense of community (Goldberg et al., 2016). For example, par­ ticipating in child-centered gatherings with sexual and gender minority parent families, Pride parade fami­ ly-centered activities, and sexual and gender minority weddings offers a sense of oneness and connection to the larger community (Goldberg et al., 2016). These experiences provide both parents and children an opportunity to engage with other families that have similar dynamics and racial backgrounds in an affirm­ ing environment (Goldberg et al., 2016). Though mak­ ing these connections can be challenging and con­ tact can be sporadic, counselors can seek community

resources that provide welcoming and affirming opportunities for sexual and gender minority parent families to engage with one another. At times, coun­ selors may need to create safe, affirming spaces for diverse sexual and gender minority parent families to interact with one another. For example, a sexual and gender minority parent support group or family gathering that includes the children is one way to support families in reconnecting to the larger community. Contraindications for Use

Genograms are counterproductive in treatment when clients seek to address issues that are not family-related and that affect only the individual (Keskin, 2017). Additionally, genograms are not useful for clients in crisis or at a precontemplative stage of change, who may lack the ability to address intergenerational family patterns of functioning (Keskin, 2017). Therefore, coun­ selors need to be aware of their client’s situation and use alternative treatment modalities when necessary. Professional Readings and Resources Bigner, J. J., & Wetchler, J. L. (2012). Handbook of LGBT-affir­ mative couple and family therapy. New York: Routledge. Family Acceptance Project. (n.d.). Welcome to the Family Acceptance Project. https://familyproject.sfsu.edu/. Family Equality Council. (2018). Family support. https:// www.familyequality.org/. Gamson, J. (2015). Modern families: Stories of extraordinary journeys to kinship. New York: New York University Press. Gay Parent: LGBT Magazine. (2019). Regional support organi­ zations. https://www.gayparentmag.com/support-groups. National LGBT Health Education Center. (2019). A program of the Fenway Institute. https://www.lgbthealtheducation.org/. PFLAG. (2019). Need support? https://pflag.org/needsupport. Shelton, M. (2013). Family pride: What LGBT families should know about navigating home, school, and safety in their neighborhoods. Boston: Beacon Press. Skinta, M. D., Curtin, A., & Pachankis, J. (2016). Mindfulness and acceptance for gender and sexual minorities: A clini­ cian’s guide to fostering compassion, connection, and equal­ ity using contextual strategies. Oakland, CA: New Harbin­ ger Publications.

References American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. Boggis, T. (2012). The real modern family . . . can be real com­ plicated. Journal of Gay and Lesbian Mental Health, 16 (4), 353–360. doi:10.1080/19359705.2012.703526.

Borden, K. A. (2014). When family members identify as les­ bian, gay, or bisexual: Parent-child relationships. Profes­ sional Psychology: Research and Practice, 45 (4), 219–220. doi:10.1037/a0037612. Chung, Y. B., Szymanski, D. M., & Markle, E. (2012). Sexual orientation and sexual identity: Theory, research, and practice. In N. A. Fouad, J. A. Carter, & L. M. Subich (eds.), APA handbook of counseling psychology, vol. 1, Theories, research, and methods, 423–451. Washington, DC: Amer­ ican Psychological Association. Clarke, V., & Demetriou, E. (2016). “Not a big deal”? Explor­ ing the accounts of adult children of lesbian, gay, and trans parents. Psychology and Sexuality, 7 (2), 131–148. doi:10.1080/19419899.2015.1110195. Cook, J. M., & Poulsen, S. S. (2011). Utilizing photographs with the genogram: A technique for enhancing couple therapy. Journal of Systemic Therapies, 30 (1), 14–23. doi:10.1521/jsyt.2011.30.1.14. Council for Accreditation of Counseling and Related Programs (CACREP). (2016). 2016 CACREP Standards. http:// www.cacrep.org/wp-content/uploads/2018/05/2016­ Standards-with-Glossary-5.3.2018.pdf. Edwards, L. L., Robertson, J. A., Smith, P. M., & O’Brien, N. B. (2014). Marriage and family training programs and their integration of lesbian, gay, and bisexual identities. Journal of Feminist Family Therapy, 26 (1), 3–27. doi:10.1 080/08952833.2014.872955. Eggebeen, D. J. (2012). What can we learn from studies of children raised by gay or lesbian parents? Social Science Research, 41 (4), 775–778. doi:10.1016/j.ssresearch.2012. 04.008. Few-Demo, A. L., Humble, A. M., Curran, M. A., & Lloyd, S. A. (2016). Queer theory, intersectionality, and LGBTparent families: Transformative critical pedagogy in family theory. Journal of Family Theory and Review, 8, 74–94. doi:10.1111/jftr.12127. Gates, G. J. (2015). Marriage and family: LGBT individuals and same-sex couples. Future of Children, 25 (2), 67–87. Glennon, T. (2015). The developmental perspective and inter­ sectionality. Temple Law Review, 88, 929–942. Goldbach, J., Fisher, B. W., & Dunlap, S. (2015). Traumatic experiences and drug use by LGB adolescents: A critical review of minority stress. Journal of Social Work Practice in the Addictions, 15 (1), 90–113. doi:10.1080/15332 56X.2014.996227. Goldberg, A. E., Kinkler, L. A., Moyer, A. M., & Weber, E. (2014). Intimate relationship challenges in early parent­ hood among lesbian, gay, and heterosexual couples adopt­ ing via the child welfare system. Professional Psychology: Research and Practice, 45 (4), 221–230. doi:10.1037/ a0037443. Goldberg, A. E., & Smith, J. Z. (2014). Predictors of parenting stress in lesbian, gay, and heterosexual adoptive parents

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during early parenthood. Journal of Family Psychology, 28 (2), 125–137. doi:10.1037/a0036007. Goldberg, A. E., Sweeney, K., Black, K., & Moyer, A. (2016). Lesbian, gay, and heterosexual adoptive parents’ socializa­ tion approaches to children’s minority statuses. Counseling Psychologist, 44 (2), 267–299. doi:10.1177/00110000156 28055. Goodman, R. D. (2013). The transgenerational trauma and resilience genogram. Counselling Psychology Quarterly, 26 (3–4), 386–405. doi:10.1080/09515070.2013.820172. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H. C., Loos, B., . . . & Kocet, M. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling com­ petencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individuals. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi:1080/15538605. 2013.755444. Julian, N., Duys, D. K., & Wood, S. M. (2014). Sexual identity formation of women who love women: A contextual view point. Journal of LGBT Issues in Counseling, 8 (2), 189–205. doi:10.1080/15538605.2014.895665. Keskin, Y. (2017). The relational ethics genogram: An integra­ tion of genogram and relational ethics. Journal of Family Psychotherapy, 28 (1), 92–98. doi:10.1080/08975353.201 7.1279881. Kosutic, I., Garcia, M., Graves, T., Barnett, F., Hall, J., Haley, E., . . . & Kaiser, B. (2009). The critical genogram: A tool for promoting critical consciousness. Journal of Feminist Family Therapy, 21 (3), 151–176. doi:10.1080/089528309 03079037. Oakley, M., Farr, R. H., & Scherer, D. G. (2017). Same-sex par­ ent socialization: Understanding gay and lesbian parent­

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ing practices as cultural socialization. Journal of GLBT Family Studies, 13 (1), 56–75. doi:10.1080/1550428X. 2016.1158685. Oswald, R. A. (2016). Theorizing LGBT-parent families: An introduction to the special collection. Journal of Family Theory and Review, 8, 7–9. doi:10.1111/jftr.12128. Oswald, R., Blume, L., & Marks, S. (2005). Decentering het­ eronormativity: A model for family studies. In V. L. Bengtson, A. C. Acock, K. R. Allen, P. Dilworth-Ander­ son, & D. M. Klein (eds.), Sourcebook of family theory and research, 143–165. Thousand Oaks, CA: Sage. Power, J., Schofield, M. J., Farchione, D., Perlesz, A., McNair, R., Brown, R., . . . & Bickerdike, A. (2015). Psychological wellbeing among same-sex attracted and heterosexual parents: Role of connectedness to family and friendship networks. Australian and New Zealand Journal of Family Therapy, 36, 380–394. doi:10.1002/anzf.1109. Shields, L., Zappia, T., Blackwood, D., Lib, D., Watkins, R., Wardrop, J., & Chapman, R. (2012). Lesbian, gay, bisexual, and transgender parents seeking health care for their chil­ dren: A systematic review of the literature. Worldviews on Evidence-Based Nursing, 4, 200–209. doi:10.1111/j.17 41-6787.2012.00251.x. Tasker, F., & Granville, J. (2011). Children’s views of family rela­ tionships in lesbian-led families. Journal of GLBT Family Studies, 7 (1–2), 182–199. doi:10.1080/1550428X.2011. 540201. Ward, B. (2012). The cultural genogram: Enhancing the cul­ tural competency of social work students. Social Work Education, 31 (5), 570–586. doi:10.1080/02615479.2011. 593623.

GENOGRAM KEY

Lesbian Couple–Identified Parents/Clients of Example Genogram

Transgender Client

Cisgenger Woman

or

Ally

or

Holds strong negative views about sexual and gender minorities

or

Is a member of the LGBT community, but does not engage in social relationships with other members of the LGBT community Sexual abuse

Fused hostile

Close

Distant

Hostile

GENOGRAM EXAMPLE

Anthony Zazzarino, Veronica M. Kirkland, and Jenae Thompson

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35 AN INFORMATIVE INTERVENTION FOR PARENTS AND CAREGIVERS OF TRANSGENDER AND GENDER­ NONBINARY CHILDREN AND ADOLESCENTS Heather Kramer Suggested Use: Group activity Objective

This activity is designed to be used in group meetings of parents and caregivers of transgender and gendernonbinary children and adolescents. The goal is to begin a conversation as well as provide basic informa­ tion and vocabulary about both the research on and the experience of being transgender and gender nonbinary. Rationale for Use

Unfortunately, the true number of transgender and gender-nonbinary children is extremely difficult to know (Bonifacio & Rosenthal, 2015). Social pressure, both in and outside the family, is a significant deter­ rent in reporting (Reed, Rhodes, Schofield, & Wylie, 2009). Even positive factors, such as highly affirming families and the fact that not all gender-variant chil­ dren experience gender dysphoria, limit our knowl­ edge of the prevalence of these identities (Bonifacio & Rosenthal, 2015). Using gender dysphoria (GD) or the older gender identity disorder (GID) as the mea­ sure of the community provides the simplest access to data, but, as noted, the data do not represent the fullness or the breadth of experience of the gendervariant community (Bonifacio & Rosenthal, 2015). In fact, some transgender or gender-nonbinary peo­ ple may never experience gender dysphoria (WPATH, 2011). Whether or not a child’s gender nonconfor­ mity or GD continues into adolescence is known in

research as persisting or desisting. The results of stud­ ies using only GD or GID as the population measure still vary widely, ranging from Wallien and CohenKettenis’s (2008) 12 percent persistence of GID or GD into adolescence to Zucker and Bradley’s (1995) per­ sistence rate of 27 percent; furthermore, the validity of those results is in question because of confounding factors such as family pressure, internalized stigma, or simple dropout. The question of the possible endurance, or lack thereof, of a gender-variant identity or gender-non­ conforming behaviors in children makes working with them and their families a delicate balance in many ways. Children presenting with gender-nonconform­ ing preferences for appearances and activities may be recognizing a discrepancy between their assigned sex and their gender identity; however, they may be explor­ ing a path that they find not to be their own, and a given child’s eventual gender identity is almost impos­ sible to predict (Drescher & Byne, 2012). For this reason, the American Psychological Association’s (APA’s) published “Guidelines for Psychological Prac­ tice with Transgender and Gender Nonconforming People” note that there is not yet an official consensus on one treatment approach over another for working with gender-variant children (2015). Some therapists encourage exploration and affirmation, while others work to affirm and encourage behaviors that better match the child’s assigned sex (APA, 2015). The doc­ ument emphasizes, however, the importance of rec­ ognizing one’s own beliefs and values about gender

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identity and development as one approaches treat­ ment possibilities. It further highlights the possibility of discrepancy between the therapist’s desired out­ come and the family’s desired outcome, and the possi­ bilities for navigating that incongruence (APA, 2015). The families of transgender and gender-nonbi­ nary children and adolescents do face a unique set of challenges and choices, after all. If they choose to support their children in the exploration and develop­ ment of their gender identity, families may experi­ ence stigma and scorn firsthand (Drescher & Byne, 2012). Extended family members, friends, neighbors, teachers, and even total strangers may challenge the choice of parents or caregivers to support their child (Drescher & Byne, 2012). Added to this is the religious or moral conflict that some parents and caregivers feel about supporting what they may view as deviant behavior (Riley, Clemson, Sitharthan, & Diamond, 2013). Some faith groups or cultures may be more inclined than others to deny the validity of a gendervariant child’s identity (Winter et al., 2009); at the same time, Wiesner-Hanks (2011) notes that gender variance and multiple genders have existed all over the world for centuries. Whatever the emotional state of the family members when they enter the therapist’s office, they will need the therapist’s support in navi­ gating challenges both within the family system and in the community (whether their child is out in the community or not). For gender-variant children themselves, their early experiences regarding their gender identity can have lifelong effects. Roberts and colleagues (2012) found early gender variance to be a risk factor for physical, sexual, and psychological abuse during childhood; those children who are gender variant also show increased risk of post-traumatic stress disorder over their lifetimes. These children also have worse relation­ ships with their families overall (Bonifacio & Rosen­ thal, 2015). If their gender-variant identity does endure into adolescence, the cumulative effects of bullying, abuse, and other serious repercussions such as home­ lessness increase rates of low self-esteem, behavioral problems, risky sexual behavior, social withdrawal, depression, anxiety, substance use, and truly horrifying rates of nonsuicidal self-harm, suicidal ideation, and suicide attempts (Balleur-van Rijn, Steensma, Kreukels,

& Cohen-Kettenis, 2012; Bonifacio & Rosenthal, 2015; dickey, Reisner, & Juntunen, 2015; Drescher & Byne, 2012). These effects are compounded by prejudices against other, intersectional parts of the client’s iden­ tity. Racism and transprejudice are a particularly potent combination that many transgender or gender­ nonbinary youth may experience (Pazos, 2009); how­ ever, being able to both claim and be fluid with their expressions of racial as well as gender identity can be a source of resilience (Singh, 2013). Regardless of race, the support and affirmation of one’s family has been shown to correlate with better physical and mental health, higher self-esteem, and lower suicid­ ality, and it is one of the keys to congruity for transgender and nonbinary individuals, especially as chil­ dren and adolescents (Pyne, 2014). Families may not be able to protect their transgender or gender-non­ binary children from all the dangers and threats that may await as they grow, but families can avoid doing harm themselves and can provide a safe space for their children to explore and self-determine. Families, with the therapist’s guidance, can be a mitigating factor against these negative outcomes. As noted above, there is as yet no community con­ sensus on appropriate interventions for gender-vari­ ant children. However, as the APA guidelines note, the World Professional Association for Transgender Health (2011) declared in its Standards of Care that any intervention with the goal of changing a person’s gender identity and expression to match their assigned sex is, in fact, unethical. The first principle of the APA (2017) code of ethics is “Beneficence and Nonmaleficence”; section 3.04, “Avoiding Harm,” was recently amended to state that clinicians may not engage in any acts “by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person.” Principle E, “Respect for People’s Rights and Dignity,” calls for clinicians to respect each per­ son’s inherent dignity and worth and to respect their right to self-determination. To that end, therapists are instructed to be knowledgeable about and respect­ ful of any cultural difference, and to frame their thera­ peutic approach appropriately (APA, 2017). One strong, flexible model for therapy is the Gender Affir­ mative Model, as presented by Bonifacio and Rosen­ thal (2015). Its five tenets are built on depathologizing An Informative Intervention for Parents and Caregivers 307

and normalizing gender diversity and gender-variant children; its goals are to promote the self-worth of the child, find access to peer support for both the child and the family, and enable adults to create safe spaces for the child in both private and social environments. What enacting the model might look like and how deeply one delves into it can vary with the therapist and further with each client. The activity offered in this chapter is based in the principles of depathologiz­ ing, normalizing, and educating. It is a tool to help parents and caregivers achieve a level of knowledge and compassion that supports those goals.

and answering the three large-group questions, to be asked by the lead therapist. Allow for group response to each pair or hold questions and responses until everyone has finished presenting. At the end, offer each parent a complete copy of the activity sheets to keep for reference. This activity is designed for no fewer than eight adults; the pairs of terms are in order of importance to the discussion. If the group is larger than fourteen, the leader may choose either to repeat the first one or two pairs or to assign some terms to two adjacent people to form some groups of three.

Instructions

Brief Vignette

The Gender Terms Discussion Exercise (see page 311) is meant for use in support groups for parents and caregivers of transgender and gender-nonbinary chil­ dren and adolescents, in conjunction with family ther­ apy. It gives many basic definitions and allows parents to discuss and process the ideas, so ideally it would be used early in the formation of the group to provide a common foundation. To use the gender terms discussion exercise, print one copy of the full set of activity sheets and use markers or colored pencils to assign each pair of defi­ nitions a unique color before cutting the sheets into one-definition strips. The definitions are noted on the sheet with alternating squares and circles to indi­ cate a pair, but be sure to assign colors before cutting the sheets to avoid confusion, as the pairs have been designed to have a common or opposing theme. In the group, have each parent draw a randomly assigned definition. Then instruct the parents to find their partners on the basis of the designated shape and color and ask them to read their definitions aloud to each other. Discussion questions for the pairs may be given aloud by the leading therapist, written on a chalkboard or whiteboard for all to see, or printed in several copies for each pair to have one between them. Allow ten minutes for this portion of the activity. After the pairs have finished their discussion, ask everyone to come back to the larger group, either in a circle or in some other configuration so that every­ one can hear one another. Process the pairs activity as a group, each pair presenting their discussion by using the Discussion Questions handout (page 313)

Mrs. B. is a fifty-one-year-old, heterosexual, cisgen­ der, Caucasian widow. She is the grandmother of William and Christopher R., her daughter’s children, and has been their legal guardian since her daughter and son-in-law were killed in an automobile accident not long after Christopher was born. Both children are mixed race, Mr. R. having been Asian American. Both were assigned male at birth and have had no developmental problems. Will, who is eight years old and comfortably iden­ tifies as male, has been in therapy periodically since his parents’ death. Chris, who is almost five years old, while still responding to masculine pronouns, has lately been making comments such as “I wish I were a girl,” “I hate my penis,” and, “Why can’t I be like you instead of Will, Grandma?” Mrs. B. grew increasingly alarmed and soon sought family therapy for what she could only guess was Chris’s response to missing his mother and not having his father as a role model. In the first session, however, Chris slowly explained that he didn’t like his body. He wanted to be a girl, and his body was wrong; he denied that these feelings had any connection to his parents. Mrs. B. became quite distraught and began to blame herself, but the therapist had suspected this outcome from the intake. Along with tissues and normalizing reassurances, the therapist gave Mrs. B. a handout for a new group for parents and caregivers of transgender and gendernonbinary children and adolescents. Mrs. B. took the flier somewhat reluctantly, but she nevertheless found herself at the meeting the next week. There they did a pairs activity in which she

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happened to be matched with another grandparent caring for his son’s child while his son was in prison, and the two discussed the terms transgender and gender nonbinary. Both were struggling with fears and misgivings, and together they worked through what felt like new-fangled ideas. Both shared a deep love for their grandchildren, however, that kept them engaged both in their pair’s discussion and the larger group dis­ cussion afterward. Mrs. B. was able to share her con­ cerns even as she and the group worked through ideas that were complicated and new to them, and she took the full handout she received to the next family session to discuss it there. Suggestions for Follow-up

This activity is intended to offer information and cre­ ate discussion in the environment of a therapy group with common experiences; ideally, the parents or caregivers would then continue in their family therapy. There, the family therapist should follow up by cov­ ering the full handout with the client in a one-on-one session to discuss the parent’s or caregiver’s reactions to the new terms and ideas in a more private envi­ ronment. Some terms or topics discussed may have brought up intensely personal feelings, unrelated to the child, and the adult may need to have several oneon-one sessions, or even find an individual therapist for long-term work. Contraindications for Use

Parents and caregivers come for help in working through conflicts or confusion about gender identity in drastically varying degrees of discomfort, concern, shame, or anger. If a group has been formed by refer­ rals or self-selection because of strong negative feel­ ings, it may not be practical to use this activity so early or in such an uncontrolled way. Another obvious group of challenges with this activity or any printed resource is that of literacy lev­ els, language differences, and difficulties with vision or with reading and comprehension. In some cases, the lead therapist may be able to move through the group, reading through a term slowly with those who are struggling, but for others it may simply not be a useful tool (for example, unless and until it is trans­ lated into Spanish or the dominant secondary language

of the area). The websites listed in the resources, how­ ever, all have multilingual resources: Gender Creative Kids, hosted in Canada, offers the entire website in English, French, and Arabic; Gender Spectrum offers online parent support groups in both English and Spanish; and Healthy Children offers the entire web­ site in both English and Spanish, including the par­ ticularly useful articles under the Grade School page of their Ages & Stages area. Professional Readings and Resources American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. doi:10.1037/a0039906. Bonifacio, H. J., & Rosenthal, S. M. (2015). Gender variance and dysphoria in children and adolescents. Pediatric Clin­ ics of North America, 62 (4), 1001–1016. doi:10.1010/j. pcl.2015.04.013. Brill, S., & Pepper, R. (2008). The transgender child: A handbook for families and professionals. San Francisco: Cleis Press. Ehrensaft, D. (2016). The gender creative child: Pathways for nurturing and supporting children who live outside gender boxes. New York: Experiment. Pyne, J. (2014). Gender independent kids: A paradigm shift in approaches to gender non-conforming children. Cana­ dian Journal of Human Sexuality, 23 (1), 1–8. doi:10:3138/ cjhs.23.1.CO1. Youth and Gender Media Project. (n.d.). youthandgender­ mediaproject.org.

Resources for Clients American Academy of Pediatrics. (2017). Healthy children. https://www.healthychildren.org. Brill, S., & Pepper, R. (2008). The transgender child: A hand­ book for families and professionals. San Francisco: Cleis Press. Davids, S. B. (2015). Annie’s plaid shirt. North Miami Beach, FL: Upswing Press. Ehrensaft, D. (2016). The gender creative child: Pathways for nurturing and supporting children who live outside gender boxes. New York: Experiment. Ewert, M. (2008). 10,000 dresses. New York: Seven Stories Press. Gender Creative Kids. (2018). Resources for gender creative kids and their families, schools and communities. https://www.gendercreativekids.ca. Gender Spectrum. (2017). https://www.genderspectrum.org.

Gino, A. (2015). George. New York: Scholastic Press.

Hall, M. (2015). Red: A crayon’s story. New York: Greenwillow

Books. PFLAG. (2019). https://www.pflag.org. An Informative Intervention for Parents and Caregivers 309

References American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. doi:10.1037/a0039906. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/ethics-code-2017.pdf. Balleur-van Rijn, A., Steensma, T. D., Kreukels, B. P. C., & Cohen-Kettenis, P. T. (2012). Self-perception in a clinical sample of gender variant children. Clinical Child Psychol­ ogy and Psychiatry, 18 (3), 464–474. doi:10.1177/1359 104512460621. Bonifacio, H. J., & Rosenthal, S. M. (2015). Gender variance and dysphoria in children and adolescents. Pediatric Clin­ ics of North America, 62 (4), 1001–1016. doi:10.1010/j. pcl.2015.04.013. dickey, l. m., Reisner, S. L., & Juntunen, C. L. (2015). Non-sui­ cidal self-injury in a large online sample of transgender adults. Professional Psychology: Research & Practice, 46 (2), 3–11. Drescher, J., & Byne, W. (2012). Gender dysphoric/gender variant (GD/GV) children and adolescents: Summariz­ ing what we know and what we have yet to learn. Journal of Homosexuality, 59, 501–510. doi:10:1080/00918369.20 12.653317. Herdt, G. (1996). Introduction. In G. Herdt (ed.), Third sex, third gender: Beyond sexual dimorphism in culture and history, 21–81. New York: Zone. Pazos, S. (2009). Social work practice with female-to-male transgender and gender variant youth. In G. P. Mallon (ed.), Social work practice with transgender and gender-variant youth, 2nd edition, 87–103. New York: Routledge. Pyne, J. (2014). Gender independent kids: A paradigm shift in approaches to gender non-conforming children. Cana­ dian Journal of Human Sexuality, 23 (1), 1–8. doi:10:3138/ cjhs.23.1.CO1. Reed, B., Rhodes, S., Schofield, P., & Wylie, K. (2009). Gender variance in the UK: Prevalence, incidence, growth and geographic distribution. Gender Identity Research and

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Education Society. https://www.gires.org.uk/wp-content/ uploads/2014/10/GenderVarianceUK-report.pdf. Richards, C., Bouman, W. P., Seal, L., Barker, M. J., Nieder, T. O., & T’Sjoen, G. (2016). Non-binary or genderqueer genders. International Review of Psychiatry, 28 (1), 95–102. doi:10.3109/09540261.2015.1106446. Riley, E. A., Clemson, L., Sitharthan, G., & Diamond, M. (2013). Surviving a gender variant childhood: The views of transgender adults on the needs of gender variant children and their parents. Journal of Sex and Marital Therapy, 39 (3), 241–263. doi:10.1080/0092623X.2011.628439. Roberts, A., Rosario, M., Corliss, H. L., Koenen, K. C., & Aus­ tin, S. B. (2012). Childhood gender nonconformity: A risk indicator for childhood abuse and post-traumatic stress in youth. Pediatrics, 129 (3), 410–417. doi:10.1542/ peds.2011-1804. Singh, A. A. (2013). Transgender youth of color and resilience: Negotiating oppression and finding support. Sex Roles, 68, 690–702. doi:10.1007/s11199-012-0149-z. Wallien, M. S., & Cohen-Kettenis, P. T. (2008). Psychosexual outcome of gender-dysphoric children. Journal of the American Academy of Child and Adolescent Psychiatry, 47 (12), 1413–1423. doi:10.1097/CHI.0b013e31818956b9. Wiesner-Hanks, M. (2011). Gender in history: Global perspec­ tives, 2nd edition. Malden, MA: Wiley-Blackwell. Winter, S., Chalungsooth, P., Teh, Y. K., Rojanalert, N., Maneerat, K., Wong, Y. W., . . . & Macapagal, R. A. (2009). Transpeople, transprejudice, and pathologization: A seven-country factor analytic study. International Journal of Sexual Health, 21 (2), 96–118. doi:10.1080/19317610 902922537. World Professional Association for Transgender Health (WPATH). (2011). Standards of care for the health of trans­ sexual, transgender, and gender nonconforming people (version 7). https://s3.amazonaws.com/amo_hub_con tent/Association140/files/Standards%20of%20Care%20 V7%20-%202011%20WPATH%20(2)(1).pdf. Zucker, K., & Bradley, S. J. (1995). Gender identity disorder and psychosexual problems in children and adolescents. New York: Guilford Press.

GENDER TERMS DISCUSSION E XERCISE

n Gender Identity A person’s gender identity is based in their own sense of being male, female, both, neither, or another gender or genders altogether. It is a valid, if subjective, brain-based form of identity that a person is conscious of as matching or not matching their assigned sex.

n Assigned Sex A person’s assigned sex is based on their external genitalia and DNA and can be male, female, intersex (having features of both male and female genitalia, representing about 1.7 percent of the population), or something else. It is a medical convention for categorization based on hormones, chromosomes, and anatomy.

● Gender Roles

● Gender Expression

Gender roles are socially accepted, gendered behavior norms. They can unfortunately be used to force a person to conform to their assigned sex rather than their gender identity, or they can be judged as flouted by a transgender, gender nonbinary, or LGB+ person in their refusal to perform stereotypically, but they are not strictly harmful in themselves.

Gender expression refers to how a person presents themselves on a day-to-day basis (as masculine, feminine, androgynous, etc.). It may or may not always match their gender identity. Mismatches are often the result of shame, fear, or oppressive gender roles, but they may simply be the result of a preferred aesthetic.

n Cisgender Cisgender is a descriptor of gender identity for those whose gender identity matches their assigned sex at birth. They are comfortable affirming their assigned sex and are largely unafraid to present their true gender expression in clothes, mannerisms, hairstyle, gait, and so on. They traditionally uphold the binary gender system of male and female.

n Gender Variant A gender-variant person is anyone whose assigned sex at birth does not match their gender identity. It is an umbrella term often divided into two main categories—transgender and gender nonbinary.

● Gender Nonbinary A nonbinary person falls under the gender variant umbrella. Their gender identity explicitly defies the idea of a binary gender system. Nonbinary is itself an umbrella term for those who identify as male and female at the same time, neither male nor female, no gender at all, transgender, multiple genders, or one of many others.

● Transgender

n Dysphoria

n Dissociation

Dysphoria is a state of physical or emotional distress that is brought on by the disconnect between one’s true identity and one’s assumed (or stated, in the case of closeted people) identity. It may be chronic, as a persistent feeling of being in the wrong body, or acute, as in a situation where one is misgendered or deadnamed (called by one’s assigned name rather than one’s true,

chosen name).

Dissociation can be a common struggle for gender

variant individuals; it is an episode in which the

person feels disconnected from the environment

and/or from the body itself for a time. It can be

brought on by severe dysphoria, either acute

or chronic, and may last anywhere from a few

seconds to several hours or even days.

A transgender person falls under the gender variant umbrella, but that person may or may not remain on the gender binary. A transgender person may have a gender identity that is the perceived opposite of their assigned sex, or they may identify as transgender as a nonbinary person, still defying the strict male-female binary.

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● Sexual Orientation

● Sexual Behavior

Sexual orientation refers to a person’s pattern of aesthetic or erotic attraction to a kind of person. It is what sexual identity describes; though sexual identity may change, sexual orientation does not (for example, if a cisgender person who is attracted to women comes to identify as transgender, their orientation remains the same but their identity changes from straight to lesbian or vice versa).

Sexual behavior is different from sexual identity and sexual orientation, referring instead to a person’s past or current experience. It may not correspond with sexual identity (especially past behavior), and it may be a part of oppressive gender roles and expectations. It should therefore never be used to deny a person’s identity or orientation (for example, a cisgender teen girl is attracted to women but dates only men throughout adolescence because of shame and fear).

n Sexual Identity

n Romantic Identity

A person’s sexual identity is defined by the terms that make up the LGB+ community. Sexual identity describes sexual orientation. It is both distinct from and framed by gender identity (for example, a person assigned female, who identifies as male, and who is attracted to other male-identified individuals, would identify as gay).

A person’s romantic identity describes their romantic orientation (their pattern of emotional or romantic attraction to a kind of person) in the same way that sexual identity describes sexual orientation. Examples include heteroromantic, panromantic, biromantic, and so on.

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DISCUSSION QUESTIONS For pairs: Are you familiar with your term or with your partner’s?

Can you think of an example of each term?

How do the two relate?

For large group, to be asked of each pair: What were your terms, and what did you learn?

What was surprising?

How are you feeling?

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36 CIRCLES OF OUTNESS: SYSTEMIC EXPLORATION OF DISCLOSURE DECISIONS IN MIXED-ORIENTATION RELATIONSHIPS Mary R. Nedela, M. Evan Thomas, and Michelle M. Murray Suggested Use: Activity Objective

The objective of this activity is to assist mixed-orien­ tation couples in exploring levels of outness through the use of support/outness mapping and systemic ques­ tioning. Another goal of this activity is to enhance rela­ tional understanding and intimacy by self-disclosing and gaining insight. Rationale for Use

As individuals are beginning to claim a wider variety of sexual orientation labels, relationships are also becoming increasingly complex. Mixed-orientation relationships are those in which each partner identifies as a different sexual orientation from the other (Ven­ cill & Wiljamaa, 2016). In such relationships, disclo­ sure of sexual orientation has been found to cause extreme distress for couples (Hernandez, Schwenke, & Wilson, 2011), similar to that of infidelity and trauma (Yarhouse, Atkinson, Doolin, & Ripley, 2015). Differing levels of outness in relationships in which each partner claims a nonheterosexual identity have also been linked to decreased relationship satisfac­ tion (Jordan & Deluty, 2000). Nonmonosexual indi­ viduals may experience even more negativity from their partners and other loved ones when they disclose owing to misconceptions about the identity (Klesse, 2011; Scherrer, Kazyak, & Schmitz, 2015). When issues regarding the effects of disclosure and level of outness arise in relationships, it is impor­

tant to address them. Research suggests that commu­ nication, mutual understanding, honesty, and forgive­ ness are important in improving relationship quality among mixed-orientation relationships (Buxton, 2000, 2006; Kays, Yarhouse, & Ripley, 2014). Experiential therapies, such as emotion-focused therapy, are effec­ tive in addressing these aspects of relationships and in increasing intimacy and relationship satisfaction (Johnson & Greenberg, 1985a, 1985b). This activity uses a narrative therapy approach (White & Epston, 1990) to assist clients in mapping their outness with narrative maps. Narrative therapy is a postmodern theory emphasizing the multiple narratives that indi­ viduals can use to describe their lives, or levels of out­ ness, for this specific activity. Narrative therapists view problems as separate from the individual and seek to collaborate with clients to help shift their narratives regarding the problem (White & Epston, 1990). The events we experience in our lives are heavily influenced by contextual variables. For example, vari­ ables such as age, gender, race, sexual orientation, nationality, social class, education, and more all inter­ sect and affect an individual’s interpretation of events. Cultural discourses have a particularly powerful influ­ ence on individual narratives (White & Epston, 1990). Individuals who experience multiple minority stress­ ors owing to their intersecting minority identities are at an increased risk of distress (Meyer, 1995, 2003; Meyer, Dietrich, & Schwartz, 2008; Meyer, Ouellette, Haile, & McFarlane, 2011). Using an intersectional approach is essential when providing therapy to all

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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clients, and especially to those who experience mul­ tiple minority stressors (Crenshaw, 1991; McCall, 2005; Meyer, 1995, 2003; Meyer et al., 2008; Meyer et al., 2011). A narrative is what links significant events together to form the story of a person’s life. The meaning that individuals make from these stories often leaves lit­ tle room for the complexities of life, which leads to a thin description (Morgan, 2000). Those with power (parents, politicians, and so on) create such descrip­ tions and maintain them through gatekeeping of events that confirm or deny them. Because thin descriptions are based on only some events, thin conclusions can develop over time and lead individuals to believe they are defined by the thin description (Morgan, 2000). It is then very easy to focus on events that further con­ firm the thin conclusion and ignore the power pro­ cesses that constructed them to begin with. Thin con­ clusions lead to more thin conclusions, which leads to problem-saturated narratives (Morgan, 2000). Because problems that frequently bring clients to therapy are relationally constructed, they can also be deconstructed to renarrate a person’s view of self (Combs & Freed­ man, 2012, 2016; Freedman & Combs, 1996; White & Epston, 1990). The goal of therapy, therefore, is for therapist and clients to collaboratively deconstruct problem narratives, explore alternative narratives, and foster thick descriptions of stories and identity that account for context and complexity of life (Morgan, 2000, White, 2007; White & Epston, 1990). By creating the narrative maps of their level of outness, clients are able to separate their outness from themselves and create a narrative that allows them and their partner to understand how their differing levels of outness affect their relationship (White & Epston, 1990). When we can shift a client’s narrative from being “a person with a problem” to being a per­ son who “is affected by a problem,” the client is able to explore a wide range of alternative narratives for their life (White, 2007, p. 9). This is the goal of therapy: to assist clients in deconstructing problematic narratives and thickening alternative narratives that the clients prefer (Morgan, 2000; White & Epston, 1990). In addition to using therapeutic modalities that specifically address communication and mutual under­

standing, it is critical for therapists to use affirmative therapy practices with mixed-orientation couples. The therapist must affirm all identities of each partner, especially sexual orientation, and not perpetuate ste­ reotypes about those identities. Both partners will have intersecting identities that affect their experiences and disclosure decisions; therefore, therapists must facilitate discussions that are embedded within these intersectional contexts (Buxton, 2006). Failing to do so would be counter to affirmative practices and ethical standards. The tenets of narrative therapy are well aligned with those of affirmative therapy practices, given the attunement to discourses of power. Cohn (2014) and Yarhouse (2008) both argue that narrative therapy is an effective approach in working with same-sex cou­ ples because of the critical attention to cultural influ­ ences on interpersonal and intrapersonal narratives. Narrative therapists take a firmly nonjudgmental stance and focus solely on deconstructing the domi­ nant discourses that lead to problem narratives. One of the dominant discourses affecting same-sex couples is heteronormativity, which can lead to a dominant individual narrative of internalized homophobia that can result in relational distress (Yarhouse, 2008). In narrative therapy practices, such narratives built from heteronormativity are deconstructed by shedding light on the origins of the narrative. Alternative stories that counter the dominant narrative based on hetero­ normativity are emphasized in order to create a new dominant narrative that honors the complexity and intersectionality of the clients (White & Epston, 1990). McGeorge and Carlson (2011) recommend com­ municating an affirmative stance by deconstructing heterosexism with clients as part of the therapeutic process. That is, affirmative therapists should be aware of common issues affecting sexual minorities and encourage their clients to recognize and name the influences of heterosexism and heteronormativity on their presenting problems (McGeorge & Carlson, 2011). Additionally, they strongly encourage LGBaffirmative therapists to reflect on their own heteronor­ mative assumptions, privileges, and identities on an ongoing basis. Narrative therapists similarly find it crucial to “clearly and publicly identify those aspects

Circles of Outness: Exploration of Disclosure Decisions 315

of our own experience, imagination, and intentions” (Freedman & Combs, 1996, p. 275) that influence the therapeutic process. Janson (2002) suggested that there are concerns that affirmative therapists must consider that relate specifically to the American Association for Marriage and Family Therapy ethical codes (AAMFT, 2015) regarding responsibility to clients and professional competence and integrity. These include understand­ ing the contexts in which sexual minorities live, spe­ cific skills for working with sexual minority clients, and reflexivity about the practitioner’s own beliefs, values, and location. The very tenets of narrative therapy already include such recommendations. Still, therapists providing services to same-sex couples should educate themselves on unique issues facing these couples (Prouty Lyness & Lyness, 2007). This activity uses affirmative therapy practices as well as a narrative therapy framework to assist couples in discussing their disclosure processes. Specifically, this activity uses affirmative practices of neutral lan­ guage and avoidance of assumptions or judgments along with the tenets of narrative therapy to draw out shared understanding and increased communi­ cation regarding disclosure decisions for partners in mixed-orientation relationships. Throughout the activity, specific attention is paid to the unique expe­ riences of intersecting identities that lead to decisions about disclosure and the effects of these disclosures on the relationship. Instructions

This activity can be done at the start of any session with individuals who are in a relationship with each other. The only materials needed for the activity are paper and writing utensils of the therapist’s or clients’ pref­ erence. The therapist will begin the session by intro­ ducing the activity to the clients. Though the example below discusses a nonmonosexual, monogamous cou­ ple, this activity can be completed with any mixed-ori­ entation relationship. Additionally, the activity could be modified for polyamorous relationships by directing the partners to take turns constructing one another’s maps and asking process questions of all partners. Step 1. Each individual is going to draw the partner’s maps. The maps will include circles that represent the 316 Nedela, Thomas, & Murray

partner’s systems in which they interact—for example, family of origin, family of choice, friends and acquain­ tances, work or school, community, social media, and any other systems that are important to the partner. The size of the circle will represent the level of the part­ ner’s outness. For example, if a partner is out concern­ ing their sexual orientation more in their family of choice than in their community, then the circle that represents family of choice will be larger. The partner can connect the different circles to one another to represent influence or overlap between the two sys­ tems. The therapist’s role during this stage is simply to provide the instructions to the clients, and then allow the clients to create their maps for their partners. Step 2. After the clients have created the maps, the therapist will ask questions regarding the maps. The therapist can begin by allowing the clients to explain the maps that they created for their partners, and the therapist can ask questions throughout this pro­ cess. These questions should stem from the activity, and they may vary between clients. Below are some sample questions. To the partner who drew the map: • How was it to create your partner’s outness map? • Was there a specific system that was easier to draw? • Was there a specific system that was more difficult? • How was it to decide in which system your partner was most out? • Is there any system in which you wish your partner were more out?

What about less?

• Is there any circle that is drawn in which it is difficult for your partner to be out? • Are there any other statements that you would like to make about the map that you drew for your partner? To the partner whom the map represents: • How well does this map represent your different levels of outness?

• Should any circle be larger? Smaller? • How is it to see the map that your partner drew for you? • Are there any other statements that you would like to make about the map that your partner drew for you? Step 3. After the clients have processed the activity, the therapist can ask questions about the different levels of outness that the clients may experience. The questions can be very specific to the clients and the different systems. • Who in this [insert a specific system] is aware of your sexual orientation? • Which were firsthand disclosures?

Secondhand?

• Who had positive reactions? Negative? Neutral or ambiguous? • What has influenced your decision to disclose to these particular people or systems? What influ­ enced your decision not to disclose? • Familial support or lack of support • Heteronormativity and/or heterosexism • Mononormativity • Monosexism • What are your feelings regarding your partner’s disclosure decisions? • What is it like to hear your partner discuss these disclosure decisions here? • What meanings do these disclosures or nondisclo­ sures have for you and your relationship? • Is this a discussion that both of you have often within the relationship? • What effects, if any, do your other identities have on your level of outness in general and in specific systems? Brief Vignette

Bill and Alex are both in their late twenties and have been in a monogamous relationship for seven months. They have recently been experiencing issues commu­ nicating and have decided to seek therapy to improve

communication and resolve arguments more effec­ tively. After Bill and Alex repeatedly brought up dif­ ferences in their sexual orientation disclosure expe­ riences in the first few sessions, their therapist decided that exploring their levels of outness in session could be beneficial. Alex identifies as a Latino bisexual transgender man and has disclosed his sexual orientation and gender identity to most of the people with whom he frequently interacts. Alex is comfortable with this and would like Bill to become more comfortable with disclosure. Bill, who identifies as a white, queer, cisgender man, has not disclosed his sexual orientation to many of his friends and family members and would prefer not to do so. This difference in disclosure con­ tributes to many arguments, as Alex feels they are not able to be honest without disclosing their identities to the people to whom they are close. The therapist asked Bill and Alex to draw dis­ closure maps for each other during the session and explained how to indicate differing levels of disclo­ sure on the map. Bill and Alex drew these maps sep­ arately, with very little discussion, and then shared them with each other. Both stated that the map their partner drew for them was fairly accurate. When discussing these maps with each other, Bill and Alex realized how different their disclosure experiences have been. Bill was surprised at how small the circles on his map were compared to Alex’s. During this dis­ cussion, Alex revealed that he gained some insight into his own disclosure practices as well, and he stated that he realized he has not disclosed his sexual orien­ tation to as many people as he had originally thought. Alex shared the experiences of tension he felt were due to his Latino racial identity and culture through­ out his sexual-orientation and gender-identity devel­ opment, and how that process influenced his coming out to family and friends. He observed that it was easy for him to consider himself open when comparing himself to Bill, but examining his experiences using a visual representation allowed him to be more objective. While processing the experience with their ther­ apist, Bill and Alex were able to discuss some of their disclosure experiences and how they may be affect­ ing their current relationship. Bill revealed that he disclosed his sexual orientation to his brother at a young age and felt very ashamed and rejected when Circles of Outness: Exploration of Disclosure Decisions 317

his brother distanced himself afterward. He noted that this experience has influenced his decision not to disclose to other family members and friends who have regular contact with his family. Bill also shared some hesitancy about disclosure because he does not want to educate every person to whom he discloses about his queer identity. Alex remarked that he has been asked to explain bisexuality many times when disclosing his identity, and he acknowledged that this is not a simple process. By processing their disclosure maps, Bill and Alex were able to discuss the various factors influ­ encing disclosure decisions and began to understand each other’s motives more clearly. They were also able to explore how their disclosure process could have been influenced by the intersection of their sexual, gender, and racial or ethnic identities. Alex acknowledged that he had not considered how dis­ closing his identity could be risky for Bill and said that he would like to know more about Bill’s past experiences with his family. Suggestions for Follow-up

It is important to continue to explore disclosure expe­ riences and the ways these experiences affect couples’ relationships throughout the next several sessions. The meaning of disclosure for each partner may differ, as can the meaning of the identity labels they use. These meanings can be explored as part of the thera­ peutic process as a way not only to explore disclo­ sure, but also to investigate their relationship with each other and the other systems they are part of. Contraindications for Use

Many clinicians believe infidelity is a contraindication for couples therapy; however, this belief may violate affirmative therapy for polyamorous relationships. An activity such as this would be contraindicated, how­ ever, when there is evidence of intimate partner vio­ lence. Clinicians must be careful to properly assess for relationship structure and signs of violence within the relationship.

318 Nedela, Thomas, & Murray

Professional Readings and Resources Bieschke, K. J., Perez, R. M., & DeBord, K. A. (2007). Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients, 2nd edition. Washington, DC: American Psychological Association. doi:10.1037/11 482-000. Chernin, J. N., & Johnson, M. R. (2002). Affirmative psycho­ therapy and counseling for lesbians and gay men. Thousand Oaks, CA: Sage. Wetchler, J. L., & Bigner, J. J. (2012). Handbook of LGBT-affir­ mative couple and family therapy. New York: Routledge.

Resources for Clients McFadzen, L. (2014, February 23). BiCast. Resources for mixedorientation marriages. https://thebicast.org/2014/02/23/ resources-for-mixed-orientation-marriages/. Rheult, M. (2007). Mixed-orientation pathways to success. https://mixedorientation.com. Rheult, M. (2012). Transcending boundaries guide to mixed orientation marriages. https://bisexual.org/wp-content/ uploads/2014/08/mixed-orientation-marrigaes-flipped. pdf. Taormino, T. (2008). Opening up: A guide to creating and sus­ taining open relationships. San Francisco: Cleis Press.

References American Association for Marriage and Family Therapy (AAMFT). (2015). User guide to the AAMFT code of ethics. Alexandria, VA: AAMFT. Buxton, A. P. (2000). Writing our own script: How bisexual men and their heterosexual wives maintain their marriages after disclosure. Journal of Bisexuality, 1, 155–189. doi:10. 1300/J159v01n02_06. Buxton, A. P. (2006). Counseling heterosexual spouses of bisexual men and women and bisexual-heterosexual couples. Journal of Bisexuality, 6, 105–135. doi:10.1300/ J159v06n01_07. Cohn, A. S. (2014). Romeo and Julius: A narrative therapy intervention for sexual-minority couples. Journal of Fam­ ily Psychotherapy, 25, 73–77. doi:10.1080/08975353.2014. 881696. Combs, G., & Freedman, J. (2012). Narrative, poststructural­ ism, and social justice: Current practices in narrative therapy. Counseling Psychologist, 40, 1033–1060. doi:10. 1177/0011000012460662. Combs, G., & Freedman, J. (2016). Narrative therapy’s rela­ tional understanding of identity. Family Process, 55, 211– 224. doi:10.1111/famp.12216. Crenshaw, K. (1991). Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Review, 43, 1241–1299.

Freedman, J., & Combs, G. (1996). Narrative therapy: The social construction of preferred realities. New York: W. W. Norton. Hernandez, B. C., Schwenke, N. J., & Wilson, C. M. (2011). Spouses in mixed-orientation marriage: A 20-year review of empirical studies. Journal of Marriage and Family Therapy, 37, 307–318. Janson, G. R. (2002). Family counseling and referral with gay, lesbian, bisexual, and transgendered clients: Ethical con­ siderations. Family Journal, 10, 328–333. doi:10.1177/ 10680702010003010. Johnson, S. M., & Greenberg, L. S. (1985a). Emotionally focused couples therapy: An outcome study. Journal of Marital and Family Therapy, 11 (3), 313–317. Johnson, S. M., & Greenberg, L. S. (1985b). Differential effects of experiential and problem-solving interventions in resolving marital conflict. Journal of Consulting and Clin­ ical Psychology, 53 (2), 175. Jordan, K. M., & Deluty, R. H. (2000). Social support, coming out, and relationship satisfaction in lesbian couples. Jour­ nal of Lesbian Studies, 4, 145–164. Kays, J. L., Yarhouse, M. A., & Ripley, J. S. (2014). Relationship factors and quality among mixed-orientation couples. Journal of Sex and Marital Therapy, 40, 512–528. Klesse, C. (2011). Shady characters, untrustworthy partners, and promiscuous sluts: Creating bisexual intimacies in the face of heteronormativity and biphobia. Journal of Bisexuality, 11, 227–244. doi:10.1080/15299716.2011.57 1987. McCall, L. (2005). The complexity of intersectionality. Signs, 30, 1771–1800. doi:10.1086/426800. McGeorge, C., & Carlson, T. S. (2011). Deconstructing hetero­ sexism: Becoming an LGB affirmative heterosexual cou­ ple and family therapist. Journal of Marital and Family Therapy, 37, 14–26. doi:10.1111/j.1752-0606.2009.009.x. Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36, 38–56.

Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Concep­ tual issues and research evidence. Psychological Bulletin, 129 (5), 674–697. doi:10.1037/0033-2909.129.5.674. Meyer, I. H., Dietrich, J., & Schwartz, S. (2008). Lifetime prev­ alence of mental disorders and suicide attempts in diverse lesbian, gay, and bisexual populations. American Journal of Public Health, 98, 1004–1006. Meyer, I. H., Ouellette, S. C., Haile, R., & McFarlane, T. A. (2011). “We’d be free”: Narratives of life without homopho­ bia, racism, or sexism. Sexuality Research and Social Pol­ icy, 8, 204–214. doi:10.1007/s13178-011-0063-0. Morgan, A. (2000). What is narrative therapy? An easy-to­ read introduction. Adelaide, South Australia: Dulwich Centre Publications. Prouty Lyness, A. M., & Lyness, K. P. (2007). Feminist issues in couple therapy. Journal of Couple and Relationship Ther­ apy, 6, 181–195. doi:10.1300/J398v06n01_15. Scherrer, K. S., Kazyak, E., & Schmitz, R. (2015). Getting “bi” in the family: Bisexual people’s disclosure experiences. Journal of Marriage and Family, 77, 680–696. doi:10.111 1/jomf.12190. Vencill, J. A., & Wiljamaa, S. J. (2016). From MOM to MORE: Emerging research on mixed-orientation relationships. Current Sexual Health Reports, 8, 206–212. doi:10.1007/ s11930-016-0081-2. White, M. (2007). Maps of narrative practice. New York: W. W. Norton. White, M., & Epston, D. (1990). Narrative means to therapeu­ tic ends. New York: W. W. Norton. Yarhouse, M. A. (2008). Narrative sexual identity therapy. American Journal of Family Therapy, 36, 196–210. doi:10.1080/01926180701236498. Yarhouse, M. A., Atkinson, A., Doolin, H., & Ripley, J. S. (2015). A longitudinal study of forgiveness and post-disclosure experience in mixed-orientation couples. American Jour­ nal of Family Therapy, 43, 138–150.

Circles of Outness: Exploration of Disclosure Decisions 319

SECTION V

HOMEWORK, HANDOUTS,

AND ACTIVITIES FOR

GENDER AND SEX

IDENTITY EXPLORATION

By focusing on gender and sexual identity exploration, the contributors to this section move beyond helping clients with concerns about coming out and instead offer clinicians creative mechanisms by which they can assist their clients to more deeply appreciate their gender and sexual identities. As clients with diverse gender and sexual identities reach for authenticity, inte­ grating their gender and sexual identities into the totality of their individuality is important. Making the invisible more visible, using mindfulness-based inter­ ventions, and integrating expressive arts into the ther­ apeutic process are common themes in this section. The section begins with Chapter 37, by K. Jod Taywaditep, “The Matrix for Sexuality and Gender: My Sexual and Gendered Self in the World of Sexual and Gender Diversity.” Using the Klein Sexual Orien­ tation Grid (Klein, Sepekoff, & Wolf, 1985), Taywa­ ditep offers therapists a matrix through which clients can deconstruct and then reconstruct their under­ standing of their sexual and gender identities. Use of this activity provides clients and clinicians with a means by which private and public identities can be explored, milestone events highlighted, and gender and sexuality appreciated along multiple dimensions. The intersections of sexual and gender identities are also discussed in Shannon Solie’s “Mapping of Desires and Gender: Explorations at the Intersec­ tions” (Chapter 41). Informed by multiple theories, though based primarily on the sexual configurations theory (SCT) (van Anders, 2015), Solie creates an activity useful for individuals, couples, or groups that operationalizes SCT so that clinicians can help clients explore how oppression and socialization have affected their understandings of their gender and sex­ ual expressions and identities. Clients are guided to map identities using a key they create and to identify those aspects of themselves that are static and fluid. In “Asexuality: An Introduction for Questioning Clients” (Chapter 42), Emily M. Lund, Bayley A. John­ son, Christina M. Sias, and Lauren M. Bouchard speak to the often stigmatized identity of asexuality, noting that those who identify as asexual often do not come out because of stigma and shame. By offering a hand­ out with which therapists can educate their clients, the authors compassionately guide clients toward a deeper recognition of their sexuality, moving them 322

gently from shame to acceptance and appreciation. For many LGBTQ people, integrating religious and sexual identities can be difficult and result in inter­ nal conflict (Haldeman, 2004). Matt Zimmerman’s “Managing Religious and Sexual Identity Intersections” (Chapter 47) helps clinicians assist clients’ explora­ tion and integration of these identities in healthy ways. Zimmerman suggests using the Religious, Spiritual, and Sexual Identities Questionnaire (Page, Lindahl, & Malik, 2013) to help clients address conflicts between religious and sexual identity. By completing the ques­ tionnaire, clients have an opportunity to pinpoint troublesome areas and find a more compassionate intersection of competing identities. Trauma and gender identity are explored in “Cre­ ative Interventions for Traumatized Transgender and Gender-Nonconforming (TGNC) Youth” (Chap­ ter 39), by Alexandra M. Rivera and Crystal Morris. They note how the majority of transgender youth have experienced at least one traumatic event in their lives (Fallot & Harris, 2001). Those who hold multi­ ple minority identities may find that their pain is exacerbated by the level of oppression they face. For this reason, the authors suggest the use of trauma-in­ formed art therapy to promote healing by building on the powerful connection between the arts and neu­ rodevelopment, which can ultimately lead to a deeper processing of the trauma. This activity allows for the engagement of the whole body, facilitating better reg­ ulation of physiological reactions and affect. Use of alternative methods to talk therapy are pre­ sented in three chapters. Marilia S. Marien’s “Using Mindfulness to Enhance Identity Integration for LGBTQ Clients” (Chapter 46) highlights the effective­ ness of mindfulness-based practices in treatment and their application to identity integration for LGBTQ clients. Marien invites clients to explore the habitual thoughts and feelings with which they may struggle in regard to their identities and move toward accep­ tance. As a result of greater awareness, clients can begin the process of letting go of harmful internalized judg­ ments, permitting space for integration of multiple aspects of the self. Jean Georgiou uses expressive art therapy to help LGBTQ youth put words to their identities. In Chapter 44, “Using Expressive Art Therapy with

LGBTQ Youth: A Picture Is Worth a Thousand Words,” she invites youth to create self- and family portraits and collages to represent how they fit into their world. This activity helps bypass the hesitation that youth sometimes experience when talk therapy feels threat­ ening or when it cannot fully capture their feelings. Through art therapy, LGBTQ youth can share their feelings of being different, heal from bullying and harassment, and move toward self-acceptance. In Chapter 43, “Inhabiting Our Bodies: Working with Gender Dysphoria in Transgender and Gen­ der-Nonbinary Children and Adults through Body Maps,” Natasha Distiller offers an activity in which clients can explore body image and the societal mes­ sages they have received about their bodies. In a gender-affirming approach, Distiller acknowledges the fluidity of gender and offers clients a nonverbal means to connect to their bodies through a body mapping activity. Recognizing that body images change, this exercise is one that clients can return to as they con­ nect more fully and organically to their nonbinary gender identity. The remaining chapters in this section focus exclu­ sively on gender identity integration. In M. Killian Kinney and Richard A. Brandon-Friedman’s “Explor­ ing Gender Identity with a Photo Diary” (Chapter 38), readers are introduced to the use of photo diary as a means to facilitate pride in clients’ gender identity. The authors propose that because of societal pressure to conform to scripted gendered behavior, many clients have not fully permitted their internal sense of gender to be visible. By using photos, drawings, or collages, clinicians can normalize the range of gender expres­ sion and thereby playfully give voice to those hidden and authentic gendered self-representations. It is also of the utmost importance in working with any client to ensure that the clinician’s assessment tools are inclusive of all identities. Specifically, for clients who identify as nonbinary, clinical forms that force a limited choice in gender identity represent a microaggression. Andrew Suth and Sorrel Rosin pro­ vide an excellent example of an assessment form designed to highlight the clinician’s open and affirm­ ing stance on gender identity in Chapter 40, “The Importance of Language: Creating Nonbinary Assess­ ment Forms That Reflect a Full Range of Gender Iden­

tities.” In presenting this information, the authors help therapists begin the therapeutic relationship in an ethical, compassionate, and welcoming manner. The topic of gender representation continues in Chapter 48, “Rose as a Name Is So Much Sweeter: Navigating the Name-Change Process with Transgender and Gender-Nonbinary Clients,” by Cadyn Cathers. The process of changing one’s name to more accurately represent one’s gender is important, as it deepens clients’ comfort with their identified gender and moves them to social affirmation. The namechange process can uncover a variety of emotions and memories for clients who have experienced microaggressions when called by a name that does not fit with their gender identity. Cathers’s handouts provide clinicians a vehicle by which they can guide their cli­ ents to explore name choices and to find safe places where they can experiment using their chosen name. Acknowledging the influence and importance of social support and group work for transgender and gender-nonconforming clients, Julie M. Mullany’s con­ tribution, “An Eight-Week Identity Exploration Group for Transgender and Gender-Nonconforming Indi­ viduals” (Chapter 45), addresses the healing power of connecting with others at varying stages of identity integration. Mullany offers the reader a planned group experience that encourages members to explore and integrate the intersection of their gender, ethnic, and other identities and to use others’ experiences not only to support their journey but also to challenge internalized messages about their gender. Each week is structured around a specific topic and activity in which group members are creatively and gently guided toward identity integration. In the final chapter of this section, Dorian Kondas addresses the concerns of aging transgender clients. In Chapter 49, “The Aging Transgender Client: Map­ ping the Acceptance of Experience,” Kondas notes the possibility of increased gender dysphoria owing to many factors, such as oppressive health-care options and dependence on family members who may be transphobic. Through the use of acceptance and com­ mitment therapy (Hayes, Strosahl, & Wilson, 2012), Kondas guides clients to explore their values, obstacles to the goals these values embody, how they regulate their emotions toward goal achievement, and how they 323

can move toward acceptance of what was lost and the resilience they have, all within the framework of their identity as an aging transgender individual. References Fallot, R. D., & Harris, M. (2001). A trauma-informed approach to screening and assessment. New Directions for Mental Health Services, 89, 23–31. https://doi.org/10.1002/yd. 23320018904. Haldeman, D. C. (2004). When sexual and religious orienta­ tion collide: Considerations in working with conflicted same-sex attracted male clients. Counseling Psychologist, 32, 691–715. doi:10.1177/0011000004267560.

324

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Accep­ tance and commitment therapy: The process and practice of mindful change, 2nd edition. New York: Guilford. Klein, F., Sepekoff, B., & Wolf, T. J. (1985). Sexual orientation: A multi-variable dynamic process. Journal of Homosexu­ ality, 11, 35–42. doi:10.1300/J082v11n01_04. Page, M. J. L., Lindahl, K. M., & Malik, N. M. (2013). The role of religion and stress in sexual identity and mental health among LGBT youth. Journal of Research on Adolescence, 23 (4), 665–677. doi:10.1111/jora.12025. van Anders, S. M. (2015). Beyond sexual orientation: Integrat­ ing gender/sex and diverse sexualities via sexual config­ urations theory. Archives of Sexual Behavior, 44, 1177– 1213. doi:10.1007/s10508-015-0490-8.

37 THE MATRIX FOR SEXUALITY AND GENDER: MY SEXUAL AND GENDERED SELF IN THE WORLD OF SEXUAL AND GENDER DIVERSITY K. Jod Taywaditep

Suggested Uses: Activity, homework Objective

The Matrix for Sexuality and Gender (MSG) delineates and organizes aspects of the self that pertain to sexu­ ality and gender. The MSG offers a reflective frame­ work for clients to consider sexuality and gender as complex, multidimensional, fluid, and dynamically interacting with factors in their personal, develop­ mental, cultural, and political contexts. The exercise aims to stimulate clients’ conceptual curiosity and clar­ ity, increase personal insights and critical conscious­ ness, and affirm their sexual and gender experiences. Rationale for Use

When individuals have sexual, affectional, and gender experiences that do not fit with the traditional norms of sexuality and gender, they often experience conflict, confusion, and distress (see Lev, 2007; McCann & Sharek, 2015; Schneider, Brown, & Glassgold, 2002). Internalized prejudices and rigid notions of sexuality and gender undermine the mental health of these individuals, who are often already culturally and polit­ ically oppressed (Bieschke, Perez, & DeBord, 2007). LGBTQ-affirmative therapists’ tasks are manifold: they must help promote clients’ positive self-concept, built on the acceptance of their attractions and gender (Beckstead & Israel, 2007). Therapists can help clients develop a clearer sense of their desires and gender, appreciate how their sexuality and gender evolve and develop, and decide how they choose to label them­

selves and relate to others through their identities (Eubanks-Carter, Burckell, & Goldfried, 2005). Ther­ apists can help clients examine how their desires and identities may or may not fit with traditional notions of man, woman, straight, gay, lesbian, and bisexual (Eubanks-Carter et al., 2005), and whether this is a source of distress for the client. Therapists can help cli­ ents identify conflicts related to their sexuality and gender and explore options to negotiate with the world who they want to be; for gender-diverse clients, the therapist’s role may include alleviating gender dyspho­ ria and facilitating the expression of clients’ gender identity, including gender-affirming transition such as hormone therapy and/or surgery (Coleman et al., 2011). Clients will benefit from the insight that their psychosocial problems are at least in part attributable to sociocultural oppression rather than any inherent deficits connected to their sexuality and gender iden­ tities (Pachankis & Goldfried, 2004). These therapeutic tasks may begin with clarifying, identifying, examining, sorting out, and prioritizing the multiple dimensions of the client’s sexuality and gender. A multidimensional assessment such as the Klein Sexual Orientation Grid (KSOG) has been used for this purpose (Beckstead & Israel, 2007). Introduced by Fritz Klein in 1980 as a research instrument to assess sexual orientation (Klein, Sepekoff, & Wolf, 1985; Weinrich, 2014a), the KSOG has contributed to the modern understanding of sexuality by positing that sexuality is multidimensional, fluid, and on a con­ tinuum. To treat sexuality as multidimensional, the

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

326

KSOG asks people to deconstruct their sexual orien­ tation into different dimensions that may or may not all line up. To treat sexuality as fluid, the KSOG allows different answers about people’s sexuality at different times in their lives. To treat sexuality as a continuum, the KSOG asks people to consider their sexuality on spectrums from completely homosexual to completely heterosexual. The KSOG facilitates self-exploration and critical thinking about sexuality (Galupo, Mitchell, Grynkiewicz, & Davis, 2014; Lovelock, 2014); hence, educators and clinicians have used it to inform the public and psychotherapy clients about nonmonolithic sexuality (Chen-Hayes, 2003; Cramer et al., 2015; Weinrich, 2014c). The Matrix of Sexuality and Gender (MSG) is an update of the KSOG. It builds on the KSOG’s inno­ vation, with two crucial distinctions: in addition to the KSOG’s focus on sexual orientation, the MSG extends the examination to gender and prompts an evaluation of social, cultural, and political contexts. From the exercise clients gain not only self-awareness but also social consciousness. With the opportunity to exam­ ine the hegemonic conceptualizations of sexuality and gender, clients can identify these notions’ strengths and limitations and appreciate how these notions influence their lives. With this insight, clients can also subvert the narratives that privilege some identities and marginalize others and participate in the collec­ tive acceptance and celebration of healthy, affirmative, and diverse sexuality and gender. Why an update on the KSOG? Researchers and sexologists have critiqued the KSOG for its construc­ tion (Weinrich, 2014a, 2014b) and implications for social justice (Galupo, Davis, Grynkiewicz, & Mitchell, 2014; Galupo, Mitchell, et al., 2014). In both Wein­ rich’s and Galupo and colleagues’ work, common crit­ icisms of the KSOG are in fact problems with how sexual orientation itself is defined and assessed, includ­ ing these problems: (a) bisexuality is represented as a blend or compromise between heterosexuality and homosexuality, (b) asexuality is ignored, (c) rating the degrees of hetero- versus homosexuality assumes that everyone is cisgender, rendering the rating scale con­ fusing and invalid for transgender, intersex, genderqueer, and genderfluid people, and (d) no attention is

paid to other variables (e.g., outness, gender confor­ mity, transitioning, kink sexualities, polyamory, part­ nered versus solitary sexuality), and non-Western and other intersectional identities, many of which have become recognized signposts in the contempo­ rary cultural landscapes. Unsurprisingly, while the KSOG is comprehensive, thought provoking, and liberating for some, for others it is confusing and frus­ trating, even marginalizing some sexualities and identities as nonnormative or abnormal (Galupo, Mitchell, et al., 2014). In other words, while the KSOG’s limitations may simply mirror the shortcomings of our paradigms about sexuality and gender, they may also perpetuate the ethical, moral, and political quan­ daries of social injustice. Given the prevailing oppressive and misinformed socialization about sexuality and gender, it is recom­ mended that therapists adopt an inclusive approach that counteracts forms of sexual and gender oppres­ sion while nonjudgmentally exploring diversity in gender expression and sexual, affectional, and value orientations (Beckstead & Israel, 2007). The affirmative approach is in line with the American Psychological Association’s ethical principle (American Psychologi­ cal Association [APA], 2002, principle E: Respect for People’s Rights and Dignity) and the practice guide­ lines of various mental health professional associa­ tions, including, but not limited to, the following: (a) APA’s “Guidelines on Multicultural Practice for Psy­ chologists” (APA, 2002, guideline 5: Striving to apply culturally appropriate skills in clinical and other applied psychological practices); (b) “Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Cli­ ents” (APA, Division 44/Committee on Lesbian, Gay, and Bisexual Concerns Joint Task Force, 2000); (c) the American Counseling Association’s ALGBTIC guidelines (Harper et al., 2013); and (d) the Stan­ dards and Indicators for Cultural Competence in the Social Work Practice (National Association of Social Workers [NASW], 2015, standards 3 and 4). The MSG reorganizes and expands the construc­ tions of sexuality and gender, and it welcomes sub­ versive paradigms that have gained visibility in recent years. With the methodological, ethical, and political criticisms of the KSOG in mind, the MSG offers a

The Matrix for Sexuality and Gender 327

conceptually sound and socially inclusive framework for psychotherapy that is affirming of diverse sexual­ ities and genders. • The KSOG deconstructed sexuality into separate dimensions: sexual attraction, sexual behavior, erotic fantasies, emotional preference, social preference, self-identification, and hetero/homosexual lifestyle. A departure from the previous assumption that sex­ ual behavior was all that mattered to understand sexual orientation, the KSOG’s multidimensional view has become common scientific practice for assessing sexuality (Beaulieu-Prévosta & Fortin, 2015). The MSG embraces deconstructed sexuality not only to be more comprehensive but also because romantic and emotional attraction is less male-cen­ tric and more inclusive of women’s sexuality (Peplau & Garnets, 2000). • With no room to address gender, the KSOG’s exam­ ination of clients’ sexuality was seriously limited because clients’ and their partners’ genders matter in the notion of sexual orientation (van Anders, 2015), while gender identity and gender conformity are significant factors for the mental health and selfesteem for heterosexual and LGBTQ individuals (Coleman et al., 2011; Good & Sanchez, 2010; Tay­ waditep, 2001). The MSG asks clients to examine their gender and how it is internally held as a private identity versus communicated to others as a public identity. As it does with sexual orientation, the MSG prompts a deconstruction of gender into multiple dimensions: gender identity, gender pronouns, genderrole conformity, and the publicness of gender iden­ tity. In discussing these dimensions of gender, cli­ ents may reveal gender dysphoria, and therapists can help clients find a comfortable gender role, and/or seek changes in gender expression, includ­ ing feminizing or masculinizing the body through hormone therapy and/or surgery, and voice and communication therapy (Coleman et al., 2011). • The MSG asks clients to rate each affinity for men and for women separately. This orthogonal approach (Weinrich, 2014c), in contrast to the KSOG’s use of Kinsey’s heterosexual-homosexual continuum, prevents a high affinity rating for one gender from automatically lowering the affinity rating for the 328 Taywaditep

other gender. Thus, the MSG does not treat bisexu­ ality and asexuality as a compromise between het­ erosexuality and homosexuality. High affinity ratings for both male and female conform to cultural con­ notations of bisexuality. Low affinity ratings for both male and female partners help identify possi­ ble labels in the typology of asexuality (e.g., grayromantic, demisexual, and heteroromantic). • By rating affinities separately for men versus women, individuals can answer affinity questions on the MSG regardless of their own gender identification; trans, genderqueer, genderfluid, and intersex indi­ viduals can more readily express their affinities. But what about the partners’ genders? Despite the fact that the dichotomous schema of men/male ver­ sus women/female still serves as a powerful and convenient organizing principle when most people process information about gender, rating affinities for men and women still assumes that clients’ part­ ners are either men or women, thus far from avoid­ ing gender binarism and cisnormativity. To circum­ vent this problem, the MSG invites clients to mark “X” when their affinities do not conform to the men/women dichotomy—for example, a cisgender client’s attraction to trans partners. To problema­ tize gender even more, the affinities for men and women can be replaced with affinities for masculin­ ity and femininity, acknowledging that one is often attracted to the partner’s gender roles, rather than their genotypes or gender labels (van Anders, 2015). Further, the MSG encourages the notion that the gender identities of clients and partners, in addition to being nonbinary, are complex and may include all kinds of personally meaningful specificities and qualifiers (e.g., a transman with a vagina, a butch cisgender woman, a transwoman undergoing gender transitioning, a genderqueer person who is male by legal definitions). • The MSG welcomes the context-specific multiplicities of sex and relationships. Sex encompasses a variety of activities, and these activities may differ accord­ ing to contexts such as who the partners are (see van Anders, 2015). For example, a cisgender male client has vaginal intercourse only with his com­ mitted female partner, has receptive oral sex from

male partners in hookups, and practices BDSM with both male and female partners as a sex worker. Romantic and emotional connections can also be context-specific: a transwoman has enjoyed hook­ ups with feminine men and women, short roman­ tic connections with multiple androgynous “boy­ friends,” and a long-term emotional and financial commitment with a woman. Because the KSOG did not attend to variables such as types of sexual activities, the nature and contexts of sex and com­ mitment, and the partners’ gender conformity and identification, the individuals in the examples above would have trouble responding on the KSOG. In contrast, the MSG makes no assumptions that one type of sexual activity (e.g., vaginal or anal inter­ course) is more valuable or central to clients’ sexu­ ality than others (e.g., oral sex, masturbation, or BDSM). Nor does the MSG assume that clients must prioritize some relationships and discount others (e.g., long-term relationships versus brief or anon­ ymous sexual encounters, crushes, or sex work). Clients can annotate these distinctions on the MSG, then particularize them in the discussion with the therapist to portray the rich tapestry of their sexual and romantic lives. In quantitative research, this level of granularity and context-dependence is a night­ mare; in psychotherapy, both patterns and excep­ tions are meaningful, informative, and valuable. • There are many nondominant, non-Western termi­ nologies for sexualities and genders (Bailey et al., 2016; DeBlaere, Brewster, Sarkees, & Moradi, 2010). By inviting clients to consider these terms, the MSG is in line with the practice of postmodern feminist and queer theories in challenging the dominant discourse that presumes heterosexuality/homosex­ uality and male/female are the only ways to catego­ rize and comprehend sexualities and genders (Baber & Murray, 2001; Elizabeth, 2014). The MSG fore­ grounds various aspects of sexuality and gender that are better treated as discrete than as degrees, including identity labels (e.g., straight, bi, grayromantic, butch, pansexual, bottom, bear, trans, gen­ derqueer, MTF) and other characteristics (e.g., gender pronouns, transitioning, open relationship). Sexuality and gender are both personal and politi­ cal, and the MSG highlights the interplay between

clients’ selves “in the sheets” and “in the streets” by explicitly asking for identity labels and social affili­ ations. Clients are invited to consider identities for their sexual and gender practices, and how these identities may become avenues for their in-person or online social support as well as social-political coalition and activism. • All individuals have multiple identities and group memberships, and these categories interact with one another in meaningful ways (Cole, 2009) and have implications for the individual’s minority stress (Budge, Thai, Tebbe, & Howard, 2016). The MSG encourages clients to contemplate the intersection­ ality of their identities. Clients can indicate identi­ ties that are ostensibly about their sexuality and gender (e.g., gay, bi, straight, asexual, and other labels of sexual orientation identity; trans, genderqueer, BDSM, femme, single, celibate, polyamorous, HIV+) and those conceptually distal yet linked (e.g., age, ability, race, religion, socioeconomic sta­ tus, feminist identity). On the MSG, intersectional identities can be articulated in a composite of social identities, short (“an asexual genderqueer person”) or long (“an atheist polyamorous queer cisgender femme woman of color with a disability”). Clients can reflect on how these group memberships play a role in their life experience, personal and social functioning, and sense of self. • The KSOG’s Social Preference represented how “some people—of all orientations—only socialize with their own sex, while others socialize with the opposite gender exclusively” (Weinrich, 2014a, p. 318). What this dimension taps is unclear, given that socializing could be at home, with one’s sexual and/or romantic partner(s), at the workplace, in the community, or online. There is also empirical support that social preference may be of less rele­ vance (Lovelock, 2014). Therefore, social preference is excluded from the MSG in favor of other dimen­ sions reflecting clients’ social reality, such as their outness, the publicness of their gender identity, and the sense of community alliance, all of which pro­ vide useful clinical information about their social support and political engagement. The therapist should be careful not to assume that all clients’ The Matrix for Sexuality and Gender 329

healthy social functioning must include public selfdisclosure of sexuality and gender (coming out), or community involvement and belonging; many clients with minority group memberships face mul­ tiple stigmas that render coming out challenging or unrealistic (Matthews, 2007, p. 213). • The social realities of the client’s gender can be exam­ ined when discussing their gender pronouns on the MSG. A cisgender man may be baffled—how else could he have chosen his gender pronouns—which would reflect his previously unacknowledged cisnormative privilege. A transman may discuss how the he/him/his pronouns in his everyday life reflect the achievements in his gender journey; other trans individuals may have chosen the male pronouns to minimize daily discrimination. Individuals who adopt they/them/their or zhe/zhim/zher as gender pronouns may share their daily communication challenges or zher moments of personal victories and affirmations. • The KSOG’s Hetero/Gay Lifestyle was originally explained as “where [people] tend to spend time,” such as whether it is “with the opposite sex” (Wein­ rich, 2014a, p. 318). There is empirical support that exclusive immersion in the gay versus straight com­ munity is less relevant in contemporary culture (Lovelock, 2014), and what clinically matters most may be clients’ subjective sense of belonging and identification with a community. The MSG reframed the KSOG’s “lifestyle” as clients’ self-perceived social affiliation with the heterosexual community, the sexual-gender minority community, or neither. Cli­ ents can also indicate other community affiliations that are important to them, such as the fetish com­ munity, disabled community, activist community, and religious community. • The one-year point demarcates the Past and Present on the KSOG, but there is nothing special about the one-year time frame apart from seeking unifor­ mity in research measurement. On the MSG, Past and Present time frames are conceived in relation to a personally meaningful gender/sexuality mile­ stone of the client’s choice. The milestone event as a marker for the client’s narrative on gender/sexu­

330 Taywaditep

ality development is based on M. Paz Galupo and colleagues’ findings: “For many self-identified sex­ ual and gender minorities milestones in past expe­ riences such as ‘coming out’ or ‘transitioning’ were more salient than discrete timeframes when inter­ preting past experiences” (Galupo, Mitchell, et al., 2014, p. 414). • The KSOG’s “future/ideal” time frame can be ambig­ uous (Weinrich, 2014b, p. 386) and difficult to respond to given the fluidity of sexuality and gender over the life span. In contrast, the MSG’s ideal time frame is the thought experiment about the client’s hypothetical conditions unencumbered by society’s prejudices or limited by life’s reality. In line with the feminist and multicultural perspectives that acknowledge the effects of one’s social location on one’s experience (Greene, 2007; Warner & Shields, 2013), the MSG prompts clients to examine how their sexuality and gender may have been influenced by social and cultural forces. Clients also examine effects of personal and environmental conditions, such as their monogamous commitment, their polyam­ orous identity, their living arrangements as a teen­ ager, their membership in a homogeneous commu­ nity, or their religiosity. • The MSG does not assume that alignment (or con­ gruence) among all the dimensions and time frames is the “right” state for sexuality and gender. Sari M. van Anders (2015) uses the terms branched (called incongruent, discordant, or unaligned by others) versus co-incident (called congruent, concordant, or aligned by others) sexualities to avoid a value judg­ ment of what should be natural or ideal. Clients can explore the positive and negative effects of align­ ment (or a lack thereof) among their sexual and gender dimensions. Instructions

Though the MSG’s message is that sexuality and gen­ der are complex, clients can be overwhelmed when attempting to respond to all cells on the MSG at once. Some clients may not have devoted much energy and time to contemplating aspects of sexuality and gen­ der that are less pertinent to them, whereas others may

have put off or avoided considering some issues. For example, asexual or demisexual clients may feel per­ plexed or uncomfortable when attempting to answer questions about sexual behavior or attraction early on in the process. Clients should be encouraged to take time to respond and to leave some cells blank if they wish. They should feel empowered to respond to A through L in any order they prefer, and they can take breaks to modulate the intensity of their selfexamination. The therapist should plan for ample time for processing, reflection, and discussion following the client’s completion of the MSG, using some of the questions provided on the final page of the worksheet. Additional time is indicated if there is a history of trauma related to sexuality or gender. If the MSG is completed by a couple or a group, more time is needed for interactions among clients. The MSG can be com­ pleted multiple times, as clients’ phenomenology is likely to change over time. Clients may also choose different sexuality or gender milestones to anchor their Past and Present time lines differently. The therapist should ensure that clients thoroughly review the instructions, rating scales, and examples on the second page before starting the worksheet. The examples signify to clients that deconstruction of sexuality and gender is expected, and diverse sexual­ ities and identities are normalized. Many terms and identities in the examples may be unfamiliar to cli­ ents, and the therapist should be comfortable explain­ ing the terms and providing references for further exploration if needed. Confusion and frustration typi­ cally occur, and the therapist may validate these feel­ ings with a message that although our familiar notions of sexuality and gender (e.g., having only the terms gay/bi/straight for sexual orientations, and man/ woman for gender) may be easy to grasp, they fall short of accounting for all the complexity, fluidity, and diversity of people’s lived experiences. On the other hand, labels and identities can help people find each other, connect sexually and emotionally, develop coalitions for social support, and mobilize for political welfare. Given the diversity within each identity group, the therapist can encourage clients to consider the costs and benefits of accepting or promoting intra­ group diversity versus championing for homogeneity.

Feelings of anger, hurt, shame, bereavement, grati­ tude, and surprise could also reflect clients’ experiences of trauma, oppression, or privilege, some of which might not have been acknowledged before. Brief Vignette

Alice is a thirty-one-year-old Asian American cisgender woman who identifies as able-bodied and middle-class, and uses the pronouns she, her, and hers. Until two years ago, Alice identified as straight, and she had been in committed relationships with men a few times. Her sexual and romantic activities were almost exclusively with the men in those relationships, except for a couple of onetime experiences with women. Over the years, Alice had erotic fantasies about both men and women, but the attraction was stronger for men. Two years ago, Alice met Ray, a forty-two-year-old lesbian-identified biracial woman who calls her own appearance and interests butch. Alice fell in love with Ray, but after two years of their committed relationship, Alice still has many questions about her own sexuality and gender. When complet­ ing the Matrix for Sexuality and Gender, Alice picked “falling in love with Ray” as the milestone event to frame her Past and Present. For the Past column, she noticed that her sexual and romantic attractions were almost exclusively toward men, but the numbers were not identical or lined up at the end of the spectrum. In the past, her emotional affinities were more toward women than men. In the present, her erotic affinities for women have moved higher on the spectrum while she retained minimal erotic affinities for men. Alice accepts that at present this profile is still in flux. She notices that the particulars of her interest in women are still developing; some days she is surprised to find that she has other “types,” and she is still working out which characteristics in people, including their gender, gender conformity, sexual activities, age, and identities, are important to her. After completing the MSG, Alice discussed in therapy how she is sorting out her sexuality in light of her ethnic and cultural identities. Thinking about coming out to her immigrant parents soon, Alice discovered that their pre-immigration culture had his­ torically respected and accepted same-sex love between

The Matrix for Sexuality and Gender 331

women before it became illegitimized and patholo­ gized after Westerners’ colonization. In the contempo­ rary U.S. culture, Alice has been drawn to using the “queer” label because of its defiant spirit and wide appeal to sexual and gender minorities. Alice had wor­ ried that she was “less of a lesbian” because she was feminine and attracted to masculinity in other women. Examining her erotic fantasies on the MSG, Alice rec­ ognized that she can be turned on to various degrees by feminine, androgynous, and masculine women. She felt validated by the therapist’s comment that the English lexicon for sexualities and genders is severely limited. With the insight that lesbian or bisexual women have diverse profiles of attractions, as is made explicit by the MSG, Alice’s anxiety about being atypi­ cal gave way to her comfort that heterogeneity is the norm, not the exception, in the LGBTQA commu­ nity when it comes to sex, love, desire, intimacy, and commitment. She came to accept that no labels will completely represent her, but it is still helpful to seek common ground with others who call themselves queer, or bi, or lesbian, in spite of the vast withingroup differences. Alice identifies as a woman, but the MSG helped her develop an insight that not all peo­ ple are either male or female. Reflecting with her ther­ apist on the prejudice and microaggressions against gender-nonconforming people, Alice sees her feminin­ ity with more awareness of her cisnormative power and privilege. Alice works on not assuming that peo­ ple are either male or female, or that their gender must match their appearance, and she uses the ciswoman self-label to heighten awareness of trans individuals and other nonbinary gender identities. Reflecting on her experience of completing the MSG, Alice noticed that her self-concept has been put into sharper focus, which has led to a sense of clarity, contentment, resolution, and closure. Still, there are other themes that have since become more compli­ cated and even frustrating, and they required further attention from her. Alice has identified her goals: accept some of the ambiguity and complexity, find avenues for her voice, seek further support, and build a coa­ lition for actions.

332 Taywaditep

Suggestions for Follow-up

The final page of the MSG handout suggests questions for clients after completing the MSG to (a) process their reactions, (b) share an idiographic narrative about their development, (c) stimulate insights and further learning, and (d) facilitate critical consciousness for social justice. The therapist can decide which questions should be addressed immediately and which questions can be saved for future discussions. Contraindications for Use

The MSG is not appropriate for clients who may become overwhelmed by complex information and have difficulties managing a state of confusion, includ­ ing those with psychosis, dementia, and severely limited cognitive and intellectual capacities. Professional Readings and Resources Baber, K. M., & Murray, C. I. (2001). A postmodern feminist approach to teaching human sexuality. Family Relations, 50, 23–33. doi:10.1111/j.1741-3729.2001.00023.x. Galupo, M. P., Mitchell, R. C., Grynkiewicz, A. L., & Davis, K. S. (2014). Sexual minority reflections on the Kinsey Scale and the Klein Sexual Orientation Grid: Conceptualiza­ tion and measurement. Journal of Bisexuality, 14, 404– 432. doi:10.1080/15299716.2014.929553. van Anders, S. M. (2015). Beyond sexual orientation: Inte­ grating gender/sex and diverse sexualities via sexual configurations theory. Archives of Sexual Behavior, 44, 1177–1213. doi:10.1007/s10508-015-0490-8. Weinrich, J. D. (2014a). Multidimensional measurement of sexual orientation: Past. Journal of Bisexuality, 14, 314– 332. doi:10.1080/15299716.2014.946198.

Resources for Clients General Information on Sexuality and Gender

Cauterucci, C. (2016, December 20). For many young queer women, lesbian offers a fraught inheritance. Slate. https://www.slate.com/blogs/outward/2016/12/20/ young_queer_ women_don_t_like_lesbian_as_a_name_ here_s_why.html. Human Rights Campaign. (n.d.). Glossary of terms. https:// www.hrc.org/resources/glossary-of-terms. Killermann, S. (2019, January 26). Comprehensive list of LGBTQ+ vocabulary definitions. It’s Pronounced Metrosexual. https://itspronouncedmetrosexual.com/2013/01/ a-comprehensive-list-of-lgbtq-term-definitions/. We Are Family. (n.d.). LGBT A–Z (Glossary). www.weare familycharleston.org/lgbt-a-z-glossary/.

Queer, Trans, Nonbinary Gender and Sexuality

Jakubowski, K. (2014, March 4). Too queer for your binary: Everything you need to know and more about non-binary identities. Everyday Feminism. https://everydayfemi nism.com/2014/03/too-queer-for-your-binary/. Asexuality

Asexuality Visibility and Education Network (AVEN). (n.d.). https://www.asexuality.org/home/. Demisexuality Resource Center. (n.d.). Resources for demi­ sexuals, partners, and allies. http://demisexuality.org/. What Is Asexuality? (n.d.). www.whatisasexuality.com/. Polyamory

Loving More. (n.d.). https://www.lovemore.com/.

Polyamory for Us. (n.d.). http://polyfor.us/.

Polyamory Society. (n.d.). www.polyamorysociety.org/.

BDSM

BDSM 101. (n.d.). Websites. http://bdsm-101.com/Websites. html.

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THE MATRIX FOR SEXUALIT Y AND GENDER My sexual and gendered self in the world of sexual and gender diversity 1. Pick a meaningful MILESTONE event in the development of your sexuality and gender. Examples: a significant sexual relationship, falling in love, a committed relationship, coming out, transitioning your gender, leaving home, relocation, beginning college or a job, graduation, getting married, etc. 2. The PAST column is your entire life up to that milestone, and the PRESENT column is your life since

the milestone up to now.

3. The IDEAL is not necessarily the future, but rather an imagined life in which you can have your sexuality and gender be anything you want with minimal negative consequences from your environment.

PAST

My MILESTONE is

PRESENT

IDEAL

A. Sexual Attraction Whom am I sexually attracted to?

M

W

M

W

M

W

B. Sexual Behavior Whom do I actually have sex with?

M

W

M

W

M

W

M

W

M

W

M

W

M

W

M

W

M

W

C. Erotic Fantasies Whom do I sexually fantasize about (e.g., during daydreams, masturbation)? D. Emotional Preference Whom do I feel emotionally close to (e.g., love, romance, infatuation, nurturance, intimate relationships)? E. Sexual Orientation Identity What term(s) do I use to describe my sexual orientation (see examples)? F. Gender Identity What term(s) do I use to describe my gender (see examples)? G.Other Terms & Identities What other terms also describe significant aspects of my sexuality & gender beyond the labels in E and F (see examples)? H.Gender Pronouns Which pronouns in the English language represent me (see examples)? I. Gender Role Conformity What gender do I most resemble in my thoughts, feelings, and actions? J. Sexual Orientation Outness How many people know about my identity in E? K. Publicness of Gender Identity How many people know about my identity in F? L. Community Affiliation Which sexual and gender community most matters to me and I belong to most?

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INSTRUCTIONS, RATING SCALES, AND EXAMPLES Answer questions in any order. Leave cells blank if you prefer not to answer. Mark “?” if you cannot find an answer. • For each of these four questions, rate once on the Men (M) scale and once on the Women (W) scale.

A

through

D

Attraction to . . . / behavior with . . . / fantasize about . . . / preference for . . . Men

Attraction to . . . / behavior with . . . / fantasize about . . . / preference for . . . Women

0 1 none

0 1 none

2

3 some

4

5

6 a lot

2

3 some

4

5

6 a lot

• Mark X if your answers do not fit with (cis)men or (cis)women (for example, you or your partners are trans, genderfluid, or intersex people), or your preferences/behaviors may have a complex pattern (for example, you have vaginal intercourse only with a committed female partner, receive oral sex from male casual partners). • Alternatively, consider replacing Men and Women scales with Masculinity and Femininity because people’s gender role may be more important to you.

E

Examples of sexual orientation identities straight, gay, lesbian, queer, questioning, bisexual, pansexual, person-not-gender, asexual, demisexual, heteroromantic, gray-romantic, gray-A, abstaining, nonsexual, solitary, any other non-Western terms

F

Examples of gender identities male, female, man, woman, transman, transwoman, trans*, transmasculine, transfeminine, MTF, FTM, cisgender, intersex, genderfluid, genderqueer, nonbinary, bigender, agender, Two-Spirited, any other non-Western terms • Some people may have other important characteristics that interplay with their sexuality and gender but have not been well captured by the E and F identities. • Some terms provide additional important information about sexuality and gender. Examples: polyamorous, top, bottom, kink, dom, sub, butch, femme, bear, twink, daddy, stud, openly gay, out, closeted, sex worker

G

• Other terms allow various sexual, gender, and cultural identities to come together in a more holistic intersecting way Examples: “a lesbian-identified genderqueer pansexual in a monogamous interracial relationship with a cis female” “a straight heteroromantic asexual cisman dating a ciswoman” “a Christian middle-age gay disabled black feminist woman married to a woman” “a dude who plays with other dudes” “a polyamorous queer-identified bisexual transitioning transman in an open but committed sex-only relationship with a gender-nonconforming cisgender gay male”

336

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Examples of gender pronouns

H

• • • •

they/them/their she/her/her zhe/zhim/zher ze/zir/zir

I

Masculine and feminine as generally defined by culture 0 Extremely masculine 1 Mostly masculine 2 Somewhat more masculine than feminine 3 Equally both masculine and feminine 4 Somewhat more feminine than masculine 5 Mostly feminine 6 Extremely feminine N Neither masculine nor feminine

J

Outness and Publicness 0 No one else knows 1 1–2 people in my life know 2 A few people in my life know 3 Some people in my life know 4 Many people in my life know 5 Almost all people in my life know 6 All people in my life know

and

K

Discuss or consider: what roles do these people play in your life?

L

Community Affiliation 0 Heterosexual community exclusively 1 Heterosexual community mostly 2 Heterosexual community somewhat more 3 Both communities equally 4 LGBTQA community (gender/sexual minorities) somewhat more 5 LGBTQA community (gender/sexual minorities) mostly 6 LGBTQA community (gender/sexual minorities) exclusively N Neither community In addition, you can write down any other communities that matter most to you (examples: African-American community, BDSM community, Christian community, immigrant community).

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QUESTIONS FOR FURTHER DISCUSSION After Completing the Matrix of Sexuality and Gender

• What thoughts and feelings came up as you were working on the matrix? • How do you feel about the sexuality/gender milestone that you chose for separating the Past and the Present in this exercise? What made you choose it over other events in your life? • Which cells did you leave blank? Which cells did you mark “X” or “?” Which ones did you want to come back later to fill out? What made you respond to the different cells in the sequence that you did? • What questions in the exercise stood out for you as particularly difficult to answer? Which ones did you find were not easy to pick an answer from the choices? Which ones did you feel were so easy to answer? • What reactions do you have seeing your own completed matrix? What surprised you? What was predictable? • Some people have feelings of sadness, anger, anxiety, guilt, joy, pride, or happiness as they complete the matrix. Would you like to process some of the feelings you have now? • What do you see in the matrix that you regret? What do you see as your accomplishments? What required strengths and efforts? What required support from others? • Some people’s answers in the matrix line up, and other people’s answers don’t. What do you think about the degree to which your answers go together? Is that a source of conflict for you? What are the consequences of those discrepancies? If you are not satisfied with the discrepan­ cies, what has to change? What are the pros and cons of reducing or increasing the discrepan­ cies among your answers? • Tell me about your experience giving your responses in the column labeled “Ideal.” • If your answers in the “Ideal” column are very different from those in the “Present” column, how might the gaps be narrowed? What do you need to help narrow the gaps? What will be the gains or losses in other areas of your life if you move closer to the ideal? • What insights do you have about your own sexuality and gender? How does this exercise chal­ lenge or confirm your understanding of sexuality and gender? • What insights have you gained about the way the world treats sexuality and gender in gener­ al? What do you think about the reality that different forms of sexualities and genders are not treated as equal?

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• Share with me your thoughts about how your sexuality and gender interact with other sides of you, including your race, ethnicity culture, ability, age, class, relationship status. (Other variables: HIV status, health conditions, pregnancy, occupation, freedom, etc.) • In what ways have you been given opportunities by the way that the world treats sexuality and gender? In what ways have you been restricted or sidelined? In what ways are you given priv­ ileges because of your sexuality and gender? In what ways are you disadvantaged? What can you do to make the world more inclusive and accepting of you and others?

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38 EXPLORING GENDER IDENTITY WITH A PHOTO DIARY M. Killian Kinney and Richard A. Brandon-Friedman

Suggested Uses: Homework, activity Objective

This activity is designed to open a dialogue with clients about their gender identity. By exploring the ways in which they visualize their bodies and express their gender, clients will increase awareness of how their gender is enacted in their lives. This activity will also help clinicians understand how their clients concep­ tualize their gender. Rationale for Use

Gender identity is an abstract component of one’s identity, yet a person’s physical appearance can be a significant source of anxiety and dysphoria or accep­ tance and integration (Devor, 2004; Kinney, 2019). Distinct from individuals’ sex assigned at birth, gender identities refer to the internal sense of self (Catalano & Shlasko, 2010; Kinney, 2019). The social construct of gender identity, however, has been predominantly understood as a continuum or dichotomy of mascu­ linity and femininity (Risman & Davis, 2013). The binary (exclusively male or female) conceptualization of gender has more recently been dismantled because of its oppressive nature and replaced by multidimen­ sional constructs of gender that include more fluid and creative gender identities (Burdge, 2007). According to Butler (1990), gender is a performative act with a basis that lies in socialization, whereas sex is a biological categorization of male, female, or intersex according to scientific indicators, including external genitalia, gonads, internal reproductive organs, and sex chromo­ somes (American Psychological Association, 2012).

Understood in this way, gender classifications must move beyond the idea of crossing the gender binary and into an arena that includes an infinite num­ ber of possible gender expressions through myriad modalities (e.g., dress, speech, choice of career). While some gender-diverse people accept the binary, others reject the binary and consider it problematic (Budge, Rossman, & Howard, 2014). Thus, the concept of gen­ der must be expanded to include dynamically fitting outside, within, around, and intertwined within the gender binary (Kinney, 2019), as the most important factor is being seen for one’s authentic self (Devor, 2004). Given the complexity of how individuals under­ stand their gender identities, guides to working with individuals who identify as gender diverse suggest that clients must be free to express their gender in any manner they choose without fear of repercussion from professionals (Ehrensaft, 2016). Failure to allow this freedom to clients can be stigmatizing and harmful, whereas providing a safe and affirming environment can assist clients in charting their own unique gen­ der path (Hidalgo et al., 2013). Despite improvements in attitudes toward sexual and gender minorities among social work faculty and students, bias and heteronomativity persist, creating barriers to services and poor overall quality of experience for LGBTQ clients (Chonody & Smith, 2013). Craig, Dentato, Messinger, and McInroy (2016) found that social work students may not be prepared to work with LGBTQ clients because of limited LGBTQ content in under­ graduate and graduate social work classes, lack of sup­ port for LGBTQ people—including experiencing or

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

340

witnessing homophobia—and minimal awareness of nondiscrimination policies. According to research by Beemyn and Rankin (2011), the strict gender roles forced on transgender and nonbinary individuals assigned male at birth as well as a lack of role models and media presentations of individuals outside the gender binary hamper the ability of many individuals to fully explore and develop their gender identities. Though these individ­ uals reported mostly conforming to socially desig­ nated gender roles and repressing their expression of their gender identity to protect their physical and psy­ chological safety, the ability to experiment socially on occasions such as Halloween allowed some of them to begin to understand their inner feelings. Once they became more comfortable with their gender identity and felt able to express it publicly, they noted improve­ ments in their psychosocial health. In all, this research demonstrates that exploring gender and gender expres­ sion is a healthy process and necessary for the overall well-being of individuals who identify as nonbinary. This exploration or modification of gender or gender expression can take many forms, ranging from temporary changes such as clothing, hairstyle, body hair (growth or shaving), breast binding, and pros­ thetics (e.g., packers, breast enhancing inserts) to per­ manent modifications such as gender-confirmation surgery or hormone-replacement therapy (Beemyn & Rankin, 2011). As individuals work to understand what type of expression is most representative of their gender identity, they may experience periods of more positive or more negative emotions and may wish to explore these within a therapeutic environment. Doc­ umentation of variations in gender expression through photography is a creative approach to helping clients reflect on the evolution of their gender expression and assisting with the healthy development of their gender identity. Photo diaries have been used in research and ther­ apy with a variety of groups, including intensive care patients (Ewens, Hendricks, & Sundin, 2015), older adults with mobility challenges (Swallow, Petrie, Power, & Edwards, 2015), and parents and children receiv­ ing medical treatment (Hartman, Bena, McIntyre, & Albert, 2009). Furthermore, this method has been used internationally, in Italy for community photo-

therapy (Parrella & Loewenthal, 2013), in New Zealand for exploring sexual cultures among secondary stu­ dents (Allen, 2011), and in Australia and New Zealand for examining representations of cultural identities in media (Denny, Sunderland, Smart, & Christofi, 2005). In San Francisco a visual-narrative approach used photography and interviews to elicit the “gen­ der stories” of transsexuals (Barbee, 2002, p. 54). This research found that for persons whose gender expres­ sion was outside mainstream gender roles, being seen was important, and their process of expression was often documented by and confirmed with photogra­ phy: “‘Photographs don’t lie,’ and the self-portrait acts as a blueprint of the transsexual individual in transi­ tion, making the transsexual’s gender real” (Barbee, 2002, p. 59). In this way, photography can empower clients to communicate their gender as they want to be seen. This photo diary activity applies several wellestablished methods—namely, native photography (Blinn & Harrist, 1991), photo elicitation (Banks & Zeitlyn, 2015; Smith, 2016), and a photo diary (Chap­ lin, 2011). Photography allows individuals to create an artificial environment in which they feel comfort­ able and to put this environment on display for others. When used to explore identities, photo-elicitation interviews allow photographers to introduce the observer to aspects of their identity that might be over­ looked in dynamic interactions while simultaneously contextualizing the experience and the motives sur­ rounding the creation of the image (Croghan, Griffin, Hunter, & Phoenix, 2008). In other words, photo­ graphic interpretation is a collaborative exercise between the photographer and the observer in which they interact to create a more nuanced understand­ ing of the subject and the subject’s presentation (Evans, 1999). Photography is an ideal venue for exploring something as intimate as individuals’ gender identities because it can act as a safe barrier between an expe­ rience and the discussion of it, as well as aiding in the articulation of private thoughts and experiences that might otherwise not be revealed (Noland, 2006). Photo diaries are a particularly useful technique for understanding visual transitions of time. When used chronologically, photographs can create an autoethnographic document that allows individuals Exploring Gender Identity with a Photo Diary 341

to speak in intimate, natural, and familiar tones to others who might not otherwise have access to their internal world (Chaplin, 2011). Individuals can use them to write complex stories highlighting periods of growth, change, or settlement. In this way they can be part of a powerful dialogue that occurs during the identity-development process, especially when the process partially occurs during discussions with others. Further, as a personal document, photo diaries can create an environment fully inclusive of individuals’ culture, race, ethnicity, and other intersecting identi­ ties. This holistic approach is most effective when used repeatedly. “How might all of our lives carry borders with them, wherever they go, wherever they remain—bor­ ders of class, ethnicity, nationality, language, gender?” (Susan Stryker quoted in Arnal, 2014, p. 11). People with multiple marginalized identities experience simul­ taneously evolving identities while traversing oppres­ sive landscapes. According to Meyer’s (2003) minority stress model, mental health problems are caused and exacerbated by the stratified effects of oppression that “create a hostile and stressful social environment” (p. 674). Of importance to mental health is not only minority stress, but also how it is modified by the way individuals process this stress (Meyer, 2003). When working with clients who identify as sexual and gender minorities, additional consideration needs to be given for each of the person’s identities and their interactions, both as a tension and as a resilience. When working with transgender people of color, Singh and McKleroy (2011) note the importance of understanding their resilience and how it may have helped them navigate challenges related to race and ethnicity in addition to gender identity. They found the key components of resilience for transgender peo­ ple of color to be (a) a pride in one’s gender and eth­ nic or racial identity; (b) an ability to recognize racialor ethnic- and gender-based discrimination; (c) acceptance by family of origin; (d) access to affirming health care and financial stability to secure treatment; (e) connection with a community of transgender peo­ ple of color and activism or advocacy for transgen­ der rights; and (f) spirituality and a maintained hope for the future. They offered several suggestions for practitioners, including self-assessing bias and knowl­ 342 Kinney & Brandon-Friedman

edge of transgender people of color; creating a safe space (inclusive brochures, literature, magazines, and all-gender bathrooms); explicitly stating a commitment to address racism, heterosexism, and transphobia; and advocacy to decrease social stigma and increase access to affirming health care and employment (Singh & McKleroy, 2011). For affirming care, practitioners need to integrate understanding of intersectionality into their practice (Grafsky & Nguyen, 2015). An understanding of intersectionality requires knowledge of how oppres­ sion affects people’s lives through stigma, prejudice, discrimination, macroaggressions (harmful legisla­ tion), microaggressions, heteronormativity, cisnorma­ tivity, internalized homophobia, and internalized transphobia. Laws and policies have strong influence on individuals who identify as sexual or gender minori­ ties and their families; awareness of current legal pro­ tections and risks is essential to this work, especially when working with families that consist of individuals who identify as sexual or gender minorities who may be considering marriage or adoption. (See Lambda Legal for current legislation and status of legal protec­ tions.) Because the literature on resilience has shown the importance of community support and access to health care, practitioners must possess knowledge of local resources for individuals who identify as sexual or gender minorities (e.g., community centers and affirming churches, housing, and health-care providers) (Asakura & Craig, 2014; Kinney, 2019; Orel & Fru­ hauf, 2015; Singh, 2013; Singh & McKleroy, 2011). Practitioners can provide affirming care by increasing their awareness of surrounding infrastructures, edu­ cating themselves on current literature related to sex­ ual and gender minorities, and seeking professional training within this area (Grafsky & Nguyen, 2015). Most mental health organizations have established guidelines and best practices for working with transgender and gender-diverse clients, among them the National Association of Social Workers (NASW), the American Counseling Association (ACA), and the American Psychological Association (APA). Profes­ sional guidelines and codes of ethics provide an imper­ ative framework by which practitioners guide their inclusive and affirming work and navigate ethical decision making.

In 2008 the revision of the NASW Code of Ethics included the addition of gender identity or expression in the protected category for explicit inclu­ sion (Reamer, 2013). Of the core social work values, most relevant when working with gender-diverse clients are the core values of service, social justice, dignity and worth of the person, and competence. In accordance with the professional code (NASW, 2008), social workers are mandated to practice with respect toward individuals (2.01) and cultural com­ petency (1.05), which includes attention to all forms of diversity, including sexual orientation and gender identity. Further, social workers must fight discrimi­ nation in all arenas (4.02), advocate in social and political action (6.04), and report social workers for incompetent practice (2.10) and unethical con­ duct (2.11). Burdge (2007) offered advice for social workers working with transgender clients that can be expanded to all therapists working with genderdiverse clients: recognize that affirmative care in­ cludes awareness that (a) gender-diverse persons are an oppressed population, (b) the gender binary reinforces harmful social constructs of gender, and (c) queer theory and social constructionism can aid in understanding gender. The value of diversity is similarly infused through­ out the ACA Code of Ethics (ACA, 2014). It states a need for practitioners to develop cultural sensitivity (A.2.c), not to discriminate (C.5), and to advocate for their clients (A.7.a.). Additionally, diversity is high­ lighted in assessment (E.8) and for faculty (F.11.a), stu­ dents (F.11.b), and competent content in counseling education (F.11.c.). For frameworks to guide practice with specific populations, the ACA’s Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) published the ALGBTIC Competencies for Counseling Transgender Clients (ALGBTIC, 2009) and the “Competencies for Coun­ seling with Lesbian, Gay, Bisexual, Queer, Questioning, Intersex, and Ally Individuals” (Harper et al., 2013). Finally, the American Psychological Association’s (APA) “Ethical Principles of Psychologists and Code of Conduct” (2016) specifically notes sexual orienta­ tion and gender identity under Respect for People’s Rights and Dignity (principle E), boundaries of com­ petence (2.01), unfair discrimination (3.01), and

harassment (3.03). Additionally, the APA published the Report of the Task Force on Gender Identity and Gender Variance (APA, 2009) and “Guidelines for Psychological Practice with Transgender and Gender Nonconforming People” (APA, 2015); it also estab­ lished the APA Division 44 to focus on sexual orienta­ tion and gender identity. Before using the activity, it is recommended that therapists review the professional codes and guidelines, noting the expectations and boundaries of practice in their profession. The photo diary activity was designed to explore gender identity ethically and in a manner that empowers clients and values diversity; it is easily adapted to meet the cir­ cumstances and needs of the client and practitioner. Instructions

A photo diary can be introduced when gender identity emerges in the therapeutic conversation. Through­ out long-term treatment, this activity can be used repeatedly to assess changes in perception and appear­ ance. Later iterations could review the previous pho­ tos and summary of remarks and reflect on the inter­ nal and external changes. This activity can be beneficial for a diversity of clients exploring their gender iden­ tity and other identities that are outwardly expressed. Clinicians should note unique cultural and environ­ mental influences. In addition to individual therapy, this activity can be used to increase understanding of the gender identity of loved ones during couples and family therapy. The structure of the photo diary can be simple (e.g., self-portrait only) or made more intricate by using additional components (e.g., multiple selfphotos, environmental photos, and more in-depth narratives), depending on the client’s readiness and ability. The instructions include the basic design as well as variations that can be used as an alternative to or in addition to the basic design. While this assign­ ment requires access to technology for taking photo­ graphs, the images can be collected by a film or digi­ tal camera, including a cellphone. Also, clients may use graphic representations of themselves if they do not have access to a camera or feel uncomfortable about taking pictures of themselves. In particular, it may be more appropriate to use drawings with chil­ dren. Follow the steps below. Exploring Gender Identity with a Photo Diary 343

1. Instruct clients to take a self-portrait (a head shot or full-body image).

and the therapist should work with the client to pro­ cess the emotions.

2. At the next session, have the client bring the pho­ tograph (printed or digital) with a title for the self-portrait or a brief narrative (or both).

1. This exercise should be repeated every one to three months, and the pictures should be saved for future reference. At subsequent explorations, clients should be asked to write a brief two- to three-sentence nar­ rative about any changes in their identity that they feel have occurred in the preceding time period. These narratives should be reviewed with clients during the photo-elicitation process to aid them in discussing their journey toward understanding their gender identity. As the exercise is repeated, a book can be created that contains all the clients’ selfportraits, their titles, and the progressive narratives.

3. At the start of the next session, ask the client to show you the photo and inquire about the story behind it. Prompts may include: a. What does your portrait photo say about you? b. What does the title mean to you? c. Would you tell me about the clothing you chose for this photo? d. How do you feel when looking at this photo of yourself? e. What do you like about this photo of you? f. Is there anything about this photo that makes you feel uncomfortable? g. Is there something missing in this photo that you would have liked to portray? h. What emotions are being shown in this picture? Were these intentional? i. What do you want others to think when they see you as you are in this photo? During this process, it is important to mirror the lan­ guage used by clients. The therapist should note the pronouns used by clients, including whether they speak of the individual in the portrait using the first person or the third person. Clients will probably give cues to the ways they interpret their own gender, and the therapist should use this language in later inter­ actions with the clients. It is essential that therapists use language that is comfortable for the client. If you are unsure of what language clients would prefer you use, ask them directly—this will not only help you, but it may also help them to consider how they want others to refer to them. Therapists must also monitor the client for signs of dysphoria during this exercise. These feelings may be apparent through the language used, particularly if clients seem to be trying to force themselves into an idealized gender role. If the activity is causing signifi­ cant emotional discomfort or provoking an intensely negative reaction, it should be stopped immediately, 344 Kinney & Brandon-Friedman

Variations 1. As an alternative to self-portraits, this exercise can be used to explore gender as the client sees it expressed in others. Clients can create a collage of images of other people whom they see as media representa­ tions, as embodying ideal appearances (e.g., cloth­ ing, hairstyles, physique), and as role models. 2. Expression of gender identity in public and private spaces may vary and potentially indicate impor­ tant factors to be examined. Photos can be col­ lected of spaces the client frequents or intends to travel to. The therapist can discuss the photos to explore sources of support, security, and empow­ erment as well as to develop plans for navigating places with uncertain safety. 3. Additional questions related to intersectionality can be asked to explore the interaction between multi­ ple identities, probing to acknowledge challenges and recognize resilience. Biopsychosocial factors to consider include race, culture, sexual orientation, age, socioeconomic status, religiosity/spirituality/ atheism, ableness, and mental health status. Brief Vignette

Sam is a thirteen-year-old Latino client referred to a gender-affirming therapist by the family’s general prac­ titioner. When asked about gender and pronouns, Sam states that male pronouns are okay, but he is unsure about gender. Sam’s parents add that Sam often plays with his younger sister and has enjoyed wearing dresses

and playing with dolls since he was five. Over the last year, Sam has reported becoming less comfortable with being in public and has secluded himself, social­ izing primarily through online gaming. Sam’s par­ ents admit they do not understand what is happening with Sam, but that they just want him to be happy. Sam is slender, his hair is shaggy, and he wears and loose-fitting jeans and a hooded T-shirt. When the therapist is speaking to Sam alone, he acknowl­ edges that he is afraid to wear the clothes that he actu­ ally wants to wear. Even with supportive parents, Sam is fearful that people will make fun of him and call him names. After speaking to both Sam and his par­ ents, the therapist suggests using the photo diary to document his exploration of gender, starting with small steps in the comfort of their home. Sam appears anxious and excited about the assignment and agrees to write a short essay about the experience. The following month Sam returns with the first entry in the photo diary. For this session, Sam shares a photo of himself in his favorite sundress and reads a short entry about the experience. Sam says that he wishes he could be planning a quinceañera like his female friends. The therapist asks him questions about his reaction and feelings, noting strengths and resil­ ience. Challenges of discomfort and fear are identified, and plans for future navigation are explored. Before leaving this session, Sam and the therapist discuss options for the next photo diary entry. After six months of therapy using the photo diary, Sam is able to identify what forms of expression feel authentic and where struggles continue. With the family’s encouragement and support, Sam changes into feminine clothing upon arriving home after school and remains in this type of clothes except when at school or in public. Sam is exploring female pronouns, growing her hair long, and considering going by Sofía because it feels more feminine. Sam and her family are discussing options for transitioning socially in school and their local community, including planning her quinceañera. In the future, the therapist can con­ tinue with the photo diary to document and explore Sam’s exploration of gender expression in school and in public while building self-awareness and confidence.

Suggestions for Follow-up

After clients have accumulated a series of photo diary entries, ask them to tell a story using all the photos together. By focusing on an entire arc of their gender presentation, clients can begin to develop a coherent narrative that they can use when telling their story to themselves and to others. Clients should be encour­ aged to consider not only the visible changes that may have occurred, but also the textual changes that may have occurred in how they described themselves in the titles and any internal changes in emotions that have occurred throughout the process. Clients should also work on integrating their experiences on their gender journey into other aspects of their lives and their more global life narrative. Once clients have developed a coherent sense of their own identity, this exercise can be used in either couples or family therapy. Clients and their signifi­ cant others should explore what messages are being delivered through the portraits and the titles. Through this discussion, the significant others in the client’s life will be able to develop a deeper understanding of the client’s gender identity and the ways in which that identity manifests itself in the client’s life. This will also allow for the navigation of any conflicting mes­ sages or ideas about gender and gender expression in a less intimate and threatening manner. Additional variations on this activity can include having clients collect photos of other people that demonstrate how they would like to express them­ selves. Probes similar to the ones described can be used, but they should focus on what the clients find attractive about those they have chosen to represent their desired self. Strengths and goals should be iden­ tified to focus on growth rather than negative body image. When using this variation, therapists must be acutely attuned to how realistic the client’s idealized self-image is, as many media images depict unhealthy ideals that can serve to harm a client who tries to attain those standards. Contraindications for Use

The photo diary activity should be used cautiously with people with severe gender dysphoria or fixation on physical appearance, including those with eating disorders. The objective of the exercise is to focus cliExploring Gender Identity with a Photo Diary 345

ents on their physical appearance and the ways in which they embody their gender, but when the exercise is used improperly this increased self-awareness can lead to increased dysphoria or physical fixation. Professionals and clients should be prepared to work through any strong emotions that emerge during this activity, and clients should have an active and accessible support system. This activity should be used only within the bounds of an established therapeutic rela­ tionship and with clients who have built up resilience and partially accepted and integrated their gender iden­ tity. It should never be used as an initial assessment or to determine the level of clients’ gender dysphoria. Professional Readings and Resources Brill, S., & Pepper, R. (2008). The transgender child: A hand­ book for families and professionals. San Francisco: Cleis Press. Ehrensaft, D. (2016). The gender creative child: Pathways for nurturing and supporting children who live outside of gen­ der boxes. New York: Experiment. Erickson-Schroth, L. (2014). Trans bodies, trans selves: A resource for the transgender community. New York: Oxford University Press. Hendricks, M. L., & Testa, R. J. (2012). A conceptual frame­ work for clinical work with transgender and gender nonconforming clients: An adaptation of the minority stress model. Professional Psychology: Research and Prac­ tice, 43 (5), 460–467. doi:10.1037/a0029597. Loewenthal, D. (2013). Phototherapy and therapeutic photog­ raphy in a digital age. New York: Routledge.

Resources for Clients Arnal, K. (2014). Bordered lives: Transgender portraits from Mexico. New York: New Press. Belge, K., & Bieschke, M. (2011). Queer: The ultimate LGBT guide for teens. San Francisco: Zest Books. Naz, D. (2014). Genderqueer and other gender identities. Los Angeles: Rare Bird Books. Testa, R. J., Coolhart, D., & Peta, J. (2015). The gender quest workbook: A guide for teens and young adults exploring sexual identity. Oakland, CA: New Harbinger.

References Allen, L. (2011). “Picture this”: Using photo-methods in research on sexualities and schooling. Qualitative Research, 11 (5), 487–504. doi:10.1177/1468794111413224. American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author.

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American Psychological Association (APA). (2009). Report of the Task Force on Gender Identity and Gender Variance. Washington, DC: Author. American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67 (1), 10–42. doi:10.1037/a0024659. American Psychological Association (APA). (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. doi:10.1037/a0039906. American Psychological Association (APA). (2016). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code. Arnal, K. (2014). Bordered lives: Transgender portraits from Mexico. New York: New Press. Asakura, K., & Craig, S. L. (2014). “It gets better”. . . but how? Exploring resilience development in the accounts of LGBTQ adults. Journal of Human Behavior in the Social Environment, 24, 253–266. doi:10.1080/10911359.2013.8 08971. Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC). (2009). Competencies for coun­ seling with transgender clients. Alexandria, VA: Author. Banks, M., & Zeitlyn, D. (2015). Visual methods in social research, 2nd edition. Los Angeles: Sage. Barbee, M. (2002). A visual-narrative approach to understand­ ing transsexual identity. Art Therapy: Journal of the Amer­ ican Art Therapy Association, 19 (2), 53–62. doi:10.1080/ 07421656.2002.10129339. Beemyn, G., & Rankin, S. (2011). The lives of transgender peo­ ple. New York: Columbia University Press. Blinn, L., & Harrist, A. W. (1991). Combining native instant photography and photo-elicitation. Visual Anthropology, 4 (2), 175–192. doi:10.1080/08949468.1991.9966559. Budge, S. L., Rossman, H. K., & Howard, K. A. (2014). Coping and psychological distress among genderqueer individu­ als: The moderating effect of social support. Journal of LGBT Issues in Counseling, 8 (1), 95–117. doi:10.1080/15 538605.2014.853641. Burdge, B. J. (2007). Bending gender, ending gender: Theoret­ ical foundations for social work practice with the transgender community. Social Work, 52 (3), 243–250. doi:10. 1093/sw/52.3.243. Butler, J. (1990). Gender trouble: Feminism and the subversion of identity. New York: Routledge. Catalano, C., & Shlasko, D. (2010). Transgender oppression: Introduction. In M. Adams, W. J. Blumenfeld, C. R. Castañeda, H. W. Hackman, M. L. Peters, & X. Zúñiga (eds.), Readings for diversity and social justice, 2nd edi­ tion, 423–429. New York: Routledge. Chaplin, E. (2011). The photo diary as an autoethnographic method. In E. Margolis & L. Pauwels (eds.), The SAGE

handbook of visual research methods, 241–262. Thousand Oaks, CA: Sage. Chonody, J. M., & Smith, K. S. (2013). The state of the social work profession: A systematic review of the literature on antigay bias. Journal of Gay and Lesbian Social Services, 25, 326–361. doi:10.1080/10538720.2013.806877. Craig, S., Dentato, M., Messinger, L., & McInroy, L. (2016). Educational determinants of readiness to practise with LGBTQ clients: Social work students speak out. British Journal of Social Work, 46 (1), 115–134. doi:10.1093/ bjsw/bcu107. Croghan, R., Griffin, C., Hunter, J., & Phoenix, A. (2008). Young people’s constructions of self: Notes on the use and analysis of the photo-elicitation methods. International Journal of Social Research Methodology, 11 (4), 345–356. doi:10.1080/13645570701605707. Denny, R. M., Sunderland, P. L., Smart, J., & Christofi, C. (2005). Finding ourselves in images: A cultural reading of transTasman identities. Journal of Research for Consumers, 8, 1–10. Devor, A. H. (2004). Witnessing and mirroring: A fourteenstage model of transsexual identity formation. Journal of Gay and Lesbian Psychotherapy, 8 (1–2), 41–67. doi:10.1 300/J236v08n01_05. Ehrensaft, D. (2016). The gender creative child: Pathways for nurturing and supporting children who live outside of gen­ der boxes. New York: Experiment. Evans, J. (1999). Regulating photographic meanings: Intro­ duction. In J. Evans & S. Hall (eds.), Visual culture: The reader, 11–21. London: Sage. Ewens, B. A., Hendricks, J. M., & Sundin, D. (2015). The use, prevalence and potential benefits of a diary as a thera­ peutic intervention/tool to aid recovery following criti­ cal illness in intensive care: A literature review. Journal of Clinical Nursing, 24 (9–10), 1406–1425. doi:10.1111/ jocn.12736. Grafsky, E. L., & Nguyen, H. N. (2015). Affirmative therapy with LGBTQ+ families. In S. Browning & K. Pasley (eds.), Contemporary families: Translating research into practice, 196–226. New York: Routledge. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H., Loos, B., & Lambert, S. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex and ally individuals. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi:10. 1080/15538605.2013.755444. Hartman, J., Bena, J., McIntyre, S., & Albert, N. (2009). Does a photo diary decrease stress and anxiety in children under­ going magnetic resonance imaging? A randomized, con­ trolled study. Journal of Radiology Nursing, 28 (4), 122– 128. doi:10.1016/j.jradnu.2009.08.002.

Hidalgo, M. A., Ehrensaft, D., Tishelman, A. C., Clark, L. F., Garofalo, R., Rosenthal, S. M., & Olson, J. (2013). The gender affirmative model: What we know and what we aim to learn. Human Development, 56 (5), 285–290. doi:10.1159/000355235. Kinney, M. K. (2017, April). A resilience-based approach to exploring non-binary identities. Poster session presented at the twenty-first annual PhD Spring Symposium of Indiana University School of Social Work, Indianapolis. doi:10.13140/RG.2.2.30921.34400. Kinney, M. K. (2019). Carving your own path: Exploring nonbinary gender identity development. Manuscript in preparation. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674– 697. doi:10.1037/0033-2909.129.5.674. National Association of Social Workers (NASW). (2008). Code of ethics of the professional association of social workers. Washington, DC: NASW Press. Noland, C. M. (2006). Auto-photography as research practice: Identity and self-esteem research. Journal of Research Practice, 2 (1), article M1. http://jrp.icaap.org/index.php/ jrp/article/view/19/65. Orel, N. A., & Fruhauf, C. A. (eds.). (2015). The lives of LGBT older adults: Understanding challenges and resil­ ience. Journal of GLBT Family Studies, 11 (5), 512–513. doi:10.1080/1550428X.2015.1071953. Parrella, C., & Loewenthal, D. (2013). Community phototherapy. In D. Loewenthal (ed.), Phototherapy and thera­ peutic photography in a digital age, 107–119. New York: Routledge. Reamer, F. G. (2013). Social work values and ethics, 4th edition. New York: Columbia University Press. Risman, B. J., & Davis, G. (2013). From sex roles to gender structure. Current Sociology, 61 (5–6), 733–755. doi:10. 1177/0011392113479315. Singh, A. A. (2013). Transgender youth of color and resilience: Negotiating oppression and finding support. Sex Roles, 68 (11–12), 690–702. doi:10.1007/s11199-012-0149-z. Singh, A. A., & McKleroy, V. S. (2011). “Just getting out of bed is a revolutionary act”: The resilience of transgender people of color who have survived traumatic life events. Traumatology, 17 (2), 34–44. doi:10.1177/1534765610 369261. Smith, J. (2016). Gender nonconformity in youth and safety: Utilizing photo-elicitation and thematic analysis. PhD diss., Georgia State University. Swallow, D., Petrie, H., Power, C., & Edwards, A. D. (2015, September). Using photo diaries to elicit user require­ ments from older adults: A case study on mobility barriers. In Human-Computer Interaction, 147–164. New York: Springer. doi:10.1007/978-3-319-22701-6_11.

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39 CREATIVE INTERVENTIONS FOR TRAUMATIZED TRANSGENDER AND GENDER-NONCONFORMING (TGNC) YOUTH Alexandra M. Rivera and Crystal Morris Suggested Use: Activity Objective

This activity is designed for traumatized transgender and gender-nonconforming (TGNC) youth, ranging from five to seventeen years in age. It is intended to allow diverse youth to express their resilience to trauma in creative and gender-affirming ways and thereby pro­ mote strength and resilience in the context of difficult emotional experiences. Rationale for Use

Transgender and gender-nonconforming (TGNC) youth encompass a wide variety of identifications, including transgender, genderqueer, nonbinary, and genderfluid, among others (Rankin & Beemyn, 2012). Additionally, a youth’s gender identity (i.e., feelings and expression related to gender) is complex and may be associated with, but is not the same as, sexual ori­ entation, defined as one’s sexual or romantic attrac­ tion toward one or more sex (Stieglitz, 2010). While developing a positive identity is challenging for most youth, transgender youth may experience additional challenges as they attempt to integrate a complex gen­ der identity with family expectations and cultural background (Riggle, Rostosky, McCants, & PascaleHague, 2011). In a study focused on transgender iden­ tity development in youth, Grossman and D’Augelli (2006) reported that youth first heard their identity labeled as transgender at a mean age of thirteen and a half years, and then labeled themselves approxi­

mately a year later (from seven to eighteen years of age), making this a critical window for intervention with this population. Early experiences of trauma in TGNC youth have been linked to serious mental health concerns, not the least of which is suicidality. Epidemiological stud­ ies suggest that transgender youth are particularly vulnerable: nearly 50 percent of transgender youth reported that they had seriously considered suicide, and 25 percent reported that they had attempted sui­ cide (Grossman & D’Augelli, 2007). It is also well established that sexual and gender minority youth undergo disproportionately high rates of traumatic experiences; 55 to 90 percent of these youth have expe­ rienced at least one traumatic event (Fallot & Harris, 2001). Transgender and gender-nonconforming youth reportedly experience several types of traumatization, including harassment (78 percent), physical assault (35 percent), and sexual violence (12 percent) (Grant et al., 2011). Fifteen percent of this population expe­ rienced harassment so severe that it led them to leave school (Grant et al., 2011). Additionally, TGNC youth who experience victimization are more likely to develop post-traumatic stress disorder later in life (Russell et al., 2011). Literature suggests that traumatization is com­ pounded by social factors, including minority stress, defined as stress resulting from perceived stigma and discrimination that are based on minority identifica­ tion (Meyer, 2003). This stress may be heightened by multiple minority statuses, as in transgender youth

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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who also identify as ethnic minorities (Almeida et al., 2009; Hendricks & Testa, 2012). There is a paucity of research on the traumatic responses of multiply mar­ ginalized groups such as these. Studies on ethnicminority gay and lesbian participants suggest, how­ ever, that TGNC youth may experience a phenomenon known as “double” or “triple jeopardy” (Greene, 2000) —that is, contending with the social stigma and trau­ matic stress associated with two or three minority identities simultaneously (e.g., gender identity, race, and sexual orientation). Regardless of whether a youth’s trauma is compounded by minority stress, it is clear that trauma-informed interventions may benefit TGNC youth engaging in psychotherapy (Mizock & Lewis, 2008). Expressive arts therapy is defined as the use of cre­ ative arts (e.g., music, art, and movement) as a form of therapy (Malchiodi, 2005). The sensory-based qual­ ities of art and expressive arts are key to helping indi­ viduals communicate traumatic memories, repair, and recover. The acclaimed neurosequential develop­ mental psychologist Bruce Perry has noted that art therapy can be a normalizing experience for children, one that children in all cultures recognize (Perry, 2004). In an effort to promote prevention and inter­ vention for traumatized youth, the International Soci­ ety for Traumatic Stress Studies (Foa, Keane, Friedman, & Cohen, 2009) provided a comprehensive summary of the role of the creative art therapies in the treatment of post-traumatic stress disorder (PTSD), underscoring the important relationship between creative arts therapies and the brain, including how the brain processes traumatic events and the possibil­ ities for repair through expressive arts therapies. In essence, trauma-informed art therapy integrates neurodevelopmental knowledge and the sensory qualities of art to provide an intervention specific to traumatized individuals (Richardson, 2015). This approach takes into consideration, but is not limited to, (a) how the mind and body respond to traumatic events; (b) recognition of symptoms as adaptive cop­ ing strategies; (c) emphasis on cultural sensitivity and empowerment; and (d) assisting traumatized indi­ viduals through skill building, support networks, and resilience (Malchiodi, 2012).

Research on this type of intervention suggests that it could be helpful in reconnecting implicit and explicit memories of trauma. As a youth’s physical body recalls and encodes experiences on a visceral level, memories may be difficult to access through word-based or cognitive therapy (Talwar, 2007). Thus, focusing solely on verbal accounts of the trauma can keep therapy at a surface level, never allowing full integration of the trauma experience (Steele & Mal­ chiodi, 2012). Addressing this issue, trauma-informed expressive arts therapy assists the individual’s capacity to regulate affect and the body’s reactions to trau­ matic experiences in order to set the stage for eventual trauma integration and recovery (Lusebrink, 2004). Central to culturally trauma-informed care is the American Psychological Association’s (APA, 2017) “Ethical Principles of Psychologists and Code of Con­ duct” Boundaries of Competence guideline (2.01). The code states that psychologists must undertake treatment only “within the boundaries of their com­ petence, based on their education, training, super­ vised experience, consultation, study, or professional experience” (p. 5). It is imperative that mental health professionals acknowledge the limits of their clinical practice, expertise, and stamina when serving trau­ matized youth. Literature suggests that clinicians working with traumatized clients often experience burnout, compassion fatigue, and other difficult inter­ nal experiences owing to the heavy emotional content involved in treatment (Maslach, 2003). When the knowledge base or professional ability of the provider is not sufficient, referrals should be made to ensure that youth are being treated effectively and with mini­ mal harm. Further, beyond competence in trauma therapy, cultural competence must also be observed. Section (b) of code 2.01 states that measures must be taken to ensure that treatment is effective and encompass­ ing of factors such as “age, gender, gender identity, race, ethnicity, culture, national origin, religion, sex­ ual orientation, disability, language, or socioeconomic status” (APA, 2017, p. 5). Providing effective care for TGNC traumatized youth requires that the clinician be up-to-date with the most current gender-affirm­ ing interventions. It also requires that clinicians hold

Creative Interventions for Traumatized TGNC Youth 349

a culturally humble approach (i.e., deferring to cli­ ents as experts in their own cultural experience). This approach includes collaboration with clients on their preferred method of practice and preferred pro­ nouns, and open dialogue about identity throughout the clinical process (Grubb et al., 2013). As is true of most clinical practice, APA code 3.04, Avoiding Harm, is a crucial part of treating trauma­ tized youth. Treatment of traumatized populations may involve exposure to uncomfortable topics in order to facilitate tolerance of the traumatic event. While this exposure does not necessarily indicate harm, it is important for providers to be thoughtful about the ways in which they use expressive arts therapy with these clients. For instance, if images in the activity begin actively triggering the client, the client becomes emotionally distressed, or the client asks to stop the activity, the provider should immediately check in with the client regarding emotional state and proceed only if the client feels ready to do so. Avoiding harm and promoting wellness should be paramount when treat­ ing any client population. Instructions

This exercise can be used in individual, group, or fam­ ily therapy and should be monitored closely, as it may bring up memories or affect related to the client’s trau­ matic history. It is helpful to introduce the exercise as a creative, interactive lesson in identity and resil­ ience. This exercise should be used only after you have established that the client has a traumatic history. It has four major steps: 1. Before starting the exercise, the therapist should have a flashlight, a diverse set of magazines, glue, scissors, tape, and a large sheet of white paper handy. Tape the white paper to a wall and have the client sit in front of the paper, facing to the side. Put the flashlight, turned on, atop a flat surface (e.g., desk, chair) and aim it toward the client so that the shadow of the client’s head appears on the paper. Trace the outline of the shadow in pencil. 2. As you sit down to discuss the silhouette with the client, it is important to engage them with questions about their identity. Some questions might be “How do you feel about your silhouette? Do you 350 Rivera & Morris

think it matches how you see yourself and your gen­ der identity?” If they answer, “No,” one response might be, “How could we change this outline to match how you feel about yourself?” Allow them to make changes to the silhouette in accordance with their gender identity and expression. 3. Next, deliver psychoeducation about the effects of trauma on self-esteem and identity. As we are exposed to trauma, especially trauma that degrades and devalues our gender expression, we may develop a difficulty affirming this part of ourselves. We may also experience our identity as “fractured” or “broken.” Introduce this exercise as a means to reaf­ firm the resilience we have in the face of these dif­ ficult moments. 4. Show the client several different magazines. Ask the client to clip out, write, or draw phrases and/or images that represent positivity, strength, and sur­ vivorship during or after their traumatic experi­ ences. These words, drawings, or clippings will go within their silhouette, eventually filling it with positive images. Emphasize that there is no “right way” to put this collage together, and it can use whatever combination of the above methods the client wants. If the client has trouble finding strengths, comment on strengths you have observed during your time in therapy. When the exercise is over, ask the client to evaluate the choices they made, their emotional reactions to the project, and their thoughts on how these pieces fit together. Give them space to discuss how these pieces of their identity have changed over time. This is a powerful exercise when clients are able to shift their thinking from the traumatic incident itself to the formation of their identity as a survivor and some­ one able to live a vibrant life. Brief Vignette

Dean is an eighteen-year-old genderfluid youth cur­ rently living and receiving therapy in a group home. Dean recently began asking peers to use the pronouns they, their, and them after several years of working toward understanding and accepting their gender iden­ tity and what that identity means. Highly intelligent

and full of humor, Dean is a strong believer in social justice issues, including racial and gender equality. Dean emigrated to the United States from Russia when they were eight years old. Once in the United States, they lived in a house with their mother and stepfather. Dean’s father passed away when they were a small child, and Dean still experiences intense sad­ ness about this loss. After years of living with their stepfather’s sexual abuse, Dean disclosed what was hap­ pening to a teacher and was finally removed from their mother’s home and placed in foster care at age eleven. When Dean came forward to report what hap­ pened, their mother refused to believe it was true, instead accusing Dean of lying and “tearing apart the family.” Dean expressed feeling hurt and betrayed by their mother for not believing them and choosing to remain with their abuser. Dean maintains a close relationship with their mother, even in the group home, but has a distant relationship with their step­ father because of this history. The sexual abuse, their mother’s allegiance to her husband over her son, and moving from group home to group home contributed to Dean’s anxiety, depressive symptoms, suicidal ide­ ation, and subsequent self-harm behaviors. As a young teenager, Dean engaged in self-destruc­ tive behaviors, such as using social media to contact men for sexual activity and substance use. Because of Dean’s experiences, trust is a challenge, which makes building trust a powerful therapeutic tool. Thus, a ther­ apeutic focus on building trust has created a safe space for Dean to heal as well as feel comfortable enough to explore their trauma freely in a gender-affirming environment. Rather than attempting an immediate solution-focused approach, it was most important for the therapist to demonstrate unconditional posi­ tive regard, acceptance, and a willingness to listen to Dean’s story. Dean responded well to the intervention. Because of their love of art and music, they were open and willing to participate in this activity as a way to pro­ cess their abuse and family loss. The clinician worked with Dean to create an outline and supported Dean with adjusting the silhouette to fit their gender iden­ tity. Once the silhouette was created, the clinician pro­ vided the necessary psychoeducation regarding trauma

and its effects on identity and self-worth. Dean was actively engaged in creating his collage, hand-drawing images and picking words related to their survivorship, such as fierce, alive, and empowered. They were able to openly process with the clinician and admitted their struggle with self-compassion after the trau­ matic incident. The clinician was able to challenge Dean not only to identify their hopes for their future self but also to identify the strengths that they possess in the present moment. Ultimately, Dean identified their own resilience and created a visual representation of their strengths and their journey toward healing. Suggestions for Follow-up

Clinician follow-up is key to ensuring that clients fully process and engage with the activity. It is im­ portant to continue exploring how clients view their identity in the context of this trauma, moving beyond the survivor framework and instead encour­ aging them to thrive. Contraindications for Use

This activity is meant to be used with clients who are prepared to address the potential thoughts and emo­ tions related to their trauma that may arise during the exercise. It should not be used with clients who are just starting treatment and are still actively trig­ gered by discussion, thoughts, or references to their trauma. It is thus important that the clinician assess the client’s readiness for in-depth trauma work. This activity is most beneficial with clients who have built a trusting therapeutic relationship with their clinician and are prepared to begin processing their trauma. Because of the activity’s visual emphasis, it should not be used with clients who have difficulty relating to visual forms of expression or clients who strongly pre­ fer cognitive approaches in therapy. Professional Readings and Resources Burnes, T. R., Singh, A. A., Harper, A. J., Harper, B., MaxonKann, W., Pickering, D. L., & Hosea, J. (2010). ALGBTIC competencies for counseling with transgender clients. Journal of LGBT Issues in Counseling, 4 (3), 135–159. doi:10.1002/j.2164490X.2001.tb00100.x. Case, K. A., & Meier, S. C. (2014). Developing allies to transgender and gender-nonconforming youth: Training for

Creative Interventions for Traumatized TGNC Youth 351

counselors and educators. Journal of LGBT Youth, 11 (1), 62–82. doi:10.1080/19361653.2014.840764. Edwards-Leeper, L., Leibowitz, S., & Sangganjanavanich, V. F. (2016). Affirmative practice with transgender and gen­ der nonconforming youth: Expanding the model. Psychol­ ogy of Sexual Orientation and Gender Diversity, 3 (2), 165. doi:10.1037/sgd0000167. Hsieh, S., & Leininger, J. (2014). Resource list: Clinical care programs for gender-nonconforming children and ado­ lescents. Pediatric Annals, 43 (6), 238–244. doi:10.3928/ 00904481-20140522-11.

Resources for Clients (Print) Brooklyn, K. (2012). For colored boys who have considered suicide when the rainbow is still not enough: Coming of age, coming out, and coming home. New York: Magnus Books. Huegal, K. (2011). GLBTQ: The survival guide for gay, lesbian, bisexual, transgender, and questioning teens. Minneapolis: Free Spirit. Krieger, N. (2011). Nina here nor there: My journey beyond. Boston: Beacon Press. Mallon, G. P. (1998). We don’t exactly get the welcome wagon: The experiences of gay and lesbian adolescents in child welfare systems. New York: Columbia University Press. Sassafras, L. (2010). Kicked out. Ypsilanti: Homofactus Press. Savage, D. (2012). It gets better: Coming out, overcoming bullying, and creating a life worth living. New York: Penguin Books.

Resources for Clients (Web-Based) American Psychological Association. (2019). LGBT youth resources. https://www.apa.org/pi/lgbt/programs/safesupportive/lgbt/. It Gets Better Project. (2018). Get help. https://itgetsbetter. org/get-help/. Loveisrespect.org. (2017). Healthy LGBTQ relationships. https://www.loveisrespect.org/healthy-relationships/ healthy-lgbtq-relationships/. National Child Traumatic Stress Network. (2016). LGBTQ youth: Voices of trauma, lives of promise. https://www. nctsn.org/resources/lgbtq-youth-voices-trauma-lives­ promise. National Domestic Violence Hotline. (2018). LGBTQ relation­ ship violence. https://www.thehotline.org/is-this-abuse/ lgbt-abuse/. Stopbullying.org (2017). LGBTQ youth: Creating a safe envi­ ronment for LGBTQ youth. https://www.stopbullying. gov/at-risk/groups/lgbt/index.html. Trevor Project. (2017). Resources: Trevor Support Center. https://www.thetrevorproject.org/pages/support-center.

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References Almeida, J., Johnson, R. M., Corliss, H. L., Molnar, B. E., & Azrael, D. (2009). Emotional distress among LGBT youth: The influence of perceived discrimination based on sex­ ual orientation. Journal of Youth and Adolescence, 38 (7), 1001–1014. doi:1007/s10964-009-9397-9. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/index.aspx. Bowleg, L., Huang, J., Brooks, K., Black, A., & Burkholder, G. (2003). Triple jeopardy and beyond: Multiple minority stress and resilience among black lesbians. Journal of Les­ bian Studies, 7 (4), 87–108. doi:10.1300/J155v07n04_06. D’Augelli, A. R., Grossman, A. H., & Starks, M. T. (2006). Childhood gender atypicality, victimization, and PTSD among lesbian, gay, and bisexual youth. Journal of Inter­ personal Violence, 21 (11), 1462–1482. doi:10.1177/ 0886260506293482. Fallot, R. D., & Harris, M. (2001). A trauma-informed approach to screening and assessment. New Directions for Mental Health Services, 89, 23–31. doi:10.1002/yd. 23320018904. Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. (eds.). (2009). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies, 2nd edition. New York: Guilford Press. Grant, J. M., Mottet, L., Tanis, J. E., Harrison, J., Herman, J., & Keisling, M. (2011). Injustice at every turn: A report of the National Transgender Discrimination Survey. Wash­ ington, DC: National Center for Transgender Equality. Greene, B. (2000). African American lesbian and bisexual women. Journal of Social Issues, 56 (2), 239–249. doi:10.1111/0022-4537.00163. Grossman, A. H., & D’Augelli, A. R. (2006). Transgender youth: Invisible and vulnerable. Journal of Homosexuality, 51 (1), 111–128. doi:10.1300/J082v51n01_06. Grossman, A. H., & D’Augelli, A. R. (2007). Transgender youth and life-threatening behaviors. Suicide and Life-Threaten­ ing Behaviors, 37 (5), 527–537. doi:10.1521/suli.2007. 37.5.527. Grubb, H., Hutcherson, H., Amiel, J., Bogart, J., & Laird, J. (2013). Cultural humility with lesbian, gay, bisexual, and transgender populations: A novel curriculum in LGBT health for clinical medical students. MedEdPORTAL, 9. doi:10.15766/mep_2374-8265.9542. Hendricks, M. L., & Testa, R. J. (2012). A conceptual frame­ work for clinical work with transgender and gender non­ conforming clients: An adaptation of the minority stress model. Professional Psychology: Research and Practice, 43 (5), 460. doi:10.1037/a0029597.

Lusebrink, V. B. (2004). Art therapy and the brain: An attempt to understand the underlying processes of art expression in therapy. Art Therapy, 21 (3), 125–135. doi:10.1080/0742 1656.2004.10129496. Malchiodi, C. (2005). Expressive therapies. New York: Guil­ ford Press. Malchiodi, C. (2012). Trauma informed art therapy with sex­ ually abused children. In P. Goodyear-Brown (ed.), Hand­ book of child sexual abuse: Identification, assessment, and treatment. Hoboken, NJ: John Wiley & Sons. Maslach, C. (2003). Burnout: The cost of caring. 1982. Reprint, Cambridge, MA: Malor Book. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129 (5), 674–697. doi:10.1037/2329-0382.1.S.3. Mizock, L., & Lewis, T. K. (2008). Trauma in transgender pop­ ulations: Risk, resilience, and clinical care. Journal of Emotional Abuse, 8 (3), 335–354. doi:10.1080/10926790 802262523. National Child Traumatic Stress Network, Child Sexual Abuse Collaborative Group (2014). LGBTQ youth and sexual abuse: Information for mental health professionals. National Center for Child Traumatic Stress. https://www. sccgov.org/sites/bhd-p/Training/Documents/2018/NOV %202018/ncstn-lgbtq-tipsheet-for-professionals.pdf. Perry, B. D. (2004). Maltreated children: Experience, brain devel­ opment, and the next generation. New York: W. W. Norton.

Rankin, S., & Beemyn, G. (2012). Beyond a binary: The lives of gender-nonconforming youth. About Campus, 17, 2–10. doi:10.1002/abc.21086. Richardson, C. (2015). Expressive arts therapy for traumatized children and adolescents: A four-phase model. New York: Routledge. Riggle, E. D., Rostosky, S. S., McCants, L. E., & Pascale-Hague, D. (2011). The positive aspects of a transgender self-iden­ tification. Psychology & Sexuality, 2 (2), 147–158. doi:10. 1080/19419899.2010.534490. Russell, S. T., Ryan, C., Toomey, R. B., Diaz, R. M., & Sanchez, J. (2011). Lesbian, gay, bisexual, and transgender adoles­ cent school victimization: Implications for young adult health and adjustment. Journal of School Health, 81 (5), 223–230. doi:10.1111/j.1746-1561.2011.00583.x. Steele, W., & Malchiodi, C. A. (2012). Trauma-informed prac­ tices with children and adolescents. New York: Routledge. Stieglitz, K. A. (2010). Development, risk, and resilience of transgender youth. Journal of the Association of Nurses in AIDS Care, 21 (3), 192–206. doi:10.1016/j.jana.2009. 08.004. Talwar, S. (2007). Accessing traumatic memory through art making: An art therapy trauma protocol (ATTP). Arts in Psychotherapy, 34 (1), 22–35. doi:10.1016/j.aip.2006. 09.001.

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40

THE IMPORTANCE OF LANGUAGE: CREATING NONBINARY ASSESSMENT FORMS THAT REFLECT A FULL RANGE OF GENDER IDENTITIES Andrew Suth and Sorrel Rosin Suggested Use: Activity Objective

The goal of this chapter is to provide intake forms to describe gender identity in a nonbinary, noncisnor­ mative manner. Rationale for Use

When clients present for an assessment or for an initial therapy session, it is useful to obtain initial develop­ mental, historical, and demographic information. This information is often gathered through a combi­ nation of a thorough history shared in the initial ses­ sions and a comprehensive developmental question­ naire. Gathering this type of information is best done with an eye toward individuals’ strengths and how they positively create meaning about their lives as well as by identifying key areas of struggle (Duckworth, Steen, & Seligman, 2005; Snyder, Ritschel, Rand, & Berg, 2006). Research increasingly suggests that gender-non­ conforming adults suffer traumatic experiences (dickey, Reisner, & Juntunen, 2015; Richmond, Burnes, & Carroll, 2012). An increased body of literature points to clinicians’ affirmative role and responsibility in combating the traumatic effect of micro- and mac­ roaggressions, which can take the form of hurtful declarative comments, willful omission, or refusal to use gender-affirming language (Richmond, Burnes, Singh, & Ferrara, 2017). Further, there is a strong need, articulated by a few clinicians, for establishing an affir­

mative psychological testing model for gender-non­ conforming individuals (Keo-Meier & Fitzgerald, 2016). The authors argue that any competent neuro­ psychological assessment understands the gender minority stress model, the effects of hormone therapy on mood and cognition, and the use of gender norms in testing (Keo-Meier & Fitzgerald, 2016). Language use on initial forms is the first indica­ tion many clients have of the practitioner’s openness and understanding of the full range of gender identity. According to calls for affirmative and advocacy mod­ els (dickey, Singh, Chang, & Rehrig, 2017; Ducheny, Hendricks, & Keo-Meier, 2017; Richmond et al., 2017), clinicians must take responsibility for the instruments they use in clinical work. Proper use of language on intake forms can set an affirming tone for clients, com­ bating the corrosive stress on gender minority indi­ viduals (Keo-Meier & Fitzgerald, 2016). Thoughtful and considerate use of language can allow for a fuller discussion about the stressful and traumatic effects of gender macro- and microaggressions and help the clinician focus on a trauma model for interpreting psychological distress (Burnes et al., 2016) as well as to be mindful of the small but important body of research on cognitive effects of hormone treatment with transitioning individuals (Schöning et al., 2009; Seiger et al., 2016). Clinicians must develop good cultural competence regarding gender in the same way they have sought to develop competence in other diversity and contex­ tual factors (Boroughs, Bedoya, O’Cleirigh, & Safren,

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

354

2015). Along with examining our language in conver­ sation, starting with the first phone call or email and continuing through interactions throughout treat­ ment, an assessment and clinical therapy practice must amend forms used for intake or information gather­ ing to reflect best practices and inclusion of gender orientation. This chapter offers one tool to help clini­ cians in this important endeavor. In an assessment practice with adults, one might expect to hear concerns about attention, memory, executive functioning (including impulsivity), and mood, among other complaints. Few clinicians, how­ ever, are trained to understand how these concerns look when intersected with other important aspects of identity (Fuentes & Shannon, 2016). Further, we tend to rely on tests that use binary gender categories (Bon­ ierbale et al., 2016). Instead, if clinicians begin by cre­ ating a discussion with clients that allows for more exploration of gender fluidity and the confines of soci­ etal gender norms, our assessments can proceed in a more nuanced, less pathologizing way. This explora­ tion along with inclusion of instruments that use the full range of gender identification can lead to more competent and inclusive assessments. To facilitate this discussion, it is important to con­ sider the initial interactions in the client-clinician relationship as of primary importance (Graybar & Leonard, 2005). From the first conversation and intro­ duction to initial requests for information, how one contextualizes and normalizes gender in all its vari­ ants (along with sexual identity) sets the tone to allow for a freer discussion later. Institutions from colleges and hospitals to psychological practices have begun to understand how important the initial language used helps individuals feel understood and welcomed (Thorpe, 2015). For example, when clinicians can iden­ tify the pronouns they use as freely as their name and title, they give comfort to clients who may not want or know how to introduce the topic on their own. It is important to avoid terminology that implies gen­ der identity as a choice versus a part of one’s identifi­ cation. For example, simply say “my pronouns are” rather than asking people for their preferred pronouns. Doing so avoids potentially belittling language that makes individuals feel as if they are being told that

their identity is merely a preference (Parks, O’Connor, & Parrish, 2016). If the stage is set correctly, poten­ tially difficult topics can be broached more successfully. For example, mood and anxiety are often significantly affected by how one responds to or perceives societal norms and expectations. That is, stigma, bias, and mal­ treatment related to gender can certainly influence depression and anxiety (Mustanski, Andrews, & Puck­ ett, 2016; Owen-Smith et al., 2017; White Hughto, Pachankis, Willie, & Reisner, 2017). It should not be assumed, however, that the relationship is reduction­ istic or simplistic. Instead, there is a complicated inter­ action between level of stigma, degree of oppression, and individual factors such as problems in processing and attention or behavioral consequences of impul­ sive or palliative coping strategies. The Health Equity Promotion Model (Fredriksen-Goldsen et al., 2014) is one endeavor to promote greater research into the intersection of cognition and identity within the LGBT community. Further, when one struggles with developmental concerns such as ADHD or bipolar disorder, gender identity can intersect as a meaning­ ful experience that causes joy, pain, or excitement without the epigenesis of these symptoms (Keo-Meier & Fitzgerald, 2016; Singh & dickey, 2017). Despite the pressing need, little research has been done that examines intersectional approaches to physical and behavioral health discrepancies among LGBTQ individuals. A recent effort to change this is the Health Equity Promotion Model (FredriksenGoldsen et al., 2014). This model seeks to understand the intersectionality of the culture and environment in the lives and mental health of LGBT individuals. The project focuses on researching how understand­ ing the lived experience of the LGBT community can both promote health and offer a better understand­ ing of impediments to healthy functioning. Other stud­ ies are starting to emerge in line with the American Psychological Association’s (APA’s) guidelines for psy­ chological practice with transgender and noncon­ forming people (APA, 2015). Professional guidelines and research also point to the need to create positive and affirming assessments using culturally appropri­ ate space and language (APA, 2015). Authors point to the changes and need for continued development

The Importance of Language: Nonbinary Assessment Forms 355

of culturally sensitive practices in assessment and diagnosis (Dana, 1994). There are clear ethical considerations related to testing (guidelines 1, 2, and 5 specifically) in conduct­ ing ethically informed assessments. These consider­ ations include age, gender, gender identity, race, eth­ nicity, culture, national origin, religion, sexual orien­ tation, disability, language, and socioeconomic status (APA, 2017). Relevant standards include but are not limited to 9.01 (bases for assessment), 9.06 (interpret­ ing test results), 9.10 (interpreting and explaining test results), and 2.01 (boundaries of competence) (APA, 2017); however, there is a need for rigorous and con­ tinual exploration of how to better define and imple­ ment these ethical guidelines (O’Donohue, 2016). This chapter offers one tool to help clinicians in this important endeavor. Instructions

At the first meeting or on the initial phone contact, therapists introduce themselves and then state the pronouns they use. Clients are similarly asked how they’d like to be called and what pronouns they use. At or before the initial meeting, clients are asked to complete the developmental questionnaire, which is intended to help the clinician better understand all clients more fully, including their early neurodevelop­ mental history, their experiences early in life, and how those experiences have informed their current situa­ tion. In other words, the assessment is designed to understand clients in the most humanistic context. It is designed specifically for a psychological/neurode­ velopmental/cognitive assessment practice. The lan­ guage regarding gender and sexuality can be adapted for other clinical forms. Brief Vignette

Sean had mentioned to his new client Kevin that he’d like to set up an initial meeting, but he would send some forms and questionnaires in advance of their meeting. Kevin had requested an appointment for an assessment to better understand recent challenges with paying attention in graduate school. On the day of the appointment, Sean entered the waiting room and introduced himself, saying, “Hi, I am Sean, nice

356 Suth & Rosin

to meet you.” Sean decided to wait to see how Kevin identified himself. Sean is aware that clients often refer to themselves differently on the phone or in official correspondence from the way they do in person. When Sean entered the waiting room and introduced him­ self, however, the client sitting in the waiting room said, “Good to meet you, I’m Keisha.” Keisha and Sean then entered the office. When they sat down, Sean warmly repeated his welcome to Keisha and went on to say that he is comfortable being called Sean or Dr. Jones, whichever Keisha felt more comfortable using. Sean also stated that he uses the pronouns he, his, and him. He then asked Keisha, “What should I call you, and what are your pronouns?” Keisha, dressed in pants and a T-shirt, with nail polish and hair in a bun, stated she uses the pronouns she, her, and hers. She explained that she has recently been exploring her gender identity and has very cau­ tiously started to identify as transgender. However, she still fears how others will respond to her if she comes out as trans. Her gender identity is still hidden from her parents, and she is not sure if she will even­ tually discuss her gender with them. Keisha is expe­ riencing a great deal of difficulty concentrating in the classroom. She has always complained of being dis­ organized and distracted. She has done well through­ out school, however, maintaining mostly As and Bs. Keisha started a graduate program in creative writing about six months earlier. Recently, she has had greater difficulty focusing than is normal for her. Keisha explained that she meets new people as Kevin until she feels comfortable being honest about her gender identity. This is why she initiated the request for an assessment as Kevin. When she received the intake questionnaire and saw that there was careful attention paid to creating open-ended, nonbinary ways to approach issues of identity, however, Keisha felt this was an opportunity to identify as herself. Sean said that he was very glad that was the outcome, and that he wanted to understand Keisha as fully as possible in order to see how together they might understand her recent struggles with attention. Sean and Keisha continued talking about the details of the intake form in the same manner. Keisha felt comfortable discussing other areas of identity such as sexuality, race, ethnicity,

and socioeconomic status. This initial discussion made for a much fuller gathering of history and ultimately a much more authentic and accurate assessment. Suggestions for Follow-up

Intake forms are an introduction to the assessment and therapeutic process as well as a vehicle for gath­ ering information. For transgender clients, like other clients, this means that the most important followup is a continued rich understanding of how one’s experience is limited, enhanced, or shaped by the find­ ings in the assessment. Forms should be followed by a strong clinical interview that incorporates the same terminology about gender as well as other key ele­ ments of identity. In the follow-up interview, clinicians should continue to use the words that the client pro­ vides. Throughout testing, clinicians should be care­ ful to modify test instructions to reflect proper pro­ noun use or proper gender identification. Very often, test forms offer binary gender choices and in fact use “male” or “female” norms. While this situation can­ not change until tests are properly altered, it is impor­ tant to explain the terminology on all forms, includ­ ing the forms the clinician completes. While assessment clinicians cannot change validated test forms, they can help clients throughout the process in demonstrating consistent commitment to cultur­ ally competent language usage regarding gender as well as honest dialogue about the inconsistencies regarding gender in the field. Contraindications for Use

It can be tricky and at times counterproductive to introduce this intake form without understanding our clients’ feelings, biases, and defenses. Therapists should use caution in discussing issues of gender before estab­ lishing a good initial rapport and conveyance of open­ ness. Clearly outlining why we speak about gender and sexuality in nonbinary ways will help those who are uncomfortable talking about these issues. It should be understood that not all clients will react positively to such a discussion. Common negative response may be fear, anger, or avoidance. If the therapist antici­ pates or experiences strong resistance to such discus­ sion, it may be wise to avoid or end the discussion. If the topic evokes strong feelings, the therapist and

client may discuss these in a therapeutic way. It may also be useful when the reaction isn’t overly negative, however, to discuss how best to create an open envi­ ronment that builds greater trust and possibly lowers defenses. Professional Reading and Resources Advocates for Youth. (n.d.). Creating safe space for LGBTQ Youth: A toolkit. https://advocatesforyouth.org/resources/ health-information/creating-safe-space-for-glbtq-youth-a­ toolkit/. Advocates for Youth. (n.d.). Gay, lesbian, bisexual, transgen­ der, and questioning (GLBTQ) youth: A population in need of understanding and support. https://www.advo catesforyouth.org/storage/advfy/documents/glbtq_youth %202010.pdf. Keo-Meier, C. L., & Fitzgerald, K. M. (2016). Affirmative psy­ chological testing and neurocognitive assessment with transgender adults. Psychiatric Clinics of North America, 40 (1), 51–64. doi:10.1016/j.psc.2016.10.011. Movement Advancement Project, National Center for Transgender Equality, and Transgender Law Center. (2015). Understanding issues facing transgender Americans. www.glaad.org/sites/default/files/understanding-issuesfacing-transgender-americans.pdf.

Resources for Clients Brill, S. A. (2016). The transgender teen: A handbook for par­ ents and professionals supporting transgender and nonbinary teens. Jersey City, NJ: Cleis Press. Jacobson, J. (2013). Helping transgender children and teens. American Journal of Nursing, 113 (10), 18–20. World Professional Association for Transgender Health (WPATH). (2012). Standards of care for the health of trans­ sexual, transgender, and gender-nonconforming people, version 7. www.wpath.org.

References American Psychological Association (APA). (2003). Guide­ lines on multicultural education, training, research, prac­ tice, and organizational change for psychologists. Ameri­ can Psychologist, 58 (5), 377–402. doi:10.1037/0003­ 066X.58.5.377. American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. doi:10.1037/a0039906. American Psychological Association (APA). (2017). Ameri­ can Psychological Association ethical principles of psy­ chologists and code of conduct. https://www.apa.org/ ethics/code/. Bonierbale M., Baumstarck K., Maquigneau A., Gorin-Lazard, A., Boyer, L., Loundou, A., . . . & Lançon, C. (2016).

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MMPI-2 profile of French transsexuals: The role of socio­ demographic and clinical factors. A cross-sectional design. Scientific Reports, 6, 24281. Boroughs, M. S., Bedoya, C. A., O’Cleirigh, C. A., & Safren, S. A. (2015). Toward defining, measuring, and evaluating LGBT cultural competence for psychologists. Clinical Psychology, Science and Practice, 22 (2), 151–171. Burnes, T. R., Dexter, M. M., Richmond, K., Singh, A. A., & Cherrington, A. (2016). The experiences of transgender survivors of trauma who undergo social and medical transition. Traumatology, 22 (1), 75–84. doi:10.1037/ trm0000064. Dana, R. (1994). Testing and assessment ethics for all persons: Beginning and agenda. Professional Psychology: Research and Practice, 25 (4), 349–354. dickey, l. m., Reisner, S. L., & Juntunen, C. L. (2015). Nonsuicidal self-injury in a large online sample of transgen­ der adults. Professional Psychology: Research & Practice, 46 (2), 3–11. dickey, l., Singh, A., Chang, S., & Rehrig, M. (2017). Advocacy and social justice: The next generation of counseling and psychological practice with transgender and gendernonconforming clients. In A. Singh and l. dickey (eds.), Affirmative counseling and psychological practice with transgender and gender nonconforming clients, 247–262. Washington, DC: American Psychological Association. Ducheny, K., Hendricks, M. L., & Keo-Meier, C. L. (2017). TGNC-affirmative interdisciplinary collaborative care. In A. Singh and l. dickey (eds.), Affirmative counseling and psychological practice with transgender and gender non­ conforming clients, 69–93. Washington, DC: American Psychological Association. Duckworth, A. L., Steen, T. A., & Seligman, M. P. (2005). Pos­ itive psychology in clinical practice. Annual Review of Clinical Psychology, 1, 629–651. Fredriksen-Goldsen, K. I., Simoni, J. M., Kim, H., Lehavot, K., Walters, K. L., Yang, J., & Muraco, A. (2014). The Health Equity Promotion Model: Reconceptualization of lesbian, gay, bisexual, and transgender (LGBT) health disparities. American Journal of Orthopsychiatry, 84 (6), 653–663. doi:10.1037/ort0000030. Fuentes, M. A., & Shannon, C. R. (2016). The state of multi­ culturalism and diversity in undergraduate psychology training. Teaching of Psychology, 43 (3), 197–203. doi:10. 1177/0098628316649315. Graybar, S. R., & Leonard, L. M. (2005). In defense of listen­ ing. American Journal of Psychotherapy, 59 (1), 1–18. Keo-Meier, C. L., & Fitzgerald, K. M. (2016). Affirmative psy­ chological testing and neurocognitive assessment with transgender adults. Psychiatric Clinics of North America, 40 (1), 51–64. doi:10.1016/j.psc.2016.10.011.

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Mustanski, B., Andrews, R., & Puckett, J. (2016). The effects of cumulative victimization on mental health among lesbian, gay, bisexual, and transgender adolescents and young adults. American Journal of Public Health, 106 (3), 527–534. O’Donohue, W. (2016). Oppression, privilege, bias, prejudice and stereotyping: Problems in the APA code of ethics. Ethics and Behavior, 226 (7), 527–544. Owen-Smith, A. A., Sineath, C., Sanchez, T., Dea, R., Giam­ mattei, S., Gillespie, T., & Goodman, M. (2017). Percep­ tion of community tolerance and prevalence of depression among transgender persons. Journal of Gay & Lesbian Mental Health, 21 (1), 64–76. doi:10.1080/19359705.201 6.1228553. Parks, R., O’Connor, M., & Parrish, J. (2016). Gender pronouns: Recommendations from an institution with solutions. College & University, 91 (4), 83–86. Richmond, K. A., Burnes, T., & Carroll, K. (2012). Lost in trans-lation: Interpreting systems of trauma for transgender clients. Traumatology 18 (1), 45–57. Richmond, K., Burnes, T. A., Singh, A. A., & Ferrara, M. (2017). In A. A. Singh & l. m. dickey (eds.), Affirmative counsel­ ing and psychological practice with transgender and gender nonconforming clients. Washington, DC: American Psy­ chological Association. Schöning, S., Engelien, A., Bauer, C., Kugel, H., Kersting, A., Roestel, C., . . . & Konrad, C. (2009). Neuroimaging dif­ ferences in spatial cognition between men and male-to­ female transsexuals before and during hormone therapy. Journal of Sexual Medicine, 7 (5), 1858–1867. doi:10.11 11/j.1743-6109.2009.01484.x. Seiger, R., Hahn, A., Hummer, A., Kranz, G. S., Ganger, S., Woletz, M., . . . & Lanzenberger, R. (2016). Subcortical gray matter changes in transgender subjects after longterm cross-sex hormone administration. Psychoneuroen­ docrinology, 74, 371–379. Singh, A., & dickey, l. m. (eds.). (2017). Affirmative counseling and psychological practice with transgender and gender nonconforming clients. Washington, DC: American Psy­ chological Association. Snyder, C. R., Ritschel, L. A., Rand, K. L., & Berg, C. J. (2006). Balancing psychological assessments: Including strengths and hope in client reports. Journal of Clinical Psychology, 62 (1), 33–46. Thorpe, A. A. (2015). Towards the inclusion of trans* identi­ ties: The language of gender identity in postsecondary student documentation. Antistasis, 5 (2), 81–89. White Hughto, J. J., Pachankis, J. E., Willie, T. C., & Reisner, S. L. (2017). Victimization and depressive symptomol­ ogy in transgender adults: The mediating role of avoidant coping. Journal of Counseling Psychology, 64 (1), 41–51. doi:10.1037/cou0000184.

DEVELOPMENTAL QUESTIONNAIRE Date: ___________________________________ I.

Identifying and Demographic Information

Name: __________________________________________________________________________________ (Last)

(First)

(Middle)

Current address: _________________________________________________________________ Cellphone number: ____________________________ Handedness: _________________________________________________ Date of birth: ____________________________ Age: ______________ Sex (current sex): ________________________

Gender (List all that fit. Examples include male, female, agender, all-gender, cisgender, designated

male at birth [dmab], designated female at birth [dfab], genderfluid, gender nonconforming,

gender variant, intergender, polygender, transgender.): ________________________________________

__________________________________ Gender-affirming surgery:

n Yes n

No

Pronouns: ____________________________

Sex assigned at birth: __________________

Sexual identity (List all that fit. Examples include lesbian, gay, straight, queer, bisexual, pansexual,

polyamorous, questioning, ally, SGL.): ______________________________________________________ Ethnicity (check all that apply):

n African American n African Caribbean n Asian and Pacific Islander n European American n Native American n Latino/a/x n Other (specify): ____________________________ Language spoken at home: Were you adopted?

n English n Other: ____________________________

n Yes n No

If yes, at what age?____________________

a. Family demographics Are you married?

n Yes n No

Do you have a SOFFA (significant other, family, friend, ally), domestic partner, or civil partner?

n Yes n No

Whom do you currently live with? ____________________________

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b. Referral information How did you hear about us? _____________________________________________________

II. Presenting Problem a. What concerns do you have at the moment, and why are you seeking help now?

b. What kind of information or assistance are you hoping to obtain from the evaluation?

c. Do you have any behavioral concerns, or have you had any behavioral problems? If yes, please describe:

d. Please describe any other problems you may have that may be of relevance to this evaluation:

e. Please describe two or three of your strengths:

f. Please describe two or three of your biggest challenges:

g. Please share as much as you are comfortable with about any history of trauma:

h. Please share as much as you are comfortable with about any history of oppression:

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i. Please list all past neurological, psychiatric, psychological, neuropsychological, educational, speech and language, or other types of evaluations administered to you (indicate where, when, and by whom these were done): EVALUATED AT

BY

ON

j. Please list all past or present interventions, treatment, or remediation you’ve received or are currently receiving, including physical therapy, occupational therapy, speech and language therapy, etc. (indicate where and when): RECEIVED AT

ON

III. Developmental History Your mother’s pregnancy and delivery: If possible, describe any difficulties that occurred during your mother’s pregnancy or any complications during labor and delivery.

Did you meet your developmental milestones “on time”? If you had any difficulties or delays in the areas of walking, talking, playing with others, etc., please describe them.

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Have you ever experienced any of the following problems? If yes, please describe: PROBLEM

DESCRIPTION

Memory difficulties Impulsivity Mood changes Changes in appetite Changes in sleep Excessive worrying Headaches Dizziness Fatigue IV. Educational History a. Please indicate if you had any of the following school experiences: i. Have you ever been retained a grade in school? If yes, when and why? ii. Have you skipped a grade in school? If yes, when and why? iii. Did you ever have any difficulty with reading? Math? If yes, describe: iv. Were you ever placed in a special education or resource room class? If yes, describe: b. Current or previous school services or placement (through IDEA, IEP, MDC, or Section 504): LD: ED/BD: Speech and language: Occupational therapy/physical therapy: Social work/counseling: Consultation: c. High school: List the names of schools attended:

d. Secondary education: List the names of colleges or universities attended:

e. Current occupation: 362

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Grades:

V.

Family Medical History

Current medications Previous medications (those taken for longer than 6 months) Allergies (food, medicine, other) Surgeries/hospitalizations/ injuries MEDICAL HISTORY

PATIENT

PARENT 1

PARENT 2

OTHER

Respiratory Cardiovascular

Endocrinologic

Oncological

Neurological

Other chronic medical Acute medical Psychiatric: alcohol/drug abuse, emotional/behavioral disorders, depression, bipolar disorder, schizophrenia, physical/sexual abuse, phobias, panic attacks, anxiety, eating disorder

Other conditions

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VI. Neurological and Psychiatric History a. Have you ever experienced meningitis, encephalitis, stroke, brain hemorrhage, narcolepsy, sleep disorders, head injury, coma, loss of consciousness, tumor, toxic metal exposure, headaches, seizures, tics, fainting, tremors, vertigo? If so, describe:

b. Have you been diagnosed with cerebral palsy, muscular dystrophy, multiple sclerosis, intellectual disability, central nervous system structural defect? If so, describe:

c. Have you been diagnosed with a neurobehavioral disorder such as Tourette’s syndrome, learning disabilities, dyslexia, ADD/ADHD, autism, Asperger’s syndrome, hyperlexia, processing deficits, obsessive-compulsive disorder, oppositional defiant disorder, nonverbal learning disability, executive function deficits? If so, describe:

d. Have you used cigarettes, drugs, or alcohol in the past? If so, describe:

e. Have you been diagnosed with or shown symptoms of emotional/behavioral disorders, depression, bipolar disorder, schizophrenia, phobias, panic attacks, anxiety, eating disorder? If so, describe:

f. Have you been a victim of emotional, physical, or sexual abuse? If so, describe:

g. Have you ever been hospitalized or treated in an emergency room following an injury to your head? Have you ever injured your head or neck? (Think about any childhood injuries, car accidents, being hit by something, playing sports, etc.) If so, describe:

h. Did you notice any drastic changes in your mood, memory, attention, or fatigue following the injury to your head or neck? If so, describe:

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Andrew Suth and Sorrel Rosin

VII. Socioemotional Functioning a. How would you describe your emotional life and personality?

b. Do you have any social difficulties in your primary relationships?

c. Have you experienced any discrimination or oppression based on any aspect of your identity?

If yes: i. How did you manage or adapt to these feelings?

ii. Can you describe these experiences?

iii. Are you still experiencing this discrimination?

d. Do you have hobbies? Belong to any social groups? If so, describe:

Additional comments:

Name of person filling out this form: __________________________________________________________ Relationship to client: __________________________________

Andrew Suth and Sorrel Rosin

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41 MAPPING OF DESIRES AND GENDER: EXPLORATIONS AT THE INTERSECTIONS Shannon Solie

Suggested Uses: Activity, homework Objective

The objective of this exercise is to give care providers and clients an activity and a tool for mapping desires and gender, thereby offering an alternative to binary systems of labeling and identity, and to provide an opportunity for deepening description, language, and exploration about gender and desires. By using this mapping exercise, the therapist and client can enhance the understanding and exploration of intersecting identities. Rationale for Use

For the purpose of this chapter, gender is defined by Erickson-Schroth as “a set of social, psychological, and emotional traits, often influenced by societal expectations, that classify an individual as feminine or masculine” (2014, p. 614). It is used here as an umbrella term to include expressions, identifications, and labels of gender, as well as sex assigned at birth (Erickson-Schroth, 2014). In sexual configurations theory (SCT), van Anders introduces the terms nurturance and eroticism to encapsulate human desire. Eroticism “denotes phe­ nomena that are sexually tantalizing, evoke one’s sexual interests or thoughts, are sexually arousing in that they elicit psychological or physiological sexual responses (whether desired or not), or are related to features tied to sexuality” (2015, p. 1183). Nurturance “implies a warm, loving, supportive, and potentially committed connection” (2015, p. 1183). This theory largely influ­ ences this exercise; however, these terms often become

too distilled when working with a client, as they are subsets of the greater term used here, desire. The verb desire is defined by Merriam-Webster as “to long or hope for” or “to express a wish for.” Here desire is as an umbrella term to connect SCT and dictionary definitions to describe an individual’s desires regard­ ing sexuality, intimate relationships, fantasies, emo­ tional desires, physiological arousal, and nurturing relationships. This exercise is based on interdisciplinary theories and literature and uses key factors from various the­ ories. The concepts of empathy and merging that fem­ inist theory (Sullivan, 1989) offers can assist the clini­ cian in working with clients who may have dissonance regarding gender and/or desire. Phenomenological theory allows the therapist and client to work with per­ ception, orientation, and ways of being in the world (Ahmed, 2006). Queer theory offers a shift of perspec­ tive from a heteronormative to a queer and intersec­ tional lens, which is necessary when working with clients who identify outside binary systems and clients with many intersecting identities of queering domi­ nant culture (Ahmed, 2006; Fausto-Sterling, 2003; Wekker, 2006). The foundation of this exercise comes from sexual configurations theory, which includes psychological, biological, and neurological research about sex, gender, and desire (van Anders, 2015). At the time of writing this chapter, SCT is the most cur­ rent and thorough evidence-based research available that looks at multiple levels and variations of sexuality and desire. SCT offers a multifaceted approach to sexuality and gender and is “intended to convey a dynamic,

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multifaceted, and value-neutral approach to sexuali­ ties” (van Anders, 2015, p. 1185). SCT provides a three-dimensional (3-D) map that gives a comprehen­ sive overview of an individual’s sexual diversities by considering the number and types of partners an indi­ vidual has both sexually and relationally. The model that van Anders uses, although thorough, does not translate into the therapy room easily. The exercise introduced here takes the SCT theory and model and simplifies them into a more accessible, two-dimen­ sional (2-D) map to use with clients. This map gives the freedom to build, connect, and open the multi­ faceted discussion of gender and sexuality with clients and shows how gender and desire expressions are separate yet interdependent components of identity. The following activity allows clients to create a fluid map of the gender and desires they feel best represent them, thus offering a comprehensive and holistic approach to exploring gender and desire. The understanding of sexual orientation is based on the gender(s) that one is attracted to and the gender(s) that one identifies as. To have a full understanding of clients’ desires, we need an understanding of their gen­ der and how their gender is constructed (van Anders, 2015). A deeper understanding of gender and desire can assist in better outcomes for mental and physical health: clients can gain agency in health-care settings as they learn to break down social constructs of gender and minority stress (Andermann, 2010; Hendricks & Testa, 2012). This exercise helps the therapist and client build a deeper understanding of how the multiple areas of socialization, oppression, and development affect one’s sense of well-being and lived experience. Andermann (2010) discusses how socialization affects the mental health of cisgender women globally, from body image and eating disorders to female genital mutilation. She reports higher depression rates and lower access to care: low economic status is one of the strongest indi­ cators of stress and lack of access to care (Andermann, 2010). When working with clients who identify as a sexual minority, the minority stress model shows how the additional layers of stress can affect mental health (Meyer, 2003). The minority stress model is a helpful tool for clinicians for assessing areas of stress

or oppression that are based on an individual’s vary­ ing minority identities. Research shows that people who identify as LGBTQ show higher rates of mental health issues, including depression and suicidality, than their heterosexual counterparts (Meyer, 2003; Erickson-Schroth, 2014). This exercise assists the client and the counselor in better understanding how a client is situated regard­ ing desire and gender. As Andermann (2010), Meyer (2003), and van Anders (2015) have shown, having a working understanding of these components of a person’s identity can assist in understanding power dynamics in relationships, stereotypes, internal and external oppressions, beliefs of how one is “supposed” to act or be; bring awareness to mind/body splits; and give greater understanding of where the authentic person and performativity for others move together and away from one another. These authors also note that the greater one’s understanding of how gender and orientation intersect (as well as how they intersect with other identities: race, age, ability status, and so on), the more understanding there is of how one expe­ riences stress. With this knowledge, the therapist can work with the client to understand, acknowledge, cope, and increase empowerment in these areas. A client’s lived experience drives this model. The map is an open space for the client to create a visual representation of the multiple aspects of experiences of gender and desire throughout a life. When using this tool in the therapeutic relationship, there is an opportunity for the counselor to validate, affirm, and empower the client’s choices and experiences in the context of the interpersonal, ideological, internalized, intersectional, and institutional levels of oppression and power (CUUSAN, 2015), as well as the historical, cultural, biological, and psychological levels of gender and desire. An understanding of gender and desire and how they affect clients is part of an ethical therapeutic rela­ tionship when working with LGBTQ individuals, according to the counseling competencies laid out by the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling, or ALGBTIC (Harper et al., 2013), a branch of the American Coun­ seling Association (ACA). ALGBTIC assists clinicians

Mapping of Desires and Gender 367

in expanding their learning and seeking specialized supervision, and it addresses specific needs of the LGBTQ population through a newsletter and conference. The ACA Code of Ethics (2014) strongly empha­ sizes the need for clinicians to have multicultural and diversity training. This exercise assists both client and therapist in understanding the intersecting identities of gender and desire in relationship with other inter­ sections (age, race, ability status, body size, national origin.). The minority stress model (Meyer, 2003) has been used to show that multiple negative health (phys­ ical and emotional) outcomes for LGBTQIA individ­ uals result from the chronic stress of everyday preju­ dices they experience (Austin & Goodman, 2016; Hendricks & Testa, 2012). Applying this map as a com­ ponent of understanding how sexuality and gender interplay with the intersecting identity of national origin and/or immigration status can offer a deeper understanding of internal and external oppression and stress. Cultural humility, which stems from multicultural competency training, involves the counselor’s taking an other-oriented approach to cultural alignment. The counselor works to hold an open and aware mindset of their own culture, a lifelong commitment to self-examination, and a commitment to rectify power imbalances in the client-counselor dynamic (Hook et al., 2013). Consultation with or supervision by some­ one who specializes in working with clients with mul­ tiple intersecting identities is advised. Supervisors overseeing cases with clients who identify as sexual minorities and/or gender diverse are required to have a working knowledge of the spe­ cific needs of these communities (ACA, 2014). This map can assist the therapist in addressing the nuances of a client’s case with a supervisor. It may also be used as a training tool for therapists and supervisors who are looking to deepen their understandings of their own maps to better understand where there is a cul­ tural difference with a client (ACA, 2014). Instructions

The activity can be used in individual, couples, or group therapy. It can be assigned as homework for cli­ ents to engage in independently or used in session as 368 Solie

a shared exploration for clients and therapist. Clients will be instructed to use colored pens or pencils (sev­ eral colors are needed) and create a key, using the options under potential plot points that are pertinent to the client. Each point should be assigned a color. The clients will then make marks and color in and around each of the map, or the map that is more rel­ evant to the client, using the colors that match the key. Encourage clients to express static and dynamic plot points using color as it fits their map of self. Sug­ gestions for types of markings: Xs, lines, shapes, shad­ ing (e.g., clients who see their gender as fluid could use a wave pattern to fill in the space between mascu­ line and feminine). This model uses two circular maps, one designed to map a client’s gender experience and the other designed to map desires an attraction. These can be used separately or combined give the option of a full spectrum: asexual/agender is at the center (meaning little to none on the scale of identifying), and strength of identification toward a gender or orientation increases the farther out in the circle one places one­ self. For example, if someone strongly identifies as bigender, they could place themselves far out along the circle and equally between feminine and masculine. Movement away from the binaries may be important, and clients may feel perplexed about how to approach each of the maps. The therapist can suggest that they look at it as a wheel, in which movement to the right or the left can show a directionality of learning or unlearning. For example, movement toward the right may indicate learning—whereas left may indicate unlearning—a gendered way of being. While the Desire Spectrum Map has different sections that are marked with labels of orientation, this can feel limit­ ing or confining and is focused on attraction while not looking at specific sex acts. Encourage your cli­ ents to rename or change labels to better represent them. This changing of labels can be an empowering act for clients. It is imperative that the therapist ask questions, change the labels as necessary, and define words with the client to deepen the understanding of what each client’s language is expressing. It is also important to think about the use of labels in the therapy room and whether these are representing a client’s way of naming

an action, a sense of self, or a way of creating shared language. Clinicians often need to label and under­ stand their clients and to create a shared language; however, labels can create a two-dimensional picture in which a whole person with changing and multiple intersecting identities exists. When using this exercise, define what each label means for the client. If done in the therapy session, you can choose to talk about the plot points the client places on each map as the client’s color. You can also wait until the client feels they have completed their maps and then look at the various plot points and assess and discuss the different ways that the client’s inner world and outer world shape their perceptions of gender and desire. The maps provided here are templates. Urge cli­ ents to make them their own. Clients can darken lines, rename sections, and color outside the given sphere, as it is right for them. Encourage creative expression in this process.

by the people around them on multiple levels. Doing this activity opened the door for deeper conversations about authenticity and empowerment work. Toby was able to see how their internal understanding of their identity and the way that the world around them views them are not aligning. Toby found grounding in their authentic self by looking at the multiple layers that create gender and desire for them. This authen­ ticity then provided a grounding for empowerment in boundary setting, communication, and education for those around them. Toby was able to think through responses they wanted to give to the questions asked of them by strangers and family in a way that felt authentic and full of self-agency for them. They have been able to build self-confidence in their authentic self, which has reduced the distress of the outside world’s views of them, and they have learned language to help close the gaps in relationships with family and friends.

Brief Vignette

Toby identifies as a vulva-loving, kinky, Latinx, gen­ derqueer. They are situated in multiple relationships of varying lengths and depths. They have two part­ ners whom they have been dating for over a year and multiple play partners with whom they engage in kink play. They found that their gender map was overlap­ ping in many areas, which created a cohesion in their sense of self. Areas that were not overlapping caused great strain in multiple aspects of “being in the world.” Relationships with family, strangers, and coworkers were all areas outside the overlap. Toby’s family iden­ tifies them as and expects them to act in accordance with the female gender that was assigned at birth. The family identifies Toby as a lesbian because of their identification as “vulva loving,” and Toby tends to date people who identify more in the femme identity. Toby has socialized components of gender based in the family’s Latin heritage and the roles that different gen­ ders hold in the family and society. The tension of heritage and family and personal and social identifi­ cation is a key place of struggle for Toby. Strangers would often misgender them, and coworkers were often asking invasive questions about Toby’s identity and orientation, which led to great distress for Toby, who felt disrespected and objectified

Suggestions for Follow-up

Using this activity may open the door for deeper exploration in the therapeutic setting as well as in the client’s interactions in the world. Below are some suggested questions for follow-up:

• What is most surprising to you as you make this map?

• How do you see socialization and sex assigned at birth? How are you read socially? How do you relate with your gender today?

• What elements of your desire map do you find to be of highest priority for you?

• Are there areas of gender that determine/create/ hinder your desire map?

• Are there areas of desire that determine/create/ hinder your understanding of your gender?

• How do you see these maps interplaying with each other?

• When you say you sexually identify as ________, does this encompass specific sexual acts and expressions, or is it about attraction to another?

• Is your desire map based on physical traits such as genitals, on emotional, energetic, and personality

Mapping of Desires and Gender 369

GENDER S P ECT RUM M A P

Feminine

A Gender

H

Masculine

KEY

H

Gender Identity Gender Expression Gender Socialization Social Read* Gender Assigned at Birth

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* Social read of gender: Being read is a term used in the gender-diverse community to describe how people in social settings assign gender to an individual. For example, a transmasculine person may be socially read as male and have strangers assign male pronouns and language to them.

D E S IRE S P ECT RUM M A P

Gay/Lesbian

A

I C Queer F A/Non B G DJ E Pan

H

Hetero

Bi (focused on cisbodies)

KEY

A B C D E F G H I J

Sexual Orientation Romantic Orientation Long-Term Relationships Short-Term Relationships Hookups Nurture Desires Erotic Desires Past Desires Current Desires Play Partners

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traits, or on a perception or identification of another’s gender and presentation? These discussions may open levels of exploration that take time to unfold. It is suggested that therapists cir­ cle back to the maps throughout the therapeutic rela­ tionship for deeper exploration and potentially create new maps as time passes. Contraindications for Use

This exercise is intended for individuals of all gender and sexual identities and at all stages of self-explora­ tion. Some clients may find that this exercise is diffi­ cult or confusing if this is a new area of exploration, and although this is can be where mapping changes/ determinations are most powerful, it may not be right for your client. This exercise may feel over­ whelming to these clients and its use may be inadvisable. It is recommended that this tool be amended to meet the clients’ individual needs and language. This tool was designed to be usable for all clients; however, it may not be relevant or helpful for clients from all cultures and backgrounds. Always practice cultural humility before applying this tool. It is important to define the terms being used with clients and include a discussion of the limitations of the terms offered. There is still a binary included here: feminine/masculine and hetero/homosexual. The circular format of the map illustrates that these are not necessarily opposites and there are times when we are closer to one or another. The terms listed here are about attraction and not sexual acts, which can feel limiting. If a client is discussing attraction or repul­ sion to particular sexual acts, it is recommended to reorient the discussion to body parts and erogenous zones or to create a second gender map of attraction with a focus on presentation, energy, and physical attraction to others as the mapping points. Professional Readings and Resources Brown, M. (2012). Gender and sexuality I: Intersectional anx­ ieties. Progress in Human Geography, 36 (4), 541–550. doi:10.1177/0309132511420973. Chinook Fund. (n.d.). General terms & forms of oppression. https://chinookfund.org/wp-content/uploads/2015/10/ Supplemental-Information-for-Funding-Guidelines.pdf.

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Fausto-Sterling, A. (2003). The five sexes: Why male and female are not enough. In J. L. Anderson (ed.), Race, gen­ der, and sexuality: Philosophical issues of identity and jus­ tice, 33–38. Upper Saddle River, NJ: Prentice Hall. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H. C., Loos, B., . . . & Hammer, T. R. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally indi­ viduals. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi:10.1080/15538605.2013.755444. Haynes, F., & McKenna, T. (eds.). (2001). Unseen genders: Beyond the binaries. New York: Peter Lang. Johnston, L. (2015). Gender and sexuality I: Genderqueer geographies? Progress in Human Geography, (40) 5, 668– 678. doi:10.1177/0309132515592109. Mair, D. (2010). Fractured narratives, fractured identities: Cross-cultural challenges to essentialist concepts of gen­ der and sexuality. Psychology and Sexuality, (1) 2, 156– 169. doi:10.1080/19419899.2010.484597. van Anders, S. M. (2015). Beyond sexual orientation: Inte­ grating gender/sex and diverse sexualities via sexual configurations theory. Archive of Sexual Behavior, 44 (5), 1177–1213. doi:10.1007/s10508-015-0490-8. Van den Berg, M. E. (2011). Bodies as open projects: Reflec­ tions on gender and sexuality. South African Journal of Philosophy, 30 (3), 385–402.

Resources for Clients

Bornstein, K. (1998). My gender workbook: How to become a real man, a real woman, the real you, or something else entirely. New York: Routledge. Butler, J. (1990). Gender trouble: Feminism and the subversion of identity. New York: Routledge. Chinook Fund. (n.d.). General terms and forms of oppression. https://chinookfund.org/wp-content/uploads/2015/10/ Supplemental-Information-for-Funding-Guidelines.pdf. Erickson-Schroth, L. (2014). Trans bodies, trans selves: A resource for the transgender community. New York: Oxford University Press. Trans Student Educational Resources. (n.d.). The gender uni­ corn. http://www.transstudent.org/gender.

References Ahmed, S. (2006). Queer phenomenology: Orientations, objects, others. Durham, N.C.: Duke University Press. American Counseling Association (ACA). (2014). ACA code of ethics. https://www.counseling.org/resources/aca-code­ of-ethics.pdf. Andermann, L. (2010). Culture and the social construction of gender: Mapping the intersection with mental health. International Review of Psychiatry, 22 (5), 501–512. doi: 10.3109/09540261.2010.506184. Austin, A., & Goodman, R. (2016). The impact of social con­

nectedness and internalized transphobic stigma on selfesteem among transgender and gender non-conforming adults. Journal of Homosexuality, 64 (6), 825–841. doi:10 .1080/00918369.2016.1236587. Bullough, V. (1990). The Kinsey scale in historical perspective. In D. P. McWhirter, S. A. Sanders, & J. M. Reinisch (eds.), Homosexuality/heterosexuality: Concepts of sexual orien­ tation, 3–14. New York: Oxford University Press. Chinook Fund. (n.d.). General terms and forms of oppression. https://chinookfund.org/wp-content/uploads/2015/10/ Supplemental-Information-for-Funding-Guidelines.pdf. Coalition for Unitarian Universalist State Action Networks (CUUSAN). (2015). Spiritual grounding. http://cuusan. org/forming-a-san/spiritual-grounding/. Erickson-Schroth, L. (2014). Trans bodies, trans selves: A resource for the transgender community. New York: Oxford University Press. Fausto-Sterling, A. (2003). The five sexes: Why male and female are not enough. In J. L. Anderson (ed.), Race, gen­ der, and sexuality: Philosophical Issues of identity and jus­ tice, 33–38. Upper Saddle River, NJ: Prentice Hall. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H. C., Loos, B., . . . Hammer, T. R. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Coun­ seling competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individu­

als. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi :10.1080/15538605.2013.755444. Hendricks, M., & Testa, R. (2012). A conceptual framework for clinical work with transgender and gender noncon­ forming clients: An adaptation of the minority stress model. Professional Psychology: Research and Practice, 43 (5), 460–467. doi:10.1037/a0029597. Hook, J. N., Davis, D. E., Owen, J., Worthington, E. L., & Utsey, S. O. (2013). Cultural humility: Measuring openness to culturally diverse clients. Journal of Counseling Psychol­ ogy, 60, 353–366. doi:10.1037/a0032595. Jordan-Young, R. M. (2010). Brainstorm: The flaws in the science of sex differences. Cambridge: Harvard University Press. Meyer, I. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129 (5), 674–697. doi:10.1037/0033-2909.129.5.674. Sullivan, B. (1989). Psychotherapy grounded in the feminine principle. Wilmette, IL: Chiron Publications. van Anders, S. M. (2015). Beyond sexual orientation: Integrat­ ing gender/sex and diverse sexualities via sexual config­ urations theory. Archive of Sexual Behavior, 44 (5), 1177–1213. doi:10.1007/s10508-015-0490-8. Wekker, Gloria. (2006). The politics of passion: Women’s sexual culture in the Afro-Surinamese diaspora. New York: Columbia University Press.

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GE NDER S P ECT RUM M A P

Feminine

A Gender

Masculine

KEY

H

Gender Identity Gender Expression Gender Socialization Social Read* Gender Assigned at Birth

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* Social read of gender: Being read is a term used in the gender-diverse community to describe how people in social settings assign gender to an individual. For example, a transmasculine person may be socially read as male and have strangers assign male pronouns and language to them.

Shannon Solie

D E S IRE S P ECT RUM M A P

Gay/Lesbian

Queer

Hetero A/Non

Pan

Bi (focused on cisbodies)

KEY

A B C D E F G H I J

Shannon Solie

Sexual Orientation Romantic Orientation Long-Term Relationships Short-Term Relationships Hookups Nurture Desires Erotic Desires Past Desires Current Desires Play Partners

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42 ASEXUALITY: AN INTRODUCTION FOR QUESTIONING CLIENTS Emily M. Lund, Bayley A. Johnson, Christina M. Sias, and Lauren M. Bouchard Suggested Use: Handout Objective

The goal of this activity is to provide information about asexuality to clients who may be questioning their sexual orientation, especially with regard to a lack of sexual attraction toward others. Rationale for Use

Asexuality—defined as the lifelong and nonpatholog­ ical lack of sexual attraction to people of any sex or gender (Asexuality Visibility and Education Network [AVEN], 2019)—is increasingly being recognized as a valid sexual orientation (Bogaert, 2004, 2006; Brotto et al., 2010; Chasin, 2011). Studies have estimated that approximately 1 percent of the population is asexual (Bogaert, 2004; Lund, Thomas, Sias, & Bradley, 2016). Many asexual people may not openly identify as such, however, because of stigma, shame, confusion, or simply the lack of knowledge that asexuality exists (Brotto et al., 2010). Asexuality may be assumed to be pathological, a phase to be “grown out of,” or a repres­ sion of one’s “true” sexuality (Bogaert, 2006; Brotto et al., 2010; Lund & Johnson, 2014). But studies of self-identified asexual people have shown that asex­ uality is not associated with higher than expected rates of medical or psychological pathology (Brotto et al., 2010), and it is described by self-identified asexual individuals as being like any other sexual ori­ entation—that is, an innate and nonpathological part of their being (Brotto, 2010; Cuthbert, 2017). Like other individuals who are sexual minori­ ties, people who come to identify as asexual typically

go through a phase of questioning their orientation (Brotto et al., 2010; Prause & Graham, 2007). For gay, lesbian, and bisexual individuals, this questioning phase is often triggered by feeling sexual attraction to someone of the same sex or gender; however, for asex­ ual individuals, questioning may start with the reali­ zation that the person does not feel—and has never felt—sexual attraction to anyone, regardless of sex or gender. Additionally, people who are asexual may grapple with differentiating sexual and romantic attrac­ tion. Studies of self-identified asexual people have shown that about four-fifths of asexual people report experiencing romantic attraction (AVEN, 2008; Van Houdenhove, Gijs, T’Sjoen, & Enzlin, 2015), and the remaining one-fifth identify as aromantic as well as asexual. Thus, asexual people may pursue, desire, and have romantic relationships without feeling sexual attraction to their partners. Such relationships may or may not involve the act of sex, depending on the needs, wants, and willingness of each person (Pinto, 2014), and individuals who are questioning whether they are asexual will also need to work out what their romantic orientation is and the implications of that for their current or future relationships (Pinto, 2014). As noted above, research supports the idea of asexuality as a legitimate and nonpathological sexual orientation (Brotto et al., 2010). Furthermore, emerg­ ing research supports the concept of discordant or dif­ fering sexual and romantic orientations, both in people who identify as asexual and in those with other sexual orientations (e.g., people who are sexually attracted to both men and women but romantically attracted to men; Lund et al., 2016; Priebe & Svedin, 2013).

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Psychotherapists and counseling professionals, including counselors (American Counseling Associ­ ation [ACA], 2014; Harper et al., 2013), psycholo­ gists (American Psychological Association [APA], 2017), and rehabilitation counselors (Commission on Rehabilitation Counseling Certification [CRCC], 2017), are tasked with providing culturally competent services to clients regardless of sexual orientation as a part of their ethical codes. For example, principle E of the “Ethical Principles of Psychologists and Code of Conduct” states that “Psychologists are aware of and respect cultural, individual, and role differences, including those based on . . . sexual orientation . . . and consider these factors when working with mem­ bers of such groups. Psychologists try to eliminate the effect on their work of biases based on those fac­ tors, and they do not knowingly participate in or condone activities of others based upon such preju­ dices” (APA, 2017). Likewise, the ACA Code of Ethics (2014), section C.5, states, “Counselors do not condone or engage in discrimination against prospective or current clients, students, employees, supervisees, or research partici­ pants based on . . . gender, gender identity, sexual orientation . . . or any basis proscribed by law.” Simi­ larly, the CRCC Code of Professional Ethics states, “Rehabilitation counselors are aware of the continuing evolution of the field, changes in society at large, and the different needs of individuals in social, political, historical, environmental, and economic contexts. The commitment involves providing respectful and timely communication, taking appropriate action when cul­ tural diversity issues occur, and being accountable for the outcomes as they affect people of all races, ethnici­ ties, genders, national origins, religions, sexual orienta­ tions, or other cultural group identities” (CRCC, 2017). Thus, psychotherapists and other counselors have an ethical duty to respect their clients’ sexual orien­ tation and not to discriminate against, deny service to, or demean clients on the basis of sexual orientation. Because asexuality is newly recognized as a sexual orientation, however, relatively few resources exist on cultural competency with asexual or potentially asex­ ual clients (Pinto, 2014). Because asexuality has long been assumed to be a sign of pathology (Lund & Johnson, 2014), clients

may be hesitant to reveal their questions about asex­ uality to clinicians or others for fear of being disbe­ lieved or pathologized (Brotto et al., 2010; Gupta, 2017). This may be especially true for clients with dis­ abilities, given the disability community’s long fight against the inaccurate assumption that all people with disabilities are asexual (Cuthbert, 2017; Lund & Johnson, 2014). Client feelings or concerns about identifying as asexual may also arise from other iden­ tities and experiences. For example, there is a long history of hypersexualization of women in general and nonwhite women in particular in the media (Sanger, 2009). Thus, many women, especially those who identify as or are read as nonwhite, may feel that they must be read as sexual to be read as desir­ able and may struggle to accept an asexual identity on that basis. Furthermore, clients from certain reli­ gious communities and backgrounds may struggle with issues such as shame related to discussion of sexuality in general (Regnerus, 2005), pressure to get married and have children and the implications of asexuality for that, or the conflation of asexuality and celibacy. Client concerns and questions related to the intersectionality of asexuality with other identities and cultural influences should be discussed in an affirmative manner. Additionally, clients may wish to explore what asexuality means to them in terms of queer or sex­ ual minority identity, especially in combination with their romantic orientation; asexual people may not always be welcomed in queer or LGBT spaces (Cuthbert, 2017; Gupta, 2017) and may feel pressure about whether to identify with their sexual orienta­ tion, romantic orientation, or both if the two are different (Prause & Graham, 2007). Finally, asexual individuals may have to navigate the implications of their asexuality in terms of cultural and social expec­ tations for sex, relationships, and childbearing (Gupta, 2017) and to what degree, if any, they would be will­ ing to have consensual sex with a partner for purposes of maintaining a romantic relationship or having chil­ dren (Pinto, 2014; Prause & Graham, 2007). Instructions

Counselors may want to give clients the handout and go through it side by side to discuss the issues raised Asexuality: An Introduction for Questioning Clients 377

and how the information about asexuality provided relates to the client’s feelings and experiences regard­ ing sexual attraction or lack thereof. For example, the client may strongly relate to points regarding “just not being interested” in sex or in feeling “broken” owing to this lack of interest. Conversely, clients may reject points raised—for example, they may cite their lack of interest in sexual behavior as a new or troubling phenomenon or state that they do experience a desire to engage in sexual behavior but not as their birth gender. These responses may give the counselor a direction to go in with further referral or identity dis­ cussion. For instance, if clients state that their lack of interest in sexual behavior is new or troubling, the counselor may want to consider referring them for medical testing to examine possible physiological causes for their sudden change in sexual interest, such as hormonal or thyroid issues (Mayo Clinic, 2012). If their change in sexual desire closely co-occurs with psychological symptoms, such as traumatic stress or a major depressive episode, the counselor may want to consider the possibility that the change in sexual inter­ est may be related to a mental health condition and not part of their innate orientation (APA, 2013). If cli­ ents say that they experience sexual attraction but do not wish to have sex because of their physiological sex, such as genital dysphoria, the counselor may want to explore issues related to gender identity. It is impor­ tant to note that asexuality can and does co-occur with physical health conditions, psychiatric health conditions, transgender identity, and a variety of other factors. Asexuality, however, is generally defined by its lifelong and nondistressing nature (Bogaert, 2006). Although asexual individuals may feel distress because of the marginalization and “otherness” that can come with being a sexual minority (Gupta, 2017), they generally do not feel distress over their lack of sexual attraction itself. Brief Vignette

Joan is a twenty-two-year-old cisgender female college student who identifies as white, physically disabled, and from a middle-class socioeconomic background. She is seeking counseling regarding her relationship with her girlfriend Grace. Up until this past year, Joan had exclusively dated men—she described one 378 Lund, Johnson, Sias, & Bouchard

six-month romantic relationship in high school and a one-year romantic relationship in college. She said that both relationships had ended because she just did not want to have sex, although she did engage in phys­ ically pleasurable sexual acts with both partners. She said that the pressure to do something that she had little to no interest in eventually became highly stress­ ful and led to conflict in the relationships, despite her mutual romantic attraction to both men. After her college relationship ended, Joan said that she realized that she had long experienced romantic attraction to other women and assumed that her lack of sexual inter­ est in her previous partners must be due to her “true identity” as a lesbian. Three months ago, Joan began dating Grace and reported a high level of romantic attraction—“an over-the-moon crush”—to her. Joan reported, however, that, despite her strong attraction to Grace emotionally and the fact that she found her girlfriend to be aesthetically beautiful, she felt no desire to engage in sexual acts with Grace. She reported that the two had tried engaging in a variety of sexual acts but that, while they felt good physically in the moment, she still felt the same level of lack of interest toward sex as she had in her previous relationships with men. “I love her,” Joan said during her counsel­ ing session. “She’s beautiful. I want to date her for a long time. I just don’t want to have sex with her. I don’t think I’ve ever wanted to have sex with anyone. What’s wrong with me?” Joan’s therapist told her that, on the basis of what she was describing, it sounded as though Joan may be asexual. When Joan expressed surprise and con­ fusion about what that meant, the therapist retrieved the handout included in this chapter, and they went through it point by point; the therapist periodically asked questions to get a sense of Joan’s understand­ ing of and reaction to the information provided. At the end of the session, the therapist gave Joan the handout to take with her so that she could look up the resources provided. Suggestions for Follow-up

The therapist may follow up with clients to ask if they have done any further investigation into asexuality (e.g., using the suggested resources below) or thought about whether the term fits them. The clients’ responses to

these questions may then guide future discussions, such as if and how to come out as asexual to friends, family members, or partners, and concerns or ques­ tions about claiming an asexual identity. Contraindications for Use

As mentioned above, this handout is probably not appropriate for clients whose lack of sexual attraction is new or ego dystonic and distressing. Such clients may have a disorder such as hyposexual drive disor­ der (Brotto, 2010), which is distinguished from asex­ uality by its marked distress and lack of innateness (Bogaert, 2006). Similarly, this handout is not appro­ priate for clients whose lack of sexual interest is rooted solely in gender or sexual dysphoria. Clients in the latter group may benefit from services regarding gen­ der identity, while clients in the former group should be referred for a medical evaluation to rule out pos­ sible physical causes for their change in sexual desire (AVEN, 2012). Similarly, this handout is probably not appropriate for clients whose lack of sexual attrac­ tion can be directly tied to something like traumatic stress or a cyclical or initial-onset major depressive episode that has not been adequately treated. Finally, this handout may not be appropriate for clients who already have a well-formed asexual identity. Professional Readings and Resources Bogaert, A. F. (2012). Understanding asexuality. Lanham, MD: Rowman & Littlefield. (One of the first texts on asexuality.) Decker, J. S. (2014). The invisible orientation: An introduction to asexuality. New York: Skyhorse. (A book written by an asexual woman on asexual identity and allyship.) Pinto, S. A. (2014) ASEXUally: On being an ally to the asex­ ual community. Journal of LGBT Issues in Counseling, 8, 331–343. (A journal article written for counselors who are working with asexual or possibly asexual clients.)

Resources for Clients Asexuality Archive. (2012). Asexuality: A brief introduction. Seattle: CreateSpace. (Includes information for those who think that they may be asexual. A free PDF download is available at http://www.asexualityarchive.com under the “Book” tab.) Asexuality Archive. (2017). Welcome to the Asexuality Archive! www.asexualityarchive.com. (Provides blog posts, termi­ nology guides, and other resources related to asexuality.) Asexuality Visibility and Education Network (2017). Welcome.

https://www.asexuality.org/. (Provides information, news, and discussion forums related to asexuality.) Bigio, E. (executive producer), & Tucker, A. (director) (2011). (A)Sexual. FilmBuff. (A documentary on asexu­ ality and asexual people that can be found on YouTube, Amazon, and other video and movie services.)

References American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders, 5th edition. Washington, DC: Author. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/. Asexuality Visibility and Education Network (AVEN). (2019). Overview. Retrieved from http://www.asexuality.org/?q =overview.html. Bogaert, A. F. (2004). Asexuality: Prevalence and associated factors in a national probability sample. Journal of Sex Research, 41, 279–287. doi:10.1080/00224490409552235. Bogaert, A. F. (2006). Toward a conceptual understanding of asexuality. Review of General Psychology, 10, 241–250. doi:10.1037/1089-2680.10.3.241. Brotto, L. A. (2010). The DSM diagnostic criteria for hypoac­ tive sexual desire disorder in women. Archives of Sexual Behavior, 39, 221–239. doi:10.1007/s10508-009-9543-1. Brotto, L. A., Knudson, G., Inskip, J., Rhodes, K., & Erskine, Y. (2010). Asexuality: A mixed-methods approach. Archives of Sexual Behavior, 39, 599–618. Chasin, C. D. (2011). Theoretical issues in the study of asexu­ ality. Archives of Sexual Behavior, 40, 713–723. doi:10. 1007/s10508-011-9757-x. Commission on Rehabilitation Counselor Certification. (2017). Code of professional ethics for rehabilitation counselors. Schaumburg, IL: Author. Cuthbert, K. (2017). You have to be normal to be abnormal: An empirically grounded exploration of the intersection of asexuality and disability. Sociology, 51 (2), 241–257. doi:10.1177/0038038515587639. Gupta, K. (2017). “And now I’m just different, but there’s nothing actually wrong with me”: Asexual marginaliza­ tion and resistance. Journal of Homosexuality, 64 (8), 991–1013. doi:10.1080/00918369.2016.1236590. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H. C., Loos, B., & . . . & Hammer, T. R. (2013). Associa­ tion for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally indi­ viduals. Journal of LGBT Issues in Counseling, 7, 2–43. doi:10.1080/15538605.2013.75544.

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Lund, E. M., & Johnson, B. A. (2014). Asexuality and disabil­ ity: Strange but compatible bedfellows. Sexuality and Disability, 33, 123–132. doi:10.1007/s11195-014-9378-0. Lund, E. M., Thomas, K. B., Sias, C. M., & Bradley, A. R. (2016). Examining concordant and discordant sexual and romantic attraction in American adults: Implications for counselors. Journal of LGBT Issues in Counseling, 10, 211–226. doi:10.1080/15538605.2016.1233840. Mayo Clinic. (2012). Low sex drive in women: Causes. https:// www.mayoclinic.com/health/low-sex-drive-in-women/ DS01043/DSECTION=causes. Pinto, S. A. (2014). ASEXUally: On being an ally to the asex­ ual community. Journal of LGBT Issues in Counseling, 8, 331–343. doi:10.1080/15538605.2014.960130. Prause, N., & Graham, C. A. (2007). Asexuality: Classification and characterization. Archives of Sexual Behavior, 36, 341–356. doi:10.1007/s10508-006-9142-3.

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Priebe, G., & Svedin, C. G. (2013). Operationalization of three dimensions of sexual orientation in a national survey of late adolescents. Journal of Sex Research, 50, 727–738. doi:10.1080/00224499.2012.713147. Regnerus, M. D. (2005). Talking about sex: Religion and patterns of parent-child communication about sex and contraception. Sociological Quarterly, 46 (1), 79–105. doi:10.1111/j.1533-8525.2005.00005.x. Sanger, N. (2009). New women, old messages? Constructions of femininities, race, and hypersexualised bodies in selected South African magazines, 2003–2006. Social Dynamics, 35 (1), 137–148. doi:10.1080/0253395080266 7301. Van Houdenhove, E., Gijs, L., T’Sjoen, G., & Enzlin, P. (2015). Asexuality: A multidimensional approach. Journal of Sex Research, 52, 669–678. doi:10.1080/00224499.2014.89801.

ASEXUALIT Y: AN INTRODUCTION What is asexuality? • Asexuality describes people who do not experience sexual attraction to others. • Asexuality is thought of as innate—that is, something someone has experienced their entire life. • Asexuality is a sexual orientation, similar to homosexuality, bisexuality, or heterosexuality. • Researchers estimate that about 1 percent of the population is asexual. Who can be asexual? • Anyone! Asexual people can be male, female, nonbinary, cisgender, and transgender. They can be of any race or ethnicity, from any religion or lack thereof, from any state or nation, and from any socioeconomic background or class. • Asexual people may be shy or outgoing. They may be athletic or not. They may have disabilities or not. They may want children or not. Asexual people are as varied and diverse as people of any other sexual orientation. • Asexual people may have sex for reasons unrelated to sexual attraction, such as curiosity or to please a partner. Asexual people may find sex to be physically pleasurable and may engage in masturbation without experiencing sexual attraction to specific people. • The one thing that all asexual people share is an innate lack of sexual attraction to others. What is asexuality NOT? • Asexuality is not a medical or psychological condition. Rather, it is an innate, lifelong sexual orientation. • Asexuality is not “a plant thing.” Asexual reproduction in biology has nothing to do with asexuality in people. • Asexuality is not a choice. Unlike celibacy—the deliberate choice not to have sex—asexuality is simply a description of someone’s sexual attractions. Asexual people may or may not be celibate. • Asexuality is not caused by being “ugly,” “undatable,” or “unlikable.” Asexual people vary in physical attractiveness just as people of other sexual orientations do. Many asexual people pursue roman­ tic relationships, and those who do not still pursue close, healthy platonic relationships with friends and family. • Asexuality is not a phase. Asexual people do not “grow out” of asexuality with time or experience. • Asexuality is not new. In fact, asexuality was documented in the Kinsey studies, some of the first large-scale scientific research on human sexuality. • Asexuality is not a lack of sexual experience. You cannot make asexual persons sexual by forcing or convincing them to have sex. Forcing someone to have sex without consent is rape, regardless of the person’s sexual orientation.

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Asexuality and romantic relationships • Some asexual people do not experience romantic attraction. This is called being aromantic. • Most asexual people report experiencing romantic attraction to other people. This means that they want to enter an emotionally intimate romantic relationship with another person—e.g., have a boyfriend or girlfriend. They may also develop romantic crushes on other people. • Asexual people may be attracted to the same sex, the opposite or other sex, or multiple or both sexes. Thus, they may identify as gay, straight, lesbian, pansexual, or bisexual in addition to being asexual. • Romantic orientation refers to genders or sexes of people to whom someone is romantically attracted. • Some asexual people may refer to themselves using words such as homoromantic (romanti­ cally attracted to people of the same gender) or biromantic (romantically attracted to people of the same and other genders) in order to distinguish romantic and sexual orientations. • Asexual people may date other asexual people or they may date sexual people. • Asexual people may or may not choose to have sex with their romantic partners. This decision should be discussed among romantic partners. • Some asexual people may be comfortable with open or polyamorous sexual or romantic relationships; others may not. Again, this should be discussed among partners. How do I learn more about asexuality? The following resources may be helpful: • Asexuality Visibility and Education Network (AVEN) provides information, news, and discussion forums related to asexuality (https://www.asexuality.org). • (A)Sexual, a 2011 documentary on asexuality and asexual people, can be found on YouTube and other video and movie services. • Asexuality Archive provides blog posts, terminology guides, and other resources related to asexuality (www.asexualityarchive.com/). • Asexuality: A Brief Introduction, a book published by the Asexuality Archive, includes information for those who think that they may be asexual. (A free PDF download is available at www.asexualityarchive.com under the “Book” tab.) Remember:

You are not broken.

You are not alone.

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43 INHABITING OUR BODIES: WORKING WITH GENDER DYSPHORIA IN TRANSGENDER AND GENDER-NONBINARY CHILDREN AND ADULTS THROUGH BODY MAPS Natasha Distiller Suggested Use: Activity Objective

The goal of this activity is to enable clients to experi­ ence a sense of possibility for the articulation of a gender identity outside of the normative binary options. Because trans*+ identifications1 can be out­ side the current language available to describe gen­ der positions, this activity makes use of a nonverbal modality—art —to enable clients to experience the process of self- creation. The activity can be used with individuals or groups, adults or children. Rationale for Use

Gendering is not a straightforward or natural or unmediated process (Butler, 1990, 2004), even if, for many cisgender people, knowing how they feel in their bodies is relatively straightforward. Cisgender people can conform to an acceptable enough degree to the social rules of gender in ways that match the bodies they were born in. Of course, this is a reduc­ tive statement. For one, feminist theory and psycho­ logical practice have explored for decades the diffi­ culties many women who were assigned female at birth have in trying to embody the fantasy of ideal

femininity (e.g., Dimen, 2003; Friedan, 2001; Goldner, 1991; Jordan, 1997; Levy, 2006; Wolf, 1991). For another, racial difference marks the body in powerful and invested ways (Fanon, 2008; Johnson & Hender­ son, 2005; Wise, 2011). And living in a raced and gen­ dered body helps shape an internal sense of self, of how and who to be. “Having” a body, and knowing the meaning of the body one has, is a process that is mediated by history and society, by context and dis­ course. This is true for everyone (Salamon, 2010). For trans*+ clients, however, there are additional difficulties. They often face violence and discrimina­ tion for transgressing the social rules of normative gen­ der (Grant, Mottet, & Tanis, 2011; James et al., 2016). Being unseen, unable to express themselves, or pun­ ished for doing so leads to many of the negative psy­ chological consequences that result from being trans*+ in a binary gender world (Langer, 2016). Family sup­ port is one of the most important resiliency factors for trans*+ people, as the Family Acceptance Project (San Francisco State University, n.d.) has clearly con­ cluded. When trans*+ children are supported, their reasons for being in therapy often resolve themselves (Ehrensaft, 2011). Understanding, asserting, and embodying one’s gender self is a process, however, and

1 Trans*+ here designates a collective noun for transgender, gender nonbinary, genderfluid, and genderqueer individuals, whatever form that gender takes. Like all umbrella terms, this term simplifies and erases the differences and complexities between and within identities. It is used in this chapter for the sake of brevity. The plus sign (+) indicates other gender identities not covered by the names provided here, in order to acknowledge them and to indicate that this activity is relevant to clients of other genders, too, as long as they would find helpful the experience of making their sense of self concrete in relation to their current gender identity. Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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often an ongoing, evolving, and sometimes painful one (Wilkinson, 2015). One of the results of having to pass through an internal and external process of acceptance might be gender dysphoria. In the DSM-V, gender dysphoria replaced gender identity disorder as the diagnosis that enables access to care for many trans*+ people. The change reflects something of a move away from the stigmatizing of a nonbinary gender identity (Bockting, 2009). The implicit pathologization of aspects of trans*+ experience that gender dsyphoria’s presence in the DSM bespeaks remains controversial, however, and it is under ongoing discussion in trans*+ communities and with the medical providers who serve them (Winters, 2008). Gender dysphoria is defined as “a marked incon­ gruence between one’s experienced/ expressed gen­ der and assigned gender” and “a strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)” (APA, 2013, p. 452). In its inclusion of the phrase in parentheses, the DSM-V diagnosis also recognizes nonbinary transgender iden­ tities (Richards et al., 2016). A genderqueer or an agender experience might entail an intolerable level of discomfort with one’s body and a desire to alter that body, without the desire to “be” the “other” gen­ der. Alternatively, no surgical or hormonal body mod­ ification may be desired (Kuper, Nussbaum, & Mus­ tanski, 2012). Part of the difficulty in resolving gender dysphoria can be that the gender toward which a cli­ ent is moving has not been quantified, which means that the client might not have an end point in mind (Ehrensaft, 2012). It is important to note that not all trans*+ people will experience gender dysphoria, that it is possible to have moments of dysphoria without its defining one’s experience, and that gender dysphoria can cause clinically significant distress and still be contextually triggered or occasional (Wilkinson, 2015). It is also important to note that gender dysphoria may be the result of internalizing transphobic projections and not caused by being trans*+ (Bockting, 2015). Because gender dysphoria is an embodied experi­ ence (APA, 2013), it can be useful to have modalities other than the verbal to help process it. In addition,

as I’ve suggested, the language available to therapist and client can be experienced as inadequate to artic­ ulate a place toward which to move (Butler, 1990; Ehrensaft, 2012; Langer, 2016; Salamon, 2010). The healing effects of creative work have been doc­ umented over the past twenty years (Heenan, 2006); recent neuropsychological evidence conclusively demonstrates that various forms of art therapy really do work to help heal mental illness and distress (van der Kolk, 2014). A targeted neuropsychological study released in the same year as van der Kolk’s impressive collation of the research to that point found that art therapy has measurable effects on resiliency in adults (Bolwerk et al., 2014). Art therapy as an intervention has been internationally documented to be effective in a wide range of client populations, from those with severe mental impairment like schizophrenia (Patter­ son et al., 2011) to PTSD sufferers (Nanda, Barbato Gaydos, Hathorn, & Watkins, 2010) and developmen­ tal trauma survivors (Greenwood, 2011; Waller, 1992), to patients with medical issues (Archibald, Scott, & Hartling, 2014; Geue et al., 2010), to clients with anxiety and depression (Aaron, Ringhart, & Ceballos, 2011; Drake, Coleman, & Winner, 2011; Sil­ ver, 2009), to name just some of the mental health cat­ egories documented in the literature. Recent studies have found both quantitative (Caddy, Crawford, & Page, 2012) and qualitative (Deaver & McAuliffe, 2009; Reynolds & Lim, 2007) evidence for the efficacy of art therapy. These include an art-based intervention that was helpful in managing gender identity issues and specifically in helping women work on establish­ ing healthy boundaries (Oster, Astrom, Lindh & Mag­ nusson, 2009), both outcomes highly pertinent to cli­ ents with gender dysphoria. Equally relevant outcomes were tracked in another study, which found improvements in self-esteem, sense of safety, and empowerment (Heenan, 2006). The activity presented here requires a commit­ ment to the gender-affirmative model, as outlined by Hidalgo and colleagues (2013). It assumes: (a) gender variations are not disorders; (b) gen­ der presentations are diverse and varied across cultures, therefore requiring our cultural sensi­ tivity; (c) to the best of our knowledge at present, gender involves an interweaving of biology, develWorking with Gender Dysphoria through Body Maps 385

opment and socialization, and culture and con­ text, with all three bearing on any individual’s gender self; (d) gender may be fluid, and is not binary, both at a particular time and if and when it changes within an individual across time; (e) if there is pathology, it more often stems from cul­ tural reactions (e.g., transphobia, homophobia, sexism) rather than from within the child [or adult]. (Hidalgo et al., 2013, p. 285) As the work of Diane Ehrensaft (2011, 2016) has shown, a gender-affirmative approach helps trans*+ clients because it shifts the emphasis from client pathology to understanding the effects of oppression as the source of mental health issues. It helps both therapists and clients see the effects of minority stress on whatever issues they might be grappling with. This is in keeping with the Standards of Care as outlined by the World Professional Association for Transgen­ der Health (WPATH) (Coleman et al., 2011). “The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maxi­ mize their overall health, psychological well-being, and self-fulfillment” (Coleman et al., 2011). In addition, the American Psychological Associ­ ation published its “Guidelines for Psychological Practice with Transgender and Gender Noncon­ forming People” (2015) to ensure “the provision of culturally-competent . . . and trans-affirmative psy­ chological practice” (p. 832). The activity described here conforms to these eth­ ical guidelines by taking as its starting point the knowl­ edge that gender identity–based distress is not evi­ dence of client pathology. Rather, it is caused by the limitations of the world in which clients find them­ selves. The artwork that client and therapist will make together in this activity seeks both to actualize and to celebrate a gender alternative identity on its own terms, whatever those might be. Instructions

The first instruction for this activity is for clinicians to think about their words, and the assumptions behind the way they speak about gender and gender 386 Distiller

identity. Therapists should be aware of the triggering potential of language for this population. Many trans*+ people have had their authentic experiences of selfhood denied, stigmatized, or pathologized, in part through society’s refusal to accept their right to self-identify (Namaste, 2000). Therefore, how we talk about and to our gender-nonconforming clients mat­ ters. It is important that the clinician is able to ask clients about the pronouns with which they identify and that clinicians can use these pronouns both in session and in talking about clients in supervisory or other professional settings. To prepare for and do the work outlined in this chapter, cisgender clinicians will need to be willing to respect the language their clients use to describe themselves. This can be some­ what anxiety-provoking for a cisgender clinician because the vocabulary regarding trans*+ identities is rapidly shifting and has also always been contested (Valentine, 2007). Different clients will prefer, or even be offended by, different terminologies. For example, older clients sometimes use the older term transsexual, which many younger trans*+ people find unaccept­ able. When in doubt, ask. Felt safety is a crucial part of this activity and necessary to facilitate its outcome. This work can happen only with a clinician who can tolerate the definitional uncertainties at the core of the client’s process, as described in this chapter. If the challenge for clients is to find a way to be themselves when the terms available to them do not reflect who they are, then the challenge for cisgender therapists is to be comfortable navigating this unstable terrain with them. A person’s gender does not have to stay the same, and it’s okay not knowing what someone’s gen­ der is. It is not a therapeutic goal of this activity to find a client’s one “correct” gender identity. Body mapping is an intervention developed by academics from the University of Cape Town in South Africa in their work with HIV-positive women (Sol­ omon, 2008). It allows for therapeutic self-explora­ tion, and it can also be useful for assessment and to mark therapeutic progress over time. It involves cli­ ents lying down on a life-size piece of paper and hav­ ing the outline of their body traced by another. Clients then make use of a range of art materials to fill in the outline of their body. They can also make marks on the space outside the outline.

You should have available, in addition to news­ print for rolling out and lying on, materials for draw­ ing, painting, and collage (if your office space allows). Glitter glue, scraps of material, and feathers also offer expressive possibilities. Crayons, markers, col­ ored pencils, charcoal, and pastels all offer different possibilities for expression. Scissors and glue will be necessary if you allow collaging. The creation of the body map can take place in one session or over multiple sessions. For example, this exercise could be run during school groups, span­ ning six to eight weekly sessions; or it could be used with individual adults in one session. Sometimes one session may be enough. At other times, clients may elect to continue in the following session. Adults may require more help than children with developing a nonjudgmental mind-set toward their work. It is useful to reiterate that the point of the activ­ ity is the process of creating the work, not the aesthetic value of the end result. This in itself can provide inter­ esting clinical material, as adult clients explore what this might mean for them. If necessary, begin by having your client doodle or paint spontaneous circles to break the creative ice. Or, for clients who are particularly reluctant or afraid to pick up brush or marker or crayon, collage is a good way to begin. An initial session can be devoted to going through magazines and cutting out images. This can also facilitate discussion. It is also fine to do this activity in relative silence. It can be a rapport-build­ ing activity with some children who have difficulty talking about their feelings, as the therapist can help identify and find the kinds of images they select. Ideally, the therapist is a quiet observer of the pro­ cess of creation, once the body mapping begins. Pay attention to all aspects of the client’s process, includ­ ing their affect when selecting and using materials, and which materials they use. The position in which they choose to put their body for tracing—the spe­ cific shape of the outline—is relevant, as is what they choose to put in the empty space around the body map. Do not discuss your observations with the cli­ ent until the work is complete, and then only if it is appropriate during discussion of the process of cre­ ation. The most important thing is to create an envi­ ronment in which the client feels safe to explore and

is not concerned about an evaluative gaze. This could mean that the process is never fully verbalized between client and therapist, in which case the therapist is the witness and holder of the process. Once the client indicates that the body map is complete (for now), therapist and client consider the work together. The therapist invites the client to reflect on what is seen, as well as on the process of creation. Therapists may subsequently comment on what they notice about the work and, if therapeutically indicated, on what they noticed about the client’s process. A rule of thumb—to be explained to the client as well— is to avoid aesthetic evaluation. It is useful to empha­ size this to the client at the start and to reiterate it, if necessary, as the work progresses. Many clients find this information liberating. It is important to have a safe, confidential space to store the body map if it will be used as part of the ongoing therapeutic process. Alternatively, it can be photographed for the chart to allow clients to take it home if they wish. Brief Vignette

Sam is a twenty-five-year-old individual who identi­ fies as transgender and nonbinary. They are white, queer identified, and from a working-class family. They were assigned female at birth, endured a child­ hood of feeling that something was terribly wrong, and began to socially transition to a masculine self at the age of sixteen. They came to therapy identifying as a transman but almost immediately began to explore whether a masculine identification was right for them. Shortly into the therapeutic process they changed their pronoun from “him” to “them” to indicate their gender indeterminacy. Sam is on hor­ mone therapy, has had top surgery, and presents as gender ambiguous. They most often wear gen­ der-neutral clothing such as shorts or jeans and T-shirts, but when they feel like it, they dress up in skirts and heels. They often wear makeup and paint their nails. They are relatively comfortable with their gender presentation at the moment, although the responses of others are often a cause of not insignifi­ cant anxiety. On bad days they are unable to leave the house, and public outings like taking the bus are always a cause of great distress for them. Working with Gender Dysphoria through Body Maps 387

Sam struggles with gender dysphoria even now that they feel their body corresponds to their gender identity. They describe a childhood during which embodiment was nothing short of an ordeal. It wasn’t just that being called on to perform normative female­ ness felt wrong to them; being touched by anyone, even casually, was horrifying in that it brought their attention to their body. These days the gender dys­ phoria manifests more as a sense of being haunted by a body they have left behind. They are also living with the burden of managing the gaze of others, which, on days when they are not feeling comfortable themselves, can be a significant anxiety trigger. The therapist suggested working on a body map to help Sam actualize their sense of who they are now. This suggestion was introduced to facilitate a concret­ ization of their identity, as well as a visual celebration of what they have achieved. Sam’s primary presenting issue is anxiety, and though they are very articulate about their feelings, they are not always able to make space to imagine alternatives to a lifetime of being trapped by the expectations of others. Because part of what Sam is going through is a normal developmen­ tal process of self-determination (a little later in their life cycle, as is not unusual for some trans*+ people), the therapist wanted both to explore who they are at the moment and to allow envisioning for who they might be becoming. The questions of how to define and own the masculine parts of their identity are ongoing issues in their therapy as well. Sam is creative and expressive, and used to some­ times using their body as a kind of canvas, but they were initially anxious at the idea of producing art­ work in therapy. They were concerned that if the end product did not look the way they wanted it to, they would feel a terrible sense of failure. Some prepara­ tory work was done to address this anxiety, and they linked their fears about the meaning of the therapist’s gaze on their body map to their fears about the mean­ ing of the gazes of others on their body in public spaces. This anxiety prevents them from occupying the body they have worked so hard to achieve and keeps them trapped in some ways in the body they wish to leave behind. How can Sam authorize themselves to inhabit the body they want now? How can they feel

388 Distiller

that the body they have means what it should to them­ selves, regardless of what others may think or see? Being touched by another, as noted earlier, is sometimes triggering for Sam, so care was taken with the process of mapping their body. Getting their body outlined took several sessions, and greatly deepened the therapeutic relationship. Sam was in charge of the process, and this experience—of being able to say when to start and stop—was helpful to them in imag­ ining that it is possible to set the terms of engagement for one’s bodily integrity. Sam spent two sessions actu­ ally filling in their body. They worked mostly with stick-on jewels, images from fashion magazines, and oil pastels. They did not want to use paint, feeling anxious at the rapid covering of space that paint allows and at the thought of any potential mess they might make if paint got spilled. The pastels allowed them to work with color that was easy to apply and blend, without having to deal with the messiness of paint. They chose to fill the space around their body map with a depiction of trees, imagining themselves alone in a forest where no one could see them and they felt free. We used this image to evoke a sense of safety and to construct an imagined safe space for recall when Sam began to feel anxious. The process of producing Sam’s body map was a long and sometimes difficult one. It triggered aspects of their dysphoria and their anxiety. When they were done, they expressed surprise at how satisfied they felt just to be done, to have succeeded in producing something after such a hard process—not unlike the actual process they have been through with their body. The therapist reflected on how they had produced an image of themselves that was only theirs, and on how they could choose when and if to show it to anyone. They liked this idea and took the body map home to share with their partner, promising to bring it back to therapy in a month to look at it again with the therapist. Suggestions for Follow-up

It can be instructive to return to a body map periodi­ cally and to discuss a client’s responses to the image and the memory of the process. Body maps can also be modified on an ongoing basis, or redone, as clini­ cally indicated.

Gender identity is not set in stone for anyone. For clients moving through the gender spectrum, who are not bound to the usual rules or, to use McKenzie’s (2010) metaphor, are outliers on the map of traversed gender expressions, this reality may be acute. One suggested follow-up to this activity is to use a series of body maps to help clients experience this point: that their gender identities can shift, and that each iteration is equally valid as its own point in the jour­ ney. If clients (and therapists) can experience gender identity as a process and not an end point, both can be freed up to allow the full development of a client’s gender-nonconforming sense of self. Contraindications for Use

Clients with a physical disability, who cannot lie on the floor or are otherwise limited in their mobility, might find this activity shaming or stigmatizing. Addi­ tional feelings involving embodiment may be trig­ gered for such clients, and only therapists with spe­ cialized knowledge of this population should broach any appropriate version of body mapping with a dis­ abled client. Some adult clients who struggle with shame, selfexpression, or self-esteem issues might need an estab­ lished therapeutic relationship in place before they feel safe enough to produce art in session. In these cases, the use of the body map early in the therapeutic relationship is contraindicated. Adults or children with unmetabolized sexual abuse or compound trauma might find this activity triggering. For clients with a highly fragmented sense of self, the prospect of visually representing the self may be too much to bear. This bears reiterating: be careful of materials cho­ sen, especially when working with children. Some art materials are more containing and structuring, and some are messier and elicit emotional responses from vulnerable clients. If necessary, limit the amount and type of art materials available. Some clients can be overwhelmed or triggered by a large variety of options, or by materials that encourage emotional flooding or lack of containment, as discussed above. Some individuals may find it difficult to have their bodies outlined by the therapist or by anyone else. If a client is currently experiencing acute gender dys­

phoria, it may be unbearable to be touched by another, or to see or feel their body being traced. When this is the case, ask clients to draw an outline of their body as they imagine it, or, if therapeutically appropriate, as they would like it to be. This can be a smaller version than the life-size body map, although it does not have to be. The client then works on the inside and out­ side of the body outline, as described above. The shape does not have to be human. A client might draw and decorate a butterfly, for example, or a totem animal. This takes the activity outside the realm of the body map per se, but it retains the function of allowing the client to imagine themselves in a different way of being, to think creatively about their body and sense of self. Professional Readings and Resources American Art Therapy Association. (2015). Art therapy out­ come bibliography. https://arttherapy.org/upload/out comebibliographyresearchcmte.pdf. Caddy, L., Crawford, F., & Page, A. (2012). “Painting a path to wellness”: Correlations between participating in a creative activity group and improved measured mental health outcome. Journal of Psychiatric and Mental Health Nursing, 19 (4), 327–333. doi:10.1111/j.1365-2850.2011.01785.x. Dimen, M. 2003. Sexuality, intimacy, power. London: Analytic Press. Gastaldo, D., Magalhães, L., Carrasco, C., & Davy, C. (2012). Body-map storytelling as research: Methodological con­ siderations for telling the stories of undocumented work­ ers through body mapping. www.migrationhealth.ca/ undocumented-workers-ontario/body-mapping. Malchiodi, C. A. (2007). The art therapy sourcebook. New York: McGraw-Hill. Oster, G. D., and Gould, P. (1987). Using drawings in assess­ ment and therapy: A guide for mental health professionals. New York: Brunner Mazel. Slayton, S. C., D’Archer, J., & Kaplan, F. (2010). Outcome stud­ ies on the efficacy of art therapy: A review of findings. Art Therapy: Journal of the American Art Therapy Associ­ ation, 27 (3), 108–118. https://arttherapy.org/upload/ outcomes.pdf. Wadeson, H. (1995). The dynamics of art psychotherapy. New York: John Wiley & Sons.

Resources for Clients Bornstein, K. (2013). My new gender workbook. New York: Routledge. (For adult clients.) Ehrensaft, D. (2011). Gender born, gender made: Raising healthy gender non-conforming children. New York: Experiment. (For parents.) Working with Gender Dysphoria through Body Maps 389

Ehrensaft, D. (2016). The gender creative child: Pathways for nurturing and supporting children who live outside gender boxes. New York: Experiment. (For parents.) Gender Spectrum. (n.d.). https://www.genderspectrum.org. (For teenagers and their parents.)

References Aaron, R. E., Ringhart, K. L., & Ceballos, N. A. (2011). Artsbased interventions to reduce anxiety levels among col­ lege students. Arts & Health, 3, 27–38. American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders, 5th edition. Washington, DC: American Psychiatric Publishing. American Psychological Association. (2015). Guidelines for psychological practice with transgender and gender non- conforming people. American Psychologist, 70 (9), 832–864. https://www.apa.org/practice/guidelines/trans gender.pdf. Archibald, M., Scott, S., & Hartling, L. (2014). Mapping the waters: A scoping review of the use of visual arts in pedi­ atric populations with health conditions. Arts & Health, 6 (1), 5–23. doi:10.1080/17533015.2012.759980. Bockting, W. O. (2009). Transforming the paradigm of transgender health: A field in transition. Sexual and Relation­ ship Theory, 24 (2), 103–107. Bockting, W. (2015). Internalized transphobia. In P. Whele­ han and A. Bolin (eds.), International encyclopedia of human sexuality. Malden, MA: Wiley-Blackwell. doi:10. 1002/9781118896877. Bolwerk, A., Mack-Andrick, J., Lang, F. R., Dörfler, A., & Maihöfner, C. (2014). How art changes your brain: Dif­ ferential effects of visual art production and cognitive art evaluation on functional brain connectivity. PLoS ONE, 9 (7). doi:10.1371/journal.pone.0101035. Butler, J. (1990). Gender trouble: Feminism and the subversion of identity. New York: Routledge. Butler, J. (2004). Undoing gender. New York: Routledge. Caddy, L., Crawford, F., & Page, A. (2012). “Painting a path to wellness”: Correlations between participating in a creative activity group and improved measured mental health outcome. Journal of Psychiatric and Mental Health Nursing, 19 (4), 327–333. doi:10.1111/j.1365-2850.2011.01785.x. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., . . . & Zucker, K. (2011). Stan­ dards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Interna­ tional Journal of Transgenderism, 13 (4), 165–232. doi:10 .1080/15532739.2011.700873. Deaver, S., & McAuliffe, G. (2009). Reflective visual journal­ ing during art therapy and counseling internships: A quali­ tative study. Reflective Practice, 10 (5), 615–632. doi:10. 1080/14623940903290687. Dimen, M. 2003. Sexuality, intimacy, power. London: Analytic Press. 390 Distiller

Drake, J. E., Coleman, K., & Winner, E. (2011). Short-term mood repair through art: Effects of medium and strategy. Art Therapy: Journal of the American Art Therapy Associ­ ation, 28 (1), 26–30. doi:10.1080/07421656.2011.557032. Ehrensaft, D. (2011). Gender born, gender made: Raising healthy gender non-conforming children. New York: Experiment. Ehrensaft, D. (2012). From gender identity disorder to gender identity creativity: True gender self child therapy. Journal of Homosexuality, 59 (3), 337–356. doi:10.1080/00918369 .2012.653303. Ehrensaft, D. (2016). The gender creative child: Pathways for nurturing and supporting children who live outside gender boxes. New York: Experiment. Fanon, F. (2008). Black skin, white masks. New York: Grove. Friedan, B. (2001 [1963]). The feminine mystique. New York: W. W. Norton. Geue, K., Goetze, H., Buttstaedt, M., Kleinert, E., Richter, D., & Singer, S. (2010). An overview of art therapy interven­ tions for cancer patients and the results of research. Com­ plementary Therapies in Medicine, 18, 160–170. doi:10. 1016/j.ctim.2010.04.001. Goldner, V. (1991). Towards a critical relational theory of gender. Psychoanalytical Dialogues, 1 (3), 249–272. Grant, J. M., Mottet, L. A., & Tanis, J. (2011). Injustice at every turn: A report of the national transgender discrimination survey. Washington, DC: National Center for Transgen­ der Equality and National Gay and Lesbian Taskforce. https:// transequality.org/sites/default/files/docs/ resources/NTDS_Report.pdf. Greenwood, H. (2011). Long-term individual art psychother­ apy. Art for art’s sake: The effect of early relational trauma. International Journal of Art Therapy, 16 (1), 41–51. doi: 10.1080/17454832.2011.570274. Heenan, D. (2006). Art as therapy: An effective way of pro­ moting positive mental health? Disability and Society, 21 (2), 179–191. doi:10.1080/09687590500498143. Hidalgo, M. A., Ehrensaft, D., Tishelman, A. C., Clark, L. F., Garofalo, R., Rosenthal, S. M., . . . & Olson J. (2013). The gender affirmative model: What we know and what we aim to learn. Human Development, 56, 285–290. doi:10. 1159/000355235. James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Ana, M. (2016). Executive summary of the report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality. www.USTrans Survey.org. Johnson, E. P., & Henderson, M. G. (eds.). (2005). Black queer studies: A critical anthology. Durham, NC: Duke Univer­ sity Press. Jordan, J. (ed.). (1997). Women’s growth in diversity. New York: Guilford Press. Kuper, L., Nussbaum, R., & Mustanski, B. (2012). Exploring the diversity of gender and sexual orientation identities

in an online sample of transgender individuals. Journal of Sex Research, 49, 244–254. doi:10.1080/00224499.2011 .596954. Langer, S. J. (2016). Trans bodies and the failure of mirrors. Studies in Gender and Sexuality, 17 (4), 306–316. doi:10.1 080/15240657.2016.1236553. Levy, A. (2006). Female chauvinist pigs: Women and the rise of raunch culture. New York: Free Press. McKenzie, S. (2010). Genders and sexualities in individuation: Theoretical and clinical explorations. Journal of Analyti­ cal Psychology, 55, 91–111. doi:10.1111/j.1468-5922.20 09.01826.x. Namaste, V. (2000). Invisible lives: The erasure of transsexual and transgendered people. Chicago: University of Chicago Press. Nanda, U., Barbato Gaydos, H. L., Hathorn, K., & Watkins, N. (2010). Art and posttraumatic stress: A review of the empirical literature on the therapeutic implications of art­ work for war veterans with posttraumatic stress disorder. Environment and Behavior, 42 (3), 376–390. Oster, I., Astrom, S., Lindh. J., & Magnusson, E. (2009). Women with breast cancer and gendered limits and boundaries: Art therapy as a “safe space” for enacting alternative sub­ ject positions. Arts in Psychotherapy, 36 (1), 29–38. doi:10.1016/j.aip.2008.10.001. Patterson, S., Debate, J., Anju, S., Waller, D., & Crawford, M. (2011). Provision and practice of art therapy for people with schizophrenia: Results of a national survey. Journal of Mental Health, 20 (4), 328–335. doi:10.3109/09638237. 2011.556163. Reynolds, F., & Lim, K. H. (2007). Contribution of visual artmaking to the subjective well-being of women living with cancer: A qualitative study. Arts in Psychotherapy, 34 (1), 1–10. doi:10.1016/j.aip.2006.09.005.

Richards, C., Bouman, W. P., Seal, L., Barker, M. J., Nieder, T. O., & T’Sjoen, G. (2016). Non-binary or genderqueer genders. International Review of Psychiatry, 28 (1), 95–102. doi:10.3109/09540261.2015.1106446. Salamon, G. (2010). Assuming a body: Transgender and rheto­ rics of materiality. New York: Columbia University Press. San Francisco State University. (n.d.) Family Acceptance Proj­ ect. https://familyproject.sfsu.edu. Silver, R. (2009). Identifying children and adolescents with depression: Review of the Stimulus Drawing Task and Draw a Story research. Art Therapy: Journal of the Amer­ ican Art Therapy Association, 26 (4), 174–180. doi:10.108 0/07421656.2009.10129619. Solomon, J. (2008). Living with X: A body mapping journey in the time of HIV and AIDS. Facilitator’s Guide. Johannes­ burg: REPSSI. Valentine, D. (2007). Imagining transgender: An ethnography of a category. Durham, NC: Duke University Press. Van der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New York: Penguin. Waller, C. S. (1992). Art therapy with adult female incest sur­ vivors. Art Therapy: Journal of the American Art Therapy Association, 9 (3), 135–138. Wilkinson, W. (2015) Born on the edge of race and gender: A voice for cultural competency. Oakland, CA: Hapa Papa Press. Winters, K. (2008). Gender madness in American psychiatry: Essays from the struggle for dignity. Dillon, CO: GID Reform Advocates. Wise, T. (2011). White like me: Reflection on race from a priv­ ileged son. Berkeley, CA: Soft Skull. Wolf, N. (1991). The beauty myth: How images of beauty are used against women. New York: HarperCollins.

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44

USING EXPRESSIVE ART THERAPY WITH LGBTQ YOUTH: A PICTURE IS WORTH A THOUSAND WORDS Jean Georgiou Suggested Use: Activity Objective

The objective of this activity (which is a combination of three art therapy exercises: self-portrait, family portrait, and collage) is to assist LGBTQ youth in exploring, conceptualizing, and/or visualizing their self-awareness as they begin their self-actualization and identity development. These exercises will help bring clients’ thoughts and feelings visually alive and aid in providing their inner voice with a microphone. As LGBTQ youth are assisted through these activities and begin to explore their inner feelings, many may begin what is known as their coming-out process. Rationale for Use

Many LGBTQ individuals, both adult and adolescent, “struggle with accepting their self-identity, which they perceive to contrast with society’s definition of what is healthy” (Sue & Sue, 2016, p. 663). This per­ sonal struggle for identity involves not only their own internal perceptions but also the external perceptions that others make regarding their sexual orientation (Sue & Sue, 2016). Various researchers (Chaney, Fil­ more, & Goodrich, 2011; Hatzenbuehler, 2011; Rosario, Schrimshaw, Hunter, & Braun, 2006; Ryan, Huebner, Diaz, & Sanchez, 2009; Sue & Sue, 2016) agree that many LGBTQ individuals describe simi­ lar feelings. Often these individuals share having felt not only different from their peers and those around them but that these feelings began during or existed from early childhood. While trying to deal with their personal struggles, LGBTQ youth who are question­

ing their sexual orientation may face a variety of additional stressors (Sue & Sue, 2016). Research sug­ gests that LGBTQ youth are also at a greater risk for experiencing harassment and various types of bullying at school than their heterosexual peers (Chaney et al., 2011; Hatzenbuehler, 2011; Kosciw et al., 2012; Meyer, Dietrich, & Schwartz, 2008). Research on LGBTQ youth indicates that, com­ pared to the general population, they are at a greater risk for an array of mental health issues. These include major depression, anxiety disorders, eating disorders, alcohol and/or drug dependency, low self-esteem, and a variety of additional stressors (Cochran et al., 2007; Fergusson, Horwood, & Beautrais, 1999; Kosciw et al., 2012; Meyer et al., 2008; Ryan et al., 2009). Some researchers have also shown that LGBTQ youth are at a greater risk of suicide as well (Eisenberg & Resnick, 2006; Fergusson et al., 1999; Hatzenbuehler, 2011; Russell & Joyner, 2001); and as Meyer and colleagues (2008) reported, this risk is higher, as are suicide attempts, among black and Latina/o LGBTQ youth. Sexual orientation and gender-identity develop­ ment are part of an ongoing process, and while often difficult for many, for ethnic minorities the process holds additional stressors. Adelson (2012) cautions clinicians as well as all in the helping professions “to be aware of gay and lesbian youth who may also be members of ethnic minorities as they may be less likely than nonminority youth to be involved in gay-related social activities, to be comfortable with others know­ ing they are gay, or to disclose a gay identity” (p. 966). In many communities it may still be dangerous for some to come out as gay, and often being from an eth-

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

392

nic minority can exacerbate the fears of homophobia, retaliation, rejection, and worse, which therefore con­ tributes to a choice of keeping their sexuality inter­ nalized (Adelson, 2012; Cochran et al., 2007; Ryan et al., 2009; Sue & Sue, 2016). Therefore, counselors have a professional responsibility to their clients to remain nondiscriminatory. This nondiscriminatory stance is grounded in a foundational belief that counselors are bound by very specific ethical codes that include not tolerating or participating in any discrimination (American Counseling Association [ACA], 2014). According to the ACA’s Code of Ethics, section C.5, Professional Responsibility, Nondiscrimination, ther­ apists must not discriminate on the basis of “age, cul­ ture, disability, ethnicity, race, religion/spirituality, gender, gender identity, sexual orientation, marital/ partnership status, language preference, socioeconomic status, immigration status, or any basis proscribed by law” (ACA, 2014, p. 9). When a specific population, such as LGBTQ youth, has been silenced for so long, it is understand­ able that a talk therapy approach may not always be the best modality to use for counseling. Although there are many therapeutic modalities to choose from when working with clients, many (American Art Therapy Association [AATA], 2013; Beaumont, 2012; Pelton-Sweet & Sherry, 2008; Talwar, 2010) suggest using the expressive arts while treating LGBTQ youth either alone or in combination with another theoretical model. Often when clients are struggling to put their thoughts or feelings into words, they are encouraged to express themselves through a different medium, such as art therapy (AATA, 2013; Addison, 2013; Malchiodi, 1998, 2007; Pelton-Sweet & Sherry, 2008; Wimmer, 2014). Art therapy has provided at-risk LGBTQ youth with additional therapeutic tools. According to Goldman (2015), “by clinicians nurtur­ ing and assisting with the expression of the imagina­ tion, adolescents may be able to protect their physical and emotional health while learning more about, and ultimately becoming, their authentic selves” (p. 214). Goldman (2015) discussed the findings that Fraser and Waldman (2003) presented after working with art therapy and LGBTQ youth who were challenged by sexuality, gender identity, homophobia, depression, coming out, and shame. “They clarified that for some

young people art creations allowed them to make visible the invisible, hidden and secret, to bear witness to pain, and to celebrate courage” (Goldman, 2015, p. 214). According to the AATA (2013), “art therapists use art media, and often the verbal processing of produced imagery, to help people resolve conflicts and prob­ lems, develop interpersonal skills, manage behavior, reduce stress, increase self-esteem and self-aware­ ness, and achieve insight” (para. 2). For some LGBTQ youth, art therapy exercises can be the beginning of their coming-out process and for others the begin­ ning of their healing process. These techniques are designed for individuals to explore and embrace them­ selves in a way that they’ve never imagined possible, through self-acceptance, self-actualization, and empowerment (Fraser & Waldman, 2003; Goldman, 2015; Pelton-Sweet & Sherry, 2008). For many LGBTQ youth, without the expressive arts, this exploration of sexuality is often silenced. “Through the creative arts clinicians can open a door to an ongoing and integral piece of their counseling process by offering a psychologically safe, nonjudgmental forum for expres­ sion” (Goldman, 2015, p. 228). The self-portrait offers both the client and the counselor a unique visual portal into the thoughts and feelings that clients may be experiencing about them­ selves. Often it invites the internal feelings to become external, as these feelings are frequently too delicate to verbalize (Addison, 2013; Goldman, 2015; PeltonSweet & Sherry, 2008). Research has shown clear signs that a negative family reaction to the LGBTQ youth’s sexual orientation, gender identity, and expres­ sion can be detrimental to the youth’s overall physi­ cal and mental health (Ryan et al., 2009). Drawing the family allows individuals to explore their perspec­ tive on their family and their place in it. Collaging, on the other hand, offers LGBTQ youth an extended way to explore their own world and how they fit in it, as well as “representations of self-in-community, with the use of words and phrases opening doors to discussion and discovery” (Pelton-Sweet & Sherry, 2008, p. 176). A collage also provides LGBTQ youth with a less intimidating place to be themselves (Gold­ man, 2015; Pelton-Sweet & Sherry, 2008). Finally, drawing what it feels like to be one’s self, sketching one’s Using Expressive Art Therapy with LGBTQ Youth 393

family as one perceives it, and constructing a collage to represent one’s worldview are all very powerful experiences. Perhaps, as the saying goes, “A picture is worth a thousand words.” Instructions

Materials for these exercises can be as simple or as elaborate as one chooses. It is important to offer clients several options in any exercise that involves drawing, as people have varying degrees of drawing abilities. Remember, however, that often too many choices can also present issues for clients. Crayons, colored pen­ cils, ballpoint pens (in a variety of colors), and a few old-fashioned lead pencils will often be sufficient. It is a good idea to have an eraser or two on hand. Eight­ and-a-half- by eleven-inch drawing paper fits neatly into the client’s folder. Have extra paper on hand, as clients often choose to start over or have extended or blended families, necessitating more than one piece of paper. If a client decides to start over, keep the first draft of the drawing (if possible) for process­ ing, as it may have important information in it. Material for the collage can be limitless. Many LGBTQ youth include photos, phrases, pictures, quotes, cutouts, drawings, poems, and any addi­ tional material that they deem important for expressing themselves. Paper for the collage can be cardboard, poster board, or even a photo album. The three exercises discussed are the self-portrait, family portrait, and collage. They are not meant to be completed all in one session or even in three consec­ utive sessions. Each of these exercises can produce a certain amount of information involving the LGBTQ youth’s feelings, thoughts, and experiences and will need to be processed. It is important to remember that like all clients, LGBTQ youth are at various levels of their growth process. Some individuals will be in the early stages of self-awareness and self-actualization, whereas others may be ready to begin their comingout process. It is important for the counselor to be present and available during the entire time the client is engaged in any and all art therapy techniques. Often clients will want to talk or process while they are drawing, and other times they may wish to draw in silence. During this time, pay particular attention to the cli­ 394 Georgiou

ent’s affect, nonverbal cues, desire to process or not to process, emotionality, lack of emotion, and any other thoughts or feelings they share while they are completing the exercise. Note that these art therapy exercises are to be com­ pleted during counseling sessions so that they can be processed by the counselor and client together. It is not advisable that these exercises be used as home­ work assignments, as the client may not process them completely, may misinterpret part or all of the exer­ cise, or may become fixated on a particular portion of any one of the drawings without the guidance of the counselor. Brief Vignette

Michael is fourteen years old. He self-identifies as a cisgender male and gay. He is the younger of two children born to an Italian Catholic upper-class fam­ ily. Michael’s father is an attorney, and his mother is a homemaker. Michael’s brother is a senior at the same high school that Michael attends. His brother is on the football team and hopes to one day join his father’s law firm. Michael is a sophomore, a B student, and a mem­ ber of the school choir. His attendance, however, has recently dropped. Michael states that he has a few close friends. He reports that he is not currently in a relationship but there is a young man to whom he is attracted. One of Michael’s friends reached out to the school counselor to report that Michael is currently being harassed. Michael asked to seek counseling out­ side school. He presented with symptoms of depres­ sion and reported having recently been the victim of harassment. His treatment includes a combination of cognitive behavioral therapy and art therapy. Self-Portrait Michael was straining to verbalize both his thoughts and his feelings. While he was able to share general information, anything beyond the surface that seemed to have meaning for him caused discomfort and even heightened his anxiety. When sharing his personal struggles, he seemed as though he was at a loss for words and yet needed and wanted to say something. It was then that Michael was asked if he was open to trying art therapy techniques, drawing

in particular, as a way of expressing himself. He was receptive to the idea. Michael was asked to draw a self-portrait. His only instructions were to draw a picture of himself, a selfportrait, “what it feels like to be you.” It took him about twenty minutes to draw this picture. At first he laughed at the prospect of drawing himself. He asked, “Can I make myself look any way I want?” Then all of a sudden, his face changed, as did the energy in the room. His smile disappeared. Michael turned the piece of paper sideways and drew a picture of a young man, about one to one and a half inches tall, looking up at a very large mountain. The mountain was steep and had zigzag switchbacks all the way up to the top. At one point, it seemed as though he had completed his drawing. He stretched out both his arms, holding his drawing between his hands, and then he quickly snatched the paper close to his chest. He shed a tear or two and started to color in various parts of the mountain. He said, “You do know that the mountain is my struggle, don’t you?” And as he cried, as the coun­ selor, I began to process his self-portrait with him. A major theme emerged. The mountain was iden­ tified as Michael’s struggle. The mountain was huge compared to the size Michael made himself in the drawing. Before making the drawing, Michael had had a difficult time expressing his thoughts and feelings. While processing the drawing and what it meant to him, hearing his own voice aloud and that of another human being (receiving validation for the first time), his emotional floodgate was opened. Family Portrait Michael was asked to draw a picture of his family. He immediately asked, “You mean my perception, right?” Michael proceeded to draw his father. He drew a tall stick figure wearing a tie. Next he drew his brother. The figure of his brother appeared to be trophylike. The stick figure looked part human and part trophy and had a football in one hand and a law degree in the other. Next he drew his mother. She had long brown hair and her head was facing upward as if looking at the sky. He also drew a cloud over her head. Last, he drew himself. He was a bit of a distance away from his family, maybe only two inches on the paper, but enough to make a statement. He was also a stick figure

and was wearing a T-shirt that said, “Be yourself.” He also had earbuds in his ears and musical notes com­ ing from his mouth. Just as I thought he was finished, he drew a square directly under each of his family members and a circle under himself. Then he drew a second square under each of the first squares. This time, however, instead of drawing a circle under his circle, he drew another square and said, “See, I’ll never fit into this family. I’m a circle being forced into a square.” From there I began to process Michael’s family portrait with him. Collage Michael was asked to make a collage that represented himself, his life, his support system, and anything else he wanted to add. He was given creative freedom for this project. Michael worked on his collage in the counseling office. It took him a few weeks to com­ plete. He went through magazines, the Internet, and books in search of pictures, single words, quotes, bursts of color, soothing photos, even sound. He included pictures of musicians, actors, actresses, stars of theater and Broadway, politicians, activists, friends, his brother, people he knew and those he didn’t. He wanted to represent lesbian, gay, bisexual, transgender, and ques­ tioning (LGBTQ) youth, and he then added an S on the end. Michael stated that he felt as though it was only fair that because he so badly wished to fit in and be accepted that straight people needed to be included, and so on his collage were the representation of les­ bian, gay, bisexual, transgender, questioning, and straight (LGBTQS) youth. Suggestions for Follow-up

Several follow-up sessions can be used for processing, depending on what is learned and interpreted from the drawings. These exercises are meant to give LGBTQ youth a platform for their voice. Follow-up questions are offered at the end of the chapter and can be used for each part of the activity. Contraindications for Use

There are no known contraindications for these art therapy techniques; however, if someone is uncom­ fortable or unwilling to draw or use art therapy, then it may be in the best interest of the client to find a Using Expressive Art Therapy with LGBTQ Youth 395

different modality. Also important to take into consid­ eration is that some individuals may find these tech­ niques anxiety provoking, as they may feel as though they are being asked to perform a task. If this is the case, try to work through the anxiety. If this is not pos­ sible, again, you may need to find another treatment modality. These exercises are meant to assist in selfexpression of feelings and thoughts and not to provoke or induce additional apprehension about the client’s recovery process. Professional Readings and Resources American Art Therapy Association (AATA). (2013). What is art therapy? https://arttherapy.org/upload/whatisartther apy.pdf. American Psychological Association. (2017). LGBT youth resources. https://www.apa.org/pi/lgbt/programs/safesupportive/lgbt/index. Darley, S. (2007). The expressive arts activity book. London: Jessica Kingsley. Dilawari, K., & Tripathi, N. (2014). Art therapy: A creative and expressive process. Indian Journal of Positive Psychology, 5 (1), 81–85. Makin, S. (2000). Therapeutic art directives and resources: Activ­ ities and initiatives for individuals and groups. London: Jessica Kingsley. Metzl, E. (2013). Artistic, therapeutic, and sexually informed: A five-week human sexuality course for art therapy stu­ dents. American Journal of Sexuality Education, 8 (4), 191–212. doi:10.1080/15546128.2013.836926. Milbrath, C., & Trautner, H. M. (2008). Children’s understand­ ing and production of pictures, drawing, and art: Theoreti­ cal and empirical approaches. Cambridge, MA: Hogrefe & Huber. Moon, B. (2016). Art based group therapy, 2nd edition. Spring­ field, IL: Charles C. Thomas. Oppenheim, D., Géricot, C., & Hartmann, O. (2002). Creative spirits. Lancet, 360 (9329), 345. Wimmer, M. (2013). Interpreting children’s drawings: Draw­ ings as windows into the inner world of children. http:// childrendrawingcenter.com/wp-content/uploads/2014/ 03/12-Must-Know-Facts-about-Childrens-Drawing-In terpretation.pdf.

Resources for Clients American Academy of Pediatrics. (2015). Gay, lesbian, and bisexual teens: Facts for teens and their parents. www. healthychildren.org/English/ages-stages/teen/dating-sex/ Pages/Gay-Lesbian-and-Bisexual-Teens-Facts-for-Teens­ and-Their-Parents.aspx.

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Dawson, J. (2015). This book is gay. Naperville, IL: Sourcebooks. GSA Network. (2009). Trans and queer youth uniting for racial and gender justice. www.gsanetwork.org. Huegel Madrone, K. (2018). LGBTQ: The survival guide for lesbian, gay, bisexual, transgender, and questioning teens, 3rd edition. Minneapolis: Free Spirit. Human Rights Campaign. (2019). Advocating for LGBTQ equality. www.hrc.org. It Gets Better Project. (2018). Welcome to the It Gets Better Project. www.itgetsbetter.org. Kuklin, S. (2015). Beyond magenta: Transgender teens speak out. Somerville, MA: Candlewick Press. Stopbullying.gov. (2017). Bullying of LBGT youth. www.stop bullying.gov/sites/default/files/2017-09/lgbtyouthtipsheet. pdf. Trevor Project. (2017). www.thetrevorproject.org.

Resources for Parents and Family Members Advocates for Youth. (2008). LGBTQ issues info for parents. http://www.paautism.org/resources/All-Resources/AllResources-Details/itemid/7273/Advocates-for-Youth­ LGBTQ-Issues-Info-for-Parents. Centers for Disease Control and Prevention. (2013, Novem­ ber). Parents’ influence on the health of lesbian, gay, and bisexual teens: What parents and families should know. https://www.cdc.gov/healthyyouth/protective/pdf/par ents_influence_lgb.pdf. Eriksen, T. (2017). Unconditional: A guide to loving and sup­ porting your LGBTQ child. Coral Gables, FL: Mango Publishing Group. Krieger, I. (2011). Helping your transgender teen. New Haven, CT: Genderwise Press. Owens-Reid, D., & Russo, K. (2014). This is a book for parents of gay kids: A question & answer guide to everyday life. San Francisco: Chronicle Books. PFLAG. (2017). Information for parents, families, friends, and allies of lesbians and gays. https://www.pflag.org. Tarney, J. (2016). My son wears heels: One mom’s journey from clueless to kickass. Madison: University of Wisconsin Press. Trevor Project. (2017). Education and resources for adults. www.thetrevorproject.org.

References Addison, D. (2013). Message of acceptance: “Gay-friendly” art therapy for homosexual clients. Art Therapy, 13 (1), 54–56. doi:10.1080/07421656.1996.10759193. Adelson, S. L. (2012). Practice parameter on gay, lesbian, or bisexual orientation, gender nonconformity, and gender discordance in children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 51, 957–974.

American Art Therapy Association (AATA). (2013). What is art therapy? https://arttherapy.org/upload/whatisartther apy.pdf. American Counseling Association (ACA). (2014). ACA code of ethics. https://www.counseling.org/Resources/aca-codeof-ethics.pdf. Beaumont, S. L. (2012). Art therapy for gender-variant indi­ viduals: A compassion-oriented approach. Canadian Art Therapy Association Journal, 25 (2), 1–6. Chaney, M. P., Filmore, J. M., & Goodrich, K. M. (2011). No more sitting on the sidelines. Counseling Today, 34, 37. Cochran, S. D., Mays, V. M., Alegria, M., Ortega, A. N., & Takeuchi, D. (2007). Mental health and substance use dis­ orders among Latino and Asian American lesbian, gay, and bisexual adults. Journal of Consulting and Clinical Psychology, 75 (5), 785–794. Coholic, D., Eys, M., & Lougheed, S. (2012). Investigating the effectiveness of an arts-based and mindfulness-based group program for the improvement of resilience in chil­ dren in need. Journal of Child and Family Studies, 21 (5), 833–844. doi.org/10.1007/s10826-011-9544-2. Di Gallo, A., & Kuehne, T. (2008). Ghost in the tree. Lancet, 372 (9649), 1570. Eisenberg, M. E., & Resnick, M. D. (2006). Suicidality among gay, lesbian, and bisexual youth: The role of protective factors. Journal of Adolescent Health, 39 (5), 662–668. Fergusson, D. M., Horwood, L. J., & Beautrais, A. L. (1999). Is sexual orientation related to mental health problems and suicidality in young people? Archives of General Psychia­ try, 56 (10), 876–880. Fraser, J., & Waldman, J. (2003). Singing with pleasure and shouting with anger: Working with gay and lesbian clients in art therapy. In S. Hogan (ed.), Gender issues in art therapy, 69–91. London: Jessica Kingsley. Goldman, L. (2015). Integrating expressive arts and researchsupported play-based interventions with LGBTQI ado­ lescents. In E. J. Green & A. C. Myrick (eds.), Play therapy with vulnerable populations: No child forgotten, 211–229. Lanham, MD: Rowman & Littlefield. Hatzenbuehler, M. L. (2011). The social environment and sui­ cide attempts in lesbian, gay, and bisexual youth. Pediat­ rics, 127 (5), 896–903. www.healthcareguild.com/ presentations_files/Hatzenbuehler - Social Environment for Suicide Attempts in LGBT Youth_1.pdf.

Kosciw, J. G., Greytak, E. A., Bartkiewicz, M. J., Boesen, M. J., & Palmer, N. A. (2012). The 2011 National School Climate Survey: The experiences of lesbian, gay, bisexual and transgender youth in our nation’s schools. New York: GLSEN. Malchiodi, C. A. (1998). Understanding children’s drawings. New York: Guilford Press. Malchiodi, C. A. (2007). The art therapy sourcebook. New York: McGraw-Hill. Meyer, I. H., Dietrich, J., & Schwartz, S. (2008). Lifetime prev­ alence of mental disorders and suicide attempts in diverse lesbian, gay, and bisexual populations. American Journal of Public Health, 98 (6), 1004–1006. Pelton-Sweet, L. M., & Sherry, A. (2008). Coming out through art: A review of art therapy with LGBT clients. Art Therapy, 25 (4), 170–176. doi:10.1080/07421656.2008.1012954. Rogers, E., Poulsen, N., & Hicks, J. (2016). Creative techniques using art. https://www.txca.org/images/Conference/ PGC14/Handouts/97.pdf. Rosario, M., Schrimshaw, E. W., Hunter, J., & Braun, L. (2006). Sexual identity development among gay, lesbian, and bisexual youths: Consistency and change over time. Jour­ nal of Sex Research, 43 (1), 46–58. doi:10.1080/002244 90609552298. Russell, S., & Joyner, K. (2001). Adolescent sexual orientation and suicide risk: Evidence from a national study. Ameri­ can Journal of Public Health, 91 (8), 1276–1281. Ryan, C., Huebner, D., Diaz, R. M., & Sanchez, J. (2009). Fam­ ily rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics, 123, 346–352. Sue, D. W., & Sue, D. (2016). Counseling the culturally diverse: Theory and practice, 7th edition. Hoboken, NJ: Wiley. Talburt, S. (2004). Constructions of LGBT youth: Opening up subject positions. Theory into Practice, 43 (2), 116–121. Talwar, S. (2010). An intersectional framework for race, class, gender, and sexuality in art therapy. Art Therapy, 27 (1), 11–17. Walkey-Thornburg, M. (2013). Multicultural and diversity issues in art therapy. www.prezi.com/iblr7pqalyby/ multicultural-and-diversity-issues-in-art-therapy/. Wimmer, M. (2014). The complete guide to children’s draw­ ings: A practical handbook to children’s emotional world. Middletown, DE: CreateSpace Independent Publishing Platform.

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FOLLOW-UP QUESTIONS Self-Portrait What did it feel like to draw yourself?

Please tell me a little bit about your drawing.

What did you learn from drawing your self-portrait?

What is the one thing you like most about yourself?

Is there something you would change about yourself if you could, and if so, what would it be?

If you could give yourself a message, what would you like to say to yourself?

Is there anything you would like to change about your drawing (add or delete), and if so, why?

Family Portrait What did it feel like to draw your family?

How do you see yourself in your family?

Can you share a little bit about each of your family members and your relationship with each of them?

What messages have you received from your family regarding sexual orientation and gender identity? About LGBTQ youth? (These can be broken down if needed.)

What messages have you received from your culture (including religion) regarding LGBTQ youth?

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Collage How did it feel to complete your collage?

Please tell me what your collage represents to you.

Can you please explain to me what this picture or these words represent to you? (It is important to process both the positive and negative in a collage).

Can you tell me who this person is and what they mean to you?

What is your favorite thing about your collage?

What is your least favorite thing?

What do you think your collage might look like in five years?

(Remember to start where the individual is and to be patient. Most LGBTQ youth are exploring their sexual orientation and gender identity and may be sharing things with you or processing things aloud for the first time. Follow the lead of the individual when it comes to terminology, validating appropriately and processing when needed.)

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45 AN EIGHT-WEEK IDENTITY EXPLORATION GROUP FOR TRANSGENDER AND GENDER-NONCONFORMING INDIVIDUALS Julie M. Mullany Suggested Use: Group activity This chapter presents an outline for conducting a semistructured, eight-week identity exploration group for transgender and gender-nonconforming (TGNC) individuals. Objective

The objective of this group is to provide participants a supportive, therapeutic space and creative format in which to explore and build greater compassion for, and understanding of, their own personal identities. It also serves to provide group leaders an outline to facilitate such a group, detailing specific weekly exer­ cises to include and offering sample questions for pro­ cessing each exercise. It is designed to enhance clarity for participants regarding the core question “Who am I?” A hope is that this group can be offered to TGNC folks as either an additional or an alternative mode of intervention to individual psychotherapy. There is also a brief vignette at the end of each weekly exercise. Rationale for Use

Positive individual and social change can occur through enhanced education, outreach, and access to resources for and about transgender and gender-non­ conforming issues (Baker, 2014). Education, outreach, and resources should be provided to the general pub­ lic, in schools, and through professional communities and organizations; all these efforts create supportive opportunities for TGNC individuals to reach their full potential (Baker, 2014; Gherovici, 2010; Pearce

& Hillabold, 2013). TGNC individuals often hold mul­ tiple intersecting identities that frequently remain invisible and marginalized in society, and so support­ ive spaces for such folks to explore their identities are critical (Robbins & McGowan, 2016). It is also the ethical and professional responsibility of health-care and mental health providers to create, with intention, such safe, enriching spaces, opportunities, and thera­ peutic interventions (Divan, Cortez, Smelyanskaya, & Keatley, 2016). This group is a mode of outreach that offers partic­ ipants opportunity to safely engage with creative exer­ cises, and then, among fellow group members, share their experiences of these exercises in a way that fosters greater clarity and understanding of their developing identities. Through guided processing of the activi­ ties (each created to help answer the question “Who am I?”), the group can help participants strengthen self-awareness. It can also offer supportive connection to others also navigating their own identities. As was true of the stages put forth decades ago in Cass’s, D’Augelli’s, and Troiden’s fundamental devel­ opmental models regarding identity formation as it relates to sexual orientation (Cass, 1979; D’Augelli, 1994; Troiden, 1989), there is often a similar acceptance or coming-out stage for TGNC folks. For example, coming out often does not occur (unless an individ­ ual’s identity is revealed, or outed, by another) with­ out a period of feeling confused or different, followed by modes of self-exploration, self-reflection, and, in essence, self-acceptance (i.e., coming out to oneself).

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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Today the developmental model, or stages of comingout conversations, in many ways has extended to gen­ der. National Geographic magazine devoted an entire issue to the gender revolution (“The Shifting Land­ scape of Gender,” 2017). In an article from this issue titled “Rethinking Gender,” Robin Marantz Henig points out that we are surrounded by “evolving notions about what it means to be a woman or a man and the meanings of transgender, cisgender, gender nonconforming, genderqueer, agender, or any of the more than 50 terms Facebook offers users for their profiles” (Henig, 2017, p. 51). Many discuss trans identity development in terms of a journey (Austin, 2016; Baker, 2014; Levitt & Ippolito, 2014; Robbins & McGowan, 2016). For those who will eventually identify as trans or gender non­ conforming, there is “an initial recognition of an exist­ ing, but unidentifiable difference toward awareness and acceptance of this TGNC identity” (Austin, 2016, p. 215). While awareness and understanding of TGNC identities are gradually evolving, models that explain the path to identity formation for TGNC folks are still scarce. On the basis of an analysis of data collected and interpreted through a constructivist groundedtheory method, Austin (2016) has contributed one of the more recent models. Austin identifies six themes associated with navigating a trans or gender-noncon­ forming identity: moving from uncertainty to know­ ing; recognizing self in others; finding me; explain­ ing work; struggling for authenticity; and evolving self-acceptance (Austin, 2016). Such processes under­ standably vary from individual to individual and are based on a number of factors. They include familial and peer supports; racial, cultural, ethnic, religious, or spiritual influence or stigma; nationality; age; resources (access to or restriction from); education; health care; economic status; and ability and/or safety concerns (Austin, 2016; Baker, 2014; Lev, 2004, 2007; Robbins & McGowan, 2016). Further research suggests that individuals often tend to feel more connected to, safer with, and vali­ dated by those who may be in similar developmental stages as themselves, particularly when interaction touches on some of their own identity questions or confusions (Divan et al., 2016; Lev, 2007). Providing space for individuals to find support and encourage­

ment to explore who they are, amid the intersection­ ality of their (often multiple marginalized) identities, without judgment or penalty, is undeniably linked to the healthy development of self-esteem, overall con­ fidence, self-compassion, and meaningful connec­ tion to others (dickey & Loewy, 2010; Robbins & McGowan, 2016). There is plenty of empirical evidence supporting the usefulness of group therapy in the exploration of identity (Corey & Corey, 2014; Goodrich & Luke, 2015; Yalom & Leszcz, 2005). That group therapy can be a supportive mode of intervention for trans-identi­ fying or transitioning individuals (and gender-non­ conforming individuals) who may be reexperiencing phases of identity development or trying to navigate an identity in flux is further explained by way of dickey and Loewy (2010) and Goodrich and Luke (2015). Given that this suggested group therapy mode is a clinical service intended to be provided to those seeking therapeutic support, facilitators must meet all the widely recognized competencies required when working with this marginalized population (APA, 2003, 2015; Coleman et al., 2011). Additionally, ethi­ cal guidelines must be followed in preparing, screen­ ing for, gaining consent, addressing confidentiality, and running and/or implementing this group (APA, 2010). Depending on where you practice, there may be additional guidelines to comply with, but most recognized worldwide regarding clinical work with transgender individuals is the World Professional Association for Transgender Health (WPATH) “Stan­ dards of Care,” version 7 (Coleman et al., 2011). In the United States, clinicians must also follow the gen­ eral ethical guidelines regarding clinical work and practice, as well as the specific guidelines for clinical work with TGNC folks and other marginalized pop­ ulations put forth by the American Psychological Association (APA, 2003, 2015). It is also recommended that clinicians meet competencies outlined by the American Counseling Association (ACA) ALGBTIC Transgender Committee (2010). The ALGBTIC guide­ lines state that they are supplemental to, or in addi­ tion to the WPATH’s Standards of Care, not a replace­ ment for them, but practitioners should be equally familiar with both sets of guidelines. All recommen­ dations and standards are easily accessible online. An Eight-Week Identity Exploration Group 401

Examples of some core competencies outlined by these governing bodies are a need to be aware of and sen­ sitive to the prevalence of issues of intersectionality with respect to gender and racial or ethnic identities, and understanding how stigma, prejudice, violence, and discrimination affect the well-being of TGNC peo­ ple (ALGBTIC, 2010; APA, 2015). The eight weekly, identity-focused exercises in this group activity are purposefully designed to encourage and provide space for members to explore these and other strug­ gles that so often are specific to this particular mar­ ginalized population. Authors of the most recent American Psycholog­ ical Association “Guidelines for Psychological Prac­ tice with Transgender and Gender Nonconforming People” (APA, 2015) noted a gap and need for greater attention to issues of intersectionality with respect to gender and other identities such as race, ethnicity, socioeconomic status, and ability status. Research is still limited regarding best practice in terms of address­ ing the effect on identity development for TGNC folks potentially navigating multiple marginalized identi­ ties, but the literature is gradually increasing (Baril, 2015; Budge, Thai, Tebbe, & Howard, 2016; Chang & Singh, 2016; Robbins & McGowan, 2016). It is criti­ cal that clinicians be aware that a common thread among the TGNC population is experiences of individ­ ual or institutionalized oppression, marginalization, stigmatization, bigotry, ridicule, exclusion, or violence in varying forms (Grant et al., 2011). Therefore, thera­ peutic interventions with this population must mind­ fully allow space for them to consider, explore, and process how such experiences may have informed or continue to inform their identity development, abil­ ity to connect, and evolving sense of worth. A hope is that this group’s exercises can encourage and allow that process.

eral personal identity–development group for any and all individuals grappling with the question “Who am I?” While such a group could, for some, feel less exclu­ sive, and probably would benefit a larger pool of poten­ tially interested participants, it may not allow all participants (particularly those with multiple margin­ alized and intersecting identities) to feel as safe or as vulnerable as they need to feel, or require them to explore as deeply and connect to who they are. To address this question, it may be worth offering both options to the group, perhaps assessing effectiveness, safety, and sense of inclusivity through anonymous surveys of participants afterward. For the purpose of this chapter, however, what fol­ lows are format and instructions for running an iden­ tity-exploration group specifically for TGNC folks. This is a semistructured group designed for ninetyminute weekly sessions that can go for six to eight con­ secutive weeks, depending on the number of activi­ ties chosen. Each week should focus on a specific (though flexible) group activity or involve the present­ ing and processing of a completed homework assign­ ment given the week before. During group, it is impor­ tant to use the homework or play exercises as a way to facilitate process within the group itself. A theme of the group activities is to help or encourage being authentic and playing with the rules—or being flexi­ ble. Additionally, the homework or out-of-group play exercises are designed not just to explore internally but also to share with others. These seem to be two different but equally important aspects of understand­ ing one’s identity. Ideally, keep group size small, at no more than six to eight participants; even with six participants, it can feel difficult to fit everything into an eight-week group, and a goal should be to ensure that all participants have equal time to share with the group their individual discoveries and experiences of each exercise or homework project.

Format and Instructions

One concern inherent in creating a separate therapy group specifically for trans-identified or gender-non­ conforming individuals is the risk of its having the unintentional effect of further marginalizing or other­ ing this population (Elkins & King, 2006; Gherovici, 2010). It raises the question “Should the group be open to anyone?” That is, should the group be a gen­ 402 Mullany

Specific Group Exercises per Week (Includes Weekly Vignette)

Week 1: Start the group with introductions from group facilitators and participants. Allow all members to share their names and preferred pronouns with the group, and perhaps a brief explanation of why they joined this group and what they are hoping to gain.

Allow them to express any fears or questions as well. This is also an opportunity for group facilitators to again explain the goals and general purpose of the group and speak to confidentiality and any other agreed-on group rules of operating or guidelines. Letter to self activity—Facilitators should provide paper, pens, and envelopes for each group participant. Have participants write a one-page letter to themselves during group. Ask participants to think about what they would like their future self to know. A prompt may be to ask them each to think about where they are currently in their life journey—literally, as well as emotionally or psychologically. Encourage them to consider their identity development thus far, what it has been like, and what, if anything, they would have liked their past self to know. Explain that this mental exercise is a means by which to ready or inspire them to consider what they would like to write to their future selves. Within group, process each member’s reactions to doing this exercise, their hopes, fears, and dreams. Once written, the letters should be inserted in the envelopes. Make sure participants put their names on the outside of their envelopes after they have sealed them. Leaders will collect sealed letters at the end of this group meeting and keep them in a secure place to later return to participants. Week 1 Vignette: Devon introduces himself to group as a twenty-year-old, African American trans male who prefers he/him pronouns. He notes that he iden­ tifies sexually as queer, adding that he has primarily been attracted to, and previously dated, female-iden­ tified partners. He says he joined the group because of feeling lost and, albeit pretty aware of the type of man he is, unsure of how to embrace him. In his letter to himself he writes about currently feeling torn, want­ ing to pass as male but also not wanting to embody overly macho or heteronormative male behaviors, as his father does, that can border on toxic masculinity. He shares his worry that he will not pass, particularly among his racial community, unless he inhabits such stereotypical male identifiers, yet at the same time, having been a target of misogyny at times from men in his past (when identifying as female), he wishes to cul­ tivate a strong feminist black male identity. He admits wishing he had had more and healthier male role mod­

els in his family and local community spaces, and he hopes to become a positive role model for others. Week 2: Free association/writing activity—Provide a blank sheet of paper and pen for each participant to free-associate thoughts on the starting point of “Here I am . . .” for at least forty-five minutes. Next, within group, process participant reactions to doing the exer­ cise: hopes, fears, and dreams. The purpose of the exercise is for participants to reflect on their current state of identity. While they are writing, ask them to consider how they currently feel and how they would define themselves right now, how they identify, how they got there—and get them to consider where they want to go, or how they want to continue to develop, change, or grow to embrace themselves with more com­ passion. Doing the writing exercise, and then talking about the experience of doing this exercise, will give them a starting point to engage in the upcoming week’s visualization. Week 2 Vignette: During the free-association writing exercise, Devon reflects in greater depth on his expe­ riences of having different marginalized intersecting identities, recalling especially incidents of gender, sexual, and racial marginalization, his earliest mod­ els of femininity and masculinity, his discomfort with many of these, and his fantasy of being a differ­ ent kind of man. He writes about black male femi­ nist heroes like the author Kevin Powell, the cultural critic Mark Anthony Neal, President Barack Obama, and the founder of Black Transmen, Inc., Carter Brown, all of whom are men he looks to and hopes to learn from in certain ways. Week 3: Guided imagery activity—Participants will be asked to think or fantasize about a future “ideal day.” Prompted by a guided meditation, they will consider where and whom they visualize themselves being, what they are doing, and with whom they are interact­ ing. The purpose is for them to continue the process of examining hopes, dreams, or even fears for them­ selves. Facilitators may use other, similarly themed guided visualizations if they have them, but one to rec­ ommend, which is online (the URL is included at the end of this chapter: Gerasimo, 2013), is the “Your Ideal Day” visualization. Created by the award-win­ ning health journalist and founding editor of ExpeAn Eight-Week Identity Exploration Group 403

rience Life magazine, Pilar Gerasimo, this visualiza­ tion runs about twenty-five minutes and comes with a thirteen-minute introduction and processing questions to consider at the end. Introduce and then play the guided visualization in group. Afterward, within the group, process the participants’ reactions to doing the exercise, including any hopes or fears that arose. See the end of this chapter for both the link to Gerasimo’s “Your Ideal Day” visualization and a printable listing of some of her suggested process­ ing questions for the group to discuss following the meditation. Week 3 Vignette: During the visualization, Devon pictures, then shares with the group, details of his envisioned future day, activities and spaces he hopes to engage in, the type of partner he dreams of shar­ ing a life with, and the career path he hopes (and juggles fears about) that his passion for gender equality and advocacy will follow. Week 4: Song activity—Have participants choose a song to bring in and play that has some meaning to them, and then share what and how it connects to aspects of who they are, or what they fear, hope, or dream. Encourage participants to access YouTube online (https://www.youtube.com/music) to find their song—this way they can pull it up during group on a facilitator’s laptop and play it aloud. Within group, process participant reactions to the exercise, and again discuss hopes, fears, and dreams. Participants may have music apps like Spotify or Pandora they can access on their cellphones. If so, it may help if group facilitators can bring in a portable speaker so that par­ ticipants can link their phones to play their chosen songs for the full group to hear. A Wi-Fi connection from cellphones or Internet access to download cho­ sen songs, and a portable speaker to play them on, will be required. Depending on the number of group participants, this activity may be extended into the following week. Divide the group time so that those presenting their songs this week have equal time to share. Some processing questions for the song activity could be to encourage participants to share how they first came across the song they chose; what the musi­ cians, lyrics, or music mean specifically to them; and what emotions, memories, or associations, if any, the song evokes for them, and why. 404 Mullany

Week 4 Vignette: Devon brings in Beyoncé’s song “Formation” to play from his phone. Explaining it is from her critically acclaimed 2016 album titled Lem­ onade, Devon shares what the song and lyrics mean to him, in terms of their embodiment of black female empowerment and resilience. He admits wanting to find a partner who balances confidence and vulnera­ bility like Beyoncé, and he shares his own challenges striving to embody both traits. Week 5: Autobiographical photography or collage proj­ ect—Recommend that participants take ten photos with their phones and upload their photos to a free photo-sharing site or email them to themselves, so that they each then have a way to go online during group to pull up the photos to show the group. The photos should be inspired by the question “Who am I?” To encourage creativity, do not provide further guide­ lines about what participants should photograph. For participants who do not have cellphones with cam­ era capability but who want to take photos, provide each with a disposable camera (and funds to pay for them to develop their photos). Again, ask them to take ten photos to bring in the next week. If any par­ ticipants are unable or uncomfortable taking photos, or if they are opposed to the exercise because of cul­ tural, religious, or other factors, offer them the option of creating a collage whereby they compile images or scenes from magazines that allow them to creatively explore the question “Who am I?” After introducing this project, continue process­ ing remaining songs from Week 4, again being mind­ ful to divide the group’s time to give equal time to those still needing to present. For Week 6 you will need Internet access to pull up photos, along with a projector and a wall or screen on which to project them. For those who make col­ lages, bring corkboard pins or tape to display them on a wall. Week 5 Vignette: Devon presented his song last week, so this week he focuses on listening to remaining group members’ songs and how they connect person­ ally to their chosen songs. He also shares some of his reactions. Week 6: Individual participants present their photo­ graphs or collages and process reactions to compiling

the images, their reactions to sharing and viewing the photographs or collages, and their experiences of tell­ ing the stories attached. Only half the group mem­ bers will probably get through presenting their proj­ ects. Divide the group time so that all who present this week have equal time to share. Some sample pro­ cessing questions to initiate discussions are: Do any specific themes stand out for you from the collection of images you compiled or gravitated toward? What do the images say about who you are and what your interests, passions, fears, hopes, or dreams may be? Is there anything that surprised you or that you dis­ covered about yourself, in a new way, while doing this activity? Week 6 Vignette: Devon accesses a Google album online and shares with the group the photos he has compiled. They are a mix of pictures: his father; him­ self as a young girl; Beyoncé; present-day, male-iden­ tified Devon; and other black people whom he respects and admires, including Barack Obama, the feminist trans scholar and filmmaker Kai M. Green, and the trans activist Janet Mock. A theme Devon notices across his collection is a quest to find healthy balance in his identity as a black man: finding middle ground between identifying as confident and vulnerable, pas­ sive and assertive, masculine and feminine, strong and sensitive, male and yet more multidimensional than his father. Week 7: Allow the remaining participants to present their photographs or collages and take time to pro­ cess their reactions to the activity and share within the group. Again, present processing questions simi­ lar to those asked last week for the group to consider, and allow all presenters an equal amount of time to present and process. Week 7 Vignette: Because Devon presented his pho­ tos the week before, this week he focuses on listening to remaining group members as they share their pho­ tos or collage projects and the meaning and themes they have attached to them. He also shares some of his reactions. Week 8: This final week will tie everything together. The letters that all the participants wrote to themselves during the first week will be returned, and roughly half the group meeting time should be allotted to pro­

cess reactions to rereading them, given what the group members may have discovered about themselves during the eight-week group. Has anything changed about how they view themselves now or not? Is there anything they would say differently to themselves upon completion of this group? Provide participants with a playlist of the songs everyone chose and shared (as a transitional object); also provide an opportu­ nity to process any final overall reactions to the group and things learned. Processing questions here should center on identifying themes about the identities that they discovered or gained further clarity about. Other important processing questions could explore whether they feel more connected to themselves, more pres­ ent, and more self-compassionate or empathetic to who they are, and whether the exercises and experi­ ence in group allowed them to gain more comfort sharing aspects of themselves with others. Allow time to process any obstacles or challenges they faced or aspects they would prefer to have done differently. Consider also using some of these questions for inclu­ sion in a post-group, anonymous evaluation by par­ ticipants if they were not discussed within the final group itself. Week 8 Vignette: Upon rereading his letter to him­ self, Devon shares the positive effect the group over­ all has had on him, and how it has validated his wish to be a different man from the one his own father modeled. He explains, too, how the validation, from other members, of his passion for feminist ideals and racial and gender balance and equality has enhanced his confidence in trusting that he can pass as the man he wants to be. Additionally, he admits learning, through the group process, that a key to this passing is passing to himself (i.e., simply learning to love and believe in the man he is and is continuing to evolve into). He thanks the group for the experience. Suggestions for Follow-up

Following completion of this group, plan to provide participants with additional resources for continued exploration, connection, and support of their devel­ oping identities. These resources could include refer­ ral information in the area to continue either group or individual therapy, as well as listings of local comAn Eight-Week Identity Exploration Group 405

munity resources, book titles, hotlines, services, and websites they can access to gain more information and additional support. See below for further informa­ tion and suggested links, titles, and other resources to hand out for follow-up.

Lev, A. I. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. New York: Haworth Press. National LGBT Health Education Center—A Program of the Fenway Institute. (n.d.). Transgender health. https:// www.lgbthealtheducation.org/topic/transgender-health/.

Contraindications for Use

Resources for Trans and Gender-Nonconforming Individuals

Depending on the identities or potential contextual factors of particular participants, some of the activi­ ties suggested here may be limiting. Those with dis­ abilities, such as a hearing or visual impairment, would need alternative creative activities to be suggested— for example, bringing in a particular dish of food (to share with the group) that may be culturally tied to the question “Who am I?” Additionally, there are some populations (including some Amish, Native Ameri­ can, and Australian Aboriginal cultures) opposed to photography for religious or spiritual reasons (Cohen, 2016; Lokke, 2012). In these cases, the collage proj­ ect, using magazine pictures, may be an alternative activity to suggest. Professional Readings and Resources ALGBTIC Transgender Committee. (2010). American Coun­ seling Association competencies for counseling with transgender clients. Journal of LGBT Issues in Counseling, 4 (3–4), 135–159. American Psychological Association (APA). (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. https://www.apa.org/practice/guidelines/trans gender.pdf. Chang, S. C., & Singh, A. A. (2016). Affirming psychological practice with transgender and gender nonconforming people of color. Psychology of Sexual Orientation and Gender Diversity, 3 (2), 140–147. doi:10.1037/ sgd0000153. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., . . . & Zucker, K. (2011). Stan­ dards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Interna­ tional Journal of Transgenderism, 13 (4), 165–232. http:// www.wpath.org/. dickey, l. m., & Loewy, M. I. (2010). Group work with transgender clients. Journal for Specialists in Group Work, 35, 236–245. doi:10.1080/01933922.2010.492904. Goodrich, K. M., & Luke, M. (2015). Group counseling with LGBTQI persons. Alexandria, VA: American Counseling Association.

406 Mullany

Books

Brill, S. A., & Kenney, L. (2016). The transgender teen: A handbook for parents and professionals supporting transgender and non-binary teens. Jersey City, NJ: Cleis Press. Brill, S. A., & Pepper, R. (2008). The transgender child: A handbook for families and professionals. San Francisco: Cleis Press. Ehrensaft, D. (2011). Gender born, gender made: Raising healthy gender-nonconforming children. New York: Experiment. Erickson-Schroth, L. (2014). Trans bodies, trans selves: A resource for the transgender community. New York: Oxford University Press. Film/TV

Gender revolution: A journey with Katie Couric. (2017). http:// channel.nationalgeographic.com/gender-revolution-a­ journey-with-katie-couric/. Hotlines

National Suicide Prevention Lifeline: 800-273-TALK (8255).

Trans Lifeline: 877-565-8860.

Trevor Lifeline: 866-488-7386, a 24/7 suicide prevention line.

Websites

Neutrois Nonsense. neutrois.com.

Trevor Project. https://www.thetrevorproject.org/.

U.S. Department of Education, Office of Civil Rights. Resources for LGBTQ students. https://www2.ed.gov/about/offices/ list/ocr/lgbt.html.

References ALGBTIC Transgender Committee. (2010). American Coun­ seling Association competencies for counseling with transgender clients. Journal of LGBT Issues in Counseling, 4 (3–4), 135–159. American Psychological Association (APA). (2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist, 58, 377–402. American Psychological Association (APA). (2010). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/principles.pdf. American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gen­ der non-conforming people. American Psychologist, 70

(9), 832–864. https://www.apa.org/practice/guidelines/ transgender.pdf. Austin, A. (2016). “There I am”: A grounded theory study of young adults navigating a transgender or gender non­ conforming identity within a context of oppression and invisibility. Sex Roles, 75, 215–230. doi:10.1007/s111 99-016-0600-7. Baker, G. V. (2014). Transgender adult perspectives on iden­ tity development and gender transition. PhD diss., Walden University. ProQuest Dissertations Publishing. Baril. A. (2015). Transness as debility: Rethinking intersections between trans and disabled embodiments. Feminist Review, 111, 59–74. Budge, S. L., Thai, J. L., Tebbe, E. A., & Howard, K. A. S. (2016). The intersection of race, sexual orientation, socioeco­ nomic status, trans identity, and mental health outcomes. Counseling Psychologist, 44 (7), 1025–1049. Cass, V. (1979). Homosexual identity formation: A theoretical model. Journal of Homosexuality, 4 (3), 219–235. Chang, S. C., & Singh, A. A. (2016). Affirming psychological practice with transgender and gender nonconforming people of color. Psychology of Sexual Orientation and Gen­ der Diversity, 3 (2), 140–147. doi:10.1037/sgd0000153. Cohen, E. M. (2016). Photographing people in other cultures: How to shoot with courtesy and respect. Outdoor Pho­ tography Guide. https://www.outdoorphotographyguide. com/article/photographing-people-in-other-cultures­ how-to-shoot-with-courtesy-and-respect/. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., . . . & Zucker, K. (2011). Stan­ dards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Interna­ tional Journal of Transgenderism, 13 (4), 165–232. http:// www.wpath.org/. Corey, M. S., & Corey, G. (2014). Groups: Process and practice, 9th edition. Belmont, CA: Brooks/Cole. D’Augelli, A. R. (1994). Identity development and sexual ori­ entation: Toward a model of lesbian, gay, and bisexual development. In E. J. Trickett, R. J. Watts, and D. Birman (eds.), Human diversity: Perspectives on people in context. San Francisco: Jossey-Bass. dickey, l. m., & Loewy, M. I. (2010). Group work with transgender clients. Journal for Specialists in Group Work, 35, 236–245. doi:10.1080/01933922.2010.492904. Divan, V., Cortez, C., Smelyanskaya, M., & Keatley, J. (2016). Transgender social inclusion and equality: A pivotal path to development. Journal of the International AIDS Society, 19 (3, Suppl. 2), 20803. doi:10.7448/IAS.19.3. 20803. Elkins, R., & King, D. (2006). The transgender phenomenon. London: Sage Publications.

Gerasimo, P. (2013). “Your ideal day” visualization. https:// www.pilargerasimo.leadpages.co/your-ideal-day-/. Gherovici, P. (2010). Please select your gender: From the inven­ tion of hysteria to the democratizing of transgenderism. New York: Routledge. Goodrich, K. M., & Luke, M. (2015). Group counseling with LGBTQI persons. Alexandria, VA: American Counseling Association. Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Kiesling, M. (2011). Injustice at every turn: A report on the national transgender discrimination survey. Washing­ ton, DC: National Center for Transgender Equality & National Gay and Lesbian Task Force. https://transequal ity.org/sites/default/files/docs/resources/NTDS_Report. pdf. Henig, R. M. (2017, January). Rethinking gender. National Geographic, 231 (1), 48–73. https://www.nationalgeo graphic.com/magazine/2017/01/. Lev, A. I. (2004). Transgender emergence: Therapeutic guide­ lines for working with gender-variant people and their families. New York: Haworth Press. Lev, A. I. (2007). Transgender communities: Developing iden­ tity through connection. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (eds.), Handbook of counseling and psy­ chotherapy with lesbian, gay, bisexual and transgender cli­ ents, 2nd edition, 147–174. Washington, DC: American Psychological Association. Levitt, H. M., & Ippolito, M. R. (2014). Being transgender: The experience of transgender identity development. Journal of Homosexuality, 61, 1727–1758. doi:10.1080/00918369. 2014.951262. Lokke, M. (2012, May 24). No photographing: Timm Rautert and the Amish. New Yorker. http://www.newyorker.com/ culture/photo-booth/no-photographing-timm-rautert­ and-the-amish. Pearce, W. D., & Hillabold, J. (eds.). (2013). Outspoken: Per­ spectives on queer identities. Regina, SK: University of Regina Press. Robbins, C. K., & McGowan, B. L. (2016). Intersectional per­ spectives on gender and gender identity development. New Directions for Student Services, 2016 (154), 71–83. doi:10.1002/ss.20176. The shifting landscape of gender: Gender revolution (special issue). (2017, January). National Geographic, 231 (1). https://www.nationalgeographic.com/magazine/2017/01/. Troiden, R. R. (1989). The formation of homosexual identities. Journal of Homosexuality, 17 (1–2), 43–73. Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy, 5th edition. New York: Basic Books.

An Eight-Week Identity Exploration Group 407

GUIDED VISUALIZATION/MEDITATION EXERCISE FOR WEEK 3 Some of Gerasimo's suggested questions for processing (after the visualization is complete): • What are some of the most vibrant scenes or striking images from your visualization—things you imagined—that surprised you?

• Are there any strongly held values that are missing or you do not see represented in some way? Are there ways you can imagine incorporating them?

• What skills or gifts are you using? Do you currently possess those strengths, or are they things you would like to develop?

• What did you notice about your physical environments? Were your home and workspaces different from those in real life? If so, how?

• What did you notice about your physical body? Was it different in feeling or appearance in any way? How was your energy or vitality different?

• In what way were you different in your attitude, personality, or self-expression? Did you seem to have more confidence or feel more at ease in some way?

• Were you conducting yourself differently or playing a different role in your relationships than you usually do?

• Consider how you interacted with others in your visualization. How much time did you spend together or alone?

Source: Pilar Gerasimo’s “Your Ideal Day” visualization (thirty-two minutes; includes questions). https:www.pilargerasimo.leadpages.co/your-ideal-day-/.

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Julie M. Mullany

46 USING MINDFULNESS TO ENHANCE IDENTITY INTEGRATION FOR LGBTQ CLIENTS Marilia S. Marien Suggested Uses: Homework, activity Objective

This activity is designed to help clients develop greater awareness of and comfort with aspects of their gen­ derqueer identity or sexual orientation by practicing mindfulness. Rationale for Use

Mindfulness-based interventions (MBIs) have been used to address several physical and psychological issues with positive results. Examples in mental health include dialectical behavior therapy for border­ line personality (Linehan, 1993), anxiety (Orsillo & Roemer, 2011), substance abuse (Witkiewitz, Marlatt, & Walker, 2005), and mindfulness-based cognitive therapy (MBCT) for depression (Segal, Williams, & Teasdale, 2013). From a mindfulness perspective, the mind can be conceptualized as having two modes: doing and being (Segal et al., 2013). Doing mode can help us achieve goals or solve problems, and it is characterized by focusing narrowly on our goals and holding thoughts and ideas in mind as we work. In doing mode, we dwell in the past or future in order to assess whether we are where we want to be or feeling how we want to feel. There is a need for things to be different from how they are, and we consider thoughts and ideas to be real (Teasdale, Williams, & Segal, 2014). When we are in doing mode, we are often on automatic pilot. That is, we act without strong awareness of what we are doing, often falling into habitual actions, thoughts, or feelings. Alternatively, in being mode, we are inten­ tional, which allows us to choose how to respond or

act. If we cultivate being mode, then when thoughts about the past or future arise, we can choose to focus on the here and now and choose to perceive them as part of the present experience, rather than be drawn into the habitual narrative (Teasdale et al., 2014). We can choose to maintain a stance of impartial obser­ vation, which helps us develop the ability to see our own thoughts as mental events, rather than seeing them as true and real. This ability decreases the power of thoughts to affect our mood or control our actions (Teasdale et al., 2014). Practicing mindfulness cultivates being mode. Segal and colleagues (2013) explain that training in mindfulness addresses two critical processes at the root of depression and other emotional problems: the tendency to overthink or worry too much about some things and the tendency to avoid or suppress other things. Training in mindfulness helps us develop the skill of approaching unpleasant feelings, physical sensations, and thoughts rather than reacting habitu­ ally or needing to avoid or get rid of them (Teasdale et al., 2014). An example of a habitual reaction is trying to avoid an unpleasant thought or feeling by sleeping or drinking alcohol. Mindfulness can be developed through engaging in formal practice, such as the body scan, sitting medi­ tation, and mindful yoga for extended periods (KabatZinn, 2013; Segal et al., 2013). In this chapter I discuss the body scan. The body scan gives clients an oppor­ tunity to practice the core mindfulness skills of dis­ engaging from old habits and noticing things they may not have noticed before or have forgotten (Segal et al., 2013). With LGBTQ clients, old habits of the mind might include self-loathing, negative thoughts

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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or feelings associated with certain parts of their bodies, or internalized negative messages about who they are as a person because of their gender or sexual ori­ entation identity (Murchison, Boyd, & Pachankis, 2017; Pachankis & Goldfried, 2004). The body scan cultivates the ability to deliberately pay attention in detail, which can transform clients’ experience of them­ selves by offering a new way to relate to the experience (Segal et al., 2013). This chapter will also discuss the three-minute breathing space. MBSR and MBCT emphasize apply­ ing mindfulness to daily life (Kabat-Zinn, 2013; Segal et al., 2013); in the MBCT program, the three-min­ ute breathing space is intended to help bridge the gap between longer, formal meditation practices (e.g., body scan or sitting meditation) and everyday life, where mindfulness skills are applied. It is a brief med­ itation that can help clients transform their experience in the moment and can be embedded in the routine of daily life (Segal et al., 2013). LGBTQ clients engage in therapy for many rea­ sons, including depression, anxiety, relationship issues, career issues, and phase-of-life issues (Benson, 2013; Pachankis & Goldfried, 2004). As they do with all clients, therapists working with LGBTQ clients should consider the presenting problems in the context of the client’s multiple identities, which can include sex­ ual orientation and gender identities (APA, 2012; Balsam et al., 2011). Considerations can include dis­ cussing where clients may be in terms of their sexual orientation and gender-identity development. For example, according to Singh and dickey (2017), transgender and gender-nonconforming individuals may engage in counseling regarding decision making about how they want to create a way of life that respects and incorporates their gender identity. It’s important to keep in mind that LGBTQ clients’ problems are not intrinsic to their sexual or gender orientation. Rather, a client’s presenting problems arise as the result of society’s negative reaction to their gender identity or sexual orientation (Meyer, 2003). Experiences of marginalization and oppression may make it hard for LGBTQ clients to want to stay present. They often experience discrimination and oppression related to their identities (Kite & Bryant-

Lees, 2016; Singh & dickey, 2017) and can be exposed to societal homophobic and heterosexist ideas (Pa­ chankis & Goldfried, 2004). These ideas and experi­ ences of oppression can become internalized, leading to thoughts and feelings that may affect a client’s com­ fort with one or more aspects of their gender or sex­ ual orientation identity (Meyer, 2003). Social oppres­ sion in many forms affects an individual’s health, which makes it important for therapists to also keep in mind that clients hold multiple identities, includ­ ing race, ethnicity, ability, and socioeconomic status. For example, experience of microaggressions can negatively affect mental health (Balsam et al., 2011). Multiply marginalized individuals such as LGBTQ people of color can experience stress related to their multiple minority identities. For example, they may be subjected to microaggressions that are the product of racism and heterosexism. Cultivating mindfulness may help LGBTQ clients become more aware of their habitual thoughts and feelings about themselves and their identities. For example, they may become more aware that they are struggling with accepting the parts of their identities that cause stress because of external pressures or inter­ nalized negative judgments (e.g., internalized homo­ phobia). Cultivating mindfulness may also help them become aware that their reactions to these thoughts or feelings have been transformed into persistent negative experiences that they then try to ignore, avoid, or minimize (Teasdale et al., 2014). Finally, cultivat­ ing mindfulness may help LGBTQ clients become more comfortable with identifying parts of their mul­ tiple identities, both privileged and marginalized, and help them choose not to habitually ignore or split off unwanted or uncomfortable parts of their identi­ ties. In this way, a therapist can help clients acknowl­ edge and integrate their complex identities, fostering a more integrated sense of self. Using a mindfulness-based framework in therapy with LGBTQ clients is consistent with ethical man­ dates that address mental health–related work with LGBTQ clients (ACA, 2014; APA, 2016; NASW, 2017). For example, it reflects an affirmative, strengthsbased approach by enhancing clients’ coping resources so that they can accept themselves as they are. In addi-

Using Mindfulness to Enhance Identity Integration 411

tion to universal ethical mandates such as those of the American Counseling Association (2014), Amer­ ican Psychological Association (2016), and the National Association of Social Workers (2017), there are spe­ cific guidelines for working with LGB clients (APA, 2012) and for practice with transgender and gendernonconforming people (ACA, 2010; APA, 2015). Clinical practice using a mindfulness perspective is consistent with several aspects of the general and specific ethical guidelines, including the guideline that “psychologists strive to recognize the challenges related to multiple and often conflicting norms, val­ ues, and beliefs faced by lesbian, gay, and bisexual members of racial and ethnic minority groups” (APA, 2012, p. 20).

did it last?” “Did you notice any thoughts or feelings associated with the pain?” It is fine to offer some guid­ ance regarding physical discomfort, but it is best if suggestions come out of the inquiry discussion. There are three inquiry questions, and they are asked in the following order:

Instructions

The three-minute breathing space and body scan are initially taught and practiced in session, and then the client practices them outside session. Start with teach­ ing the body scan so the client can develop a degree of experience with basic mindfulness practice and the skills of paying attention, from moment to moment, without judgment in a deeper way, before practicing the three-minute breathing space. According to Segal and colleagues (2013), the intentions for the body scan are “practicing deliberately engaging and disen­ gaging attention; noticing and relating differently to mental states and mind wandering: acknowledging and returning to what you had intended to be focusing on; using breath as a ‘vehicle’ to help direct and sus­ tain attentional focus; allowing things to be as they are; cultivating direct experiential knowing” (p. 150). In a therapy session, start mindfulness practice early enough to have sufficient time to at least briefly process the experience, explain how you would like the client to practice it this week, and answer any ques­ tions. To ensure that clients know what they are prac­ ticing, each activity should be completely guided during a therapy session before clients are encouraged to practice on their own at home. Therapists are urged to practice the body scan at least twice in session so that clients gain some experience with the timing of the script. The therapist can offer to record the guided meditation practice section of the session and should also give the client a copy of the guided meditation scripts used so that the client can practice at home.

The therapist should start by briefly explaining what mindfulness is and how it might help. Next, the ther­ apist can briefly explain the intention behind mind­ fulness-based activities and discuss how these activi­ ties relate to the work they are doing. It is important to include information about the tendency to be on automatic pilot and doing versus being mode. After practicing the body scan or three-minute breathing space in session, the therapist can process the experience by following the general outline of the formal practice of inquiry based in MBSR and MBCT (Segal et al., 2013; Woods, 2013). The spirit of inquiry asks that the therapist embody and reflect the mind­ fulness attitudes in the discussion following in-session practice or during the discussion of home practice. Through inquiry the therapist explores the connections the client is making that are related to developing a different relationship to experiences or sensations. For example, clients might report that while doing the body scan in session they felt physical discomfort and were unable to keep their attention on any part of their body for very long and ask the therapist what they should do about it. Here the therapist can embody the atti­ tudes of curiosity, nonjudging, and patience and avoid trying to quickly explain what they might do to become more comfortable. The therapist could ask questions about the physical discomfort, such as “When did you notice the physical pain?” “At what point in the body scan did you become aware of it?” “How long 412 Marien

1. What did you notice? What showed up? What are or were you aware of? 2. How might this be different from how you normally pay attention to your body? 3. How might this contribute to a sense of comfort with your sexual identity, gender identity, and so on? How might this help you with . . . ? (Here you can relate the question to what you are focusing on in therapy.)

Because the therapist will guide the client in both mindfulness-based activities, it is important that the clinician have experience with formal mindfulness practice and leading formal mindfulness practices. The resource section of this chapter includes links to train­ ing programs to gain this experience. There are some general principles to keep in mind while guiding cli­ ents: when reading a script aloud, make sure to read slowly and pause occasionally to give the client time to be fully present with any experience, and it is helpful to speak as naturally as possible. To help the client develop comfort and skill with mindfulness, the therapist should encourage practic­ ing the body scan for thirty minutes daily. Clients may find it helpful to discuss how they could make room in their lives for mindfulness practice. If they can more realistically practice three or four times a week, then that should be encouraged, with the explanation that the more they practice, the more they will culti­ vate their mindfulness skills. Also, practicing around the same time of day may help support developing a habit of formal mindfulness practice. After the client begins to practice the body scan, the therapist can begin to integrate the client’s experi­ ence and any increased self-awareness into the overall therapy work. One way to do this is for the therapist to encourage clients to practice paying attention to emotions or thoughts that arise, linger, and change from moment to moment in session, much as they are practicing that with the body scan. For example, if a client is working on getting past the fear that keeps her from telling her parents about her same-sex attraction, the therapist might ask questions about where in her body she feels the fear, to describe the sensation, and to notice how it might change from moment to moment as she is describing it. The thera­ pist can ask the client how this awareness and experi­ ence might relate to the fear that comes up when she thinks about talking with her parents. The therapist might then help the client explore ways she can apply this insight and skill of present-moment awareness to talking with her parents. Brief Vignette

Eduardo is a nineteen-year-old, cisgender, male-iden­ tified sophomore who attends a local university. He

identifies as half Ecuadorian and half Puerto Rican. He has been in a romantic relationship with a woman and states that it is going well. He is also aware of being sexually attracted to men and has told his girlfriend, who is supportive, but not anyone else. Eduardo said that he doesn’t think it’s wrong to be gay, but he is aware of some discomfort with the thought of poten­ tially being romantically involved with another man. He would like to be more comfortable with and less anxious about his same-sex attraction and to be more authentic and congruent about this identity when he is with others. Eduardo and the therapist explored and processed his experience of anxiety, where it came from, and his insight that he had been minimizing or ignoring his thoughts of being attracted to men. To attend more to Eduardo’s anxiety and tendency to avoid unwanted or anxiety-provoking thoughts, the therapist suggested incorporating mindfulness training into their sessions. The therapist explained what mindfulness was, how it might help, and how it could be incorporated into their sessions. Eduardo agreed, and in the next session the therapist guided Eduardo through the body scan for half an hour. Afterward, she asked what Eduardo noticed both during the practice and at that moment, as they were discussing his experience. The therapist encouraged Eduardo to practice the body scan at home, and they discussed when he could find time to do it and prob­ lem-solved any anticipated roadblocks to practicing, such as feeling tired, too busy, or that it was too much work. In the next session, the therapist introduced the three-minute breathing space practice. After this practice, Eduardo was encouraged to practice the half-hour body scan and three-minute breathing space outside session. To develop the habit and experience of cultivating mindfulness in session, the therapist and Eduardo agreed to start each session with the threeminute breathing space. As Eduardo became more familiar and comfort­ able with both mindfulness practices, the therapist then explained how he could apply the formal prac­ tices to the present moment by intentionally incorpo­ rating moment-to-moment awareness in session. For example, noting that he was feeling nervous while sharing a story in session, the therapist encouraged Eduardo to practice paying attention to emotions Using Mindfulness to Enhance Identity Integration 413

and thoughts as they arose while discussing his attrac­ tion to a man he met recently. The therapist invited Eduardo to see this as an opportunity to choose to practice observing the nervousness without trying to change it or make it go away, and without further engaging in any anxiety-producing thoughts. In this way, Eduardo had the opportunity to practice mind­ fulness and nonreactivity during a normally anxietyprovoking experience, and he was encouraged also to apply this mindfulness outside session. By integrating mindfulness into therapy through formal (body scan) and informal practice (e.g., apply­ ing mindfulness in session), Eduardo cultivated his ability to be less reactive to his thoughts and feelings. Through discussion with his therapist, Eduardo moved toward greater comfort with his attraction to men and beginning to share this part of his identity with others. Suggestions for Follow-up

The therapist should check in each week with clients regarding their practice at home. At first, it might be a longer discussion, ten to fifteen minutes, as clients may have more questions about the practice and may need more encouragement and support to keep prac­ ticing. Follow-up includes asking about what they are experiencing as they practice at home and helping clients make decisions about whether to continue if it is turning out that clients are not clinically ready because of, for example, trauma-related symptoms or their level of anxiety or depression. Contraindications for Use

Given the potential for higher rates of trauma for LGBTQ individuals (Mizock & Lewis, 2008; Singh & McKleroy, 2011; Smith, Cunningham, & Freyd, 2016), a therapist should assess for trauma and current level of functioning related to the trauma. The therapist and client can discuss whether symptoms such as dereal­ ization or disassociation are present, and to what degree these could get exacerbated by practicing mind­ fulness. Although mindfulness practice as taught in the MBSR and MBCT tradition is intended to help people remain grounded by deliberately placing their attention on the present moment, some clients might experience the practice as anxiety-producing or less grounding. Additionally, if a client’s experience of 414 Marien

depression or anxiety is making it too difficult to con­ centrate and do these practices, it can be prudent to wait for a time when the client is better able to do so. Professional Readings and Resources Didonna, F. (ed.). (2009). Clinical handbook of mindfulness. New York: Springer. Germer, C. K., Siegel, R. D., & Fulton, P. R. (2016). Mindfulness and psychotherapy. New York: Guilford Press. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford Press. University of California at San Diego. Center for Mindfulness. https://health.ucsd.edu/specialties/mindfulness/Pages/ default. aspx. University of Massachusetts Medical School. Center for Mind­ fulness in Medicine, Health Care, and Society. http:// www.umassmed.edu/cfm/.

Resources for Clients Gunuratana, B. H. (2011). Mindfulness in plain English. Somer­ ville, MA: Wisdom Publications. Kabat-Zinn, J. (1994). Wherever you go there you are. New York: Hyperion. Kabat-Zinn, J. (2013). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness, revised edition. New York: Bantam Books. Orsillo, S., & Roemer, E. (2011). The mindful way through anxiety. New York: Guilford Press. Williams, J. M. G., Teasdale, J. D., Segal, Z., & Kabat-Zinn, J. (2007). The mindful way through depression: Freeing your­ self from chronic unhappiness. New York: Guilford Press.

References American Counseling Association (ACA). (2010). American Counseling Association competencies for counseling with transgender clients. Journal of LGBT Issues in Counseling, 4 (3–4), 135–159. doi:10.1080/15538605.2010.524839. American Counseling Association(ACA). (2014). ACA code of ethics. https://www.counseling.org/Resources/aca-code­ of-ethics.pdf. American Psychological Association (APA). (2012). Guidelines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67 (1), 10–42. doi:10. 1037/a0024659. American Psychological Association (APA). (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. doi:10.1037/a0039906. American Psychological Association (APA). (2016). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/.

Baer, R. A. (2003). Mindfulness training as a clinical interven­ tion: A conceptual and empirical review. Clinical Psychol­ ogy: Science and Practice, 10 (2), 125–143. doi:10.1093/ clipsy.bpg015. Balsam, K. F., Molina, Y., Beadnell, B., Simoni, J., & Walters, K. (2011). Measuring multiple minority stress: The LGBT People of Color Microaggressions Scale. Cultural Diver­ sity and Ethnic Minority Psychology, 17 (2), 163–174. doi:10.1037/a0023244. Benson, K. E. (2013). Seeking support: Transgender client experiences with mental health services. Journal of Femi­ nist Family Therapy, 25 (1), 17–40. doi:10.1080/0895283 3.2013.755081. Kabat-Zinn, J. (2013). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness, revised edition. New York: Bantam Books. Kite, M. E., & Bryant-Lees, K. B. (2016). Historical and con­ temporary attitudes toward homosexuality. Teaching of Psychology, 43 (2), 164–170. doi:10.1177/00986283166 36297. Linehan, M. (1993). Cognitive-behavioral treatment of border­ line personality disorder. New York: Guilford Press. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129 (5), 674–697. doi:10.1037/0033-2909.129.5.674. Mizock, L., & Lewis, T. K. (2008). Trauma in transgender pop­ ulations: Risk, resilience, and clinical care. Journal of Emotional Abuse, 8 (3), 335–354. doi:10.1080/109267908 02262523. Murchison, G., Boyd, M., & Pachankis, J. E. (2017). Minority stress and the risk of unwanted sexual experiences in LGBQ undergraduates. Sex Roles, 77 (3–4), 221–238. doi:10.1007/s11199-016-0710-2. National Association of Social Workers (NASW). (2017). Code of ethics of the National Association of Social Workers. https://socialworkers.org/About/Ethics/Code-of-Ethics/ Code-of-Ethics-English.

Orsillo, S., & Roemer, E. (2011). The mindful way through anx­ iety. New York: Guilford Press. Pachankis, J. E., & Goldfried, M. R. (2004). Clinical issues in working with lesbian, gay, and bisexual clients. Psycho­ therapy: Theory, Research, Practice, Training, 41 (3), 227– 246. doi:10.1037/0033-3204.41.3.227. Sarno, E. L., Mohr, J. J., Jackson, S. D., & Fassinger, R. E. (2015). When identities collide: Conflicts in allegiances among LGB people of color. Cultural Diversity and Ethnic Minority Psychology, 21 (4), 550–559. doi:10.1037/cdp0000026. Segal, Z. V., Williams, J. M., & Teasdale, J. D. (2013). Mind­ fulness-based cognitive therapy for depression. New York: Guilford Press. Singh, A. A., & dickey, l. m. (2017). Affirmative counseling and psychological practice with transgender and gender non­ conforming clients. Washington, DC: American Psycho­ logical Association. Singh, A. A., & McKleroy, V. S. (2011). “Just getting out of bed is a revolutionary act”: The resilience of transgender peo­ ple of color who have survived traumatic life events. Trau­ matology, 17 (2), 34–44. doi:10.1177/1534765610369261. Smith, C. P., Cunningham, S. A., & Freyd, J. J. (2016). Sexual violence, institutional betrayal, and psychological out­ comes for LGB college students. Translational Issues in Psychological Science, 2 (4), 351–360. doi:10.1037/tps 0000094. Teasdale, J. D., Williams, J. M., & Segal, Z. V. (2014). The mind­ ful way workbook: An 8-week program to free yourself from depression and emotional distress. New York: Guilford Press. Witkiewitz, K., Marlatt, G. A., & Walker, D. (2005). Mindful­ ness-based relapse prevention for alcohol and substance use disorders. Journal of Cognitive Psychotherapy, 19 (3), 211–228. doi:10.1891/jcop.2005.19.3.211. Woods, S. (2013). Mindfulness-based stress reduction 5-day teacher training participant packet. Course packet.

Using Mindfulness to Enhance Identity Integration 415

GUIDED BODY SCAN

The body scan allows us to develop the ability to direct, sustain, and shift our attention while being present with the actual experience of our body. It is impor­ tant to find a quiet place where you can lie down or sit comfortably on a chair and where you won’t be interrupted. It is also important to try to stay awake throughout the practice. It is helpful to begin the body scan by setting the intention to be fully present and to bring a deep level of awareness of your body and your mind, as best you can. This includes giving yourself permission to adopt an attitude of nonjudg­ mental curiosity about whatever comes into your awareness and acknowledging and letting go of what­ ever thoughts, feelings, or sensations arise as you pay attention from moment to moment. Allow yourself to settle into a comfortable position lying on your back with your arms beside you, palms facing up if that is comfortable, or with your hands folded comfortably in your lap if you are in a chair. Decide now either to close your eyes or to keep your eyes open with a soft gaze. And now gather your attention and allow it to rest on your abdomen; you may become aware of its gently rising as you inhale (in-breath) and falling as you exhale (out-breath). Allow yourself to breathe normally, not trying to change how you are breathing. Just be with the breath and your body as it is now. Then gather your attention, along with the breath, and take your awareness from your abdomen, allowing it to travel down both legs, through both feet, and out to both sets of toes. On the next out-breath, release your attention into your toes and become aware of any sensations that may be present. You might notice sen­ sations of heat or cold, moisture or dryness, perhaps the sensation of the toes touching each other, or a sense of the toes themselves, including the nails and skin. You may not notice any sensations. And on the next out-breath, release your awareness from your toes and move your attention along with your breath into both feet. Bring a gentle, investigative curiosity to any sensations you might notice in this part of your body. Allow your awareness to rest on the soles of your feet and then to travel to the tops of both feet. Also be aware that your breath is with you in the background of your awareness. On the next out-breath, gently release the tops of both feet and, along with your breath, 416

place your attention on both heels. Here you might become aware of the contact your heels make with the floor, including sensations of pressure and touch. Just notice whatever is present for you right now. Then, on the next out-breath, release your attention from your heels and move your awareness, along with your breath, to both lower legs. Starting with the ankles, notice any sensations that might be present, sensing inside the joint as well as allowing your attention to notice the front, back, and sides of your ankles. Allow your body and your breath to be an anchor to the pres­ ent moment. Then become aware of any sensations in the area between your ankles and your knees. Remem­ ber that there is no right or wrong way to be present and aware. Notice whatever is arising as you sense the front of the lower leg, the sides, and calf muscles. Notice sensations on the skin or of the legs touching the floor. Through paying attention in this way, you may become aware of thoughts. Thinking is a natural part of how our minds work. When that happens, you can choose to acknowledge that thoughts have arisen and gently place your attention back on the part of the body you are focusing on. In this way, over time, you learn to become aware of and choose to let go of thoughts. Then, on the next out-breath, release awareness from the lower legs and place your attention on both knees. Sense both joints. Bring an investigative curi­ osity to what you might notice as you sense the front of the knees and around the sides of your knees, and the back of the knees. Allow yourself to be with the experience of whatever is arising from this part of your body. Then, let go of awareness of the knees and take your attention, along with your breath, to your thighs. Notice any sensations on the skin, perhaps feeling the touch of your clothes, lightness, heaviness, tingling, tension, whatever is arising. There is no right way or wrong way. Simply allow the experience just as it is without changing anything. And then, on the next out-breath, allow your awareness of your thighs to recede and choose to take your attention, along with a sense of your breath in the background, to the pelvis and lower abdomen. Perhaps feel where your buttocks rest on the bed or chair, the left side of your hip, the right side of your hip, and your genitals. Some­ times strong sensations arise from awareness of this

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area and if that happens to you, you can remember that you can always return to paying attention to your breath as a way to anchor yourself to the present moment. Then, with the next out-breath, release awareness of the pelvis and take your awareness, along with the breath, to your back. Here you might sense the natural arch of the lower back. Perhaps sense the muscles or any tension in your back. Sense the full length of your spine and your upper back. Perhaps notice a sense of pressure where the back rests on the bed or chair, a sense of comfort or pain, or no sensa­ tion at all. As best you can, allow yourself to be pres­ ent with whatever arises. Observe sensations and thoughts, and choose not to get caught up in them. On the next out-breath, release your awareness of your back and take your attention along with your breath to the abdomen. Notice the gentle rise and fall of your belly as you breathe in and breathe out. As best you can, rest with the breath and any sensations. As you continue with this body scan, you might become aware of thoughts or judgments about this experience or about different parts of your body. You might also notice feelings arise. They may be pleasant, neutral, or unpleasant thoughts or feelings as you make associations with different parts of your body. When these thoughts or feelings arise, you can choose to allow yourself to accept that this is your experi­ ence and then gently but firmly take your attention back to the part of the body you are focusing on as best you can. And then, with the next out-breath, let go of awareness of the abdomen and move your attention, along with your breath, to the entire torso, including the area of the chest. You may become aware of the movement of your ribs as you breathe in and out. Per­ haps notice the beating of your heart. Allow yourself to be present for all sensations or lack of sensations, as best you can. On the next out-breath, release your awareness of your torso and move your awareness, along with the breath, to both your arms, down the lengths of both arms to the hands and out to both sets of fingers. Allow yourself to become aware of the fingers, including the nails. Perhaps notice the sen­ sation of touch where they come in contact with each other, sensations of warmth or coolness, dryness or moisture, tingling, and whatever arises as you pay

attention to sensations from moment to moment. And with the next out-breath, choose to draw your awareness, along with your breath, up to your hands. Notice the palms and then the backs of the hands. Perhaps notice where the hand comes in contact with the bed or chair, the weight of the hand, and any other sensations. And then release your attention from the hands as you take your awareness along with your breath to the wrists. Sense the top, sides, back, and wrist joint. Notice whatever sensation or lack of sensation is there in each moment, without judgment. On the next out-breath, let go of the wrists and gently move your attention, along with your breath, up to the forearms and then into the elbows. Allow your awareness to notice sensations such as contact with the bed or chair, tenseness or relaxation, coolness, warmth, whatever is arising in your awareness. Do not try to avoid or prolong any sensation or lack of sensation. With the next out-breath, release awareness of the fore­ arms and elbows and take your awareness, along with your breath, to the upper arms. Allow yourself to bring a gentle investigative curiosity to whatever sen­ sations you notice from moment to moment. And then, with the next out-breath, release your attention from both upper arms and take your awareness along with your breath to both shoulders. Sense the back of the shoulders as they make contact with the bed or chair, including the sides of the shoulders and the front of the shoulders. Allow whatever arises to show up. And, if thoughts arise, remember that you can choose to notice them and then gently take your atten­ tion back to awareness of sensations in your shoul­ ders. On the next out-breath, let go of the shoulders and move your attention along with your breath to the throat and the neck. Perhaps notice any sensations such as swallowing, warmth, or coolness. On the next out-breath, release awareness of the throat and neck, and take your awareness and your breath to the head and face. Sense the chin, jaw, lips, mouth, tongue, teeth, cheeks, nose and nostrils, eyes, eyebrows, forehead, sides of the head, and ears. Allow yourself to be present from moment to moment as best you can. With the next out-breath, release awareness of the face, and move your attention along with your breath to the back of the head, then to the top of the head. Perhaps notice a sense of touch or weight where

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your head rests. On the next out-breath, let go of the head and move your attention along with your breath to a sense of your whole body. As best you can, place your awareness on your body as a whole, just as it is now, not needing to change or be anything other than how you are as a complete, whole being. And now, as you come to the end of this body scan, allow yourself to notice your breath wherever you notice it most vividly. Then allow your eyes to open if they have been closed, and move your body in whatever way feels comfortable. And when you are ready, come to a sitting position if you have been lying down. Allow awareness of this movement to be a part of your transition from this practice to the next activity in your day. The Three-Minute Breathing Space

Therapists can guide the client through the threeminute breathing space in session and then suggest that every day that week the client take a three-min­ ute breathing space three times a day at times chosen in advance. It is best to try to practice it at the same times each day. The client can use a recording of the breathing space once a day. The rest of the times, they can guide themselves from memory or by using the script provided by the therapist. The practice starts by inviting clients to choose to adopt an upright, digni­ fied posture, sitting or standing. They can close their eyes or adopt a soft gaze while casting their eyes slightly downward. Next, guide the client through the following steps, taking about one minute for each (Teasdale et al., 2014).

• What feelings are present? Acknowledge their pres­ ence, allowing yourself to turn toward any unpleas­ ant feelings or emotional discomfort. • What body sensations are present? Quickly scan your body to pick up any sensations of tightness or bracing. Acknowledge the sensations without trying to change them in any way. Step 2. Gathering

Then redirect your attention to focus on the physical sensations of breathing. Notice more closely becoming aware of the sense of the breath in the abdomen. Feel the sensations as the abdominal wall expands with the in-breath and falls back with the out-breath. Fol­ low the breath all the way in and all the way out, using the breathing to anchor yourself in the present. If you notice that your mind wanders away at any time, gently escort it back to the breath. Step 3. Expanding

Now expand the field of your awareness of your breath­ ing so that it embraces a sense of the body as a whole, including your posture and facial expression. Have a sense of your whole body breathing. If you become aware of any unpleasant sensations of discomfort, ten­ sion, or resistance, take your awareness there by breath­ ing into those sensations as you inhale. Then breathe out from those sensations, softening and opening with the out-breath. As best you can, bring your expanded awareness to the next moments of your day.

Step 1. Becoming Aware

Begin by bringing your awareness to your inner expe­ rience. Ask yourself: What is my experience right now? • What thoughts are going through my mind? Acknowledge thoughts as mental events, as best you can.

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47 MANAGING RELIGIOUS AND SEXUAL IDENTITY INTERSECTIONS Matt Zimmerman Suggested Uses: Activity, homework Objective

This chapter focuses on clients coping with the chal­ lenges of sexual and religious identity intersections that are often in conflict. The activity centers on explo­ ration and evaluation of faith-based values, beliefs, and practices, and how they interface with the client’s sexual identity. Homework assignments are intended to help clients differentiate values and beliefs that are authentic and meaningful to the individual from those that have been automatically and unconsciously inter­ nalized. The assignment also assists in identifying communities that will be most supportive of the cli­ ent’s resolved approach to the religious and sexual identity intersection. Rationale for Use

The integration of sexual and religious identities for many LGBT clients is a difficult struggle (Haldeman, 2004). The intersection of LGBT and religious iden­ tities represents a crucial dyad within a complex socio­ cultural context that includes gender, race, ethnicity, social class, ability status, and age (Fassinger & Arse­ neau, 2007), yet this particular intersection often causes marked suffering for clients (Ganzevoort, van der Lann, & Olsman, 2011). LGBT clients commonly endure psychological stress associated with religious conflict (Sherry, Adelman, Whilde, & Quick, 2010). Furthermore, minority-related stress such as that endured by sexual minorities includes structural or institutional discrimination and victimization, expec­ tations of victimization or prejudice, and internalized

homophobia (Meyer, 2003). More specifically, data indicate that a negative sense of self for LGBT young adults (aged fourteen to twenty-four) mediates both gay-related and religious stress as a predictor for wors­ ening mental health (Page, Lindahl, & Malik, 2013). A growing evidence base shows that a religious group’s attitude toward same-sex sexuality can be a protective factor, even compared to secular influence, if that group is affirming of minority sexual orientation sta­ tuses (Gattis, Woodford, & Han, 2014). Lytle, De Luca, Blosnich, and Brownson (2015) demonstrate such protective factors against suicidal ideation for LGBQ self-identified Christian and Jewish college students compared to agnostic or atheist LGBQ students. It becomes all the more important, then, for clients and counselors to identify authentic religious beliefs of LGBT clients, as well as communities that offer affirm­ ing attitudes toward individuals whose sexual orien­ tation is in the minority. The intersection of sexual and religious identities requires discussion of the multiple intersections that further interface to form a complex and dynamic mosaic for each individual. Fish and Pasley’s (2015) analysis, in which the relatively fluid developmental factor of sexual trajectories of first reported same-sex attraction and sexual-minority identities is addressed, indicates that although sexual-minority groups expe­ rience more depressive symptoms and suicidality than those who experience different-sex attraction and heterosexual identity, the magnitude differs over time. It was also found that LGB-identified individuals reported lower levels of alcohol use in adolescence and the highest in adulthood. Several recent studies show

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differences in a variety of health risks regarding the intersecting identities of race or ethnicity, sexual identity, identified gender, and age, including but not limited to cigarette smoking (Corliss et al., 2014), substance use problems (Mareish & Bradford, 2014), and bullying victimization (Mueller, James, Abrutyn, & Levin 2015). Ultimately, as Williams and Fredrick (2015) note in “One Size May Not Fit All: The Need for a More Inclusive and Intersectional Psychological Science on Stigma,” there is a need for psychological scientists to integrate inclusivity and intersectionality to improve the knowledge base and increase specificity of stud­ ies so that conclusions are less overgeneralized. For example, Lassiter’s qualitative study (2015) describes how several black same-gender-loving (SGL) men reconciled their Christian beliefs and sexual identity through a range of individualized strategies that reduced cognitive dissonance. Such strategies ranged from geographically distancing themselves from fam­ ily and home church to creating personal interpreta­ tions of biblical texts, to seeking and providing inter­ personal support for other black SGL people. Another key strategy employed included “reconciliation as a practice” (Lassiter, 2015, p. 348), whereby individuals sought SGL-affirming environments, churches, mes­ sages, and people. When addressing the intersectionality of sexual and religious identities, therapists should engage in affirmative practices aligned with the APA “Ethical Principles of Psychologists and Code of Conduct” (including principle A: Beneficence and Nonmalefi­ cence; principle E: Respect for People’s Rights and Dignity; and 3.01: Unfair Discrimination), as well as best practices and practice guidelines (APA, 2009, 2012, 2015, 2017). Affirmative practice includes a commitment to increased awareness of personal biases, behaviors, or language that is heteronormative and disenfranchising to sexual-minority clients (APA, 2012). It further requires open communica­ tion about the provider’s commitment to an affirming approach to therapy that supports positive therapeutic outcomes (Craig & Austin, 2016; Millar, Wang, & Pachankis, 2016). Finally, it is important for counsel­ ors working with clients who are struggling with this intersectionality to have an adequate basis of educa­

tion, training, and supervision regarding these identi­ ties (APA, 2017, 2.01: Boundaries of Competence). The activity below, collaboratively discussed by pro­ vider and client, serves as a tool to explore both sex­ ual and religious identity, as well as to model affir­ mative practice as complicated and emotional material is processed. Instructions

Counselors and psychotherapists can use the follow­ ing questions, in or outside a counseling session, with clients who have become contemplative about both their sexual and religious identities (see The Religious, Spiritual, and Sexual Identities Questionnaire [RSSIQ] in Page et al., 2013). The questionnaire is intended to assist clients in clarifying the degree of their reli­ gious and sexual orientation conflict. It is best to engage the client in several sessions before introduc­ ing a potentially charged area of exploration. Each client’s readiness needs to be carefully assessed in regard to how the intersection, as well as the fragmen­ tation, of these identities is affecting the client’s emo­ tional, social, physical, and academic or professional life. There may be identities that feel more salient to the client than those the therapist believes are having the most significant influence on the client’s life. As always, joining the client’s phenomenological experi­ ence as a primary approach is likely to open the nec­ essary space to address this particular intersection as therapy continues. It is also important to orient the client about the activity with the full rationale regarding the poten­ tial therapeutic benefit and how the task will be com­ pleted. A counselor may find it useful to go over the items with the client in session before having the cli­ ent rate them, along with the recommendation to reflect on each item outside session before completing the activity in session. It can also be helpful during this orientation period to ask the client if any items feel too uncomfortable to answer. Brief Vignette

James was a twenty-one-year-old, gay, cisgender, ablebodied, white male student completing his fourth and final undergraduate year at a midsize, highly com­ petitive rural university. He emailed this provider Managing Religious and Sexual Identity Intersections 421

requesting psychotherapy to address interpersonal and cultural challenges as a gay man in this university culture. James had undergone previous individual therapy for several months at this same counseling cen­ ter with a different provider, and he had attended the Gay, Bisexual, and Questioning Men’s Support Group on and off since his second year. At the time of his meeting with this provider, James was experiencing symptoms of mild depression that included urges to withdraw from relationships and organizations. James’ sexual-identity development was compli­ cated and conflicted. He had been raised in a family with a father and younger brother openly hostile to his sexual identity. He offered several examples of his father’s making antigay comments throughout James’s childhood and early adolescence, and his father contin­ ued these comments and direct name-calling of James after he came out in his junior year of high school. James described his younger brother as “following suit” and similarly engaging in derogatory treatment because of James’s sexual identity. He attributed this behavior, as well as occasional bullying experiences in high school, to his living in a rural community that was dominated by Christian values unaccepting of sexual minorities. James described himself as a non­ denominational Christian who was committed to his faith throughout his life. James was aware that unlike his home church, nondenominational churches affirm­ ing of sexual minority identities existed, but he had no experience attending such an institution. James expressed a hope of one day finding a Christian com­ munity that was affirming of his sexual identity. He noted that he did not attend church during college because he hadn’t found “the right fit.” He further reported that he left a Christian service organization during his third year, after experiencing criticism regarding his sexual identity that made him feel mar­ ginalized and unwelcome. In the first meeting with this provider, James told of experiencing invalidations from friends and peers, which resulted in feelings of alienation and anger, for which he wanted to find ways to cope more effectively. He also reported feeling emotionally wounded by the Christian service organization, which he experi­ enced as highly judgmental of his sexual identity. James often expressed a sense of injustice as anger, yet he 422 Zimmerman

came to allow the hurt and insecurities into his con­ sciousness as the therapy relationship strengthened. He further connected his feelings toward peers in his here-and-now life to long-standing feelings of fear, unfairness, and anger as a result of mistreatment from his family and community regarding his sexual ori­ entation. As James’s anger shifted and he lost a selfidentified “edge” that we realized was making it difficult for others to hear him, he was better able to express himself assertively and effectively. The simultaneous process of accessing deeper feelings and experiencing a return of empathy toward others helped James confront his father and brother (on separate and repeated occasions) about their hurt­ ful behavior. Surprisingly to both of us, James’s father dramatically shifted his language and treatment toward his son as a result, and James experienced a conse­ quent respect from his father for the first time in his life. His brother once again “followed suit,” and the two began a more supportive relationship. The intersectionality of James’s sexual and religious identities was affected by remaining internalized homophobia from family and church that James had initially thought was worked through, yet manifested itself at this developmental time as defensiveness and politically based argumentativeness with peers. He was comfortable with not being sexually active at this time, choosing to “hold out” for a longer-term rela­ tionship after graduating from college. This therapist and James explored his relationship to his sexuality and his faith, as well as his multiple identities as a white, rural-raised, male, cisgender, able-bodied indi­ vidual. In doing so, James found that his connected­ ness to his faith was strengthened, as he increasingly appreciated that an affirming church would allow him to practice his faith and connect with others who could further affirm this intersection. James chose to not return to any university Chris­ tian-affiliated organization for the remaining few months of his college career, believing that he would continue to experience a high level of judgment and preferring to focus on his newfound agency with his family and a few closer friends. The positive experi­ ences with family and friends, however, were a coun­ terpoint to his sense that the local Christian commu­ nities would be less responsive, and this led him to

seek his first postgraduation job in an urban setting in which his sexual and religious identities could both be affirmed. During a later session, James and this pro­ vider collaboratively searched for gay Christian com­ munities in one particular city of interest to him, which provided him with a hope that he had not yet experienced. James concluded his brief therapy having resolved his depressed mood, reduced his anxiety, and improved relationships with family and peers. Per­ haps most important, he gained a hope that he could find affirming communities at the next stage of his life. James also developed a deeper understanding of his own privilege associated with other identities, which further informed his long-standing interest in a public-policy career in health and economic equality. Suggestions for Follow-up

In supporting therapeutic change for individuals strug­ gling with sexual and religious identity intersectional­ ity, it is important to be present for both the tradi­ tional exploratory and skills-based aspects of therapy, as well as to identify religious institutions that can be affirming. Providers who collaboratively support cli­ ents, many of whom will have little to no experience with seeking out such resources, serve as models of affirming figures who will serve the client long after therapy comes to a close. In this regard, post-therapy contacts to offer additional resource ideas, as well as simply checking on the client’s ongoing journey, fur­ ther solidify the process of internal reconciliation of sexual and religious identities. Contraindications for Use

Contraindications for addressing this particular inter­ sectionality include clients struggling with severe symptomatology such as psychosis, drug or alcohol dependence, severe depression, mania, dissociation, or severe panic. It can also be countertherapeutic with clients who are likely to endure psychological decom­ pensation as a result of feeling overwhelmed by the task. Fully orienting and giving time between orienta­ tion and completion of the task may reduce the likeli­ hood of such a negative outcome. Finally, clients com­ ing from a moral objectivist perspective in which there is a rigidly held orthodoxy may experience the focus as unhelpful or unempathetic. The client may reveal these feelings while discussing how the activity felt.

Professional Readings and Resources American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67 (1), 10–42. doi:10.1037/a0024659. American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. doi:10.1037/a0039906. Bieschke, K. J., Perez, R. M., & DeBord, K. A. (eds). (2007). Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients, 2nd edition. Wash­ ington, DC: American Psychological Association. doi:10. 1037/11482-000. Boso, L. A. (2013). Urban bias, rural sexual minorities, and the courts. UCLA Law Review, 60 (3), 562–637. Omoto, A. M., & Kurtzman, H. S. (2005). Sexual orientation and mental health: Examining identity and development in lesbian, gay, and bisexual people. Washington, DC: American Psychological Association. Terepka, A. (2014). Sexual identity and religious ideals: Thera­ peutic considerations when working with contending areas of diversity. Washington, DC: American Psychological Association, Division 44.

Resources for Clients Gold, M. (ed.). (2008). Crisis: 40 stories revealing the personal, social, and religious pain and trauma of growing up gay in America. Austin, TX: Greenleaf. Hardin, K. N. (2008). Message of faith: Religious authorities. In Hardin, Loving ourselves: The gay and lesbian guide to self-esteem. Los Angeles: Alyson Books. Savin-Williams, R. C. (2006). The new gay teenager. Cambridge: Harvard University Press. White, M. (1994). Stranger at the gate: To be gay and Christian in America. New York: Simon & Schuster.

References American Psychological Association (APA). (2009). Report of the APA Task Force on Appropriate Therapeutic Responses to Sexual Orientation. https://www.apa.org/ pi/lgbt/resources/sexual-orientation.aspx. American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67 (1). doi:10. 1037/a0024659. American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. doi:10.1037/a0039906. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. http:// www.apa.org/ethics/code/index.aspx. Managing Religious and Sexual Identity Intersections 423

Corliss, H. L., Rosario, M., Birkett, M. A., Newcomb, M. E., Buchting, F. O., & Matthews, A. K. (2014). Sexual orien­ tation disparities in adolescent cigarette smoking: Inter­ sections with race/ethnicity, gender, and age. American Journal of Public Health, 104 (6), 1137–1147. doi:10.210 5/AJPH.2013.301819. Craig, S. L., & Austin, A. (2016). The AFFIRM open pilot feasi­ bility study: A brief affirmative cognitive behavioral coping skills group intervention for sexual and gender minority youth. Children and Youth Services Review, 64, 136–144. doi:10.1016/j.childyouth.2016.02.022. Fassinger, R. E., & Arseneau, J. R. (2007). “I’d rather get wet than be under that umbrella”: Differentiating the experiences and identities of lesbian, gay, bisexual, and transgender people. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (eds.), Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients, 2nd edi­ tion, 19–49. Washington, DC: American Psychological Association. doi:10.1037/11482-000. Fish, J. N., & Pasley, K. (2015). Sexual (minority) trajectories, mental health, and alcohol use: A longitudinal study of youth as they transition to adulthood. Journal of Youth and Adolescence, 44, 1508–1527. doi:10.1007/s10964­ 015-0280-6. Ganzevoort, R. R., van der Lann, M., & Olsman, E. (2011). Growing up gay and religious: Conflict, dialogue, and reli­ gious identity strategies. Mental Health, Religion & Cul­ ture, 14 (3), 209–222. doi:10.1080/13674670903452132. Gattis, M. N., Woodford, M. R., & Han, Y. (2014). Discrimi­ nation and depressive symptoms among sexual minority youth: Is gay-affirming religious affiliation a protective factor? Archives of Sexual Behavior, 43, 1589–1599. doi:10. 1007/s10508-014-0342-y. Haldeman, D. C. (2004). When sexual and religious orienta­ tion collide: Considerations in working with conflicted same-sex attracted male clients. Counseling Psychologist, 32, 691–715. doi:10.1177/0011000004267560. Lassiter, J. M. (2015). Reconciling sexual orientation and Chris­ tianity: Black same-gender loving men’s experiences. Mental Health, Religion & Culture, 18 (5), 342–353. doi: 10.1080/13674676.2015.1056121.

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Lytle, M. C., De Luca, S. M., Blosnich, J. R., & Brownson, C. (2015). Associations of racial/ethnic identities and reli­ gious affiliation with suicidal ideation among lesbian, gay, bisexual, and questioning individuals. Journal of Affective Disorders, 178 (1), 39–45. doi:10.1016/j.jad.2014.07.039. Mareish, E. H., & Bradford, J. B. (2014). Intersecting identities and substance use problems: Sexual orientation, gender, race, and lifetime substance use problems. Journal of Stud­ ies on Alcohol and Drugs, 75 (1), 179–188. doi:10.15288/ jsad.2014.75.179. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Concep­ tual issues and research evidence. Psychological Bulletin, 129, 674–697. doi:10.1037/0033-2909.129.5.674. Millar, B. M., Wang, K., & Pachankis, J. E. (2016). The moder­ ating role of internalized homonegativity on the efficacy of LGB-affirmative psychotherapy: Results from a ran­ domized controlled trial with young adult gay and bisex­ ual men. Journal of Consulting & Clinical Psychology, 84 (7), 565–570. doi.org/10.1037/ccp0000113. Mueller, A. S., James, W., Abrutyn, S., & Levin, M. L. (2015). Research and practice. Suicide ideation and bullying among U.S. adolescents: Examining the intersections of sexual orientation, gender, and race/ethnicity. American Journal of Public Health, 105 (5), 980–985. doi:10.2105/ AJPH.2014.302391. Page, M. J. L., Lindahl, K. M., & Malik, N. M. (2013). The role of religion and stress in sexual identity and mental health among LGBT youth. Journal of Research on Adolescence, 23 (4), 665–677. doi:10.1111/jora.12025. Russell, S. T., & Fish, J. N. (2016). Mental health in lesbian, gay, bisexual, and transgender (LGBT) youth. Annual Review of Clinical Psychology, 12, 465–487. doi:10.1146/annurev clinpsy-021815-093153. Sherry, A., Adelman, A., Whilde, M. R., & Quick, D. (2010). Competing selves: Negotiating the intersection of spiritual and sexual identities. Professional Psychology: Research and Practice, 41 (2), 112–119. doi:10.1037/a0017471. Williams, S. L., & Fredrick, E. G. (2015). One size may not fit all: The need for a more inclusive and intersectional psy­ chological science on stigma. Sex Roles, 73 (9–10), 384– 390. doi:10.1007/s11199-015-0491-z.

QUESTIONNAIRE

For each of the items below, circle the response that best characterizes how you feel about the statement, where 1 = Strongly Disagree, 2 = Disagree, 3 = Neither Agree nor Disagree, 4 = Agree, and 5 = Strongly Agree. After I came out to myself . . . Strongly Disagree

Disagree

Neither Agree nor Disagree

Agree

Strongly Agree

I felt accepted or supported by my religion.

1

2

3

4

5

I felt rejected or betrayed by my religion.

1

2

3

4

5

I felt conflicted between my spiritual beliefs and my sexuality.

1

2

3

4

5

I had doubts about my religion.

1

2

3

4

5

I had doubts about my spiritual beliefs.

1

2

3

4

5

Strongly Disagree

Disagree

Neither Agree Nor Disagree

Agree

Strongly Agree

I used my religious activities to comfort and reassure myself.

1

2

3

4

5

I used my religion to understand and make sense of my sexuality.

1

2

3

4

5

I used my private spiritual practices to comfort and reassure myself.

1

2

3

4

5

I used my private spiritual practices to understand and make sense of my sexuality.

1

2

3

4

5

I used my spiritual beliefs to comfort and reassure myself.

1

2

3

4

5

I used my spiritual belefs to understand and make sense of my sexuality.

1

2

3

4

5

While I was coming out to myself . . .

Matt Zimmerman

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48

ROSE AS A NAME IS SO MUCH SWEETER: NAVIGATING THE NAME-CHANGE PROCESS WITH TRANSGENDER AND GENDER-NONBINARY CLIENTS Cadyn Cathers Suggested Uses: Activity, handout Objective

The goal of these activities is to help transgender and gender-nonbinary (TGNB) clients navigate the namechange process. The activities in this chapter will help therapists assist clients with the therapeutic process involving selecting a name, disclosing the name, and using assertiveness and communication skills for deal­ ing with transphobic microaggressions. Rationale for Use

Fewer than 30 percent of psychologists are familiar with the needs of transgender and gender-nonbinary clients (American Psychological Association Task Force on Gender Identity and Gender Variance, 2009), and yet 75 percent of TGNB people seek mental health services (Grant et al., 2011). Competent therapists can be integral in helping clients through the transi­ tion processes (Lev, 2004; Singh & dickey, 2017). Tran­ sition may involve social, medical, or legal compo­ nents (Fein, Salgado, Alvarez, & Estes, 2017; Teich, 2012). Social transition may include picking a new name and using it socially, coming out, asking others to use congruent gender pronouns and language, or changing gender expression or role. Legal transition involves changing one’s name through a court order or the department of motor vehicles, a passport, a Social Security card, or a birth certificate. Medical tran­ sition may include hormones, nonmedical proce­ dures, or surgeries to alter the body to match one’s gen­

der identity. Changing one’s name is one of the most important components in feeling comfortable in one’s identified gender (Fein et al., 2017). Social gender affirmation can minimize the negative effects of societal transphobia (Glynn et al., 2016). Affirmation includes respecting and support­ ing authentic expression of gender and affirming identity for TGNB people (American Psychological Association [APA], 2015). Guideline 11 set forth by the APA for psychological practice with transgender or gender-nonconforming (TGNC) clients states, “Psychologists recognize that TGNC people are more likely to experience positive life outcomes when they receive social support or trans-affirma­ tive care” (APA, 2009, p. 846). Affirmative practices with transgender and gender- nonbinary people emphasize the importance of using proper names and pronouns (Singh & dickey, 2017). Some clients may use masculine (he/him/his), feminine (she/her/ hers), or gender-neutral (ze/zim/zir, they/them/ theirs, or another variation) pronouns. Asking the client about his/her/zir/their pronouns and name for use in clinical documentation and in session is central to affirmative practice with TGNB clients (Singh & dickey, 2017). TGNB clients may feel intense distress when others misgender them or use the name that was assigned at birth (Nadal et al., 2014). Some clients will even use the term deadname as either a noun (the name assigned at birth) or as a verb (the act of calling someone by the name assigned at birth; Yin, 2016).

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Transgender and gender-nonbinary people face discrimination, prejudice, and transphobic violence; the highest rates are experienced by transgender women of color (Grant et al., 2011). Guideline 5 of the APA’s “Guidelines for Psychological Practice with Transgender and Gender Nonconforming People” (2015) states, “Psychologists recognize how stigma, prejudice, discrimination, and violence affect the health and well-being of TGNC people” (p. 838). Microaggressions are overt or covert invalidations of identity (Galupo, Henise, & Davis, 2014). Recurring exposures to transphobic microaggressions can be a traumatic stressor (Espin & Gawelek, 1992). Re­ peated misgendering is a type of microaggression for TGNB clients (Nadal et al., 2014). Transgender people may react to transphobic microaggressions emotionally, behaviorally, or cogni­ tively (Nadal et al., 2014). Emotional reactions include anger, sense of betrayal, distress, hopeless­ ness, exhaustion, feelings of being invalidated and misunderstood. Cognitive reactions include rational­ ization, feelings of being in a double-bind, vigilance, self-preservation, resilience, and empowerment. Behavioral reactions include direct confrontation, indi­ rect confrontation, and passive coping. Assertiveness of one’s gender identity is an example of direct con­ frontation. One of the goals in therapy is to assist clients in developing productive coping strategies and skills. For TGNB clients, therapy may include helping them navigate transphobic microaggressions effectively. Assertiveness is the confident and respectful com­ munication of needs, values, and preferences while respecting the needs of others (Sims, 2017). Individ­ uals expressing their rights, thoughts, and feelings in a manner that respects others promotes equality in relationships (Chaudhary, 2016). Research supports the notion that people with diminished assertiveness may struggle with anxiety and depression (Thomp­ son & Berenbaum, 2011). Assertiveness is positively correlated with quality of life and social support, and it is negatively correlated with physical health prob­ lems (Chaudhary, 2016). Additionally, it is positively correlated with psychological well-being and selfesteem (Sarkova et al., 2013). This social skill allows people to express themselves in different scenarios

with limited anxiety and aggression (Bouvard et al., 1999). The Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC, 2009) competency A.10 states that counselors should strive to “understand how transgender individuals navigate the complexities for self and others with regard to inti­ mate relationships throughout the lifespan” (p. 5). This exercise focuses on helping transgender and gendernonbinary people develop better interpersonal skills. Assertiveness training is a powerful tool, but pair­ ing it with other interventions can be helpful. Mind­ fulness can also help reduce negative reactivity in com­ munication (Huston, Garland, & Farb, 2011). Assisting clients in the development of cognitive flexibility in addition to assertiveness may be important for miti­ gating depression (Skowron, Fingerhut, & Hess, 2014). Cognitive flexibility is defined as knowing what options are available in a situation and a willingness to be flexible to adapt (Martin & Rubin, 1995). Assertiveness training includes teaching the basic skills of clearly expressing oneself and standing up for oneself despite opposition, conflict, or criticism (Obiageli, 2015). Assertiveness training often includes the use of “I” statements. Thomas Gordon (1970) introduced the concept of “I” statements, which are declarative sentences that describe thoughts, feelings, or experiences in the first person. They can be a simple declarative sentence such as “I want to be called Rose” to a compound sentence such as “I feel angry and sad when you use my deadname because I have asked you to call me Rose numerous times.” This technique has been used in couples and family therapy to improve communication extensively (Kellas, 2005). Instructions

Handout and Activity 1: Helping Your Client Find His/Her/Zir/Their New Name The “Choosing Your Name” handout is designed to assist clients through the process of choosing a name. This activity is indicated for clients in individual ther­ apy; some adaptations can make it appropriate for group therapy. Some clients may do portions of this activity on their own, and others may need more sup­ port within the sessions. The therapist can give the client the handout of

Navigating the Name-Change Process 427

questions to consider when choosing a new name. The client can consider the questions in session or as a homework assignment. The therapist can suggest an online search for baby name websites or a baby name book for clients who are stuck. Many databases can be searched by ethnicity, gender, and meaning. The therapist may spend additional time exploring the reasoning for the answers for particular questions on the handout. For example, if clients wish to pick a name that is completely different from the name assigned at birth, is there a need to “kill” or “disown” their history? What drives that split? What is that expe­ rience like for them? The therapist can explore the client’s meaning-making process. Therapists may want to spend more time and use the activity of choosing a name in a manner similar to the way they work with dreams or fantasies. The process of finding a new name can be ripe for explo­ ration of the client’s inner world. Exploring feelings, beliefs, meanings, and experiences can be most effec­ tive for clients. Exploring the reasons behind clients’ answers to the questions on the handout can alleviate some clients’ anxiety about whether they have picked the “right” name. The therapist can suggest that clients try out the name in a safe space. Some clients may try this out in online forums, but this space can be limited because there is less potential for vocalization of the name. Others may try it at places like Starbucks where orders are called out by the name given. Clients may decide to bring a friend with them during this experiment for safety (physical, emotional, or both) reasons. Oth­ ers may ask a close friend or the therapist to call them by that name for a short while to see if it “fits.” The therapist should explore with the client how it felt to be called the name. It is essential that the thera­ pist validate and normalize any and all feelings that arise. Some clients feel distress that they didn’t respond to the new name right away. The therapist should explain that it is normal to go through an adjustment period in which the client may feel “nameless” and struggle to respond automatically to either name. The therapist should also say that it is normal for some clients to try on several names before they find the right one. Some clients have a “transitional” name that feels safer while they are in the middle of transition, before 428 Cathers

choosing a more gendered name. Everyone’s journey is different! Handout and Activity 2: Helping Your Clients Assert Their Name and Pronouns Once the client has picked a name, he/she/ze/they have the task of telling others and managing feelings about people using the incorrect name and pronouns. Some clients will seek assistance during the decisionmaking process for finding the best way to disclose their new name. The therapist can explore the pros and cons of each method of disclosure with the cli­ ent either verbally or with a sheet of paper. Some cli­ ents wish to tell each person individually, whereas others may do a blanket online post or send an email to everyone in their contacts list. Others may tell some close friends and allow the name to travel in the com­ munity by word of mouth. The “Asserting Your Name and Pronouns” hand­ out is focused on dealing with people using the incor­ rect name and pronouns, but it may be useful to pro­ vide TGNB-specific information about communication skills. The “Asserting Your Name and Pronouns” hand­ out focuses on clients’ voicing their needs effectively through using assertiveness skills. When teaching about assertiveness communication, it is especially important not to minimize clients’ anger and pain about being misgendered or misnamed. Anger is a common and natural reaction to misgendering and misnaming; the anger should be held and processed. The “Asserting Your Name and Pronouns” hand­ out provides psychoeducation about the four com­ munication styles: aggressive, passive, passive-aggres­ sive, and assertive (Paterson, 2000). The therapist can explore with clients how much insight they have into their communication style and how it affects their interactions with others. Assertiveness can feel foreign to some clients, and further exploration of their experience of asking for their needs (rather than ignoring them or demanding them) can be helpful. Some transgender women are afraid that being asser­ tive will be seen as masculine. Psychoeducation about “I” statements allows clients to learn concrete skills about how to communicate assertively. To help clients practice being assertive, the therapist can role-play with them. In addition to the actual words vocalized,

the therapist should have the client focus on tone, body language, and facial expression. Brief Vignette

Rose, a thirty-three-year-old black heterosexual transgender woman, sought support with her transition and severe depression. When she began therapy, she hadn’t picked a name yet and still used the name assigned to her at birth and male pronouns. She was clear that her gender identity is female and she would like to express herself more femininely, but she felt stuck in moving forward. She presented in genderneutral clothing, such as skinny jeans and a T-shirt. She was extremely shy and at times struggled to speak in a voice that was audible during sessions. During therapy, she asked for assistance in picking a new name and coming out to her mother. Rose had ambivalence about picking a feminine name. She was named after her father, who was killed while attempt­ ing to return home from deployment. Rose and her mother still lived together. Part of Rose’s dynamics involve caring for her mother; she was terrified that moving out would lead her mother to further depres­ sion. Additionally, Rose was scared that picking a name that is different from her father’s would be expe­ rienced by her mother as abandonment. The “Choosing Your Name” activity helped deter­ mine what her criteria for the right name would be: she wanted a feminine name rather than a genderneutral one, and she wanted a name that was common enough that she “would not trouble people with com­ plicated spelling.” Many names she liked were quickly rejected, however, because they “didn’t connect enough with her father.” With exploration of life events, Rose recalled that her father loved giving roses to her mother. The therapist commented, “Rose is a beauti­ ful feminine name, too.” Rose considered the name, and it met all the items on her checklist: similar initials, fairly uncomplicated spelling, common name, femi­ nine and not gender neutral, and, most important, con­ nected to her father. Rose’s ambivalence disappeared as soon as she found the right name. The therapist used an informal pros-and-cons list that helped Rose determine which method and order of disclosure were most appealing to her. Because of the intense meaning for Rose and closeness with her

mother, Rose didn’t want to share her new name with friends or coworkers until she had told her mother. Disclosing through a letter wasn’t right for Rose either, even though her difficulty with assertiveness made it an attractive option. Rose didn’t feel like she could share the name with her mother by herself, and she requested a family session in order to facilitate the conversation. Although the therapist was concerned about enabling Rose’s lack of assertiveness, the thera­ pist agreed to be a witness to support Rose’s coming out to her mother. The therapist provided the “Asserting Your Name and Pronoun” handout to help Rose understand her passive communication style and provide education about assertiveness. Several sessions before the family session involved role-plays and scripting what she wanted to say to her mother. The therapist needed to contain Rose’s anxiety and reiterate that Rose was not responsible for her mother’s feelings or well-being. Rose used the empty-chair technique to practice using “I” statements, discuss her feelings, and ask for what she wanted. During the family session, Rose used the assertiveness communication skills that she had practiced in earlier sessions. Once Rose came out to her mother and received her mother’s support, coming out to friends and other family members was considerably easier. She decided to meet with her close friends one-on-one and post on Facebook for her acquaintances. She and the therapist role-played how she wanted to handle the situation if friends or coworkers misgendered or misnamed her. Rose was particularly concerned about coming out to her cisgender white male boss because of having been raised with the message that, for safety reasons, passivity is necessary with white people, particularly men and authority figures. The therapist provided a space to validate her feelings and explore how her pas­ sivity served her in certain situations but didn’t in oth­ ers. The therapist explored how culture and racism have affected Rose’s interpersonal communication style. Suggestions for Follow-up

Transition, including social transition, is a process rather than a destination. These activities are meant to be a starting point on the journey. They can be adapted to assist clients in choosing and processing Navigating the Name-Change Process 429

pronouns as well. Feelings and thoughts can shift with time. Following up with weekly sessions can help with navigation of social transition. Experiential exposure as the social transition develops can offer opportunity to explore meaning. For this reason, transition can offer a unique processing opportunity. In addition, there should be ongoing support for the parts of transition that are outside the scope of this chapter. Some clients may wish to complete a legal name and gender change; a referral to a nameand gender-change legal clinic or the Transgender Law Center’s website can help clients navigate this pro­ cess. Continuing to explore the client’s experiences is important. Additional self-soothing skills may be needed when practicing assertiveness for some clients. Asser­ tiveness, planning, and problem solving may be ongo­ ing skills to practice as part of transition as well. Contraindications for Use

These activities were not designed for family work. Some adaptations will be needed for other applications, such as a TGNB-specific therapy or support group. These activities are specific to the name-change part of social transition and are not a comprehensive list of activities related to social, medical, or legal tran­ sition. Social transition looks different for everyone. Some clients may choose not to pick a new name, but they will change the way they dress or wear their hair. Others may change their name but not change their gender expression. Some people disclose to only a select few, and others are more out. In addition, social transition goes at different rates for each client, and it can be tempting for a therapist to feel that social transition is an exciting goal that must be achieved for full identity formation. It is important to follow the client’s needs and desires before assigning one or more of these activities. Acknowledgments

The author wishes to thank Patricia Gonzalez, MA, LMFT, for her work on the first draft, and Melissa Dellens and Tessa Babcock for assistance with proofreading.

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Professional Readings and Resources American Counseling Association, Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC). (2009). Competencies for counseling with transgender clients. Alexandria, VA: Author. American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender non-binary people. American Psychologist, 70 (9), 832–864. doi:10.1037/a0039906. Budge, S. L. (2013). Interpersonal psychotherapy with transgender clients. Psychotherapy, 50 (3), 356–359. doi:10. 1037/a0032194. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., . . . & Meyer, W. J. (2011). Standards of care for the health of transsexual, transgen­ der, and gender-nonconforming people, version 7. Inter­ national Journal of Transgenderism, 13 (4), 165–232. doi: 10.1080/15532739.2011.700873. Edwards-Leeper, L., Leibowitz, S., & Sangganjanavanich, V. F. (2016). Affirmative practice with transgender and gender non-binary youth: Expanding the model. Psychology of Sexual Orientation and Gender Diversity, 3 (2), 165–172. doi:10.1037/sgd0000167. Fraser, L. (2009). Depth psychotherapy with transgender peo­ ple. Sexual and Relationship Therapy, 24 (2), 126–142. doi:10.1080/14681990903003878. VanderSchans, A. (2016). The role of name choice in the con­ struction of transgender identities. Western Papers in Linguistics/Cahiers linguistiques de Western, 1, article 2. http://ir.lib.uwo.ca/wpl_clw/vol1/iss2/2.

Resources for Clients Boedecker, A. L. (2011). The transgender guidebook: Keys to a successful transition. N.p.: Boedecker. Brill, S. A., & Pepper, R. (2008). The transgender child: A hand­ book for families and professionals. San Francisco: Cleis Press. California Courts. (2019). Gender change. www.courts.ca. gov/genderchange.htm. Carey, T. (2016, February 4). Can choosing a new name really change your future? Express. https://www.express.co.uk/ life-style/life/640730/choosing-new-name-change-future­ numerology. Cotten, T. T. (2012). Hung jury: Testimonies of genital surgery by transsexual men. Oakland, CA: Transgress Press. Ehrensaft, D. (2011). Gender born, gender made: Raising healthy gender non-binary children. New York: Experiment. Erickson-Schroth, L. (2014). Trans bodies, trans selves: A resource for the transgender community. New York: Oxford Uni­ versity Press Gibson, C. (2016, July 31). Another challenge for transgender people: Choosing a new name. Washington Post. https://

www.washingtonpost.com/lifestyle/style/another-chal lenge-for-transgender-people-choosing-a-new-name/ 2016/07/29/07df80f2-49d8-11e6-acbc-4d4870a079da_ story.html?utm_term=.7cdb35bbf24e. Hoffman-Fox, D. (2017). You and your gender identity: A guide to discovery. Colorado Springs: DHF Press. Huston, D. C., Garland, E. L., & Farb, N. A. S. (2011). Mech­ anisms of mindfulness in communication training. Jour­ nal of Applied Communication Research, 39 (4), 406–421. National Center for Transgender Equality. ED documents cen­ ter. https://www.transequality.org/documents. Paterson, R. J. (2000). The assertiveness workbook: How to express your ideas and stand up for yourself at work and in relationships. New York: MUF Books. Rosenberg, M. B. (2005). Nonviolent communication: A lan­ guage of life. Encinitas, CA: PuddleDancer Press. Teich, N. M., & Green, J. (2012). Transgender 101: A simple guide to a complex issue. New York: Columbia University Press. Testa, R. J., Coolhart, D., Peta, J., Lev, A. I., & Sallans, R. K. (2016). The gender quest workbook: A guide for teens and young adults exploring gender identity. Oakland, CA: New Harbinger Publications. Transgender Law Center. https://transgenderlawcenter.org/. Trans Road Map. (n.d.). Name choosing for transgender women. http://www.tsroadmap.com/reality/nameindex. html. Tuhovsky, I. (2015). Communication skills: A practical guide to improving your social intelligence, presentation, per­ suasion and public speaking skills. Positive Psychology Coaching Series. Self-published. WikiHow. (n.d.). How to choose a new name (transgender). https://www.wikihow.com/Choose-a-New-Name­ (Transgender).

References American Counseling Association, Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC). (2009). Competencies for counseling with transgender clients. Alexandria, VA: Author. American Psychological Association (APA). (2015). Guidelines for psychological practice with transgender and gender non-binary people. American Psychologist, 70 (9), 832–864. American Psychological Association, Task Force on Gender Identity and Gender Variance. (2009). Report of the task force on gender identity and gender variance. Washington, DC: Author. https://www.apa.org/pi/lgbt/resources/pol icy/gender-identity-report.pdf. Bouvard, M., Arrindell, W. A., Guerin, J., Bouchard, C., Rion, A., Ducottet, E., et al. (1999). Psychometric appraisal of the Scale for Interpersonal Behavior (SIB) in France. Behaviour Research and Therapy, 37, 741–762. Chaudhary, N. (2016). Psycho-social correlates of health and

quality of life among women: A multivariate study. Indian Journal of Health & Wellbeing, 7 (8), 823–826. Espin, O. M., & Gawelek, M. A. (1992). Women’s diversity: Ethnicity, race, class, and gender in theories of feminist psychology. In L. S. Brown & M. Ballou (eds.), Personality and psychopathology: Feminist reappraisals, 88–107. New York: Guilford Press. Fein, L. A., Salgado, C. J., Alvarez, C. V., & Estes, C. M. (2017). Transitioning transgender: Investigating the important aspects of the transition: A brief report. International Jour­ nal of Sexual Health, 29 (1), 80–88. Galupo, M. P., Henise, S. B., & Davis, K. S. (2014). Transgender microaggressions in the context of friendship: Patterns of experience across friends’ sexual orientation and gen­ der identity. Psychology of Sexual Orientation and Gender Diversity, 1 (4), 461–470. Glynn, T. R., Gamarel, K. E., Kahler, C. W., Iwamoto, M., Oper­ ario, D., & Nemoto, T. (2016). The role of gender affir­ mation in psychological well-being among transgender women. Psychology of Sexual Orientation and Gender Diversity, 3 (3), 336–344. Gordon, T. (1970). Parent effectiveness training. New York: Wyden. Grant, J. M., Mottet, L., Tanis, J. E., Harrison, J., Herman, J., & Keisling, M. (2011). Injustice at every turn: A report of the National Transgender Discrimination Survey. Wash­ ington, DC: National Center for Transgender Equality and National Gay and Lesbian Taskforce. Huston, D. C., Garland, E. L., & Farb, N. A. S. (2011). Mech­ anisms of mindfulness in communication training. Jour­ nal of Applied Communication Research, 39 (4), 406–421. Kellas, J. K. (2005). Family ties: Communicating identity through jointly told family stories. Communication Mono­ graphs, 72 (4), 365–389. doi:10.1080/03637750500322453. Lev, A. I. (2004). Transgender emergence: Therapeutic guide­ lines for working with gender-variant people and their fam­ ilies. New York: Haworth Clinical Practice Press. Martin, M. M., & Rubin, R. B. (1995). A new measure of cog­ nitive flexibility. Psychological Reports, 76, 623–626. doi:10. 2466/pr0.1995.76.2.623. Nadal, K. L., Davidoff, K. C., Davis, L. S., & Wong, Y. (2014). Emotional, behavioral, and cognitive reactions to microaggressions: Transgender perspectives. Psychology of Sexual Orientation and Gender Diversity, 1 (1), 72–81. doi:10.1037/sgd0000011. Obiageli, J. (2015). Management of negative self-image using rational emotive and behavioural therapy and assertiveness training. ASEAN Journal of Psychiatry, 16 (1), 42–53. Paterson, R. J. (2000). The assertiveness workbook: How to express your ideas and stand up for yourself at work and in relationships. Oakland, CA: New Harbinger. Sarkova, M., Bacikova, S. M., Orosova, O., Geckova, A. M., Katreniakova, Z., Klein, D., . . . & Dijk, J. P. (2013). Asso-

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ciations between assertiveness, psychological well‐being, and self‐esteem in adolescents. Journal of Applied Social Psychology, 43 (1), 147–154. Scott, N. (1978). Beyond assertiveness training: A problemsolving approach. Personnel and Guidance Journal, 57 (9), 450–457. Sims, C. M. (2017). Do the big-five personality traits predict empathic listening and assertive communication? Inter­ national Journal of Listening, 31 (3), 163–188. Singh, A. A., & dickey, l. (2017). Affirmative counseling and psychological practice with transgender and gender nonbinary clients. Washington, DC: American Psychological Association.

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Skowron, A., Fingerhut, R., & Hess, B. (2014). The role of assertiveness and cognitive flexibility in the development of postpartum depressive symptoms. Journal of Repro­ ductive and Infant Psychology, 32 (4), 388–399. doi:10.10 80/02646838.2014.940518. Teich, N. M. (2012). Transgender 101: A simple guide to a com­ plex issue. New York: Columbia University Press. Thompson, R., & Berenbaum, H. (2011). Adaptive and aggres­ sive assertiveness scales (AAA-S). Journal of Psychopathol­ ogy & Behavioral Assessment, 33 (3), 323–334. Yin, K. (2016, March 15). Trans terminology 201: Talking about members of the transgender community with sensitivity and accuracy. Conscious Style Guide. https://conscious styleguide.com/trans-terminology-201/.

CHOOSING YOUR NAME Choosing a name can be quite the process! It is a rite of passage for many transgender or gender-nonbi­ nary (TGNB) people. You might feel a lot of pressure to find the “right” name. Some people have an easier time than others; some people try a few names before they find the one that fits. There is no right way to go through this process, but this handout is here to help you consider a few things for finding your name. 1. Do you want it to sound the same as your given name? Do you want it to sound different? 2. What do you want your name to sound like? Do you want it to be simply the different-gendered version of your given name (Christina vs. Christopher, Samantha vs. Samuel, etc.)? 3. Do you want to change your last name, too? 4. Do you want a middle name? 5. Do you want your parent(s) or another important person(s) to name you? 6. Do you want your initials to stay the same? 7. Do you want a gender-neutral name or a gendered name? 8. How common or rare do you want your name to be? 9. Do you want it to have roots in your race, ethnicity, or cultural heritage? 10. Do you want your name to have a particular meaning? What would you want that meaning to be? 11. If you are bilingual or bicultural, do you want two names in different languages? 12. Is it important for you to find an “age-appropriate” name (common in your birth year)? 13. Do you want a name that is popular in the transgender or gender-nonbinary community right now? 14. Do you want a unique spelling of your name? 15. Do you want a nickname that is different from your name (for example, Cathy for Catherine)? Make sure to consider that some names have male or female nicknames (Mel can be short for Melvin or Melissa). 16. Do you want to keep any part of your given name? (Example: Howard changes name to Bianca, uses Howard as last name, and becomes Bianca Howard.) 17. How do you like how your name sounds with your last name? Does it roll off the tongue? 18. How does it look when it’s written? What do you want your signature to look like? 19. Is there a celebrity, role model, relative, or character whom you would like to name yourself after? 20. Is there a life event that is meaningful to you that may translate well into a name?

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Asserting Your Name and Pronouns There are different ways to communicate our needs. For transgender and gender-nonbinary people, having an affirmed name and pronouns can help create a sense of well-being, assist in development of community, and decrease stress. It can really hurt when people, especially those we care about, don’t treat us the way we want to be treated. There are ways to deal with it that can leave us feeling more alienated or helpless and other ways that can allow us to have our voices heard. This handout highlights the different ways that we can respond when someone misgenders us or uses the incorrect name.

Communication Style

What It Is

Consequences

Examples

Aggressive

• Demanding what you want or need. • Refusing to listen to other people’s experiences. • Often includes staring, intimidating body language, and eye contact.

• Feelings of anger, loneliness, shame, guilt, or isolation. • People avoiding you out of fear. • People minimizing your feelings as irrational.

• Yelling at someone for misgendering you or using the incorrect name. • Calling people names when they upset you. • Angrily telling people that they don’t care about you because they misgendered you or used the incorrect name.

Passive

• Not asking for what is in your best interest. • Not communicating with others about what you want or need. • Letting others make decisions for you. • Allowing yourself to get upset rather than upsetting others. • Often includes slumped body language and avoiding eye contact.

• Feeling controlled, helpless, unheard, resentful, withdrawn, or little. • People continuing to ignore your needs.

• Not correcting someone who misgenders you or uses the incorrect name.

Passive­ Aggressive

• Includes the passivity of not communicating your needs, but also aggressiveness toward others when your needs aren’t met. • Includes the worst parts of both passive and aggressive communication styles.

• Feelings of anger, isolation, loneliness, guilt, shame, being controlled, helplessness, resentfulness, and feeling unheard. • People continue to ignore your needs. • People may avoid you out of fear.

• Rolling your eyes, grunting, or sighing when someone mis­ genders you or uses the incorrect name. • Sabotaging, punishing, or gossiping about people behind their backs because they misgendered you or used the incorrect name in the past.

434

Cadyn Cathers

Communication Style

Assertive

What It Is

• Asking for 100% of what you want while respecting other people’s experiences. • Directly, clearly communicating your feelings or thoughts. • Allows for negotiation so that both your needs and the other person’s needs can be met.

Consequences

• Feeling honest, proud, and capable. • Building self-esteem. • Not feeling guilty about expressing your needs. • A feeling that respectful negotiation for your needs to be met can begin. • Feeling connected with others.

Cadyn Cathers

Examples

• Respectfully reminding people about your name, pronouns, and other needs. • Letting people know how their actions affect you. • Using “I” statements.

435

49 THE AGING TRANSGENDER CLIENT: MAPPING THE ACCEPTANCE OF EXPERIENCE Dorian Kondas Suggested Uses: Activity Objective

The objective of these exercises is to collaborate effec­ tively with aging transgender or gender-nonconform­ ing clients to develop a strong therapeutic alliance and a client-centered treatment plan, and to imple­ ment an acceptance-based mode of clinical intervention. Rationale for Use

Aging presents unique challenges for trans individuals (Persson, 2009) often attributable to systemic sources of oppression and marginalization. Life challenges as a result may not always be amenable to change and, consequently, contribute to increased distress and gender dysphoria (Jackson, Johnson, & Roberts, 2008). Conditions are frequently worse when other oppressed identities intersect with those of age and trans identity; these other identities include race or ethnicity, sexual­ ity, class, and female identification and appearance (Skinta & Curtin, 2016). Some sources of distress are: • Grief resulting from having had a lack of opportu­ nity in one’s youth for medical transition and transaffirming social support (Cook-Daniels, 2015) • Increased loneliness and isolation from lack of avail­ able social resources for older trans individuals (Persson, 2009), including, for example, support groups composed of older trans members or trans­ portation to trans-related events • Exacerbated gender dysphoria and loneliness from increased dependence on transphobic family, trans insensitivity among professional caregivers, and dis­

criminatory systems of care that may require trans individuals to hide their gender identity for fear of losing care and emotional support (Persson, 2009) • Increased religious or spiritual distress in managing existential concerns of chronic pain and mortality without the support of a trans-affirming spiritual community and belief systems (Kidd & Witten, 2008) • Despair and anger about failing to qualify for hor­ mone therapy or surgery because of risks that may develop with age, including cardiologic, diabetic, weight-related, hypertensive, and cancer risks (Coleman et al., 2011) • Resistance to seeking medical care because of past experiences with trans-insensitive medical provid­ ers (Cook-Daniels, 2015) and barriers to medical access (real and perceived) because of institution­ alized cisgender bias or transphobia (Simpson et al., 2013) • Barriers of access to affordable housing and commu­ nity resources for the elderly because of transpho­ bic policies and transphobic experiences of discrim­ ination (Jackson et al., 2008) • Increased risk of harassment or violence (CookDaniels, 2015) because of perceived diminishment of physical attractiveness and ability to “pass” owing to the physical effects of aging and the previous lack of opportunity for medical transition • Gender dysphoria and stigma related to coercive cisnormative policies that force trans individuals in institutional facilities to use showers, restrooms, and living quarters that do not match their gender identity (Jackson et al., 2008)

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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• Risk of nonconsensual outing with requirement of medical documents for entering some assistedliving facilities (Cook-Daniels, 2015) and coerced nudity in shared bathrooms and showers that do not match trans gender identity. A form of therapy that facilitates compassionate accep­ tance of self, of difficult life circumstances, and of psychological distress, while increasing capacity for realistic goal achievement, may be well suited for trans populations who are faced with so many compound­ ing factors of aging that may be beyond their ability to change (Skinta & Curtin, 2016). Such an approach has been conceptualized in acceptance and commit­ ment therapy (ACT; Hayes, Strosahl, & Wilson, 2012). It should be stressed that the exercises offered below do not require the therapist to take an ACT-based approach; it is only noted that the empirical literature supporting the exercises is drawn largely from ACT. Any therapeutic orientation that is values-driven by the client and goal-focused, and that emphasizes the importance of helping clients effectively open them­ selves to, rather than avoid, distressing psychological material, may be compatible. Third-wave approaches that build skills of mindfulness are particularly relevant (Hayes et al., 2012). Acceptance of distressing affect and of difficult life situations has been found to be helpful across oppressed populations (Polk & Schoendorff, 2014; Skinta & Curtin, 2016). Though there is a dearth of research on trans populations using an acceptancebased model, supportive findings across general LGBT populations for reducing stigma and coping with minority stress (Hughto, Reisner, & Pachankis, 2015; Luoma & Platt, 2015) are reason to believe an acceptance approach may be well suited to trans cli­ ents (Skinta & Curtin, 2016). Additionally, an accep­ tance approach has been found to be helpful for issues for which trans populations in general may be more at risk, including anxiety, depression, and substance use (Ruiz, 2010). Studies of general aging populations sup­ port quality-of-life improvements that may occur in some health domains. These improvements include community participation, increased resilience, improved pain management, and long-term stress reduction (Butler & Ciarrochi, 2007; Feros, Lane, Ciarrochi, & Blackledge, 2013; McCracken & Jones,

2012). Research suggests that increased acceptance may increase mood (Karlin et al., 2013) and may be at least as effective with elder depression as other approaches (Ruiz, 2010). Finally, it is understood that no set of techniques or exercises is sufficient for best therapy outcomes with trans individuals; rather, it is the relationship as the mechanism of change defined by the therapeutic alliance that research supports as being of central importance in most cases across diverse populations (Norcross, 2011). The importance of the alliance cannot be overstated for trans individuals, many of whom have experienced relationship betrayal, rejec­ tion, stigma, and abuse (Hughto et al., 2015; Skinta & Curtin, 2016). The harmful cycles of systemic oppression and cisgender privilege must be challenged and reversed in therapy with trans clients in the pro­ cess of alliance building. When trans individuals are invited to define their values and empowered to speak from their intersecting identities of race or ethnicity and other identifiers, deeper bonds of trust and alli­ ance may develop (Fraser, 2009; Israel, Gorcheva, Burnes, & Walther, 2008). For this reason, the exer­ cises below are meant to serve the function of deep­ ening the alliance. Where and how this may be done in the course of the exercises are detailed in the instructions below. The American Psychological Association (APA) has recognized the potentially harmful effects of cisnormative attitudes on the part of clinicians in its “Guidelines for Psychological Practice with Transgen­ der and Gender Nonconforming Individuals” (2015). Cisgender bias may lead to alliance ruptures in ther­ apy with trans individuals (Israel et al., 2008), and, consequently, the APA has stressed not only general competency but also the necessity of clinicians’ selfawareness of their cisnormative attitudes (APA, 2010). Lack of clinician self-awareness in the context of ther­ apy violates the general principles of “justice” (p. 3) and of “respect for people’s rights and dignity” (p. 4) in the Ethical Principles of Psychologists and Code of Conduct (APA, 2010), which specifies self-awareness of bias and the elimination of prejudice in practice. Such fundamental competency for working with trans populations is essential for the successful application of the exercises proposed here. The Aging Transgender Client 437

Instructions

The exercises below proceed in three chronological steps. The first exercise requires contributions from both client and therapist for the collaborative elabo­ ration of client values versus the biases and systemic forms of oppression the client may face (ageism, transphobia, institutionalized cisgender norms, and so on). Goals are then formally derived from the client’s listed values. The second exercise develops a list of the dilemmas an aging trans client may face, which is paired with a corresponding list of affective psycho­ logical experiences produced as a result. The last exer­ cise uses the information collected in the first two phases to illustrate otherwise abstract psychological principles, inform the treatment, and facilitate accep­ tance of psychological experience for the client. Part 1: Values to Obstacles to Goals Using paper or an easel pad, the therapist draws a ver­ tical line down the middle to create two columns. On the left, the therapist and client together make a list of the client’s salient values. The range of values is lim­ itless but may include the following: family or chil­ dren, freedom of gender expression, trans community, the right to receive trans-competent care, trans-affirm­ ing religion, and trans-affirming living quarters that include the right to bathrooms and dorm arrange­ ments that match one’s gender identity. The therapist next collaborates with the client to fill out the right-hand column, which is a list of obsta­ cles to the client’s values listed on the left. The client may be supported and challenged to consider more abstract, less obvious obstacles at the level of systemic, cisgender, oppressive “values” expressed in cis-domi­ nant cultural assumptions. Cisnormative values may include transphobia, cisgender privilege, and institu­ tionalized cisgender norms that cover a wide range of issues, including cisgender-assigned bathrooms and living quarters, male- or female-only gender catego­ ries on legal documents, religious beliefs about gender, barring of adoption of children by trans parents, and gender-role expectations for dress, career, habits, and social grouping. Other privileged “values” include the prejudices of racism, classism, ageism, ableism, body shaming, and a consumer culture that encourages compulsions, including alcohol use and overspend­ 438 Kondas

ing. Each of the oppressive “values” should be listed directly opposite the client’s values in the left-hand column that they challenge. They can be listed more than once. What is important here is that the therapist not impose language and meaning that conflict with the client’s but instead make sure that new language introduced is confirmed by the client as a “good fit.” The final step to Part 1 is to generate a list of goals that are based on the values listed that will guide treatment planning and serve to develop the alliance in terms of joining the client with the goals developed. Part 2: Emotion Regulation and Distress Just as Part 1 begins with two columns, so does Part 2, by illustrating two related ideas. In the left-hand col­ umn, the client and therapist collaborate to generate a list of previous attempts at emotion regulation that, while perhaps effective in the short term, have not resulted in eliminating current distress or goal achieve­ ment. It is important that the therapist validates the client’s previous forms of coping and distress manage­ ment, at the same time making space in the dialogue for how previous attempts may have fallen short of their intended purpose. It is in the right-hand column that distressing emotions are listed directly across from those behav­ iors that the client has used to cope with or manage them. As is often the case, the therapist may need to coach the client in naming specific feeling words like afraid or angry. Providing clients with a list of feeling words may be helpful. Part 3: Mapping Dilemmas and Acceptance The last phase may continue from session to session for as long as it remains helpful for the client. The therapist and client cocreate a map using the informa­ tion gathered in Parts 1 and 2. Both therapist and client are encouraged to be playful, creative, and flex­ ible in drawing and revising the map throughout the course of therapy. There are no strict rules. The map illustrates many principles that might otherwise be difficult for some clients to grasp. The client is depicted on the map as a ship sailing on a river. The ship sails downriver in the direction of the goals (downriver “ports of call”) listed in Part 1. The water on which the client sails corresponds to the client’s cognitive and

emotional experience. Sometimes the river is wider and more placid, indicating reduced distress; at other times the river become narrow, and the waters are churned into rapids that represent distressing cogni­ tion and emotion. The listed obstacles of Part 1 may be represented as rocky shoals, bad weather, fallen trees, and any other images the client favors. The client’s earlier, unsuc­ cessful methods of managing distress from Part 2 are depicted as “ports of rest” along the river where the client avoids narrow, turbulent waters for a brief time. When the client rests, however, their goal achieve­ ment is slowed down; only acceptance allows the cli­ ent to “go with the flow” of the river, whether calm or turbulent. Finally, the land on either side of the river corresponds to dilemmas faced by the client. The “tighter” the dilemma at any given time, the narrower the river becomes between the two opposing forces of the dilemma. The narrower the river, the worse the rapids depicted on the map—that is, the more dis­ tressing the client’s cognitive and emotional experi­ ence. The map is developed session by session; it is never drawn as a projection into the future, which remains always uncertain; consequently, goal achieve­ ment is not depicted until it has been accomplished. Acceptance occurs as the trans client becomes more willing and skilled at leaving ports of rest and entering back into the waters of distress that move toward the client’s goals or “ports of call.” It is up to the therapist and client together to decide how accep­ tance of psychological experience will be approached. Several exercises, skill-building activities, and thera­ peutic interventions may be used to build a client’s willingness and ability to experience rather than avoid distressing cognition and affect (Hayes, 2005; Luoma, Hayes, & Walser, 2007). Suggestions for Follow-up

The map is an excellent tool for following up on the client’s perceived successes and failures because the map is drawn session-to-session to depict the client’s experience. If there is a perceived failure, the river tightens and the waters become more distressed; if there is success, the river widens. If the client reports a new willingness to feel feelings, the ship moves down­ stream into the rapids closer to goal achievement.

New obstacles may be added or old ones crossed out. Ports of rest may be repeated or new problematic behaviors of emotional avoidance added as ports of rest. The river and its symbols are always subject to change in adapting to the changes in the trans client’s life. Because skill and ability to accept experience are charted on the map, as represented by forward move­ ment of the ship, the client has a graphic feedback loop that motivates and encourages further growth. Brief Vignette

Danny is a seventy-two-year-old client who identifies as a trans-masculine, African American, heterosexual from a low socioeconomic background with a his­ tory of homelessness and alcohol use. He is single and medically disabled because of a degenerative spinal disease and a partial stroke. Danny informs the therapist that he was on hor­ mone replacement therapy for one year until he was diagnosed with cardiac fibrillation three years ago. Danny states he has never had the income to consider surgical transition. His husband divorced him when he was forty-four. He remains in conflict with his children when he refuses to dress in women’s cloth­ ing. His son Timothy visits him regularly and shops for Danny’s food, clothing, and other necessities that he cannot get on his own. He permits Danny to have a relationship with his grandchildren, ages two and four, but only on the condition that he dress in tradi­ tional women’s clothing and “play Nanna” when he is with them. Danny is required to use the women’s quarters and bathrooms at his living facility. He fears that disclos­ ing his trans identity and self-advocating for genderconsistent living facilities would open him to shun­ ning and verbal or physical attacks by residents, rule out finding another assisted-living home, and force him back into homelessness. He attends a black Bap­ tist church that is not trans-affirming. He is reluctant to find a trans-affirming church because they are “too white.” Danny discloses that he has been visiting a local bar where he drinks as “medicine” for chronic pain and depressed mood. He has not disclosed his trans identity to his current primary care physicians, his psychiatrist, or his disability case worker for fear they will discriminate against him. The Aging Transgender Client 439

Part 1 In the case of Danny, the therapist immediately noticed that he was highly concrete in his thinking style. The therapist helped him transition from discussing his issues as life narratives toward discussing the implicit underlying values behind the story lines. To do so, the therapist reflected Danny’s implicit values as fol­ lows (value-loaded words are in italics): “Despite their rejection of your true identity, it sounds like your fam­ ily is still of primary importance to you”; “All your life you’ve been seeking the freedom to express your true identity”; “It sounds like you are saying you have a right to good, competent care as a trans individual”; and “Your relationship with God and church community really plays a central role in your life.” After Danny con­ firmed that these reflections were accurate, the ther­ apist listed the values in the left-hand column. The therapist next listed obstacles in the righthand column that challenged Danny’s values (trans­ phobic family, lack of privacy, poverty, chronic pain, cisgender bathrooms and living quarters, incompe­ tent medical staff); however, the therapist chose to intentionally explore the obstacles in Danny’s case as Danny uniquely understood them. Further, the ther­ apist noticed that Danny was not familiar with many trans-sensitive words and phrases understood by younger clients, such as “gender norms,” “cisgender,” “internalized transphobia,” and the idea that gender is a “social construct.” The therapist described these terms to Danny when it was appropriate. The therapist discovered that once Danny was armed with words to better understand his experience, he felt empowered to further define his values and goals by contrasting them to the implicit values of cis privilege and atti­ tudes of the larger cis culture. In doing so, the thera­ pist took the first steps in helping Danny reverse his internalized stigma by naming the unjust “cis norms” he had faced since childhood. Being sensitive also to issues of socioeconomic status and race or ethnicity, the therapist discussed how these dimensions of oppression may further shape his trans-related values and goals. The alliance deepened for Danny because he experienced both the strengthening of an emo­ tional bond with the therapist as an ally and an agreed-on collaboration with the therapist that was based on his goals. 440 Kondas

Part 2 The therapist co-constructed the list of unsuccessful strategies for managing distress that Danny had used in the past. Having deepened the alliance through Part 1 of the exercise, the therapist was able to gently question Danny about what “had worked temporar­ ily” before coming to therapy. Danny listed the fol­ lowing in the left-hand column: attending services at a non-trans-affirming church; binge-watching TV; overeating; alcohol use; gender secrecy with caregiv­ ers, with residential staff, and at church. In listing emotions of distress he sought to avoid, Danny chose to place “loneliness” across from overeating, bingewatching TV, and going to church; across from over­ eating and alcohol use, he listed “anger,” “self-hatred,” and “anxiety.” Rather than explore only Danny’s “failure,” the therapist also explored and reframed with Danny his successes in using the above strate­ gies. For example, in Danny’s overuse of alcohol, the therapist said, “It makes total sense why you would want to medicate the emotional pain just like the physical pain using alcohol. It sounds like that worked for you for a while. Now it sounds like you want to learn new ways to work with the emotional pain.” Part 3 There are no standard symbols for the map; there­ fore, it was up to Danny and the therapist to play­ fully derive the symbols on their own. The therapist explained to Danny that the images of the TV, church, knife and fork (for overeating), and bottle of alcohol illustrate “ports of rest” that provided shortterm coping for Danny. The ports of rest, however, were ultimately unsuccessful because Danny used them to avoid the experience of distress, which delayed the resolution of his targeted problems. That is, they delayed his movement “downstream” toward goal achievement. Danny and the therapist depicted his life dilemmas in the map by making the river narrower at dilemma choice points and by drawing symbols of rocks, storm clouds, and churning rapids at these locations. These dilemmas included whether to request trans-appropriate living quarters and bathrooms; whether to seek trans-competent health-care providers; whether to confront his son

Timothy to be openly trans with his grandchildren; whether to disclose his trans identity with select, trusted church members or find a new church; and whether to seek transportation to attend a trans support group and become more active at an LGBT clubhouse. Throughout therapy, at any time Danny succeeded in achieving a goal, he and the therapist directly after­ ward drew new symbols on the map at ports of call that represented goals achieved. For example, in fig­ ure 1 they drew symbols of Danny’s residential facil­ ity and the medical caduceus, which represented Danny’s goal achievement of being able to use a gen­ der-neutral staff bathroom and successfully switching health-care providers. After landing at ports of call, the therapist broadened the river, illustrating Danny’s relief of distress. The map, consequently, helped sen­ sitize Danny to the tasks of emotional experiencing, goal achievement, and distress reduction. Some of Danny’s dilemmas were never resolved. For example, his loneliness and self-hatred were compounded by unintended yet ongoing insensitive language of the residential staff. Where some dilem­ mas could not be resolved, the therapist first explored with Danny healthier, intentional forms of distress avoidance such as making artwork; going to the LGBT club; doing light, gentle exercise; and socializ­ ing with other residents instead of drinking or over­ eating. Second, the therapist taught Danny basic skills of mindfulness in the form of meditation, mindful eating, and self-guided imaginal exercises for working with distressing affect (Hayes, 2005; Luoma, Hayes, & Walser, 2007). Contraindications for Use

The above exercises may not be as helpful for some clients owing to physical impairments such as a visual disability. The third exercise requires the elaboration of an extended metaphor of rivers and sailing and several symbols that may be difficult for some clients to follow because of an intellectual disability or prob­ lems of visual-spatial perception. Elderly trans indi­ viduals with visual impairment or cognitive disor­ ders may benefit from a more simplified and direct form of the exercise that could include more basic psychoeducation and more hands-on physical manip­

ulation of materials. For example, chess pieces or board game tokens could be used on a piece of con­ struction paper or poster board. The river could be drawn on this surface, laid flat on a table, the game pieces serving as the obstacles and as the client’s ship. Therapists are encouraged to be creative and adapt to the particular needs of each client. It deserves mention that when clients are in crisis or experience states of distress that are overwhelming, the acceptance of distress is contraindicated because the client’s distress could be overly heightened if accepted into experience. Instead, therapists should help clients not to accept distress but rather to reduce, avoid, or sublimate the distress in order to avoid a crisis. Marsha Linehan’s (2014) exercises and work­ sheets of dialectical behavior therapy provide several methods for helping clients reduce their distress in critical situations where acceptance of experienced distress could potentially harm the client. Professional Readings American Psychological Association. (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., . . . & Zucker, K. (2011). Standards of care for the health of transsexual, transgen­ der, and gender-nonconforming people, version 7. Inter­ national Journal of Transgenderism, 13, 165–232. doi:10. 1080/15532739.2011.700873. Fredriksen-Goldsen, K. I., Hoy-Ellis, C. P., Goldsen, J., Emlet, C. A., & Hooyman, N. R. (2014). Creating a vision for the future: Key competencies and strategies for culturally competent practice with lesbian, gay, bisexual, and transgender (LGBT) older adults in the health and human services. Journal of Gerontological Social Work, 57 (2–4), 80–107. Luoma, J. B., & Platt, M. G. (2015). Shame, self-criticism, selfstigma, and compassion in acceptance and commitment therapy. Current Opinion in Psychology, 2, 97–101. Skinta, M., & Curtin, A. (eds.). (2016). Mindfulness and accep­ tance for gender and sexual minorities: A clinician’s guide to fostering compassion, connection, and equality using con­ textual strategies. Oakland, CA: Context Press.

Client Readings Erickson-Schroth, L. (2014). Trans bodies, trans selves: A resource for the transgender community. New York: Oxford University Press. The Aging Transgender Client 441

Hayes, S. C. (2005). Get out of your mind and into your life: The new acceptance and commitment therapy. Oakland, CA: New Harbinger Publications.

Online Resources for Clients Forge. https://forge-forward.org/. GRIOT Circle. https://griotcircle.org/. Lambda Legal for Seniors. https://www.lambdalegal.org/ issues/seniors. National Resource Center on LGBT Aging. https://lgbtaging center.org. Services and Advocacy for LGBT Elders (SAGE). www.sage usa.org. Transgender Aging Network (TAN). https://forge-forward. org/aging/.

Video Resource for Clients Maddux, S. (producer and director), Atkin, B. J., & Applebaum, J. (producers). (2011). Gen silent. Interrobang Productions.

References American Psychological Association (APA). (2010). Ethical principles of psychologists and code of conduct. Washing­ ton, DC: Author. American Psychological Association (APA). (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. Butler, J., & Ciarrochi, J. V. (2007). Psychological acceptance and quality of life in the elderly. Quality of Life Research, 16 (4), 607–615. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., . . . & Zucker, K. (2011). Stan­ dards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism, 13, 165–232. doi:10.1080/155 32739.2011.700873. Cook-Daniels, L. (2015). Transgender aging: What practitioners should know. In N. A. Orel & C. A. Fruhauf (eds.), The lives of LGBT older adults: Understanding challenges and resilience. Washington, DC: American Psychological Association. Feros, D. L., Lane, L., Ciarrochi, J., & Blackledge, J. T. ( 2013). Acceptance and commitment therapy (ACT) for improv­ ing the lives of cancer patients: A preliminary study. Psych-Oncology, 22 (2), 459–464. Fraser, L. (2009). Psychotherapy in the World Professional Association for Transgender Health’s Standards of Care: Background and recommendations. International Journal of Transgenderism, 11 (2), 110–126. Fredriksen-Goldsen, K. I., Hoy-Ellis, C. P., Goldsen, J., Emlet, C. A., & Hooyman, N. R. (2014). Creating a vision for the future: Key competencies and strategies for culturally competent practice with lesbian, gay, bisexual, and trans442 Kondas

gender (LGBT) older adults in the health and human services. Journal of Gerontological Social Work, 57 (2–4), 80–107. Hayes, S. C. (2005). Get out of your mind and into your life: The new acceptance and commitment therapy. Oakland, CA: New Harbinger Publications. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mind­ ful change, 2nd edition. New York: Guilford. Hughto, J. M. W., Reisner, S. L., & Pachankis, J. E. (2015). Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. Social Science and Medicine, 147, 222–231. Israel, T., Gorcheva, R., Burnes, R. T., & Walther, W. A. (2008). Helpful and unhelpful therapy experiences of LGBT clients. Psychotherapy Research, 18 (3), 294–305. Jackson, N. C., Johnson, M. J., & Roberts, R. R. (2008). The potential impact of discrimination fears of older gays, lesbians, bisexuals and transgender individuals living in small- to moderate-sized cities on long-term healthcare. Journal of Homosexuality, 54 (3), 325–339. Karlin, B. E., Walser, R. D., Yesavage, J., Zhang, A., Trockel, M., & Taylor, C. B. (2013). Effectiveness of acceptance and commitment therapy for depression: Comparison among older and younger veterans. Aging and Mental Health, 17 (5), 555–563. Kidd, J. D., & Witten, T. M. (2008). Understanding spirituality and religiosity in the transgender community: Implica­ tions for aging. Journal of Religion, Spirituality and Aging, 20 (1–2), 29–62. Linehan, Marsha. (2014). DBT skills training: Handouts and worksheets. New York: Guilford Press. Luoma, J. B., Hayes, S. C., & Walser, R. D. (2007). Learning ACT: An acceptance & commitment therapy skills-train­ ing manual for therapists. Oakland, CA: New Harbinger. Luoma, J. B., & Platt, M. G. (2015). Shame, self-criticism, selfstigma, and compassion in acceptance and commitment therapy. Current Opinion in Psychology, 2, 97–101. McCracken, L. M., & Jones, R. (2012). Treatment of chronic pain in adults in the seventh and eighth decade of life: A preliminary study of acceptance and commitment ther­ apy. Pain Medicine, 13 (7), 860–867. Norcross, J. (2011). Psychotherapy relationships that work. New York: Oxford University Press. Persson, D. (2009). Unique challenges of transgender aging: Implications from the literature. Journal of Gerontologi­ cal Social Work, 52 (5), 633–646. Polk, K. L., & Schoendorff, B. (eds.). (2014). The ACT matrix: A new approach to building psychological flexibility across settings and populations. Oakland, CA: New Harbinger Publications. Ruiz, F. J. (2010). A review of acceptance and commitment therapy (ACT) empirical evidence: Correlational, exper­ imental psychopathology, component, and outcome stud­

ies. International Journal of Psychology and Psychological Therapy, 10, 125–162. Simpson, T. L., Balsam, K. F., Cochran, B. N., Lehavot, K., & Gold, S. D. (2013). Veterans Administration health care utilization among sexual minority veterans. Psychological Services, 10 (2), 223–232.

Skinta, M., & Curtin, A. (eds.). (2016). Mindfulness and accep­ tance for gender and sexual minorities: A clinician’s guide to fostering compassion, connection, and equality using contextual strategies. Oakland, CA: Context Press.

The Aging Transgender Client 443

SECTION VI

HOMEWORK, HANDOUTS,

AND ACTIVITIES FOR

SUBSTANCE USE DISORDERS

Sexual and gender minority clients often present with concerns about the use of substances, but therapists are not always prepared to tailor their approach to meet these clients’ unique needs. Addiction is a seri­ ous problem in the LGBTQ community; this popula­ tion is more likely than heterosexuals to suffer with substance use disorders (Marshal, Friedman, Stall, & Thompson, 2009). Internalized heterosexism, oppres­ sion based on their marginalized social identities, and the prominent role of bars and clubs in the gay community all contribute to this reality (Chaney & Brubaker, 2014). For this reason, several chapters in this section are devoted to working with clients who are struggling with substance use and abuse. In Chapter 50, “A Relapse-Prevention Intervention for LGBTQ Clients with Substance Use Disorders: The C3PO,” Michael P. Chaney and Fiona D. Fonseca guide clients through a time line to plot milestones in their identity development and substance use and relapse patterns in order to gain insight into the ways in which one may affect the other. John J. S. Harrichand and Christian D. Chan also address the powerful relation­ ship between the negative consequences of oppres­ sion and experiences of substance use, addiction, and sexually compulsive behaviors. In Chapter 53, “The Inextricable Relationship between Marginalization and Addiction: Bridging the Gap through Charting,” they offer an activity rooted in cognitive behavioral therapy that guides the client to identify maladaptive behaviors and to engage in imagery rescripting. Central to the two chapters by George Stoupas and Mia Ocean is the importance of understanding the ways in which clients’ experiences with margin­ alization and isolation owing to their identities affect their ability to access recovery support. In Chapter 51, “Exploring the Concept of Honesty with Transgen­ der Clients in Recovery from Addiction,” clinicians’

446

goal is to help clients distinguish between what may be a healthy desire for privacy and safety that is based on their lived experiences in the world, and a tendency to harbor secrets that can undermine the recovery process. In Chapter 54, “LGB Addiction Recovery and Community Membership,” Stoupas and Ocean empha­ size the importance of building an affirming support system to enhance clients’ feelings of belonging in their recovery. Much of the literature on eating concerns has focused on white, cisgender, female clients (Diemer et al., 2015) without much attention paid to the needs of trans clients, who may engage in disordered eat­ ing to suppress or accentuate specific physical fea­ tures associated with their gender identity. Jeannine Cicco Barker offers a creative activity to increase body acceptance while normalizing clients’ desire for their body to be congruent with their gender identity in Chapter 52, “Using Art Therapy to Address Body Dysphoria, Body Image, and Eating Concerns with Trans and Nonbinary Clients.” References Chaney, M. P., & Brubaker, M. (2014). The impact of sub­ stance abuse and addiction in the lives of gay men, ado­ lescents, and boys. In M. M. Kocet (ed.), Counseling gay men, adolescents, and boys: A strengths-based guide for helping professionals and educators, 109–128. New York: Routledge. Diemer, E. W., Grant, J. D., Munn-Chernoff, M. A., Patterson, D. A., & Duncan, A. E. (2015). Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. Journal of Adolescent Health, 57, 144–149. doi:10.1016/j.jadohealth.2015.03.003 Marshal, M. P., Friedman, M. S., Stall, R., & Thompson, A. L. (2009). Individual trajectories of substance use in lesbian, gay and bisexual youth and heterosexual youth. Addiction, 104, 974–981. doi:10.1111/j.1360-0443.2009.02531.x.

50 A RELAPSE-PREVENTION INTERVENTION FOR LGBTQ CLIENTS WITH SUBSTANCE USE DISORDERS: THE C3PO Michael P. Chaney and Fiona D. Fonseca Suggested Use: Activity Objective

The purpose of this activity (the C3PO) is to explicate a collaborative exploration of lesbian, gay bisexual, transgender, and queer (LGBTQ) clients’ identity development and histories of substance use, paying particular attention to lapses and relapses in order to develop more effective, individualized relapse-preven­ tion plans. By integrating the use of time lines that chart the influence of a client’s LGBTQ identity devel­ opment on substance use history and path to recov­ ery, counselor and client can work together to better understand milestones and experiences as relapse learning opportunities. Rationale for Use

According to the National Institute on Drug Abuse (NIDA), approximately 24.6 million Americans in 2013 had used an illegal substance in the preceding thirty days (2015). This number represents an esti­ mated 9.4 percent of the total population. Furthermore, the lifetime prevalence of diagnosable substance use disorders (SUDs) among the general population is about 10 percent, a number based on past-year sub­ stance use (JAMA Network Journals, 2015). When looking specifically at nonheterosexual and gendervariant Americans, there is a salient discrepancy in rates of illicit substance use. Research has consistently demonstrated that LGBTQ individuals are more likely than heterosexuals to struggle with substance use disorders (Cochran, Ackerman, Mays, & Ross, 2004; Marshal, Friedman,

Stall, & Thompson, 2009; Marshal et al., 2008; McCabe et al., 2009). Specifically, nonheterosexuals’ use of alco­ hol, stimulants, cannabis, hallucinogens, inhalants, heroin, sedatives, and tranquilizers is significantly higher than it is for heterosexuals (Cochran et al., 2004; Dahan, Feldman, & Hermoni, 2007). When we com­ pare substance use among all sexual orientations, we find that a nonheterosexual orientation is related to elevated risk of substance use and dependence (McCabe et al., 2009). In addition, LGBTQ people are more likely than heterosexuals to report histories of familial substance use (McCabe, West, Hughes, & Boyd, 2013). What is clear is that because of the increased rates of substance use among this population, counselors who work with LGBTQ clients must have comprehensive knowledge about substance use trends, factors that contribute to the etiology of use, and affirmative coun­ seling practices to effectively treat them. A component of LGBTQ-affirming substance use counseling is having knowledge of substance use trends within these communities. An exhaustive review of all classes of drugs is beyond the scope of this chap­ ter, and readers are encouraged to educate themselves about prevalence rates of the other substances used by LGBTQ populations (e.g., hallucinogens, inhal­ ants, anabolic steroids, heroin, analgesics). In this chapter we briefly review trends of alcohol, smoking (including marijuana), and stimulant use among LGBTQ individuals. Although alcohol is classified as a depressant, depending on how much is consumed it can also pro­ vide a disinhibiting and uplifting effect. LGBTQ indi­ viduals use alcohol at rates higher than those for het-

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

448

erosexuals. It has been estimated that 91 percent of men who have sex with men (MSM) use alcohol, and 40 percent of these men engage in binge drinking (Wong, Kipke, & Weiss, 2008). Lesbians and bisexual women also use alcohol at elevated rates compared to their heterosexual peers (Hughes, 2005). Interest­ ingly, among people who drink regularly, drinking levels typically decrease with age; however, among many sexual minorities, drinking rates do not decrease with age; they tend to stay the same or increase (New­ comb, Heinz, & Mustanski, 2012). A plausible expla­ nation is that alcohol is often used by nonheterosex­ uals to regulate negative affect associated with living in an oppressive society (Hughes, 2005). Substances such as cocaine, amphetamine, meth­ amphetamine, and 3,4-methylenedioxymethamphet­ amine (MDMA, or ecstasy), which arouse and energize the central nervous system, are classified as stimu­ lants. Most of what is known about stimulant use in LGBTQ individuals is based on research involving gay and bisexual men. It is estimated that approximately 23 percent of LGB individuals use cocaine, compared to 9 percent of the general population (Chaney & Brubaker, 2016). These statistics mirror other findings that showed gay, bisexual, and transgender men are more likely to engage in methamphetamine use com­ pared to other populations (Cochran & Cauce, 2006). One explanation for high rates of stimulant abuse among nonheterosexual and non-cisgender commu­ nities is the ways particular substances are perceived within various populations. For example, Fazio, Hunt, and Moloney (2011) explored MSM’s attitudes toward and beliefs about cocaine use and found that because cocaine use is expected in bars and clubs, the men in the study viewed cocaine as acceptable. Their attitudes toward methamphetamine use, however, were nega­ tive because of its association with HIV infection. Cigarette smoking and marijuana use also are problematic within LGBTQ communities. LGB peo­ ple smoke more than their heterosexual counterparts (Lee, Griffin, & Melvin, 2009). Specifically, approxi­ mately 31.4 percent of gay men and 48 percent of les­ bians smoke cigarettes, compared to 24.7 percent of heterosexual men and 14.9 percent of heterosexual women (Chaney & Brubaker, 2016). Marijuana use also is elevated among nonheterosexuals: an estimated

56 percent of LGB people abuse cannabis, compared to 20 percent of the general population. Explanations for these disparities are discussed later in this chapter. Several factors contribute to the etiology and main­ tenance of substance use disorders among LGBTQ individuals, including the role of LGBTQ bars and clubs, internalized heterosexism, minority stress, inter­ sectionality, and psychosexual stimulation (Chaney & Brubaker, 2014). Historically, LGBTQ establishments such as bars and clubs were places where LGBTQ people could connect and interact with others with­ out fear of negative consequences. Furthermore, bars and clubs helped solidify LGBTQ cultural identities and norms and build cohesion among LGBTQ com­ munities (Ghaziani & Cook, 2005). One challenge associated with bars and clubs as the central meeting spot for many people is the use of alcohol and drugs at these establishments. Because this environment is often where LGBTQ cultural norms and values are established, for some subcultures within LGBTQ populations alcohol and drug use is a cultural norm. This is especially true with club drugs such as cocaine, methamphetamine, and ecstasy (Kelly, Parsons, & Wells, 2006). Because norms tend to be established through the influence of social networks, it is not surprising that frequent socializing with gay men is associated with ecstasy, cocaine, and inhalant use. In addition, having diverse social networks (i.e., a mix of heterosexual and LGBTQ friends) is associated with decreased multiple drug use (Carpiano, Kelly, Easterbrook, & Parsons, 2011). This finding is consis­ tent with other research that found that sexual minori­ ties who are highly involved in LGBTQ communities are more likely to regularly use alcohol and other drugs (Lea, Reynolds, & de Wit, 2013). Though bars and clubs can contribute to high rates of substance use among LGBTQ individuals, internalized heterosexism and minority stress (i.e., stress associated with being a member of an oppressed cultural group) must also be considered. Several studies have found relationships between internalized heterosexism and alcohol and drug use. For example, internalized heterosexism has been cited as a strong predictor for abuse of alcohol among gay men (Amadio, 2006). Weber (2008) found that nonheterosexual women and men who had been diagA Relapse-Prevention Intervention for LGBTQ Clients 449

nosed with at least one SUD experienced heterosexism and internalized heterosexism more frequently than individuals who did not meet criteria for an SUD. In a meta-analysis of studies from 1988 to 2008 that inves­ tigated the relationship between internalized hetero­ sexism and alcohol and/or drug abuse, Brubaker, Gar­ rett, and Dew (2009) reported that the majority of studies showed support or partial support for a rela­ tionship between the two constructs. The aforemen­ tioned results suggest that some people self-medicate the shame, distress, and other negative feelings asso­ ciated with identifying as LGBTQ and living in a het­ erosexist and transphobic society. In other words, alco­ hol and drugs serve as a maladaptive coping strategy. The intersection of multiple oppressed identities also contributes to discrepant rates of alcohol and drug use among LGBTQ populations. Marginalization of one facet of identity can negatively influence other components of a person’s identity (Shields, 2008). Bauermeister (2007) demonstrated that some Latino sexual minorities engage in substance use to escape nonaffirming Latin cultural messages and values and to lower inhibitions when engaging with the LGBTQ community. A study conducted by Halkitis and Jerome (2008) illustrated the relationship among race, sexual orientation, and socioeconomic location as influenc­ ing substance use among African American gay and bisexual male users of methamphetamine. In addi­ tion to abusing stimulants, MSM were more likely to be HIV-positive and to have lower educational attain­ ment. Similar findings have been associated with transgender people of color. A 2005 study reported that almost half of the sample of transpeople of color engaged in substance use (Xavier, Bobbin, Singer, & Budd, 2005). Further, only half of those who used substances sought treatment. Keeping these findings in mind when working with LGBTQ clients with sub­ stance use disorders, competent counselors must explore how clients’ intersecting identities contribute to or maintain substance use. A good amount of research has shown that a con­ tributing factor to substance use among LGBTQ indi­ viduals, especially MSM, are the psychosexual effects of some substances (Brubaker & Chaney, 2017; Newcomb, Clerkin, & Mustanski, 2011). Because many substances enhance sexual arousal, particularly club 450 Chaney & Fonseca

drugs (e.g., ecstasy) and stimulants (e.g., methamphet­ amine), many LGBTQ people find them appealing. Additionally, alcohol and drugs are often used as a way to self-regulate anxiety or tension that may develop between LGBTQ individuals during sexual interactions and to provide sexual endurance to facil­ itate the ability to have sex with partners whom one has just met. Green and Halkitis (2006) called this phenomenon sexual sociality. Interestingly, research has demonstrated that LGBTQ individuals who expe­ rienced high levels of internalized heterosexism tended to have high expectations that substance use will enhance sexual experiences, which for some could lead to high-risk sexual activities (Kashubeck-West & Szymanski, 2008). Therefore, affirming counselors must explore how LGBTQ clients connect alcohol and drug use to sexuality and sexual behavior. When doing so, affirming counselors must remember that they have an ethical obligation not to impose their values, attitudes, and beliefs on clients, especially when cli­ ents share potentially shameful or embarrassing sex­ ual activities and behaviors in which they engaged while high, and throughout the process of treatment (American Counseling Association [ACA], 2014). The National Center on Addiction and Substance Abuse (CASA, 2012) concluded that our current treat­ ment of SUDs mirrors how medicine was approached in the early 1900s. In other words, our present treat­ ment of SUDs is inadequate, and helping professionals need more training and education. This is especially true for treatment providers who work with LGBTQ clients. Because there is no one treatment interven­ tion that is appropriate for all clients, counselors who work with nonheterosexuals and gender-nonbinary clients should be able to select interventions that are effective, culturally responsive, and affirming. More­ over, counselors must take into consideration their ethical responsibilities to use interventions that are grounded in theory and have an empirical basis for use (see ACA, 2014, C.7.a). Research findings related to LGBTQ substance use treatment are rather grim. Although LGBTQ cli­ ents are more likely to seek out substance use treat­ ment services than heterosexuals, they report negative experiences with the services received. Cheng (2003) reported that nonheterosexual clients in substance

abuse programs felt less well supported in treatment because of heterosexist attitudes of staff and other clients. In general, LGBTQ clients with SUDs give sub­ stance use counselors and programs low ratings on being LGBTQ-affirming (Matthews, Selvidge, & Fisher, 2005). LGBTQ participants in treatment in Senreich’s (2009) study reported feeling disconnected, not ther­ apeutically supported, and less satisfied with treatment than the heterosexual clients. Notable is a finding that the sexual minority clients had higher rates of relapse at the end of treatment. Relapse, or the return to substance use, tends to be part of SUDs and the recovery process. In addition, relapse can be influenced by a client’s drug of choice. According to the Substance Abuse and Mental Health Administration, relapse rates are as follows: heroin (87 percent), alcohol (86 percent), crack cocaine (84 percent), and cocaine (55 percent). Given that relapse is part of recovery, it is crucial for counselors to use culturally responsive relapse-prevention strategies in general, and affirming interventions for LGBTQ cli­ ents specifically (Brubaker & Chaney, 2017). Treat­ ment providers who work with LGBTQ clients with SUDs must select interventions that are beneficial and not harmful (see ACA, 2014, ethical code C.7.c). One such intervention is an activity that we conceptu­ alized called the C3PO, which is composed of chart­ ing three (C3) distinct time lines, developing a relapseprevention plan (P), and increasing social support and connecting with others (O). The use of time lines in counseling is not uncom­ mon and has been shown to be effective in the treat­ ment of a variety of issues. Chaney and Burns-Wortham (2015) recommended using time lines for the treat­ ment of MSM to explore how sexually compulsive behavior across the life span has influenced clients’ lev­ els of loneliness and self-esteem. Spiritual time lines have been found to be helpful to assist LGBTQ cli­ ents who have experienced religious abuse to move toward healing (Super & Jacobson, 2011). In addi­ tion, time lines have been strongly recommended as part of the recovery process for clients with psychosis to enhance concordance (i.e., compliance) (Marland, McNay, Fleming, and McCaig, 2011). An additional strength of this activity is that it integrates a service or volunteering activity into the

recovery process and treatment plan, in order to allow clients to give back to their communities, seek out social support, or feel a sense of belonging to others— or a combination of these. Volunteering and service also take some of the emphasis off their subjective negative experiences and allow clients to feel a sense of accomplishment, which can enhance self-esteem by creating positive change, simultaneously offering the client an alternative to substance use (Crocker, Brook, Niiya, & Villacorta, 2006; Miller, Schleien, Rider, & Hall, 2002). Service to the community and develop­ ing a sense of belonging can assist the client to over­ come feelings of personal failure, which could serve as a potential relapse trigger. The following section provides instructions how to implement the C3PO with clients. Instructions

Charting the Time Lines (C3) First, the client is invited to construct a time line that includes LGBTQ identity development milestones. Because there is no right way to craft a time line, cli­ ents may chart a time line that is simply a straight line connecting points along the continuum, or clients can be as creative as they want and draw ornate roads and paths decorated with trees, shrubs, rocks, or other visual symbols of identity development milestones. Clients chart milestones from birth to the present day, focusing on landmarks related to LGBTQ identity development—for example, first awareness of samesex attractions or gender variance, first same-sex sex­ ual experience, coming out to others, entering a first relationship, transitioning, finding a sense of belong­ ing to the LGBTQ community, first experience of heterosexism/transphobia/biphobia/aphobia, and so on. Throughout this first step, counselors should encourage dialogue about client experiences by asking open-ended questions to explore meanings on a deeper level. In the second step, clients can either chart a second time line on a separate sheet of paper or add to the original time line. The second time line should reflect substance use history, milestones, and experi­ ences from birth to the present day. Sample landmarks might include first awareness of alcohol or drugs, first use, first blackout, times in rehab, periods of absti­ nence, relapses, legal consequences, and so on. Again, A Relapse-Prevention Intervention for LGBTQ Clients 451

counselor and client should discuss the time line events. The counselor should pay particular attention to potential links and connections between the plots on the first time line to those on the second. Can relation­ ships be inferred among the timing of points on chart one and chart two? More important, it can be more empowering for clients if they can make the connec­ tions on their own. Next, the client charts a third time line that begins at the present day and extends to a point in the future (e.g., thirty days, six months, one year) mutually agreed on by counselor and client. This third time line plots upcoming relapse-trigger­ ing events and future recovery and LGBTQ identitydevelopment goals. Example points on this chart might include leaving treatment, entering aftercare, finding employment, managing money, attending a self-help group, earning a six-month chip, disclosing sexual ori­ entation or gender identity to family members, or navi­ gating dating life and sexual behavior while sober. Charting of these time lines should happen over the course of three or more sessions. Thorough atten­ tion should be given to exploration of the relevant points on each time line. Furthermore, counselors should demonstrate patience with clients and a nonjudgmental attitude toward what clients chart on their time lines. Planning (P) This stage involves the cocreation of a relapse-preven­ tion plan, with a specific focus on concerns elicited during the C3 section. Counselor and client identify short-term and long-term goals, and they come up with a plan that will help the client stay on track. Coun­ selor and client collaborate on which aspects of the cli­ ent’s environment and personal resiliencies will support recovery and prevent relapse. For each relapse trigger, a relapse-prevention plan must be developed. Moreover, for each identity-development goal, detailed actions steps should be defined. Of utmost concern is a client’s recovery; therefore, future goals must be realistic and achievable, and they should support abstinence. Others (O) A significant aspect of this intervention is the addi­ tional emphasis to help clients feel a sense of belonging within their communities. Although the service or 452 Chaney & Fonseca

volunteer experience will be determined on the basis of where clients are in their recovery process, it should be negotiated between counselor and client. Suggested service activities include volunteering at an animal shel­ ter, setting up and serving coffee at twelve-step meet­ ings, speaking about the risks of substance abuse at local schools or universities, doing work at Habitat for Humanity, donating time to a soup kitchen, and vol­ unteering at a local PFLAG meeting or LGBTQ center. Brief Vignette

Alex is a twenty-four-year-old trans, bisexual, Asian American woman with a history of alcohol abuse. She was assigned male at birth, and her pronouns are she, her, and hers. Chart (C3) When she plots her time lines, certain life events stick out, such as feeling different from her peers at the age of eight, being bullied in eighth grade for being feminine and feeling a pressure to embrace more rigid, masculine gender roles. At fourteen years old she had her first drink, and she began to smoke and drink regularly. She quit drinking in the final year of high school, with the help of her school counselor, and was able to come out to her family as bisexual. They were accepting of her sexuality, as she had dated only women until that point. She doubted her family’s gen­ uine acceptance but says, “This was enough to tide me over for a while, and besides I really needed to clean up my act in order to graduate.” She entered university and started drinking again—at first socially, and then more regularly. She says that while the liberal arts university she attended was very accepting of LGB indi­ viduals, she still felt out of place. At this time she had her first relationship with a man, and she reports that this relationship was extremely abusive. She used alco­ hol in order to cope. She says that this relationship lasted three years. She is currently taking a year off from college and is working. She has broken up with this partner and has found a new, more supportive friend circle, but she continues to drink. She hasn’t come out as being transgender yet, and this is a part of her identity she has only recently started to explore. She reports drinking approximately six large glasses of wine four to five times per week and discloses daily

marijuana use. Because this amount of alcohol no lon­ ger relaxes her, she sometimes drinks a couple shots of vodka in addition to the wine. Upon her completion of the first two time lines, the counselor examined the identity milestones and substance use history charted on them. Themes that emerged included Alex’s use of alcohol and nicotine (fourteen-year-old and twenty-two- to twenty-three­ year-old Alex) to cope with negative emotions and bullying associated with her nonheterosexual and non-cisgender identities. Other themes identified included Alex’s use of alcohol to cope with interper­ sonal violence while in her first relationship with a cisgender man. The time lines revealed that her alco­ hol use increased as she began to explore her trans identity, and she started smoking marijuana daily to self-regulate feelings of fear, anxiety, and shame. The third time line illustrated goals that included achiev­ ing abstinence and coming out to her family and friends as trans. Planning (P) Alex and her counselor established short- and longterm goals that aligned with plots on her third time line. Alex’s primary goal is to achieve sobriety. There­ fore, she agreed to attend AA meetings (thirty meet­ ings in thirty days, to start). In addition, Alex com­ mitted to identifying a sponsor and educating herself about the relationship between her substance use and her sexual orientation and gender identity. She also charted the goal of coming out to her family and friends as trans. She worries that negative reactions to the disclosure might lead to a relapse. To facilitate the coming-out process, Alex worked with her counselor to explore the pros and cons (a decisional matrix was created) of disclosure, engaged in coming-out roleplays, and generated a short list of people to whom she can come out who will be supportive. Further, Alex committed to contacting her sponsor in the event she feels tempted to relapse. In the long term, Alex would like to go back to school and would like to find a healthy, intimate relationship. Both Alex and her counselor agreed not to focus on these long-term goals until Alex has gained healthy recovery time. They will revisit these goals at a later date.

Others (O) Alex continues to reach out to her new friends for support. She committed to attend thirty AA meetings in the next thirty days, which will bolster her support system. In addition, she volunteers with a local com­ munity garden to reinforce mindfulness skills and to foster a sense of accomplishment and social belonging. Suggestions for Follow-up

Relapse-prevention plans should be evaluated and revised as needed. At follow-up, counselors should check in with clients to see if there are milestones or goals on time lines that need to be added, deleted, or revised. In addition, counselors need to assess for clients’ compliance to the relapse-prevention plan and recovery action steps. Because relapse is the rule rather than the exception when it comes to the treat­ ment of substance use disorders, counselors would serve their clients well to use lapses or relapses as edu­ cational opportunities rather than to be punitive. Contraindications for Use

Because some level of insight is necessary to identify relapse triggers, this activity might not be as effective for clients who struggle with psychosis. Counselors who work with clients with visual impairments might need to write portions of the C3PO intervention (including the charting of three time lines) on behalf of the client. Professional Readings and Resources Association of Lesbian, Gay, Bisexual, Transgender Addic­ tion Professionals and Their Allies (NALGAP). (2008). Welcome. www.nalgap.org. Chaney, M. P., & Brubaker, M. (2014). The impact of sub­ stance abuse and addiction in the lives of gay men, ado­ lescents, and boys. In M. M. Kocet (ed.), Counseling gay men, adolescents, and boys: A strengths-based guide for helping professionals and educators, 109–128. New York: Routledge. Hendershot, C. S., Witkiewitz, K., George, W. H., & Marlatt, G. A. (2011). Relapse prevention for addictive behaviors. Substance Abuse Treatment, Prevention, and Policy, 6, 17. doi:10.1186/1747-597X-6-17. Shelton, M. (2017). Fundamentals of LGBT substance use dis­ orders: Multiple identities, multiple challenges. New York: Harrington Park Press.

A Relapse-Prevention Intervention for LGBTQ Clients 453

U.S. Department of Health & Human Services, Substance Abuse and Mental Health Services Administration. (2016). Behavioral health equity: Lesbian, gay, bisexual, and transgender (LGBT). https://www.samhsa.gov/ behavioral-health-equity/lgbt. U.S. Department of Health & Human Services, Substance Abuse and Mental Health Services Administration. Free publications ordering. https://store.samhsa.gov/.

Resources for Clients Alcoholics Anonymous. (2019). Welcome to Alcoholics Anonymous. http://www.aa.org. Najavits, L. M. (2002). A woman’s addiction workbook: Your guide to in-depth healing. Oakland, CA: New Harbinger Publications. PRIDE Institute. (n.d.). PRIDE Institute philosophy. http:// www.pride-institute.com/. SAMHSA’s national helpline: 1-800-662-HELP (4357); TTY: 1-800-487-4889. https://www.samhsa.gov/find-help/ national-helpline. Shelton, M. (2011). Gay men and substance abuse: A basic guide for addicts and those who care for them. Center City, MN: Hazelden. SMART Recovery. (2018). Self-management and recovery training. http://www.smartrecovery.org. Szalavitz, M. (2016). Unbroken brain: A revolutionary new way of understanding addiction. New York: St. Martin’s Press.

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A Relapse-Prevention Intervention for LGBTQ Clients 455

51 EXPLORING THE CONCEPT OF HONESTY WITH TRANSGENDER CLIENTS IN RECOVERY FROM ADDICTION Mia Ocean and George Stoupas

Suggested Uses: Individual activity, homework Objective

This activity is intended for transgender clients in treat­ ment for substance use disorders. The activity cen­ ters on prompts that explore the concept of honesty as it pertains to recovery from addiction. It specifically addresses felt tension between privacy and secrets, and how this tension affects the experiences of transgender people in recovery from addiction. The goal of this activity is to empower clients to make conscious decisions about what they choose to share and with whom while still feeling confident that they are com­ mitted to their recovery. It was designed to be admin­ istered in individual psychotherapy, but it can be mod­ ified for group work. Rationale for Use

There is a need for addiction treatment for transgen­ der individuals, and the services need to address the community’s unique needs. According to the 2015 National Survey on Drug Use and Health, 20.8 million Americans meet the criteria for a substance use dis­ order (SUD), or one in thirteen (Center for Behavioral Statistics and Quality, 2016). Unfortunately, largescale epidemiological surveys often fail to ask about respondents’ gender identity, effectively assuming all are cisgender, that is, that their gender identity corre­ sponds to their sex assigned at birth (Alper, Feit, & Sanders, 2013; GenIUSS Group, 2014). Addiction research and treatment guidelines also often make the same assumption, and few have addressed the spe­ cific characteristics or needs of transgender clients

(Cochran, Peavy, & Robohm, 2007; Green & Feinstein, 2012). It is estimated, however, that between 0.3 and 0.6 percent of the general population identifies as transgender (Conron, Scott, Stowell, & Landers, 2012). In a recent survey of transgender people entering addic­ tion treatment, Flentje, Heck, and Sorensen (2014) found that transgender men (female to male) were younger, less likely to have legal problems, more likely to be employed, more likely to live with a person who abuses substances, and more likely to have experi­ enced recent family conflict compared to the general population seeking treatment. Transgender women (male to female) were less likely to have children, more likely to have had a recent HIV test, and more likely to use methamphetamines than the general popula­ tion. Both groups were more likely to have both phys­ ical and mental health problems than cisgender people seeking addiction treatment. Moreover, transgender people face challenges shared by members of sexual minority communities, such as high rates of substance use, victimization, and discrimination from the general public as well as treat­ ment providers (Eliason, 2000; Lyons et al., 2015; Sen­ reich, 2011; Substance Abuse and Mental Health Ser­ vices Administration [SAMHSA], 2012); however, other issues are unique to this group. These include not being called by their preferred name, being required to live in residential treatment units and use bath­ rooms corresponding to their sex assigned at birth rather than gender identity, not being allowed to dress as they choose, and being prohibited from using hor­ mones—regardless of whether they are prescribed by a physician or illicitly purchased on the street (Lom-

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bardi & van Servellen, 2000; Lyons et al., 2015; SAM­ HSA, 2001; Singh & Burnes, 2010; Sperber, Landers, & Lawrence, 2005). In an exploratory study, Senreich (2011) interviewed 305 addiction treatment clients about their experiences and compared the responses of those who identified as cisgender heterosexual, cisgender LGB, and transgender. Responses indicated that transgender clients feel lower levels of therapeu­ tic support, have more concerns about being open and honest, and are less satisfied with treatment than those in the other groups. Moreover, only about onethird of the transgender clients completed treatment, half as many as LGB clients. While many clinicians may have some training regarding best practices with sexual minority clients, many fewer report training specific to working with the transgender community (Eliason, 2000; Lyons et al., 2015). It is critical that clinicians understand the particular obstacles faced by members of this population. One such issue is the concept of “rigorous hon­ esty” found throughout twelve-step literature (Alco­ holics Anonymous, 2001, p. 58). The twelve-step model is used in 84 percent of U.S. addiction treatment pro­ grams (SAMHSA, 2015) and therefore has signifi­ cant influence on how addiction and recovery are understood. A common saying in addiction recovery is “we are only as sick as our secrets.” Addiction coun­ selors, sponsors, and members of the recovery com­ munity place great emphasis on transparency and openness as antidotes to the deception and isolation typically involved in drug culture (SAMHSA, 2014). People in early recovery are often warned that hiding information—especially that which elicits feelings of shame—will lead to relapse (Brown, 2008). Clinicians who fail to take into account how this emphasis on honesty translates to the experience of transgender clients may risk doing harm. As previously noted, this population experiences significantly high rates of social rejection, harassment, and violence—sometimes from staff and peers while receiving treatment (Lyons et al., 2015). Therefore, transgender people may attempt to pass as cisgender to protect themselves (Flentje et al., 2014; SAMHSA, 2001), though some do not have this option. Clinicians must help transgender clients differentiate between healthy privacy and the secrets that undermine recovery from addiction (Association

for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling [ALGBTIC], 2010). This activity affirms transgender clients’ experi­ ences and in doing so may reduce the risk that they leave treatment prematurely. It reflects the ALGBTIC (2010) “Competencies for Counseling with Transgen­ der Clients” by recognizing that discrimination and marginalization influence transgender people’s selfesteem and that problem substance use can be caused or exacerbated by these experiences. The activity recognizes that the intersecting identities as a trans person and a person in recovery may sometimes be in conflict; it also recognizes that sociocultural forces outside the person’s control often shape related expe­ riences. This activity is also meant to empower this group of people by highlighting the role of personal choice in sharing information and supporting auton­ omy. It recognizes that helping professionals can be intentionally or unintentionally hurtful through insen­ sitivity and inattention, and it seeks to remedy this problem through a spirit of respect and knowledge. The following sections of the American Counsel­ ing Association’s Code of Ethics (2014) are reflected in this activity: A.1.a. Primary Responsibility; A.4.a. Avoiding Harm; A.4.b. Personal Values; A.7.a. Advo­ cacy; B.1.a. Multicultural/Diversity Considerations; B.1.b. Respect for Privacy; B.1.c. Respect for Confiden­ tiality; C.5. Nondiscrimination; E.5.b. Cultural Sen­ sitivity; and E.5.c. Historical and Social Prejudices in the Diagnosis of Pathology. Specifically, this activity embodies these guidelines by affirming the dignity of transgender clients and respecting their right to pri­ vacy. Through an understanding of the unique expe­ riences of this group, counselors engage in ethical practice by recognizing cultural differences in con­ cepts like honesty. Clients are supported in their auton­ omy and empowered to make their own choices. Instructions

This activity consists of a number of prompts (found at the end of this chapter) designed to elicit thinking and discussion about these concepts. They are written in a specific order to encourage an initial exploration of the terms and concepts before moving into practi­ cal application in the client’s life. The prompts can be used once rapport has been formed between the clini-

Exploring the Concept of Honesty with Transgender Clients 457

cian and client, as there should be a sense of safety in the therapeutic environment; however, it is appropri­ ate to complete this exercise in the early stages of the clinical relationship, as it can assist in developing the therapeutic relationship by helping the client feel understood. Additionally, these prompts can engage and empower clients to consciously decide what they want to share with their counselor and what they want to keep private. This exercise offers an opportunity to investigate what the client has learned about honesty, secrets, and privacy. Because this process can be exceedingly complex, it is best to move from a general definition of concepts (e.g., privacy) into more nuanced analysis. Doing so can serve as a primer for planning future decisions, as the therapist can help clients explore their choices in these areas from a position of empower­ ment. Finally, this activity includes specific scenarios tailored to the client’s concerns. These can be used to role-play the new choices and rehearse the skills needed to execute them. The prompts are most useful when the client is given time to read, reflect, and write about them as a journaling homework assignment before processing in the next session with the counselor. Because home­ work assignments are not always appropriate (or com­ pleted), however, these prompts can also be used to create a worksheet for the client to complete during an individual session or used verbally within a therapy session. The questions could also be used for group work if a safe environment has been created and a range of potentially divergent perspectives can be respected simultaneously. Ideally, the counselor will be knowledgeable about the laws and protections that exist for transgender individuals in the community, not only in case the cli­ ent has questions, but also so that the clinician can provide educated feedback and additional prompts that address the environmental constraints and resources. This information can be found by consult­ ing national advocacy centers, local discrimination legislation, and institutional policies. It is important to be realistic and take into consideration safety when discussing issues of disclosure with transgender clients. Note: Though the primary focus of this chapter is transgender individuals, it is important to note that 458 Ocean & Stoupas

many intersex individuals face similar issues. We acknowledge that socially constructed, binary defini­ tions are limited and do not reflect the natural world. Individuals who do not fit neatly within these catego­ ries can experience distress as the result of this social arrangement, and therefore this activity may also be used with intersex clients in recovery from addiction who face similar problems (Dreger & Herndon, 2009; Johnson, Mimiaga, & Bradford, 2008). Brief Vignette

Lamar is a twenty-four-year-old African American, transgender man. He was cast out of his family home as a teenager for failing to “act like a girl,” and he sub­ sequently lived with a number of different friends. Lamar began selling small amounts of cocaine as a means to support himself, and later he began using it. His use escalated quickly, which resulted in a num­ ber of problems that culminated in an arrest for pos­ session. Because he was a first-time offender, Lamar was given the option of completing an inpatient treat­ ment program to avoid conviction. He developed a good rapport with his counselor at the facility, who allowed Lamar to stay in a room by himself and did not force him to disclose his status to the other clients there. Now nearing the end of his treatment, Lamar wants to transfer to a halfway house to safeguard his recovery and because he has nowhere else to go. He is anxious, however, as all the halfway houses are gender-specific and will not offer him the same level of accommodations he has received in the treatment center. Lamar is questioning issues of safety and hon­ esty in terms of his recovery and gender. The counselor uses the activity prompts to help Lamar explore what might happen after he leaves the facility and enters the halfway house. As a homework assignment, Lamar writes in his journal about the role of honesty in his recovery and reflects on the way in which he kept secrets about his gender identity in the past. Together with his counselor, Lamar processes his experiences growing up, such as keeping a sepa­ rate set of male clothing hidden from his family and the initial anxiety he felt about the chance of his get­ ting caught in public using a different name. During this discussion, Lamar also reflects on the role that African American culture played in his family’s gender

expectations, as well as the racial discrimination he experienced in addition to the discrimination he has faced as a trans person. In Lamar’s writing, he differ­ entiates between his feelings about privacy related to being transgender and the shame he felt as the result of his addiction. Lamar observes, “I am who I am, and some stuff isn’t anybody’s business. I don’t feel ashamed about who I am, but I also don’t need to go tell every­ body about being trans for fear I might relapse.” In reference to his drug use, he states, “When I started lying about my drug use, stealing from my friends, doing illegal stuff like dealing—that’s what I have to watch out for. I have to be honest about what I did and the hurt I caused, and I have to share about my triggers going forward because it will help me stay sober.” With these differences in mind, the counselor and Lamar role-play boundary setting in situations that might come up at the halfway house, including his plan to discuss his privacy concerns with the staff when he arrives. Suggestions for Follow-up

The prompts constitute a onetime activity, but the top­ ics and reflections are likely to require exploration over many sessions. Honesty, secrecy, and privacy are com­ plicated topics for the general population, and the associated complexities are intensified for transgender individuals in recovery. Untangling a history of secrecy and shame requires patience and persistence by the counselor. Additionally, this is an exercise that can be revisited, and the client’s views and positions are likely to change from early recovery to long-term recovery. Contraindications for Use

It is unlikely that these prompts will provide therapeu­ tic value when clients are in the process of detoxifi­ cation or presenting with co-occurring disorders that require immediate care. They are intended for use with individuals in any stage of change and a variety of treatment settings; however, they may need to be tailored to the individual client. The clinician needs to remain mindful that being more open about one’s gender is not a sign of self-actualization, and in some cases it may jeopardize the client’s physical safety or financial security.

Professional Readings and Resources Luke, D. A., Ribisl, K. M., Walton, M. A., & Davidson, W. S. (2002). Assessing the diversity of personal beliefs about addiction: Development of the Addiction Belief Inven­ tory. Substance Use & Misuse, 37 (1), 89–120. http:// www.tandfonline.com/loi/isum20. NALGAP: The Association of Lesbian, Gay, Bisexual, Transgender Addiction Professionals and Their Allies. (2008). Welcome. www.nalgap.org/. Office of Disease Prevention and Health Promotion. (2017). Lesbian, gay, bisexual, and transgender health. https:// www.healthypeople.gov/2020/topics-objectives/topic/ lesbian-gay-bisexual-and-transgender-health?topicid=25. Toscano, P. (2009, October 15). Privileges of non-transgender people. https://petersontoscano.wordpress.com/2009/10/ 15/ privilege-of-non-transgender-people/.

Resources for Clients Print Resources

Block, S. H., Block, C. B., & du Plessis, G. (2016). Mind-body workbook for addiction: Effective tools for substance-abuse recovery and relapse prevention. Oakland, CA: New Har­ binger Publications. Denning, P., & Little, J. (2017). Over the influence: The harm reduction guide to controlling your drug and alcohol use. New York: Guilford Press. Groups

GLBT Recovery. Gay, lesbian, bisexual & transgender. http:// usrecovery.info/GLBT/index.htm. Online Intergroup Alcoholics Anonymous. LGBT meetings. https://aa-intergroup.org/directory_glbt.php. Substance Abuse and Mental Health Services Administration. Behavioral health treatment services locator. https:// findtreatment.samhsa.gov/. Documentary Films

Duran, I. (2015). The trans list. HBO Studios. Jarecki, E., Cullman, S., Shopsin, M., & St. John, C. (2012). The house I live in. Virgil Films and Entertainment. Thomas, A., & Nevins, S. (2005). Middle sexes: Redefining he and she. HBO Studios. Williams, G. D. (producer). (2013). The anonymous people. 4th Dimension Productions. National Transgender Organizations

Human Rights Campaign. www.hrc.org. National Center for Transgender Equality. https://www. transequality.org. Transgender Law Center. https://transgenderlawcenter.org.

References Alcoholics Anonymous. (2001). Alcoholics Anonymous, 4th edition. New York: A.A. World Services. Alper, J., Feit, M. N., & Sanders, J. Q. (2013). Collecting sexual

Exploring the Concept of Honesty with Transgender Clients 459

orientation and gender identity data in electronic health records: Workshop summary. https://www.ncbi.nlm.nih. gov/books/NBK132859/pdf/Bookshelf_NBK132859.pdf. American Counseling Association, (2014). Code of ethics and standards of practice. Alexandria, VA: Author. Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) (2010). Competencies for coun­ seling with transgender clients. Journal of LGBT Issues in Counseling, 4 (3–4), 135–159. doi:10.1080/15538605.201 0.524839. Brown, H. M. (2008). Shame and relapse issues with the chem­ ically dependent client. Alcoholism Treatment Quarterly, 8 (3), 77–82. doi:10.1300/J020V08N03_07. Center for Behavioral Statistics and Quality. (2016). Key sub­ stance abuse and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication no. SMA 16-4984, NSDUH series H-51). Rockville, MD: Substance Abuse and Men­ tal Health Services Administration. Cochran, B. N., Peavy, K. M., & Robohm, J. S. (2007). Do spe­ cialized services exist for LGBT individuals seeking treat­ ment for substance misuse? A study of available treatment programs. Substance Use & Misuse, 42 (1), 161–176. doi:10. 1080/10826080601094207. Conron, K. J., Scott, G., Stowell, G. S., & Landers, S. J. (2012). Transgender health in Massachusetts: Results from a household probability sample of adults. American Journal of Public Health, 102 (1), 118–122. doi:10.2105/AJPH.2011. 300315. Dreger, A. D., & Herndon, A. M. (2009). Progress and politics in the intersex rights movement: Feminist theory in action. GLQ: A Journal of Lesbian and Gay Studies, 15 (2), 199–224. doi:10.1215/10642684-2008-134. Eliason, M. J. (2000). Substance abuse counselors’ attitudes regarding lesbian, gay, bisexual, and transgendered clients. Journal of Substance Abuse, 12, 311–328. Flentje, A., Heck, N. C., & Sorensen, J. L. (2014). Characteris­ tics of transgender individuals entering substance abuse treatment. Addictive Behaviors, 39, 969–975. doi:10.1016/ j.addbeh.2014.01.011. GenIUSS Group. (2014). Best practices for asking questions to identify transgender and other gender minority respondents on population-based surveys. Edited by J. L. Herman. Los Angeles: Williams Institute. https://williamsinstitute.law. ucla.edu/wp-content/uploads/geniuss-report-sep-2014. pdf. Green, K. E., & Feinstein, B. A. (2012). Substance use in les­ bian, gay, and bisexual populations: An update on empir­ ical research and implications for treatment. Psychology of Addictive Behaviors, 26 (2), 265–78. doi:10.1037/a00 25424. Johnson, C. V., Mimiaga, M. J., & Bradford, J. (2008). Health care issues among lesbian, gay, bisexual, transgender, and

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intersex (LGBTI) populations in the United States. Journal of Homosexuality, 54 (3), 213–224. http://dx.doi.org/10. 1080/00918360801982025. Lombardi, E. L., & van Servellen, G. (2000). Building cultur­ ally sensitive substance use prevention and treatment programs for transgendered populations. Journal of Sub­ stance Abuse Treatment, 19 (3), 291–296. doi:10.1016/ S0740-5472(00)00114-8. Lyons, T., Shannon, K., Pierre, L., Small, W., Krüsi, A., & Kerr, T. (2015). A qualitative study of transgender individuals’ experiences in residential addiction treatment settings: Stigma and inclusivity. Substance Abuse Treatment, Pre­ vention, and Policy, 10 (17). https://substanceabusepolicy. biomedcentral.com/track/pdf/10.1186/s13011-01 5-0015-4. Senreich, E. (2011). The substance abuse treatment experiences of a small sample of transgender clients. Journal of Social Work Practice in the Addictions, 11 (3), 295–299. doi:10.1 080/1533256X.2011.592795. Singh, A. A., & Burnes, T. R. (2010). Shifting the counselor role from gatekeeping to advocacy: Ten strategies for using the Competencies for Counseling with Transgender Cli­ ents for individual and social change. Journal of LGBT Issues in Counseling, 4 (3–4), 241–255. doi:10.1080/15538 605.2010.525455. Sperber, J., Landers, S., & Lawrence, S. (2005). Access to health care for transgendered persons: Results of a needs assess­ ment in Boston. International Journal of Transgenderism, 8 (2–3), 74–91. doi:10.1300/J485v08n02_08. Substance Abuse and Mental Health Services Administration (SAMHSA). (2001). A provider’s introduction to substance abuse treatment for lesbian, gay, bisexual, and transgender individuals. HHS Publication no. (SMA) 01–3498. Rock­ ville, MD: Substance Abuse and Mental Health Services Administration. Substance Abuse and Mental Health Services Administration (SAMHSA). (2012). Top health issues for LGBT popula­ tions: Information & resource kit. HHS Publication no. (SMA) 12-4684. Rockville, MD: Substance Abuse and Mental Health Services Administration. Substance Abuse and Mental Health Services Administration (SAMHSA). (2014). Improving cultural competence. Treat­ ment Improvement Protocol (TIP) series no. 59. HHS Publication no. (SMA) 14-4849. Rockville, MD: Substance Abuse and Mental Health Services Administration. Substance Abuse and Mental Health Services Administration (SAMHSA). (2015). National Survey of Substance Abuse Treatment Services (N-SSATS): 2014. Data on substance abuse treatment facilities. BHSIS series S-79, HHS Publi­ cation no. (SMA) 16-4963. Rockville, MD: Substance Abuse and Mental Health Services Administration.

JOURNAL/DISCUSSION PROMPTS Opening prompts: Defining terms • How do you define honesty, secrecy, and privacy?

• What have you learned about honesty, secrecy, and privacy in your life?

• What experiences (positive or negative) have you had with honesty, secrecy, and privacy?

• What is the difference between secrecy and privacy?

• What has been your philosophy about honesty, secrecy, and privacy?

Teasing out the nuances • In what ways have you been forced to lie about your gender?

• In what ways have you been forced to tell the truth about your gender?

• In what ways were you honest with yourself and others about your use?

• In what ways were you deceptive to yourself and others about your use?

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• In what ways is being open about your gender different from being open about your use (or other aspects of your life)?

• In what ways is being open about your gender the same as being open about your use (or other aspects of your life)?

• What are the expectations regarding honesty in recovery? Which do you agree with, and which do you disagree with?

• What have you been told about your gender and honesty from people in the recovery world (e.g., peers, professionals)? How has that affected you and your recovery? What do you think they got right, and what did they get wrong?

• How can people be honest and maintain their right to privacy in recovery?

Choices about privacy • What are specific signs you will notice if deception is jeopardizing your recovery?

• Which aspects of your gender or recovery do you want to disclose to others?

• Which aspects of your gender or recovery do you want to keep private?

• How could you respond honestly, while simultaneously respecting your privacy, to a question from a family member, friend, colleague, or acquaintance about your gender or recovery? How might your response vary on any given day?

• Brainstorm responses you can use on days you do not feel like talking about your gender or recovery with anyone.

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• It is a privilege, not a right, to know things about you, including your gender or recovery. Which characteristics and qualities must individuals possess to earn that privilege?

• Write your own personal philosophy about honesty, secrecy, and privacy. Be sure to include examples of how your personal philosophy relates to your recovery and gender identity.

Practice scenarios • During a conversation with a fellow twelve-step member, that persons asks you, “How female or male are you, really?” clearly inquiring about your genitals. Pushing the issue, the person says, “We are only as sick as our secrets.” How would you ideally like to respond? How confident are you that you could respond that way right now?

• A fellow member of a peer-support group voices the opinion that people who use needles to inject hormones have relapsed and need to “start over.” What thoughts and feelings might this opinion bring up for you? Would you challenge this opinion? If so, what would you say? If not, then why not?

• The group facilitator in your aftercare program pulls you aside after the first group and says, “I think it’s really important that you tell the group you are trans.” How would you respond? What are your thoughts about the benefits and the risks of doing so?

• You are completing treatment soon and in the process of exploring living arrangements for aftercare. All the programs in your area are gender-specific. Do you share personal details with the staff at prospective programs? If so, what do you say? If not, why not?

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52 USING ART THERAPY TO ADDRESS BODY DYSPHORIA, BODY IMAGE, AND EATING CONCERNS WITH TRANS AND NONBINARY CLIENTS Jeannine Cicco Barker Suggested Use: Activity Objective

This chapter presents an art-therapy task that can be incorporated into therapy with clients who have trans, nonbinary, or gender-nonconforming (GNC) identi­ ties. There are three objectives for this art-therapy intervention. The first is to provide a tool that thera­ pists can employ with trans and gender-diverse-iden­ tifying clients to express and explore body dysphoria and body image issues that may put them at risk for eating concerns. The second is to facilitate the assess­ ment of body-related concerns and whether eating concerns and body image problems may be related to body dysphoria. The third is to give clients a space to begin to process their experiences in their bodies: spe­ cifically, identifying with a gender other than that which was assigned to them at birth and any body dysphoria that may exist as a result; the influence of society and culture on body ideals, which may be inter­ nalized by the client; their experiences in the world given their intersecting identities and the cisnormative societal standards for female and male bodies; and the effects of a lack of representation for trans and nonbinary people. Rationale for Use

Eating disorders were once believed to affect primar­ ily white, cisgender, middle- and upper-middle-class females (Kashubeck-West & Tagger, 2012; National Eating Disorders Association, 2016). Though clini­

cians and eating disorder specialists now recognize that eating disorders can affect anyone, regardless of class, gender, racial or ethnic background, and sexual orientation, unfortunately the literature has not fully caught up to reflect this knowledge. Eating disorders present in similar prevalence rates across racial back­ grounds, with the exception of anorexia nervosa, which is highest among white individuals (National Eating Disorders Association, 2016). Even so, the liter­ ature on eating concerns among marginalized and underrepresented groups, especially trans and genderdiverse clients, is lacking (Diemer et al., 2015; Jones, Haycraft, Murjan, & Arcelus, 2016; Kashubeck-West & Tagger, 2012). Most of the literature geared toward the treatment of eating concerns, including even the DSM criteria of eating disorders, has been based on the clinical presentations and treatment of white, cisgender female clients (Diemer et al., 2015; KashubeckWest & Tagger, 2012). Indeed, it has been largely white, cisgender female clients who have presented for eating disorder treatment, which in turn has affected the available research and literature. There is some evidence to suggest that marginalized groups, such as people of color and LGBTQ clients, may not present for treatment as often as their white cisgender female counterparts, or they may underreport symptoms or be misdiagnosed because of unintentional bias from providers and even the DSM (National Eating Disor­ ders Association, 2016). As a review of the literature, discussed below, shows, trans and GNC clients also present with eating concerns. Understanding these

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clinical presentations, which may differ from what is described in the literature, which is focused mostly on cisgender females, is important in treating these clients sensitively and effectively. A survey of the literature as it relates to transidentified clients with eating concerns yields minimal results. Most of the articles written on the subject include case studies, and more research is thus needed to inform the treatment of trans-identifying clients with eating concerns (Diemer et al., 2015; Jones et al., 2016). In their review of the literature, Jones and colleagues (2016) found common themes: that most trans clients had past or present disordered eating patterns in order to “suppress features of their biological gender or to accentuate features of their gender identity” (p. 90); and that overall, trans cli­ ents suffered from higher levels of dissatisfaction with their bodies and disordered eating behaviors when compared to the cisgender population. Simi­ larly, Witcomb et al. (2015) found that trans clients had higher presentations of body dissatisfaction and disordered eating than matched cisgender controls but did not score as high as cisgender clients in terms of clinical diagnoses of eating disorders. Further, in one study, eating problems were found to be more prevalent among trans and sexual-minority clients than cisgender heterosexual participants, possibly as a result of minority stress (Diemer et al., 2015), and Watson, Veale, & Saewyc (2017) found that transgender youth had higher levels of disordered eating compared to cisgender samples. On the basis of their review, Jones and colleagues (2016) asserted that trans clients are at risk for, or may present with, dis­ ordered eating related to body dissatisfaction because of gender dysphoria (see also Vocks, Stahn, Loenser, & Legenbauer, 2009), but that they may not present with “clinically significant eating disorders” (Jones et al., 2016, p. 91), according to diagnostic criteria. Thus, the authors encourage clinicians to assess what is driving eating concerns with trans clients in order to ascertain how to best approach treatment. If the eating behaviors are driven by gender dysphoria, then treatment may look different from the way it would if the eating behaviors are driven by body dis­ satisfaction that leads to a desire to lose weight, as is

reflected in a large portion of the literature to date (Jones et al., 2016). Indeed, gender dysphoria does appear to play an important role in the eating problems seen in trans clients, according to the limited research available. Negative mood is a risk factor for many with eating concerns; however, this does not appear to be the case for trans clients, supporting the idea that eating con­ cerns may result from body dysphoria (Bell, Rieger, & Hirsch, 2019). For clients who identify as trans, dis­ ordered eating may become a way to attain a more feminine body to fit their gender identity, to obtain a more masculine or muscular physique, or to accentu­ ate or suppress gender-related physical features (Cou­ turier, Pindiprolu, Findlay, & Johnson, 2015; Diemer et al., 2015; Jones et al., 2016; Murray, Boon, & Touyz, 2013; Strandjord, Ng, & Rome, 2015). For trans women in particular, this may mean that there has been an internalization of the thin ideal, a risk factor for eating disorders among cisgender females (Jones et al., 2016). Notably, the literature suggests that with successful gender-confirmation treatment, which leads to a healthy expression of gender identity, eating concerns and body dissatisfaction may improve for trans clients, although additional eating-concern­ focused therapy may be required (Couturier et al., 2015; Strandjord et al., 2015). Further, experiences of marginalization and enacted stigma are also con­ nected to higher levels of eating concerns among transgender youth (Watson et al., 2017). These find­ ings have important implications for the treatment of trans and nonbinary persons with eating concerns. As a result of this review, it is clear that trans-iden­ tified clients are at risk for eating concerns and dis­ orders because of gender and body dysphoria and mar­ ginalization. Given the limitations of the literature and of our diagnostic systems, as well as a lack of access to resources for underrepresented groups, it is possi­ ble that some trans clients may go underdiagnosed for eating concerns. Gender dysphoria, and not nec­ essarily a more classic drive for thinness as represented in the DSM-5 (American Psychiatric Association, 2013), may contribute to the eating concerns seen in trans and GNC clients (see Jones et al., 2016). Thus, clients who are trans may not neatly fit into the pres-

Art Therapy to Address Body Dysphoria and Eating Concerns 465

ent diagnostic criteria for eating disorders, but they may nevertheless present with distressing symptoms that warrant multiculturally informed and evi­ dence-based treatment of these issues. Instructions

To practice as an art therapist, one must obtain gradu­ ate-level training and supervision by a board-certi­ fied art therapist. The following is an art-therapy direc­ tive that can be woven into therapy by therapists who do not have such a background in art therapy. Please be advised that incorporating a task such as this does not make one an art therapist. Still, using art-related directives and interventions in therapy can be appro­ priate at times, especially under consultation with a certified art therapist. Thus, the following activity has been designed particularly for therapists who do not have a background in art therapy, and it may prove to be a useful therapeutic approach. This task is meant to be completed in the context of a therapy session with the therapist present. The task should be introduced at the beginning of a session so that there is enough time to process, ground the client if needed, and address any other areas of diffi­ culty that could come up because of related problems. Specifically, therapists should be mindful of other con­ cerns their clients may have that could become acti­ vated in discussing themes related to body dysphoria and experiences of marginalization because of their gender identity. Please leave ample time to address traumatic experiences that may be triggered, such as trauma-related experiences of oppression and minority stress; increased feelings of depression or hopelessness; urges to engage in harmful eating behaviors; and urges to engage in self-harm. Along these lines, therapists should assess for risk, including suicidal ideation, and leave time to plan for safety, as appropriate. For this task, clients will be asked to create a col­ lage to reflect on and express their experiences in their bodies. Clients are invited to share body dysphoria and body-image-related concerns in the art. Further, clients are asked to reflect on the influence of society and culture, as well as the cisnormative ideals for bod­ ies in society. In so doing, therapists may attempt to empower their clients and encourage them to think

466 Cicco Barker

critically about the systems of oppression in society that further these messages and the marginalization of trans and gender-diverse clients. Materials. Please supply the following materials for your client: • 18- × 12-inch white drawing paper, preferably 60–80 lb., if possible • A wide variety of collage materials (Note: Precut and preselected materials are best in order to save time and to bypass potentially triggering imagery in magazines. Include words and images of multicul­ turally diverse people, nonhuman animals, nature, various objects, and so on) • Colored construction paper (any size is fine) for collage work • Fine-tipped markers and/or colored pencils (Note: Please stay away from other drawing or art materi­ als as they can be affectively flooding; for this task, markers and colored pencils are best as they offer control and containment) • Glue sticks (Note: Those that change from purple to clear are best, as clear glue can sometimes trigger those with traumatic histories) • Scissors Art therapy task. This task works best if you can pro­ vide a workspace, preferably a table, for your client during the art-making portion of the session. The ther­ apist can sit at the table with the client but should refrain from making comments on the artwork as the client is working. Particularly avoid comments about the art that qualitatively judge it as “good art.” Art therapy is not about the aesthetics of the finished prod­ uct, but rather about what clients are able to express and learn about themselves through their art making. Clients often come to art therapy with anxiety about making art in front of someone else; therefore, abstain­ ing from such commentary will promote a safe, judg­ ment-free environment for clients to express them­ selves and engage in self-reflection. In introducing the task, invite your client to make art. Therapists should not force clients to participate in this task but instead empower them to choose what may work best for them in the session. To invite your

client to engage in art making in session, you may introduce the task in the following, or a related, man­ ner: “I am wondering if you would be willing to make some artwork today to express some of your experi­ ences in your body, so that perhaps we can talk more about what this is like for you and, in particular, what is difficult and challenging for you. Sometimes thoughts, feelings, and experiences can be difficult to put into words, and art making can provide a safe way to express and understand these things, as well as provide an opportunity for both of us to learn more about you and your experiences. This isn’t about what your art looks like, or how good an artist you are—don’t worry, I will not be judging your cre­ ative talent today! This is more about expressing what you need to say, having a safe space to do this, and seeing what comes out of this process. I have art materials over there at the table, and I will be giving you some directions to help you explore this further, and then we can talk more about your artwork together. Does this sound like something you would be open to doing today?” You may also choose to introduce this activity in one session and, upon agree­ ment from your client, have the materials available in the following session. If your clients agree, lead them over to the table with the art materials. Give them a piece of the 18- × 12-inch drawing paper. Present the task in the follow­ ing manner. Ask your clients to orient their paper horizontally and fold the paper in half vertically. Then ask them to create an outline of their body based on how they feel in their body today on the left side of the page. Ask your clients to fill the body outline and sur­ rounding area on the left with how they currently feel in their body, using collage images, lines, shapes, colors, words, and symbols. Then ask your clients to create a collage on the right that speaks to their body ideal, including messages from society about what a female or male body should look like, which may be contributing to body dysphoria, body image, or eating concerns. They may start with an outline of this body ideal first, if doing so is helpful, or they may simply fill this side with imagery and words. If clients do not identify as male or female, you may have them use the right side of the page to create a collage to express

the messages they receive from society about gender and gender expression through one’s body. They can use the collage materials or drawing materials, or a combination, for any portion of this task. Give your clients ample time to engage in the art making, as art making also provides space for self-reflection and distance from internal experiences. Twenty to thirty minutes should be enough time for most clients. Gently inform clients when they have five minutes left, then one minute left, if needed. Discussion points after art making. Allow for time in session to process what the clients have created. This is also an opportunity for you as the therapist to gather more information to inform your assessment of these concerns and to further inform treatment plan­ ning, as appropriate. Pay particular attention to assess­ ing eating-related concerns and giving clients space in session to share with you any harmful eating pat­ terns they have ever engaged in to change their body in any way. To begin, ask them to tell you about what they have created. You can say something like, “I am look­ ing forward to hearing more about what you have made here. Can you tell me about your artwork?” Again, in talking about the artwork, abstain from mak­ ing qualitative comments about the artwork, such as “This is great!” or “You are such a talented artist!” Also avoid assuming that your clients’ artwork has a particular meaning; instead, ask your clients to tell you more about their artwork to learn what they intended it to represent. Explore with your clients what they have expressed in their artwork and what this means for them. Use their imagery, words, the arrange­ ment on the page, and (importantly) their asso­ ciations to gather information to assess any body dys­ phoria and any connected eating-related concerns. Please see the handout at the end of the chapter for some discussion questions. Brief Vignette

Dani is a twenty-four-year-old, self-identified queer, Latinx graduate student. Dani’s pronouns are they, them, and theirs, they are able-bodied, and they come from a middle-class, first-generation American Latinx family. Dani’s assigned sex at birth was female,

Art Therapy to Address Body Dysphoria and Eating Concerns 467

and they identify as genderqueer and genderfluid; their gender expression may fluctuate between male and female, or both at times. Julie, a postdoctoral fel­ low at the university counseling center, who identi­ fies as a ciswoman and white, began working with Dani six weeks ago, when Dani came into therapy to address depressed mood and decreased motivation to engage in their academic work. In establishing a relationship with Dani, Julie spoke to some of her more visible identities with Dani, processing what it was like for Dani to work with her as a white, cisgender female therapist. This promoted safety within the context of their relationship and helped Dani feel comfortable sharing more about their identities with their therapist. Julie introduced this art therapy task with Dani when they began sharing more about the discomfort they feel in their body. Dani expressed experiencing high levels of anxiety in anticipating what they might have to wear to a conference where they will be pre­ senting some of their research later in the year. This anxiety was causing Dani to feel more depressed and socially anxious. On the left of their artwork, Dani depicted an exaggerated female form, with accentuated breasts, waist, and hips. Imagery and words spoke to feeling “trapped,” “isolated,” and “misunderstood” in their body, as well as “confused” and “mixed up,” but also “powerful” and “beautiful” in identifying with aspects of male and female genders. They spoke about their discomfort at times with the feminine aspects of their body, particularly how their body is deemed “too curvy” by American standards but acceptable within the Latinx community. Still, Dani shared the recollection that growing up they were called “gordita” (a term of endearment meaning “chubby” or “little fat one”) by their family members, and that this, cou­ pled with their discomfort with their feminine body, led to restrictive eating at times in high school and college in order to lose weight. Dani noted that in high school and college, they wanted to be thinner to have a more androgynous gender expression, which led to their losing about twenty pounds through restrictive eating and overexercise. Further, Dani expressed dis­ dain for the traditional gender roles in their family’s culture and observed with sadness how they have to

468 Cicco Barker

conceal their gender identity when with their family, which was quite distressing for them. Though Dani moved toward embracing their genderqueer, more fluid identity, eating concerns remained a struggle at times. They noted that on days when they feel more disgusted with their breasts, hips, and thighs, they are prone to skipping meals. Dani remarked that they may be less likely to skip meals on days when they embrace a more female expression of their gender, but that this back-and-forth cycle is common for them. In creating the artwork, Dani was able to express to their therapist more about these experiences in their body, began to open up about the ways in which their Latinx and genderqueer identi­ ties intersect and contribute to their body dysphoria and body image concerns, and started to share their memories of how eating problems developed out of this struggle and have continued to this day. Suggestions for Follow-up

This activity can be revisited and employed later in therapy, as appropriate. For example, if the client is in the process of transitioning, you may want to rein­ troduce this task at a later date to assess levels of body dysphoria, presence of body-image concerns, and so on. The collages can also be referred to if you and the client are revisiting any of these themes or issues in later sessions. If, during this session or in a follow-up session with clients, you determine that they are struggling with a serious eating problem or disorder, alternative treatment options may need to be considered. In par­ ticular, you may need to consider connecting them to multidisciplinary treatment providers, including nutritionists or physicians, or a higher level of care if that is warranted. You may need to serve as an advo­ cate for your client in such a scenario, as finding treat­ ment providers and agencies that are trans compe­ tent and affirming is essential. Connecting your client to a provider who is not trans competent or affirming may, in the worst-case scenario, lead to a worsening of symptoms. Last, your clients may also need to be connected to medical providers who can assist with transition­ ing, should they desire to pursue this. If this is the case,

you should consult the WPATH Standard of Care guidelines (Coleman et al., 2011) to understand the treatment of clients who are seeking to transition, and what your role may be in that process as a therapist and as an advocate. Contraindications for Use

If you are working with a client with a disability, the task and materials may need to be modified. For example, if your client has a visual impairment, you can increase the size of images and words on a pho­ tocopy machine and/or print in black and white with increased contrast to improve visibility. Or, if your clients have limited mobility in their hands or lim­ ited fine motor skills, you may want to consider using thicker markers, which may be easier to hold, assisting with the cutting and placing of materials on the page at your client’s direction. For trans and gen­ der-diverse clients who also have disabilities, the intersections of their identities will probably have implications for their experiences in their bodies and therefore what they might express in this task. Discussing these themes could trigger painful feelings related to gender dysphoria, minority stress, marginalization, and other traumas. For this reason, anticipating what your client may need both in and after the session to cope with painful emotions is important, and planning for safety as appropriate is imperative. One final note on this task is that it was designed in consideration of the influence of U.S. society and culture on clients. This task may need to be appro­ priately adapted when working with clients from other cultural backgrounds or countries of origin. Author's Statement

This chapter was written by a specialist in the field of eating concerns who identifies as a ciswoman. As she is not a member of the trans community, it is important to acknowledge that she does not have the personal experiences described in this chapter. It is her hope that contributing to the literature in this way will further inclusivity in the field and bring more awareness to the experiences of margin­ alized individuals.

Professional Readings and Resources (Note: Given the limitations in the literature, some of these references are not specifically inclusive of trans and gendernonconforming clients, but they may still prove to be help­ ful resources.) Bloom, C., Gitter, A., Gutwill, S., Kogel, L., & Zaphiropou­ lous, L. (1994). Eating problems: A feminist psychoana­ lytic treatment model. New York: Basic Books. Grilo, C. M., & Mitchell, J. E. (2010). The treatment of eating disorders: A clinical handbook. New York: Guilford Press. Thompson, B. W. (1996). A hunger so wide and so deep: A multiracial view of women’s eating problems. Minneapo­ lis: University of Minnesota Press. Thompson-Brenner, H. (2015). Casebook of evidence-based therapy for eating disorders. New York: Guilford Press.

Resources for Clients The Body Is Not an Apology. (n.d.). https://thebodyisnot anapology.com/magazine/tag/gender/. Gender Spectrum. (n.d.). https://www.genderspectrum.org. Nalgona Positivity Pride. (n.d.). https://www.nalgonapositivi typride.com. National Eating Disorders Association (NEDA) offers these resources on gender and eating concerns: • Eating disorders in the LGBTQ community. https:// www.nationaleatingdisorders.org/blog/Eating-Dis orders-LGBTQ-Community. • Israel, D. (2012). Eating disorders and body image: What do gender and sexuality have to do with it? https://www.nationaleatingdisorders.org/sites/default/ files/ResourceHandouts/WhatDoGenderSexuality HaveToDoWithIt.pdf. • The Marginalized Voices Project. https://www.natio naleatingdisorders.org/marginalized-voices. • Sallans, R. K. (2012). Finding me: Looking past the surface to discover my transgender identity. https:// www.nationaleatingdisorders.org/sites/default/files/ ResourceHandouts/FindingMe.pdf. • Sallans, R. K. (2015). Gender outside the binary: Eating disorder recovery and my transgender identity (part 1). https://www.nationaleatingdisorders.org/ blog/gender-outside-binary-eating-disorder-recovery -and-my-transgender-identity. • Stories of hope. https://www.nationaleatingdisorders. org/node/6825. Thick Dumpling Skin. (n.d.). www.thickdumplingskin.com/. Trans Folx Fighting Eating Disorders (T-FFED). (n.d.). https://www.transfolxfightingeds.org.

Art Therapy to Address Body Dysphoria and Eating Concerns 469

References American Psychiatric Association. (2013). Diagnostic and sta­ tistical manual of mental disorders, 5th edition (DSM-5). Arlington, VA: American Psychiatric Publishing. American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gen­ der nonconforming people. American Psychologist, 70 (9), 832–864. doi:10.1037/a0039906. Bell, K., Rieger, E., & Hirsch, J. K. (2019). Eating disorder symp­ toms and proneness in gay men, lesbian women, and transgender and non-conforming adults: Comparative levels and a proposed mediational model. Frontiers in Psychol­ ogy, 9, 1–13. doi:10.3389/fpsyg.2018.02692. Bloom, C., Gitter, A., Gutwill, S., Kogel, L., & Zaphiropoulous, L. (1994). Eating problems: A feminist psychoanalytic treat­ ment model. New York: Basic Books. Butryn, R. (2014). Art therapy and eating disorders: Integrat­ ing feminist poststructuralist perspectives. Arts in Psycho­ therapy, 41 (3), 278–286. doi:10.1016/j.aip.2014.04.004. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., . . . & Zucker, K. (2011). Stan­ dards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Interna­ tional Journal of Transgenderism, 13, 165–232. doi:10.10 80/15532739.2011.700873. Couturier, J., Pindiprolu, B., Findlay, S., & Johnson, N. (2015). Anorexia nervosa and gender dysphoria in two adoles­ cents. International Journal of Eating Disorders, 48 (1), 151–155. doi:10.1002/eat.22368. Diemer, E. W., Grant, J. D., Munn-Chernoff, M. A., Patterson, D. A., & Duncan, A. E. (2015). Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. Journal of Adolescent Health, 57, 144–149. doi:10.1016/j.jadohealth.2015.03.003. Hesse-Biber, S., Leavy, P., Quinn, C. E., & Zoino, J. (2006). The mass marketing of disordered eating and eating disorders: The social psychology of women, thinness, and culture. Women’s Studies International Forum, 29, 208–224. doi:10. 1016/j.wsif.2006.03.007.

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Hinz, L. D. (2006). Drawing from within: Using art to treat eating disorders. Philadelphia: Jessica Kingsley. Jones, B. A., Haycraft, E., Murjan, S., & Arcelus, J. (2016). Body dissatisfaction and disordered eating in trans peo­ ple: A systematic review of the literature. International Review of Psychiatry, 28 (1), 81–94. doi:10.3109/0954026 1.2015.1089217. Kashubeck-West, S., & Tagger, L. (2012). Feminist multicul­ tural perspectives on body image and eating disorders in women. In E. N. Williams & C. Z. Enns (eds.), The Oxford handbook of feminist multicultural counseling psychology. New York: Oxford University Press. Murray, S. B., Boon, E., & Touyz, S. W. (2013). Diverging eat­ ing psychopathology in transgendered eating disorder patients: A report of two cases. Eating Disorders, 21, 70–74. doi:10.1080/10640266.2013.741989. National Eating Disorders Association. (2016). Diversity issues. https://www.nationaleatingdisorders.org/diversity. Strandjord, S. E., Ng, H., & Rome, E. S. (2015). Effects of treat­ ing gender dysphoria and anorexia nervosa in a transgender adolescent: Lessons learned. International Journal of Eating Disorders, 48 (3), 942–945. doi:10.1002/eat.22438. Thompson, B. W. (1996). A hunger so wide and so deep: A mul­ tiracial view of women’s eating problems. Minneapolis: University of Minnesota Press. Vocks, S., Stahn, C., Loenser, K., & Legenbauer, T. (2009). Eat­ ing and body image disturbances in male-to-female and female-to-male transsexuals. Archives of Sexual Behavior, 38 (3), 364–377. doi:10.1007/s10508-008-9424-z. Watson, R. J., Veale, J. F., & Saewyc, E. M. (2017). Disordered eating behaviors among transgender youth: Probability profiles from risk and protective factors. International Journal of Eating Disorders, 50 (5), 515–522. doi:10.1002/ eat.22627. Witcomb, G. L., Bouman, W. P., Brewin, N., Richards, C., Fernandez-Aranda, F., & Arcelus, J. (2015). Body image dissatisfaction and eating-related psychopathology in trans individuals: A matched control study. European Eating Disorders Review, 23, 287–293. doi:10.1002/erv.2362.

ACTIVIT Y HANDOUT: DISCUSSION DIRECTIONS AND REL ATED QUESTIONS While viewing the artwork and hearing the clients’ associations, consider: • Given their gender identity, how do they now feel in their body? • Are they presenting with body dysphoria or body image concerns (as it relates to body weight and shape)? If appropriate, ask questions to gather information about the presence of disordered eating patterns and any connection to gender and body dysphoria: • Have the clients engaged in any efforts to change their eating habits in order to alter their bodies’ gender expression? If so, encourage them to discuss the purpose their eating habits serve them, maintaining an open and nonjudgmental stance. • You may use the artwork and what your clients have shared with you as a foundation for the discussion of these issues, and in so doing, you may tailor your questions to assess these areas further. In discussing the artwork with your clients, you may want to address other areas related to body dysphoria or eating concerns, specifically the influence of society and culture. • Give your clients a space to explore cultural and societal influences. • Encourage your clients to consider the oppressive systems that perpetuate certain messages about ideal body standards for female and for male gendered bodies. • If appropriate at this time, you may help your clients explore whether they want to internalize these standards, and in this way encourage critical thinking about these messages. These discussions can begin to empower clients to have a different relationship with themselves and their bodies. • Invite them to share what it is like for them to live with limited, if any, representation in the larger culture. What is the effect of this lack of representation? • If your clients hold multiple marginalized identities, help them explore these experiences given the cis-heteronormative, Eurocentric beauty standards that exist. • You may also help clients recognize the systems of oppression at work that further the message that only certain body types and features are acceptable (see Hesse-Biber, Leavy, Quinn, & Zoino, 2006; Thompson, 1996). In processing the artwork, normalize their experiences with body and gender dysphoria. You may also want to give clients a space to express how they believe their life will be different when their body expresses their gender identity. Please note that it is important to recognize that not all clients who identify as trans want to transition, and transitioning may look different for different clients. If it is appropriate, give your clients a space to discuss their needs and desires for this process, if any, while also validating any pain or distress associated with being in their present body.

Jeannine Cicco Barker

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53 THE INEXTRICABLE RELATIONSHIP BETWEEN MARGINALIZATION AND ADDICTION: BRIDGING THE GAP THROUGH CHARTING John J. S. Harrichand and Christian D. Chan Suggested Uses: Homework, activity Objective

This homework/activity focuses on addiction, broadly defined, as it relates to sexual, gender, and affectional identity. It is designed for clients who are navigating challenges with oppressive interactions and events with their sexual, gender, and affectional identities and who employ addictive behaviors as a means of cop­ ing. Our hope is for clients to gain an awareness of the relationship among their sexual, gender, and affec­ tional identities and their addictive behaviors while working with their therapist to develop healthier cop­ ing mechanisms and a more integrated sense of self. Rationale for Use

Individuals from the lesbian, gay, bisexual, transgen­ der, and queer/questioning (LGBTQ+) population may experience stigma from their coming-out process and sexual-, affectional-, and gender-identity devel­ opment (Chan, Erby, Farmer, & Friday, 2017; Chan, Erby, & Ford, 2017; Talley et al., 2016). Negative con­ sequences resulting from their sexual and gender minority status may include family rejection, social iso­ lation, negative sense of self, the internalization of negative messages, discrimination, prejudice, and hate crimes that increase mental health concerns, such as depression and suicidal behavior (Hirsch, Cohn, Rowe, & Rimmer, 2017; Oberheim, DePue, & Hagedorn, 2017). King and colleagues (2008) conducted a global review of the prevalence of mental disorders, substance

misuse, suicide, suicidal ideation, and deliberate selfharm in lesbian, gay, and bisexual people. They found that lesbian, gay, and bisexual individuals may be at an increased risk of mental health disorders compared to heterosexual individuals; this finding was further supported by Blondeel and colleagues (2016). Research indicates that LGBTQ+ adolescents and young adults experience heightened rates of substance use com­ pared to heterosexual individuals (Centers for Disease Control and Prevention [CDC], 2016). Likewise, sex­ ual minority adults of various ages stand a greater chance of engaging in high-risk drinking compared to heterosexual adults (Bryan, Kim, & Fredriksen-Gold­ sen, 2017). Chaney and Burns-Wortham (2015) also reported that sexual compulsivity had a statistically significant relationship with not coming out to their mothers among gay and bisexual men. Consequently, addictive behaviors, when added to the use of sub­ stances, operate as a coping mechanism for individu­ als navigating their experiences related to their sexual, gender, and affectional identity, especially in cases involving marginalization and discrimination (Bryan et al., 2017; Kecojevic et al., 2012; Meyer, 2003, 2010, 2016). Addiction (process or substance) and sexual, gender, and affectional identities are sometimes over­ lapping entities (Brubaker, Garrett, & Dew, 2009). To more effectively integrate interventions associated with LGBTQ+ clients, it is imperative to consider cul­ turally relevant and salient aspects and fortify prac­ tices with current research (Oberheim et al., 2017). In the intersectionality paradigm (Collins, 1986,

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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1990, 2004; Collins & Bilge, 2016; Crenshaw, 1989, 1991), sexuality, affectional identity, and gender iden­ tity are inextricably linked to a complicated structure of oppression and social power (Association for Les­ bian, Gay, Bisexual, and Transgender Issues in Coun­ seling [ALGBTIC], 2009; Button, O’Connell, & Gealt, 2012; Goodrich et al., 2017; Harper et al., 2013; Singh, 2013). Sexuality, affectional identity, and gender iden­ tity stem from social structures that are based on nor­ mative experiences of historically privileged groups (Lugg, 2003; Lugg & Murphy, 2014; Misgav, 2016), which create visibility predominantly through expe­ riences of cisgender and heterosexual individuals. Embodying representations counter to heteronorma­ tive and cisnormative experiences constitutes a refusal of historically predisposed norms determined by groups and individuals in power (e.g., heterosexual, cisgender; Duong, 2012; Lugg & Murphy, 2014). Inter­ sectionality scholars reconsider the multiple dimen­ sions of social identity to negotiate the social identities tied to LGBTQ+ communities while navigating mul­ tiple overlapping forms of oppression (ALGBTIC, 2009; Bowleg, 2017; Chan, Erby, Farmer, & Friday, 2017; Chan, Erby, & Ford, 2017; Farmer & Byrd, 2015; Harper et al., 2013; Singh, 2013). An intersectional approach concomitantly integrating social identities with the primacy of LGBTQ+ identities results in the identification of problematic issues within social struc­ tures, including personal experiences of oppression (Bowleg, 2017; Bowleg & Bauer, 2016; Chan, Erby, & Ford, 2017; Collins & Bilge, 2016). Employing an intersectional approach highlights contextual, tempo­ ral, and historical dimensions necessary to connect and comprehend personal experiences of oppression (Collins & Bilge, 2016; Crenshaw, 1989, 1991). Uni­ fying with the philosophical underpinnings of inter­ sectionality theory, formulating interventions and approaches for more effective services with LGBTQ+ clients relies on an analysis of dominance often con­ nected to heterosexist, genderist, homophobic, and transphobic forces (Lugg, 2003; Lugg & Murphy, 2014; Misgav, 2016). Numerous researchers have documented a sig­ nificant relationship between heterosexism and sub­ stance use. McCabe and colleagues (2010) noted that the prevalence of substance use was four times greater

among lesbian, gay, and bisexual individuals who reported three types of discrimination (sexual orien­ tation, rage, and gender) than among lesbian, gay, and bisexual individuals who did not report discrimina­ tion. Hequembourg and Dearing (2013) augmented these findings by highlighting the relationship between shame and internalized heterosexism while alluding to positive correlations among alcohol and drug use with shame. The Hequembourg and Dearing (2013) study additionally discussed the increased outcomes of risky substance use and internalized heterosexism among bisexual individuals. Therefore, stigmatization is cause for concern when viewed in relation to inter­ nalized heterosexism experienced by members of the LGBTQ+ community (Brubaker et al., 2009). More specifically, Brubaker and colleagues (2009), comment­ ing on the theory of internalized heterosexism, reported that members of LGBTQ+ communities use alcohol as a coping mechanism in response to expe­ riences of heterosexism frequently associated with shame, depression, guilt, and low self-esteem. A study by Lyons and colleagues (2016) noted that illicit drug use and experiences as sexual minorities led to a multitude of health challenges, and that women who have sex with women reported a lesser likelihood of seeking services for addiction. The counseling profession is governed by the ACA Code of Ethics (American Counseling Association [ACA], 2014), which is primarily responsible for ensuring the welfare of clients. According to code C.7.a (ACA, 2014), counselors are mandated to use pro­ cedures and techniques with an empirical basis or grounded in theory. More specifically, regarding mul­ ticultural issues and diversity, code E.8 calls for coun­ selors to recognize the gender and sexual orientation of clients, and code E.5.b requires counselors to be culturally sensitive to the needs of all clients. Therefore, counselors are mandated to engage in professional development practices, explicitly in areas relating to counselors imposing values on clients (i.e., counselor values that might be discriminatory or inconsistent with those of clients; ACA, 2014, A.4.b). The ALGBTIC Competencies for Counseling with Lesbian, Gay, Bisexual, Queer, Questioning, Intersex, and Ally Indi­ viduals (Harper et al., 2013) aligns with the ACA Code of Ethics (2014). Harper and colleagues developed The Relationship between Marginalization and Addiction 473

the ALGBTIC competencies to highlight the need for counselors to “affirm that [LGBTQ+] persons have the potential to integrate their affectional orientations and gender identity into fully functioning and emotionally healthy lives and relationships” (2013, A.2., p. 8). Counselors are, however, also called on to be aware of the negative mental health effects of heterosexism, biphobia, transphobia, homophobia, and homopreju­ dice while simultaneously responding appropriately and ethically in treatment (ALGBTIC, 2009; Harper et al., 2013). The “Multicultural and Social Justice Counseling Competencies” (Ratts et al., 2015) also emphasize the need for counselors to be knowledge­ able and equipped to address various mental health concerns contextualized across systems of disenfran­ chisement, marginalization, and oppression. This set of values aligns with the ALGBTIC competencies (Harper et al., 2013, C.4) by focusing on assisting individuals with overcoming negative self-perceptions regarding affectional orientation, gender identity, and gender expression in LGBTQ+ communities. The homework/activity outlined in this chapter draws on the theoretical foundations of cognitive behavioral therapy (CBT) and is derived from tech­ niques and ideas published in The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Bar­ low, Sauer-Zavela, et al., 2018; Barlow, Farchione, et al., 2018). These publications allow counselors to col­ laboratively work with members of the LGBTQ+ com­ munity by helping them modify emotion-based mis­ perceptions of significant events, while building resil­ ience in the face of negative and emotionally loaded internal and external triggers (Payne et al., 2014). According to Pachankis and colleagues (2015), CBT operates as an appropriate treatment modality for addressing affective, behavioral, and cognitive minority stress. Lesbian-, bisexual-, and gay-affirmative CBT (Pachankis et al., 2015) was found to be effective when compared with a wait list control group in addressing co-occurring health problems, including alcohol use in gay and bisexual men stemming from sexual ori­ entation–related mental health incongruences. CBT, therefore, allows counselors to work with members of LGBTQ+ communities by identifying maladaptive behaviors (e.g., health-risk behaviors such as alcohol

474 Harrichand & Chan

use) as they navigate the challenges associated with their sexual, gender, and affectional identities. Cognitive-behavioral therapy, according to Sosin and Rockinson-Szapkiw (2016), is an approach to counseling that is both present-centered and solutionfocused. The approach aims to assist clients in devel­ oping a philosophy of life that is realistic and attain­ able rather than maladaptive and anxiety provoking by using techniques focused on minimizing emotional disturbances and self-defeating behaviors (Sosin & Rockinson-Szapkiw, 2016). Originating from the works of Beck (1976) and Ellis (2004), CBT attends signifi­ cantly to cognitive factors; however, the approach also addresses the behavioral, emotional, and physical factors that can contribute to the emergence or main­ tenance of a disorder. From this theoretical framework, problems are observed as originating from maladap­ tive thoughts, behaviors, and feelings. The process of change therefore occurs when the client actively par­ ticipates in replacing cognitive processes described as being maladaptive with adaptive ones (Sosin & Rock­ inson-Szapkiw, 2016). A long-standing technique used in CBT is imagery rescripting (Beck, 1976); an adapted version of this technique is used in the charting homework/activity. Imagery rescripting is based on the understanding that mental processes can take the form of either ver­ bal or visual cognitions. Because emotional distress is frequently associated with visual cognitions, mod­ ifying one’s visually distressing thoughts increases the ability to experience changes in thinking, feeling, and behavior (Beck, 1976). This technique has been used successfully in the treatment of post-traumatic stress disorder (PTSD) by reducing PTSD symptoms (Brewin et al., 2009; Hirsch & Holmes, 2007), specif­ ically in treating survivors of childhood abuse (Wild & Clark, 2011) and adolescents exposed to trauma (Heyes, Lau, & Holmes, 2013). This technique was adapted and modified for the purposes of working with LGBTQ+ individuals who employ addictive behaviors as a means of navigating oppressive interactions and events with their sexual, gender, and affectional identities. Through the home­ work/activity, clients are asked to document the name and frequency of the addictive behaviors in conjunction

with the positive and negative events associated with sexual, gender, and affectional identity. The informa­ tion documented through charting is then processed with the therapist in session. Instructions

The homework/activity chart can be used in individ­ ual, couples, or group therapy. It can be assigned as homework for clients to engage in independently, or it can be used in session as a shared exploration for the therapist and clients. Clients will be instructed to complete the chart, which will allow the therapist and clients to process the contents. The main purpose of the homework/activity is to create a visible account of clients’ addictive behaviors and frequency by form­ ing associations with positive and negative events they experience in relation to sexual, gender, and affec­ tional identity. This information brings consciousness to the clients about the potential use of maladaptive coping strategies in conjunction with experiences of marginalization. Additionally, discussing the frequency of each addictive behavior through this activity offers clients the possibility to add context or build on nar­ ratives regarding experiences of oppression in their lives while negotiating the construction of new coping strategies. Sample narratives could include the possi­ bilities of community, belongingness, isolation, social network, families, and friends. Bridging narratives on these topics could contextualize the assessment by triangulating an activity with more concentration on quantitative data in conjunction with qualitative data through interpretation and meaning from clients. Therapists can adapt the chart to fit the needs of clients using multiple addictive behaviors. For couples. When the homework/activity is used in couples counseling, the therapist can instruct either partner or both partners to complete the chart, depending on the needs of the couple seeking mental health services. Instructing each partner to complete the chart will allow the therapist and clients to process the contents individually at first, and, subsequently, together as a couple. By creating a visible account of the client couple’s addictive behaviors and frequency, the intention is to begin forming associations with positive and negative events that clients experience in

relation to sexual, gender, and affectional identity. The charts will provide the couple with visual descriptions of their potential use of maladaptive coping strategies in conjunction with experiences of marginalization. For groups. For therapists employing this home­ work /activity in group counseling, instruct each group member to complete the chart. This instruction will allow the therapist and group members to pro­ cess the contents within the context of the group. Hav­ ing all group members create a visible account of their addictive behaviors and frequency that they then share with the entire group will allow them to begin forming associations with positive and negative events that they experience in relation to sexual, gender, and affectional identity. Group sharing will also serve to normalize experiences while creating a support net­ work for group members to freely process concerns. This information brings consciousness to each group member and to the group as a whole regarding the potential use of maladaptive coping strategies in con­ junction with experiences of marginalization. Brief Vignette

In a university counseling center, a therapist begins the sixth consecutive weekly meeting with a twenty-one­ year-old client who is seeking services regarding bul­ lying in their residence hall. The client identifies as pansexual, nonbinary, and Christian. The client uses the pronouns they, them, and theirs, and they iden­ tify as Asian American with Filipino and Chinese her­ itage. As the child of immigrant parents, the student grew up in a working-class family with limited access to education and opportunities and is a first-genera­ tion college student. Throughout the past five meet­ ings, the client indicated that their grades have been slipping in conjunction with decreasing class atten­ dance. Although the client was a successful student in the first three years of their undergraduate career, the beginning of this year has been the most difficult, and their success has wavered in recent months. Upon acquiring more information through the intake and gaining a further sense of the client’s presenting issues, the therapist realizes that the client has experienced severe bullying, including microaggressions, namecalling, and derogatory comments. Additionally, the

The Relationship between Marginalization and Addiction 475

client discloses their identification as a pansexual nonbinary person and reports that they came out to more social networks, friends, and family at the beginning of the academic year. Although their family has been generally supportive, the client relates that no one in their family has been out as a member of LGBTQ+ communities. Conversations about sexuality, affection, and gender identity within their family have been nearly nonexistent. The client believes that silence about their sexuality, affectional identity, and gender identity might also be related to their family’s histori­ cal ties to disaffirming values of religiosity. The client has faced extensive prejudice since their experience of coming out and finds that many of the derogatory comments come from fellow residents in the residence hall. In fact, the client received a note in their mailbox that stated, “You are what is wrong with society.” The client recalled their distraught response to this note but chose not to report the incident to a residence hall director. The client also explained that they do not believe the residence hall director would be of any assistance; they feel helpless and isolated as well. The bullying, especially within the residence hall, has not changed since the client began using coun­ seling services at the university counseling center. Part of the client’s sadness stems from discriminatory expe­ riences within LGBTQ+ communities, as they men­ tion particular slights from gay cisgender men in the past two months. In conjunction with many of these issues, the client reports their use of alcohol as a cop­ ing strategy has increased over time. Although the client did not seek counseling services specifically for substance use and addiction, they indicate that their use of alcohol has slowly increased while working with the therapist. To increase the client’s awareness regarding their heightened alcohol use and their difficulties with find­ ing alternative coping strategies, the therapist thinks about the possibility of using a chart to help the client organize and reflect on their experiences of discrimi­ nation and increased alcohol use. The therapist begins by explaining to the client the purpose of charting and how it might help clarify some of their experiences and coping. The therapist draws an example with the client in the sixth session; the therapist also provides context for how the client can expand this assignment 476 Harrichand & Chan

into a journal or work on this activity with the thera­ pist each week during counseling. The therapist pro­ vides the chart with three categories: (a) type of coping or behavior; (b) frequency of behavior during the week; and (c) positive and negative events associated with their discrimination as a pansexual nonbinary person. After participating in the activity, the therapist engages the client with additional follow-up on their experience with completing the chart together in ses­ sion in conjunction with the chart’s meaning. Col­ laboratively, the therapist and client set a goal to build on this activity for the next few weeks and use it as a point of departure for more discussion. Suggestions for Follow-up

This homework/activity is designed to document cli­ ents’ addictive behaviors and the positive and negative events associated with their sexual, gender, or affec­ tional identity, which can be processed and further explored in session. The therapist can assign the homework/activity weekly to assess clients’ addictive behaviors. Clients and therapist can also process each documented addictive behavior (i.e., one behavior per session or more, depending on the content of each event resulting in the addictive behavior and the num­ ber of sessions allowed for therapy). It is important that the therapist assigns adequate time to process the instructions and example before assigning the home­ work/activity and have sufficient time to explore each event documented. The homework/activity can be used as an informal measure to track clients’ progress regarding their addictive behaviors and coming to terms with their sexual, gender, or affectional identity. Contraindications for Use

This homework/activity is designed for clients who are currently experiencing addictive behaviors and strug­ gling with their sexual, gender, or affectional iden­ tity. It should not be used with clients who refuse to acknowledge that they are addicted (process or sub­ stance) or clients who are not experiencing oppression with their sexual, gender, or affectional identity. It is important to acknowledge that this activity makes the assumption that a connection exists between addic­ tive behaviors (process or substance) and sexual, gen­ der, and affectional identities, and that clients use

addictive behaviors as a way of coping with their sex­ ual, gender, and affectional identities. Clients may reveal in therapy, however, that although they engage in addictive behaviors, they may not use them to cope with their sexual, gender, or affectional iden­ tity. At this point, further clarification and explora­ tion by the therapist may be warranted. Professional Readings and Resources Aromin, R. A. (2016). Substance abuse prevention, assessment, and treatment for lesbian, gay, bisexual, and transgender youth. Pediatric Clinics of North America, 63 (6), 1057– 1077. doi:10.1016/j.pcl.2016.07.007. Heck, N. C., Flentje, A., & Cochran, B. N. (2013). Intake inter­ viewing with lesbian, gay, bisexual, and transgender clients: Starting from a place of affirmation. Journal of Contemporary Psychotherapy, 43 (1), 23–32. doi:10.1007/ s10879-012-9220-x. Livingston, N. A. (2017). Avenues for future minority stress and substance use research among sexual and gender minority populations. Journal of LGBT Issues in Coun­ seling, 11 (1), 52–62. doi:10.1080/15538605.2017. 1273164. Shelton, M. (2017). Fundamentals of LGBT substance use dis­ orders: Multiple identities, multiple challenges. New York: Harrington Park Press. Silvestre, A., Beatty, R. L., & Friedman, M. R. (2013). Substance use disorder in the context of LGBT health: A social work perspective. Social Work in Public Health, 28 (3–4), 366– 376. doi:10.1080/19371918.2013.774667.

Resources for Clients Alton, W. L. (2015). Flesh and bone. Carmel, IN: Luminis Books. Isensee, R. (2005). Reclaiming your life: The gay man’s guide to recovery from abuse, addictions, and self-defeating behav­ ior. Lincoln, NE: iUniverse. Kominars, S. B., & Kominars, K. D. (1996). Accepting ourselves and others: A journey into recovery from addictive and com­ pulsive behaviors for gays, lesbians, and bisexuals. Center City, MN: Hazelden. Larkin, J. (1998). Glad day: Daily meditations for gay, lesbian, bisexual and transgender people. Center City, MN: Hazelden. Ryan, C. (2009). Helping families support their lesbian, gay, bisexual, and transgender (LGBT) children. https://nccc. georgetown.edu/documents/LGBT_Brief.pdf. Shelton, M. (2011). Gay men and substance use: A basic guide for addicts and those who care for them. Center City, MN: Hazelden. Weiss, R. (2013). Cruise control: Understanding sex addiction in gay men, 2nd edition. Carefree, AZ: Gentle Path Press.

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Goodrich, K. M., Farmer, L. B., Watson, J. C., Davis, R. J., Luke, M., Dispenza, F., . . . & Griffith, C. (2017). Standards of care in assessment of lesbian, gay, bisexual, transgender, gender expansive, and queer/questioning (LGBTGEQ+) persons. http://nebula.wsimg.com/25f926853dfd90b80 6d0a06be9835182?AccessKeyId=720287C8355A159A B9E1&disposition=0&alloworigin=1. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H., Loos, B., . . . & Lambert, S. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individu­ als. https://www. counseling. org/docs/ethics/algbtic­ 2012-07. Hequembourg, A. L., & Dearing, R. L. (2013). Exploring shame, guilt, and risky substance use among sexual minority men and women. Journal of Homosexuality, 60 (4), 615–638. doi:10.1080/00918369.2013.760365. Heyes, S., Lau, J. Y. F., & Holmes, E. A. (2013). Mental imagery, emotion and psychopathology across child and adoles­ cent development. Developmental Cognitive Neuroscience, 5, 119–133. doi:10.1016/j.dcn.2013.02.004. Hirsch, C. R., & Holmes, E. A. (2007). Mental imagery in anxiety disorders. Psychiatry, 6, 161–165. doi:10.1016/j. mppsy.2007.01.005. Hirsch, J. K., Cohn, T. J., Rowe, C. A., & Rimmer, S. E. (2017). Minority sexual orientation, gender identity status and suicidal behavior: Serial indirect effects of hope, hope­ lessness, and depressive symptoms. International Journal of Mental Health and Addiction, 15 (2), 260–270. doi:10. 1007/s11469-016-9723-x. Kecojevic, A., Wong, C. F., Schrager, S. M., Silva, K., Bloom, J. J., Iverson, E., & Lankenau, S. E. (2012). Initiation into pre­ scription drug misuse: Differences between lesbian, gay, bisexual, transgender (LGBT) and heterosexual high-risk young adults in Los Angeles and New York. Addictive Behaviors, 37 (11), 1289–1293. doi:10.1016/j.addbeh. 2012.06.006. King, M., Semlyen, J., Tai, S. S., Killaspy, H., Osborn, D., Pope­ lyuk, D., & Nazareth, I. (2008). A systematic review of mental disorder, suicide, and deliberate self harm in les­ bian, gay and bisexual people. BioMed Central Psychiatry, 8 (1), 70–87. doi:10.1186/1471-244X-8-70. Lugg, C. (2003). Sissies, faggots, lezzies, and dykes: Gender, sexual orientation, and new politics of education? Educa­ tional Administration Quarterly, 39 (1), 95–134. doi:10. 1177/0013161X02239762. Lugg, C. A., & Murphy, J. P. (2014). Thinking whimsically: Queering the study of educational policy-making and poli­ tics. International Journal of Qualitative Studies in Educa­ tion, 27 (9), 1183–1204. doi:10.1080/09518398.2014.916009. Lyons, T., Shannon, K., Richardson, L., Simo, A., Wood, E., & Kerr, T. (2016). Women who use drugs and have sex with

women in a Canadian setting: Barriers to treatment enrollment and exposure to violence and homelessness. Archives of Sexual Behavior, 45 (6), 1403–1410. doi:10. 1007/s10 508-015-0508-2. McCabe, S. E., Bostwick, W. B., Hughes, T. L., West, B. T., & Boyd, C. J. (2010). The relationship between discrimina­ tion and substance use disorders among lesbian, gay, and bisexual adults in the United States. American Journal of Public Health, 100 (10), 1946–1952. doi:10.2105/AJPH. 2009.163147. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674–697. doi:10.1037/0033-2909.129.5.674. Meyer, I. H. (2010). Identity, stress, and resilience in lesbians, gay men, and bisexuals of color. Counseling Psychologist, 38 (3), 442–454. doi:10.1177/0011000009351601. Meyer, I. H. (2016). The elusive promise of LGBT equality. American Journal of Public Health, 106 (8), 1356–1358. doi:10.2105/AJPH.2016.303221. Misgav, C. (2016). Some spatial politics of queer-feminist research: Personal reflections from the field. Journal of Homosexuality, 63 (5), 719–739. doi:10.1080/00918369.2 015.1112191. Oberheim, S. T., DePue, M. K., & Hagedorn, W. B. (2017). Sub­ stance use disorders (SUDs) in transgender communities: The need for trans-competent SUD counselors and facil­ ities. Journal of Addictions & Offender Counseling, 38 (1), 33–47. doi:10.1002/jaoc.12027. Pachankis, J. E., Hatzenbuehler, M. L., Rendina, H. J., Safren, S. A., & Parsons, J. T. (2015). LGB-affirmative cognitive-

behavioral therapy for young adult gay and bisexual men: A randomized controlled trial of a transdiagnostic minority stress approach. Journal of Consulting and Clinical Psychol­ ogy, 83 (5), 875–889. doi:10.1037/ccp0000037. Payne, L. A., Ellard, K. K., Farchione, T. J., Fairholme, C. P., & Barlow, D. H. (2014). Emotional disorders: A unified transdiagnostic protocol. In D. H. Barlow (ed.), Clinical hand­ book of psychological disorders: A step-by-step treatment manual, 5th edition, 237–274. New York: Guilford Press. Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2015). Multicultural and social jus­ tice counseling competencies. https://www.counseling. org/docs/default-source/competencies/multicultural-and­ social-justice-counseling-competencies.pdf?sfvrsn=20. Singh, A. A. (2013). Transgender youth of color and resilience: Negotiating oppression and finding support. Sex Roles, 68 (11–12), 690–702. doi:10.1007/s11199-012-0149-z. Sosin, L. S., & Rockinson-Szapkiw, A. J. (2016). Creative expo­ sure intervention as part of clinical treatment for adoles­ cents exposed to bullying and experiencing posttraumatic stress disorder symptoms. Journal of Creativity in Mental Health, 11 (3–4), 391–408. doi:10.1080/15401383.2016.1 251370. Talley, A. E., Gilbert, P. A., Mitchell, J., Goldbach, J., Marshall, B. D., & Kaysen, D. (2016). Addressing gaps on risk and resilience factors for alcohol use outcomes in sexual and gender minority populations. Drug and Alcohol Review, 35 (4), 484–493. doi:10.1111/dar.12387. Wild, J., & Clark, D. (2011). Imagery rescripting of early trau­ matic memories in social phobia. Cognitive Behavioral Practice, 18, 433–443. doi:10.1016/j.cbpra.2011.03.002.

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CHARTING HOMEWORK/ACTIVIT Y OF ADDICTIVE BEHAVIORS, FREQUENCY, AND EVENTS IN REL ATION TO SEXUAL, GENDER, AND AFFECTIONAL IDENTITIES

Date & time

480

Name of addictive behavior

Frequency of addictive behavior

Positive and negative events in relation to sexual, gender, or affectional identity

John J. S. Harrichand and Christian D. Chan

54 LGB ADDICTION RECOVERY AND COMMUNITY MEMBERSHIP George Stoupas and Mia Ocean Suggested Uses: Group activity, homework Objective

This activity is intended for lesbian, gay, and bisexual (LGB) clients with substance use problems. It is de­ signed to facilitate the process of establishing new social relationships that are supportive of recovery. The activity centers on prompts that help identify and explore feelings, thoughts, and behaviors that contrib­ ute to substance use. It specifically addresses the influ­ ence of sexual orientation, community membership, and stigmatization or oppression, as well as their effects on addiction and recovery. The goal of this activity is to help clients gain insight into their sense of identity and membership in both the LGB and recovery com­ munities to achieve synthesis. It was designed to be administered in a therapy group, but it can be modified for individual work. Rationale for Use

An estimated 20.8 million Americans aged twelve and older meet the criteria for a substance use disorder (SUD), and 21.7 million are in need of specialized treatment (Center for Behavioral Statistics and Quality, 2016). Although it is impossible to tell exactly how many identify as lesbian, gay, or bisexual, members of sexual minority communities have been shown to have higher rates of substance abuse compared to hetero­ sexuals, and they often have more severe problems (Cochran & Cauce, 2006; Green, 2012; McCabe, West, Hughes, & Boyd, 2013). This increased risk has not been attributed to sexual orientation itself, but, rather, to negative societal responses such as rejection, isola­

tion, and hostility (Eliason, 2000). For some LGB peo­ ple, substance use is an attempt to cope with these negative experiences as well as internalized homopho­ bia or heterosexism (Cabaj, 2000; Hequembourg & Dearing, 2013). These negative experiences can be magnified for LGB individuals who are members of other marginalized groups. For instance, LGB people of color, in addition to heterosexism, face racism both inside and outside the LGB community, which can increase their level of psychological stress (Balsam et al., 2011). This discrimination, often resulting in a lack of opportunities, could contribute to higher rates of substance use and abuse in communities of color (Cen­ ter for Behavioral Health Statistics and Quality, 2016). While internalization of discrimination may partially explain the higher rates of substance abuse in the LGB community compared to the heterosexual population, it is important to consider the historical oppression of the LGB community as well (Green, 2012). For decades, bars were among the few places that provided a space for LGB people to meet publicly (Wolf, 2004). These spaces could be viewed positively as a place to gather as a form of resistance (Kennedy & Davis, 1993), but bars, as a forced meeting place to develop community, simultaneously contributed to a culture of use. Therefore, for LGB clients in early recovery, community membership can be a doubleedged sword. Gay bars may be the only safe place in which to be oneself and socialize with others; how­ ever, this environment can also increase the risk of relapse because of exposure to substances or pressure to use (Green, 2012; Hicks, 2000). LGB clients may feel ambivalent about changing or giving up their social

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network, feeling as though they are losing member­ ship in the gay community. Moreover, these clients may not feel comfortable in mainstream twelve-step recov­ ery communities, where other members sometimes have little sensitivity to or tolerance for issues related to sexual orientation and oppression (Callicott, 2012; Hall, 1996). Because of the significant role they play, clinicians must explore their clients’ sense of identity and belongingness in both the LGB and recovery communities. In general, most Americans who need specialized addiction treatment do not receive it (Center for Behav­ ioral Health Statistics and Quality, 2016); however, sexual minorities face additional obstacles to receiv­ ing care. These include systemic barriers like homopho­ bia/heterosexism as well as lack of culturally compe­ tent providers and a lack of specialized, gay-affirmative treatment programs (Eliason & Hughes, 2004; Rowan, Jenkins, & Parks, 2013). This activity reflects the Asso­ ciation for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) “Competencies for Counseling with Lesbian, Gay, Bisexual, Queer, Ques­ tioning, Intersex, and Ally Individuals ”(2013). Spe­ cific competencies covered by this activity include A.7, Understanding that normative developmental tasks can be compromised through substance use problems; B.3, Understanding the history, contributions, and points of pride for the LGB community; B.6, Recog­ nizing the pervasiveness of heterosexism and sexism in social institutions and how these shape attitudes towards LGB people; B.9, Exploring the intersection of oppressions related to race, sexual orientation, class, and other factors; C.15, Acknowledging that helping professionals may cause harm via ignorance or bias; D.2, Using group work to strengthen community and identity; and E.5, Using interventions that affirm, accept, and support the autonomy of intersecting iden­ tities and communities. The activity is grounded in best practices for work­ ing with LGB clients in addiction treatment, as out­ lined below (Hicks, 2000; Rowan et al., 2013; Substance Abuse and Mental Health Services Administration [SAMHSA], 2012). Because the activity is LGB-spe­ cific, the activity takes a culturally specific approach to treatment and does not assume that all addiction and recovery are the same. It demonstrates an LGB-

affirmative perspective by addressing specific aspects of gay culture, history, and identity, effectively com­ municating to clients that their sexual orientation is valid and good (ALGBTIC, 2013; SAMHSA, 2012). The activity also validates the vital role of social net­ works and community membership, and it gently challenges the simplistic notion that certain people or places should be avoided because they might pose a risk to the client’s sobriety. It recognizes the unique challenge that LGB clients face when attempting to develop an identity as a person in recovery; it also recognizes how these intersecting identities are some­ times in conflict. The group prompts include a discus­ sion of how other intersecting cultural factors such as gender, race, age, and socioeconomic status influ­ ence community membership. The activity recognizes and attempts to address the ways in which helping professionals have added to the discrimination expe­ rienced by LGB clients by being insensitive or unedu­ cated about their unique needs. Finally, this activity is empowering to clients because it is delivered in a group format, which allows clients to openly share their feel­ ings regarding sexual orientation, substance use, and community belongingness with others who under­ stand. Often, LGB clients are discouraged from dis­ cussing these topics in mainstream addiction pro­ grams because it makes others uncomfortable or is seen as irrelevant to addiction recovery (Hicks, 2000). The following sections of the American Counseling Asso­ ciation’s (ACA’s) Code of Ethics (2014) are reflected in this activity: A.1.d, Support Network Involvement; A.4.b, Personal Values; A.9.a, Screening in Group Work; A.9.b, Protecting Clients in Group Work; B.1.a, Mul­ ticultural/Diversity Considerations; C.5, Nondiscrimi­ nation; E.5.b, Cultural Sensitivity; and E.5.c, Historical and Social Prejudices in the Diagnosis of Pathology. Instructions

This activity is best completed as a group to encourage community building and forming healthy connec­ tions. It can be modified, however, for an individual session or to create a homework worksheet for an individual. Additionally, each group can be unique; therefore, we provide a broad range of prompts for clinicians to customize. Generally, the group facilitator will enable a dialogue about four major content areas: LGB Addiction Recovery and Community Membership 483

(a) ways in which people connect and bond with one another; (b) representations of LGB persons and addic­ tions in the media; (c) connections between use, recov­ ery, and the LGB community; and (d) ways that indi­ viduals can contribute to communities of membership. This group activity can run from fifty minutes to three hours, depending on time constraints. The following items will help facilitate the group activity: a white­ board or flip chart, markers, and rating cards (which can be cards printed with the numbers one through five or pieces of scrap paper). It is important that the counselor help group mem­ bers form connections among themselves and be aware that the LGB community can be segregated at times in an effort to gain power in the larger society (see Ocean, 2008). For instance, as the LGB popula­ tion has advocated for marriage equality, a nonthreat­ ening image that matches a traditional family has often been presented (e.g., white, middle-class, suburban). This characterization omits the beautiful diversity found in the community and can sideline individuals of color, people with low incomes, and members who do not fit into traditional categorizations (Albelda, Badgett, Schneebaum, & Gates, 2017; Redman, 2010). It is important when facilitating this dialogue not to blame the oppressed group or reinforce the divisions in the community, but rather to contextualize all factors and influences. Because of the intense and damaging stigmas embedded in our culture with respect to individuals dealing with addictions and the LGB community, counselors and clients should explore their own explicit and implicit beliefs about sexual orientation and addiction. The following tools can be used with clients and by counselors before conducting this exercise: the Heterosexual Questionnaire (Rochlin, 1977), the Heterosexual Privilege Checklist, the Sexuality Implicit Test, and the Addiction Belief Inventory (Luke, Ribisl, Walton, & Davidson, 2002). Individual results can be used to spur discussion about oppression of the LGB and recovery communities. However, clinicians also need to have a plan for how to handle negative and persistent comments about the LGB community and about people with substance use disorders.

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Brief Vignette

Tom, a cisgender, Caucasian, gay man in his late twen­ ties, entered the LGB community through the bar scene years ago. Though he lives in an area that has protections for LGB people in the city and county codes, he was raised in a conservative Christian fam­ ily that did not accept his sexual orientation. Tom initially found acceptance and companionship at bars, but he later became sexually involved with other men who introduced him to methamphetamines. Over the past few years, Tom’s use has become progressively worse, resulting in many interpersonal and health problems, an arrest for possession, and one previous inpatient treatment episode. He did not find the tradi­ tional program helpful. Tom’s assigned counselor—a middle-aged, cisgender, Caucasian straight man who was himself in recovery—told him that he suffered from “terminal uniqueness” when he expressed diffi­ culty identifying with other men on the unit. Follow­ ing his discharge from this facility, Tom attended a local Narcotics Anonymous meeting, as recommended; however, he did not feel comfortable sharing in this exclusively heterosexual group and did not return. After one month, Tom became lonely and depressed. He returned to the bar he previously frequented, and he relapsed soon after. Tom agreed to attend LGB group therapy as a part of his revised recovery treatment plan. During the group activity outlined in this chapter, Tom began to explore his socialization in the LGB community and with individuals dealing with addiction. Tom believed that because there are limited representations of these groups in the media, and because he grew up in a community where these topics were not discussed, he was and continues to feel unsure about how to connect with people without using. Through the group pro­ cess, he was able to see that he was not alone in those experiences and that he could form a new support network with individuals who identify as sober and LGB. Additionally, the group itself served as a safe environment to practice his new sober socialization skills while remaining out as a gay man. As the coun­ selor probed group members about their comfort level with their sexual orientation when they are using and not using, Tom also realized he has continued shame about his sexual orientation. The group was able to

help support him in identifying and normalizing his experiences rather than leading to more shame and potential relapse.

to these topics very differently, and the group may illicit strong emotions.

Suggestions for Follow-up

Arizona State University, Project Humanities. Heterosexual privilege checklist. https://projecthumanities.asu.edu/ content/heterosexual-privilege-checklist. LGBT HealthLink. https://www.lgbthealthlink.org. Luke, D. A., Ribisl, K. M., Walton, M. A., & Davidson, W. S. (2002). Assessing the diversity of personal beliefs about addiction: Development of the Addiction Belief Inven­ tory. Substance Use & Misuse, 37 (1), 89–120. NALGAP: The Association of Lesbian, Gay, Bisexual, Transgender Addiction Professionals and Their Allies. http:// www.nalgap.org/. Office of Disease Prevention and Health Promotion. (2017). Lesbian, gay, bisexual, and transgender health. https:// www.healthypeople.gov/2020/topics-objectives/topic/ lesbian-gay-bisexual-and-transgender-health?topicid=25. Project Implicit. Sexuality test. https://implicit.harvard.edu/ implicit/. Rochlin, M. (1977). The heterosexual questionnaire. https:// higherlogicdownload.s3.amazonaws.com/NASN/784ade29­ 1f66-48a8-8c2d-3f9bc57af6bf/UploadedImages/Oregon% 20Microsite/Documents/HeterosexualQuestionnaire.pdf.

During the next group session after the exercise is implemented, it is important to revisit these topics, even if only briefly. It is advantageous to evaluate group members’ reflections and their conversations, if any, with others in their lives since the activity. The work completed during the previous group may have been reinforced, or it may have been eroded. Assessing for both is recommended. Additionally, after this activ­ ity has been completed, the topics and perceptions identified can be revisited in later groups. Ideally, the concepts and community building will, in fact, be reinforced in future groups (although this is not always possible if the group does not meet on a routine basis). Contraindications for Use

This activity is appropriate for clients in both inpatient and outpatient programs; however, clients should be fully detoxified and without severe co-occurring dis­ orders that might limit participation. Individuals in any stage of change can participate in this group activ­ ity, though clinicians should be mindful of group members’ individual differences in levels of motivation and commitment to recovery, which may influence intra- and interpersonal dynamics. Moreover, if a group member has recently been exposed to a conver­ sion therapy abuse, it is not be a good time to explore the positive and negative views of various sexual ori­ entations. Individuals should also be screened for unresolved relationship issues with a member from one of the communities (e.g., a lesbian who harbors nega­ tive feelings for a bisexual woman because of a recent, traumatic breakup and has generalized her feelings to bisexuals rather than that specific ex-girlfriend) to avoid harm to another member. In addition to indi­ vidual assessment, the group should also be assessed for appropriateness for the activity. For instance, if the therapeutic group is overly lopsided or dominated by lesbian, gay, or bisexual individuals, the result may be harm to individuals who belong to the other groups. Finally, clinicians should be aware that clients in dif­ ferent stages of the coming-out process may respond

Professional Readings and Resources

Resources for Clients Print Resources

Larkin, J. (1998). Glad day daily affirmations: Daily meditations for gay, lesbian, bisexual, and transgender people. Center City, MN: Hazelden. Williams, R. E., & Kraft, J. S. (2012). The mindfulness work­ book for addictions: A guide to coping with the grief, stress, and anger that trigger addictive behaviors. Oakland, CA: New Harbinger Publications. Groups

GLBT Recovery. Gay, lesbian, bisexual & transgender. http:// usrecovery.info/GLBT/index.htm. Online Intergroup Alcoholics Anonymous. LGBT meetings. https://aa-intergroup.org/directory_glbt.php. Substance Abuse and Mental Health Services Administration. Behavioral health treatment services locator. https:// findtreatment.samhsa.gov/. Documentaries

Gertler, H., & Thorpe, D. (producers), & Thorpe, D. (director). (2014). Do I sound gay? U.S. IFC Films/Sundance Selects. Jarecki, E., Cullman, S., Shopsin, M., & St. John, C. (2012). The house I live in. Virgil Films and Entertainment. Williams, G. D. (producer). (2013). The anonymous people. 4th Dimension Productions. Ziering, A. (producer), & Dick, K. (director). (2009). Outrage. U.S. HBO Documentary Films.

LGB Addiction Recovery and Community Membership 485

National LGBT Organizations

Gay & Lesbian Alliance Against Defamation (GLAAD). http://www.glaad.org/. National LGBTQ Task Force. http://www.thetaskforce.org/.

References Albelda, R., Badgett, M. V. L., Schneebaum, A. & Gates, G. J. (2017). Poverty in the lesbian, gay, and bisexual commu­ nity. UCLA CCPR Working Papers. http://papers.ccpr. ucla.edu/index.php/pwp/article/view/855. American Counseling Association (2014). Code of ethics and standards of practice. Alexandria, VA: Author. Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC). (2013). Competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individuals. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi:10.1080/15538605.2013.75 5444. Balsam, K. F., Molina, Y., Beadnell, B., Simoni, J., & Walters, K. (2011). Measuring multiple minority stress: The LGBT people of color microaggressions scale. Cultural Diversity & Ethnic Minority Psychology, 17 (2), 163–174. doi:10. 1037/a0023244. Cabaj, R. P. (2000). Substance abuse, internalized homophobia, and gay men and lesbians: Psychodynamic issues and clin­ ical implications. Journal of Gay & Lesbian Psychotherapy, 3 (3–4), 5–24. Callicott, Q. (2012). Exploring strengths of gay men in 12-step recovery. Journal of Gay & Lesbian Social Services, 24 (4), 396–416. doi:10.1080/10538720.2012.722825. Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication no. SMA 16-4984, NSDUH series H-51). www.samhsa.gov/data/report/key-sub stance-use-and-mental-health-indicators-united-states­ results-2015-national-survey-0. Cochran, B. N., & Cauce, A. M. (2006). Characteristics of lesbian, gay, bisexual, and transgender individuals enter­ ing substance abuse treatment. Journal of Substance Abuse Treatment, 30, 135–146. doi:10.1016/j.jsat.2005. 11.009. Eliason, M. J. (2000). Substance abuse counselors’ attitudes regarding lesbian, gay, bisexual, and transgendered clients. Journal of Substance Abuse, 12, 311–328. Eliason, M. J., & Hughes, T. L. (2004). Treatment counselors’ attitudes about lesbian, gay, bisexual, and transgender clients: Urban vs. rural settings. Substance Use and Misuse, 39, 625–644. doi:10.1081/JA-120030063.

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Green, K. E. (2012). Substance use in lesbian, gay, and bisexual populations: An update on empirical research and impli­ cations for treatment. Psychology of Addictive Behaviors, 26 (2), 265–278. doi:10.1037/a0025424. Hall, J. M. (1996). Lesbians’ participation in Alcoholics Anon­ ymous: Experience of social, personal, and political ten­ sions. Contemporary Drug Problems, 23 (1), 113–138. Hequembourg, A. L., & Dearing, R. L. (2013). Exploring shame, guilt, and risky substance use among sexual minority men and women. Journal of Homosexuality, 60 (4), 615–638. doi:10.1080/00918369.2013.760365. Hicks, D. (2000). The importance of specialized treatment pro­ grams for lesbian and gay patients. Journal of Gay & Les­ bian Psychotherapy, 3 (3–4), 81–94. doi:10.1300/J236 v03n03_07. Kennedy, E. L., & Davis, M. D. (1993). Boots of leather, slippers of gold: The history of a lesbian community. New York: Routledge. Luke, D. A., Ribisl, K. M., Walton, M. A., & Davidson, W. S. (2002). Assessing the diversity of personal beliefs about addiction: Development of the Addiction Belief Inventory. Substance Use & Misuse, 37 (1), 89–120. McCabe, S. E., West, B. T., Hughes, T. L., & Boyd, C. J. (2013). Sexual orientation and substance abuse treatment utiliza­ tion in the United States: Results from a national survey. Journal of Substance Abuse Treatment, 44, 4–12. doi:10.10 16/j.jsat.2012.01.007. Ocean, M. (2008). Bisexuals are bad for the same-sex marriage business. Journal of Bisexuality, 7 (3–4), 303–311. doi:10. 1080/15299710802171373. Redman, L. F. (2010). Outing the invisible poor: Why economic justice and access to health care is an LGBT issue. George­ town Journal on Poverty Law & Policy, 17 (3), 451–459. Rochlin, M. (1977). The heterosexual questionnaire. https:// higherlogicdownload.s3.amazonaws.com/NASN/784ade29­ 1f66-48a8-8c2d-3f9bc57af6bf/UploadedImages/Oregon% 20Microsite/Documents/HeterosexualQuestionnaire.pdf. Rowan, N. L., Jenkins, D. A., & Parks, C. A. (2013). What is valued in gay and lesbian specific alcohol and other drug treatment? Journal of Gay & Lesbian Social Services, 25 (1), 56–76. doi:10.1080/10538720.2012.751765. Substance Abuse and Mental Health Services Administration (SAMHSA). (2012). Top health issues for LGBT populations: Information and resource kit. HHS Publication no. (SMA) 12-4684. Rockville, MD: Substance Abuse and Mental Health Services Administration. Wolf, S. (2004). The roots of gay oppression. International Socialist Review, 37. www.isreview.org/issues/37/gay_ oppression.shtml.

GROUP ACTIVIT Y Connecting and Bonding Prompts • What are all the ways that people bond and connect with one another? • Of these identified ways, which do you use to bond or connect with people generally? • How do you bond or connect with people in the LGB community?

Representations in the Media Prompts • How are sexual orientation and substance use represented in the media? (Identify and list on the board representations of the LGB community in media.) Follow-up prompts: What percentage of LGB people are shown using substances? How many identify as being in recovery? Who are specific people or characters that come to mind regarding these topics? (Try to gather specific examples for each of the LGB groups and explore intersectional­ ity with other demographic groups—e.g., race, gender, etc.) • What beliefs do these representations translate into? (Identify and list.) • How have these representations and beliefs influenced you and your use? • Which beliefs have you internalized, and which have you rejected? How does that process happen?

Rating Prompts • Rate your connection to the LGB community when you are not using. • Rate your connection to the LGB community when you are using. • Rate your comfort level being a member of the LGB community when you are not using. • Rate your comfort level being a member of the LGB community when you are using. • Rate your level of pride in being a member of the LGB community when you are not using. • Rate your level of pride in being a member of the LGB community when you are using. • Rate your connection to the recovery community. George Stoupas and Mia Ocean

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• Rate your comfort level being a member of a recovery community. • Rate your level of pride in being a member of a recovery community. Follow-up prompts: What affects your ratings in this area? What influences your experience and perception? (Be sure to explore environment, substances, people, work, legal protections, and cultural identity factors such as gender, race or ethnicity, age, and socioeconomic status.) Which community is easier to be a member of? What connection do your ratings have to the conversation we were just having?

LGB & Recovery Prompts • How would your addiction be different if you were not a member of the LGB community? • How would your recovery be different if you were not a member of the LGB community? • Describe the relationship between substances and sexual orientation that exists for you. • What is your experience with AA, NA, or the twelve-step community? • What are your concerns about participating in the AA, NA, or the twelve-step community? • (Be sure to explore clients’ experiences with oppression and how these experience relate to their substance use.)

Community Building Prompts • How has the LGB community helped you? Hurt you? • How have you helped the LGB community? Hurt it? • How has the recovery community helped you? Hurt you? • How have you helped the recovery community? Hurt it? • How can you help build a community you want to be a member of?

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George Stoupas and Mia Ocean

SECTION VII

HOMEWORK, HANDOUTS,

AND ACTIVITIES FOR

CAREER, EMPLOYMENT, AND

EDUCATION ISSUES

running foot 489

The consequences of discrimination and oppression for LGBTQ individuals are multifaceted in terms of their influence on career development and the pur­ suit of education (Rheineck, Wise, & Williams, 2016; Schneider & Dimito, 2010). Many careers may seem unattainable because of discrimination, internalized oppression, and lack of role models (Gedro, 2009). This section addresses the concerns that clients with diverse sexual and gender identities may face with career choice, employment options, and college pur­ suits. Strong support networks and contacts within the LGBTQ communities as well as accurate informa­ tion can help clients make choices about coming out in the workplace, choosing LGBTQ-friendly employ­ ers, and gaining stronger identities to create resilience and manage oppression. The first two chapters address the job-search process. In Chapter 55, “Job Search and Career Resources for LGBT People,” Anita A. Neuer Colburn offers clinicians a list of resources they can share with clients searching for employment. The websites range from advocacy and legal information to job listings. In Chapter 56, “Sexual-Identity Man­ agement in the Job- Search Process with Lesbian and Gay Clients,” Suzanne M. Dugger and Jason A. Owens take a slightly different approach to the jobsearch process by first helping clients decide whether, how, and to what degree they may want to come out in the workplace. Using the workplace sexual-identi­ ty-management model developed by Lidderdale and colleagues (2007), the authors offer an activity that addresses identity-management strategies, enlists cli­ ents’ ideas about how to use those strategies during the job-search process, and explores clients’ sense of self-efficacy and expectations. Discrimination in the workplace can take many forms. Chapter 57, “Strategies for Helping LGBTQ Clients Address Discrimination in the Workplace,” by Randall L. Astramovich and Matthew J. Wright, offers means by which clinicians can explore strategies to help clients manage workplace discrimination, includ­ ing filing grievances and lawsuits and making deci­ sions not to come out for safety reasons. They offer an LGBTQ Workplace Discrimination Checklist that is useful for systematically deciding how, if, and when

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to confront discrimination based on their sexual and/ or gender identity. Resources to pursue legal action are also provided. Chapter 58, “Exploring Values in Career Explo­ ration with Adolescent LGBTQ Clients,” by Jane E. Rheineck and Tracy Peed, focuses on the process of exploring clients’ values as they decide on career options. Because personal values may lead clients to employment where discrimination could be more prevalent, exploring these values in light of the cur­ rent status of discrimination and oppressive policies is crucial. The authors tend to these concerns by using a values card–sorting activity in which clients priori­ tize their values and clinicians facilitate discussion about how those values can lead to career choices that fit with clients’ sexual and gender identities. The last two chapters in this section focus on the concerns that potential and current college students may have when deciding which college to attend and what careers are most viable. In Chapter 59, “The College Search: Campus Climate Check­ list,” Suzanne M. Dugger, Carina Lindsey, and Jason A. Owens address high school and potential transfer college students’ interest in choosing a university or college campus that provides a climate where they can be freer from harassment and bullying because of their sexual and gender identities. This chapter’s two-part activity includes first an invitation for cli­ ents to explore those facets of their identities they deem most important to them. In the second part, clinicians are advised to tailor a checklist based on the important aspects identified by the clients. In “Exploring Career Decision-Making SelfEfficacy with Sexual and Gender Minority College Students” (Chapter 60), Marilia Marien and Yuhong He use a career decision-making self-efficacy approach to facilitate career exploration among college students. Competing demands of sexualor gender-identity exploration and career exploration may complicate clients’ decision making. The inter­ section of multiple identities adds to the complex rocess. The activities in this chapter are framed within an approach that acknowledges the specific barriers that clients may face, thus leading to empowerment when facing them.

References Gedro, J. (2009). LGBT career development. Advances in Devel­ oping Human Resources, 11 (1), 54–66. doi:10.1177/ 1523422308328396. Lidderdale, M. A., Croteau, J. M., Anderson, M. Z., TovarMurray, D., & Davis, J. M. (2007). Building lesbian, gay, and bisexual vocational psychology: A theoretical model of workplace sexual identity management. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (eds.), Handbook of counsel­ ing and psychotherapy with lesbian, gay, bisexual, and

transgender clients, 245–270. Washington, DC: American Psy­ chological Association. Rheineck, J., Wise, S. M., & Williams, J. D. (2016). Lesbian, gay, bisexual, and transgender individuals. In W. K. Killam, S. Degges-White, & R. E. Michel (eds.), Career counsel­ ing interventions: Practice with diverse clients, 117–127. New York: Springer. Schneider, M. S., & Dimito, A. (2010). Factors influencing the career and academic choices of lesbian, gay, bisexual, and transgender people. Journal of Homosexuality, 57, 1355– 1369. doi:10.1080/00918369.2010.517080.

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55 JOB SEARCH AND CAREER RESOURCES FOR LGBT PEOPLE Anita A. Neuer Colburn Suggested Use: Handout Objective

This handout provides information on a variety of web­ sites that LGBT clients may find useful during a job search. These websites can help connect clients to appropriate professional organizations, advocacy orga­ nizations, and sites that list jobs with LGBT-friendly employers. LGBT clients may feel affirmed in response to the growing number of resources available and specifically tailored for their use in career development and job hunting. Clients may also be encouraged to develop additional local and regional resources for LGBT people navigating a job search. Rationale for Use

In many places of employment, LGBT persons remain misunderstood, marginalized, and underemployed. Fickling, Chan, and Cooper (2016) highlighted the ongoing marginalization that LGBT people experience in the workplace. Gedro (2009) suggested that the dearth of scholarly inquiry regarding LGBT-specific career needs contributes to workplace discrimination. Kormanik (2009) found that workplace awareness of sexual orientation and gender identity was quite low in comparison to awareness of sex discrimination, sexual harassment, and sexual attraction. Sangganja­ navanich (2009) reported that even career profession­ als often misunderstand the needs of LGBT people. Lehman (2016), when presenting statistics regarding diversity and unemployment, reported there were “no official government labor force data” for LGBTQ+ peo­ ple (p. 27). This lack of data further underscores the

need for LGBT people to identify affirming employ­ ment environments. Career decision making is complicated by techno­ logical advancements, and the political climate cre­ ates unpredictable shifts within the broader employ­ ment marketplace (Whitson & Blustein, 2013). It is further exacerbated for people who identify as LGBT. For example, transgender employees can be fired because of their gender identity in thirty-one states, 43 percent of LGBT workers have experienced workplace discrimination, and 14 percent of LGBT Americans make less than $10,000 annually—more than double the rate of the general U.S. population (Hennig Ruiz & Singh Law Firm, 2016). The intersectionality of career choice, job opportunities, and gender and sex­ ual identities can yield a complex maze for LGBT job seekers, particularly those who are also members of other marginalized groups (e.g., those who are Afri­ can American, Hispanic or Latino, female, or immi­ grants). The opportunity for discrimination and harm increases when individuals are members of multiple marginalized groups (Evans, 2012; Ratts et al., 2015). Schneider and Dimito (2010) found that sexual orientation and gender identity had a strong influence on academic and career choices for LGBT people, and particularly for those who had experienced antiLGBT discrimination. Career choice for LGBT peo­ ple appears to be at least partially informed by the extent to which they internalize messages about gen­ der roles and sexuality (Gedro, 2009). LGBT people and members of other marginalized groups face myr­ iad decisions when it comes to the world of work, including finding an environment where they won’t

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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be discriminated against (even if they’re not out at work), developing job-search materials (e.g., résumés, cover letters, websites), and strategically preparing for job interviews to maximize their qualifications, hon­ oring their own comfort level with their sexual ori­ entation and gender identity, and choosing the degree to which they share those identities with a future employer (Evans, 2012; Harnois, 2018; Lehman, 2016). The Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC) devel­ oped the LGBQQIA Competencies (Harper et al., 2013), which included an entire section on working with LGB people on career issues (II.F). Specifically, standard II.F.11 asks counselors to “link individuals with . . . resources that increase their awareness of via­ ble career options, when appropriate” (p. 18). ALGBTIC developed a similarly structured document to specifically address the needs of transgender peo­ ple. More recently, the “Multicultural Social Justice Counseling Competencies” document (Ratts et al., 2015) was developed, inviting practitioners to con­ sider the intersection of identities in the various pair­ ings of privileged or marginalized client and privi­ leged or marginalized counselor. The competencies themselves are sorted into four main categories: “Counselor Self-Awareness,” “Client Worldview,” “Counseling Relationship,” and “Counseling and Advocacy Interventions.” The “Counseling and Advo­ cacy Interventions” section outlines multiple layers of advocacy and social justice within the dynamics of power and oppression that can influence counseling relationships. Providing LGBT people with a list of employers and organizations intentionally affiliated with the LGBT community may be considered a form of social justice and advocacy for LGBT people (Ratts et al., 2015, IV.C) as they search for a place to work where they can feel free to be themselves and are least likely to have to worry about being mistreated or mar­ ginalized because of their gender or sexual identity. Additionally, several ethics codes and competency lists point counselors toward intentional advocacy for LGBT people. The Code of Ethics (2015) published by the National Career Development Association (NCDA) called for counselors to fight against margin­ alization, pointing specifically to the importance of cul­ tural sensitivity (A.2.c), avoiding harm (A.4.a), avoid­

ing imposing their own values (A.4.b), advocacy (A.6.a), nondiscrimination (C.5), and diversity issues in assessment (E.8). The NCDA’s (2009) “Minimum Competencies for Multicultural Career Counseling and Development” called on counselors who work with clients on career issues to “promote the career devel­ opment and functioning of individuals of all back­ grounds” (Introduction). The competencies (NCDA, 2009) further require that counselors regularly eval­ uate resources to ensure their appropriateness for the needs of diverse populations and that they contin­ uously update their knowledge of multicultural and diversity issues. Providing LGBT people with a custom­ ized list of LGBT resources is consistent with the mandates of NCDA’s Code of Ethics (2015) and “Com­ petencies” (2009). Further, the NCDA, as a division of the American Counseling Association (ACA), mod­ eled its Code of Ethics (2015) after the ACA Code of Ethics (2014), which contains similar calls for counsel­ ors to serve diverse populations and to advocate for marginalized populations. Similarly, the “Guidelines for Psychological Practices with Lesbian, Gay, and Bisexual Clients” (American Psychological Association [APA], 2012) encourages practitioners to be sensitive to the negative effects of disenfranchisement and alienation that some LGBT people may experience socioeconomically (guideline 17). Hence, the extant literature, competencies for affirmative practice, and applicable ethical codes together provide a solid rationale for counselors to provide LGBT-affirmative resources to their clients. This handout is one such resource. Instructions

The “LGBT Job Search and Career Resources” docu­ ment is arranged by category, and the descriptions offered are taken directly from the websites themselves. Sites are listed on the basis of a thorough Internet search and are current and active as of the time of this writing. Counselors should always check the web­ sites first to be sure they are still active and appropri­ ate before providing them as resources to clients. New sites are added frequently, and some sites are shut down or are not kept current. In addition to providing this list as a resource to clients, counselors should use it as a starting place to develop a list of local resources. Job Search and Career Resources for LGBT People 493

Counselors may provide clients selected infor­ mation from this handout in the form of one or several individual resources, or they could give their client the entire list. Counselors should make this decision on the basis of currently assessed needs, barriers, strengths, and goals of their individual client. This hand­ out should be used in conjunction with other career resources and is specifically designed for use with cli­ ents who have embraced the intersectionality of their sexual and gender identity with their career identity, and who seek LGBT-affirmative workplaces. It may also be useful to those seeking employment advocacy opportunities. “LGBT Job Search and Career Resources” could be used as a starting place to look for jobs or other resources, and it could be used as a starting place from which job seekers or advocates could garner additional information to support their current or future career goals. Counselors should ensure that cli­ ents are trained to appropriately conduct informational interviews before clients contact any of the organiza­ tions on the list. Chung, Chang, and Rose (2015) advise counselors to be intentional and explicit about their LGBT-affir­ mative positions. To that end, this handout (and other LGBT-affirmative literature, brochures, or handouts) might be displayed in the lobby of the office. Doing so would demonstrate to LGBT people and non-LGBT people alike that they are in a safe and affirming place. Brief Vignette

Ken, a Latino fifty-three-year-old gay cis man, pre­ sented for counseling because of his desire to find a job where he “didn’t have to hide who he was.” Ken had been out since he was a young adult and was currently in a long-term relationship with Joe, whom he intended to marry. Ken and Joe had been living together for over ten years, and both were doing odd jobs, including catering, landscaping, and in-home renovations. They were frugal and able to make ends meet while still “living well.” Ken shared the fact that he’d been working since he was fourteen years old, but that in all his jobs, even the jobs where his employers knew he was gay, he’d ended up losing the job because of his sexual orientation. He explained, “I would get hired because I had this talent they loved, and they would know who I was. But not everybody 494 Neuer Colburn

agrees with being gay, and it only takes one person who’s a loudmouth to make things difficult. Sooner or later, they’d look for some reason to get rid of me, and then I’d be stuck having to start over.” The counselor conducted full biopsychosocial and vocational histories and determined that Ken’s key need was to find stable employment in a safe and affirming environment. In the therapeutic relationship, the coun­ selor helped Ken grieve his lost employment opportu­ nities—the ones that ended prematurely as well as the ones that never came to be. Together, they worked on preparing Ken’s résumé to best highlight his skills, along with a basic cover letter that could be adapted for individual employers. Next they worked on developing some questions that Ken might ask during informa­ tional interviews, as well as Ken’s thirty-second “eleva­ tor speech” that he could adapt for different settings (cocktail parties, job interviews, chance meetings). The counselor then provided Ken the “LGBT Job Search and Career Resources” handout, instructing him to identify appropriate resources on that list and to make a connection with them for informational purposes. Ken perused some of the sites on the list and con­ tacted representatives from several of them. Using those connections and conversations, he identified some open jobs in his area that were with LGBT-affir­ mative employers. At his follow-up session, he admit­ ted that he’d never sought jobs from exclusively LGBTaffirmative places and that despite the length of time he’d been so open about his sexual orientation, he hadn’t thought about doing so. Previously, he’d hoped that if the interviewer knew he was gay and still hired him, then it would be okay in the rest of the environ­ ment. His hopes had not been realized, and he endured many forms of workplace discrimination and mar­ ginalization. Those experiences informed the kinds of questions Ken intended on asking his new sources during informational sessions and job interviews. Eventually, Ken landed a job with a company that was LGBT-affirmative, both in its advertising and in its day-to-day environment. He reported that using the “LGBT Job Search and Career Resources” handout, along with receiving coaching and preparation from his counselor with respect to conducting thorough informational interviews, helped him move from try­ ing to blend in to an environment where only a few

people were LGBT-affirming to advocating for him­ self by being selective about an employer and choosing to work only where both the job and the environment were a good fit. Suggestions for Follow-up

Counselors should follow up with clients after provid­ ing this handout to check on how helpful the resources were and how the client felt in accessing them. This debriefing process may help the counselor assess the client’s current level of overall preparedness for the job-search process and may also provide important information about the resources themselves. To be consistent with the Ratts and colleagues’ (2015) stan­ dard II.4, counselors should also encourage clients to check the local community for additional resources that might be added to the list. As a part of a broader effort to serve and advocate for LGBT people, counselors should seek out addi­ tional LGBT-affirmative resources in their local com­ munities. Counselors should also invite collaboration with community resources to best serve their LGBT clients. Such collaboration might include volunteer­ ing to make a presentation on current employment barriers and resources in the local community. Contraindications for Use

Refrain from using this handout as the only career resource with LGBT clients. Chung et al. (2015) warned that career counseling effectiveness can be hampered by either avoidance of or overemphasis on sexuality and gender issues. Clients who are still feel­ ing uncomfortable about being out in the workplace may not be prepared to engage in an LGBT-specific job search. Be sure to update the list before offering it to a client. Counselors should refrain from using this hand­ out before processing some of the natural anxiety that most clients have about the job-search process, par­ ticularly the anxiety that LGBT clients might have. LGBT people may have additional job-search anxiety that is based on their own or others’ history of dis­ crimination in the workplace, or on their own place in their sexual- or gender-identity development. Use this handout with LGBT clients who are in the “prepa­ ration” stage of change or later as it applies to securing new employment.

Professional Readings and Resources Busacca, L. A., & Rehfuss, M. C. (eds.). (2017). Postmodern career counseling: A handbook of culture, context, and cases. Alexandria, VA: American Counseling Association. Capuzzi, D., & Stauffer, M. D. (eds.). (2012). Career counseling: Foundations, perspectives, and applications, 2nd edition. New York: Routledge. Ellis, A. L., & Riggle, E. D. B. (eds.). (2014). Sexual identity on the job: Issues and services. New York: Routledge. Killam, W. K., Degges-White, S., & Michel, R. E. (eds.). (2016). Career counseling interventions: Practice with diverse clients. New York: Springer.

Resources for Clients (Most colleges offer career information specifically designed and tailored for LGBTQ people. Check in your local com­ munity for possible resources available to the public.) Colgan, F. (2014). Sexual orientation at work: Contemporary issues and perspectives. New York: Routledge. Fetherstonhaugh, B. (2016). The long view: Career strategies to start strong, reach high, and go far. New York: Diver­ sion Books. Folds, R. B., III. (2013). Your queer career: The ultimate career guide for lesbian, gay, bisexual, and transgender job seekers. Bronx, NY: Riverdale. Our Tomorrow. http://shareourtomorrow.org/. Streufert, B. (2014, October 11). Out at work: LGBT job search tips. USA Today. https://college.usatoday.com/2014/10/ 11/out-at-work-lgbt-job-search-tips/.

References American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. American Psychological Association (APA). (2012). Guidelines for psychological practices with lesbian, gay, and bisexual clients. American Psychologist, 67 (1), 10–42. Chung, Y. B., Chang, T. K., & Rose, C. S. (2015). Managing and coping with sexual identity at work. Psychologist, 28, 212–215. Evans, K. M. (2012). Career counseling with couples and fam­ ilies. In D. Capuzzi & M. D. Stauffer (eds.), Career coun­ seling: Foundations, perspectives, and applications, 2nd edition, 467–496. New York: Routledge. Fickling, M. J., Chan, C. C., & Cooper, Y. (2016). Diversity, inclusion, and equity & career development. NCDA Career Developments: Diversity, Inclusion, and Equity in Career Development, 33 (1), 6–11. Gedro, J. (2009). LGBT career development. Advances in Devel­ oping Human Resources, 11 (1), 54–66. doi:10.1177/152 3422308328396. Harnois, C. (2018). Analyzing inequalities: An introduction to race, class, gender, and sexuality using the General Social Survey. Thousand Oaks, CA: Sage. Job Search and Career Resources for LGBT People 495

Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H., Loos, B., . . . & Hammer, T. R. (2013). Association for Les­ bian, Gay, Bisexual, and Transgender Issues in Counsel­ ing competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individuals. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi:10.1080/15 538605.2013.755444. Hennig Ruiz & Singh Law Firm (2016, January). LGBT dis­ crimination in the workplace (infographic). https://employ mentattorneyla.com/lgbt-discrimination-in-the-workplace­ statistics/. Kormanik, M. B. (2009). Sexuality as a diversity factor: An examination of awareness. Advances in Developing Human Resources, 11 (1), 24–36. doi:10.1177/1523422308329369. Lehman, C. (2016). The marketplace: Diversity and unemploy­ ment. NCDA Career Developments: Diversity, Inclusion, and Equity in Career Development, 33 (1), 27. National Career Development Association (NCDA). (2009). Minimum competencies for multicultural career counsel­ ing and development. Broken Arrow, OK: Author. https:// www.counseling.org/docs/default-source/competencies/

496 Neuer Colburn

multi-cultural-career-counseling-competencies-august2009.pdf?sfvrsn=727f422c_4. National Career Development Association (NCDA). (2015). NCDA code of ethics. Broken Arrow, OK: Author. https:// www.ncda.org/aws/NCDA/asset_manager/get_file/3395. Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2015). Multicultural and social justice counseling competencies. https://www.counseling.org/ docs/default-source/competencies/multicultural-and-social­ justice-counseling-competencies.pdf?sfvrsn=20. Sangganjanavanich, V. F. (2009). Career development practi­ tioners as advocates for transgender individuals: Under­ standing gender transition. Journal of Employment Coun­ seling, 46, 128–135. doi:10.1002/j2161-0045.2013.00061.x. Schneider, M. S., & Dimito, A. (2010). Factors influencing the career and academic choices of lesbian, gay, bisexual, and transgender people. Journal of Homosexuality, 57, 1355– 1369. doi:10.1080/00918369.2010.517080. Whitson, S. C., & Blustein, D. L. (2013). The impact of career interventions: Preparing our citizens for the 21st century jobs. https://ncda.org/aws/NCDA/asset_manager/get _file/63826?ver=46610.

LGBT JOB SEARCH AND CAREER RESOURCES—CURRENT AS OF APRIL 2019

Advocacy and Legal

LGBT in Higher Ed. https://www.lgbtinhighered.

com/.

Equality Federation. https://www.equalityfederation.org.

ProGayJobs. www.ProGayJobs.com.

GLMA. Health professionals advancing LGBTQ

equality. www.glma.org/.

Human Rights Campaign. 2017 corporate equality

index. https://www.hrc.org/campaigns/corporate­ equality-index.

Lambda Legal. Making the case for equality.

https://www.lambdalegal.org.

National Center for Lesbian Rights. Employment.

www.nclrights.org/our-work/employment/.

Out and Equal Workplace Advocates.

http://outandequal.org/.

Out in Tech. https://www.outintech.com/about.

Pipeline Project. People of color leadership,

advancement & program development. https://

lgbtpipeline.org/about.

Pride at Work. www.prideatwork.org/.

Start Out. Empowering LGBTQ entrepreneurs.

https://startout.org/.

U.S. Equal Employment Opportunity Commission. https://www.eeoc.gov/eeoc/newsroom/wysk/ enforcement_protections_lgbt_workers.cfm. Federal Employees Department of Justice Pride. The official web pres­ ence for LGBT employees of the U.S. Department of Justice and their allies. https://dojpride.org. Federal Globe. Department of Defense. www.dod fed globe.com. Job Listings Career Builder. LGBT jobs. https://www.career

builder.com/jobs-lgbt.

Diversity Working. Job search engine for LGBT

jobseekers. https://www.diversityworking.com/

communityChannels/lgbt/.

Idealist Careers. Find, land, love, and grow in your

social-impact career. https://idealistcareers.org/

want-to-work-with-lgbtq-organizations-check­ out-these-jobs-internships-and-events/.

Professional Associations Consortium of Higher Education LGBT Resource

Professionals. “We envision higher education envi­ ronments in which LGBTQ people, including of all

of our intersecting identities, are fully liberated.”

http://www.lgbtcampus.org/.

National Association of LGBT Journalists. https://

www.nlgja.org/about.

National LGBT Bar Association. Fighting to protect

the LGBT community. http://lgbtbar.org/.

National Organization of Gay and Lesbian Scien­ tists and Technical Professionals. https://www.

noglstp.org/.

OUT Professionals. The nation’s leading LGBT net­ working organization. www.outprofessionals.org/.

Training and Education College Scholarships. www.collegescholarships. org/scholarships/lgbt-students.htm. Gay, Lesbian & Straight Education Network. Championing LGBTQ issues in K–12 education since 1990. https://www.glsen.org. Out for Undergrad. https://outforundergrad.org/. Out for Work. https://www.outforwork.org. Trans Resources Center for Gender Sanity. For trans people. www. gendersanity.com/for_trans_people.html. National Center for Transgender Equality. Issues: Employment. https://www.transequality.org/ issues/employment. Trans Can Work. Building a culture nationwide for transgender people to thrive in the workplace. https://www.transcanwork.org. Transgender Law & Policy Institute. Employer and union policies. www.transgenderlaw.org/ employer/index.htm.

Anita A. Neuer Colburn

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56 SEXUAL-IDENTITY MANAGEMENT IN THE JOB-SEARCH PROCESS WITH LESBIAN AND GAY CLIENTS Suzanne M. Dugger and Jason A. Owens Suggested Uses: Handout, activity Objective

This three-part activity is designed to assist lesbian and gay clients who are preparing for a job search. More specifically, this activity will (a) introduce clients to a variety of sexual-identity management strategies; (b) facilitate client brainstorming on how each strategy might be used during the job-search process; and (c) explore client self-efficacy levels, outcome expectations, and learning needs regarding each strategy. Rationale for Use

This activity represents an extension of the workplace sexual-identity management (WSIM) model devel­ oped by Lidderdale and colleagues (2007) and instru­ ments designed to assess WSIM strategies used by les­ bian and gay employees (Anderson, Croteau, Chung, & DiStefano, 2001; Lance, Anderson, & Croteau, 2010). This activity is not recommended for use with cli­ ents who identify as bisexual or transgender because research has yielded mixed results when counselors have attempted to apply the WSIM model or use the WSIM instrument with individuals who identify as bisexual (Lance, 2006) and because the WSIM model is specific to sexual identity and does not address gen­ der identity or expression (Lidderdale et al., 2007). From a theoretical perspective, the WSIM model uses social cognitive career theory (SCCT) to concep­ tualize the complex interaction of factors affecting les­ bian and gay individuals’ decisions and behaviors related to sexual-identity management at work. This model has received empirical support (Lance et al.,

2010; Rummell & Tokar, 2015) and offers useful insights about factors influencing lesbian and gay individuals’ decisions about whether to conceal or reveal their sex­ ual identity at work. Abundant in the literature are research findings regarding the experiences of lesbian and gay individuals within the workplace. These stud­ ies explore the nature and prevalence of discrimination within the workplace (Chung, 2001; Chung, Chang, & Rose, 2015; Parnell, Lease, & Green, 2012; Ragins, Singh, & Cornwell, 2007), costs and benefits of being out at work (Chung, 2001; Klawitter, 2014; Mohr & Fassinger, 2013; Ragins, 2004; Trau, 2014), and strat­ egies for sexual-identity management in the work­ place (Croteau, Anderson, & VanderWal, 2008; Lidder­ dale et al., 2007; Rummell & Tokar, 2015). For example, Chung (2001) and Chung and colleagues (2015) noted that lesbian, gay, bisexual, and transgender (LGBT) individuals may experience both “formal” and “infor­ mal” discrimination in the workplace (Chung et al., 2015, p. 212). Formal discrimination may involve employer or organizational decisions related to hiring, compensation, and termination, whereas informal discrimination tends to occur on an individual level and may include coworker comments, jokes, exclusion, “or even physical assault” (Chung et al., 2015, p. 212). Mohr and Fassinger (2013) summarized potential outcomes of such discrimination and heteronormativ­ ity, which include both physical and mental health problems as well as lower levels of job satisfaction and fewer advancement opportunities. These authors high­ lighted the “importance of investigating within-per­ son variability” when seeking to understand the effect of identity management strategies on “work attitudes

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

498

and distress” (Mohr & Fassinger, 2013, p. 158). Peo­ ple may use a variety of sexual-identity management strategies, some of which involve concealing of sexual identity and some of which involve revealing sexual identity, both through explicit and implicit means (Chung et al., 2015; Croteau, Anderson, & VanderWal, 2008; Lidderdale et al., 2007; Rummell & Tokar, 2015). Summarizing the literature, Chung and col­ leagues (2015) identified potential benefits of reveal­ ing sexual identity as including “relief and freedom to be oneself; increased self-esteem and affirmation; closer interpersonal relationships; opportunities for resources, support, and mentoring; and being part of organizational and social change” (p. 214). In contrast, potential costs include “loss of employment, discrim­ ination, harassment, social isolation, and physical assault” (p. 214). Despite the extensive literature related to sexualidentity management in the workplace, only a few studies focus specifically on the experiences of gay and lesbian individuals during the job-search process. Although the WSIM model has yet to be applied to the job-search process and has not yet been validated for use with bisexual or transgender individuals (Lance et al., 2010), career counselors may find it useful in assisting lesbian and gay clients in exploring options related to sexual-identity management when applying and interviewing for jobs. Job seekers who identify as gay or lesbian may benefit from counseling interventions focused on sex­ ual-identity management in the job-search process. Despite some progress with regard to societal accep­ tance of and legal protections for LGBT individuals (e.g., the U.S. Supreme Court’s legalization of same-sex marriage), LGBT individuals are still without federal protection against discrimination in employment situations (Human Rights Campaign, 2014b; Rheineck, Wise, & Williams, 2016; Rhodes & Stewart, 2016; Rummell & Tokar, 2019). Although twenty-two states have passed employment laws prohibiting discrimina­ tion on the basis of sexual orientation (Human Rights Campaign, 2016; Movement Advancement Project, 2019), federal law still allows employers to make hir­ ing, promotion, and termination decisions simply on the basis of actual or perceived sexual orientation (Human Rights Campaign, 2019; Movement Advance­

ment Project, 2019; Ragins et al., 2007; Rhodes & Stewart, 2016). Given that employers in twenty-eight states may legally discriminate against LGBT appli­ cants in their hiring decisions, it behooves LGBT indi­ viduals to consider whether to reveal or conceal their sexual identity during a job search and to develop skills in evaluating the climate regarding LGBT issues in employment settings to inform their decisions about where to apply. Counselors may use this activity to support lesbian and gay clients in doing so. Such an approach to career counseling represents affirmative practice in that it both honors the identity of lesbian and gay clients and supports them in making autonomous choices about how best to manage their sexual identity in order to protect their welfare. Such affirmative practice is con­ sistent with the ethical obligations of mental health professionals to offer nondiscriminatory and equita­ ble services to all clients. Through its Code of Ethics, the American Counseling Association (ACA) expressly prohibits “discrimination against prospective or cur­ rent clients, students, employees, supervisees, or research participants” on the basis of a wide variety of cultural characteristics, including sexual identity and gender identity (ACA, 2014, C.5). Further, the code implores counselors to “honor diversity and embrace a multicultural approach” and to “promote social justice” (preamble). Similar expectations for other pro­ fessionals are conveyed by the American Psychologi­ cal Association (APA, 2017, principle E) and the National Association of Social Workers (NASW, 2017, 4.02). Such standards reflect the commitment of the wider professions of counseling, psychology, and social work to social justice advocacy. Affirmative prac­ tice with LGBT clients is consistent with these expec­ tations, and this activity is designed to support ther­ apists in enhancing their repertoire when providing career counseling to gay and lesbian clients. To sup­ port practitioners in the provision of affirmative prac­ tice, the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) has articulated “Competencies for Counseling with Les­ bian, Gay, Bisexual, Queer, Questioning, Intersex, and Ally Individuals” (Harper et al., 2013). Section F is dedicated to the competencies related to career and lifestyle development; one competency is dedicated Sexual-Identity Management in the Job-Search Process 499

to assisting “LGBQQ individuals in making career choices that facilitate identity acceptance and job satisfaction” (p. 17). Instructions

This activity may be used with an individual client or in a group counseling setting. To begin this activity, introduce the four sexual-identity-management strat­ egies originally identified by Griffin (1992) and por­ trayed in Handout 1, “Sexual-Identity-Management Strategies.” Explain that these strategies can be used in a variety of settings, including the workplace and the job-search process. Also explain that there is no one right or better strategy to use because decisions about how much to conceal or reveal one’s sexual identity are complex and often depend not only on one’s per­ sonal comfort with being a sexual minority but also on contextual factors such as one’s current relationship status and the anticipated consequences of being out in any given situation. Next, using Worksheet 1, “Sexual-Identity-Man­ agement Strategies for the Job Search,” have the clients brainstorm examples of how each strategy may be used specifically in the job-search process. For instance, a job seeker may use “covering” strategies by eliminat­ ing items highlighting leadership positions in LGBT organizations during college. In contrast, a job seeker may use “explicitly out” strategies by explaining in a cover letter that, as a gay man, one reason that he is applying for a particular job is the employer’s reputa­ tion for being inclusive and welcoming of diversity. Once the worksheet is completed, the final part of this activity involves processing each brainstormed strategy within the context of the social cognitive the­ ory constructs on which the WSIM model is based. Specifically, this portion of the activity attends to selfefficacy beliefs, outcome expectations, and learning experiences. Worksheet 2, “Feelings and Beliefs about Sexual-Identity-Management Strategies for the Job Search,” is designed to facilitate this discussion. With regard to self-efficacy beliefs, ask clients to identify how confident they are in their ability to employ each brainstormed identity-management strategy during a job search. Also explore with clients their outcome expectations—the consequences they anticipate—for each strategy. In a group setting, this exploration may 500 Dugger & Owens

result in a rich conversation among clients regarding outcome expectations. Whereas some clients may anticipate the possibility of not being hired if they are explicitly out during the interview, other clients may expect that use of an explicitly out strategy will result in their being hired by a gay-friendly company. Finally, have clients identify any areas for future learning. For example, clients may wish to know more about tools to use to assess the workplace climate for lesbian and gay employees in certain companies to which they are interested in applying. Brief Vignette

Rubilynne (Ruby) Brown-Jackson is a twenty-three­ year-old, African American cis female who visits you in the university career center in the final semester of her undergraduate studies. Ruby has been a highly motivated and successful student, and in four weeks she will graduate with honors with a bachelor of arts degree in the area of business management with an emphasis in human resources. She hopes to use her experience and education to pursue a career in corpo­ rate event planning and employee relations. During four of her five years of undergraduate studies at Jackson State University, Ruby has held the coveted elected position of vice president of campus events and outreach for her sorority, Delta Sigma Theta. Although this leadership position has kept Ruby busy, she has found this challenging role exciting, and she explains that it has also enhanced her career prepara­ tion. In this position Ruby has had many opportuni­ ties to coordinate all aspects of many campus events (securing volunteers, funding, location, marketing, and so on), and she feels that these experiences will benefit her in the job market. In addition to immers­ ing herself in these extracurricular responsibilities, Ruby has excelled academically, and she declares that she has been diligently preparing for graduation and the pursuit of a successful career since her first day on campus. Ruby has always been hard on herself, driven almost to a fault, as she will be the first person in her family to earn a college degree. The youngest of nine children from the Mississippi Delta, Ruby explains that her entire family (her mother, stepfather, father, and stepmother, in addition to all eight of her siblings and

her grandmother) has worked to ensure there would be money available to pay for her tuition, rent, car, sorority fees, and any other school-related needs. Although Ruby readily acknowledges her gratitude for her family’s sacrifices, she also reveals that she has been distancing herself from them in the past year. Ruby indicates that her family strictly adheres to its strong Baptist background, and she explains that they believe family is the most important thing, sec­ ond only to God. Although she is thankful that her family has demonstrated this belief by coming together in support of her education (emotionally and finan­ cially), she divulges that their conservative belief sys­ tem is becoming a burden. Going to church when visiting home had been an uplifting experience until recently, but now Ruby finds herself feeling increas­ ingly uncomfortable at church. What Ruby has not shared with her family, or any­ one other than her girlfriend (who is also extremely closeted, a member of Delta Sigma Theta, and in an elected position within the sorority), is that she is a lesbian. Ruby shares with you the fact that, although they have been together for three years, she and her girlfriend have discussed not coming out to their fam­ ilies at all. Although they are committed to staying together and equally committed to remaining closeted with regard to their families, Ruby has some interest in a work environment in which she could come out in the future. Therefore, Ruby comes to you looking for guid­ ance in finding a career where there may be an oppor­ tunity to be herself and the possibility of domestic partner benefits. She also expresses concerns about race relations in the workplace, as she has never lived or worked in an environment that did not consist of mostly (90 percent or more) African American people. Ruby indicates, however, that her first priority is hav­ ing the earning potential to help her family, which has struggled financially to help her pay for college. During her first counseling session with you, Ruby is visibly nervous and obviously withholding. Ruby needs a counselor who is going to listen to her, as only her girlfriend knows the entire story, and this is the first time she will be sharing any of her goals with another human being. It is imperative to listen fully to her story, affirm her goals, and validate her feelings regarding

the situation at hand. Because Ruby is so deeply clos­ eted, her exposure to other sexual minority individu­ als has been extremely limited, and she is completely unprepared to investigate what the sexual orientation portion of her life means in regard to the job search. Ruby is not accustomed to being vulnerable; this is a rare feeling for her. On the other hand, Ruby values learning and is eager to obtain information that can help her move forward in a positive way. This is the driving force that has led her through her entire collegiate experience. Therefore, after establishing sufficient trust, it is time for the counselor to provide Ruby with some psychoeducation. It will be useful to share information with Ruby about various ways LGBT individuals choose to operate at a place of employment during the stages of sexual-identity development. More specifically, the psychoeducation should introduce Ruby to the four basic strategies of sexual-identity management and explore how they might apply to her situation. These strategies, depicted in Handout 1, are (a) passing, (b) covering, (c) explicitly out, and (d) implicitly out. This exploration may include an examination of how Ruby currently manages her sexual identity as well as her desired operating levels in the future. The first worksheet may be used to assist Ruby in identi­ fying ways each strategy can be used in the job-search process. In addition to heightening Ruby’s self-aware­ ness, this exploration can also empower her to decide whether to continue relying on her current strategies of concealing her sexual identity or to begin selectively revealing it to others. It is important to note that the options should not be presented to Ruby as an either-or (concealing vs. revealing) choice or as progressive stages. Instead, every interaction represents an opportunity for Ruby to choose among these four strategies, and a variety of individual factors (such as sexual-identity develop­ ment, relationship status, and race) and contextual factors (such as mounting bills and employer policies) may influence her decisions in any given situation. In this discussion the counselor should also broach the topic of race and the intersection of being African American and lesbian. Although Ruby has few options regarding how out to be where her race is concerned, she has many options with regard to how to manage Sexual-Identity Management in the Job-Search Process 501

the exposure of her sexual identity. Additionally, it is likely that this intersectionality will have some bearing on Ruby’s decisions about sexual-identity management in the job-search process. Worksheet 2 may be used to guide a conversation about Ruby’s thoughts and feelings about each strategy. It will be useful to explore how confident Ruby feels about her ability to use each strategy and important also to examine what consequences she would antici­ pate in response to her use of any given strategy. For example, Ruby may expect to feel a great sense of free­ dom resulting from being out in the job-search pro­ cess, followed by the ability to focus on performing her new job unencumbered by worry that she may be dis­ covered. Alternatively, Ruby may fear that use of a revealing strategy would result in “double discrimina­ tion” in the hiring process and difficulty obtaining employment. It is likely that these conversations will also identify learning opportunities for her. For example, Ruby may decide to participate in an anonymous online chat room and inquire about the experiences other LGBT individuals have had in being implicitly or explicitly out in the job search process or at work. Such informa­ tion may (a) increase Ruby’s skills and concomitant self-efficacy in using any given strategy, and (b) improve her understanding of the potential positive and neg­ ative consequences of each strategy. Suggestions for Follow-up

As Ruby chooses among the various sexual-identitymanagement strategies in her job search, it will be important to provide a venue in which she can pro­ cess her experiences. More generally, because the WSIM model includes feedback loops in which selfefficacy levels and outcome expectations change as a result of learning experiences, it is important to fol­ low up with clients as they engage in the job-search process and employ sexual-identity-management strat­ egies. Finally, once a client’s job search is complete, it will be useful to assist the client in considering work­ place sexual identity management strategies. Contraindications for Use

This activity is designed specifically for clients engaged in or preparing for a job search. As such, this activity 502 Dugger & Owens

would not be appropriate for clients who are not engaged in or preparing for a job search. Additionally, this activity is designed specifically for clients who identify as lesbian or gay. Research has yielded mixed results when attempting to apply the WSIM model or using the WSIM instrument with individuals who identify as bisexual (Lance, 2006). Similarly, use of the WSIM model is specific to sexual identity and does not address gender identity or expression. As such, it is not recommended for use with clients who identify as transgender. Professional Readings and Resources Anderson, M. Z., Croteau, J. M., Chung, Y. B., & DiStefano, T. M. (2001). Developing an assessment of sexual iden­ tity management for lesbian and gay workers. Journal of Career Assessment, 9, 243–260. Lance, T. S., Anderson, M. Z., & Croteau, J. M. (2010). Improving measurement of workplace sexual identity management. Career Development Quarterly, 59, 19–26. Lidderdale, M. A., Croteau, J. M., Anderson, M. Z., TovarMurray, D., & Davis, J. M. (2007). Building lesbian, gay, and bisexual vocational psychology: A theoretical model of workplace sexual identity management. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (eds.), Handbook of counseling and psychotherapy with lesbian, gay, bisex­ ual, and transgender clients, 245–270. Washington, DC: American Psychological Association.

Resources for Clients CenterLink. (2016). The community of LGBT centers. https://www.lgbtcenters.org/Centers/find-a-center.aspx. Although websites and books are helpful resources, sometimes clients may want to visit a physical brickand-mortar establishment where they can speak with a live human being regarding their needs, career or oth­ erwise. This website can direct clients to the nearest LGBT center for a face-to-face interaction. Cornell University Career Services. (2016). LGBT career resources. www.career.cornell.edu/resources/Diversity/ lgbt.cfm. This comprehensive website includes resources on the career-planning challenges faced by LGBT people, LGBT conferences and networking organizations, and LGBT publications and scholarship information. Friskopp, A., & Silverstein, S. (1996). Straight jobs, gay lives: Gay and lesbian professionals, the Harvard Business School, and the American workplace. New York: Touchstone. Although rather dated, this book offers still-relevant insights about the reasons to conceal as well as reasons to reveal one’s sexual orientation at work.

Human Rights Campaign. (2019). LGBTQ employee resources. https://www.hrc.org/resources/lgbt-employee-resources. The Human Rights Campaign (HRC) has been a leader in advocating for LGBTQ people across the country since it was formed in 1980 as the first LGBTQ politi­ cal action committee (PAC) in the United States. The HRC website can lead clients forward from their indi­ vidual level of comfort toward reaching their career goals—whether as an employee, advocate, or leader. Human Rights Campaign. (2019). Workplace discrimination laws and policies. https://www.hrc.org/resources/Work place-Discrimination-Policies-Laws-and-Legislation. This website includes a map featuring data regarding current legislative and policy protections offered at the state and local levels. Such information may be partic­ ularly useful to clients when they are gathering data to inform their outcome expectations as well as in iden­ tifying geographic locations in which they will be legally protected against discrimination and harassment on the basis of sexual orientation. More encompassing than some other sites, this site addresses legislation and policies related not only to employment but also to gen­ der marker change on identification documents, transgender health care, housing, public accommodations, marriage equality, hate crimes, school antibullying reg­ ulations, and school nondiscrimination regulations. Lyle, S. W. (2013). The power of being yourself: Navigating the corporate world when you are a minority. Bloomington, IN: iUniverse. Clients interested in being explicitly out at work may benefit from insights shared by the openly gay author about his experiences in a corporate environment. Movement Advancement Project. (2019). Non-discrimination laws. http://www.lgbtmap.org/equality-maps/non_dis crimination_laws. This website offers data regarding current legislative and policy protections offered at the state and local levels. Such information may be particularly useful to clients when they are gathering data to inform their out­ come expectations as well as in identifying geographic locations in which they will be legally protected against discrimination and harassment on the basis of sexual orientation or gender identity. Out and Equal Workplace Advocates. (2016). LGBT careerlink. http://outandequal.org/lgbt-careerlink/. Out and Equal Workplace Advocates is a website on which clients can search for positions on the basis of their interest and educational or training level without worry of their sexual identity being a factor in obtain­ ing employment. Positions range from entry level to doctorate required. Snyder, K. (2003). Lavender road to success: The career guide for the gay community. Berkeley, CA: Ten Speed Press.

The Lavender Road guides clients through the steps in building success, from laying the foundation through creating success and finally achieving their dreams. This book emphasizes the importance of living a con­ gruent life, being oneself inside and outside the work­ place. Although this book is somewhat dated, it may still hold value for clients working in more oppressive, less progressive workplaces.

References American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/. Anderson, M. Z., Croteau, J. M., Chung, Y. B., & DiStefano, T. M. (2001). Developing an assessment of sexual identity management for lesbian and gay workers. Journal of Career Assessment, 9, 243–260. doi:10.1177/10690727010090 0303. Chung, Y. B. (2001). Work discrimination and coping strate­ gies: Conceptual frameworks for counseling lesbian, gay, and bisexual clients. Career Development Quarterly, 50, 33–44. doi:10.1002/j.2161-0045.2001.tb00887.x. Chung, Y. B., Chang, T. K., & Rose, C. S. (2015). Managing and coping with sexual identity at work. Psychologist, 28, 212– 215. doi:10.5040/9781472552945.ch-007. Croteau, J. M., Anderson, M. Z., & VanderWal, B. L. (2008). Models of workplace sexual identity disclosure and man­ agement. Group & Organization Management, 33, 532– 565. doi:10.1177/1059601108321828. Griffin, P. (1992). From hiding out to coming out: Empower­ ing lesbian and gay educators. Journal of Homosexuality, 22, 167–196. doi:10.1300/J082v22n03_07. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H. C., . . . & Hammer, T. R. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling com­ petencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individuals. Journal of LGBT Issues in Counseling, 7, 2–43. doi:10.1080/15538605.2013. 755444. Human Rights Campaign. (2014a). Beyond marriage equality: A blueprint for federal non-discrimination protections. http://hrc-assets.s3-website-us-east-1.amazonaws.com// files/documents/HRC-BeyondMarriageEquality-42015. pdf. Human Rights Campaign. (2014b). The cost of the closet and the rewards of inclusion: Why the workplace environment matters for LGBT people matters to employers. http:// hrc-assets.s3-website-us-east-1.amazonaws.com//files/ assets/resources/Cost_of_the_Closet_May2014.pdf. Human Rights Campaign. (2019). Workplace discrimination

Sexual-Identity Management in the Job-Search Process 503

laws and policies. http://www.hrc.org/resources/Work place-Discrimination-Policies-Laws-and-Legislation. Klawitter, M. (2014). Meta-analysis of the effects of sexual iden­ tity on earnings. Industrial Relations, 54 (1), 4–32. Lance, T. S. (2006). More in than out of the classroom closet: A study of lesbian, gay, and bisexual teachers’ identity man­ agement strategies. PhD diss., Western Michigan Univer­ sity. https://scholarworks.wmich.edu/cgi/viewcontent. cgi?referer=https://www.bing.om/&httpsredir=1&article= 1965&context=dissertations. Lance, T. S., Anderson, M. Z., & Croteau, J. M. (2010). Improv­ ing measurement of workplace sexual identity manage­ ment. Career Development Quarterly, 59, 19–26. doi:10.1 002/j.2161-0045.2010.tb00127.x. Lidderdale, M. A., Croteau, J. M., Anderson, M. Z., Tovar-Mur­ ray, D., & Davis, J. M. (2007). Building lesbian, gay, and bisexual vocational psychology: A theoretical model of workplace sexual identity management. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (eds.), Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients, 245–270. Washington, DC: American Psy­ chological Association. doi:10.1037/11482-010. Mohr, J., & Fassinger, R. E. (2013). Work, career, and sexual identity. In C. J. Patterson & A. R. D’Augelli (eds.), Hand­ book of psychology and sexual identity, 151–164. New York: Oxford University Press. Movement Advancement Project. (2019). Non-discrimination laws. http://www.lgbtmap.org/equality-maps/non_discrim ination_laws. National Association of Social Workers (NASW). 2017. Code of ethics of the National Association of Social Workers. https://www.socialworkers.org/About/Ethics/Code-of­ Ethics/Code-of-Ethics-English.

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Parnell, M. K., Lease, S. H., & Green, M. L. (2012). Perceived career barriers for gay, lesbian, and bisexual individuals. Journal of Career Development, 39, 248–268. doi:10.1177/ 0894845310386730. Ragins, B. R. (2004). Sexual identity in the workplace: The unique work and career experiences of gay, lesbian, and bisexual workers. Research in Personnel and Human Resources Management, 23, 35–120. doi:10.1016/s0742­ 7301(04)23002-x. Ragins, B. R., Singh, R., & Cornwell, J. M. (2007). Making the invisible visible: Fear and disclosure of sexual identity at work. Journal of Applied Psychology, 92, 1103–1118. doi:10. 1037/0021-9010.92.4.1103. Rheineck, J., Wise, S. M., & Williams, J. D. (2016). Lesbian, gay, bisexual, and transgender individuals. In W. K. Killam, S. Degges-White, & R. E. Michel (eds.), Career counseling interventions: Practice with diverse clients, 117–127. New York: Springer. Rhodes, C. D., & Stewart, C. O. (2016). Debating LGBT work­ place protections in the Bible belt: Social identities in legislative and media discourse. Journal of Homosexuality, 63, 904–924. doi:10.1080/00918369.2015.1116341. Rummell, C. M., & Tokar, D. M. (2015). Testing an empirical model of workplace sexual identity management. Psychol­ ogy of Sexual Identity and Gender Diversity, 3, 49–61. doi:10.1037/sgd0000144. Trau, R. N. C. (2014). The impact of discriminatory climate perceptions on the composition of intraorganizational developmental networks, psychosocial support, and job and career attitudes of employees with an invisible stigma. Human Resource Management, 54, 345–366. doi:10.1002/ hrm.21630.

HANDOUT 1. SEXUAL-IDENTIT Y-MANAGEMENT STRATEGIES

Strategies designed to conceal gay or lesbian identity by actively portraying oneself as heterosexual

Strategies designed to reveal gay or lesbian identity by actively portraying oneself as lesbian or gay

Examples:

Examples:

• Fabricating stories of opposite sex dates/ partners

• Telling others that you are gay or lesbian

• Using opposite sex pronouns when referring to same sex dates/partners • Telling or laughing at jokes about gay or lesbian people

• Correcting others who assume or suggest that you are heterosexual • Bringing a same-sex person to events and openly identifying them as your date/partner • Using blatant indicators (buttons, stickers, jewelry) generally recognized by the public as gay or lesbian symbols

• Choosing gender-traditional clothes, items, or behaviors

Passing

Explicitly Out

CONCEALING

REVEALING

Covering Strategies designed to conceal gay or lesbian identity by passively portraying oneself as heterosexual

Implicitly Out

Strategies designed to reveal gay or lesbian identity by passively portraying oneself as lesbian or gay

Examples:

Examples:

• Avoiding gendered names and pronouns when referring to same-sex dates/partners • Avoiding conversations, friends, and ac­ tivities through which others may suspect my sexual orientation or ask about my personal life

• Being accurate in self-portrayal but not explicit about one's sexual orientation

• Not correcting others when they assume or state that I am heterosexual

• Referring to partners/dates with accurate pronouns but not explicitly coming out • Challenging anti-gay comments/dis­ crimination without explicitly identifying yourself as gay or lesbian • Using subtle indicators (buttons, stickers, jewelry) generally recognized by the public as gay or lesbian symbols

Sources: Anderson, Croteau, Chung, & DiStefano, 2001; Lance, 2006; Lance, Anderson, & Croteau, 2010.

Suzanne M. Dugger and Jason A. Owens

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WORKSHEET 1

Sexual-Identity-Management Strategies for the Job Search LGBT individuals use a variety of strategies to manage how much they reveal and/or conceal to others about their sexual identity. There is no one right or better strategy to use, as individuals and situations are complex. Use this worksheet to identify how each of the following strategies may be used specifically when searching for a job.

Strategies for Concealing

Passing

Covering

Strategies designed to conceal gay or lesbian identity by actively portraying oneself as heterosexual

Strategies designed to conceal gay or lesbian identity by passively portraying oneself as heterosexual

Strategies for Revealing Strategies designed to reveal gay or lesbian identity by actively portraying oneself as lesbian or gay

Strategies designed to reveal gay or lesbian identity by passively portraying oneself as lesbian or gay

506

Suzanne M. Dugger and Jason A. Owens

Explicity Out

Implicity

Out

WORKSHEET 2

Feelings and Beliefs about Sexual­ Identity-Management Strategies for the Job Search

Passing

Explicitly Out

Covering

Implicitly Out

Feelings of Confidence: How confident do you feel in your ability to effectively use each strategy in the job-search process?

Anticipated Consequences: What consequences do you anticipate will result from use of each strategy in the job-search process?

Learning needs: Identify any skills or practice you would like to gain in the use of specific strategies. Identify any information or tools you would like to help you improve your ability to accurately anticipate outcomes.

Suzanne M. Dugger and Jason A. Owens

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57 STRATEGIES FOR HELPING LGBTQ CLIENTS ADDRESS DISCRIMINATION IN THE WORKPLACE Randall L. Astramovich and Matthew J. Wright Suggested Use: Homework Objective

The LGBTQ Workplace Discrimination Checklist was developed to help counselors empower LGBTQ clients who are coping with job discrimination or intolerance. Rationale for Use

Research suggests that up to 42 percent of LGBTQ individuals face workplace discrimination or a hostile work environment (Pizer, Sears, Mallory, & Hunter, 2012). Workplace discrimination may affect the men­ tal health of LGBTQ people, increasing their risk for psychological distress (Discont, Russell, Gandara, & Sawyer, 2016); PTSD has been documented in some cases of minority discrimination (Carter, 2007). In addition, workplace discrimination may lead to diffi­ culties in LGBTQ people’s relationships with work supervisors and coworkers, as well as affect relation­ ships with their families and friends. Workplace preju­ dice and discrimination against LGBTQ people may include verbal harassment, physical threats, exclusion from workplace events, and denial of workplace cour­ tesies (Gates, 2011). Additionally, LGBTQ people with other intersecting minority identities may also expe­ rience discrimination that is based on ethnicity, dis­ ability, or gender (Shaw, Chan, & McMahon, 2012). Given the significant stress often associated with work­ place discrimination, counseling services can be an important component of helping LGBTQ individuals respond to intolerance and discrimination in their work setting (Anderson, 2016; Chung, Chang, & Rose, 2015). For LGBTQ clients coping with workplace dis­

crimination, options for addressing prejudice and intolerance may seem limited, risky, or infeasible. Beyond quitting the workplace, clients might consider altering their degree of openness or outness at work or attempt to hide their identity (Chung, 2001). Some clients may refrain from addressing the discrimina­ tion, in hopes it will go away or to prevent it from escalating. Clients may also decide to confront the discrimination directly and choose to file grievances with supervisors and the human resources depart­ ment. Furthermore, clients may seek to explore legal recourse to address the discrimination. Counselors can therefore play a pivotal role in helping empower an LGBTQ client to identify and assess options and responses to workplace intolerance and discrimina­ tion. Because professional counselors may have lim­ ited experience with and knowledge about LGBTQ workplace discrimination and legal options, the authors developed the LGBTQ Workplace Discrimi­ nation Checklist as a means for helping clients explore options in addressing job-related prejudice and intolerance. Research suggests multiple deleterious effects of workplace discrimination on LGBTQ people, includ­ ing reduced wages, fewer promotions, and increased physical and mental health concerns (Sears & Mallory, 2011). Surprisingly, no studies to date appear to have examined outcomes of LGBTQ workplace discrimi­ nation interventions, and no federal laws currently protect LGBTQ people from discrimination (MooreRamirez, Kautzman-East, & Ginicola, 2017). Given these concerns, the Association for Lesbian, Gay, Bisex­ ual, & Transgender Issues in Counseling (ALGBTIC)

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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developed competencies for counselors working with LGBTQ people regarding career development (Harper et al., 2013). Counselors are compelled to understand the ways that workplace discrimination and systemic oppression affect the lives of LGBTQ people (F.4, F.7). In addition, counselors can help empower LGBTQ clients to address inequities in workplace settings (F.8) and help them identify resources for support (F.12). The LGBTQ Workplace Discrimination Checklist addresses these competencies by helping empower cli­ ents to gain knowledge and develop support systems needed to challenge discrimination successfully. Instructions

The LGBTQ Workplace Discrimination Checklist provides a variety of potential homework activities for clients to pursue as part of their process in address­ ing workplace discrimination. The counselor may introduce the checklist as a way for the client to begin exploring options for confronting the discrimination. The checklist is not sequential, and clients should be encouraged to select items that reflect their current needs and readiness to confront the discrimination. The counselor should carefully review the checklist with the client to determine the appropriateness of specific checklist items for the client to pursue as between-session homework. During subsequent sessions, the counselor should spend time exploring the client’s experiences with the homework activities and help the client identify next steps. To facilitate this follow-up discussion, the coun­ selor may specifically ask the client: (a) What activi­ ties from the checklist did you pursue? (b) What new information have you gathered that will inform your decision-making process? (c) What additional infor­ mation do you need? (d) What support systems do you have in place? (e) What are some potential barriers that you need to address? (f) What are potential rami­ fications both personally and at work for proceeding with action to address the discrimination? (g) What is a realistic time line for taking action? Brief Vignette

Kellee is a forty-three-year-old transgender African American who identifies as a heterosexual female. She has worked for ten years as a loan officer at a bank in

a rural setting. When she was first hired by the bank, she was known to her coworkers as a cisgender male named Clint. Kellee began the process of transition­ ing from male to female during the past year, however. During this time she notified the human resources department about her process; she also discussed the transition with her immediate supervisors and cowork­ ers. At that time, she began to change her legal identity, and she requested employees at the bank to begin referring to her as Kellee and to use female pronouns. Initially, some bank employees expressed shock at the news of Kellee’s transition. Human resources honored her requests, and her supervisors did not dis­ play any overt hostility, although some occasionally misgendered her or referred to her as Clint. Kellee’s coworkers reacted less positively. Kellee worked closely with several other loan officers, most of whom are male. Kellee had been good friends with her male coworkers, and the office environment had always been collegial and friendly. Throughout her transition, her male coworkers frequently made disparaging remarks about transgender people, including offensive com­ ments about her body and genitalia. Kellee admits that when she identified as a male, she and other male coworkers would engage in sexist and homophobic discussions when female employees were absent. Because her male coworkers believe that Kellee has become a different person, they have marginalized her at the office, and she has been excluded from numer­ ous work-related meetings. Kellee has repeatedly gone to her supervisors, upper management, and the human resources depart­ ment to complain about the discriminatory work environment. Although all have been personally sup­ portive, they seem unwilling to directly address the discrimination or to impose disciplinary action if the harassing behavior does not cease. Kellee indicates that racial bias seems to receive more intervention and action by bank administrators, but she does not believe that race is part of the discrimination in her situation because she never experienced racial bias previously on the job. When Kellee first began her transition, she used a gender-neutral bathroom in the workplace. She recently began using the women’s restroom, however, and sev­ eral female employees filed complaints. As a result, KelHelping LGBTQ Clients Address Workplace Discrimination 509

lee’s supervisors asked Kellee to use the gender-neutral bathroom. Because Kellee refused this request, ten­ sions at work escalated and Kellee sought counseling services to deal with the anxiety she is experiencing. Using items from the LGBTQ Workplace Dis­ crimination Checklist, Kellee was encouraged by her counselor to explore her legal options. Kellee con­ tacted the state bar association and received a referral to an LGBTQ-affirming attorney. Kellee also located a social media support group for transgender people coping with workplace difficulties and discrimination. Ultimately, the bank president agreed to a mediation process with Kellee, and a settlement was reached that ensured Kellee’s dignity and rights in the work­ place. During counseling sessions, the counselor helped Kellee explore her abilities to manage stress and main­ tain her mental and physical wellness during the mediation process. Suggestions for Follow-up

After clients have researched workplace and legal options, counselors may want to help them assess the benefits and potential risks associated with various choices. Clients may also need to debrief any difficult interactions or events related to filing complaints at work or proceeding with legal actions. Contraindications for Use

Clients who are experiencing high levels of distress, including anxiety and depression, may not benefit from exploring workplace rights and legal options until symptoms of mental health disorders are reduced. Cli­ ents with limited family and social support may feel isolated and need to focus on developing support net­ works before addressing the discrimination directly. In addition, clients with limited financial resources may be unable to secure legal services necessary to pur­ sue litigation. Finally, clients who are at risk of being dismissed from their position after initiating a com­ plaint may need to plan for other income sources and jobs before initiating formal complaints. Professional Readings and Resources Dipboye, R. L., & Colella, A. (eds.). (2005). Discrimination at work: The psychological and organizational bases. Mahwah, NJ: Lawrence Erlbaum.

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Kapardis, A. (2014). Psychology and law: A critical introduction, 4th edition. New York: Cambridge University Press. Kite, M. E., & Whitley, B. E. (2016). Psychology of prejudice and discrimination, 3rd edition. New York: Routledge.

Resources for Clients Equal Employment Opportunity Commission (EEOC). (n.d.). https://www.eeoc.gov/. Lambda Legal. (n.d.). https://www.lambdalegal.org/. Mental Health America. (n.d.). Lesbian/gay/bisexual/trans gender communities and mental health. www.mental healthamerica.net/lgbt-mental-health. NAMI: National Alliance on Mental Illness. (n.d.). https:// www.nami.org/Find-Support/LGBTQ. Repa, B. K. (2014). Your rights in the workplace: An employee’s guide to fair treatment, 10th edition. Berkeley, CA: Nolo. Williams Institute, UCLA School of Law. (n.d.). https://williams institute.law.ucla.edu/.

References Anderson, C. W. (2016, March 23). The APA on discrimina­ tion-related stress and its effect on LGBT lives. Advocate. www.advocate.com/commentary/2016/3/23/apa-discri mination-related-stress-and-its-effect-lgbt-lives. Carter, R. T. (2007). Racism and psychological and emotional injury: Recognizing and assessing race-based traumatic stress. Counseling Psychologist, 35, 13–105. doi:10.1177/ 0011000006292033. Chung, Y. B. (2001). Work discrimination and coping strate­ gies: Conceptual frameworks for counseling lesbian, gay, and bisexual clients. Career Development Quarterly, 50, 33–44. doi:10.1002/j.2161-0045.2001.tb00887.x. Chung, Y. B., Chang, T. K., & Rose, C. S. (2015). Managing and coping with sexual identity at work. Psychologist, 28, 212–215. https://thepsychologist.bps.org.uk/volume-28/ march-2015/managing-and-coping-sexual-identity-work. Discont, S., Russell, C., Gandara, D., & Sawyer. K. (2016). LGB issues in the workplace 101. Industrial-Organizational Psychologist, 53 (4), 39–44. www.siop.org/tip/april16/ pdfs/lgbt.pdf. Friedman, M. (2014, February 11). The psychological impact of LGBT discrimination. Psychology Today. https://www. psychologytoday.com/blog/brick-brick/201402/the­ psychological-impact-lgbt-discrimination. Gates, T. G. (2011). Why employment discrimination matters: Well-being and the queer employee. Journal of Workplace Rights, 16, 107–128. doi:10.2190/WR.16.1.g. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H. C., Loos, B., . . . & Hammer, T. R. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individuals.

Journal of LGBT Issues in Counseling, 7, 2–43. doi:10.1080/15 538605.2013.755444. Moore-Ramirez, A., Kautzman-East, M., & Ginicola, M. M. (2017). LGBTQI+ persons in adulthood. In M. M. Gini­ cola, C. Smith, & J. M. Filmore (eds.), Affirmative coun­ seling with LGBTQI+ people, 49–60). Alexandria, VA: American Counseling Association. Pizer, J. C., Sears, B., Mallory, C., & Hunter, N. D. (2012). Evi­ dence of persistent and pervasive workplace discrimina­ tion against LGBT people: The need for federal legislation

prohibiting discrimination and providing for equal employ­ ment rights. Loyola of Los Angeles Law Review, 45, 715–779. Sears, B., & Mallory, C. (2011). Documented evidence of employment discrimination and its effects on LGBT peo­ ple. Los Angeles: Williams Institute. https://escholarship. org/uc/item/03m1g5sg. Shaw, L. R., Chan, F., & McMahon, B. T. (2012). Intersection­ ality and disability harassment: The interactive effects of disability, race, age, and gender. Rehabilitation Counseling Bulletin, 55, 82–91. doi:10.1177/0034355211431167.

Helping LGBTQ Clients Address Workplace Discrimination 511

LGBTQ WORKPL ACE DISCRIMINATION CHECKLIST 1. The Equal Employment Opportunity Commission (EEOC) handles complaints based on discrimination or harassment; it has regional offices located across the United States. Explore the process for initiating a complaint and how to file a charge online at https://www.eeoc.gov/ federal/fed_employees/filing_complaint.cfm. 2. Most states have a state human rights commission or other similar body that takes discrimination complaints. Identify those organizations in your state and explore the resources available. 3. All fifty states have a statewide LGBTQ advocacy organization, usually named Equality followed by the name of the state. For example, see Equality California’s website: https://www.eqca.org. Many of these organizations investigate discrimination complaints or can make referrals to lawyers and other organizations to assist you. 4. Do some basic legal research about nondiscrimination laws including Title VII or similar state legislation. Some online starting points include: a. Lambda Legal: http://www.lambdalegal.org/ b. Williams Institute, UCLA School of Law: https://williamsinstitute.law.ucla.edu/ c. Equal Employment Opportunity Commission (EEOC): https://www.eeoc.gov/ 5. Depending on your work setting, human resources personnel may be available for helping you investigate options for addressing discrimination by supervisors or coworkers. If this option is available, arrange to meet with a representative from your human resources department to discuss your concerns. 6. Brainstorm different resolution scenarios and assess the pros and cons of each resolution scenario, including the likelihood of success. Possible resolution scenarios include mediation, working with the human resources department on a solution, leaving the workplace and finding other employment, and filing a discrimination complaint. 7. Explore the possibility of obtaining legal counsel. Be advised, however, that litigation can be both psychologically difficult and financially straining. Research the cost of filing a lawsuit, and identify any lawyers who could meet with you to review your situation and provide an estimate of the financial costs involved. State bar associations may be able to make recommendations on the basis of your location and type of case. 8. Identify and consider joining support groups (either in-person or virtual) for people in similar situations for additional help during this time. 9. Research the potential effects of discrimination on your mental and physical well-being, and identify strategies to help foster your wellness while coping with the discrimination. 10. Consider advocating for the establishment of ally “safe zones” in your work setting. The Human Rights Campaign offers suggestions at http://www. hrc.org/resources/establishing-an-allies­ safe-zone-program.

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58 EXPLORING VALUES IN CAREER EXPLORATION WITH ADOLESCENT LGBTQ CLIENTS Jane E. Rheineck and Tracy Peed Suggested Uses: Handout, activity Objective

This activity is designed to help clients determine the compatibility of their personal values and career choices. Card sorts, in particular, allow clients to expand their awareness and develop their self-con­ cept, and they provide strategies that help clients identify and make comparisons among their values. Card sorting, an integrative approach and appropriate for lesbian, gay, bisexual, trans, and queer (LGBTQ) youth, considers the whole person, the person’s val­ ues, and the developmental process of constructing a successful career. Rationale for Use

Despite the legal, political, and social progress LGBTQ individuals have made in recent years, many people who identify as LGBTQ still experience barriers, chal­ lenges, and discrimination (Beck, Rausch, Lane, & Wood, 2016; Rheineck, Wise, & Williams, 2016). A report by the Human Rights Campaign (HRC) in 2014 reported that between 15 and 43 percent of LGBTQ persons have experienced some type of harassment in the workplace, and 90 percent of transgender employ­ ees reported some form of harassment or mistreat­ ment. The 2015 GLSEN National School Climate Sur­ vey reported that 57.6 percent of LGBTQ students felt unsafe at school because of their sexual orienta­ tion, and 43.3 percent because of their gender expres­ sion. In addition, LGBTQ youth reported high levels of bullying and victimization, often reported low lev­ els of self-esteem, and were twice as likely as hetero­

sexual, cisgender youth not to report postsecondary educational or vocational plans: 10 percent versus 5.2 percent (GLSEN, 2015). All these variables (along with other variables) can lead to career confu­ sion and indecisiveness (Schmidt, Miles, & Welsh, 2011). Therefore, it is imperative that counselors working with LGBTQ youth understand the complex­ ity of conditions that affect career counseling with LGBTQ youth. To mitigate future workplace barriers and chal­ lenges, Datti (2009) and Morrow, Gore, and Campbell (1996) recommend an integrative approach, consid­ ering the whole person during the career counseling process. Developmental theories of career decision making, such as Super’s (1990), which introduced the idea of the self-concept, illustrate an integrative approach. Super believed that our identities (includ­ ing our careers) are a product of how we see ourselves and how we put this concept into practice. In addition, the application of career-construction theory (Sav­ ickas, 2005) integrates self-concept and social accep­ tance into career development and choice. A successful career is one that makes use of as much of a person’s self-concept as possible (Savickas, 2005; Super, 1990). School counselors, in particular, are positioned to recognize the issues that LGBTQ youth encounter and the barriers they face (Beck et al., 2016). Beck and colleagues also discussed the value in evaluating the person-environment fit that involves personal values examination such as the “desire to fulfill a social and emotional need as coming out” (p. 201). Accord­ ing to Beck and colleagues, examining the personenvironment fit can serve as a rich and comprehensive

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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strategy that can help LGBTQ youth conceptualize and articulate their values. Counselors are then able to assist LGBTQ youth in either their college or their career choice. Counselors thus need to be knowledgeable about the LGBTQ community, as well as the salient common and diverse concerns of this population. In addition to coursework and continuing education, it is impor­ tant to understand that “coming out is an on-going and multi-layered process for LGBTQ individuals and that coming out may not be the goal for all individu­ als. While coming out may have positive results for a person’s ability to integrate their identity into their lives thus relieving the stress of hiding, for many indi­ viduals coming out can have high personal and emo­ tional costs (e.g., being rejected from one’s family of origin, losing a job/career, or losing one’s support system” (Harper et al., 2013, p. 9). Therefore, counsel­ ors should strive to meet clients where they are and assist them in making career decisions that “facilitate identity acceptance and job satisfaction” (Harper et al., 2013, p. 17). Counselors also need to take into consideration the effects of intersectionality in terms of clients’ vari­ ous identities. Some clients will experience marginal­ ization or oppression in several identities (e.g., black, lesbian, female, with an intellectual disability), which magnify the effect of marginalization and oppression. The Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) competencies note that counselors need to “understand how experi­ ences of discrimination and oppression related to affec­ tional orientation and/or gender identity/expression at work may be compounded when other experiences of discrimination or oppression are also experienced (e.g. racism, classism, ableism, ageism, religious dis­ crimination, lookism, nationalism)” (Harper et al., 2013, p. 18). Accommodations can be considered for persons with disabilities; these accommodations may include reading the cards aloud, simplifying the direc­ tions, and using assistive technology. The American Counseling Association’s (ACA’s) 2014 Code of Ethics mandates key components to increase the opportunity for success. Although many sections of the ACA code apply, professional counsel­ ors should pay special attention to section E, Evalua­

tion, Assessment, and Interpretation: “Counselors use assessment as one component of the counseling pro­ cess, taking into account the clients’ personal and cultural context” (p. 11). Client Welfare (E.1.b) and Cultural Sensitivity (E.5.b) are of the utmost impor­ tance, and taking into account Multicultural Issues/ Diversity in Assessment (E.8), and Scoring and Inter­ pretation of Assessments (E.9) is critical. Instructions

This activity or intervention is an example of a values card sort (Knowdell, 2011, 2013) that demonstrates self-concept and social acceptance while construct­ ing career choice. Values connected to these ideas of self-directed career choice (Super, 1990) and card sorts can assist in the process of choosing a career. Values-clarification exercises have been used in a wide variety of issues, including career decision mak­ ing. Values-clarification exercises, such as the Knowdell card sorts, provide strategies that enable clients to iden­ tify and make comparisons among their values (Hays, 2013). Card sorts have application for a variety of pop­ ulations and are used as a purely exploratory learn­ ing tool that includes exercises that one could choose or reject to build a unique career self-profile. The Knowdell Career Values Card Sort is a self-adminis­ tered card sort designed to help individuals identify or clarify their career-related values. It consists of fifty-four values, each printed and defined on a separate card. The card sort has good face validity and can be an effective tool for helping LGBTQ youth with their career decision making. This exercise is adaptable and can be used with an individual client, in a small group, or in a large class­ room setting. The activity consists of processing ques­ tions related to the sorting and prioritizing experience, and it can be extended to include matching values to work settings, occupations, and potential employers. The value sort may be done as homework or as part of the session. The approximate time allotted for the card sort would be ten to fifteen minutes; follow-up questions can take as long as needed. The purpose of the card sort is for individuals to understand and assign priority to personal and career values (either in categories or along a continuum) in order to determine which values are most important in their career-develCareer Exploration with Adolescent LGBTQ Clients 515

opment process. It is critical that the client’s reading comprehension and vocabulary level are appropriate for the exercise to work effectively. Clients are encouraged to engage in a quick sort of the cards into two to five piles, ranging from always valued or very important to never valued or not important. If using the continuum method, a work­ sheet should be provided on which a value and a coun­ tervalue are placed opposite each other on a scale. For example, in the case of the continuum for working autonomously versus working under supervision, individuals will indicate where they fall between the values or value statements. Once the initial sort is com­ pleted, individuals will focus on prioritizing their most important value cards—that is, their top five to ten career-related values. Brief Vignette

Kelsey is a fifteen-year-old high school sophomore who identifies as a cisgender lesbian female. She is a bira­ cial, Latina, Caucasian American who identifies as Christian and whose family’s socioeconomic status is lower middle class. She has been an honors student since entering high school, and she is involved with sports (soccer and basketball) and Future Farmers of America (where she holds a leadership board position and has recently attended a national conference). She attends a moderately sized consolidated high school that draws students from four rural communities. She is an outgoing student and likes to use humor. Her peers see her as a leader. She tends to hang out with a mix of students in a variety of social circles. Lately, there has been a significant change in Kelsey’s academic performance. Once a solid A/B student in her honors courses, she now has all Cs and Ds. She reports she has recently started working as a farmhand for the farmer down the road from her home and is working twenty-five to thirty-five hours per week. She is thinking about a career in an agriculture-related field. Kelsey reports that she needs to save money to move out. She discloses the fact that she has recently come out to her parents as a lesbian and her dad went “through the roof.” Kelsey is concerned not only about the present but also about her future. Because of her family’s socioeconomic status, Kelsey was relying on grades to earn her a scholarship to a local state univer­ 516 Rheineck & Peed

sity. Additionally, she questions if she will be accepted and supported in the agriculture program and industry and wonders if it would be better to choose another profession. She has already encountered some barriers in this male-dominated sector but now worries about how her sexual orientation may pose future challenges. Kelsey’s school counselor identifies the need to help Kelsey make meaning regarding her future career and academic plans while considering the social and emotional needs related to her evolving identities as a Christian biracial lesbian who wishes to enter a non­ traditional career field. A values card sort and subse­ quent processing with the school counselor will allow Kelsey to define career values; rank-order the values on the basis of what is important to her; process the meaning, feelings, and connections associated with the career values; consider how facets of cultural devel­ opment influence career values; and make plans for the future. The school counselor, who has recently started a school organization for LGBT students and allies, and who has recently completed a continuing education course on counseling LGBT+ youth and young adults, feels competent to assist Kelsey in exploring the inter­ sections of career choice, her sexual orientation, and her gender. The counselor invited Kelsey to complete the card-sort activity. The counselor explained that Kelsey will be given X number of cards (depending on the sort used). Kelsey will complete a primary sort of the cards by reading each card, assigning personal meaning to the card, and placing it into one of the sort piles (depending on the sort used; the idea is to sepa­ rate the most important values from the less important values—two to five stacks). This first sort will take approximately ten to fifteen minutes. Kelsey is encouraged to go with her first instinct while sorting and not to think too long about any one card. Once Kelsey completes the primary sort, she will focus only on the cards with values that are most important to her. Kelsey is asked to rank them from most to least important, laying the cards out for both her and the counselor to see. At this point, to save the ranking for future use, Kelsey will record her ranked values on a sheet of paper or take a picture with her phone or tablet. The counselor then begins to work with Kelsey to draw out the meaning of her career val­

ues. They spend time exploring values and how they relate to Kelsey’s various identities; facilitating con­ nections between her values; and thinking about how these values connect with Kelsey’s choices regarding future careers. Suggestions for Follow-up

To best use clients’ personal and work values through­ out, those values should be documented, possibly using a worksheet where students record their top val­ ues for future review. When working on career or LGBTQ identity development, the counselor will find it useful to link the results of this activity to the clients’ identity and their developmental processes with open questions, and reflect on content, feeling, meaning, and interpretation/reframe facilitation. Additionally, the counselor should identify the client’s current stage or phase of development using models of LGBTQ identity development. These models, such as Coleman’s (1982), are limiting, but they do provide a framework for conceptualizing a student’s presenting issues. Under­ standing the level of LGBTQ identity development can help facilitate discussions about connections related to career values and career plans. For example, Kelsey falls into Coleman’s fourth stage of coming out: IV. First relationships. This stage is characterized by Kelsey’s learning how to navigate a same-sex relationship in a predominantly heterosexual world. For Kelsey, this experience has caused dissonance that affects her abil­ ity to share details about herself and her partner with current coworkers, and she wonders how this disso­ nance will translate to her future environment and her work values of family and security. As counseling progresses, card-sort results can be reevaluated and modified as the client progresses through various sex­ ual-identity development stages and new experiences. Contraindications for Use

When using card sorts with LGBTQ individuals, sev­ eral potential concerns can be identified. These con­ cerns include being outed by the assessment, bias or prejudice of the counselor, sex role or sexual orienta­ tion stereotyping, and appropriate interpretation of responses on measures that have been standardized on non–sexual minorities (Pope, 1992; Pope et al., 2004). Therefore, care must be taken regarding sexual and

gender identity, and the counselor must be careful not to make heteronormative assumptions. For example, it is imperative that both assessment and interpreta­ tion use language that promotes safety and inclusion. Counselors should take great care in minimizing con­ traindications as best as possible and should include these possibilities with informed consent (ACA, 2014). Professional Readings and Resources GLSEN. http://www.glsen.org/. Human Rights Campaign. Explore: Children & youth. https:// www.hrc.org/explore/topic/children-youth. Knowdell, R. (2011). The Knowdell career values card sort. www.careertrainer.com/trainingsys/career-values-plan ning-kit-knowdell--ff80818123928a9601241754d0186ff 2-p.html. Knowdell, R. (2013). Knowdell career values worksheet. https:// www.career-lifeskills.com/pdf/Sample-Sam-KValues­ career.PDF. Lambda Legal. Teens & young adults. http://www.lambdale gal.org/issues/teens. Miller, W. R., C’de Baca, J., Matthews, D. B., & Wilbourne, P. L. (2001). Personal values card sort. www.motiva tionalinterviewing.org/sites/default/files/valuescard sort_0.pdf. Ouer, R. (2016). Solution-focused brief therapy with the LGBT community. New York: Routledge.

Resources for Clients Belge, K., & Bieschke, M. (2011). Queer: The ultimate LGBT guide for teens. San Francisco: Zest Books. Bryant University. (2017). LGBTQ career and educational resources. https://career.bryant.edu/resources/files/ LGBTQ%20Career%20Resources.pdf. Huegel, K. (2011). GLBTQ: The survival guide for gay, lesbian, bisexual, transgender, and questioning teens, 2nd edition. Minneapolis: Free Spirit Publishing.

References American Counseling Association (ACA). (2014). 2014 ACA code of ethics. http://www.counseling.org/docs/ethics/ 2014-aca-code-of-ethics.pdf?sfvrsn=4. Beck, M. J., Rausch, M. A., Lane, E. M. D., & Wood, S. M. (2016). College, career, and lifestyle development with stu­ dents who are LGBQQ: Strategies for school counselors. Journal of LGBT Issues in Counseling, 10 (4), 197–210. http://dx.doi.org/10.1080/15538605.2016.1233838. Coleman, E. (1982). Developmental phases of the coming out process. Journal of Homosexuality, 7, 31–43. doi:10.1300/ J082v07n02_06. Datti, P.A. (2009). Applying social learning theory of career decision making to gay, lesbian, bisexual, transgender, and Career Exploration with Adolescent LGBTQ Clients 517

questioning young adults. Career Development Quarterly, 58, 54–64. doi:10.1002/j.2161-0045.2009.tb00173.x. Drummond, R. J., Sheperis, C. J., & Jones, K. D. (2016). Assess­ ment procedures for counselors and helping professionals, 8th edition. Boston: Pearson. GLSEN (2015). 2015 National School Climate Survey: The expe­ riences of lesbian, gay, bisexual, transgender, and queer youth in our nation’s schools. https://www.glsen.org/sites/ default/files/2015%20National%20GLSEN%202015%20 National%20School%20Climate%20Survey%20%28NSCS% 29%20-%20Full%20Report_0.pdf. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H., Loos, B., . . . & Hammer, T. R. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Coun­ seling competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individuals. Journal of LGBT Issues in Counseling, 7 (1), 2–43. www. algbtic.org/competencies.html. Hays, D. G. (2013). Assessment in counseling: A guide to the use of psychological assessment, 5th edition. Alexandria, VA: American Counseling Association. Human Rights Campaign (2014). Equality act. https://www.hrc. org/resources/entry/employment-non-discrimination-act. Knowdell, R. (2011). The Knowdell career values card sort. www.careertrainer.com/trainingsys/career-values-plan ning-kit-knowdell--ff80818123928a9601241754d0186ff 2-p.html. Knowdell, R. (2013). Knowdell career values worksheet. https:// www.career-lifeskills.com/pdf/Sample-Sam-KValues­ career.PDF. Morrow, S. L., Gore, P. A., Jr., & Campbell, B. W. (1996). The application of sociocognitive framework to the career development of lesbian women and gay men. Journal of Vocational Behavior, 48, 136–148. doi:10.1006/jvbe. 1996.0014. Parnell, M. K., Lease, S. H., & Green, M. L. (2012). Perceived career barriers for gay, lesbian, and bisexual individuals. Journal of Career Development, 39 (3) 248–268. doi:10. 1177/0894845310386730. Pope, M. (1992). Bias in the interpretation of psychological tests. In S. Dworkin & F. Gutierrez (eds.), Counseling gay

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men & lesbians: Journey to the end of the rainbow, 277–292. Alexandria, VA: American Counseling Association. Pope, M., Barret, B., Szymanski, D. M., Chung, Y. B., Singara­ velu, H., McLean. R., & Sanabria, A. (2004). Culturally appropriate career counseling with gay and lesbian clients. Career Development Quarterly, 53, 158–177. doi:10.1002/ j.2161-0045.2004.tb00987.x. Rheineck, J. E., Wise, S. M., & Williams, J. D. (2016). Lesbian, gay, bisexual, and transgender individuals. In W. K. Killam, S. Degges-White, & R. E. Michel (eds.), Career counseling interventions: Practice with diverse clients, 117–127. New York: Springer. Savickas, M. (2005). The theory and practice of career con­ struction. In S. D. Brown & R. W. Lent (eds.), Career devel­ opment and counseling: Putting theory and research to work, 42–70. Hoboken, NJ: Wiley. Schmidt, C. K., Miles, J. R., & Welsh, A. C. (2011). Perceived discrimination and social support: The influences on career development and college adjustments of LGBT col­ lege students. Journal of Career Development, 38 (4), 293– 309. doi:10.1177/0894845310372615. Schmidt, C. K., & Nilsson, J. E. (2006). The effects of simulta­ neous developmental processes: Factors relating to the career development of lesbian, gay, and bisexual youth. Career Development Quarterly, 55, 22–37. doi:10.1002/ j.2161-0045.2006.tb00002.x. Super, D. E. (1990) A life-span, life-space approach to career development. In D. Brown & L. Brooks & Associates (eds.), Career choice and development, 2nd edition, 197–261. San Francisco: Jossey-Bass. Super, D. E., Savickas, M. L., & Super, C. M. (1996). The life­ span, life-space approach to careers. In D. Brown & L. Brooks & Associates (eds.), Career choice and development, 3rd edition, 121–178. San Francisco: Jossey-Bass. Szymanski, D. M. (2013). Counseling lesbian, gay, bisexual, and transgendered clients. In G. McAuliffe (ed.), Culturally alert counseling: A comprehensive introduction, 2nd edi­ tion, 415–451. Los Angeles: Sage Publications. Weiler, N. W., & Schoonover, S. C. (2001). Your soul at work: Five steps to a more fulfilling career and life. New York: HiddenSpring.

H A NDO UT

MY TO P FIVE CA REER-REL AT ED VA LUES

1. __________________________________________________________________________

2. __________________________________________________________________________ 3.__________________________________________________________________________ 4.__________________________________________________________________________ 5.__________________________________________________________________________

Values and Definitions VALUE

DEFINITIONS

Family

To have time with my family

Wealth

To earn lots of money and be financially secure

Service

To contribute to the satisfaction of others; to help people who need help

Achievement

To accomplish important things, to be involved in significant undertakings

Independence

To have freedom of thought and action, to be able to act in terms of my own schedule and priorities

Self-realization

To do work that is personally challenging and that will allow me to realize my full potential

Power

To have the authority to approve or disapprove of proposed courses of action, to make assignments and control allocation of resources

Location

To be able to live where I want to live

Leadership

To become an influential leader

Prestige

To be seen as successful, to become well known, to obtain recognition and status in my chosen field

Expertness

To become a known and respected authority in what I do

Loyalty

To be loyal to my company and to my boss and to have their loyalty in return

Friendship

To work with people I like and to be liked by them

Security

To have a secure and stable position

Jane E. Rheineck and Tracy Peed

519

H A NDO UT

CO UNS ELO R Q UES T IO NS

INTRODUCTION Describe your process when sorting the cards.

How did you go about identifying your list of top values?

How did your LGBTQ identity or level of outness influence your rankings, if at all?

What do these values mean to you personally?

How are these values connected to or disconnected from your gender identity or sexual orientation?

What connections do you see among your top values, if any?

Which values nearly made the list, and were there any values you omitted that are related to your gender identity or sexual orientation?

Were there any values absent from the cards that are important for you to include?

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H A NDO UT

CO UNS ELO R Q UES T IO NS

EXTENDING THE ACTIVIT Y How do you see these values connecting with occupations in which you are interested currently?

What advantages and disadvantages do you associate with being out in your desired career field or workplace?

Will you be affected by multiple minority statuses (e.g., black and lesbian), and how might they influence your career decision making?

What are some potential barriers you envision regarding your LGBTQ identity, work values, and future occupational choices?

What concerns do you have about discrimination in the workplace?

What career resources and social supports exist, both in and outside the LGBTQ community, to assist you in managing or overcoming potential barriers?

What future research is needed to connect your LGBTQ identity and values with your future work site or occupation?

How might you look at occupations differently as a result of your values you uncovered through this activity, particularly those related to your LGBTQ identity?

Jane E. Rheineck and Tracy Peed

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59 THE COLLEGE SEARCH: CAMPUS CLIMATE CHECKLIST Suzanne M. Dugger, Carina Lindsey, and Jason A. Owens

Suggested Uses: Handout, activity Objective

The purpose of this handout and activity is to support LGBT students in the college-search process. Specif­ ically, this activity and handout consist of a two-part process. The first part facilitates the students’ explora­ tion of the most salient aspects of their identity, high­ lighting the intersection of multiple minority identities. The results of this activity then inform the customi­ zation of a checklist designed to help evaluate the cli­ mate for LGBT students on various college campuses. Rationale for Use

Mental health professionals need tools specifically designed for working with LGBT youth who aspire to attend college. The rationale for this particular tool is based on several factors, including (a) challenges related to college matriculation for all students (Dugger, 2016); (b) college adjustment challenges faced by LGBT stu­ dents as well as by students with other or additional minority identity statuses (Kirsh, Conley, & Riley, 2015; McAleavey, Castonguay, & Locke, 2011; Oswalt & Wyatt, 2011; Rankin, 2003); (c) the ethical obliga­ tions of mental health professionals to offer nondis­ criminatory, affirmative, and equitable services to all clients (American Counseling Association [ACA], 2014; American Psychological Association [APA], 2017; National Association of Social Workers [NASW], 2017); and (d) the increasing expectation that men­ tal health professionals use interventions and treatment strategies that have empirical evidence to support their use (Luzzo, 2000). Given projections that approximately two-thirds

of all jobs in the United States will require postsecond­ ary education by 2020 (Carnevale, 2013), a national movement to increase the percentage of students who graduate from college has emerged, evidenced in part by the Obama White House’s “Reach Higher” initiative (https://www.whitehouse.gov/reach-higher). These efforts are largely consistent with the college-choice model developed and refined by Hossler and col­ leagues, which identifies three specific stages: predis­ position, search, and choice (Hossler, 1984; Hossler & Gallagher, 1987; Hossler, Schmit, & Vesper, 1999). More specifically, this movement has included strate­ gies for building a college-going culture (McCollough, 2011; McDonough, 2005); widespread adoption of core curricular standards to ensure the academic preparation needed to be ready for college (Center on Education Policy, 2011); attention to the need for increased access to higher education for racial minority students, students attending urban schools, and firstgeneration college students (McKillip, Godfrey & Rawls, 2012; Perna, 2006); support of financial-aid application processes (Bettinger, Long, Oreopoulos, & Sanbonmatsu, 2012); and the proliferation of college search engines (Dugger, 2016). These search engines, along with abundant print resources, assist students in learning about the more than three thousand col­ leges in the United States from which they may choose. Information about these schools typically includes total enrollment, costs of attendance, admissions crite­ ria, typical standardized test scores of admitted students, and available majors (Dugger, 2016). Assistance with the college-search process is espe­ cially important to underrepresented students, whose choices may directly affect their matriculation and per­

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

522

sistence rates. For example, Eberle-Sudré, Welch, and Nichols (2015) reported that the graduation rate of Caucasian students is 14 percentage points higher than that for underrepresented students, but they noted that some colleges and universities have been more successful than others in closing this gap. Resources such as the College Results Online web­ site (Education Trust, 2016) and the College Score­ card (U.S. Department of Education, 2016) provide useful information related to affordability as well as graduation rates disaggregated by sex and race. In contrast, fewer resources focus on the LGBT student population. LGBT students are in particular need of assistance with the college-search process because many LGBT students experience a “chilly climate” (Woodford, Kulick, & Atteberry, 2015, p. 73) when arriving on cam­ pus, owing to their being “the least accepted group when compared with other under-served populations” (Rankin, Weber, Blumenfeld, & Frazer, 2010, p. 9). In a large-scale national study of the campus climate experienced by LGBT students, Rankin (2003) found that LGBT students experience harassment, deroga­ tory remarks, exclusion, assault, or violence at signifi­ cantly higher rates than heterosexual students. Such experiences have a negative psychosocial effect on LGBT students, especially during their first year of col­ lege (Kirsh et al., 2015). As a result, LGBT students are at greater risk for mental health concerns (Kirsh et al., 2015; McAleavey et al., 2011), and they experi­ ence “a more frequent impact on academics because of these issues than heterosexual students” (Oswalt & Wyatt, 2011, p. 1255). These campus climate issues, therefore, have a negative influence on LGBT students’ comfort, safety, mental health, and academic success in college. Not surprisingly, almost a third of LGBT students who responded to the Campus Pride survey indicated that they had considered leaving their college (Rocken­ bach & Crandall, 2016). For these reasons, it is essen­ tial that LGBT clients receive assistance with the college-search process. Indeed, their choice of college may “make the difference between persisting and drop­ ping out” (Burlson, 2010, p. 10). For students who hold multiple minority identities (e.g., minority status not only with regard to sexual

identity but also involving membership in and iden­ tification with oppressed racial, ethnic, or religious communities), the challenges associated with college choice and college adjustment increase exponentially. Research suggests that the challenges of college adjust­ ment may be especially difficult for LGBT students of color, regardless of whether they attend a primarily white institution (PWI) or a historically black college or university (HBCU) (Goode-Cross & Good, 2009; Marfield, 2012; Patton & Simmons, 2008). For exam­ ple, Bing (2004) observed that lesbians of color may struggle with a sense of isolation from both the les­ bian community, as a result of racism, and their ethnic community, as a result of homophobia. Therefore, it is essential that mental health professionals explore with students how they experience and make mean­ ing of the intersectionality of their multiple minority identities (Bing, 2004; Goode-Cross & Good, 2009; Marfield, 2012; Patton & Simmons, 2008; Russell, 2012; Tillapaugh, 2016; Warner & Shields, 2013). This attention to diversity issues and the effects of oppressed social identities on our clients is especially important in light of recent updates to the ethical codes guiding the work of mental health profession­ als. For example, the ACA’s Code of Ethics expressly prohibits “discrimination against prospective or cur­ rent clients, students, employees, supervisees, or research participants” on the basis of a wide variety of cultural characteristics, including sexual orienta­ tion and gender identity (ACA, 2014, C.5). Further, this code charges counselors with “honoring diver­ sity and embracing a multicultural approach” and “promoting social justice” (preamble). Similar expec­ tations for other professionals are conveyed by the APA (2017, principle E) and the NASW (2017, 4.02). Such standards reflect the commitment of the profes­ sions of counseling, psychology, and social work to social justice advocacy. Affirmative practice with LGBT clients is consistent with these calls, and this activity and handout are designed to support thera­ pists in enhancing their repertoire when supporting LGBT clients with the college-search process. The content and organization of the handout, the Campus Climate Checklist, are grounded in research findings. Items on the checklist are organized into three categories: (a) institutional factors, (b) campus The College Search: Campus Climate Checklist 523

resources, and (c) community climate. These catego­ ries are based on research by Kane (2013), which focused on identifying the factors most correlated with “safe” campuses. Also, each item on the checklist is drawn from the professional literature. For example, Squire and Mobley (2015) pointed to the importance of LGBT-specific college fairs, visual marketing, and application materials as useful in discerning which colleges may be more supportive or less supportive of LGBT students. Similarly, Kirsh and colleagues (2015) identified LGBT-specific programming as important, and Woodford and colleagues (2015) emphasized the need to review “institutional antidiscrimination poli­ cies and student codes of conduct” (p. 83) for LGBTspecific provisions. Burlson (2010) recommended chat rooms for admissions officers to talk with pro­ spective students who may not be out to their fami­ lies, and Worthen (2014) endorsed the use of ally programs especially with historically intolerant cam­ pus groups such as student athletes and fraternity members. Focusing on indicators that a college may be proactively seeking to recruit LGBT students, Cegler (2012) identified a number of active and pas­ sive recruitment strategies, including participation in LGBT-specific college fairs and residence halls that feature a “rainbow floor” (p. 21) on which LGBT stu­ dents may choose to reside. Baum (2012) identified financial-aid exceptions for LGBT youth whose par­ ents refuse to support their college attendance because of their sexual identity as another important indicator of an LGBT-supportive college. Instructions

To begin this activity, mental health professionals will want to broach the concept of multiple layers of iden­ tity and explain that social identities are “identities that stem from group membership” (Warner & Shields 2013, p. 803). Acknowledge that individuals typically have numerous social identities, some of which are associated with privilege and power and others that have historically been subjected to oppression and discrimination. Next, invite clients to identify the var­ ious aspects of their social identities using a visual model developed by Jones and McEwen (2000) and later refined by Abes, Jones, and McEwen (2007). See Figure 1. 524 Dugger, Lindsey, & Owens

Core

FIGURE 1. INTERSECTIONALIT Y ACTIVIT Y Source: Adapted from Jones & McEwen, 2000, p. 409.

Using the Intersectionality Activity handout (Fig­ ure 1), instruct clients to begin by inserting into each box a facet of their identities. Examples may include their race or ethnicity, sex or gender, religion, sexual orientation, and disability status. Once this step is complete, point out to clients that each corresponding ring encircles and contributes to their core identity (the center circle) and that these identities also inter­ sect and overlap with one another. Next, ask clients to place dots on each of the five rings to illustrate how central each facet is to their core identity. The closer the dot is to the core, the more central the clients con­ sider it to their identity. A completed example appears in Figure 2, which is included in the brief vignette later in this chapter. Using the clients’ completed diagrams as a visual prompt, discuss the clients’ perceptions about the power or privilege and oppression or discrimination associated with each element. Additionally, explore with clients what they hope to experience on a college campus with regard to each facet of identity, and deter­ mine which elements are most salient to the clients when selecting a college. In the next step, share the Campus Climate Check­ list with the clients, making sure all terms are under­ stood. Briefly review the content of the checklist and help clients identify any items they would consider must-haves and deal breakers. Assist the clients in iden­ tifying where their top priorities from the intersec­ tionality activity fit into the Campus Climate Check­ list. Also, in the context of the preceding discussion

of intersecting identities, customize the Campus Cli­ mate Checklist by highlighting or adding items of particular interest to the clients. For example, a cli­ ent whose primary minority identities involve the intersection of being female, lesbian, and Jewish may choose to highlight “major or minor in gender studies,” “courses on LGBT topics such as feminism,” “groups for LGBT people of faith,” and she may wish to add an item to the checklist regarding the pres­ ence of a synagogue in town and a Hillel on campus. Following the customization of the checklist, dis­ cuss strategies for gathering information needed to complete the checklist. In addition to consulting sev­ eral websites included on the checklist, clients may choose to call the LGBT resource center on campus, to scour university websites for information, and even to contact admissions officers. The Campus Climate Checklist can then be assigned as homework. Finally, remind the client that, although most of the informa­ tion can be found online, campus visits are also essen­ tial. Once clients have narrowed their list of colleges under serious consideration, it is strongly recom­ mended that they visit each campus and complete the Campus Climate Checklist once again using additional information gathered during the visit. Brief Vignette

Constantino Stamos, who has been called Dean for as long as he can remember, is a seventeen-year-old cisgender male who is a junior at Maya Angelou Senior High School (MASHS). Dean is in the first genera­ tion of his family to be born in the United States. His parents, who had emigrated from Greece, started a family relatively late in life and are now in their early sixties. Because of his parents’ age and immigration status, Dean has spent most of his life outside the school day helping run their popular family grocery store in the Greektown neighborhood of Detroit. Although the family business is located in the city, Dean’s parents value suburban life and have worked to ensure that Dean and his sister, Athena, could attend the best public schools their hard-earned real estate dollar could buy them. The Stamos family moved many times during Dean’s K–12 school career as his par­ ents were always striving for the best school in the best neighborhood. Three years ago, just before Dean

entered his freshman year in high school, the Stamos family purchased a home in the MASHS school dis­ trict largely because this public school was known for its high rate of seniors admitted to four-year col­ leges and universities. Mr. and Mrs. Stamos are proud of their children, but they are concerned that Dean will not be admitted to the area’s top universities because of his average grades and lack of participation in extracurricular activ­ ities. Dean assures them it will be fine and expresses confidence that his experience working at the family’s store will set him apart from his classmates and will be a plus on his college applications. In addition, Dean reassures his parents that his leadership in their Greek Orthodox Church youth group and his fluency in mul­ tiple languages will result in numerous college admis­ sion offers. In actuality, however, Dean is deeply con­ flicted about attending college at all. Unbeknown to his parents, who have assumed he is heterosexual and simply too busy to date, Dean has had a secret romantic relationship with a boy from his biology class for the majority of his junior year. This boy, Brian, is out to his family, and Dean has had numerous interactions with them over the past year. Brian’s family has offered acceptance and support of the relationship between the two boys. Having expe­ rienced acceptance in a family that knows his secret, Dean is often finding more excuses to spend time at Brian’s house. He is unsure that he can go back to a life of lies to hide his secret. One thing Dean knows for certain: he is tired of managing the growing web of lies necessary at this point in his life. Because he has taken over the family finances (in preparation for an accounting degree, says his father), Dean has learned that his family is wealthy. His par­ ents have saved, have invested well, and own multiple properties in highly desirable areas. He could run the family store, get married, have children, maintain a relationship with a secret boyfriend in a similar sit­ uation, and lead a successful life. Deep down, Dean believes that his only way out is to attend college far away from home. Doing so, how­ ever, would go against everything he has been taught to believe. God, family, and the family business are his priorities—in that exact order. Dean comes to the school counseling office for guidance. He knows his The College Search: Campus Climate Checklist 525

parents expect him to attend college near home so that he can continue to work at the store. Dean asks you what he should do and hopes you can help him develop a compelling case to attend an out-of-state college. The process of helping Dean begins by gaining a holistic understanding of him by truly listening to his story, affirming his feelings, and validating his goals. Dean is conflicted. Dean desperately needs a coun­ selor to comprehend how the many facets of his life are atypical among his peer group. Furthermore, Dean needs a counselor who can impartially help him rec­ oncile these factors and choose a college that would not only benefit him but also be agreeable to his par­ ents and a point of pride for his family. The feelings he experiences are in direct conflict with the life he has been raised not only to live but also to want. At this point, Dean has not had the opportunity to have some­ one simply listen to his whole story. He lies to his parents and shares only positives with Brian and his family. Dean is so used to sharing the positives that he has never shared his full story, for better or worse, with anyone. Once the counselor has heard Dean, it is time to move into a deeper understanding of his story. This may be done by helping Dean explore and articulate how he prioritizes each aspect of his life, helping him formulate goals that are based on these priorities, and identifying the concrete steps needed to achieve his goals. The Intersectionality Activity is a solid way to help Dean put his thoughts onto paper and to gain per­ spective on what the many facets of Dean’s life mean to him. The Intersectionality Activity that Dean com­ pleted shows his main priorities (those closest to his core) to be listed in this order: sexual orientation, sex or gender, religion, race and ethnicity, and disability status (see Figure 2). Upon seeing his priorities on paper, Dean and the counselor discuss how Dean’s priorities differ from his family’s priorities, and they explore whether Dean wishes to set goals on the basis of his own or his fami­ ly’s priorities. Although Dean has expressed wanting to go to college out of state to be farther from home, location should not be the only factor when choosing a college. The counselor therefore explains how Dean’s identification of priorities should guide his goals for 526 Dugger, Lindsey, & Owens

Race/Ethnicity Caucasion/Greek

Sex/Gender Male

Religion

Core Core

Greek Orthodox

Sexual Orientation Gay

Disability STatues No current disability

FIGURE 2. DEAN'S NTERSECTIONALIT Y A CTIVIT Y Source: Adapted from Jones & McEwen, 2000, p. 409.

college choice and be used to determine what is most important in regard to his selection of a college. The counselor asks Dean to use the week between sessions to ponder whether he wishes to set his goals on the basis of his own or his family’s priorities. When returning for the next session, Dean indi­ cates a desire to use his own priorities to set goals for college selection. This session therefore focuses on Dean’s goals to find a college in which he is most likely to feel safe and valued as a gay male and, he hopes, in which he can find a gay Christian community with which to worship. The session concludes with Dean’s customizing the Campus Climate Checklist to reflect these goals. Dean determines that the only modifica­ tion to the checklist he needs is to specify “gay, Chris­ tian community” in the “Other groups of interest to you” item on the checklist. He agrees to begin using the checklist when researching colleges online and during campus visits. Suggestions for Follow-up

Because clients will probably complete the Campus Climate Checklist between sessions as homework, it is essential that counselors follow up and explore the client’s findings and reactions. Follow-up questions might include: • What information was easiest to find? What infor­ mation was most difficult to find? (Note that clients

may need additional guidance regarding how to find some of the information.) • What information felt most important to you? • Did you discover a must-have for any college you choose? • Did you discover any deal-breaker information in your search? • Given what you’ve discovered so far, which colleges are of greatest interest to you? • Would you like to add any items related to other facets of your identity that we discussed during the Intersectionality Activity? In addition to using follow-up sessions to process the client’s findings when using the Campus Climate Checklist, it will also be important to follow up with clients after they make a final college choice. The goal of this follow-up is to enhance clients’ ability to adjust well to and thrive in the college environment of their choice. Topics worth exploring in these sessions include contacting the housing office to request con­ sideration of LGBT issues in the roommate-matching process and emailing the LGBT resource center in advance to begin establishing a support system. Contraindications for Use

If the activity focused on intersectionality reveals that LGBT issues are not central to the client’s identity, use of this Campus Climate Checklist is not recom­ mended. Although it may be provided to the client for possible future reference, a client who currently considers other facets of identity to be more salient will probably benefit from other interventions. For example, a client who considers his status as a black male as most central to his core identity may acknowledge having sex with other men but not con­ sider this as central to his identity and may not, indeed, even identify as LGBT. Therefore, use of the LGBT-focused Campus Climate Checklist would not be advisable. Instead, this client may benefit more from interventions focused on race relations on cam­ pus and in the community and from a database such as College Results Online (collegeresults.org), which allows users to compare graduation rates by gender and race.

Professional Readings and Resources Baum, B. S. (2012). LGBT applicants and challenges for admis­ sion: Five cases. Journal of College Admission, 217, 24–29. Burlson, D. A. (2010). Sexual orientation and college choice: Considering campus climate. About Campus, 14, 9–14. GLSEN. (n.d.). Championing LGBTQ issues in K–12 educa­ tions since 1990. https://www.glsen.org/. Kane, M. D. (2013). Finding “safe” campuses: Predicting the presence of LGBT student groups at North Carolina col­ leges and universities. Journal of Homosexuality, 60, 828–852. Rankin, S., Weber, G., Blumenfeld, W., & Frazer, S. (2010). 2010 state of higher education for lesbian, gay, bisexual & transgender people. Charlotte, NC: Campus Pride. Southern Poverty Law Center. (n.d.). https://www.splcenter. org/. Windmeyer, S. L. (2006). The Advocate college guide for LGBT students. New York: Alyson.

Resources for Clients Best Colleges.com. (2019). Best colleges for LGBT students. https://www.bestcolleges.com/features/best-colleges-for -lgbt-students/. Campus Pride. (2019). Campus visit scorecard for LGBT stu­ dents & their families. https://www.campuspride.org/ campusvisitscorecard/. Campus Pride. (2019). Index: National listing of LGBTQfriendly colleges and universities. https://www.campus prideindex.org/. Campus Pride. (2019). Lambda 10 project for fraternities and sororities. https://www.campuspride.org/lambda10/. Campus Pride. (2019). Shame list: The absolute worst cam­ puses for LGBTQ youth. https://www.campuspride.org/ ShameList/. College Equality Index. (n.d.). List of colleges with a LGBT center. www.collegeequalityindex.org/list-colleges-lgbt -center/. College Insight. (2018). From the institute for college access & success. http://college-insight.org/. College Results Online (2019). http://collegeresults.org/. Great Value Colleges. (2019). 50 great LGBTQ-friendly col leges. http://www.greatvaluecolleges.net/50-great-lgbtq­ friendly-colleges/. PFLAG. (2019). https://www.pflag.org/.

References Abes, E. S., Jones, S. R., & McEwen, M. K. (2007). Reconcep­ tualizing the model of multiple dimensions of identity: The role of meaning-making capacity in the construction of multiple identities. Journal of College Student Develop­ ment, 48, 1–22. doi:10.1353/csd.2007.0000. American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. The College Search: Campus Climate Checklist 527

American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/index. Baum, B. S. (2012). LGBT applicants and challenges for admis­ sion: Five cases. Journal of College Admission, 217, 24–29. Bettinger, E. P., Long, B. T., Oreopoulos, P., & Sanbonmatsu, L. (2012). The role of application assistance and infor­ mation in college decisions: Results from the H&R Block FAFSA experiment. Quarterly Journal of Economics, 127, 1205–1242. Bing, V. M. (2004). Out of the closet but still in hiding: Con­ flicts and identity issues for a black-white biracial lesbian. Women & Therapy, 27, 185–201. doi:10.1300/j015v27 n01_13. Burlson, D. A. (2010). Sexual orientation and college choice: Considering campus climate. About Campus, 14, 9–14. doi:10.1002/abc.20003. Carnevale, A. P. (2013). Recovery: Job growth and education requirements through 2020. Washington, DC: George­ town Public Policy Institute. https://cew.georgetown. edu/wp-content/uploads/2014/11/Recovery2020.FR_. Web_.pdf. Cegler, T. D. (2012). Targeted recruitment of GLBT students by colleges and universities. Journal of College Admission, 215, 18–23. Center on Education Policy. (2011). States’ progress and chal­ lenges in implementing common core state standards. Washington, DC: Author. di Bartolo, A. N. (2013). Is there a difference? The impact of campus climate on sexual minority and gender minority students’ level of outness. PhD diss., Claremont Graduate University. https://eric.ed.gov/?id=ED553093. Dugger, S. M. (2016). Foundations of career counseling: A casebased approach. Upper Saddle River, NJ: Pearson Education. Eberle-Sudré, K., Welch, M., & Nichols, A. H. (2015). Rising tide: Do college grad rate gains benefit all students? Wash­ ington, DC: Education Trust. Education Trust. (2019). College results online. http://col legeresults.org/. Goode-Cross, D. T., & Good, G. E. (2009). Managing multipleminority identities: African American men who have sex with men at predominately white universities. Journal of Diversity in Higher Education, 2, 103–112. doi:10. 1037/a0015780. Grov, C., Bimbi, D. S., Nanin, J. E., & Parsons, J. T. (2006). Race, ethnicity, gender, and generational factors associ­ ated with the coming-out process among gay, lesbian, and bisexual individuals. Journal of Sex Research, 43, 115– 121. doi:10.1080/00224490609552306. Hossler, D. (1984). Enrollment management: An integrated approach. New York: College Board Publications. Hossler, D., & Gallagher, L. (1987). Studying college choice:

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A three-phase model and the implications for policy makers. College and University, 2, 201–221. Hossler, D., Schmit, J., & Vesper, N. (1999). Going to college: How social, economic, and educational factors influence the decisions students make. Baltimore: Johns Hopkins University Press. Jones, S. R., & McEwen, M. K. (2000). A conceptual model of multiple dimensions of identity. Journal of College Student Development, 41, 405–414. Kane, M. D. (2013). Finding “safe” campuses: Predicting the presence of LGBT student groups at North Carolina col­ leges and universities. Journal of Homosexuality, 60, 828– 852. doi:10.1080/00918369.2013.774837. Kirsh, A. C., Conley, C. S., & Riley, T. J. (2015). Comparing psychosocial adjustment across the college transition in a matched heterosexual and lesbian, gay, and bisexual sample. Journal of College Student Development, 56, 155– 169. doi:10.1353/csd.2015.0017. Luzzo, D. A. (2000). Career counseling of college students: An empirical guide to strategies that work. Washington, DC: American Psychological Association. Marfield, J. D. (2012). Performing race, gender, and sexual orientation in context: How undergraduates make mean­ ing of the multiple dimensions of their identity. PhD diss., University of California at Los Angeles. ProQuest Dis­ sertations and Theses database (UMI no. 35332454). McAleavey, A. A., Castonguay, L. G., & Locke, B. D. (2011). Sexual orientation minorities in college counseling: Prev­ alence, distress, and symptom profiles. Journal of College Counseling, 14, 127–142. doi:10.1002/j.2161-1882.2011. tb00268.x. McCollough, C. A. (2011). Creating a college-going culture: A family science program that motivates disadvantaged students. Science Teacher, 78 (3), 51–55. McDonough, P. M. (2005). Counseling and college counseling in America’s high schools. In D. Hawkins (ed.), State of college admission, 107–121. Washington, DC: National Association for College Admission Counseling. McKillip, M. E. M., Godfrey, K. E., & Rawls, A. (2012). Rules of engagement: Building a college-going culture in an urban school. Urban Education, 48, 529–556. doi:10. 1177/0042085912457163. National Association of Social Workers (NASW). (2017). Code of ethics. https://www.socialworkers.org/About/ Ethics/Code-of-Ethics/Code-of-Ethics-English. Oswalt, S. B., & Wyatt, T. J. (2011). Sexual orientation and dif­ ferences in mental health, stress, and academic perfor­ mance in a national sample of U.S. college students. Jour­ nal of Homosexuality, 58, 1255–1280. doi:10.1080/00918 369.2011.605738. Patton, L. D., & Simmons, S. L. (2008). Exploring complexities of multiple identities of lesbians in a black college envi­ ronment. Negro Educational Review, 59, 197–215.

Perna, L. W. (2006). Studying college access and choice: A pro­ posed conceptual model. In J. C. Smart (ed.), Higher edu­ cation: Handbook of theory and research, 91–157. New York: Springer. doi:10.1007/1-4020-4512-3_3. Rankin, S. (2003). Campus climate for gay, lesbian, bisexual, and transgender people: A national perspective. New York: National Gay and Lesbian Task Force Policy Institute. Rankin, S., Weber, G., Blumenfeld, W., & Frazer, S. (2010). 2010 state of higher education for lesbian, gay, bisexual, and transgender people. Charlotte, NC: Campus Pride. Rockenbach, A. N., & Crandall, R. E. (2016). Faith and LGBTQ inclusion: Navigating the complexities of the campus spiritual climate in Christian higher education. Christian Higher Education, 15, 62–71. doi:10.1080/15363759.2015 .1106355. Russell, E. I. (2012). Voices unheard: Using intersectionality to understand identity among sexually marginalized undergraduate college students of color. PhD diss., Bowling Green State University. ProQuest Dissertations and Theses database (UMI no. 3510815). Squire, D. D., & Mobley, S. D., Jr. (2015). Negotiating race and sexual orientation in the college choice process of black

gay males. Urban Review, 47, 466–491. doi:10.1007/ s11256-014-0316-3. Tillapaugh, D. (2016). Understanding sexual minority male students’ meaning-making about their multiple identi­ ties: An exploratory comparative study. Canadian Jour­ nal of Higher Education, 46, 91–108. U.S. Department of Education. (2016). College scorecard. https://collegescorecard.ed.gov/. Warner, L. R., & Shields, S. A. (2013). The intersections of sexuality, gender, and race: Identity research at the cross­ roads. Sex Roles, 68, 803–810. doi:10.1007/s11199-013 -0281-4. Woodford, M. R., Kulick, A., & Atteberry, B. (2015). Protective factors, campus climate, and health outcomes among sex­ ual minority college students. Journal of Diversity in Higher Education, 8, 73–87. doi:10.1037/a0038552. Worthen, M. G. F. (2014). Blaming the jocks and the Greeks? Exploring collegiate athletes’ and fraternity/sorority mem­ bers’ attitudes toward LGBT individuals. Journal of Col­ lege Student Development, 55, 168–195. doi:10.1353/ csd.2014.0020.

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CAMPUS CLIMATE CHECKLIST Your choice of a college should depend on numerous factors. For all students, these factors include many important considerations such as tuition costs, majors and types of degrees, location, and admissions requirements. For LGBT students, it is also important to consider issues of safety and inclusiveness. This checklist is designed to help you conduct your own evaluation of the campus climate for each college you are considering. Institutional Factors First things first! It is important to assess how committed each college is, as an institution, to LGBT safety and inclusion. Some important ways in which colleges show their commitment are by adopting policies, funding LGBT resource centers, using inclusive admissions forms, and recruiting LGBT students. Nondiscrimination Statements Find the college’s nondiscrimination statement online and determine whether the university prohibits the following: • Discrimination on the basis of sexual orientation

n Yes n No

• Discrimination on the basis of gender identity or expression

n Yes n No

These are important indicators of safety. Offices and Staff Members Determine whether the university • Has an LGBT resource center

n Yes n No

• Supports the LGBT resource center with paid staff members

n Yes n No

• Has an Ally or Safe Space program

n Yes n No

Research shows that the existence of a well-funded LGBT resource center is one of the best indicators of a positive college climate for LGBT students. Admission Forms Find the college’s application form online and check whether it provides an option for applicants to self-identify their • Gender identity

n Yes n No

• Sexual orientation

n Yes n No

Although applicants may differ in their desire to share this information during the admissions process, including these options is an important indicator that the college recognizes and seeks to be inclusive of LGBT students. Recruiting Determine whether the college actively recruits LGBT students. Active recruitment reflects an institutional commitment to inclusiveness.

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• Included in the www.campusprideindex.org website

n Yes n No

• Participates in LGBT admissions fairs (www.campuspride.org/collegefair/)

n Yes n No

Suzanne M. Dugger, Carina Lindsey, and Jason A. Owens

• Offers LGBT scholarships

n Yes n No

• Has a mentoring program for LGBT students

n Yes n No

These colleges actively seek to enroll LGBT students. Campus Resources It is also important to evaluate how welcoming and supportive you will find the following types of campus resources. Physical Space Even if you do not plan to live on campus, determine whether the college offers • Roommate-matching program for LGBT students

n Yes n No

• LGBT-themed residence halls, floors, or living space

n Yes n No

• Gender-inclusive residence halls, floors, or living space

n Yes n No

• Gender-inclusive bathrooms in campus buildings

n Yes n No

Health and Counseling Services Determine whether the college provides health services, including: • LGBT-trained medical, counseling, and clerical staff

n Yes n No

• LGBT counseling/support groups

n Yes n No

• Anonymous, free HIV/STI tests

n Yes n No

• Health insurance covering hormone therapy and gender-affirmation surgery

n Yes n No

Academic and Career Offerings Check the college’s course catalogue to determine whether it offers • Major or minor in LGBT issues

n Yes n No

• Major or minor in gender studies

n Yes n No

• Courses on LGBT topics such as feminism, queer theory, and gender

n Yes n No

• LGBT-inclusive career services

n Yes n No

Programming and Events Determine which of the following types of events are typically held at the college: • Welcome picnics or events for LGBT students

n Yes n No

• LGBT History Month programs

n Yes n No

• National Coming-Out Week programs

n Yes n No

• Recognition of Transgender Day of Remembrance

n Yes n No

• LGBT social activities

n Yes n No

• LGBT graduation celebrations (such as Lavender Graduation)

n Yes n No

• Educational events focused on LGBT issues, including the intersectionality of race, faith, and sexual orientation

n Yes n No

Suzanne M. Dugger, Carina Lindsey, and Jason A. Owens

531

Groups/Organizations Determine which of the following groups or organizations exist on campus: • LGBT student organization

n Yes n No

• Gay/Straight Alliance or Ally program

n Yes n No

• LGBT sororities or fraternities

n Yes n No

• Queer People of Color

n Yes n No

• Groups for LGBT people of faith

n Yes n No

• Groups for queer athletes

n Yes n No

• Other groups of interest to you: ____________________________________

n Yes n No

Community Climate Although colleges often represent a more progressive “bubble” within a community, it is also important to assess what the climate of the community (and state as a whole) is like for LGBT people. State Laws Determine whether the state has laws prohibiting • Employment discrimination on the basis of sexual orientation

n Yes n No

• Employment discrimination on the basis of gender identity or expression

n Yes n No

• Housing discrimination on the basis of sexual orientation

n Yes n No

• Housing discrimination on the basis of gender identity or expression

n Yes n No

• Public accommodations discrimination on the basis of sexual orientation

n Yes n No

• Public accommodations discrimination on the basis of gender identity or expression

n Yes n No

• Health insurance exclusions for transgender health care Also determine whether the state has • Laws allowing for changes of gender identification on legal documents such as driver’s licenses and birth certificates

n Yes n No n Yes n No

Online resources you may find useful in evaluating these items on a statewide basis include www. lgbtmap.org/equality-maps/non_discrimination_laws and http://www.hrc.org/state_maps.

City/Community Laws Even in the absence of state laws, cities may pass ordinances legally prohibiting discrimination. Determine whether the city in which the college exists has any ordinances that • Prohibit discrimination on the basis of sexual orientation

n Yes n No

• Prohibit discrimination on the basis of gender identity or expression

n Yes n No

Note: The Human Rights Campaign offers an online resource to identify the Municipal Equality Index for some cities: http://www.hrc.org/mei.

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Suzanne M. Dugger, Carina Lindsey, and Jason A. Owens

Supports for LGBT Youth Determine whether the K–12 schools and community offer the following supports for LGBT youth: • Antibullying school policy that is LGBT inclusive

n Yes n No

• At least one agency that provides LGBT-specific services for youth

n Yes n No

• At least one support group for LGBT youth

n Yes n No

LGBT Community • LGBT bookstore

n Yes n No

• LGBT center (How active is the center? What does it provide?)

n Yes n No

• LGBT safe spaces (restaurants, coffee shops, nightclubs, bars)

n Yes n No

• LGBT community Pride events

n Yes n No

• LGBT support and social events

n Yes n No

• Presence of businesses that support LGBT individuals (e.g., Starbucks, Macy’s, Microsoft, Apple)

n Yes n No

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60 EXPLORING CAREER DECISION-MAKING SELF-EFFICACY WITH SEXUAL AND GENDER MINORITY COLLEGE STUDENTS Marilia Marien and Yuhong He Suggested Uses: Activity, handout Objectives

This chapter aims to help therapists (a) increase LGBTQ college students’ awareness of the role of self-efficacy in career decision making, (b) explore with clients their beliefs in their abilities to engage in career-related tasks, and (c) help clients develop greater career deci­ sion-making self-efficacy. Rationale for Use

Making a career-related decision is one of the most common and important tasks experienced at different life stages in modern society (Lent, 2013). The degree of confidence that individuals feel about their ability to successfully carry out tasks associated with making a career choice and with commitment to a career has been described as career decision-making self-efficacy (CDMSE) in social cognitive career theory (SCCT) (Betz, 2007; Lent, 2013). Efficacy expectations often determine if a specific behavior occurs at all and whether the behavior continues when obstacles arise (Betz, 2007). Further, research shows that CDMSE plays a significant role in individuals’ vocational iden­ tity, interests, activities, choice, motivation, and goals (Choi et al., 2012; Komarraju, Swanson, & Nadler, 2013; Lent, 2013). Perceived inadequacies in individu­ als’ abilities or skills and barriers (e.g., social support) may decrease CDMSE and limit career aspirations and career options (Betz & Hackett, 2006; Russon & Schmidt, 2014).

Career decision-making self-efficacy, one of the most highly researched constructs in the field of career psychology, has been particularly relevant to college students (Harlow & Bowman, 2016). Additionally, the college years are a period when many individuals engage in exploration of sexual orientation and gen­ der identity. For college students, it was found that CDMSE surpassed all other variables as a predictor of academic and social integration (Betz, Hammond, & Multon, 2005; Scott & Ciani, 2008). Increased attention to and research on the voca­ tional needs and concerns of a variety of minority groups have found that sexual- and gender-identity development are salient and pressing dimensions of an individual’s general vocational development and identity formation (O’Neil, McWhirter, & Cerezo, 2008; Tomlinson & Fassinger, 2003). Thus, effective practices for career counseling ought to consider the intersectionality of individuals’ multiple identities and how it influences their career development. Les­ bian, gay, bisexual, transgender, and queer (LGBTQ) individuals’ career development, self-efficacy, and vocational preparation may suffer a disruption owing to the concurrent nature and competing demands of sexual- and career-identity developmental processes, as well as oppression and marginalization imposed on them (Budge, Tebbe, & Howard, 2010; Tomlinson & Fassinger, 2003; White, 2014). Preston-Sternberg (2009) found that 72 percent of the participants who identified as gay, lesbian, and bisexual in his study reported that their sexual orientation affected their

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

534

education, job, or career. CDMSE can have an influ­ ence on LGB individuals’ sexual identity: higher levels of CDMSE are associated with a healthy sexual identity (Russon & Schmidt, 2014). Thus, it is of great impor­ tance to help LGBTQ clients explore their CDMSE. CDMSE can be explored in five distinct areas of ability: to appraise one’s career-related interests and skills, to gather information related to various occu­ pations, to choose goals related to careers, to make specific career plans, and to solve problems as they arise (Betz, 2007). Individuals with multiple margin­ alized identities could experience greater challenges (e.g., psychological distress, lack of social support, limited information, absence of role models) in these areas as a result of the internal and external barriers presented to them (Chaney, Hammond, Betz, & Mul­ ton, 2007; Parnell, Lease, & Green, 2012). Once cli­ ents gain a better understanding of their self-efficacy beliefs related to career decision making, the next steps are to explore barriers to developing a stronger CDMSE and then to identify ways and resources to improve their CDMSE. Career counseling that acknowledges and affirms LGBTQ identities reflects an affirmative approach that facilitates a safe and welcoming environment that is essential to the effectiveness of the counseling pro­ cess (Pope et al., 2004; Sangganjanavanich & Headley, 2013). This approach is consistent with general and more specific ethical guidelines of professional orga­ nizations that support the work of therapists who engage in career counseling. For example, there are universal ethical mandates that address work with all clients published by most major professional mental health organizations, including the American Coun­ seling Association (ACA, 2014), American Psycho­ logical Association (APA, 2017), and the National Association of Social Workers (NASW, 2017). Addi­ tionally, there are specific guidelines for working with LGB clients (APA, 2012) and for practice with transgender and gender-nonconforming people (ACA 2010; APA, 2015). The APA has published “Guidelines for Psychological Practice with Transgender and Gender Noncomforming People” (2015) and “Guidelines for Psychological Practice with Lesbian, Gay, and Bisexual Clients” (2012). In the former (APA, 2015), for exam­ ple, guideline 5 states, “Psychologists recognize how

stigma, prejudice, discrimination, and violence affect the health and well-being of TGNC people” (p. 838). Because transgender and gender-nonconforming people (TGNC) can face discrimination on the basis of their gender identity or gender expression in the workplace (James et al., 2016), a therapist engaging in career counseling should be aware of and sensitive to these issues and consider their effects on career decision-making self-efficacy. The National Career Development Association (NCDA, 2015) ethics guidelines specifically discuss the importance of attending to multicultural issues and diversity in the professional relationship, as well as in the areas of evaluation, assessment, and inter­ pretation. Of additional importance is that the career counselor also consider the potential effects of the intersectionality of those identities on a client’s career counseling needs and decision-making ability. It is both necessary and ethical to attend to a client’s mul­ tiple identities when engaging in career counseling. The “Guidelines for Psychological Practice with Transgender and Gender Noncomforming People,” for example, states, “Psychologists seek to understand how gender identity intersects with the other cultural identities of TGNC people” (APA, 2015, p. 836). Guideline 11 of the “Guidelines for Psychological Practice with Lesbian, Gay, and Bisexual Clients” (APA, 2012) states, “Psychologists strive to recognize the challenges related to multiple and often conflicting norms, values, and beliefs faced by lesbian, gay, and bisexual members of racial and ethnic minority groups” (p. 20). It urges psychologists to understand the different ways a client’s multiple minority sta­ tuses may complicate and exacerbate the difficulties a client might experience. In career counseling, the counselor can apply this guideline by talking with clients about how they identify in multiple ways and discussing their insights into how any of those iden­ tities affects their other identities and how they view their ability to consider different occupations as via­ ble options and make career decisions. This kind of conversation may help clients understand how they might view a particular job or career or their ability to see themselves in it because of how their culture of origin views or stigmatizes their LGBTQ identity.

Exploring Career Decision-Making Self-Efficacy 535

Instructions

This exercise includes three steps: (1) assessing career decision-making self-efficacy, (2) exploring barriers to developing a strong sense of career decision-making self-efficacy, and (3) identifying ways and resources to improve self-efficacy. All clients will have their own distinct career-development path and career-coun­ seling needs. Given the influence of different social identities on the development of career interests, a good place to start any course of career counseling is to assess and begin to understand the client’s concerns and social identities. An initial meeting should include a concerted effort to learn about a client’s multiple identities. Gathering this knowledge can be accom­ plished both formally, through an intake question­ naire, and informally, by having a conversation with clients about how they identify in several areas (includ­ ing gender and gender identity, sexual orientation, ethnicity, race, ability, and spirituality) and asking them what they consider their salient identities. To begin, a therapist working with a client who presents with difficulty making career-related deci­ sions should assess whether one of the reasons for this difficulty is a low sense of self-efficacy. To do so, the therapist can ask the client several questions that focus on self-efficacy. See the handout “Questions to Help Clients Explore Career Decision-Making Self-Effi­ cacy” for questions. These questions are open-ended and can be either asked in session to guide discussion or given to the client to complete at home and brought to the next session to be discussed together. When the goal is to integrate awareness of the effects of mul­ tiple identities on career development, a more openended questionnaire may elicit greater information about the effects of those contextual factors on a par­ ticular client’s CDMSE. To more formally assess career decision-making self-efficacy, a therapist can use the Career DecisionMaking Self-Efficacy Short Form (CDMSE-SF) devel­ oped by Taylor and Betz (1983). The CDMSE-SF is a self-report assessment that asks clients to rate how much confidence they have in their ability to accom­ plish twenty-five different tasks. Next, barriers to devel­ oping a strong sense of career decision-making selfefficacy may include parental and societal messages about what a person with the client’s identities can 536 Marien & He

and cannot do, or should and should not do. Other potential barriers are discrimination, fewer role mod­ els in certain occupations, and lack of social support (Schmidt, Miles, & Welsh, 2010). To stimulate reflection on and insight into these potential barriers, a therapist can ask a client the questions suggested in the handout “Questions for Exploring Barriers.” Finally, using knowledge of the literature and reflect­ ing on how a client responded in the first two steps, a therapist can work with a client to identify ways and resources to improve CDMSE. See the handout “Identifying Ways and Resources to Improve Career Decision-Making Self-Efficacy” for suggestions. Brief Vignette

Sharon has been struggling to choose a major, and her adviser has referred her to the university’s counseling center. During the initial meeting, Sharon and her ther­ apist explored her multiple identities as a nineteenyear-old white, lesbian, cisgender woman in her soph­ omore year from a conservative and working-class background and their influence on her difficulty in making a career decision. She has taken and really enjoyed a couple of courses in human sexuality and gender studies. She was hesitant to choose a major in these areas, however, because she was unsure whether she actually wanted to pursue further studies on the topic or whether she liked them because she gained information and affirmation about her sexual orienta­ tion. She did not know what career majoring in those areas could lead to, and she was concerned about what her parents would think about those majors. Sharon’s therapist explained the concept of career-decision making self-efficacy briefly. Using the sample questions related to CDMSE at the end this chapter, Sharon and her therapist evaluated and explored her career decision-making self-efficacy. On the basis of these discussions, the therapist noted that Sharon had rather low self-efficacy in making a career decision. Upon exploration, Sharon identified some barriers, includ­ ing lack of exposure to career options, lack of role models and social support, fear of being judged and marginalized, worry about making a mistake, and lack of familiarity with the career decision-making pro­ cess. Building on their discussion, her therapist worked with Sharon on generating ideas and strategies to

address those barriers. For example, to address the lack of role models, Sharon was encouraged to connect with her campus’s LGBTQ center and participate in its program that connects undergraduates with alumni mentors. To increase Sharon’s sense that a range of career options is available for LGBTQ individuals, her therapist also suggested she explore websites and obtain pamphlets and books that describe the reality that LGBTQ individuals work in all careers (e.g., Out and Equal Workplace Advocates at http://outandeq ual.org, and Pride@Work at www.prideatwork.org/). To address Sharon’s fear of being judged and mar­ ginalized, the therapist processed and normalized Sharon’s concerns, and they discussed how she might identify and work to connect with students and staff at the university who would be affirming and sup­ portive. In addition to facilitating a connection to the LGBTQ center on campus so that she might develop more of a community, the therapist referred Sharon to a support group for LGBTQ students in the counsel­ ing center. Through opening up to more friends and receiving greater social support, seeking services from her university’s career services office, and connecting with her own passions and aspirations, she eventu­ ally gained more clarity about what major to choose and felt more confident about her decision. Suggestions for Follow-up

A therapist can support the in-session work by direct­ ing clients to other sources that can further their career exploration and information gathering. For example, the client can be given the homework of engaging in further career exploration by using O*Net OnLine (https://www.onetonline.org/), a free online source of occupational information that allows users to search for information on hundreds of occupations. It also offers the Interest Profiler (https://www.mynextmove. org/explore/ip). This is an instrument that can help identify a person’s interests, how they relate to the world of work, and what kinds of careers to consider exploring. Additionally, if clients need further help with identifying possible careers and occupations that are based on their interests, the therapist can recom­ mend using the Strong Interest Inventory (SII) to clar­ ify their interests (Consulting Psychologists Press, 1994). The SII is a self-report career assessment that

evaluates a person’s career and leisure interests. It is standardized assessment that was normed on diverse populations. Additionally, results from a more recent study suggest that the SII is psychometrically sound for use with LGBT individuals (Schaubhut & Thomp­ son, 2016). Another helpful resource to suggest for followup exploration is The Occupational Outlook Handbook (U.S. Department of Labor, 2017) found online at https://www.bls.gov/ooh/, which can help clients find career information for hundreds of occupations. This is a good next step once clients have identified some occupations they would like to learn more about. Sometimes a client comes in with career-related concerns and, in the course of career counseling, it becomes clear that there are other issues that the cli­ ent is facing. For example, a client might be experi­ encing anxiety or depression. Should these issues be present to the extent that they warrant focused coun­ seling, a therapist may follow up with treating the depression or anxiety as a primary focus of therapy, or refer the client for further treatment. Contraindications for Use

The therapist is encouraged to assess a client’s overall level of functioning. A good place to start career coun­ seling is to assess whether a client is experiencing other issues that may need to be addressed first, before career decision-making issues can be addressed. For example, if a client is significantly depressed or anx­ ious and unable to function well in activities of daily living or primary responsibility (e.g., academics), then that issue should be addressed first. When the client is able to function more highly, a reassessment of career needs can be made and career counseling started. While engaging in the process of career deci­ sion making may be somewhat stressful, if the client is functioning well and has good therapeutic, social, and environmental supports for this process, there are no foreseen contraindications for working with clients in this way regarding career decision making. Professional Readings and Resources Betz, N. E., & Taylor, K. M. (2012). Career decision self-efficacy scale. https://www.mindgarden.com/79-career-decision­ self-efficacy-scale.

Exploring Career Decision-Making Self-Efficacy 537

Gysbers, N. C., Heppner, M. J., & Johnston, J. A. (2014). Career counseling: Holism, diversity, and strengths. Alex­ andria, VA: American Counseling Association. National Career Development Association. https://www. ncda.org. National Employment Counseling Association. www.employ mentcounseling.org. O’Neil, M. E., McWhirter, E. H., & Cerezo, A. (2008). Transgender identities and gender variance in vocational psy­ chology: Recommendations for practice, social advocacy, and research. Journal of Career Development, 34 (3), 286–308. doi:10.1177/0894845307311251. Prince, J. (2013). Career development of lesbian, gay, bisexual, and transgender individuals. In S. D. Brown & R. W. Lent (eds.), Career development and counseling: Putting theory and research to work, 2nd edition, 275–298. Hoboken, NJ: Wiley. Society for Vocational Psychology. https://www.div17.org/ sections/vocational-psychology/. Strong Interest Inventory. https://www.themyersbriggs.com/ en-US/Products-and-Services/Strong.

Resources for Clients Folds, R. B. (2013). Your queer career. Riverdale, NY: Riverdale Avenue Books. U.S. Department of Labor. (2017). The occupational outlook handbook. https://www.bls.gov/ooh/. There are several LGBTQ organizations that do not focus specifically on career exploration as a topic but that offer infor­ mation that can help a person engaging in career exploration by offering information about companies, the workplace, and other relevant resources. Examples of those resources are: Human Rights Campaign. Corporate equality index and LGBTQ employee resources. https://www.hrc.org/. National Center for Transgender Equality. Issues: Employment. https://transequality.org/issues/employment. Out and Equal. Workplace advocates. www.outandequal.org/. Pride@Work. www.prideatwork.org/.

References American Counseling Association (ACA). (2010). American Counseling Association competencies for counseling with transgender clients. Journal of LGBT Issues in Coun­ seling, 4, 135–159. doi:10.1080/15538605.2010.524839. American Counseling Association (ACA). (2014). 2014 ACA code of ethics. https://www.counseling.org/Resources/ aca-code-of-ethics.pdf. American Psychological Association (APA). (2012). Guidelines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67 (1), 10–42. doi:10.1037 /a0024659. American Psychological Association (APA). (2015). Guidelines for psychological practice with transgender and gender 538 Marien & He

nonconforming people. American Psychologist, 70 (9), 832–864. doi:10.1037/a0039906. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. http:// www.apa.org/ethics/code/. Betz, N. (2007). Career self-efficacy: Exemplary recent research and emerging directions. Journal of Career Assessment, 15 (4), 403–422. doi:10.1177/1069072707305759. Betz, N., & Hackett, G. (2006). Career decision-making selfefficacy theory: Back to the future. Journal of Career Assessment, 14 (1), 3–11. doi:10.1177/106907270528 1347. Betz, N., Hammond, M., & Multon, K. (2005). Reliability and validity of five-level response continua for the career decision self-efficacy scale. Journal of Career Assessment, 13 (2), 131–149. doi:10.1177/1069072704273123. Budge, S. L., Tebbe, E. N., & Howard, K. A. S. (2010). The work experiences of transgender individuals: Negotiating the transition and career decision-making processes. Journal of Counseling Psychology, 57 (4), 377–393. doi:10.1037/ a0020472. Chaney, D., Hammond, M. S., Betz, N. E., & Multon, K. D. (2007). The reliability and factor structure of the Career Decision Self-Efficacy Scale-SF with African Americans. Journal of Career Assessment, 15 (2), 194–205. doi:10. 1177/1069072706298020. Choi, B. Y., Park, H., Yang, E., Lee, S. K., Lee, Y., & Lee, S. M. (2012). Understanding career decision self-efficacy: A meta-analytic approach. Journal of Career Development, 39, 443–460. doi:10.1177/0894845311398042. Consulting Psychologists Press. (1994). Strong Interest Inven­ tory. Palo Alto, CA: Author. Harlow, A. J., & Bowman, S. L. (2016). Examining the career decision self-efficacy and career maturity of community college and first-generation students. Journal of Career Development, 43 (6), 512–525. doi:10.1177/0894845316 633780. James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Ana, M. (2016). The Report of the 2015 U.S. Transgen­ der Survey. Washington, DC: National Center for Transgender Equality. https://transequality.org/sites/default/ files/docs/usts/USTS-Full-Report-Dec17.pdf. Komarraju, M., Swanson, J., & Nadler, D. (2013). Increased career self-efficacy predicts college students’ motivation, and course and major satisfaction. Journal of Career Assessment, 22 (3), 420–432. doi:10.1177/106907271349 8484. Lent, R. (2013). Social cognitive career theory. In S. D. Brown & R. W. Lent (eds.), Career development and counseling: Putting theory and research to work, 2nd edition, 115–146. Hoboken, NJ: John Wiley & Sons. National Association of Social Workers (NASW). (2017). Code of ethics of the National Association of Social Workers.

https://www.socialworkers.org/about/ethics/code-of­ ethics/code-of-ethics-english. National Career Development Association (NCDA). (2015). Code of ethics. https://www.ncda.org/aws/NCDA/asset_ manager/get_file/3395. O’Neil, M. E., McWhirter, E. H., & Cerezo, A. (2008). Transgender identities and gender variance in vocational psy­ chology: Recommendations for practice, social advocacy, and research. Journal of Career Development, 34 (3), 286–308. doi:10.1177/0894845307311251. Parnell, M., Lease, S., & Green, M. (2012). Perceived career barriers for gay, lesbian and bisexual individuals. Journal of Career Development, 39 (3), 248–268. doi:10.1177/08 94845310386730. Pope, M., Barret, B., Szymanski, D. M., Chung, Y. B., Singara­ velu, H., McLean, R., & Sanabria, S. (2004). Culturally appropriate career counseling with gay and lesbian clients. Career Development Quarterly, 53 (2), 158–177 doi:10.1 002/j.2161-0045.2004.tb00987.x. Preston-Sternberg, M. M. (2009). Multimethod analysis of social support and career self-efficacy among gay, lesbian and bisexual persons. PhD diss., University of Texas at San Antonio. Available from ProQuest Dissertations & Theses Global database (UMI no. 3387663). Russon, J. M., & Schmidt, C. K. (2014). Authenticity and career decision-making self-efficacy in lesbian, gay, and bisexual college students. Journal of Gay and Lesbian Social Services, 26 (2), 207–221. doi:10.1080/10538720.2014.891090. Sangganjanavanich, V. F., & Headley, J. A. (2013). Facilitating career development concerns of gender transitioning indi­ viduals: Professional standards and competencies. Career

Development Quarterly, 61 (4), 354–366. doi:10.1002/ j.2161-0045.2013.00061.x. Schaubhut, N. A., & Thompson, R. C. (2016). Technical brief for the Strong Interest Inventory® assessment: Using the Strong with LGBT populations. Updated version. https:// www.themyersbriggs.com/download/item/9a0a56f23e5b 4fd99a40bda64eef6f54. Schmidt, C. K., Miles, J. R., & Welsh, A. C. (2010). Perceived discrimination and social support: The influences on career development and college adjustment of LGBT col­ lege students. Journal of Career Development, 38 (4), 293– 309. doi:10.1177/0894845310372615. Scott, A. B., & Ciani, K. D. (2008). Effects of an undergradu­ ate career class on men’s and women’s career decisionmaking self-efficacy and vocational identity. Journal of Career Development, 34 (3), 263–285. doi:10.1177/0894 845307311248. Taylor, K. M., & Betz, N. E. (1983). Applications of self-efficacy theory to the understanding and treatment of career indecision. Journal of Vocational Behavior, 22, 63–81. Tomlinson, M. J., & Fassinger, R. E. (2003). Career develop­ ment, lesbian identity development, and campus climate among lesbian college students. Journal of College Student Development, 44 (6), 845–860. doi:10.1353/csd.2003.0078. U.S. Department of Labor. (2017). The occupational outlook handbook. https://www.bls.gov/ooh/. White, L. M. (2014). Lesbian and gay career development and Super’s life-span, life-space theory. PhD diss., University of Toronto. https://tspace.library.utoronto.ca/bitstream/ 1807/68440/1/White_Lisa_201411_PhD_thesis.pdf.

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H A NDO UT

QU E STIO N S TO H EL P CL IENT S EXP LO RE CA REER

D E C ISIO N-M A KING S EL F-EF F ICACY

Instructions: For each question, fill in the blank with a brief explanation. Please bring this to our next session. 1. How confident do you feel that you can accurately assess your skills and abilities? __________________________________________________________________________________ __________________________________________________________________________________ 2. How confident do you feel in your ability to know how to find information related to various occupations? __________________________________________________________________________________ __________________________________________________________________________________

3. How confident do you feel that you can identify your career goals? __________________________________________________________________________________ __________________________________________________________________________________ 4. How confident do you feel that you can solve problems that might get in the way of achieving your career goals? __________________________________________________________________________________ __________________________________________________________________________________ 5. How confident do you feel that you know how to enter the career you are interested in? __________________________________________________________________________________ __________________________________________________________________________________ 6. How confident do you feel that you can make specific career plans? __________________________________________________________________________________ __________________________________________________________________________________ 7. How confident do you feel that you can solve problems that get in the way of your career plans? __________________________________________________________________________________ __________________________________________________________________________________

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QU E STIO NS F O R EXP LO RING BA RRIERS

Common barriers can include low confidence in your decision-making ability, fear that you may experience discrimination in the hiring process, thinking some careers are unattainable because of your social identities, worries about being able to express all your identities at work, and fear of discrimination at work. Here are some questions that can help you explore what those barriers might be for you.

1. What are some of the barriers you have encountered in exploring your career options?

2. What are some of the barriers you have encountered in making decisions about your education or career?

3. How might you address each barrier? Choose one or two to talk about, prioritizing with the counselor which barrier to explore first.

4. How confident are you in your ability to address that barrier?

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H A NDO UT

ID E N TIF YIN G WAYS A ND RES O URCES T O IM P ROVE CA REER

D E C ISIO N-M A KING S EL F-EF F ICACY

1. Seek out social support. Identify two or three people who are positive influences and sup­ ports in career-related issues.

2. Seek help from your school’s counseling center, career services, LGBT center, cultural centers, and other on-campus resources.

3. Engage in self-reflection activities.

4. Recognize and acknowledge successes and accomplishments.

5. Make a list of all your skills and abilities. Include everything you can think of.

6. Identify what you need to learn more about—for example, learning more about what your interests and skills are, or learning more about certain jobs or careers.

7. Identify and connect with mentors and role models in the career you are interested in. To develop a list, consider asking advisers, instructors, family, friends, and campus and local community leaders if they know any LGBTQ and LGBTQ-affirming professionals whom you can talk with.

8. Identify and acknowledge that there are potential internal and external barriers to achieving your career. [Here the therapist might list what has already been discussed in earlier sessions.]

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Marilia Marien and Yuhong He

SECTION VIII

HOMEWORK, HANDOUTS,

AND ACTIVITIES FOR

USE IN OUTREACH

PROGRAMMING AND

TRAINING WORKSHOPS

The last section of the book extends our work beyond direct service for clients with diverse sexual and gen­ der identities and their families to education for com­ munities that serve these clients. The goals of the chap­ ters in this section are to create safety in a wide range of social and clinical spaces, beginning with the explo­ ration of clients’ or group participants’ identities and moving toward an analysis of the amount of power or oppression associated with each identity. Many of the activities assist various audiences in increasing awareness of and confronting internalized stereotypes that lead them to engage in microaggressions. Outreach programming and workshops are com­ mon on college campuses and can often be used as vehicles for enhancing safety and understanding for diverse student communities (Asidao & Sevig, 2014). Thus, several chapters in this section are geared spe­ cifically for use on college campuses. In Chapter 62, “Building Community on Campus: A Workshop on Sharing and Support for LGBTQ College Students,” Alaina Spiegel notes that harassment of LGBTQ stu­ dents is more frequent than it is of heterosexual stu­ dents on college campuses (Rankin, Weber, Blumen­ feld, & Frazer, 2010) and that support from peers can be a powerful protective factor. The two activities she provides are designed to enhance intimacy and increase a sense of connectedness within the queer community through personal stories and exploration of intragroup differences. In Chapter 68, “Under­ standing Me, You, and LGBTQ: An Outreach Work­ shop for General Audiences and Allies,” Spiegel focuses on creating greater safety for LGBTQ students within the larger campus community. By exploring partici­ pants’ statuses of privilege and marginalization, the workshop facilitates participants’ greater self-aware­ ness of their own identities and the ways in which they can use these insights to develop greater empathy and become stronger allies. Two chapters by Batsirai Bvunzawabaya and Mat­ thew LeRoy also address the goal of creating a more inclusive and supportive campus climate. In Chapter 67, “Outreach on a College Campus: Understanding the Campus Climate,” the authors note the many ways in which LGBTQ students may not feel at home on their campus. In addition to experiencing heterosex­ ism, homophobia, and transphobia, LGBT students 544

may have many practical concerns, such as finding appropriate housing, gender-inclusive restrooms and locker rooms, and affirming health care. They recom­ mend a public health approach to outreach program­ ming and emphasize the importance of understand­ ing students’ experiences and perspectives through the use of a thoughtful and detailed survey, the results of which may guide appropriate campus interven­ tions. In Chapter 69, “Living in Intersectional Spaces: Exploration of Social Identities in the LGBT Com­ munity,” the goal is to generate a discussion among LGBTQ students about identity, privilege, and margin­ alization within the queer community. The authors suggest a group format and provide guiding questions and prompts to strengthen the experience of cohesion and increase a sense of belonging. Other chapters, designed to create safer spaces for LGBTQ individuals, emphasize providing psychoedu­ cation for allies. For example, in Chapter 63, “Out­ reach Ally-Training Activities,” Brandy L. Smith details strategies to provide accurate information on sexualand gender-diverse clients as well as training on avail­ able resources for those who work with LGBTQ+ clients. Jayleen Galarza and Matthew R. Shupp also highlight the ways in which psychoeducation can reduce microaggressions in Chapter 64, “Reflections of Assumptions.” They provide an activity that invites participants to sit with a level of discomfort as they explore identities, implicit bias, and the inaccuracy of the stereotypes they may hold. Awareness of microaggressions is an integral part of cultural competence. A microaggression can do significant damage to the therapeutic alliance, a friend­ ship, or a working relationship (Owen, Tao, & Rodolfa, 2010). To help group participants better understand the deep effects of microaggressions, Jeanne L. Stanley offers a powerful exercise in Chapter 65, “The Papercut Activity: Understanding the Subtle and Ongoing Effects of Microaggressions.” After taking part in this activity, in which Stanley uses a metaphor of a papercut to illustrate the effect of microaggressions, the audience will probably have a better understanding of the destructive consequences of repeated microinsults, microassaults, and microinvalidations. Specifically targeting clinicians in Chapter 61, “Intersecting Identities: A Self-Reflective Activity for

Outreach Programming and Workshops,” Laura Boyd Farmer and Christian D. Chan highlight and work with the fact that most people experience both privi­ lege and oppression in their lives. They encourage counselors to explore more deeply the complex inter­ sections of their lived experiences so that they can become more attuned to and aware of their influence on clients. Michelle M. Murray also provides a train­ ing geared for clinicians in Chapter 66, “Examining Our Blind Spots: Considerations in Working with Lesbian, Gay, and Bisexual Clients with Disabilities.” She discusses the prevalence of ableism within the LGBT and straight communities, and she cautions clinicians to evaluate their own biases while provid­ ing excellent guidance to enhance competency in working with disabled populations. Another important group within the LGBTQ com­ munity are survivors of sexual violence. In Chapter 70, “Creating Consciousness to Create Connection: Attending to Biases When Working with Queer Vic­ tim-Survivors of Sexual Violence,” Deborah O’Neill and Laura Kay Collins point out the ways in which even subtle negative reactions and implicit bias can have long-term, negative mental or physical health consequences for clients. Their activity, which encour­ ages clinicians to be more self-aware and to engage in

appropriate self-care, is an effective tool to ensure sen­ sitivity for every clinician who works with survivors. Finally, Soumya Madabhushi helps participants look at their own expectations regarding gender in Chapter 71, “Addressing Anti-Trans Prejudice: Decod­ ing the Gender Matrix.” Her activity is designed spe­ cifically for enhancing understanding of the trans community. In this innovative activity, participants explore their attitudes toward “otherness” and gender privilege to decrease adherence to whatever stereo­ types they might hold. The goals are to increase selfawareness and to gain a greater understanding of oth­ ers, thus creating a safer place in clinical and social spaces for the trans community. References Asidao, C., & Sevig, T. (2014). Reaching in to reach out: One counseling center’s journey in developing a new outreach approach. Journal of College Student Psychotherapy, 28 (2), 132–143. doi:10.1080/87568225.2014.883881. Owen, J., Tao, K., & Rodolfa, E. (2010). Microaggressions and women in short-term psychotherapy: Initial evidence. Counseling Psychologist, 38 (7) 923–946. doi:10.1177/ 0011000010376093. Rankin, S., Weber, G., Blumenfeld, W., & Frazer, S. (2010). 2010 state of higher education for lesbian, gay, bisexual, and transgender people. Charlotte, NC: Campus Pride.

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61 INTERSECTING IDENTITIES: A SELF-REFLECTIVE ACTIVITY FOR OUTREACH PROGRAMMING AND WORKSHOPS Laura Boyd Farmer and Christian D. Chan Suggested Use: Activity Objective

This activity is intended to raise participants’ aware­ ness of the unique intersections of their individual identities and to consider how experiences of privilege and oppression affect experiences. Participants are asked to reflect on all aspects of their cultural and indi­ vidual background, including but not limited to age, race, ethnicity, ability status, gender identity, gender expression, sexual and affectional orientation, rela­ tionship orientation, religious and spiritual identity, socioeconomic status, education, factors related to family of origin, family constellation, and any other factors that they deem relevant or salient to their expe­ riences of privilege and oppression. Rationale for Use

The explosion of intersectionality as a visionary para­ digmatic approach on multicultural and social justice topics continues to enrich perspectives on the com­ plexity of experience across multiple social identities (Carbado, Crenshaw, Mays, & Tomlinson, 2013; Cho, 2013; Cho, Crenshaw, & McCall, 2013; Corlett & Mavin, 2014). Intersectionality also offers a method of critical analysis to decolonize power relations (Bow­ leg, 2008; Corlett & Mavin, 2014). With roots in the scholarship practice of law (Crenshaw, 1989, 1991) and sociology (Collins, 1990), intersectionality has expanded as a multidisciplinary force, most notably in disciplines reliant on applied practice (e.g., economics,

higher education, psychology, counseling). Intersec­ tionality offers a call to action to examine power rela­ tions critically across multiple overlapping forms of oppression that are sewn into the fabric of social struc­ tures (Bowleg, 2008, 2012; Cho, 2013; Cho et al., 2013; Cole, 2008, 2009; McCall, 2005; Shields, 2008; War­ ner, 2008; Warner & Shields, 2013). Intersectionality poses the theory that human development, culture, and social identities do not exist as mutually exclusive categories, given that social identities carry overlap­ ping forms that assume a mutually shaping interaction. In laying a foundation for intersectionality, seminal scholars (Crenshaw, 1989, 1991; Collins, 1990) argued that the voices of multiply marginalized communities were often removed from advocacy in human rights movements intended to counteract oppression. Spe­ cifically, Crenshaw (1989, 1991) argued that she, as a woman of color, had been excluded from the overar­ ching feminist movement, which exposed the sexism in movements that advocate for racial and ethnic minorities and racism in movements that advocate for women. As a result, Crenshaw explained that anti­ discrimination law cannot operate on a “single axis” (Crenshaw, 1989, p. 139). Using the framework offered by intersectionality, privilege and oppression may be viewed as operating within this confluence, where individuals can simul­ taneously experience both. The necessity of examin­ ing this confluence is both contextual and develop­ mental; special attention is paid to the social structures and interactions that contribute to the salience of priv-

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ilege or oppression. White privilege has been a pri­ mary focus; other aspects of identity have also been relevant in the lives of marginalized subgroups. Within queer communities, individuals have described invis­ ible power structures that are based on binary ideas of gender and sexuality in spaces where unity and equality are assumed (Farmer & Byrd, 2015). Fortu­ nately, dialogues emphasizing the complexity of inter­ secting identities and experiences are increasing (Farmer & Byrd, 2015; Hammer, Crethar, & Cannon, 2016; Singh, 2013); thus, so is our professional aware­ ness. The following activity offers one way to begin the complex conversation about the unique intersec­ tions of social, cultural, and individual identities. Within the counseling profession, core values out­ lined in the American Counseling Association’s (ACA) Code of Ethics (2014) support philosophical under­ pinnings that are based on developmental, strengthsbased, holistic, wellness, and multicultural perspec­ tives. Examples include the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) “Competencies for Counseling with Les­ bian, Gay, Bisexual, Queer, Questioning, Intersex, and Ally Individuals” (Harper et al., 2013); ALGBTIC Competencies for Counseling Transgender Clients (2009); “New ASERVIC Competencies for Address­ ing Spiritual and Religious Issues in Counseling” (Cashwell & Watts, 2010); and the “Multicultural and Social Justice Counseling Competencies” (Ratts et al., 2016). Of particular relevance to the proposed activity is counselors’ maintaining competence by seeking continuing education to “remain informed regarding best practices for working with diverse pop­ ulations,” which includes affirmative practice with LGBTQ individuals (ACA, 2014, C.2.f). Affirmative practice emphasizes standards of excellence to move beyond simply meeting a baseline of cultural competence. Therefore, counseling pro­ fessionals are expected to engage in continuing educa­ tion and competency building. In addition, affirmative practice highlights the complexity of interactions denoted in cultural and social identity. Counseling competency standards provide extensive descriptions of language to expand knowledge and understanding for helping professionals. More important, critically

examining the converging experiences of privilege and oppression connects with principles of affirmative practice through a constant process of self-assessment and self-evaluation. Instructions

This activity may be used in presentations, workshops, and seminars that are focused on affirmative prac­ tices with clients who embrace diverse identities in sexual, affectional, and gender orientation. After tak­ ing some time to create a safe, nonjudgmental atmo­ sphere among participants, the following sequence of questions and activities may be offered, using the “Intersecting Identities” color wheel diagram as a guide (page 550). 1. To begin, you are invited to reflect on the unique aspects of your identities: What makes up who you are? What are the different dimensions of your personal identities? 2. Next, write down specific aspects of your identities in the intersecting color wheel. You may include the following examples: your age, race, ethnicity, ability status, gender identity, gender expression, sexual and affectional orientation, relationship orientation, religious and spiritual identity, socio­ economic status, education, factors related to your family of origin, and family constellation. You are encouraged to include any other aspects of your identities that are relevant and important to you. 3. In the center of the wheel, write down aspects of who you are that transcend identity labels. Exam­ ples might include your personality traits, deeply held personal values, and other core aspects that define who you are (e.g., honest, compassionate, trustworthy, smart). 4. After completing the activity, which identities felt most salient to you? Which identities did you notice more prominently in your recall of experiences? Which identities appeared more explicit or more subtle to you? Which experiences and contexts might change the prominence of specific identities? 5. Reflecting on each aspect of identity on the inter­ secting color wheel, consider experiences of both privilege and oppression. Which identities hold a Intersecting Identities: A Self-Reflective Activity 547

more privileged status in your current context? Which identities do you experience as being mar­ ginalized or oppressed in your current context? How might those experiences change within dif­ ferent contexts? 6. Pair up with a partner and take turns sharing your intersecting identity wheel. Together, consider the complex, interactional nature of your identities. Consider the core aspects of who you are in the cen­ ter. How do you reflect on these different aspects? 7. How might your awareness of intersectionality affect your understanding and relationships with clients, students, or coworkers? Suggestions for Follow-up

After this intersectionality activity is presented in a professional development workshop or seminar, par­ ticipants are encouraged to continue their own per­ sonal reflection to deepen their understanding of inter­ sectionality. Participants may also be encouraged to follow up with one another through a staff meeting or team consultation to put their understanding into prac­ tice. The intersectionality color wheel could be used as an activity with clients to broach cultural, social, and individual identities. Furthermore, case concep­ tualization of a client could be enhanced through use of the intersectional identity color wheel. Contraindications for Use

This activity should be offered in an atmosphere of safety and mutual respect. Therefore, this intersec­ tionality activity would be contraindicated in a con­ tentious atmosphere—for example, in a workplace environment where there have been recent issues or accusations of harassment between group members. Mediation would be recommended as an interven­ tion before introducing this activity, which requires a safe atmosphere. Professional Readings and Resources Carastathis, A. (2016). Intersectionality: Origins, contestations, horizons. Lincoln: University of Nebraska Press. Collins, P. H. (1990). Black feminist thought: Knowledge, con­ sciousness, and the politics of empowerment. New York: Routledge.

548 Farmer & Chan

Crenshaw, K. (1989). Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. Univer­ sity of Chicago Legal Forum, 139–167. Crenshaw, K. (1991). Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Review, 43 (6), 1241–1299. doi:10.2307/1 229039. Davis, K. (2008). Intersectionality as a buzzword. Feminist Theory, 9 (1), 67–85. Dhamoon, R. K. (2011). Considerations on mainstreaming intersectionality. Political Research Quarterly, 64 (1), 230–243. Gopaldas, A. (2013). Intersectionality 101. Journal of Public Policy and Marketing, 32 (1), 90–94. Hammer, T. R., Crethar, H. C., & Cannon, K. (2016). Conver­ gence of identities through the lens of relational-cultural theory. Journal of Creativity in Mental Health, 11 (2), 126– 141. doi:10.1080/15401383.2016.1181596. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H., Loos, B., . . . & Hammer, T. R. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Coun­ seling competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individu­ als. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi: 10.1080/15538605.2013.755444. Walby, S., Armstrong, J., & Strid, S. (2012). Intersectionality: Multiple inequalities in social theory. Sociology, 46 (2), 224–240.

Resources for Clients Carastathis, A. (2016). Intersectionality: Origins, contestations, horizons. Lincoln: University of Nebraska Press. Collins, P. H., & Bilge, S. (2016). Intersectionality. Malden, MA: Polity Press. Harding, S. (2004). The feminist standpoint theory reader: Intel­ lectual and political controversies. New York: Routledge. Kimberlé Crenshaw’s Intersectionality Guide. www.racial equitytools.org/resourcefiles/Kimberle-Crenshaw-In structors_-Guide-1.pdf. A Primer on Intersectionality. www.intergroupresources. com/rc/Intersectionality%20primer%20-%20African%20 American%20Policy%20Forum.pdf.

References American Counseling Association (ACA). (2014). Code of ethics and standards of practice. Alexandria, VA: Ameri­ can Counseling Association. American School Counselor Association (ASCA). (2016). ASCA ethical standards for school counselors. https:// www.schoolcounselor.org/asca/media/asca/Ethics/Ethi calStandards2016.pdf.

Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC). (2009). Competencies for coun­ seling with transgender clients. Alexandria, VA: Author. Bowleg, L. (2008). When black + lesbian + woman ≠ black les­ bian woman: The methodological challenges of qualita­ tive and quantitative intersectionality research. Sex Roles, 59 (5–6), 312–325. doi:10.1007/s11199-008-9400-z. Bowleg, L. (2012). The problem with the phrase women and minorities: Intersectionality—an important theoretical framework for public health. American Journal of Public Health, 102 (7), 1267–1273. doi:10.2105/AJPH.2012. 00750. Carbado, D. W., Crenshaw, K. W., Mays, V. M., & Tomlinson, B. (2013). Intersectionality. Du Bois Review, 10 (2), 303– 312. doi:10.1017/S1742058X13000349. Cashwell, C. S., & Watts, R. E. (2010). The new ASERVIC com­ petencies for addressing spiritual and religious issues in counseling. Counseling and Values, 55 (1), 2–5. doi:10.10 02/j.2161-007X.2010.tb00018.x. Cho, S. (2013). Post-intersectionality: The curious reception of intersectionality in legal scholarship. Du Bois Review, 10 (2), 385–404. doi:10.1017/S1742058X13000362. Cho, S., Crenshaw, K. W., & McCall, L. (2013). Toward a field of intersectionality studies: Theory, applications, and praxis. Signs, 38 (4), 785–810. doi:10.1086/669608. Cole, E. R. (2008). Coalitions as a model for intersectionality: From practice to theory. Sex Roles, 59 (5–6), 443–453. doi:10.1007/s11199-008-9419-1. Cole, E. R. (2009). Intersectionality and research in psychol­ ogy. American Psychologist, 64 (3), 170–180. doi:10.1037/ a0014564. Collins, P. H. (1990). Black feminist thought: Knowledge, con­ sciousness, and the politics of empowerment. New York: Routledge. Corlett, S., & Mavin, S. (2014). Intersectionality, identity, and identity work. Gender in Management, 29 (5), 258–276. doi:10.1108/GM-12-2013-0138. Crenshaw, K. (1989). Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. Univer­ sity of Chicago Legal Forum, 1989 (1), article 8. Crenshaw, K. (1991). Mapping the margins: Intersectionality, identity politics, and violence against women of color.

Stanford Law Review, 43 (6), 1241–1299. doi:10.2307/ 1229039. Farmer, L. B., & Byrd, R. (2015). Genderism in the LGBTQQIA community: An interpretative phenomenological analy­ sis. Journal of LGBT Issues in Counseling, 9 (4), 288–310. doi:10.1080/15538605.2015.1103679. Hammer, T. R., Crethar, H. C., & Cannon, K. (2016). Conver­ gence of identities through the lens of relational-cultural theory. Journal of Creativity in Mental Health, 11 (2), 126– 141. doi:10.1080/15401383.2016.1181596. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H., Loos, B., . . . & Hammer, T. R. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Coun­ seling competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individu­ als. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi :10.1080/15538605.2013.755444. Kaplan, D. M., Tarvydas, V. M., & Gladding, S. T. (2014). 20/20: A vision for the future of counseling: The new consensus definition of counseling. Journal of Counseling and Devel­ opment, 92 (3), 366–372. doi:10.1002/j.1556-6676.2014. 00164.x. McCall, L. (2005). The complexity of intersectionality. Signs, 30 (3), 1771–1800. doi:10.1086/426800. Ratts, M. J., Singh, A. A., Nassar‐McMillan, S., Butler, S. K., & McCullough, J. R. (2016). Multicultural and social jus­ tice counseling competencies: Guidelines for the coun­ seling profession. Journal of Multicultural Counseling and Development, 44 (1), 28–48. doi:10.1002/jmcd.12035. Shields, S. A. (2008). Gender: An intersectionality perspective. Sex Roles, 59 (5–6), 301–311. doi:10.1007/s11199-008­ 9501-8. Singh, A. A. (2013). Transgender youth of color and resilience: Negotiating oppression and finding support. Sex Roles, 68 (11–12), 690–702. doi:10.1007/s11199-012-0149-z. Warner, L. R. (2008). A best practices guide to intersectional approaches in psychological research. Sex Roles, 59 (5–6), 454–463. doi:10.1007/s11199-008-9504-5. Warner, L. R., & Shields, S. A. (2013). The intersections of sex­ uality, gender, and race: Identity research at the crossroads. Sex Roles, 68 (11–12), 803–810. doi:10.1007/s11199-013­ 0281-4.

Intersecting Identities: A Self-Reflective Activity 549

I NT ERSE C TIO N O F ID E N T IT IES

Intersectionality: Aspects of identity are interconnected and cannot be accurately examined when considered separately from each other; the same interconnectedness applies to systems of oppression that are based on identities (e.g., age, race, ethnicity, ability, gender identity, sexual/affectional orientation, relational orientation, religion/spirituality, socioeconomic status, education, family status, and others).

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Laura Boyd Farmer and Christian D. Chan

1. What are the unique intersections of your identities? How do these interact and affect your experiences?

2. Using this intersectional lens of your identities, consider your own experiences of both privilege and oppression.

3. How might your awareness of intersectionality affect your relationships with clients or students?

Laura Boyd Farmer and Christian D. Chan

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62 BUILDING COMMUNITY ON CAMPUS: A WORKSHOP ON SHARING AND SUPPORT FOR LGBTQ COLLEGE STUDENTS Alaina Spiegel

Suggested Use: Activity Objective

The goals of this workshop include normalizing LGB­ TQ college student experiences, exposing students to intragroup differences and issues of intersectionality, and discussing the importance of peer support. The overall aim of this workshop is to facilitate a space of mutual sharing and social support for LGBTQ college students. Rationale for Use

Vera and Speight (2003) discuss how counseling psy­ chology necessitates a commitment to social justice that expands beyond individual counseling. Counsel­ ing centers on college campuses can provide an ideal setting to provide social justice outreach outside the counseling center walls. Asidao and Sevig (2014) found that counseling centers that combine clinical ser­ vices and education and prevention, with a focus on diverse communities, could empower health and con­ nection on campus. They explained how individuals and the agencies delivering outreach services on cam­ pus must be multiculturally competent and under­ stand the specific needs of students on the basis of their gender, race, sexual orientation, national ori­ gin, and ability or disability status. Campus outreach to LGBTQ college students is particularly crucial given the national data on campus climate for sexual minori­ ties. In a national study, Rankin, Weber, Blumenfeld, and Frazer (2010) found that lesbian, gay, bisexual,

and queer college students were more likely to experi­ ence harassment and discrimination than heterosex­ ual students, and that these experiences were related to their sexual identity. Additionally, using a national college student data set, Oswalt and Wyatt (2011) examined the relationship between mental health issues and sexual orientation among college students who identified as gay, lesbian, bisexual, or unsure. The authors found that gay, lesbian, bisexual, and unsure students, in comparison to heterosexual students, expe­ rienced higher rates of feelings and behaviors consis­ tent with poorer mental health. More specifically, Oswalt and Wyatt (2011) reported that gay and lesbian students reported higher rates of anxiety and attempt­ ing suicide in the previous twelve months and that bisexual individuals reported higher rates of suicide attempts outside the previous twelve months. Another study suggested that individuals who identify as hav­ ing multiple marginalized identities concerning their LGBT status and racial or ethnic identity experience microaggressions that may be linked to depression and perceived stress (Balsam et al., 2011). Despite the many challenges faced in LGBTQ com­ munities, research has supported the idea that family and peer social support for LGBT youth and young adults can serve as a protective factor against mental health issues (McConnell, Birkett, & Mustanski, 2015; Snapp et al., 2015). McConnell and colleagues (2015) found that LGBT youth who have supportive relation­ ships with peers and significant others, even in the absence of family support, were significantly less lonely.

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The authors suggest that peer support may also serve as a protective factor against hopelessness and anxiety (McConnell et al., 2015). Snapp and colleagues (2015) suggested that schools sponsor peer-based groups where LGBT youth can openly discuss their experi­ ences and receive support. Margolies, Joo, and McDa­ vid (2014) suggested that best practices in LGBTQ competency trainings in health and social service agencies should include a variety of training methods such as lecture, personal anecdotes, and small-group and large-group activities and discussions. Although these studies refer to schools and health and social service agencies, this work can be easily translated to young adults in college settings. By facilitating mental health workshops on cam­ pus, mental health professionals are practicing in line with the American Psychological Association’s (APA’s) (2012) guidelines for psychological practice with les­ bian, gay, and bisexual clients. Although these guide­ lines do not specifically address outreach trainings, therapists can apply guideline 19, which involves pro­ fessional education and training. This guideline sug­ gests that psychologists prioritize diversity in the institutions they work in, offer support systems for LGBTQ individuals, and, for those with expertise, pro­ vide training, consultation, or supervision to others (APA, 2012). To facilitate this workshop, all facilitators must be LGBTQ-affirmative and competent in social justice. They must also create a welcoming space, especially for those with multiple marginalized identities. Guide­ line 4 of APA’s (2012) guidelines for psychological practice with lesbian, gay, and bisexual clients indi­ cates that psychologists evaluate their own attitudes, knowledge, and limitations in order not to compro­ mise their work with a heterosexist bias. Although this guideline refers to assessment and treatment of cli­ ents, it can also apply to any professional who engages in outreach interventions. Moreover, ethical standard 2.01 (Boundaries of Competence) suggests that those who provide services or teach consider their level of competence as determined by education, training, supervision, consultation, study, or professional expe­ rience (Pope & Vasquez, 2007). Facilitators should make every effort to respect all cultural and individual differences they encounter (Pope & Vasquez, 2007).

Facilitators should follow ethical standard 3.04 (Avoid­ ing Harm), which states that steps should be taken to minimize harm to those with whom one is working (Pope & Vasquez, 2007). Facilitators should reduce harm by following principles D (Justice) and E (Respect for People’s Rights and Dignity). The workshop in this chapter is designed to promote emotional safety and respectful dialogue within groups by discussing community agreements and guidelines and allowing time to process reactions from group participants. Regarding facilitator roles, Killermann and Bolger (2016) write, “If you’re asking others to leap, as a facil­ itator it’s your responsibility to catch them” (p. 91). Therefore, it is important that the facilitators promote and model vulnerability, while also making space to process and contain the participants’ experiences and emotions. Finally, facilitators should make every effort to respect all cultural and individual differences they encounter (Pope & Vasquez, 2007). Instructions

Overview This is a ninety-minute workshop that emphasizes the importance of sharing personal narratives to normal­ ize LGBTQ college students’ experiences, to expose participants to intragroup differences and issues of intersectionality, and to discuss the importance of peer support. The participants will engage in two different exercises in which they can share pieces of their sto­ ries and have a chance to process with their peers. This workshop can be facilitated alone, but having a co-facilitator is encouraged. Before beginning the workshop, the facilitator should consider the makeup of the group (Who is in the group? How do they know one another? How might they feel about opening up? How many people should be in the group?), the space in which the workshop is held (Is it a confidential space?), and how the facilitator knows the audience members (How might the group perceive the facilita­ tor’s identities?). It is also important to consider the university climate (Are there any unique challenges that LGBTQ students face on campus?). Sections Introduction of facilitator(s), workshop participants, and the goals of the workshop (ten minutes) Building Community on Campus 553

• Introduce yourself and your role as the workshop facilitator. Workshop facilitators should consider whether they would like to disclose their own per­ sonal or professional background related to this topic. If facilitators decide to disclose to the group, they should first think about how the group could perceive their disclosure and how these percep­ tions could be addressed within the workshop, if needed. Facilitators should consult with colleagues as appropriate. • Ask the group members to introduce themselves and say what brought them to the workshop today. • Review the objectives described in the beginning of this chapter to outline the goals of the workshop. Ask if anyone has any questions or concerns before the group gets started. Community agreements and guidelines (five minutes) • Ask the group what would make people feel safe and respected in today’s workshop and see if they would like to come up with community agreements and guidelines to promote safety. • Provide suggestions, such as: the conversation stays within the room (confidentiality); express your­ selves with good intentions; and speak from your own experience. Write these agreements/guide­ lines down on a whiteboard or large piece of paper. Keep the agreements/guidelines on display during the workshop and refer to them as needed. • Provide an overview of the workshop, the time allocated, and location of bathrooms (including gender-inclusive bathrooms). • Let the group know that these activities can bring up tough stuff for people. The facilitators are encour­ aged to model how challenging and personal these activities can feel and emphasize that they are there to support the group members. Inform the group that, if any group members feel triggered or need support during or after the workshop, they should let the facilitators know. Inform the group mem­ bers that their participation is optional, and they do not need to participate in any activity if they choose not to. Be prepared to check in with (and poten­

554 Spiegel

tially refer for more support) anyone who may dis­ cuss any clinically concerning material. Activity no. 1: The “I” statement circle (fifteen minutes) • This activity is adapted from Bolger & Killermann, “Crossing the Gender Line” (https://ayr1as72agc ddsn3cyd41uu9-wpengine.netdna-ssl.com/ wp-content/uploads/2013/06/Crossing-the­ Gender-Line.pdf). • Ask each group member to take three small pieces of paper. Give the following directions: “I would like to start with an activity to help you all get to know each other. Please write down three statements on three different pieces of paper. These statements should begin with ‘I’ (‘I’ statements) and be about your experi­ ence as an LGBTQ­identified individual. For example, you can say, ‘I have experienced discrimination on campus’; ‘I do not feel accepted in my culture’; ‘I have a supportive partner’; ‘I am transgender.’ You do not need to say anything if you are not comfortable doing so, but the more open you can be, the more everyone can learn together. Do not write your name on the pieces of paper. When you are done, please hand them to me.” • You or a co-facilitator may want to briefly read over the statements to yourself to make sure there is not any clinically concerning material before they are read aloud. Place the papers in a hat, bag, or box and mix them up. • Provide the next directions: “I’d now like everyone to stand in a circle. I am going to read these statements aloud. If you agree with the statement, please step forward and then step back to your starting place in the circle. If you do not agree, you remain standing in your starting place. Let’s try a few neutral exam­ ples: ‘I like going out to eat’; ‘I have a pet at home’; ‘I am a middle child.’ Does anyone have any questions before we start?” • Once they have practiced, let them know they should not have side conversations between statements and that the activity should be done in silence. • Facilitate the activity for approximately ten minutes

by reading the participants’ statements aloud. Pause briefly between statements to allow the participants to return to their starting place in the circle. • Take five minutes after the activity to process with the group. Some questions can include: How did it feel doing this exercise? What did you notice? Were you surprised by anything? Activity no. 2: “I” statement stations (fifty minutes) • Before the workshop, the facilitators should write or type out the station labels, prepare the associ­ ated questions, and create four stations around the room by taping the labels on the walls. If available, chairs can be placed at these stations. The facilita­ tors can also see if students are comfortable sitting on the floor. • The facilitators should provide pens and index cards to the participants. • Station labels

º Identity Station: How does the “I” statement in your hand affect your identity and experiences on or off campus?

º Heteronormativity Station: How has the “I” state­

ment in your hand been perceived or received in a heteronormative campus or society?

º Intersectionality Station: When you read your “I” statement, are there intersecting, marginalized identities not listed on this card that affect how you move through the world?

º Peer Support Station: When you reflect on your

“I” statement, how could your LGBTQ peers on campus help support you? What has been helpful in the past or could be helpful moving forward?

• Once the room is set up, read the following direc­ tions: “As you saw from the first activity, there are many ‘I’ statements that you may relate or not relate to, but the important piece is trying to understand and learn about people’s unique experiences in the world. We are now going to dive a little deeper into this, but feel free to share only what you are comfort­ able sharing. Please take an index card and write down one of your ‘I’ statements from the last activity or come up with a new one that relates to your expe­

rience as an LGBTQ individual. There are four sta­ tions around the room. You will be put into small groups and rotate with your group through the four stations [groups should not be bigger than five peo­ ple]. At each station, you will read the station label and questions on the wall, take turns reading aloud the statement in your hand, and have a short dis­ cussion with your peers about your responses to the questions (approximately ten minutes at each sta­ tion). These are big questions that cannot possibly be explored fully in this time frame. This activity is meant to give you a small window into others’ expe­ riences in hopes that these conversations can con­ tinue after this workshop. You are also welcome to sit back and listen if you do not want to share. The facili­ tators will tell you when to move to the next station. We will have time at the end to process how it went.” • Ask the groups to shift every ten minutes. Facilita­ tors are encouraged to walk around and check in on the groups as needed. • For the remaining ten minutes of the activity, the facilitators should process the participants’ experi­ ences with the activity. Processing can be done in a large group or smaller groups. Some questions can include: What stations were easier or harder to talk about? What areas did you feel that you could connect to your peers on? What did you learn from your peers’ experiences that you were unaware of before? What came up in your groups regarding peer support in the LGBTQ communities? Wrap-up and process (ten minutes) • The facilitators should spend approximately ten minutes wrapping up the workshop and providing space to process any reactions and answer ques­ tions. The facilitators can ask about any feelings or thoughts that came up for the participants, what was challenging about the workshop, whether the group members have any new insights, and how these dis­ cussions can continue outside this workshop. • Open up the conversation for any questions. Brief Vignette

A mental health professional working at a university counseling center could facilitate this workshop with a Building Community on Campus 555

group of fifteen LGBTQ-identified students. Consider the experience of Mike, an eighteen-year-old, African American, cisgender male who identifies as gay. Before the “I” statement” stations activity, Mike wrote down an “I” statement: “I face microaggressions daily for being a black, gay male.” While going through the sta­ tions, Mike began to open up to his peers about his experiences with identities, heteronormativity, inter­ sectionality, and peer support. Mike described how he feels safer in his identities on campus than he does in his hometown, where he feels that people are less supportive of his gay identity. He noted, however, that he still struggles to find people on campus who “get him” and that he experiences microaggressions in class and in primarily white spaces on campus. The other participants in Mike’s group shared similar sen­ timents in terms of social isolation and microaggres­ sions on campus. In processing the activity, Mike reported feeling less alone, knowing that other people struggle in similar ways. He also said that being in this space with other LGBTQ individuals felt connect­ ing for him, and that he plans to go to more social events at the campus LGBTQ center. Suggestions for Follow-up

If a participant discusses any concerning clinical infor­ mation, especially regarding safety concerns, the facil­ itator should be prepared to check in with the indi­ vidual after the workshop and refer to the appropriate therapeutic resource. The facilitator can also proac­ tively provide participants with a copy of the resources listed in this chapter or local therapeutic or crisis resources on campus. The facilitator should also be pre­ pared to make referrals for further support if requested by the participants. Contraindications for Use

The workshop in this chapter is contraindicated if the facilitators do not have multicultural competency, are not LGBTQ-affirmative, or are not open to exploring their own biases. Additionally, before any workshop, the facilitator should consider various aspects of the group to determine whether the participants will feel emotionally safe enough to engage in the activities. For example, if this workshop is being done for a college

556 Spiegel

community (e.g., LGBTQ center or student-led LGBTQ group), and there has been recent conflict among some of the students, it would be important to assess if the students are in a place where they feel comfortable opening up with their peers. If it is determined that participants could experience more harm than help from this workshop, the workshop is contraindicated. Professional Readings and Resources Killermann, S. (2017). A guide to gender: The social justice advo­ cate’s handbook, 2nd edition. Austin, TX: Impetus Books. Killermann, S., & Bolger, M. (2016). Unlocking the magic of facilitation: 11 key concepts you didn’t know. Austin, TX: Impetus Books.

Resources for LGBTQ Participants The Gay and Lesbian Alliance Against Defamation (GLAAD). (n.d.). GLAAD media reference guide—directory of community resources. https://www.glaad.org/reference/ communityresources. LGBT National Help Center. (n.d.). www.glbtnationalhelp center.org/. National Alliance on Mental Illness (NAMI). (2019). LGBTQ. https://www.nami.org/Find-Support/LGBTQ. Testa, R. J., Coolhart, D., & Peta, J. (2015). The gender quest workbook: A guide for teens and young adults exploring gen­ der identity. Oakland, CA: New Harbinger Publications. Trevor Project. (2017). Get help now. https://www.thetrevor project.org/pages/get-help-now.

References American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67 (1), 10–42. doi:10.1037/a0024659. Asidao, C., & Sevig, T. (2014). Reaching in to reach out: One counseling center’s journey in developing a new outreach approach. Journal of College Student Psychotherapy, 28 (2), 132–143. doi:10.1080/87568225.2014.883881. Balsam, K. F., Molina, Y., Beadnell, B., Simoni, J., & Walters, K. (2011). Measuring multiple minority stress: The LGBT People of Color Microaggressions Scale. Cultural Diversity and Ethnic Minority Psychology, 17 (2), 163–174. doi:10. 1037/a0023244. Bolger, M., & Killermann, M. (n.d.). Crossing the gender line. https://ayr1as72agcddsn3cyd41uu9-wpengine.netdna­ ssl.com/wp-content/uploads/2013/06/Crossing-the­ Gender-Line.pdf. Killermann, S., & Bolger, M. (2016). Unlocking the magic of facilitation: 11 key concepts you didn’t know. Austin, TX: Impetus Books.

Margolies, L., Joo, R., & McDavid, J. (2014). Best practices manual for creating and delivering LGBT cultural com­ petency for health and social service agencies. https:// cancer-network.org/wp-content/uploads/2017/02/best_ practices.pdf. McConnell, E. A., Birkett, M. A., & Mustanski, B. (2015). Typologies of social support and associations with men­ tal health outcomes among LGBT youth. LGBT Health, 2 (1), 55–61. doi:10.1089/lgbt.2014.0051. Oswalt, S. B., & Wyatt, T. J. (2011). Sexual orientation and dif­ ferences in mental health, stress, and academic perfor­ mance in a national sample of U.S. college students. Jour­ nal of Homosexuality, 58 (9), 1255–1280. doi:10.1080/00 918369.2011.605738.

Pope, K. S., & Vasquez, M. J. T. (2007). Ethics in psychotherapy and counseling: A practical guide. San Francisco: Jossey-Bass. Rankin, S., Weber, G., Blumenfeld, W., & Frazer, S. (2010). 2010 state of higher education for lesbian, gay, bisexual, and transgender people. Charlotte, NC: Campus Pride. Snapp, S. D., Watson, R. J., Russell, S. T., Diaz, R. M., & Ryan, C. (2015). Social support networks for LGBT young adults: Low-cost strategies for positive adjustment. Family Rela­ tions: An Interdisciplinary Journal of Applied Family Stud­ ies, 64 (3), 420–430. Vera, E. M., & Speight, S. L. (2003). Multicultural competence, social justice, and counseling psychology: Expanding our roles. Counseling Psychologist, 31 (3), 253–272. doi: 10.1177/0011000003031003001.

Building Community on Campus 557

63 OUTREACH ALLY-TRAINING ACTIVITIES Brandy L. Smith

Suggested Use: Activity Objective

Ally trainings as defined in this chapter involve train­ ing about sexual orientation and gender identity top­ ics, also known as LGBTQ+ topics. The two activities described below address practical yet engaging ways to attend to LGBTQ+ terminology using an interac­ tive approach and to help allies brainstorm practical strategies for navigating various scenarios they may encounter regarding intersecting identities. While these two activities do not constitute an exhaustive ally training program, they can be a relevant part of almost all ally trainings. Rationale for Use

The American Psychological Association’s (APA’s) (2017) ethical code states that it is important for men­ tal health providers to educate themselves and others on accurate and up-to-date information, as referenced in APA’s standard 2 (Competence), specifically 2.01 (Boundaries of Competence) and 2.03 (Maintaining Competence). Attending to the diversity of those with whom we work is also highlighted in the APA code among its principles, particularly principles D (Justice) and E (Respect for People’s Rights and Dignity), and in standard 3, Human Relations, specifically 3.01 (Unfair Discrimination). Codes of ethics along with treatment recommendations for working with diverse populations make it clear that it is our role to provide psychoeducation along with advocacy for equal treat­ ment. Thus, ally training fits neatly within our scope of competence, and the two activities described in this chapter offer specific ways to achieve those goals.

The goal of ally training is to provide accurate information, skills, and resources that assist people who want to provide support to individuals who identify as LGBTQ+. A 2006 Campus Pride website article that was posted in 2013 referred to two sources that highlight the positive effect of ally trainings (Evans, 2002; Poynter & Lewis, 2003). Because of the amount of misinformation, myths, and inaccurate information that many people are exposed to about sexual orientation and gender identity, ally training is intended to provide corrective information and to teach skills that people can use in practical ways. Katz, Federici, Ciovacco, and Cropsey (2016) addressed the possible benefits of a Safe Zone symbol and found that it had a positive influence on perceptions of campus climate for sexual minority students. Alvarez and Schneider (2008) and McKinley, Luo, Wright, and Kraus (2015) addressed the need for ally programs because of the environment that still often exists for LGBTQ+ individuals. Ally programs have become more common, but as Young and McKibban (2014) point out, there is no one uniform training. Further information about the types of activities included in an ally training were addressed by Finkel, Storaasli, Bandele, and Schaefer (2003) and Young and McKibban (2014) and included information about terminology, practical scenarios, and experiential activities. Finkel and colleagues (2003) reported that attendees rated terminology and experi­ ential activities as two of the most beneficial training components. Thakral and colleagues (2016) and Young and McKibban (2014) offered insight into why the scenario activities described in this chapter are useful to consider. Both articles highlighted the importance

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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of hearing people’s stories. Connecting information to people’s actual experiences helps information resonate more and be retained longer. One salient consideration in understanding others’ experiences is acknowledgment of an intersection of identities and experiences. For instance, counselors should consider what it is like to be a black same-gen­ der-loving ciswoman in Mississippi who is actively involved in church or a pansexual able-bodied Asian American transman from California who is now work­ ing in Florida as a social worker. The relevance of intersectionality was highlighted by Finkel and col­ leagues (2003) in their future directions and implica­ tions section. It is important to keep intersectionality in mind in ally training because of the range of inter­ sections that may be present for LGBTQ+ individuals and their allies. Because bias exists about so many identities (e.g., race, nationality, religion, sexual orientation, gender) and because professionals are not exempt from expo­ sure to bias, it is important to remember the nuances that are probably present within each person’s expe­ rience. The APA’s principles D (Justice) and E (Respect for People’s Rights and Dignity) highlight the relevance of self-awareness and reflection. Principle D notes, “Psychologists exercise reasonable judgment and take precautions to ensure that their potential biases, the boundaries of their competence, and the limitations of their expertise do not lead to or condone unjust practices” (APA, 2017, p. 4). Principle E offers another helpful reminder: “Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices” (APA, 2017, p. 4). As our professional guidelines also direct, one goal is to be sufficiently informed about a person’s possible experiences without making generalizations and assumptions about a person’s actual experiences (APA, 2017). While part of this knowledge is obtained through conversations with the individual, it is also our responsibility to sufficiently educate ourselves. APA’s competence standard 2.04 (Bases for Scientific and Professional Judgments) clearly directs profes­ sionals to be informed about scientific and professional knowledge within our discipline to best inform the services we provide. Another professional goal is to

affirm the whole person, so effort has to be made to know the whole person. While it is beyond the scope of an ally training to encompass all possible intersec­ tions, training can directly address the need for such consideration and intentionally include examples that capture intersectionality. Instructions

These activities are useful across populations and settings; there is no contraindication for including the activities because the activities meet professional guide­ lines of competence. The presenter, however, should keep in mind the unique audience and its needs and adjust content and response style accordingly. For instance, terminology and scenarios may need to be edited because of the ages of people in attendance, whether the training is presented to a voluntary or required group of attendees, and whether the train­ ing is presented to groups already knowledgeable about LGBTQ+ topics or to groups with limited or no knowledge about LGBTQ+ topics. Group size also affects how to use these activities. Because of the interactive nature of the activities, it is recommended not to have groups of more than thirty people and to require a minimum of ten people. Larger groups detract from the depth that is beneficial to discus­ sion, and small groups sometimes struggle to gener­ ate sufficient energy and discussion points. Activity 1—Terminology When introducing this activity, acknowledge the dif­ ficulty of language as a segue to the activity. Then con­ textualize it by saying that many people in ally train­ ings have echoed the literature on not knowing which words to use and which words to avoid when dis­ cussing certain LGBTQ+ topics. Next, highlight how critical language is, but remind the participants that language changes, which means that what the group is learning today may not be current and affirming six months or a year after the training. Because termi­ nology changes often, direct the group members to review trusted resources from LGBTQ+-supportive organizations, such as HRC (Human Rights Cam­ paign), PFLAG (formerly known as Parents, Families, and Friends of Lesbians and Gays), and GLAAD (for­ merly the Gay and Lesbian Alliance Against DefaOutreach Ally-Training Activities 559

mation), to stay abreast of terminology changes. A sam­ ple list of selected terms is included at the end of this chapter, but because of changes in language over time, you are encouraged to consult additional resources before facilitating the terminology activity. • Select the terminology you want to include. • Print out the term on one sheet of paper and the corresponding definition on a separate piece of paper. Make sure the font is large and legible. • Pass out one sheet of paper to each person so that each person has either a term or a definition. (For small groups of fewer than ten people, you may decide to give each person two sheets of paper for which to find a match.) • Once a match has been made, have the paired peo­ ple confirm their match with you so that you are sure the term and definition are correctly paired. • After all matches have been confirmed, have peo­ ple gather into a circle so that everyone can see the various term-and-definition pairings. • Ask each pair to read aloud their term and definition.

º Invite questions during this part of the activity. º Impart additional information about the termi­ nology as you go around as a way to further expand awareness. For example, after talking about the term bisexual, it would be helpful to note that this identity has low visibility and often goes unconsidered because of the assump­ tions people make about others’ sexual orienta­ tion that are based on the perception of the romantic partner’s gender. º Be considerate of those who may need to sit rather than stand for this activity.

• After reviewing terminology, note terms to avoid using—such as choice, preference, and lifestyle—so that by the end of this section of the training, attendees are familiar with words to avoid. Activity 2—Tailored Scenarios That Showcase the Intersections of Identities Begin this activity by explaining how this training component expands the ways attendees can consider 560 Smith

responding in various situations they may encounter as allies. To enhance attendees’ engagement and the applicability of material covered, make minor (or major, if needed) adjustments to scenarios so that they better capture the ways attendees can expand the ways they create and maintain an LGBTQ+ safe space. For example, you can alter the demographics or circum­ stances if presenting to college students rather than faculty members. While ally trainings are focused on sexual orien­ tation and gender identity, it is important to acknowl­ edge intersections of all social identities and thus to include examples that highlight these intersections. For example, make sure to include examples that overtly mention race, visible or invisible disability, class, reli­ gion, or country of origin. Also keep in mind the range of sexual and gender identities reflected in the sce­ narios, and make an effort to represent a wide range. Scenario examples appear at the end of this chapter. • Create groups of three to five participants, depend­ ing on the size of the training group. • Present each group with a scenario to discuss. • Make it clear that you are not looking for one cor­ rect answer but rather are seeking to facilitate con­ sideration of ways to potentially handle an ally sit­ uation that they may encounter. • Allow five to eight minutes for each group to dis­ cuss the scenario, depending on how involved the scenarios are and how much time is left in the train­ ing. Provide an alert when the groups are halfway through the allotted time. • After each small group has discussed its scenario, review all scenarios together.

º Everyone will need to be informed of what each

scenario is, and then each small group can share the ideas it generated.

º As the facilitator, you will have identified certain suggestions as important to offer. If group mem­ bers do not mention them, you should.

º As the facilitator, you may have to redirect peo­

ple or their comments at times, which is why solid group-facilitation skills are useful to ally training facilitators.

º When time permits, after the small group has

shared ideas, invite others in the larger group to share additional ideas.

• Depending on the duration and setup of the train­ ing, you can do two rounds of scenarios as a way to permit attendees to talk in depth about two dif­ ferent scenarios and to be exposed to a larger total number of possible situations. Brief Vignette

An ally training offered through a university’s human resources development office consisted of eighteen faculty and staff from across the university, along with three graduate students from various departments. The activity of matching terms and definitions was introduced, and after the terms and definitions were matched and attendees were reviewing the terminol­ ogy as a group, the term homosexual was reviewed. A white ciswoman in her thirties or forties said that she did not know that the term homosexual was prob­ lematic and that she thought she was being affirming when she said it. Another attendee, a Latino cisman of about the same age, chimed in that he has heard that term used positively as well. The facilitator responded that the term had been considered affirming at one point and may not be con­ sidered offensive by everyone now, as there are gen­ erational effects that can influence its interpretation, as can tone and context. The facilitator added, “Since a lot of effort and activism went into getting homo­ sexuality removed from the Diagnostic and Statistical Manual, which is the diagnostic resource mental health providers use, we discourage allies from using that term because of the high likelihood it could come across as an indicator of not being sufficiently knowl­ edgeable about LGBTQ+ matters or of not being invested in creating a safe space for LGBTQ+ individ­ uals since it is often used negatively.” During an ally training with a specific department on campus that included fifteen professors, the sec­ ond scenario below was addressed. A black ciswoman in her fifties who had shared the importance of her Christian religion said that the scenario made her think of someone she knew, Henry, and that while she wanted him to have support, she was not sure how

to help Henry feel supported within a religious black community because he has a bisexual identity and those intersections often aren’t accepted. The facilitator validated the divide that often comes up for black, religious, LGBTQ+-identified individuals and how people like Henry may very well feel that there are times when they have to choose between their identities to have support. The facilita­ tor also used this opportunity to highlight the unique experiences that queer people of color (QPOC) often talk about, including, unfortunately, sometimes being in LGBTQ+ spaces and not feeling connected or sup­ ported in those spaces. Finally, the facilitator high­ lighted the importance of the person Henry is talking with in communicating that she will work to affirm his whole self. Suggestions for Follow-up

The primary follow-up is to ensure sufficient time for questions and answers about the information dis­ cussed during the training. Additionally, attendees can be provided an electronic or hard copy of the terminology and scenarios to aid consideration of the information after the training. If you are open to future questions that may emerge, provide your con­ tact information and invite attendees to follow up with additional questions or concerns. Future train­ ings can also be offered if attendees want a refresher or are interested in a training that is more focused on a certain aspect that a specific unit (e.g., office, depart­ ment, agency) wants covered. Contraindications for Use

While the activities recommended may be difficult to navigate in mandated settings or with hostile partici­ pants, this is not a contraindication for use of the activities. Rather, a recommendation is offered when­ ever presenting an ally training to be prepared with group-facilitation skills and emotional resolve. Professional Readings and Resources Evans, N. J. (2002). The impact of an LGBT safe zone project on campus climate. Journal of College Student Develop­ ment, 43 (4), 522–539. Logie, C. H., Bogo, M., & Katz, E. (2015). I didn’t feel equipped: Social work students’ reflections on a simulated client

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coming out. Journal of Social Work Education, 51, 315– 328. doi:10.1080/10437797.2015.1012946. Miles, J. R., & Fassinger, R. E. (2014). Sexual identity issues in education and training for professional psychologists. In W. B. Johnson & N. J. Kaslow (eds.), The Oxford hand­ book of education and training in professional psychology, 452–471. New York: Oxford University Press. Poynter, K., & Lewis, E. (2003). SAFE on campus assessment report. Durham, NC: Duke University, Center for LGBT Life. Riggs, D. W., & das Nair, R. (2012). Intersecting identities. In R. das Nair & C. Butler (eds.), Intersectionality, sexuality, and psychological therapies: Working with lesbian, gay, and bisexual diversity, 9–30. Malden, MA: Blackwell. Rosenkrantz, D. E., Rostosky, S. S., Riggle, D. B., & Cook, J. R. (2016). The positive aspects of intersecting reli­ gions/spiritual and LGBTQ identities. Spirituality in Clinical Practice, 3 (2), 127–138. doi:10.1037/scp00 00095. Sung, M. R., Szymanski, D. M., & Henrichs-Beck, C. (2015). Challenges, coping, and benefits of being an Asian Amer­ ican lesbian or bisexual woman. Psychology of Sexual Orientation and Gender Diversity, 2 (1), 52–64. doi.19. 1037/sgd000085.

Resources for Clients GLSEN. Ally Week. (2019). https://www.glsen.org/allyweek. Human Rights Campaign. (n.d.). Establishing an allies/safe zone program. https://www.hrc.org/resources/establish ing-an-allies-safe-zone-program. Perrin, P. B., Bhattacharyya, S., Snipes, D. J., Calton, J. M., & Heesacker, M. (2014). Creating lesbian, gay, bisexual, and transgender allies: Testing a model of privilege investment. Journal of Counseling and Development, 92, 241–251. doi:10.1002/j.1556-6676.2014.00153.x. PFLAG. (n.d.). Straight for Equality guide to being a straight ally, 3rd edition. https://bolt.straightforequality.org/files/ Straight%20for%20Equality%20Publications/3rd-edition­ guide-to-being-a-straight-ally.pdf. Ryan, M., Broad, K. L., Walsh, C. F., & Nutter, K. L. (2013). Professional allies: The storying of allies to LGBTQ stu­ dents on a college campus. Journal of Homosexuality, 60 (1), 83–104. doi:10.1080/00918369.2013.735942. Wernick, L. J., Dessel, A. B., Kulick, A., & Graham, L. F. (2013). LGBTQQ youth creating change: Developing allies against bullying through performance and dialogue. Children and Youth Services Review, 35 (9), 1576–1586. doi:10.1016/j. childyouth.2013.06.005.

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References Alvarez, S. D., & Schneider, J. (2008). One college campus’s need for a safe zone: A case study. Journal of Gender Stud­ ies, 17 (1), 71–74. doi:10.1080/09589230701838461. American Psychological Association (APA). (2017). American Psychological Association ethical principles of psycholo­ gists and code of conduct. https://www.apa.org/ethics/ code. Campus Pride (2013, June 12). The importance of safe zone. https://www.campuspride.org/resources/the-importance­ of-safe-zone/. Evans, N. J. (2002). The impact of an LGBT safe zone project on campus climate. Journal of College Student Develop­ ment, 43 (4), 522–539. Finkel, M. J., Storaasli, R. D., Bandele, A., & Schaefer, V. (2003). Diversity training in graduate school: An exploratory evaluation of the safe zone project. Professional Psychol­ ogy: Research and Practice, 34 (5), 555–561. doi:10.1037/ 0735-7028.34.5.555. GLAAD. (n.d.). http://www.glaad.org/. Human Rights Campaign. (n.d.). http://www.hrc.org/. Katz, J., Federici, D., Ciovacco, M., & Cropsey, A. (2016). Effect of exposure to a safe zone symbol on perceptions of cam­ pus climate for sexual minority students. Psychology of Sexual Orientation and Gender Diversity, 3 (3), 367–373. doi:10.1037/sgd0000186. McKinley, C. J., Luo, Y., Wright, P. J., & Kraus, A. (2015). Reexamining LGBT resources on college counseling cen­ ter websites: An over-time and cross-country analysis. Journal of Applied Communication Research, 43 (1), 112– 129. doi:10.1080/00909882.2014.982681. PFLAG (Parents, Families and Friends of Lesbians and Gays). (n.d.). https://www.pflag.org/. Poynter, K., & Lewis, E. (2003). SAFE on campus assessment report. Durham, NC: Duke University, Center for LGBT Life. Thakral, C., Vasquez, P. L., Bottoms, B. L., Matthews, A. K., Hudson, K. M., & Whitley, S. K. (2016). Understanding difference through dialogue: A first-year experience for college students. Journal of Diversity in Higher Education, 9 (2), 130–142. doi:10.1037/a0039935. Young, S. L., & McKibban, A. R. (2014). Creating safe places: A collaborative autoethnography on LGBT social activ­ ism. Sexuality and Culture: An Interdisciplinary Quar­ terly, 18 (2), 361–384. doi:10.1007/s12119-013-9202-5.

ACTIVIT Y 1: TERMINOLOGY Terminology Examples 1. Aromantic: A person who experiences little or no romantic attraction to others. Often satisfied

with friendships and other platonic relationships.

2. Asexual: A person who does not experience sexual attraction to others, although some people who are asexual will engage in sexual activity. Emotional connection remains important. 3. Bisexual: A person who is physically, emotionally, or spiritually attracted to both men and women. 4. Cross-dresser: A person who, for whatever reason, wears clothes, makeup, and so on that are

considered by the culture to be typical for another gender but not their own.

5. Demisexual: A person who does not experience sexual attraction unless they have formed a strong emotional connection with another person, often within a romantic relationship. 6. Gender assignment: An individual’s presumed gender at birth, based on biological sex. 7. Gender expression: An individual’s presentation of gender through behavior, clothing, hairstyle,

voice, body characteristics, and so on.

8. Genderfluid: A gender identity that describes not having a fixed gender all the time. A person may have a greater sense of one gender than another at various times. 9. Gender identity: An individual’s sense of their own gender. 10. Heterosexism: The societal, institutional, and individual beliefs and practices that privilege hetero­ sexuals and subordinate and disparage LGBTQ+ people. 11. Homosexual: A clinical term used to describe gay men and sometimes lesbians. Although the word is still frequently used in the media, it is largely rejected by members of the gay community. 12. Intersex: Formerly termed hermaphrodites; individuals born with reproductive or sexual anatomy— and/or variant chromosomal configurations—that don’t seem to fit the typical definitions of female or male. 13. Pansexual: A person who is attracted or emotionally drawn to others regardless of the person’s sex or gender, or whether the person is cisgender or transgender. 14. Queer: Traditionally a pejorative term for LGBTQ+ people, the word has been reclaimed by some LGBTQ+ people to describe themselves. If the word is used by people who are heterosexual who are not allies, it is still considered derogatory. 15. Questioning: The process of exploration by people who may be unsure or have questions about their sexuality, sexual identity, and/or gender identity. 16. Sexual prejudice: Negative attitudes toward individuals because of their actual or perceived sexual orientation. 17. Transgender: Most commonly used as an umbrella term for people whose gender identity and/or expression is different from what is typically associated with their gender assigned at birth or bio­ logical sex.

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ACTIVITY 2: TAILORED SCENARIOS THAT SHOWCASE THE INTERSECTIONS OF IDENTITIES Scenario and Discussion Prompt Examples • Scenario examples: Sam is a genderqueer student with an androgynous presentation who has requested gender-neutral pronouns. Sie has a visible physical disability and wants to be more involved locally with organizations and physical activities but isn’t sure what space may be physically or emotionally safe for hir. Sie noticed you have an ally training symbol in your office and has broached hir question to you. Henry is a black student who in the past came out to you as bisexual. He said it’s been tough lately because of all the comments made in his church, on social media, and among people in general that have been negative toward LGBTQ+ people. Henry said it’s been especially hard since the Orlando shooting for him to feel okay considering coming out to anyone around town because of fear about what may happen to him. He added, “It’s already hard enough as a black man!” You overhear a colleague, in a passing conversation, ask a mutual female coworker, Daria, if she has a boyfriend to take to this weekend’s game. You know the woman has a same-sex partner because you two have talked about it. • Discussion prompt examples: General discussion prompts: • How can you handle this conversation, including how you may feel, what you may say, and what next steps you would take? • How might you help this person? • Take into consideration your own intersecting identities and how those identities, along with simi­ larities and differences between you and the client, may affect the conversation. Specific prompts for examples above: • What will help you keep in mind the gender-neutral pronouns when talking with and conceptual­ izing Sam? How might Sam’s gender and physical disability affect which organizations you consider or in general how you direct Sam? • What are some of Henry’s known intersecting identities that you would want to keep in mind, and how might that intersection of identities influence your consideration of his experiences? How might you communicate validation to Henry? • How could you help your colleague use less heteronormative language? And how might the tim­ ing of what you say to the colleague be affected by knowing or not knowing the information about Daria’s romantic partner?

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64 REFLECTIONS OF ASSUMPTIONS Jayleen Galarza and Matthew R. Shupp

Suggested Use: Activity Objective

The objectives of this activity are to promote dialogue within groups about breaking down assumptions about others and to explore the importance of moving beyond surface assumptions when understanding someone’s identity, specifically as it relates to gender and sexual identities. This group-based activity is designed to offer opportunities to explore implicit bias and stereotypes as well as the inherent dangers these pose to creating meaningful, genuine, and sustained relationships. It is suitable for general audiences (class­ rooms, religious groups, work or corporate settings, student groups, and academic staff and faculty). Rationale for Use

Given the increased attention to the effects of microaggressions and implicit bias on LGBT-identified peo­ ple, especially those who identify with intersecting identities (Nadal et al., 2011; Platt & Lenzen, 2013; Woodford, Howell, Silverschanz, & Yu, 2012), there is a need to create space for individuals to reflect on and work through some of the personal assumptions they hold and may impose on others (Woodford, Kolb, Durocher-Radeka, & Javier, 2014). As our society becomes more diverse, we must find ways to connect people across differences. Zúñiga, Nagda, and Sevig (2002) identified intergroup dialogue as an effective means to communicate, explore myriad perspectives, increase knowledge and understanding, and move toward sustained change. Intergroup dialogue is at the core of this activity.

In an effort to bring attention to the various implicit biases people hold when encountering new experiences or relationships, such as those on a col­ lege campus, participants in this activity are challenged to reflect on and process these ideas with the support of facilitators and peers. This activity is suitable for psychoeducational workshops targeted to groups as a means of breaking down assumptions about others, such as college safe-zone training programs. It is use­ ful in opening dialogue about concepts of gender identities, sexual identities, and sexual orientation, as well as related intersectional experiences. The American Counseling Association (ACA) 2014 Code of Ethics notes the importance of “honoring diversity and embracing a multicultural approach in support of the worth, dignity, potential, and unique­ ness of people within their social and cultural con­ texts” as well as “promoting social justice” (p. 3). A sim­ ilar set of values is outlined in the National Association of Social Workers (NASW) 2017 “Code of Ethics,” which draws specific attention to the importance of diversity and social justice within the social work profession, including the empowerment of vulnerable and oppressed populations. Thus, professionals in the helping services, as part of their ethical practice of creating an inclusive environment for all, must attend to all aspects of their clients’ identity. This is possible only through multicultural competence and deliberate exploration of one’s knowledge, skills, and self-aware­ ness (Pope, Reynolds, & Mueller, 2004, 2014). Individuals are not two-dimensional beings lack­ ing depth. People embody a variety of innate and socially constructed identities that shape their identity.

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Evans and colleagues (2010) defined a person’s inter­ section of multiple identities as “the ways in which individual identities such as race, class, and gender are woven together to create a whole, unique individual, not a person with separate, distinct, unrelated identity categories” (p. 247). They spoke of an ever-growing pluralistic society and the importance of paying atten­ tion to how these multiple identities intersect, ulti­ mately resulting in the formation of a unique identity (Evans et al., 2010). Professionals in the helping ser­ vices thus must work to challenge the tendency to simplify individuals’ identities into categories most easily understood by society. Advocacy is most certainly an important aspect of this work. Advocacy involves assisting clients in challenging systemic barriers that impede justice and equity. Danica Hays, Elizabeth Prosek, and Amy McLeod (2010) indicated that social advocacy “helps counselors become more attuned to social injustices and thereby work with clients in a more sensitive and just manner” (as quoted in Gladding, 2013, p. 24). This activity can facilitate such advocacy by helping indi­ viduals challenge preconceived notions about identity. Preconceived assumptions about sexual orienta­ tion and gender identity are often linked to microag­ gressions, which are “brief, commonplace, and daily verbal, behavioral, and environmental slights and indignities directed toward specific groups of people” (Platt & Lenzen, 2013, p. 1012). Researchers have emphasized the significant effects of microaggressions on marginalized communities, including LGBT indi­ viduals (Nadal et al., 2011; Platt & Lenzen, 2013; Sue et al., 2007; Woodford et al., 2012). For many LGBTidentified people, such encounters lead to experiences of harassment, feelings of invalidation, and a perpet­ uation of heteronormative norms (Platt & Lenzen, 2013; Woodford et al., 2012). Furthermore, in explor­ ing the effects of navigating prejudice and oppression in society, researchers have concluded that minority stress is a significant factor in the health and well-being of sexual and gender minorities (Institute of Medi­ cine, 2011; Meyer, 2003), including college students (Rankin, 2005; Woodford et al., 2013). As Rankin (2005) found, encountering prejudice and harassment on college campuses negatively influences students’ ability to achieve academic goals. Rankin also found

that students who contend with multiple oppressions, such as LGBT people of color, had to manage addi­ tional factors such as being mindful of potential rac­ ism and heterosexism while making decisions about coming out. Given the effects of daily microaggressions on LGBT communities, it would prove beneficial to develop strategies for decreasing these experiences throughout society. One method of doing so is the development of outreach and programming on college campuses. Safe-zone programs on college campuses are designed for a variety of reasons, most notably to help create safe and affirming spaces for LGBT people and increase allyship (Poynter & Tubbs, 2008; Woodford et al., 2014). Expanding such programming and outreach can contribute to improved awareness and interruption of implicit bias and microaggressions. As Woodford and colleagues (2014) discovered, many safe-zone or ally programs have limitations, includ­ ing a lack of training focused on helping participants gain awareness of personal biases, which is an essen­ tial aspect of creating a safer environment for LGBT people on campus. This activity is designed to pro­ mote dialogue among participants in hopes of explor­ ing and breaking down personal assumptions rooted in stereotypes and bias that may have a negative effect on future interactions with sexual and gender minority communities. Instructions

During this activity, facilitators will encourage partic­ ipants in small groups to identify deeply held assump­ tions about people they may encounter and deem as different. Throughout this activity, connections will be made to the identities that are often silenced or made invisible within particular communities, specifically those that do not align with the dominant Western discourse as white, heterosexual, cisgender, Christian, wealthy, able-bodied, and male. Within this group experience, individuals will think of and share iden­ tities that have personal meaning but are not so read­ ily shared with or known by others. They will write these identities on pieces of paper, taking great care to remain anonymous. The slips of paper will then be collected in a container and shared with a different group. Participants will then review and match idenReflections of Assumptions 567

tities shared by members of the other group solely on the basis of their initial (and often superficial) obser­ vations and assumptions. Following the conclusion of this activity, the facilitator will guide participants as they reflect on their affective responses, insights gained, strategies for breaking down personal assump­ tions or biases, and application to future interactions. A handout for facilitators is provided at the conclusion of this chapter; it provides detailed instructions for lead­ ing this activity and includes questions designed to pro­ cess participants’ experiences and knowledge gained. Brief Vignette

You are the director of new student orientation pro­ grams on a college campus. A highlight of your posi­ tion is working with twenty undergraduate student leaders. You decide to use this activity as part of ori­ entation-leader fall training to help orientation lead­ ers connect with and understand the assumptions related to students’ sexuality, sexual identities, and gender identities and how these assumptions could affect their interactions with new students. Through this activity, a group identifies the statement “I love to work out and get girls” with a seemingly athletic black male in the other group. It turns out their assump­ tion is wrong, and an opportunity opens up for dia­ logue about their misperceptions of this person’s racial and gender identities. Please note that this activity could be tailored to fit a variety of institutional needs. For example, the authors encourage readers to talk about how additional individual identities (e.g., race, ethnicity, religion, socioeconomic status, family situation) may affect the scenario. Suggestions for Follow-up

Given the potential for difficult conversations to emerge during this activity, it is important that the group facilitators provide ample time for processing participants’ responses to this experience. The authors suggest that this “Reflections of Assumptions” activ­ ity could be a good opening into more discussion and information regarding the diversity of sexuality, sex­ ual identities, and gender identities, such as the discus­ sions held and the information offered in many safezone trainings. In processing key takeaways from the 568 Galarza & Shupp

activity, the facilitators can discuss with participants the following: (a) their affective response to engaging in this activity; (b) lessons gained from this process and how they relate to assumptions made about an indi­ vidual’s gender and sexuality; (c) strategies for break­ ing down personal assumptions about others; and (d) insights about the activity’s effect on group mem­ bers’ future practice and interactions. Contraindications for Use

This activity is best used in groups of people who have not been mandated to attend. Therefore, this activity is not recommended for involuntary psychoeducational groups. Likewise, this activity should be used in groups with participants who are eighteen years and older and who have a healthy level of cognitive functioning. Using this activity with a group whose members may not know each other could pose some emotional risks, such as limited expression of vulnerability or potential discomfort regarding conflict. There is also great potential for teachable moments that illustrate this activity’s main purpose, however, which is to offer space for individuals to reflect on the assumptions and implicit biases they hold when encountering new experiences and people. Professional Readings and Resources Hill-Collins, P., & Bilge, S. (2016). Intersectionality. Malden, MA: Polity Press. Killermann, S. (2013). The social justice advocate’s handbook: A guide to gender. Austin, TX: Impetus Books. Nadal, K. L. (2013). That’s so gay! Microaggressions and the lesbian, gay, bisexual, and transgender community. Wash­ ington, DC: American Psychological Association. Nadal, K. L., Issa, M. A., Leon, J., Meterko, V., Wideman, M., & Wong, Y. (2011). Sexual orientation microaggressions: “Death by a thousand cuts” for lesbian, gay, and bisexual youth. Journal of LGBT Youth, 8 (3), 234–259. Sue, D. W. (2010). Microaggressions in everyday life: Race, gender, and sexual orientation. Hoboken, NJ: John Wiley & Sons.

Resources for Clients Campus Pride. Being an ally to queer people of color. https:// www.campuspride.org/resources/being-an-ally-to-queer -people-of-color/. Consortium of Higher Education LGBT Resource Profession­ als. Policy & Practice recommendations. https://www. lgbtcampus.org/policy-practice-recommendations.

Gay, Lesbian, and Straight Education Network (GLSEN). GLSEN safe space kit: Be an ally to LGBTQ youth! https://www.glsen.org/safespace. Project Implicit. https://implicit.harvard.edu/implicit/aboutus. html. Teaching Tolerance. Test yourself for hidden bias. https:// www.tolerance.org/professional-development/test-yourself­ for-hidden-bias.

References American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. Evans, N. J., Forney, D. S., Guido, F. M., Patton, L. D., & Renn, K. A. (2010). Student development in college: Theory, research, and practice, 2nd edition. San Francisco: Jossey-Bass. Gladding, S. (2013). Counseling: A comprehensive profession, 7th edition. Boston: Pearson. Hays, D. G., Prosek, E. A., & McLeod, A. L. (2010). A mixed methodological analysis of the role of culture in the clin­ ical decision-making process. Journal of Counseling and Development, 88 (1), 114–121. Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: National Academies Press. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Concep­ tual issues and research evidence. Psychological Bulletin, 129, 674–697. doi:10.1037/0033-2909.129.5.674. Nadal, K. L., Issa, M. A., Leon, J., Meterko, V., Wideman, M., & Wong, Y. (2011). Sexual orientation microaggressions: “Death by a thousand cuts” for lesbian, gay, and bisexual youth. Journal of LGBT Youth, 8 (3), 234–259. National Association of Social Workers (NASW). (2017). Code of ethics of the National Association of Social Workers. https://www.socialworkers.org/about/ethics/code-of-ethics. Platt, L. F., & Lenzen, A. L. (2013). Sexual orientation microaggressions and the experience of sexual minorities. Jour­

nal of Homosexuality, 60, 1011–1034. doi:10.1080/00918 369.2013.774878. Pope, R. L., Reynolds, A. L., & Mueller, J. A. (2004). Multicul­ tural competence in student affairs. San Francisco: Jossey-Bass. Pope, R. L., Reynolds, A. L., & Mueller, J. A. (2014). Creating multicultural change on campus. San Francisco: Jossey-Bass. Poynter, K. J., & Tubbs, N. J. (2008). Safe zones: Creating LGBT safe space ally programs. Journal of LGBT Youth, 5, 121– 132. doi:10.1300/J524v05n01_10. Rankin, S. R. (2005). Campus climates for sexual minorities. New Directions for Student Services, 111, 17–23. doi:10.1 002/ss.170. Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M., Nadal, K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist, 62, 271–286. doi:10.103 7/0003-066X.62.4.271. Woodford, M., Han, Y., Craig, S., Lim, C., & Matney, M. (2013). Discrimination and mental health among sexual minority college students: The type and form of discrimination does matter. Journal of Gay and Lesbian Mental Health, 18 (2), 142–163. doi:10.1080/19359705.2013.833882. Woodford, M., Howell, M. L., Silverschanz, P., & Yu, L. (2012). “That’s so gay!” Examining the covariates of hearing this expression among gay, lesbian, and bisexual college stu­ dents. Journal of American College Health, 60 (6), 429– 434. doi:10.1080/07448481.2012.673519. Woodford, M. R., Kolb, C. L., Durocher-Radeka, G., & Javier, G. (2014). Lesbian, gay, bisexual, and transgender ally training on campus: Current variations and future direc­ tions. Journal of College Student Development, 55 (3), 316– 321. doi:10.1353/csd.2014.0022. Zúñiga, X., Nagda, B. A., & Sevig, T. D. (2002). Intergroup dia­ logues: An educational model for cultivating engagement across differences. Equity and Excellence in Education, 35, 7–17. doi:10.1080/713845248.

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HANDOUT: REFLECTIONS OF ASSUMPTIONS, FACILITATOR GUIDE Establishing Norms Because this activity can be used within an opening session with an audience that may not have had the opportunity to develop group cohesion, it is important to start with establishing a set of group norms. Emphasize that although facilitators will strive for a safe space for this activity, the reality is that emotional safety is not guaranteed. Therefore, encourage participants to be mindful of potential discom­ forts in sharing personal information. In addition, the possibility for outing may exist. Participants should disclose information only when and if they feel comfortable doing so. Activity Instructions I.

Following a brief discussion about group norms, inform participants that they will be engaging in an activity about assumptions and implicit bias regarding identities.

II. Ask the large group the following: Can you think of some identities that could have a significant effect on people’s lives but may not be identities that are immediately or readily shared? III. Once the group has had an opportunity to brainstorm and share their ideas, offer some examples of identities that may not have been mentioned; these examples should include identifying as lesbian, gay, bisexual, pansexual, queer, gender-nonconforming, and transgender. a. Facilitators should also offer some additional identities that intersect with these experiences, such as identifying as a queer person of color or other characteristics that do not fit a white, cisgender, able-bodied, Christian, heteronormative narrative. IV. After this initial discussion about the goal of this activity, facilitators should split the group into two groups of equal size. V. Next, ask all group members to write down one thing on a sheet of paper that they identify with that no one in the room would know. a. Examples: Matthew might write down that he has been skydiving, or that he loves watching The Golden Girls, or that he has an uncanny knack for remembering movie quotes. Jayleen might write down that she loves Prince, or she self-identifies as queer. VI. After all members have written down their personal statements, ask them to fold the pieces of paper, put them into a container, and give the container to the opposite group. Each group should now have the sheets of paper from the other group. Each group then takes turns reading a state­ ment aloud and, as a group, attempts to decide which statement matches which group member. Most important, the group must state why they attributed the statement to the particular group member. As each group shares, the other group is asked to hold their initial response until the end. At the end, group members are asked to clarify which assumptions were correct or incorrect. VII. It is important to remember that this activity is designed to elicit participants’ immediate assump­ tions and the implicit biases they hold about other people, especially about people they do not know well or at all. Therefore, many of these assumptions will be based on stereotypes, which may produce feelings of discomfort or conflict within the group. Facilitators should encourage partici­ pants to stay with this discomfort, helping them process it during the activity and at its conclusion.

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VIII. If participants begin to express hesitation in following the instructions or sharing ideas about stereotyping, facilitators can rely on the following prompts: a. Let’s pause for a moment and address what is happening right now. We noticed that some folks are experiencing discomfort with identifying their initial assumptions about the other group members. We want to acknowledge that for most people this isn’t a comfortable experience. Let’s talk for a minute before we continue. b. What is important for you to hear in this moment before we move forward? c. What is important for us to hear in this moment before we move forward? IX. While being mindful of and observing the dynamics occurring within the group, it is important for facilitators to complete the activity and continue with the processing portion. X. At the conclusion of this activity, participants may not have directly shared experiences related to sex­ ual or gender identities. During the concluding moments of the activity, encourage the group to think of ways the group dynamics and shared thoughts connect with the implicit and explicit assumptions that are often held about people’s sexual orientation or gender identities. Additional Comments It is imperative that group leaders continually assess the group dynamic. We recommend providing what we have defined as a “safety range,” as there are inherent risks associated with this type of activity. For example, a group’s assessment of a member of the other group might be deeply rooted in sexist, heterosexist, or heteronormative beliefs. Sometimes these sentiments will not be articulated well or with a participant’s feelings in mind and can be received as hurtful. Check-ins with participants are strongly encouraged to hear how participants are receiving the information.

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Process Questions The following are sample questions for facilitating the conclusion of this activity. In asking these questions, group facilitators can choose to use a think-pair-share approach to help encourage further dialogue. If using this method for further processing, the facilitator would do the following: offer a question to the larger group; ask participants to reflect on their individual responses; have all participants turn to the individual next to them and share their responses; and then, finally, offer participants the opportunity to share common themes with the larger group. I.

Affective response to engaging in activity a. What did it feel like to participate in this type of activity?

b. What were some feelings that came up for you during the first part of this exercise—identifying assumptions about people in the other group?

c. What feelings that came up for you when you had to share those assumptions and reasons why out loud?

d. What was your response when asked to be on the receiving end of the assumptions made?

II. Lessons gained from this process and relationship to assumptions made of an individual’s gender and sexuality a. Which of the identities, and related discussions, that were touched on during this activity had a particular effect on you?

b. Were there any identities that did not emerge but would be useful to think about during future interactions?

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c. What has this experience taught you about implicit biases you might hold regarding someone’s sexual orientation or gender identity?

d. What has this experience taught you about implicit biases you might hold about others’ addi­ tional identities that may influence their sexuality, such as race, ethnicity, ability, socioeconomic status, or religion? III. Strategies for breaking down personal assumptions about others a. Given your experience today, what strategies will you commit to in order to minimize or eliminate making assumptions about other people?

b. How will you apply these strategies to different identities you may encounter—for example, if you were to interact with an individual whom you perceive to express a different sexual orientation or gender identity than your own?

IV. Insights about the effect on future practice and interactions a. What did you learn about yourself today that will affect your future interpersonal relationships?

b. What did you learn from others today that you can keep in mind when building new relationships?

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65 THE PAPERCUT ACTIVITY: UNDERSTANDING THE SUBTLE AND ONGOING EFFECTS OF MICROAGGRESSIONS Jeanne L. Stanley Suggested Use: Activity Objective

The objective of this activity is to bring the concept of microaggressions experienced by lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) individuals to a more immediate and visceral under­ standing for clients and participants in trainings. Rationale for Use

Microaggressions are “brief, everyday exchanges that send denigrating messages to certain individuals because of their group membership” (Sue, 2010, p. xvi). These commonplace indignities, whether verbal, behav­ ioral, or environmental, may be intentional or unin­ tentional and can have potentially unpleasant or harm­ ful effects on the target person or group (Sue et al., 2007). Chester Pierce first coined the term in the 1970s to describe these more subtle and insidious forms of insults. This period, following the Civil Rights era in the United States, brought forth a shift to more indi­ rect slights and invalidations that can have a cumula­ tive effect on a person (Pierce, 1974). Over the past decade, Derald W. Sue and colleagues (Sue, 2010; Sue et al., 2007; Sue et al., 2009) have expanded the concept of microaggressions to include three forms of microaggressions that Yosso, Smith, Ceja, and Solórzano (2009) summarize as microassaults (intentional and overtly derogatory verbal or nonver­ bal attacks), microinsults (insensitive, rude, or subtle put-downs of a person’s sociocultural identities), and microinvalidations (comments that dismiss, lessen, or negate a person’s sociocultural identities). No matter

how well intentioned a person may be, microaggres­ sions can still occur toward another person who has real or perceived group membership in a nondomi­ nant status. Microaggressions may be toward such sociocultural identities as race, ethnicity, gender iden­ tity, sexual orientation, and disabilities (Sue et al., 2007). Once a term used exclusively in academic class­ rooms, journals, and conferences, microaggressions has moved into the everyday U.S. vernacular. Having a sense of what the word means, however, does not necessarily mean one fully comprehends the various types and effects of microaggressions. The Papercut Activity is a means to bring insight to the effects of microaggressions on sexual minorities and genderdiverse people as well as those holding other socio­ cultural identities. Mental health professionals (MHPs) can be instru­ mental in assisting clients to become aware of the effects of microaggressions and to support other per­ sons and consequently develop a more healthy under­ standing of their gender and sexual identities. Validat­ ing such experiences and providing psychoeducation in regard to everyday microaggressions are instrumen­ tal in supporting the well-being of LGBTQ individu­ als (Nadal et al., 2011). Hearing such phrases as “that’s so gay” to describe something in a negative context or experiencing assumptions about the gender of one’s spouse may seem innocuous to many. Yet to an LGBTQ person, such comments or actions may be another painful experience of denying, denigrating, or being oblivious to their sexual or gender diversity. In highlighting such everyday microaggressions, Nadal and colleagues (2011) named their article

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“Sexual Orientation Microaggressions: ‘Death by a Thousand Cuts’ for Lesbian, Gay, and Bisexual Youth.” Such cuts resonate with the papercut exer­ cise, which highlights several themes, including use of heterosexist terminology, endorsement of heteronor­ mative culture and behaviors, and assumptions of universal LGBT experience (Nadal et al., 2011). It is essential for MHPs to have a strong working knowledge of microaggressions in order to main­ tain an affirmative practice with a range of clients. For example, MHPs need to be aware, when possible, of their own LGBTQ-related microinvalidations and avoid unknowingly making them toward a client. Owen, Tao, and Rodolfa’s (2010) research points to how microaggressions on the part of MHPs toward clients can be “cultural ruptures” that “can weaken a working alliance, which in turn may negatively affect clinical outcomes” (p. 941) and should therefore be avoided through knowledge and awareness of microaggressions. APA’s “Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists” (2003) urges psychologists to work with clients as well as organizations to expand their understanding of cultural awareness and rec­ ommends that psychologists expand their use of “interventions to include multicultural awareness and culture-specific strategies” (p. 392). The work of researchers such as Dovidio and colleagues (2004) and the meta-analysis research of Denson (2009) have shown the effectiveness of antibias diversity activities, such as those focusing on microaggressions, in reduc­ ing internal bias and stereotypes as well as increasing understanding, awareness, and resiliency in participants. In relation to the application of ethical codes, microaggressions are indeed relevant for MHPs. The American Psychological Association (APA, 2017) and American Counseling Association (ACA, 2014) ethi­ cal codes address the necessity of MHPs’ becoming aware of and maintaining competency on factors that affect a diverse range of clients. For example, APA’s “Ethical Principles of Psychologists and Code of Conduct” principle E, Respect for People’s Rights and Dignity, states, “Psychologists are aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sex­

ual orientation, disability, language and socioeco­ nomic status, and consider these factors when work­ ing with members of such groups”; they also “try to eliminate the effect on their work of biases based on those factors” (APA, 2017). APA’s ethical code 2.01b, Boundaries of Competence, states that “an under­ standing of factors associated with age, gender, gen­ der identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective imple­ mentation of their services” and that psychologists must have or obtain the training, experience, consul­ tation, or supervision necessary to ensure the compe­ tence of their services (APA, 2017). Furthermore, APA’s ethical code 2.03, Maintain­ ing Competence, specifically states that “psycholo­ gists undertake ongoing efforts to develop and main­ tain their competence” regarding factors affecting people’s range of sociocultural identities (APA, 2017). ACA (2014) also holds that “counselors respect the diversity of clients, trainees, and research participants and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory in nature” (ACA, 2014, A.4.b). All these guidelines speak to the importance of MHPs’ having not only a firm knowledge base but also an integral understanding of how actions or inactions, including their own, can have a negative influence on clients in relation to their sociocultural identities. The following exercise offers participants an immediate and visceral reaction when the exercise links the metaphor of receiving multiple papercuts to losing or being denied privileges over and over by means of microaggressions. Additionally, it helps the learner understand not only the singular but also the cumulative effect of microaggressions on individuals. Instructions

The Microaggression Papercut Activity works equally well with students or in a presentation to a group of any size to assist participants in better understanding the subtle yet powerful effects of microaggressions. Before you start the exercise, ask participants to keep in mind that at the end of the exercise, you are going to ask people to volunteer to state the feelings, thoughts, The Papercut Activity 575

and reactions they experienced during the exercise. Begin by asking participants, if they are able, to place one hand high in the air with their thumb extended out away from their index finger. Instruct them to continue holding their hand up as you give the rest of the steps of the exercise. You as the instructor will also hold your hand up. Next, with your other hand, pick up an index card and make a gesture to imply that the index card is making a papercut between your thumb and index finger on your raised hand. Ask participants to continue keeping their hand in the air. State to the group that it is unlikely that any of us will die from a papercut, but they hurt, continue to annoy us, and are a painful reminder for a few days. At this point, explain that papercuts are like microaggressions: they are brief and commonplace, they hurt, they continue to sting for a few days, and even though we try to avoid them, they still happen. Again, use the index card to make an imaginary papercut between your thumb and index finger on your raised hand. Ask the group to imagine that they experience these repeated cuts about two or three times a month, without warning but with the same stinging result. Point out that this is what it is like to experience microaggressions at unexpected times and in unexpected ways. Then make several imaginary papercuts in the same area again and again. Explain to the group that if a person keeps making these papercuts on an indi­ vidual, at some point the recipient is going to lash out in order to stop the pain. The recipient may then hear such responses as “You are overreacting; it was just a mistake. Stop being so sensitive.” Following the exercise, the trainer will ask for vol­ unteers to state in one or two words a feeling they experienced during the exercise. The trainer will then offer a summary of the range of feelings and ask par­ ticipants to briefly describe their thoughts or reac­ tions during the exercise. The trainer should point out that in a similar manner, an LGBTQ person experi­ encing a buildup of microaggressions may also expe­ rience a myriad of such reactions, including guilt, shame, simmering frustration, and increased anger; the LGBTQ person may also choose to disconnect from people and situations that could leave them vul­ nerable. Ask group participants to then give examples 576 Stanley

of microaggressions they could imagine LGBTQ peo­ ple experiencing in their daily lives involving family, friends, educators, colleagues, and strangers. If time permits, ask participants to give examples of microag­ gressions that LGBTQ people may experience at macro levels such as work or school policies (or lack of poli­ cies) and local, state, and federal laws and legislation. With minimal changes, this exercise can be mod­ ified to work with individuals in a therapeutic con­ text. The MHP would want to first ask if individual clients are interested in doing an exercise in the session that may bring clarity to their experiences. Brief Vignette

A twenty-seven-year-old cisgender Asian American female named Sue Ellen has been in counseling with you, her MHP, to assist her in “getting more clear about my pansexual identity.” This is your fourth ses­ sion with Sue Ellen, and in this interchange she explains to you that she is concerned she has been oversensi­ tive with her friends lately. SE: Yeah, I don’t know, I feel like my two closest friends from high school whom I hang out with a lot don’t really get me lately. I’ve tried to talk to them about my pansexuality but they keep talking about how lucky I am that I can have anyone and that I have figured out how to increase my odds of getting a date. One even said last weekend when we were out at a dance club, “You can have all the women in here you want, but don’t be greedy, leave me at least one guy.” I pretended to laugh but I don’t know, maybe I’m just being over­ sensitive. I mean we all three joke all the time about things, and I don’t want them to get all sensitive and stop talking to me about things, you know? MHP: What was it like for you when you heard your friends say, “Don’t be greedy?” SE: I think it made me angry. MHP: Have you ever heard of the word micro­ aggressions? SE: I think so, but I’m not really sure what it means. MHP: Microaggressions are subtle, indirect, and often unintentional slights involving a person’s iden­ tities, such as race, ethnicity, gender identity, sexual orientation, or religious identity. If you like, we can

do an exercise that may illustrate this concept more

clearly. It is completely up to you if you do or do not

want to, and we can stop at anytime if you like.

SE: Sounds good, let’s try it.

MHP: Okay, I will read out loud a list of statements,

and you will indicate for each one if you agree or do

not agree.

The MHP takes Sue Ellen through the papercut exer­ cise, and with the working knowledge of the term

microaggressions, the two can now discuss in more

detail the client’s reaction and thoughts about how she

may want to talk to her friends.

Suggestions for Follow-up

Beyond establishing a foundational understanding of microaggressions with clients, the MHP may choose to describe microinsults, microassaults, and microinvalidations. It is also useful to contrast microaggres­ sions with the concept of macroaggressions, which are more overt verbal, emotional, or physical attacks toward a person. Discuss these various terms and ask a client or participants for examples to illustrate each of these types of microaggressions. Have your own examples ready to discuss in case clients or par­ ticipants have difficulty giving examples. Contraindications for Use

Contraindications are few for this exercise; however, it is important to be aware that people may become upset when gaining awareness of the effects of microaggressions on themselves or on others. For some, it may be upsetting to reflect for the first time on one’s own unintentional microaggressions. It is therefore important to state in the beginning of the exercise that it is completely voluntary, that it may bring up a range of thoughts and feelings, and that people may step out of the exercise at any time. When doing the exercise with individual clients, it is as important that they know the exercise is voluntary and they may stop at any time or pause to process their thoughts or feelings in the session. In addition, some people find the word microag­ gressions itself to have negative connotations and view the term as offensive. You may recommend alterna­ tive language such as micro­offense or microinsult for

those who find the word aggression too strong to be able to focus on the point of the exercise. Professional Readings and Resources Granger, N. (2012, October). Microaggressions and their effect on the therapeutic process. Society for Humanistic Psychol­ ogy Newsletter. http://www.apadivisions.org/division-32/ publications/newsletters/humanistic/2012/10/micro aggressions. Nadal, K. L. (2013). That’s so gay! Microaggressions and the lesbian, gay, bisexual, and transgender community. Wash­ ington, DC: American Psychological Association. Nadal, K. L., Davidoff, K. C., Davis, L. S., Wong, Y., Marshall, D., & McKenzie, V. (2015). A qualitative approach to inter­ sectional microaggressions: Understanding influences of race, ethnicity, gender, sexuality, and religion. Qualitative Research, 2 (2), 147–163. Nadal, K. L., Issa, M., Leon, J., Meterko, V., Wideman, M., & Wong, Y. (2011). Sexual orientation microaggressions: “Death by a thousand cuts” for lesbian, gay, and bisexual youth. Journal of LGBT Youth, 8 (3), 234–259. doi:10.108 0/19361653.2011.584204. Nadal, K. L., Rivera, D. P., & Corpus, M. J. H. (2010). Sexual orientation and transgender microaggressions in every­ day life: Experiences of lesbians, gays, bisexuals, and transgender individuals. In D. W. Sue (ed.), Microaggressions and marginality: Manifestation, dynamics, and impact, 217–240. Hoboken, NJ: Wiley. Nadal, K. L., Skolnik, A., & Wong, Y. (2012). Interpersonal and systemic microaggressions toward transgender peo­ ple: Implications for counseling. Journal of LGBT Issues in Counseling, 6 (1), 55–82. doi:10.1080/15538605.2012. 648583. Nadal, K. L., Wong, Y., Issa, M., Meterko, V., Leon, J., & Wideman, M. (2011). Sexual orientation microaggressions: Processes and coping mechanisms for lesbian, gay, and bisexual individuals. Journal of LGBT Issues in Counseling, 5 (1), 21–46. doi:10.1080/15538605.2011.554606. Sue, D. W. (2010). Microaggressions in everyday life: Race, gen­ der, and sexual orientation. Hoboken, NJ: Wiley. Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M., . . . & Esquilin, M. (2007). Racial microaggressions in everyday life: Implications for clinical prac­ tice. American Psychologist, 62 (4), 271–286. doi:10. 1037/0003-066X.62.4.271. Sue, D. W., Lin, A. I., Torino, G. C., Capodilupo, C. M., & Rivera, D. P. (2009). Racial microaggressions and difficult dialogues on race in the classroom. Cultural Diversity and Ethnic Minority Psychology, 15 (2), 183–190.

Resources for Clients Boboltz, S. (2013, December 17). These photos show how far we are from a truly post-racial society. Huffington Post. The Papercut Activity 577

https://www.huffpost.com/entry/racial-microaggressions­ photos_n_4441249. Broverman, N. (2016, February 10). 24 microaggressions endured by LGBT folks. Advocate. https://www.advocate. com/commentary/2016/2/10/24-microaggressions­ endured-lgbt-folks. I, too, am Harvard. (2014). http://itooamharvard.tumblr.com. Sue, D. W. Microaggression: More than just race. https:// www.psychologytoday.com/us/blog/microaggressions­ in-everyday-life/201011/microaggressions-more­ just-race.

References American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. American Psychological Association (APA). (2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist, 58 (5), 377–402. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// apa.org/ethics/code/index. Denson, N. (2009). Do curricular and cocurricular diversity activities influence racial bias? A meta-analysis. Review of Educational Research, (79) 2, 805–838. doi:10.3102/0 034654309331551. Dovidio, J. F., Gaertner, S. L., Stewart, T. L., Esses, V. M., Ver­ gert, M., & Hodson, G. (2004). From intervention to out­ come: Processes in the reduction of bias. In W. G. Stephan & W. P. Vogt (eds.), Education programs for improving intergroup relations, 243–265. New York: Teachers Col­ lege Press.

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Nadal, K. L., Issa, M., Leon, J., Meterko, V., Wideman, M., & Wong, Y. (2011). Sexual orientation microaggressions: “Death by a thousand cuts” for lesbian, gay, and bisexual youth. Journal of LGBT Youth, 8 (3), 234–259. doi:10.108 0/19361653.2011.584204. Owen, J., Tao, K., & Rodolfa, E. (2010). Microaggressions and women in short-term psychotherapy: Initial evidence. Counseling Psychologist, 38 (7), 923–946. doi:10.1177/ 0011000010376093. Pierce, C. (1974). Psychiatric problems of the black minority. In S. Arieti (ed.), American handbook of psychiatry, 512– 523. New York: Basic Books. Sue, D. W. (2010). Microaggressions in everyday life: Race, gen­ der, and sexual orientation. Hoboken, NJ: Wiley. Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M., . . . & Esquilin, M. (2007). Racial microaggressions in everyday life: Implications for clinical prac­ tice. American Psychologist, 62 (4), 271–286. doi:10.103 7/0003-066X.62.4.271. Sue, D. W., Lin, A. I., Torino, G. C., Capodilupo, C. M., & Rivera, D. P. (2009). Racial microaggressions and difficult dialogues on race in the classroom. Cultural Diversity and Ethnic Minority Psychology, 15 (2), 183–190. Wong, G., Derthick, A. O., David, E. J. R., Saw, A., & Oka­ zaki, S. (2014). The what, the why, and the how: A review of racial microaggression research in psychology. Race and Social Problems, 6, 181–200. doi:10.1007/s12552-013­ 9107-9. Yosso, T., Smith, W., Ceja, M., & Solórzano, D. (2009). Critical race theory, racial microaggressions, and campus racial climate for Latino/a undergraduates. Harvard Educational Review, 79 (4), 659–691. doi:10.17763/haer.79.4.m686 7014157m707l.

66 EXAMINING OUR BLIND SPOTS: CONSIDERATIONS

IN WORKING WITH LESBIAN, GAY, AND BISEXUAL

CLIENTS WITH DISABILITIES Michelle A. Murray Suggested Use: Workshop Objective

The objective of this workshop is to increase therapists’ understanding of the unique experiences of LGB cli­ ents with physical disabilities and to facilitate thera­ pists’ awareness of their own biases when working with clients with these intersecting identities. Rationale for Use

Sexual identity and able-bodiedness are two social identities to which various levels of power and privi­ lege are attributed (Asch, 2004; Fraley, Mona, & Theodore, 2007). Individuals who hold identities that differ from being heterosexual and able-bodied are marginalized. Just as all of our identities (privileged and oppressed) interact with one another to create a unique experience, individuals with a disability who identify as gay, lesbian, or bisexual experience multi­ ple forms of oppression because of the complexity of their marginalized identities (Carroll, 2010). Goffman (1963) posits that a person’s behavior and presenta­ tion of self in public spaces comes from a combination of what they believe themselves to be, how they believe others view them, and what they believe is to be expected of them. Thus, clients with various margin­ alized identities may present themselves in ways that are not congruent with how they view themselves as a way to reduce further stigmatization (Jewell, McCutch­ eon, Harriman, & Morrison, 2012). Often LGB-iden­ tified clients with disabilities do not have a space to

speak about sexual desires and sexuality, nor do they often have a space where they can explore and speak about their experience of integrating these multiple identities (Butler, 2012; Colligan, 2004; O’Neill & Hird, 2001). There are often serious consequences for those who are out with their sexual identity, such as loss of jobs, lack of social support, and being targeted for vio­ lence or physical, emotional, and sexual abuse (Hunt, Matthews, Milsom, & Lammel, 2006; Singh & Shelton, 2011). Similarly, there is a history of LGB individuals with disabilities being over- or misdiagnosed and mistreated by mental health professionals. As a result, LGB individuals with disabilities are often selective and strategic about being out, depending on their envi­ ronment (Miller, 2015), and there is often stigma or a healthy mistrust toward seeking mental health ser­ vices (Lick, Durso, & Johnson, 2013). Thus, it is our role as therapists to avoid the pitfalls of overdiagnos­ ing, further stigmatizing, and abusing our power as mental health professionals. Clinicians treating LGB clients with disabilities should consider how sexual identity and ability status can intersect for clients, and how clients are affected by the identities they hold. For example, a client who identifies as a gay male with a disability and who says that his sexual identity is most salient to him may seek support and affirmation about his sexual iden­ tity through the LGBTQ community. Given that the LGBTQ community and the greater society are pre­ dominantly able-bodied, it is then important for the clinician to acknowledge the marginalization that

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individuals with disabilities in the LGBTQ community may experience. For example, often there is a “body beautiful” aesthetic focus within the gay male com­ munity that individuals with disabilities may not be able to participate in, or in which they are not wel­ come to participate in (Butler, 2001; Lanzieri & Hilde­ brandt, 2016; Levesque & Vichesky, 2006). Thus, sup­ port from the LGBTQ community for individuals with disabilities can be limited because of expectations about appearance and behavior: sexuality is expressed only under the gaze of the dominant able-bodied majority (Butler, 2001; Levesque & Vichesky, 2006). Furthermore, for an individual who has sought out a community for support of one or more marginalized identities, the experience of ableism within the LGBTQ community can be even more traumatic (Butler, 2001; Fraley et al., 2007). For other LGB clients who have disabilities, their disabled identity may be salient, and therefore it may be important for them to be connected to or seek sup­ port from the disabled community. In this case, it is important for the clinician to consider how the sexual expression of individuals with disabilities has often been censored in our society and how these individ­ uals’ bodies have either been shamed or medicalized (Butler, 2001; Colligan, 2004; Fraley et al., 2007; Tugut et al., 2016). As a result of our ableist, heteropatriar­ chal society, disability is often seen as synonymous with asexuality as a result of fears of disease, weakness, and impairment; and the idea of a person with a dis­ ability being sexual is often seen as horrific or as a fetish (Hazlett, Sweeney, & Reins, 2011; O’Neill & Hird, 2001; Peta, McKenzie, Kathard, & Africa, 2016). Fur­ thermore, because of the assumption that people with disabilities cannot be sexual, covert and overt homo­ phobia is common (Butler, 2001; Fraley et al., 2007). It is also important to consider that some individuals may need a third party for assistance, making privacy with regard to sex and sexuality impossible. Thus, LGBidentifying individuals may be forced to out them­ selves or be constrained by pursuing only the relation­ ships that their personal assistants allow. On the other hand, the assumption of asexuality for those with visible disabilities may allow for passing or reduction of the heterosexual pressures an individual may expe­ rience (Butler, 2001). For example, a woman who expe­

riences paralysis may not receive messages to fulfill her role as a mother or find a husband, or a man with a cane who locks arms with another male may find that he is not perceived as part of a couple. As a clinician, it is also important to understand how invisible impairments can be marginalized or misunderstood as a result of false assumptions about norms and ability. Also noteworthy is the stigma that partners of disabled individuals often receive (e.g., beliefs that they are desperate, insecure, or ill-inten­ tioned; Butler, 2001). Additionally, it is important to think about how gender, racial or ethnic identity, socio­ economic status, and religious identity can affect how clients perceive themselves and how they are per­ ceived by the various communities to which they are connected (Israel & Hackett, 2004). Although there is a lack of applied counseling research specific to LGBTQ-identified clients with dis­ abilities (Hunt et al., 2006; Singh & Shelton, 2011), there is some literature on the client’s perspectives on their counseling experiences. In a qualitative study of twenty-five white lesbians with physical disabilities, the importance of counselors’ understanding and being responsive to their individual identities and needs was identified as a central common theme (Hunt et al., 2006). Participants said that the therapists’ understanding of the complexity of their identities and ability to foster the exploration of their identities in therapy were crucial. Another common theme was the importance of counselors’ own awareness of biases and assumptions; and several participants stated that despite clinicians’ good intentions to talk about their clients’ identities, the apparent discomfort the clinicians had with talking about sexuality and disability was getting in the way of their treatment (Hunt et al., 2006). The value of increasing therapists’ understanding and self-awareness in working with clients with marginalized identities is echoed in the ethical guide­ lines for practice among mental health professionals. One set of guidelines specific to psychologists is the APA’s “Guidelines for Psychological Practice with Lesbian, Gay, and Bisexual Clients” (2012), which states that psychologists should strive to understand the effects of stigma and discrimination (guideline 1), recognize how their attitudes and knowledge about LGB issues may be relevant in their work with

Considerations in Working with LGB Clients with Disabilities 581

LGB-identified clients (guideline 4), and acknowl­ edge the particular challenges that LGB-identified individuals with disabilities may experience (guide­ line 15). Clinicians can work to meet these guidelines for best practice through continuing their education in understanding the influence of stigma and contex­ tual factors on LGB individuals with disabilities. One way for clinicians to educate themselves on these issues is to become familiar with theoretical frame­ works and developmental models of oppression and sexuality (see “Professional Readings and Resources” at the end of the chapter). Another challenging yet effective way for clinicians to educate themselves is by becoming aware of the explicit and implicit biases they may have and identifying how their own identi­ ties may influence their assessment and treatment of clients from these communities (Israel & Hackett, 2004). Furthermore, it is paramount that clinicians explore how individuals from marginalized commu­ nities use resilience in the face of oppression and pay close attention to clients’ multiple marginalized identi­ ties (Brown, 2008; Hartling, 2004; Singh & McKleroy, 2011). Instructions

This activity is designed to foster therapists’ awareness of their own biases and perspectives when working with clients who identify as LGB and have disabilities. Its goal is to facilitate discussion about topics that are typically viewed as taboo so that clinicians can become more comfortable asking about sexuality and disabilities. The facilitator can integrate this activity into a workshop for mental health professionals that focuses on intersecting social identities, working with marginalized populations, or working with LGB individuals with physical disabilities. To introduce the activity, the facilitator can state the importance of the “use of self ” in the therapy relationship (i.e., therapy is an interactive, interper­ sonal process in which clients and clinicians react and respond to each other) and highlight the idea that clinicians must be attuned to clients’ needs. The facili­ tator can then state that when clinicians are not attuned to clients’ needs, it is more likely that they uninten­ tionally oppress clients by engaging in overvisibility or undervisibility of identities that do not match the 582 Murray

clients’ experience or perpetrate macro- and microaggressions. The facilitator should tell the participants that the activity is designed to help clinicians engage in the process of examining their own perspectives about working with LGB individuals with disabilities in a group setting and “getting their feet wet” in learning how to talk about sexual identity and disability. Before passing out the first worksheet, the facilita­ tor and audience should have cocreated ground rules, including such points as being respectful of others, remaining curious and open to other perspectives, and remembering that everyone is there to learn some­ thing. If this activity is integrated into a larger train­ ing and the creation of ground rules has already occurred, then the facilitator can remind the partici­ pants of the ground rules created earlier in the day. The facilitator can then read the instructions and pass out “Taking Off the Mask: Recognizing Your -Isms (Worksheet 1)” for the participants to complete indi­ vidually. After participants have completed Work­ sheet 1 (fifteen minutes), the facilitator will have the participants break into dyads or triads and pass out “Looking in the Mirror: Sharing Your Process and Growth (Worksheet 2).” After thirty minutes of letting the participants reflect on and discuss Worksheet 2, the facilitator will have participants return to the larger group and allow for time to process reactions and realizations. Brief Vignette

Clinicians at a college counseling center requested training on increasing multicultural competency in working with individuals with intersecting identities. The clinicians are from various mental health profes­ sional backgrounds, so the facilitator began the work­ shop by sharing general information about how sys­ tems of oppression affect the mental health services that individuals receive. The facilitator highlighted the barriers to mental health treatment that people with marginalized sociocultural identities face, in particu­ lar LGB individuals with disabilities (e.g., lack of access to services, stigma with respect to seeking ser­ vices, general mistrust of mental health profession­ als, macro- or microaggressions from professionals). In addition to discussing the barriers to seeking men­ tal health services, the facilitator shared some of the

research from the “Rationale” portion of this chapter and cited the ethical guidelines for working with LGB-identified individuals in the field. The facilitator used the research and ethical guidelines as a founda­ tion for introducing the importance of therapists’ examining their own perspectives as a way to avoid further perpetuating the oppression of LGB individ­ uals with disabilities. The facilitator normalized the difficulty of examining one’s own biases and fears of being perceived as insensitive, oppressive, or unin­ formed. The facilitator and audience cocreated ground rules, and the facilitator passed out the worksheet activities as detailed in the instructions. Common themes that emerged from the clinicians’ discussion of “Looking in the Mirror: Sharing Your Process and Growth (Worksheet 2)” were: • Learning about inclusive or exclusive messages addressed to LGB individuals or people with disabilities • Internalizing what these messages mean for them­ selves and their own identities • Having potential feelings of guilt, confusion, or pain regarding various messages received, and not knowing what to do or how to act • Uncertainty about how to ask LGB clients with dis­ abilities to talk about their identities • Fears of making a mistake or creating a rupture in the therapeutic alliance • Acknowledgment of biases and assumptions about LGB individuals with disabilities with regard to life­ style, relationships, and sexual activity • Recognition of comfort or discomfort with specific situations because of feeling more connected or less connected to the particular individual or narrative • Acknowledging feelings of guilt, shame, embarrass­ ment, and discomfort • Noticing how knowledgeable or unknowledgeable they are about certain topics; identifying areas of strength and growth regarding their work with LGB individuals with disabilities • Recognizing their own privilege or ignorance through a discussion of their personal histories and own social identities

• Sharing feelings of helplessness, lack of knowledge, acknowledgment of rupture in alliance or mistake with a client, or use of supervision or consultation • Commitment to continue learning and challenging themselves about blind spots After the completion of Worksheet 2, the facilitator asked the participants to return to the larger group and allowed for time to process reactions and realiza­ tions. The facilitator led the discussion by asking openended questions about how the audience felt about the exercise and if they learned anything about them­ selves. The facilitator noticed that participants were hesitant to share in the larger group and responded to the silence by stating that no one is immune to hold­ ing biases and assumptions because we are all prod­ ucts of a heterosexist and ableist society. Then the facilitator shared an anecdote about a microaggres­ sion that she made in the past and her process of learn­ ing to model vulnerability. The participants became more willing to share their feelings about the activi­ ties. They were invited to share the similarities and differences they noticed in their dyads and how they made sense of them. While members where sharing, the facilitator noticed the use of some outdated and derogatory language to describe LGB individuals with disabilities. The facilitator responded by asking per­ mission to correct the language and use a different term that is more current, asking if the audience could continue the discussion using the term the facilitator introduced instead. During the discussion, the facili­ tator used active listening skills, paraphrased indi­ viduals’ comments, and highlighted common themes. The facilitator ended the workshop with a discussion of next steps in continuing education (question 5 from Worksheet 2) and asked the clinicians to continue challenging themselves to grow as multiculturally sen­ sitive and aware clinicians. Suggestions for Follow-up

At the completion of the activity, it is important for the large group to discuss their reactions to reestablish group cohesion, normalize their discomfort, and fur­ ther challenge themselves to engage in and be more comfortable with difficult dialogues. It is important not to take a defensive stance if the audience struggled

Considerations in Working with LGB Clients with Disabilities 583

with the exercise. It is also crucial to model respect­ ful behavior and language, and the facilitator may even have to correct audience members’ use of deroga­ tory words. The facilitator should keep in mind that some of the audience members for whom this training is designed may also be members of the LGB or dis­ abled community. Questions for the group discussion should aim at helping the audience members com­ pare and contrast their experiences of the activity. The goal for the group discussion is for audience mem­ bers to begin feeling comfortable talking with one another about their own experiences and biases, and to start learning from one another’s experiences of the activity. Contraindications for Use

This workshop is not recommended if there are mem­ bers in the audience who are overly defensive and are unable to identify the importance of looking at them­ selves in a self-reflective way to further their growth as clinicians. Similarly, if group members are strug­ gling to identify and discuss areas in which they are privileged or oppressed, such as labeling a privileged identity as marginalized, then before engaging in this workshop they need more foundational training focused on their own identities and understanding systems of power and oppression. If audience members are struggling to share or stay on topic with Worksheet 2, it may be an indication that they are struggling with their anxiety about being seen as homophobic or ableist. It is important for the facilitator to think about ways to normalize this anx­ iety and “give permission” for audience members to be open to discomfort as a way to identify and work through areas they need to focus on. It may be helpful for the facilitator to share the answers from the vignette or some of their own answers. Professional Readings and Resources Biaggio, M., Orchard, S., Larson, J., Petrino, K., & Mihara, R. (2003). Guidelines for gay/lesbian/bisexual-affirmative educational practices in graduate psychology programs. Professional Psychology: Research and Practice, 34 (5), 548–554. doi:10.1037/0735-7028.34.5.548. Bidell, M. P. (2005). The sexual orientation counselor compe­ tency scale: Assessing attitudes, skills, and knowledge of counselors working with lesbian, gay, and bisexual clients. 584 Murray

Counselor Education and Supervision, 44 (4), 267–279. doi:10.1002/j.1556-6978.2005.tb01755.x. Brown, L. S. (2006). The neglect of lesbian, gay, bisexual, and transgendered clients. In J. Norcross, L. Beutler, & R. Levant (eds.), Evidence­based practices in mental health: Debate and dialogue on fundamental questions, 346–352. Washington, DC: American Psychological Association. Carroll, L. (2010). Counseling sexual and gender minorities. Upper Saddle River, NJ: Merrill. Chernin, J. N., & Johnson, M. R. (2002). Affirmative psycho­ therapy and counseling for lesbians and gay men. Thousand Oaks, CA: Sage Publications das Nair, R., & Butler, C. (eds.). (2012). Intersectionality, sexu­ ality, and psychological therapies: Working with lesbian, gay, and bisexual diversity. Malden, MA: Blackwell. Singh, A. A., & dickey, l. m. (eds.). (2016). Affirmative counsel­ ing and psychological practice with transgender and gen­ der nonconforming clients. Washington, DC: American Psychological Association.

Resources for Clients Blind-LGBT Pride International. (2019). https://blindlgbt pride.org/. Disability Rights Advocates. (2019). https://dralegal.org/. International Stuttering Association. (2019). Passing twice: Gay, lesbian, bi, and trans people who stutter and allies. www.isastutter.org/passing-twice. My Pleasure: Transforming Lives through Better Sex. (2019). https://www.mypleasure.com. Regard. (2016). http://regard.org.uk/.

References American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67, 10–42. Asch, A. (2004). Critical race theory, feminism, and disability: Reflections on social justice and personal identity. In B. G. Smith & B. Hutchison (eds.), Gendering disability. New Brunswick, NJ: Rutgers University Press. Brown, L. S. (2008). Cultural competence in trauma therapy: Beyond the flashback. Washington, DC: American Psy­ chological Association. Butler, C. (2012). Disability. In R. das Nair & C. Butler (eds.), Intersectionality, sexuality and psychological therapies: Working with lesbian, gay, and bisexual diversity, 213–238. Malden, MA: Blackwell. Butler, R. (2001). A break from the norm: Exploring the expe­ riences of queer crips. In K. Backett-Milburn & L. McKie (eds.), Constructing gendered bodies, 224–242. New York: Palgrave. Carroll, L. (2010). Counseling sexual and gender minorities. Upper Saddle River, NJ: Merrill.

Colligan, S. (2004). Why the intersexed shouldn’t be fixed: Insights from queer theory and disability studies. In B. G. Smith & B. Hutchison (eds.), Gendering disability. New Brunswick, NJ: Rutgers University Press. Fraley, S. S., Mona, L. R., & Theodore, P. S. (2007). The sexual lives of lesbian, gay, and bisexual people with disabilities: Psychological perspectives. Sexuality Research and Social Policy, 4 (1), 15–26. doi:10.1525/srsp.2007.4.1.15. Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall. Hartling, L. (2004). Fostering resilience throughout our lives: New relational possibilities. In D. Comstock (ed.), Diver­ sity and development: Critical contexts that shape our lives and relationships. Pacific Grove, CA: Thomson/Wadsworth. Hazlett, L. A., Sweeney, W. J., & Reins, K. J. (2011). Using young adult literature featuring LGBTQ adolescents with intel­ lectual and/or physical disabilities to strengthen classroom inclusion. Theory into Practice, 50 (3), 206–214. doi:10.10 80/00405841.2011.584031. Hunt, B., Matthews, C., Milsom, A., & Lammel, J. A. (2006). Lesbians with physical disabilities: A qualitative study of their experiences with counseling. Journal of Counseling and Development, 84 (2), 163–173. doi:10.1002/j.1556­ 6678.2006.tb00392.x. Israel, T., & Hackett, G. (2004). Counselor education on lesbian, gay, and bisexual issues: Comparing information and atti­ tude exploration. Counselor Education and Supervision, 43 (3), 179–191. doi:10.1002/j.1556-6978.2004.tb01841.x. Jewell, L. M., McCutcheon, J. M., Harriman, R. L., & Morrison, M. A. (2012). “It’s like a bunch of mosquitoes coming at you”: Exploring the ubiquitous nature of subtle discrimi­ nation and its implications for the everyday experiences of LGB individuals. In T. G. Morrison, M. A. Morrison, M. A. Carrigan, & D. T. McDermott (eds.), Social justice, equality, and empowerment: Sexual minority research in the new millennium, 157–185. New York: Nova Science Publishers.

Lanzieri, N., & Hildebrandt, T. B. (2016). Using objectification theory to examine the effects of media on gay male body image. Clinical Social Work Journal, 44 (1), 105–113. doi:10.1007/s10615-015-0562-1. Levesque, M. J., & Vichesky, D. R. (2006). Raising the bar on the body beautiful: An analysis of the body image con­ cerns of homosexual men. Body Image, 3 (1), 45–55. doi:10.1016/j.bodyim.2005.10.007. Lick, D. J., Durso, L. E., & Johnson, K. L. (2013). Minority stress and physical health among sexual minorities. Perspectives on Psychological Science, 8 (5), 521–548. doi:10.1177/ 1745691613497965. Miller, R. A. (2015). “Sometimes you feel invisible”: Perform­ ing queer/disabled in the university classroom. Educa­ tional Forum, 79, 377–393. doi:10.1080/00131725.2015.1 068417. O’Neill, T., & Hird, M. J. (2001). Double damnation: Gay dis­ abled men and the negotiation of masculinity. In K. Backett-Milburn & L. McKie (eds.), Constructing gendered bodies. New York: Palgrave. Peta, C., McKenzie, J., Kathard, H., & Africa, A. (2016). We are not asexual beings: Disabled women in Zimbabwe talk about their active sexuality. Sexuality Research and Social Policy: A Journal of the NSRC, 1, 1–15. doi:10.1007/ s13178-016-0266-5. Singh, A. A., & McKleroy, V. S. (2011). “Just getting out of bed is a revolutionary act”: The resilience of transgender people of color who have survived traumatic life events. Traumatology, 17 (2), 34–44. doi:10.1177/1534765610 369261. Singh, A. A., & Shelton, K. (2011). A content analysis of LGBTQ qualitative research in counseling: A ten-year review. Journal of Counseling and Development, 89 (2), 217–226. doi:10.1002/j.1556-6678.2011.tb00080.x. Tugut, N., Golbasi, Z., Erenel, A. S., Koc, G., & Ucar, T. (2016). A multicenter study of nursing students’ perspectives on the sexuality of people with disabilities. Sexuality and Dis­ ability, 34 (4), 433–442. doi:10.1007/s11195-016-9455-7.

Considerations in Working with LGB Clients with Disabilities 585

TAKIN G O F F TH E M A S K: RECO GNIZ ING YO UR -IS M S

( WO RKS H EET 1)

Please take around fifteen minutes to reflect on and answer the questions below. Give yourself permission to be candid and feel uncomfortable. (Remember, there are no right or wrong answers for this exercise, and discomfort is normal. If you feel uncomfortable, that means you are growing.) 1. Think of someone you know who is gay, lesbian, or bisexual. What were your initial impres­ sions of that person? What messages did you receive about people who identify as LGB when you were growing up? How might your own sexual identity (similar or different) influence these impressions?

2. Think of someone you know who identifies as disabled. What were your initial impressions of that person? What messages did you receive about people who identify as disabled when you were growing up? How might your own abilities or disabilities (similar or different) influence these impressions?

3. Think about a client whom you have had who holds both or one of these identities. How have that person’s identities been included or not included in your work together? Why? When have discussions of these identities come up in therapy? Is there a pattern?

4. Are there particular client disabilities or sexual identities that you would find yourself reacting to? For example: How would you feel about working with a lesbian who has had an amputa­ tion? What about a gay man who is blind? What assumptions would you make about these individuals?

5. What would change your assumptions about these individuals? Imagine that you find out the lesbian with a leg amputation is a combat war veteran, or that the gay man who is blind is seventy years old. Is there a shift in your reactions to or assumptions about these clients? Why or why not?

Fun Fact: A study on counselor education of LGB issues found that clinicians who engaged in attitudinal exploration of LGB issues reported significantly higher negative attitudes about the LGB community than they had before the attitude exploration (Israel & Hackett, 2004). This does not necessarily mean that the attitude exploration of LGB issues led counselors to become more heterosexist or homophobic, but, rather, that counselors’ implicit biases became more explicit. Remember, this activity is not about pushing away your biases to deny that they exist, but making them explicit in order to work through them so you can better serve diverse populations.

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Michelle M. Murray

LOO KIN G IN THE M IRRO R: S H A RING YO UR P RO CES S A ND GROW TH

( WO RKS H EET 2 )

Find a partner whom you would like to work with. Take a minute to read over the questions on this worksheet. You will have about thirty minutes to take turns discussing these questions with your partner. Be ready to share any parts of your process with the whole group at the end of the thirty minutes. 1. Discuss any thoughts or reactions you had about the exercise. How do you feel after Worksheet 1?

2. Did anything about your process of going through the questions on Worksheet 1 surprise you?

3. How do you think your own identities affect your reactions to Worksheet 1? In other words, in what ways are your privileged or oppressed identities (e.g., able-bodiedness, race, gender, sexual orientation, class, religion) affecting your perspectives?

4. Take turns sharing your responses to Worksheet 1, question 3. The person not sharing should take on a peer consultative role. (Remember not to divulge any identifying data about your clients.)

5. After completing Worksheet 1, what assumptions or biases did you recognize that you are holding? What steps can you take to continue working through these biases?

Michelle M. Murray

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67 OUTREACH ON A COLLEGE CAMPUS: UNDERSTANDING THE CAMPUS CLIMATE Batsirai Bvunzawabaya and Matthew LeRoy Suggested Use: Activity Objective

The purpose of conducting this campus climate assess­ ment is to use the data to foster an inclusive and affirm­ ing campus environment for lesbian, gay, bisexual, trans, and queer (LGBTQ) students. The climate assess­ ment could also be used to increase awareness of stu­ dents’ experiences of marginalization, thus providing insight on how best to meet the identified student needs on a college campus. Rationale for Use

There has been continued growth in the number of LGBTQ students on college campuses since the late 1960s; many campuses now house a resource center specifically for these students (Cawthon & Guthrie, 2011). Despite this increase, there is minimal under­ standing of LGBTQ students’ college experiences and the circumstances that promote their development and allow them to feel accepted on campus (Stewart & Howard-Hamilton, 2014). LGBTQ students are often viewed as a single group with similar needs, but they have many unique needs that often go unrecog­ nized (Cawthon & Guthrie, 2011) because there are subgroups within the larger community (Stewart & Howard-Hamilton, 2014). Even within the LGBTQ acronym, there are many differences. Trans identities encompass gender identity and/or forms of gender expression, whereas LGB identities refer to sexual ori­ entation, which can lead to a further lack of recogni­ tion of the nuances in providing support to these students on campus (Marine & Catalano, 2014). Fur­

thermore, queer can be used to encompass all nonheterosexual and non-cisgender identifications, which allows more exploration of both gender and sexuality (Ziyad, 2016). Although there is increased attention to LGBTQ student needs, students continue to report experiencing campuses as not being affirming or inclu­ sive (Cawthon & Guthrie, 2011). In addition, despite improved recognition of the rights of LGBTQ students, they still experience heterosexism, homophobia, and transphobia that affect their daily experiences (Stew­ art & Howard-Hamilton, 2014). Trans students’ needs have traditionally gone unrec­ ognized, which has resulted in institutional discrimi­ nation and isolation (Becker et al., 2017). Trans stu­ dents may see little acknowledgment of their presence on campus, as demonstrated by housing policies with inadequate room privacy or options, lack of genderneutral restrooms, uninformed primary health-care providers, and an inability to change records or docu­ ments to validate their identities (Beemyn, Curtis, Davis, & Tubbs, 2005). Trans students may receive inad­ equate health care even though they may use the health center or counseling center on campus in an effort to receive much-needed care, such as access to hor­ mones and gender-affirmation surgeries (Pusch, 2005). There may be inadequate policies protecting LGBTQ students on campus. Trans-identified students often experience more overt forms of oppression (e.g., violence and exploitation) as opposed to subtle forms of oppression (Marine & Catalano, 2014). They can have experiences of feeling unsafe, be victims of vio­ lence, and lack the protection of campus policies (Beemyn et al., 2005). Additionally, campus sex and

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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sexual orientation nondiscrimination policies may be outlined, but those policies may not include trans students who experience discrimination (Beemyn et al., 2005). Therefore, these students may be tasked with finding an ally on campus who can serve to advocate specifically on their behalf (Beemyn & Pettit, 2006). Stewart and Howard-Hamilton (2014) identified six issues affecting LGB students on a college campus. The first involves the claiming of identity and lan­ guage, where students may not identify with certain terms such as gay or lesbian but instead prefer the terms queer or same-gender loving, as the latter terms may reflect a less racialized or less predominantly white identity. Terms may vary depending on geographic location and campus culture. Decision making about the disclosure of one’s sexual orientation is the sec­ ond issue LGB students often grapple with. For exam­ ple, students may have to decide whether to disclose their identity in a specific area of campus but not another (Stewart & Howard-Hamilton, 2014). Navi­ gating heteronormative campuses where systemic oppression is present is the third concern students may hold (Stewart & Howard-Hamilton, 2014). Systemic oppression involves the presence of privilege and power resulting in nonmajority groups’ experiencing marginalization and oppression (Howard-Hamilton & Hinton, 2011). College and university campuses are not immune to the homophobia that is present in our society, and individuals who are oppressed are often silenced (Howard-Hamilton & Hinton, 2011). In the subtlest form of oppression, LGB students experience microaggressions (Sue, 2010) when they are assumed to be heterosexual. The most notable example of a violent act is the murder of a gay student, Matthew Shepard, at the University of Wyoming in 1998 (How­ ard-Hamilton & Hinton, 2011). The fourth issue for LGB students outlined by Stewart and Howard-Hamilton (2014) is reframing and redefining relationships and life events. Students may be in the process of adjusting expectations in familial, interpersonal, and romantic relationships while also deciding whether they want to develop new scripts for navigating those relationships. The fifth concern is identity intersections, where their identity as LGBTQ students intersect with their race and ethnicity, social class, ability, and religion (Stewart & Howard-Hamil­

ton, 2014); for example, international queer students of color may also be first-generation college students (where they are the first person in their family to study abroad and attend college). Holding these multiple marginalized identities in addition to their sexual ori­ entation can provide unique challenges. The sixth issue identified by Stewart and Howard-Hamilton (2014) involves finding mentors and role models on campus who can relate to and provide support to the student. Developmentally, students may be in the process of exploring, redefining, and questioning their sexu­ ality, so they may be reluctant to seek any campus services (Stewart & Howard-Hamilton, 2014). There­ fore, students may be hesitant to access the resources that are available to them on campus, including the counseling center (Asidao & Sevig, 2014). Outreach efforts on a college campus are a key component in promoting mental and emotional health through edu­ cation and prevention; such efforts also convey to students that they “matter and belong at the institution” (Asidao & Sevig, 2014, p. 132). Outreach work has evolved most recently because of (a) an increase in mental health concerns among the student body, (b) greater diversity within groups of students who have varying needs, and (c) more attention to mental health by other campus constituents (Asidao & Sevig, 2014). There is a general rise in mental health diffi­ culties for students on college campuses today (Asidao & Sevig, 2014); however, LGBTQ individuals are almost three times more likely to experience mental health conditions such as depression, anxiety, posttraumatic stress disorder, thoughts of suicide, and sub­ stance use (National Alliance on Mental Illness, 2019). Given the issues that LGBTQ students experience, it is vital that college campuses continue to explore ways to recognize and meet these students’ needs. Perhaps one such way is to understand the unique needs of students on a specific campus. Increasing the visibility of the counseling center through outreach is vital for students who may not come in for clinical services on their own (Asidao & Sevig, 2014). Therefore, in addition to LGBTQ stu­ dents’ having access to the counseling center and other resources on campus, the college counseling center needs to engage in culturally informed outreach efforts using a public health approach (Asidao & Sevig, 2014). Outreach on a College Campus 589

A public health approach to outreach would entail an evaluation of needs and resources, with an emphasis on factors that promote or present barriers to student well-being, along with prevention and intervention education (Parcover, Mays, & McCarthy, 2015). Because of the variability in campus culture and the availabil­ ity of resources, a comprehensive approach to out­ reach with a public health focus can provide an avenue to better understanding students’ needs and to tailoring services to those needs. The American Psychological Association (APA) encourages the promotion of values related to fair­ ness and justice; one of its key goals is to ensure that psychologists maintain clients’ rights and dignity in regard to all aspects of identity, including sexual ori­ entation and gender identity, in all facets of their work (2017). The APA provides guidelines for working with transgender and gender-nonconforming people (APA, 2015), as well as guidelines for practice with lesbian, gay, and bisexual clients (APA, 2012). These guidelines urge the recognition of stigma, prejudice, discrimination, and violence that affect the LGBT community (APA, 2012, 2015). For example, the guide­ lines for working with transgender and gender-non­ conforming people state that, when a trans person “faces discrimination based on gender identity or gen­ der expression, psychologists may facilitate emotional processing of these experiences and work with the per­ son to identify supportive resources and possible courses of action” (APA, 2015, p. 839). The guidelines also encourage the identification of the institutional barriers (e.g., school or work environments) this popu­ lation may have to navigate (APA, 2012, 2015). There­ fore, it is important that counseling centers provide services that offer institutional support through reduc­ tion of stigma and discrimination. Counseling centers should also create avenues for support and resources. Instructions

A campus climate assessment is a good step in think­ ing about ways to better understand student needs and create an inclusive campus for LGBTQ students. Before meeting with the students to conduct the cli­ mate assessment, facilitators must consider two key factors. First, facilitators are encouraged to explore the presence of any biases that are inherent in their 590 Bvunzawabaya & LeRoy

work as mental health professionals. Therefore, they should engage in a never-ending self-examination process to ensure that their values and assumptions do not adversely affect these students as they disclose their experiences (Goodman et al., 2004). Culturally appropriate services that reflect an understanding of issues related to coming out, identity development, navigating gendered and heterosexist environments, and experiences of discrimination are paramount (Becker et al., 2017; Beemyn et al., 2005; Chang & Singh, 2016); thus, continuing education and ongoing consultation are encouraged. Second, the facilitators must attempt to take on the role of “colearner” instead of the role of expert, as a learning role can foster a meaningful relationship, particularly in LGBTQ communities that have been marginalized. The ability to approach students with respect, humility, a desire to share power, and a will­ ingness to allow LGBTQ students to voice their needs is strongly recommended in building relationships with this community (Goodman et al., 2004). Hence, outreach programming that reflects the concerns and raises awareness of LGBTQ students and coun­ selors’ positioning themselves as allies invested in the safety and well-being of LGBTQ students are both vital. For example, having programming that recog­ nizes important national days (e.g., Transgender Day of Remembrance), witnessing and responding to tragedies affecting the community (e.g., the Orlando shooting), recognizing issues specific to the commu­ nity (e.g., sexual violence), and holding trainings that increase awareness and understanding (e.g., Safe Zone) are crucial. The counseling center can cospon­ sor initiatives that are inclusive, providing printed and online material on the aforementioned areas. When administering the climate survey, the fol­ lowing steps are encouraged: 1. An important first step is to ensure that diverse students are recruited to participate. For example, advertising for the climate assessment should take place in dining halls, cultural centers, admission offices, and through LGBTQ student groups and stu­ dent leaders on campus. Participants should have an equal opportunity to participate; therefore, the venue, time, and students’ availability should be taken into account.

2. Climate assessment groups should have about eight to ten students and last approximately two and a half hours to ensure that each student has an oppor­ tunity to contribute. Offering multiple groups with diverse participants (e.g., year in school, gen­ der, racial and ethnic identity, level of participa­ tion on campus, religion, ability, and socioeco­ nomic class) can provide richer opportunities for student dialogue. 3. It is recommended that each group have two facil­ itators in order to provide support for any student who may experience difficult emotions during the climate assessment. 4. When students arrive, allow them to introduce themselves to one another. If possible, provide some light refreshments. Explain your role at the coun­ seling center, outline the purpose of the climate assessment, and discuss confidentiality and safety and community guidelines to ensure safety within the group. Encourage the students to share within their own limits and to speak from their own expe­ rience, as opposed to trying to build consensus or speak on behalf of someone else in or outside the group. (Time allotted: thirty minutes.) 5. Give the students the climate assessment worksheet (pp. 594–595) to write and reflect on their responses. Provide alternatives for students who may be visually or hearing impaired or prefer other avenues of relaying information besides writing and reporting to a group. Include your counseling center’s confidentiality statement and how the information that the students provide will be used. For example: “The responses you provide will remain anonymous; therefore, specific identi­ fying information will be redacted in the climate assessment report. This information will be shared with campus staff and faculty in order to provide recommendations to improve the experiences of current and future LGBTQ students on this cam­ pus. We will ensure that this information is not used to stigmatize, stereotype, or minimize stu­ dent experiences. If you would like to receive the final report, please provide your contact informa­ tion.” (Time allotted: thirty minutes.)

The list of questions in the climate assessment is not comprehensive. The questions should not be used in a “one-size-fits-all” approach to generalize the experience of all LGBTQ students. There is diversity in the experiences and needs of LGBTQ students, and the responses should not be used to tokenize or pathologize these students. Additionally, it is import­ ant that facilitators feel competent in their ability to facilitate difficult dialogues about discrimination and personal experiences in a group format. 6. Discuss the responses and explore any themes that arise. Ask students for permission to take down some general notes about the themes or sugges­ tions they offer during the discussion. Pay atten­ tion to the students who may be quieter or trying to find an opportunity to speak but have not man­ aged to do so yet. Remind participants to make space for others to ensure that the activity is inclu­ sive. (Time allotted: sixty minutes.) 7. After the participants have had a chance to share their experiences, debrief the participants before they leave regarding what it was like for them to share their thoughts and feelings in the group. Pro­ vide appreciation and affirmation for their ability to be vulnerable within the group. (Time allotted: thirty minutes.) 8. Stay a little longer after the group is dismissed, in case some students request any mental health, cam­ pus, or community resources. Brief Vignette

Students contacted the counseling center expressing concerns that the center’s services were inaccessible and disengaged from their experience as LGBTQ students. Particularly, students who held multiple mar­ ginalized identities (e.g., people of color who iden­ tify as queer) reported feeling that the counseling cen­ ter lacked understanding of their experiences. These complaints were presented to the LGBTQ center, other multicultural centers on campus, and the director of the counseling center. The counseling center staff reported feeling uncertain of LGBQ students’ needs on campus. The center decided to conduct a climate assessment with students in collaboration with campus partners. LGBTQ-identified students were recruited Outreach on a College Campus 591

with assistance from campus partners. Approximately thirty students volunteered to participate; facilitators from the counseling center and campus partners offered to facilitate and host the groups in different campus locations. After the climate assessment was administered, the facilitators provided a comprehensive report of the students’ concerns and suggestions. In the staff discus­ sion that followed, the clinicians became curious about the effect that engaging in general outreach activities (as opposed to conducting specific outreach activities that targeted LGBTQ students) had on the students. They also became aware that few staff mem­ bers identified as members of the LGBTQ commu­ nity, noting the importance of having role models and allies for students. This realization led to a discussion about the need for a more diverse staff, including someone with experience focusing on trans clients (a population many people felt uncertain and cautious about). It was decided the staff needed several in-ser­ vices to enhance staff knowledge and skills. They also identified the need for an increased connection with the campus community and a need to revise their out­ reach approach to include student collaboration in programming that was based on student needs. To encourage change in institutional policies and struc­ tures, the counseling center also explored ways of having more integrated outreach with various cam­ pus partners. Suggestions for Follow-up

The needs of LGBTQ students are diverse and require a comprehensive approach. The questions in the cam­ pus assessment activity provide a starting point in work that will continue to evolve as time passes. The hope is that implementing some of the changes will result in an increase in campus safety and an outreach program that is robust in meeting LGBTQ students’ needs. It is recommended that this climate assessment be conducted every four to five years because of the natural turnover of students and possible staff changes. Each cohort will be different in terms of its experi­ ences on and off campus; therefore, consistent atten­ tion to check the pulse of the current student body is advised. Additionally, counselors should create time to develop an action plan as a result of the climate 592 Bvunzawabaya & LeRoy

assessment with students and begin implementing the suggestions with campus partners and the staff at the counseling center. With the students’ permission, con­ tact them to collaborate on implementing these changes and later to assess the effectiveness of such changes. This climate assessment can be adapted for use in other settings, such as community centers. Contraindications for Use

It is important that facilitators are aware of the cam­ pus and sociocultural climate at the time the climate assessment is conducted. Therefore, it is not advised to conduct this assessment after a tragedy, when students may be feeling afraid and vulnerable. Conducting the assessment at such a time may result in students’ feeling less safe on campus when the focus should be on listening, healing, and fostering community, as opposed to exploring concerns that might heighten a focus on students’ concerns or worries. Professional Readings and Resources Dadlani, M., Overtree, C., & Perry-Jenkins, M. (2012). Culture at the center: A reformulation of diagnostic assessment. Professional Psychology Research and Practice, 43, 175–182. doi:10.1037/a0028152. Manis, A. A., Brown, S. L., & Paylo, M. J. (2009). The helping professional as an advocate. In C. M. Ellis & J. Carson (eds.), Cross cultural awareness and social justice in coun­ seling, 23–43. New York: Routledge. Nadal, K. L. (2013). That’s so gay! Microaggressions and the les­ bian, gay, bisexual, and transgender community. Washing­ ton, DC: American Psychological Association. Rankin, S. R. (2003). Campus climate for gay, lesbian, bisexual, and transgender people: A national perspective. Washing­ ton, DC: National Gay and Lesbian Task Force Policy Institute. Renn, K. A. (2007). LGBT student leaders and queer activists: Identities of lesbian, gay, bisexual, transgender, and queeridentified college student leaders and activists. Journal of College Student Development, 48 (3), 331–330. doi:10. 1353/csd.2007.0029. Smith, L., Baluch, S., Bernabei, S., Robohm, J., & Sheehy, J. (2003). Applying a social justice framework to college counseling center practice. Journal of College Counseling, 6, 3–13. Whitcomb, D. H., & Loewy, M. I. (2006). Diving into the hor­ net’s nest: Situating counseling psychologists in LGB social justice work. In R. L. Toporek, L. H. Gerstein, N. A. Fouad, G. Roysircar, & T. Israel (eds.), Handbook for social justice in counseling psychology, 215–230. Thousand Oaks, CA: Sage Publications.

Resources for Clients Bornstein, K. (2006). Hello, cruel world: 101 alternatives to suicide for teens, freaks, and other outlaws. New York: Seven Stories Press. Campus Pride. https://www.campuspride.org/. Consortium of Higher Education. LGBT resource professionals. https://www.lgbtcampus.org/. Human Rights Campaign. https://www.hrc.org/. It Gets Better Project. https://itgetsbetter.org/. Kuklin, S. (2014). Beyond magenta: Transgender teen speaks out. Somerville, MA: Candlewick Press. Mock, J. (2014). Redefining realness: My path to womanhood, identity, love, and so much more. New York: Atria. National Alliance on Mental Illness. LGBTQ. https://www. nami.org/Find-Support/LGBTQ. Parents, Families, and Friends of Lesbians and Gays (PFLAG). https://www.pflag.org/. Point Foundation. The national LGBTQ scholarship fund. https://pointfoundation.org/. Pride Foundation. https://www.pridefoundation.org/. Transgender Law Center. https://transgenderlawcenter.org/. Trevor Project. https://www.thetrevorproject.org/.

References American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67, 10–42. doi:10.1037/a0024659. American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70, 832–864. doi:10.1037/a0039906. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/. Asidao, C., & Sevig, T. (2014). Reaching in to reach out: One counseling center’s journey in developing a new outreach approach. Journal of College Student Psychotherapy, 28 (2), 132–143. doi:10.1080/87568225.2014.883881. Becker, M. A., Roberts, S., Ritts, S., Branagan, W., Warner, A., & Clark, S. (2017). Supporting transgender college stu­ dents: Implications for clinical intervention and campus prevention. Journal of College Student Psychotherapy, 31 (2), 155–176. doi:10.1080/87568225.2016.1253441. Beemyn, B. G., Curtis, B., Davis, M., & Tubbs, N. J. (2005). Transgender issues on college campuses. New Directions for Student Services, 111, 49–60. doi:10.1002/ss.173. Beemyn, B. G., & Pettit, J. (2006). How have trans-inclusive non-discrimination policies changed institutions? GLBT Campus Matters, 3 (1), 6–7. Cawthon, T., & Guthrie, V. (2011). Lesbian, gay, bisexual, and transgender college students. In M. J. Cuyjet, M. F. How-

ard-Hamilton, & D. L. Cooper (eds.), Multiculturalism on campus: Theory, models, and practices for understanding diversity and creating inclusion, 291–326. Sterling, VA: Stylus. Chang, S. C., & Singh, A. A. (2016). Affirming psychological practice with transgender and gender nonconforming people of color. Psychology of Sexual Orientation and Gen­ der Diversity, 3 (2), 140. doi:10.1037/sgd0000153. Croteau, J. M., & Lark, J. S. (1995). A qualitative investigation of biased and exemplary student affairs practices concern­ ing lesbian, gay, and bisexual issues. Journal of College Student Development, 36 (5), 472–482. Goodman, L. A., Liang, B., Helms, J. E., Latta, R. E., Sparks, E. & Weintraub, S. R. (2004). Training counseling psychol­ ogists as social justice agents: Feminist and multicultural principles in action. Counseling Psychologist, 32, 793–837. Howard-Hamilton, M. F., & Hinton, K. G. (2011). Oppression and its effect on college student identity development. In M. J. Cuyjet, M. F. Howard-Hamilton, & D. L. Cooper (eds.), Multiculturalism on campus: Theory, models, and practices for understanding diversity and creating inclusion, 19–36. Sterling, VA: Stylus. Marine, S. B., & Catalano, D. C. J. (2014). Engaging trans* stu­ dents on college and university campuses. In S. J. Quaye & S. R. Harper (eds.), Student engagement in higher edu­ cation: Theoretical perspectives and practical approaches for diverse populations, 135–148. New York: Routledge. National Alliance on Mental Illness. (2019). https://www. nami.org/Find-Support/LGBTQ. Parcover, J., Mays, S., & McCarthy, A. (2015). Implementing a public health approach to addressing mental health needs in a university setting: Lessons and challenges. Jour­ nal of College Student Psychotherapy, 29 (3), 197–210. doi:10.1080/87568225.2015.1045781. Pusch, R. S. (2005). Objects of curiosity: Transgender college students’ perceptions of the reactions of others. Journal of Gay and Lesbian Issues in Education, 3 (1), 45–61. Stewart, D. L., & Howard-Hamilton, M. F. (2014). Engaging lesbian, gay, and bisexual students on college campuses. In S. J. Quaye & S. R. Harper (eds.), Student engagement in higher education: Theoretical perspectives and practical approaches for diverse populations, 121–134. New York: Routledge. Sue, D. W. (2010). Microaggressions in everyday life: Race, gender, and sexual orientation. Hoboken, NJ: John Wiley & Sons. Ziyad, H. (2016, March 1). 3 differences between the terms “gay” and “queer”—and why it matters. Everyday Feminism. https://everydayfeminism.com/2016/03/difference­ between-gay-queer/.

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C L IM AT E A S S ES S M ENT

WO RKS H EET

Thank you for participating in our climate assessment. We are interested in exploring your experiences as an LGBTQ-identified student on campus. Please answer the following questions to the best of your ability. If you are uncomfortable responding or you are unable to provide an answer, feel free to move on to the next question. If you would like any clarification on the questions, please ask one of the facilitators. 1. How would you describe your everyday experience as an LGBTQ student on campus?

2. Do you believe your various identities are taken into consideration and affirmed on campus?

3. Do you believe that homophobia, transphobia, and heterosexism occur on campus?

4. What is your experience of oppression within your campus community? Have you encountered any discrimination on campus related to your LGBTQ identities?

5. Do you feel physically safe on campus?

6. Would you describe your campus as inclusive academically and socially and in its housing services?

7. How do you think discrimination targeting your community is discussed or addressed on campus?

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8. Have you received support on campus for experiences of discrimination or marginalization? If so, where? What kind of support felt helpful?

9. Do you view the counseling center as an ally for you on campus? Do you perceive the counseling center as understanding and sensitive to your mental health needs (for example, through print material, outreach events, website, and responses to national or local incidents)?

10. Do you have access to LGBTQ role models such as faculty, staff, and administrators across campus?

11. What are some offices on campus that you view as supportive of your concerns or needs?

12. Are there policies that express your institution’s commitment to being an ally? Do you feel that there are adequate institutional commitment and support?

13. From your perspective, what could the counseling center and our campus do to improve some of the challenges you experience here on campus?

14. Are there off-campus resources that you view as supportive of your concerns or affirming of your identities? If so, what are they?

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68 UNDERSTANDING ME, YOU, AND LGBTQ: AN OUTREACH WORKSHOP FOR GENERAL AUDIENCES AND ALLIES Alaina Spiegel Suggested Uses: Activity, handouts Objective

For this workshop, the goals include (1) increasing awareness in a general audience and (2) achieving comfort in discussing cultural identities (e.g., sex, gen­ der, sexual identity, race, religion, ethnicity, nationality, physical and mental ability status, and socioeconomic status or class) and areas of privilege and marginaliza­ tion. The workshop aims to help participants under­ stand how these identities relate and interact to others’ experiences of anatomical sex, attraction, gender iden­ tity, and gender expression. By engaging in structured, safe dialogue and activities, participants can begin to process how recognizing one’s privilege can translate into ally empathy, understanding, and action. Rationale for Use

According to Vera and Speight (2003), a commitment to social justice requires psychologists to redefine mul­ ticultural competence beyond individual psychother­ apy and to engage in advocacy and other interventions. Like a therapist, the facilitator guides and encourages deep personal and interpersonal learning (BrooksHarris & Stock-Ward, 1999). This chapter highlights how mental health professionals can expand their role by facilitating outreach workshops aimed at advo­ cacy and allyship, specifically for the LGBTQ popula­ tion. Mental health professionals who facilitate such workshops are practicing in accordance with the American Psychological Association’s (APA’s) guide­ lines for psychological practice with lesbian, gay, and bisexual clients (2012). Guideline 19, involving pro­

fessional education and training, suggests that psychol­ ogists emphasize diversity in the institutions they work in, offer support systems for LGBTQ individu­ als, and, for those with expertise, provide training, consultation, or supervision to others (APA, 2012). Although this guideline is not specific to outreach interventions, it can be applied to those providing workshops in various communities. Training programs on LGBTQ mental health should engage a variety of audiences (Rutherford, McIntyre, Daley, & Ross, 2012). Trainings for general audiences can take place in academic, religious, work, or other settings within a community (Grzanka, Adler, & Blazer, 2015). Promoting an understanding and acceptance of LGBTQ issues is important for general audiences, given that social support is a protective fac­ tor for the mental health of LGBTQ individuals. Ryan and colleagues (2010) found that family acceptance of LGBT adolescents and young adults predicted greater social support, self-esteem, and overall health status for LGBT youth. Of note, youth with certain intersect­ ing identities had different levels of family acceptance. Specifically, youth from Latino, immigrant, religious, and low-socioeconomic-status families experienced lower levels of acceptance. Additionally, using the LGBT People of Color Microaggressions Scale, researchers found that those with intersecting marginalized identities, such as those who are LGBT and racial or ethnic minorities, expe­ rience microaggressions that may be linked to depres­ sion and perceived stress (Balsam et al., 2011). In one study, Dessel (2010) addressed the intersection of religion and LGBTQ status. Dessel had teachers from

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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a religious and conservative school district engage in an intergroup dialogue intervention. The interven­ tion illustrated significant positive changes in teacher attitudes, feelings, and behaviors toward LGBTQ stu­ dents and parents (Dessel, 2010). Therefore, it is equally important for general-audience workshops to include discussions about intersecting marginalized identities and how multifaceted societal issues, such as racism and heterosexism, can affect community members and loved ones. Grzanka and colleagues (2015) state that hetero­ sexual allies can play a crucial role in LGBT activism, but that educators, organizers, and leaders can influ­ ence whether that role is productive or unproduc­ tive. In addition to recognizing the identities of the audience, facilitators must work with allies to man­ age the discomfort that arises when discussing privi­ lege and inequality (Grzanka et al., 2015). Killermann and Bolger (2016) discuss creating a space for “Both/ And,” where disagreeing is acceptable and audience members can have coexisting, rather than competing, perspectives. When discussing privilege and oppres­ sion, the “Both/And” concept can help audience mem­ bers learn how people have many identities and that they can experience both oppression and privilege. Moreover, helping the audience members process their emotions is critical. Killermann and Bolger (2016) suggest taking the “emotional road in facilitation.” The authors state that “the experience of being personally affected by something in the moment, compared to just thinking about it hypothetically, plants deep roots, which, if nurtured, can grow into powerful learning” (p. 113). The hope is that the facilitators of this work­ shop can promote a supportive environment for gen­ eral audience members, with or without LGBTQ iden­ tities, to reflect on their own privilege and to consider how they can act as allies for their LGBTQ family mem­ bers, friends, students, or community members. This chapter conforms to APA ethical principles, standards, and guidelines. Guideline 1 of the APA’s (2012) guidelines for psychological practice with les­ bian, gay, and bisexual clients states that psychologists should strive to understand how stigma, including prejudice, discrimination, and violence, has affected the lives of LGBTQ individuals, and how creating

safety is of utmost importance. Therefore, facilitators of this workshop must be LGBTQ-affirmative, and they must create a welcoming, safe space, especially for those with multiple marginalized identities. Guide­ line 4 indicates that psychologists must evaluate their attitudes, knowledge, and limitations so as not to com­ promise their work with a heterosexist bias (APA, 2012). Although this guideline refers to assessment and treatment of clients, it should also apply to any professional engagement in outreach interventions. Before asking audience members to explore areas of power, privilege, and oppression, it is important that facilitators of this workshop have done their own exploration of these areas. Guideline 6 emphasizes that psychologists must understand the difference between sexual orientation and gender identity. This under­ standing is especially important given that this work­ shop addresses the differences between sexual orien­ tation and gender identity. Moreover, ethical standard 2.01 (Boundaries of Competence) suggests that those who provide services or teach consider their level of competence in terms of education, training, supervi­ sion, consultation, study, or professional experience (Pope & Vasquez, 2007). It is recommended that all workshop facilitators demonstrate a level of compe­ tence in social justice topics and terminology related to LGBTQ populations. Once trained to a level of cul­ tural competence, facilitators should feel more ade­ quately prepared to train others in the workshops. Grzanka and colleagues (2015) discuss the impor­ tance of working with cisgender heterosexuals in managing their discomfort engaging in intergroup dia­ logue and other activities addressing privilege and inequality. They state that discussions about privilege and inequality are important in “crafting efficacious coalitions across social identity groups” (pp. 178–179). Moreover, facilitators should also follow principle E (Respect for People’s Rights and Dignity) and recog­ nize that audience members may be at different lev­ els of awareness about privilege or other material presented in the workshop. Facilitators should make every effort to respect all cultural and individual dif­ ferences they encounter (Pope & Vasquez, 2007). Furthermore, the general audiences for this workshop may also include family members of LGBTQ indi-

An Outreach Workshop for General Audiences and Allies 597

viduals, and facilitators should strive to understand how LGBTQ issues affect individuals and their fami­ lies of origin (APA, 2012). Instructions

This two-hour workshop is geared toward general audiences. The participants will first reflect on their own cultural identities (e.g., sex, gender, sexual iden­ tity, race, religion, ethnicity, nationality, physical and mental ability status, and socioeconomic status or class) and areas of privilege and marginalization. Then participants will engage in an experiential activity that looks at how their own privilege relates more spe­ cifically to experiences of anatomical sex, attraction, gender identity, and gender expression. The participants will also engage in group discussions to process their experiences in the activities. If the facilitator feels com­ fortable and competent, this workshop can be facili­ tated alone, but a co-facilitator is recommended. This workshop can be adapted to various settings and age ranges. For general audiences, there may be different levels of exposure to the topic of privilege, and discussions could be triggering for some audience members. Before any workshop, the facilitator should consider many aspects of the audience (Who is in the audience? How do they know one another? How might they feel being vulnerable? How many people should participate?), physical space (Is this a confi­ dential space? Is the space part of a workplace?), and the relationship between the facilitator and the audi­ ence (How does the facilitator know the participants? How might the audience perceive the facilitator’s identities?). Introduction of facilitators, workshop participants, and the goal of the workshop (fifteen minutes). • Introduce yourself and your role as the workshop facilitator. Workshop facilitators decide whether they want to disclose their own personal or profes­ sional background that brought them to facilitate an LGBTQ-related workshop. If the facilitators decide to disclose, they are encouraged to think about how the audience could perceive their identities and disclosures and how they could address these dis­ closures within the workshop if needed. Consulta­ tion with colleagues is encouraged. 598 Spiegel

• Ask the group members to introduce themselves and say what brought them to the workshop today. • Review the objectives described in the beginning of this chapter to outline the goals of the workshop. Ask if anyone has any questions or concerns. Community agreements and guidelines (five minutes). • Ask the group what would make people feel safe and respected in today’s workshop and see if they would like to come up with community agreements and guidelines to promote safety. • Provide suggestions, such as: the conversation stays within the room (confidentiality), express yourself with good intentions, and speak from your own experience. Write these agreements and guidelines down on a whiteboard or large piece of paper. Keep them on display during the workshop and refer to them as needed. • Provide an overview of the workshop, the time allocated, and location of bathrooms (including gender-inclusive bathrooms). • Let the group know that these activities can bring up tough stuff for people. Inform the group that, if anyone feels triggered or needs support during or after the workshop, that person should let the facili­ tators know. Inform the group that their participa­ tion is optional and they do not need to participate in any activity if they choose not to. Activity 1: Identity Reflection Handout and Discussion (see handout on p. 602) (twenty minutes) • Provide each audience member with a handout and a pen, and read the directions out loud. • Give participants approximately five minutes to fill out the handout and spend fifteen minutes process­ ing the activity. You can do this activity as a large group or break into smaller groups. • Ask questions such as: What was it like to think about the various identities you hold? We all hold areas of privilege and marginalization; what areas are most salient in your life? [Break (fifteen minutes)] Activity 2: Privilege Links Activity (see handout on p. 603) (forty-five minutes) • For this workshop, facilitators should be competent using and explaining different terms, including ana­

tomical sex, attraction, gender identity, and gender expression, which Sam Killermann (in The Social Justice Advocate’s Handbook: A Guide to Gender, 2017) explains using different continua and label combinations. Before engaging in this exercise, the facilitator is encouraged to review the “GenderBread Person,” as described by Killermann, to explain each continuum to the audience and to provide exam­ ples. The facilitator should also be able to explain how attraction can refer to both sexual and roman­ tic attraction. Furthermore, the facilitator should emphasize how an LGBTQ individual can identify in different ways along different continua and that each is independent of the others. The facilitator may want to draw these continua on a board or use a PowerPoint presentation to help clarify them for the audience. • Make a copy of the station statements listed on the Privilege Links Activity and create four stations around the room (Anatomical Sex Station, Attrac­ tion Station, Gender-Identity Station, and Gen­ der-Expression Station). • Cut thin strips of different-colored paper and place them at each station (each station should have its own color). There should be enough strips for each person to take five at each station. • Provide participants with staplers or tape. • Read the following directions: There are four different stations, which focus on anatomical sex, attraction, gender­identity, and gender­expression continua. Each station includes a sheet of paper with five statements. The statements you read are just examples of privi­ lege and are not exhaustive. Read each statement silently to yourself. If you say “yes” or “basically yes” to a statement, take a paper slip from that station. If you answer “yes” to all the statements, you should have five paper slips. If you answer “no” to a state­ ment, do not take a slip. Repeat this process for each station. This activity is not meant to make people feel guilty or ashamed, but rather to explore how our privilege influences who we are and how we see the world. • Once audience members are back at their seats, remind them which colors represent which stations. Encourage the group members to link the paper

strips together as a visual representation of their own privilege (they can use a stapler or tape). If there are certain intersecting identities that feel very “linked,” participants can cluster them together. They can choose to keep their feelings private, or they can choose to share in order to elicit conversations about privilege with family, friends, community members, or coworkers. Wrap up and process (twenty minutes) • Use the Privilege Links Discussion Handout to pro­ cess the activity. You can do the processing in a large group or smaller groups. You can also ask if people want to write down some thoughts first and then discuss the themes as a larger group. • Ask the audience for any reactions to today’s work­ shop. You can ask about any feelings or thoughts that came up for the participants. What was chal­ lenging about this workshop? Did the participants have any new insights? Do they want to share their privilege links with others, or do they prefer to keep them to themselves? What factors play a role in this decision? How might this activity make them think about their role as an ally to LGBTQ individ­ uals and communities? • Open up the conversation for any questions. Brief Vignette

Sara is a straight, cisgender female who works as a counselor at a university counseling center. She is asked to provide a social justice–informed workshop for ten resident assistants (RAs) in the dorms. Before doing the workshop, Sara consults with the RA community director and discusses their goals for a social justice workshop, who will be in the audience, the relation­ ship among the RAs, and whether this workshop is a good fit for the students. Sara also consults with oth­ ers in her office to understand how her identities as a straight, cisgender female may affect the audience, given that they may identify in different ways. Through consultation, Sara determines that she will share her identities with the group. She hopes to model talking about one’s identities and vulnerability, and she wants to begin an open dialogue about privilege and other social justice themes. During the workshop, Sara begins with introduc­ tions and facilitates a discussion about community An Outreach Workshop for General Audiences and Allies 599

agreements and guidelines to create safety within the group. She then guides the group through the vari­ ous workshop activities. During the activities, an RA named Tim, a twenty-year-old, white, cisgender, straight male, fills out the Identity Reflection Hand­ out, and he begins to realize that he has many areas of privilege and few areas of marginalization. He then does the Privilege Links Activity and is reminded of how little he understands about the challenges that many LGBTQ individuals face in a heteronormative society. Another RA in the work­ shop, Bianca, is a nineteen-year-old, Latina, cisgender woman who identifies as queer. Unlike Tim, she finds herself grappling with how her marginalized identi­ ties have come to the surface during this activity. In the discussion component of the workshop, Tim reports that he feels guilty for his “white privilege.” Bianca observes that she feels frustrated by Tim’s comments and that he cannot begin to understand her experiences. Sara asks if they feel comfortable sharing more about their own reactions and emo­ tions to the activities and to each other’s feedback. She also notes that these activities can bring up vul­ nerability and pain for different reasons. After they both share their reactions, the group members process the fact that, while they have many different identi­ ties and life experiences, they can hope to under­ stand one another’s stories and support one another. At the end of the workshop, Sara lets the group know that she is available if anyone needs to check in or receive any additional support. Suggestions for Follow-up

Facilitators should check in with participants after the workshop, especially with anyone who seems to have follow-up questions or concerns about the material presented in the workshop. Facilitators should also be prepared to provide a list of resources for the participants, including resources for LGBTQ individuals and for allies. Contraindications for Use

The workshop in this chapter is contraindicated if the facilitators do not have multicultural competency, are not LGBTQ-affirmative, or are not open to explor­ ing their own biases. In addition, this workshop could be contraindicated if the group is already engaged in 600 Spiegel

conflict, which could affect audience members’ sense of emotional or physical safety. If it is determined that participants could experience more harm than help, the workshop is contraindicated. Professional Readings and Resources Bolger, M., & Killermann, M. (n.d.). The safe zone project. https://thesafezoneproject.com/. Brooks-Harris, J. E., & Stock-Ward, S. R. (1999). Workshops: Designing and facilitating experiential learning. Thousand Oaks, CA: Sage Publications. Killermann, S. (2017). The social justice advocate’s handbook: A guide to gender, 2nd edition. Austin, TX: Impetus Books. Killermann, S., & Bolger, M. (2016). Unlocking the magic of facilitation: 11 key concepts you didn’t know. Austin, TX: Impetus Books.

Resources for General Audiences Resources for Allies

Gay and Lesbian Alliance Against Defamation (GLAAD). (2007). Be an ally & a friend. https://www.glaad.org/ resources/ally. Killermann, S. (2017). The social justice advocate’s handbook: A guide to gender, 2nd edition. Austin, TX: Impetus Books. Straight for Equality. Resources for straight allies. http://bolt. straightforequality.org/allyresources. Resources for LGBTQ Participants

Gay and Lesbian Alliance Against Defamation (GLAAD). (n.d.). GLAAD media reference guide—directory of community resources. https://www.glaad.org/reference/ communityresources. LGBT National Help Center. (n.d.). www.glbtnationalhelp center.org/. National Alliance on Mental Illness (NAMI). (2019). LGBTQ. https://www.nami.org/Find-Support/LGBTQ. Testa, R. J., Coolhart, D., & Peta, J. (2015). The gender quest workbook: A guide for teens and young adults exploring gender identity. Oakland, CA: New Harbinger Publications. Trevor Project. (2017). Get help now. https://www.thetrevor project.org/pages/get-help-now.

References Allen, B. J. (2018). Privilege beads exercise. Unpublished man­ uscript, University of Colorado at Denver. Adapted and revised from exercises created by Arlene Sgoutas, Metro­ politan State University of Denver, and Thomas E. Walker, University of Colorado at Denver. www.differencematters. info/uploads/pdf/privilege-beads-exercise.pdf. American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67 (1), 10–42. doi:10.1037/a0024659.

Balsam, K. F., Molina, Y., Beadnell, B., Simoni, J., & Walters, K. (2011). Measuring multiple minority stress: The LGBT People of Color Microaggressions Scale. Cultural Diversity and Ethnic Minority Psychology, 17 (2), 163–174. doi:10. 1037/a0023244. Brooks-Harris, J. E., & Stock-Ward, S. R. (1999). Workshops: Designing and facilitating experiential learning. Thousand Oaks, CA: Sage Publications. Dessel, A. B. (2010). Effects of intergroup dialogue: Public school teachers and sexual orientation prejudice. Small Group Research, 41 (5), 556–592. doi:10.1177/1046496 410369560. Grzanka, P. R., Adler, J., & Blazer, J. (2015). Making up allies: The identity choreography of straight LGBT activism. Sexuality Research & Social Policy: A Journal of the NSRC, 12 (3), 165–181. Killermann, S. (2017). The social justice advocate’s handbook: A guide to gender, 2nd edition. Austin, TX: Impetus Books.

Killermann, S., & Bolger, M. (2016). Unlocking the magic of facilitation: 11 key concepts you didn’t know. Austin, TX: Impetus Books. Pope, K. S., & Vasquez, M. J. T. (2007). Ethics in psychotherapy and counseling: A practical guide. San Francisco: Jossey-Bass. Rutherford, K., McIntyre, J., Daley, A., & Ross, L. E. (2012). Development of expertise in mental health service pro­ vision for lesbian, gay, bisexual and transgender commu­ nities. Medical Education, 46 (9), 903–913. Ryan, C., Russell, S. T., Huebner, D., Diaz, R., & Sanchez, J. (2010). Family acceptance in adolescence and the health of LGBT young adults. Journal of Child and Adolescent Psychiatric Nursing, 23 (4), 205–213. doi:10.1111/j.1744­ 6171.2010.00246.x. Vera, E. M., & Speight, S. L. (2003). Multicultural competence, social justice, and counseling psychology: Expanding our roles. Counseling Psychologist, 31 (3), 253–272. doi:10.11 77/0011000003031003001.

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IDENTIT Y REFLECTION HANDOUT

Our cultural identities shape how we move through and experience the world. Take a moment to fill out the following handout to reflect on your identities, areas of privilege, and areas of marginalization (including intersecting marginalized identities).

Sex

Ethnicity/Nationality

Gender

Religion

Sexual identity

Ability status (physical/mental)

Race

Socioeconomic status/class

Now that you have reflected on your cultural identities, think about the areas of privilege you hold or do not hold and any areas of marginalization that you experience. We all hold some areas of privilege. Privi­ lege is “any unearned advantages you have in society as a result of your identity group memberships. Privilege is not something you choose to receive or dismiss. It is automatically granted to you based on your identity, and it informs the ways individuals and groups interact with you” (Killermann, 2013, p. 34). What are your areas of privilege?

What are your areas of marginalization (including intersecting marginalized identities)?

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PRIVILEGE LINKS ACTIVIT Y:

Station Statements

Anatomical Sex Station 1. I was born with biological anatomy that matched my assigned gender on my birth certificate. 2. I have internal reproductive organs that match my assigned sex at birth. 3. I was not born intersex. 4. I was born with chromosomal configurations (XX for females, XY for males) that match my assigned sex at birth. 5. When I am asked about my sex on forms, it is clear which category to choose. Attraction Station 1. I can hold my partner’s hand in public without fear of discrimination or feeling unsafe. 2. I can go for months without anyone referring explicitly to my sexual identity. 3. I do not have to fear that if my family or friends find out about my sexual identity, there could be consequences. 4. I do not have to worry about if and when I should tell people my sexual identity. 5. I do not think about my attraction to others falling on a continuum (women or feminine or female people; men or masculine or male people). Gender Identity Station 1. I define my gender in a way that is consistent with the sex I was assigned at birth. 2. I do not worry about how my gender identity affects my physical safety. 3. People don’t look at me with confusion when I tell them my gender. 4. At doctor’s offices, I can easily fill out paperwork regarding my gender. 5. I can comfortably go into bathrooms designated for my gender identity. Gender Expression Station 1. I behave and interact in ways that society says “fit” my gender. 2. When I get ready in the morning, I do not worry about how people at school or work will receive my gender expression. 3. My clothing, mannerisms, and grooming habits align with what society considers appropriate for my gender. 4. I don’t worry about how others view my gender expression. 5. I am cisgender. Discussion Questions How did it feel engaging in this activity? What thoughts or emotions came up for you?

How did this activity make you think about LGBTQ individuals’ experiences in a heteronormative society?

How might the cultural dimensions (e.g., race, religion, etc.) from the first activity affect LGBTQ individuals who move through the world with intersecting, marginalized identities?

The identities in this exercise are adapted from B. J. Allen, “Privilege Beads Exercise,” unpublished manuscript, University of Colorado at Denver (2018). Adapted and revised from exercises created by Arlene Sgoutas and colleagues, Metropolitan State College, Denver, and Thomas E. Walker, University of Colorado Denver. Retrieved from www.differencematters.info/uploads/pdf/privilege-beads-exercise.pdf.

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69 LIVING IN INTERSECTIONAL SPACES: EXPLORATION OF SOCIAL IDENTITIES IN THE LGBT COMMUNITY Matthew LeRoy and Batsirai Bvunzawabaya Suggested Use: Activity Objective

This chapter describes an outreach activity designed to help LGBT university or college students under­ stand the ways in which membership in the LGBT community affects their experiences on campus and to provide mutual validation of these experiences, increase awareness of their multiple identities, and foster sensitivity to peers’ identities. These goals are achieved by discussing with participants the ways in which they connect with one another and as a larger community at their university. Rationale for Use

Social identity refers to people’s sense of who they are, which is based on their group memberships (Hays, 2013; Tajfel & Turner, 1979). These identities exist within societal systems in which some identities have greater power or privilege and other identities are marginalized. For example, in the United States transgender people have less societal power because they are the targets of transphobia and systemic barriers that target transgender individuals. When an identity lacks societal power, it is a marginalized or oppressed identity (Sue, 2010). All people hold multiple identi­ ties, all of which affect their experience (Hays, 2008, 2013). These multiple identities intersect to inform individuals’ experience of the world, including how much or how little power they have. Therefore, one can simultaneously have marginalized identities and privileged identities, depending on the context (Hays, 2008).

Experiences of marginalization are stressful and emotionally taxing (Sue, 2010). One way to cope with the stress of these experiences is to engage in a dialogue about them. Engaging in these conversations with friends, family, and those who share similar iden­ tities can be beneficial to one’s mental health and pro­ vide affirmation of one’s identity (Bockting et al., 2013). These discussions, much like therapy, help people feel connected to and understood by others. Decreas­ ing their feelings of isolation allows people to feel part of a community (Bockting et al., 2013). It is impor­ tant when discussing identity to recognize the inter­ sectional nature of identity and to acknowledge that multiple forms of oppression and multiple forms of privilege coexist and can affect a person’s mental and physical health (Sue, 2010). Heterosexism creates an environment in which LGB people may have lower self-esteem and more struggles in relationships (Frost & Meyer, 2009). These mediating factors can affect mental health; studies indi­ cate that LGB individuals are 4.39 times more likely to attempt suicide and 1.96 times more likely to report bullying (LeVasseur, Kelvin, & Grosskopf, 2013). According to a recent survey, 41 percent of transgen­ der respondents indicate they have attempted suicide (Haas, Rodgers, & Herman, 2014). This number stands in stark contrast to the national average (4.6 percent) and the number of LGB people (10 to 20 percent) (Haas et al., 2014). Additional literature indicates similar stress for other minority statuses, including women and people of color (Sue, 2010). It can be particularly difficult when one has multiple marginalized identities, such

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as an LGBT person of color (Chang & Singh, 2016). Stress associated with being a member of a minority can include intense experiences of hate (e.g., hate crimes or violence) and smaller invalidations of one’s identity (Bockting et al., 2013; Sue, 2010). To explain the stress caused by these common invalidations of one’s identity, Derald Wing Sue (2010) revived the term microaggressions. Microaggressions are “the brief and commonplace daily verbal, behavioral and environ­ mental indignities, whether intentional or uninten­ tional, that communicate hostile, derogatory, or neg­ ative racial, gender, sexual orientation and religious slights and insults to the target person or group” (p. 5). Through microaggressions, individuals feel affected by members of their community and by people who have more power and privilege in society. Microaggressions often occur when a privileged group interacts with a marginalized group. The LGBT community is a diverse community, with varying lev­ els of societal power. For example, a cisgender white gay male on campus will have a different experience from a gender-nonconforming Asian queer student because of the ways in which classmates, faculty, and staff engage with the multiple marginalized and privi­ leged identities each student holds. Thus, attending to microaggressions in shared spaces can create a sense of safety and increase connectedness. The ethical guidelines of the American Psycho­ logical Association (APA) encourage exploration of identity owing to its importance in understanding human experience (2012). The APA has released mul­ tiple guidelines for working with different identities, including working with ethnic minorities (APA, 1990), transgender and gender-nonconforming people (APA, 2015), and lesbian, gay, and bisexual clients (APA, 2012). These guidelines encourage awareness of the counselor’s attitudes and potential biases, as well as a focus on recognizing the stigma, discrimination, and violence that affect these populations. Additionally, these guidelines encourage social change, which includes assisting communities in learning how to have conversations on issues affected by social identity (APA, 2015). As the guidelines emphasize, it is essen­ tial to provide affirmative practice in working with the LGBT community. Affirmative practice includes

strengthening peer support (Bockting et al., 2013) and acknowledgment, exploration, and validation of their experiences of marginalization with the com­ munity (Chang & Singh, 2016). Instructions

An important first step is to understand the commu­ nity that you will be working with. To this end, it is vital to talk with community partners, particularly those requesting this workshop, to understand their goals in conducting a workshop focusing on identity. Because of the potential for the material to evoke strong feelings from the participants, it is recommended that this workshop have two facilitators. Multiple facil­ itators ensure adequate flexibility and support in facilitation; for instance, if someone becomes distressed and leaves the room, one facilitator can support that person while the other facilitator stays with the other participants. This strategy helps all students feel sup­ ported. Additionally, it is important that facilitators feel confident in conducting sensitive conversations in a group format. Introduction 1. Presenting to participants, it is helpful to begin with an explanation of the importance of social identities. Acknowledge that participants may be asked to think about themselves and others in a way that they have not in the past. 2. Share with the group the fact that the goals of this exercise are to help them become more aware of their privileged and marginalized identities and of how these identities influence their view of the world and their relationships. 3. After providing the definition of social identities, ask participants to identify the groups to which they belong. As they share, observe what larger catego­ ries these identities fit into (e.g., if someone says “gay,” mention sexual identity; if someone says “Latina,” mention ethnicity or race). It is likely participants will disclose identities that are not social, such as extrovert or daughter. Acknowledge that these are important identity statuses, but encourage participants to think about social identi­ ties as being formed by connections to a group.

Exploration of Social Identities in the LGBT Community 605

Microaggressions 1. Explain that identity affects our daily lived experi­ ences, introducing the concept of microaggressions. 2. Ask the participants to share what they know about microaggressions. 3. After soliciting associations to microaggressions, offer Sue’s definition (2010): “the brief and common­ place daily verbal, behavioral and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial, gender, sexual orientation and religious slights and insults to the target person or group” (p. 5). 4. Once this term is defined, solicit examples from the group and model the complexity of microaggres­ sions by acknowledging a time you have committed one. This modeling is important to encourage par­ ticipants to take responsibility for their actions, and to allow individuals to begin thinking about their own experiences. Small and Large Groups Next, ask people to form small groups, and encourage participants to keep groups small (around four mem­ bers) so that everyone has an opportunity to share. After the groups have formed, tell students that the goal is not to pressure participants to share more than they feel comfortable sharing, but, rather, to learn about their identity as well as others’ identities. Rec­ ognize that this topic is inherently personal and can stir up powerful feelings. Encourage people to share if they feel comfortable doing so, but also be mindful in ensuring that they are not vulnerable to a point that feels unsafe. Explore whether certain safety rules and guidelines would help people feel more comfort­ able in sharing meaningful experiences. Write down these safety rules and guidelines, and keep them visi­ ble throughout the conversation. Each group will be prompted to address (for about twenty minutes) the small-group discussion questions found at the end of this chapter. After twenty minutes, return to the larger group and ask the participants what they learned about one another. Stay attentive to the conversation, and focus on themes of inclusion rather than exclusion. Model 606 LeRoy & Bvunzawabaya

a curiosity and a growth-oriented mind-set, possibly through self-disclosure of your own increased under­ standing of identity as you have grown as a person. Because of the personal nature of identity, it is impor­ tant that facilitators discuss the ways they are embodied within their own social identities. Include both privileged identities and marginalized identities in this modeling. If this conversation is going well in the large group, continue the conversation with everyone. If the conversation is stilted and participants are struggling to talk, however, have them return to their small groups, or have the room divide in half, so that facilitators can facilitate two separate conversations. As the discussion continues, use some of the prompts at the end of the chapter to stimulate more in-depth discussion. During this discussion, it can be useful to observe if people are struggling to answer specific questions and to be curious about the reasons for this difficulty. Your curiosity allows participants to become more aware of their privileged identities, which are harder to discuss. It is essential to model curiosity so that participants do not feel too exposed or vulnerable. The leaders could say something like “I notice that it seems hard for people to answer this question; what do you all make of that?” The large-group discussion questions are found at the end of this chapter. Finish the conversation by enlisting the partici­ pants to talk about which next steps would be best for them. Discuss potential ways for them to learn more about one another, and ask if any identities were neglected in the discussion. Be particularly sensitive to identities such as asexual, pansexual, or genderqueer that can be marginalized within the LGBT com­ munity. Discuss ways to create inclusion for these identities within the LGBT community. Some students engaging in the discussion may think it is important to create more LGBT-friendly spaces around cam­ pus. Validate the importance of focusing both within the community and outside the community. Discuss ways to achieve these broader goals. Brief Vignette

As a result of a feeling of division within the commu­ nity at the LGBT center, facilitators from the coun­ seling center were asked to help the community dis­

cuss the experience of conflict. Before meeting with student leaders, administrators at the LGBT center believed that a part of the struggle was related to “per­ sonality factors.” Before the presentation, the facilita­ tors wondered if some of these personality differences were also emblematic of power and privilege within the group. During the meeting, as the facilitators asked about the effect of the participants’ identities, students shared their experiences of their identities with one another. Certain themes emerged. For example, students were aware of their LGBT identity, specifically in hetero­ sexual or cisgender spaces. One trans student observed that when around other LGBT students, they were aware of the differences within the LGBT community. The student also mentioned being misgendered at times and acknowledged the way racial, socioeco­ nomic, and gender differences are hard to talk about as a community. Individuals who felt privileged in these categories reported being surprised, stating that they are frequently less aware of their privileges and regret that they may have inadvertently contributed to others’ feeling marginalized. Students expressed their desire to make the community a safe space for all, and they wanted to continue talking about identities’ influ­ ence on their experiences and their relationships. Suggestions for Follow-up

The follow-up should focus on the reactions to the themes that emerge in the group, and it should occur collaboratively with the students and any involved administrators. Common themes involve an increased awareness of cultural identity and how it affects expe­ riences. At times, people report feeling guilty about their privilege, sad and angry about oppression in the world, and motivated to change these systems of oppression. Divisions within the LGBT community can create challenges. For example, bisexual people may feel that other members of the community invalidate or dismiss their identities, or asexual individuals who use the services of the LGBT center may at times feel they do not belong. If themes of inclusion and exclu­ sion are discussed in the LGBT center, talk with the center’s administrators about ways to create inclusive programming and space for all community members.

Contraindications for Use

For these conversations to take place, participants need to feel a degree of safety in the community. If an event has recently occurred that has left people feel­ ing unsafe and anxious, such as hate speech or explicit, socially motivated exclusion, this activity may be difficult to implement and may further exacerbate unsafe feelings. Professional Readings and Resources Aldarondo, E. (2007). Rekindling the reformist spirit in the mental health professions. In E. Aldarondo (ed.), Advanc­ ing social justice through clinical practice, 3–17. Mahwah, NJ: Lawrence Erlbaum Associates. Cross, W. E. (1971). The Negro-to-black conversion experience. Black World, 20 (9), 13–27. Dadlani, M., Overtree, C., & Perry-Jenkins, M. (2012). Cul­ ture at the center: A reformulation of diagnostic assess­ ment. Professional Psychology Research and Practice, 43, 175–182. doi:10.1037/a0028152. Greenleaf, A. T., & Williams, J. M. (2009). Supporting social justice advocacy: A paradigm shift towards an ecological perspective. Journal for Social Action in Counseling and Psychology, 2, 1–14. doi:10.1.1.476.6637. Helms, J. E. (1992). A race is a nice thing to have: A guide to being a white person or understanding the white persons in your life. Topeka, KS: Content Communications. Howard-Hamilton, M. F., & Hinton, K. G. (2011). Oppression and its effect on college student identity development. In M. J. Cuvjet, M. F. Howard-Hamilton, & D. L. Cooper (eds.), Multiculturalism on campus: Theory, models, and practices for understanding diversity and creating inclusion, 19–36. Sterling, VA: Stylus. Manis, A. A., Brown, S. L., & Paylo, M. J. (2009). The helping professional as an advocate. In C. M. Ellis & J. Carson (eds.), Cross cultural awareness and social justice in coun­ seling, 23–43. New York: Routledge. Nadal, K. L. (2013). That’s so gay! Microaggressions and the les­ bian, gay, bisexual, and transgender community. Washing­ ton, DC: American Psychological Association. Rust, P. (2003). Finding a sexual identity and community: Ther­ apeutic implications and cultural assumptions in scien­ tific models of coming out. In L. Garnets & D. Kimmel (eds.), Psychological perspectives on lesbian, gay, and bisexual experiences, 2nd edition, 227–269. New York: Columbia University Press.

Resources for Clients Flores, J. (2015, July 16). How to explore gender when you are a person who was assigned male at birth. Everyday Femi­ nism. https://everydayfeminism.com/2015/07/exploring­ gender-as-amab/. Exploration of Social Identities in the LGBT Community 607

Gonchair, M. (2017, March 15). 25 mini-films for exploring race, bias and identity with students. New York Times. https://www.nytimes.com/2017/03/15/learning/lesson­ plans/25-mini-films-for-exploring-race-bias-and-identity­ with-students.html. Mock, J. (2014). Redefining realness: My path to womanhood, identity, love, and so much more. New York: Atria. Trevor Project: The Trevor Project is the leading national orga­ nization providing crisis intervention and suicide preven­ tion services to lesbian, gay, bisexual, transgender, and questioning (LGBTQ) young people ages 13–24. http:// www.thetrevorproject.org/.

References American Psychological Association (APA). (1990). Guide­ lines for providers of psychological services to ethnic, linguistic, and culturally diverse populations. https:// www.apa.org/pi/oema/resources/policy/provider­ guidelines. American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67, 10–42. doi: 10.1037/a0024659. American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70, 832–864. doi:10.1037/a0039906. Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Hamilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103 (5), 943–951. doi:10.2105/AJPH.2013. 301241.

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Chang, S. C., & Singh, A. A. (2016). Affirming psychological practice with transgender and gender nonconforming people of color. Psychology of Sexual Orientation and Gender Diversity, 3 (2), 140. doi:10.1037/sgd0000153. Frost, D., & Meyer, I. (2009). Internalized homophobia and relationship quality among lesbians, gay men, and bisex­ uals. Journal of Counseling Psychology, 56 (1), 97–109. doi:10.1037/a0012844. Haas, A., Rodgers, P., & Herman, J. (2014). Suicide attempts among transgender and gender non-conforming adults: Findings of the National Transgender Discrimination Survey. American Foundation for Suicide Prevention & Williams Institute, University of California School of Law. Hays, P. A. (2008). Addressing cultural complexities in practice: Assessment, diagnosis, and therapy, 2nd edition. Wash­ ington, DC: American Psychological Association. Hays, P. A. (2013). Connecting across cultures: The helper’s toolkit. Thousand Oaks, CA: Sage. LeVasseur, M. T., Kelvin, E. A., & Grosskopf, N. A. (2013). Intersecting identities and the association between bully­ ing and suicide attempt among New York City youths: Results from 2009 New York City Youth Risk Behavior Survey. American Journal of Public Health, 103 (6), 1082– 1089. doi:10.2105/AJPH.2012.300994. Sue, D. W. (2010). Microaggressions in everyday life: Race, gen­ der, and sexual orientation. Hoboken, NJ: John Wiley & Sons. Tajfel, H., & Turner, J. C. (1979). An integrative theory of inter­ group conflict. In W. Austin & S. Worchel, The social psy­ chology of intergroup relations, 33–47. Monterey, CA: Brooks/Cole.

SMALL-GROUP DISCUSSION QUESTIONS • In your daily life, which identities are you the most aware of holding? • In what ways do you feel that conversations within the LGBT community are affected by other identities? For example, have you noticed that conversations change when someone who identifies as bisexual enters a conversation, or do you realize that people make jokes focused on race when only white people are around? • In your experience, how does identity affect conversations in the LGBT community at this college or university? • Which identities have you noticed are difficult to talk about in this LGBT community? • What part do you think you play in the way these conversations can be challenging?

L ARGE-GROUP DISCUSSION QUESTIONS • When was a time you were very aware of your race? • When was a time you were very aware of your gender presentation? • When was a time you were very aware of your sexual identity? • When was a time you were very aware of your ability status? • When was a time you were very aware of your religious or faith background? • When was a time you were very aware of your age? • When was a time you were very aware of your class or socioeconomic background? • Which identities are you the least aware of on a daily basis? (Give an example, such as ability status, and explain how being able-bodied allows you not to think about this identity until you see someone who is not as able-bodied.) • Talk about a time when the awareness of your own identity changed. Where were you? What was it like to notice a different part of your identity? • How has your own awareness of your identity evolved? • How does the way you identify affect your relationships with other people? (If participants do not attend to how their identity affects relationships with people who have similar or different identities from them, query them further.) • Are there times where you pay less attention to a core identity you hold? • How do you feel the community fosters inclusion of different opinions and different experiences?

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70 CREATING CONSCIOUSNESS TO CREATE CONNECTION: ATTENDING TO BIASES WHEN WORKING WITH QUEER VICTIM-SURVIVORS OF SEXUAL VIOLENCE Deborah O’Neill and Laura Kay Collins Suggested Use: Activity Objective

The goal of this activity is to increase clinician aware­ ness of internalized biases and assumptions about their clients’ various intersectional identities. Queeridentified individuals are vulnerable to the ways in which implicit biases affect their identity development throughout the life span (Gemberling et al., 2015; Greenwald & Krieger, 2006). Victim-survivors are also vulnerable to the ways that myths and assumptions about sexual violence are projected onto their experi­ ence (Süssenbach, Albrecht, & Bohner, 2017). This activity is designed to help groups of people (mental health clinicians, health-care workers, legal profes­ sionals) working with queer victim-survivors bring potential biases to the surface of their awareness. Throughout this chapter, the term victim­survivor denotes an identity associated with the experience of sexual violence. An aspect of recovery for people who have experienced this kind of trauma is having the power to control the language of the narrative. The internalization of an identity associated with sex­ ual violence is reflected in the terminology a person uses throughout the postviolence process (Hamby & Koss, 2003; Peterson & Muehlenhard, 2004). We acknowledge that there are many terms and ways to talk about sexual violence and honor the right of those who have experienced violence to claim their own identity. For the purpose of this chapter, however, we use the term victim­survivor. We use the term queer

in this chapter to represent multiple identities associ­ ated with the lesbian, gay, bisexual, transgender/trans­ sexual, queer/questioning, intersex, allies, asexual, and pansexual (LGBTQIAAP) community. Rationale for Use

Establishing safety in the therapeutic relationship is critical in reducing further harm to queer victimsurvivors (Munson & Cook, 2016; Neville & Henrick­ son, 2006; Sigurvinsdottir & Ullman, 2015). Trauma theories suggest that victim recovery occurs through processes of reconnection that reestablish victim safety, autonomy, identity, intimacy, and trust (Herman, 1992; Rothschild, 2000; van der Kolk, 2014). Creating safety within the therapeutic dyad obligates treating clinicians to attend to any implicit biases or assump­ tions that are present (Chapman, Kaatz, & Carnes, 2013; Dovidio & Fiske, 2012; Fallin-Bennett, 2015): “The science of implicit cognition suggests that actors do not always have conscious, intentional control over the processes of social perception, impression forma­ tion, and judgment that motivate their actions” (Greenwald & Krieger, 2006, p. 946). Unconscious bias may be directed toward social identities (Hays, 2008), or it may be directed toward identities associ­ ated with victim-survivorhood (Süssenbach et al., 2017). Implicit biases associated with stereotyped iden­ tities or assumptions about sexual violence can inter­ fere with treatment, compromise client safety, and project onto clients clinician-idealized outcomes for treatment (Chapman et al., 2013; Dovidio & Fiske,

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2012; Fallin-Bennett, 2015; Munson & Cook, 2016; Neville & Henrickson, 2006). Victim-blaming atti­ tudes, behaviors, and practices that cause victims to experience additional trauma have been defined as secondary victimization (Campbell, 2005). Vic­ tim-survivors who receive negative reactions upon disclosure are more likely to experience negative mental and physical consequences (Ullman, 2010). Lifetime sexual violence against gay and bisexual males ranges from 12 percent to 54 percent. Against lesbians and bisexual females, prevalence ranges from 16 percent to 85 percent (Rothman, Exner, & Baugh­ man, 2011), and 47 percent of respondents to the U.S. Transgender Survey reported experiencing sexual violence at some point in their lifetimes (National Center for Transgender Equality, 2015). Experiencing sexual violence situates victim-survi­ vors with a new layer of identity (Brison, 2002; Smith & Kelly, 2001). This victim-survivor identity is equally affected by the beliefs and norms inherent in the com­ munities within which victim-survivors exist (Ber­ kowitz, 2010; Campbell, Dworkin, & Cabral, 2009). For example, rape myths, which are faulty assumptions that influence cultural beliefs about rape, reinforce sex­ ual inequality by supporting male sex-drive discourse, blaming victims, and fostering ambiguity about the difference between sex and rape (Payne, Lonsway, & Fitzgerald, 1999). These kinds of socially constructed biases and assumptions about sexual violence can delegitimize victim-survivor experiences that do not conform to clinician-internalized beliefs (Chapman et al., 2013; Dovidio & Fiske, 2012). Working through the experience of sexual violence can help restore safety in a world that has been fraught with dangers for queer victim-survivors (Chapman et al., 2013; Dovidio & Fiske, 2012; Munson & Cook, 2016; Neville & Henrickson, 2006). This activity is designed to help clinicians make conscious what is too often left out of awareness. Greater attention to a vic­ tim-survivor’s cultural context can improve the deliv­ ery of mental health treatment (Griner & Smith, 2006). Feminist literature frames sexual violence as a crime motivated by issues of power and control (Brown­ miller, 1975; McPhail, 2015), and without introspective focus on unconscious biases, it would be possible to overlook or undervalue internalized beliefs associated

with privileged identities and identities in which power and control are enacted through the use of unreal­ ized biases. This activity seeks to make explicit how implicit evaluations represent our immediate response to people, objects, or events (Süssenbach et al., 2017), thus calling attention to internalized assumptions associated with possible privileged identities. The American Psychological Association (APA) and the National Association of Social Workers (NASW) advocated in the 1970s and 1980s for treat­ ment models for LGBTQIAAP clients that were more consistent with the specific and unique needs of these populations, as opposed to being tailored to the needs of heterosexual clients (Hunter & Hickerson, 2003). The establishment of gay-affirmative practice models provided clinicians and helping professionals with a framework for working with queer victim-survivors with the purpose of reducing unintended retrauma­ tization. This practice model is organized using guidelines that honor and validate the identities of LGBTQIAAP persons, encourage clients to explore internalized homophobia, and allow clients to be the architects of positive identities as LGBTQIAAP per­ sons (Crisp, 2006). Additionally, “It rests on a prem­ ise that appreciates diverse gender expressions and identities within society, and encourages the highest potential for individuals to follow their own paths to positive emotional well-being” (Edwards-Leeper, Lei­ bowitz, & Sangganjanavanich, 2016, p. 165). In addi­ tion, practices consistent with gay-affirmative values complement social work theories that emphasize a person-in-environment approach, a strengths per­ spective, and cultural competency (Edwards-Leeper et al., 2016). Of equal consideration is awareness of the pres­ ence in the health-care field of heteronormative assumptions and unexamined racial biases, both of which can contribute to further marginalization and invisibility for queer victim-survivors (Chapman et al., 2013; Dovidio & Fiske, 2012; Munson & Cook, 2016). This activity endeavors to unearth the intersection of possible cultural and racial biases, as well as biases directed toward victims of sexual violence. This activity has been informed by principles of social justice, awareness of the reciprocal influence of person-in-environment, a humanistic perspective, Creating Consciousness to Create Connection 611

and social work values of empowerment, advocacy, dignity, and inclusivity (NASW, 2017). This activity attends to the stress of living in a heteronormative society for LGBTQIAAP individuals, paying attention to how services tailored to heterosexual clients may affect their mental and emotional health. For institu­ tions and clinicians serving LGBTQIAAP populations, the possible neglect by practitioners in not address­ ing personal biases may unintentionally promote inter­ nalized homophobia and heterosexism in their cli­ ents (Ruckle, 2013). Catherine Crisp developed a scale to measure affirmative practice with LGBTQIAAP clients (2006). The Gay Affirmative Practice Survey is grounded in principles that support the following: (1) assumptions are not made about a client’s sexual­ ity; (2) an understanding that same-gender sexual desires are a distinct and normal variation of human sexuality; (3) an awareness that LGBTQIAAP accep­ tance is associated with positive development of sexual self; (4) attunement to possible internalized homopho­ bia as a means of decreasing said homophobia; (5) a working knowledge of the stages of the coming-out process; and (6) attention to internalized heterosexual biases and assumptions held by the clinician (Appleby & Anastas, 1998). Instructions

Facilitators should be careful not to single out any spe­ cific member’s silence in the room. If possible, offer­ ing activity descriptions before the meeting may allow victim-survivors an opportunity to opt out without publicly having to disclose their survivor status. Mem­ bers should be encouraged to practice self-care during and after the exercise. This activity requires self-aware­ ness, and therefore enough time and support should be allotted for this activity to help promote increased reflexivity. This activity is designed for a group of profession­ als who are working closely with queer victim-survi­ vors of sexual violence. It is meant to be used during a staff meeting or as a stand-alone workshop. The facil­ itator of the group will guide the participants through this activity. The materials needed are a large pad of paper (e.g., newsprint), a whiteboard, or a smartboard and a writing tool. The facilitator will share with the

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group the rationale for this activity and how it can be helpful in attending more directly to inherent biases. The facilitator will read three separate vignettes that provide minimal details about an experience of sexual violence. The vignettes provide a brief descrip­ tion of the violence narrative as reported by the vic­ tim-survivor. The facilitator will provide participants with worksheets to record their responses to the questions. The questions that follow the narrative are intended to elicit possible internalized assumptions associated with social identities and survivorship fol­ lowing a sexually traumatic experience. The facilita­ tor will guide group discussion about the differences and similarities between vignette details and clini­ cians’ assumptions. This discussion is intended to pro­ mote deeper consideration of the origins of biases and support the reintegration of a worked-through bias. Brief Vignette

The facilitators handed out the Participant Worksheets included in this chapter (pages 620–622) to team members. The facilitators used the Facilitator Work­ sheet (pages 616–617) as their guide. The activity began with the facilitators’ providing some information about a victim-survivor’s experience of a sexual trauma (Modified Vignettes, pages 616–617). Some of the identities of both the victim-survivor and the alleged offender were not provided initially, as the intention of the activity is to uncover assumptions participants may have associated with the possible multiple identities of the victim-survivor and the alleged offender. The facilitator allowed fifteen to twenty minutes for the members of the group to record their assump­ tions on the worksheets provided. The facilitator then invited members to share their responses and record their assumptions on a large piece of newsprint or on the whiteboard. Facilitators discussed confidentiality and established a safe environment, ensuring that members felt invited to share openly and honestly about their biases. Facilitators also offered a disclaimer that the exercise might be triggering and invited par­ ticipants to leave or to choose not to participate in this activity. Once the group completed the Participant Worksheet for Modified Vignette 1 (Jane), the facili­

tators read the complete description of case details (“Full Vignette 1 [Jane]”) to the group. Finally, the facilitators initiated a larger discussion in the group, encouraging participants to ask the group what they noticed about the differences between assumptions and the actual details of the full vignette. What is similar? What is different? What do these similarities and differences mean for our work with queer victim-survivors? How can we work on becom­ ing more aware of the biases that we hold? The facili­ tators allotted thirty to forty minutes for the larger group discussion; however, the time allotted for discus­ sion can be adapted to fit the needs of a specific group. For example, during discussion, a common assumption that might emerge from participants about the first Modified Vignette is that Jane is a heterosexual woman. We learn in the Full Vignette that Jane identi­ fies as a bisexual woman. The facilitators can engage the group in a discussion of models of gay-affirmative practices. The facilitators could introduce the idea that a gay-affirming professional would not assume that everyone is a heterosexual-identified person. Suggestions for Follow-up

Once clinicians have increased awareness about biases and assumptions, this activity can be used again with the group to explore other types of biases, such as those based on social class, able-bodied status, religious iden­ tities, ethnic origins, and any other possible contextual factors in a queer victim-survivor’s life. We encourage facilitators to offer a follow-up session or a meeting to check in about how the process felt and what the group needs to feel supported in this work. We encourage members to continue to work on engaging in reflexive practices to promote increased awareness of internal­ ized and implicit biases and assumptions. Contraindications for Use

To establish as much safety in this group activity as possible, it is important to acknowledge that this activ­ ity may feel activating for victim-survivors in the room. It is critical that the facilitators explicitly acknowl­ edge that this activity may be activating and that par­ ticipation in the activity is voluntary. Participants should not be forced to share what they recorded on

their worksheets, though all are invited and encour­ aged to participate. Professional Readings and Resources Brison, S. J. (2002). Aftermath: Violence and the remaking of a self. Princeton, NJ: Princeton University Press. Clarke, A. E., & Pino, A. L. (2016). We believe you: Survivors of campus sexual assault speak out. New York: H. Holt. Dick, K., & Ziering, A. (2016). The hunting ground: The inside story of sexual assault on American college campuses. New York: Hot Books. Douglas, R. M. (2016). On being raped. Boston: Beacon Press. Herman, J. (1992). Trauma and recovery: The aftermath of violence—from domestic abuse to political terror. New York: Basic Books. Hill Collins, P., & Bilge, S. (2016). Intersectionality. Malden, MA: Polity Press. INCITE! Women of Color against Violence (eds.). (2006). Color of violence: The Incite! anthology. Cambridge, MA: South End Press. Levine, P. (1997). Waking the tiger: Healing trauma. Berkeley, CA: North Atlantic Books. Patterson, J. (2016). Queering sexual violence: Radical voices from within the anti­violence movement. Riverdale, NY: Riverdale Avenue Books. Rothschild, B. (2000). The body remembers: The psychophysi­ ology of trauma and trauma treatment. New York: W. W. Norton. Van der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New York: Viking.

Resources for Clients Bass, E., & Davis, L. (2008). The courage to heal: A guide for women survivors of child sexual abuse, 4th edition. New York: Collins Living. Brison, S. J. (2002). Aftermath: Violence and the remaking of a self. Princeton, NJ: Princeton University Press. Clarke, A. E., & Pino, A. L. (2016). We believe you: Survivors of campus sexual assault speak out. New York: H. Holt. Davis, L. (1990). The courage to heal workbook: For women and men survivors of child sexual abuse. New York: HarperPerennial. Davis, L. (1991). Allies in healing: When the person you love was sexually abused as a child. New York: HarperPerennial. Dick, K., & Ziering, A. (2016). The hunting ground: The inside story of sexual assault on American college campuses. New York: Hot Books. Factora-Borchers, L. (2014). Dear sister: Letters from survivors of sexual violence. Oakland, CA: AK Press. Patterson, J. (2016). Queering sexual violence: Radical voices from within the anti­violence movement. Riverdale, NY: Riverdale Avenue Books.

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References Appleby, G., & Anastas, J. (1998). Not just a passing phase: Social work with gay, lesbian, and bisexual people. New York: Columbia University Press. Berkowitz, A. D. (2010). Fostering healthy norms to prevent violence and abuse: The social norms approach. http:// www.alanberkowitz.com/articles/Preventing%20Sexual% 20Violence%20Chapter%20-%20Revision.pdf. Black, M. C., Basile, K. C., Breiding, M. J., Smith, S. G., Walters, M. L., Merrick, M. T., . . . & Stevens, M. R. (2011). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 summary report. Atlanta: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Brison, S. J. (2002). Aftermath: Violence and the remaking of a self. Princeton, NJ: Princeton University Press. Brownmiller, S. (1975). Against our will: Men, women, and rape. New York: Simon and Schuster. Campbell, R. (2005). What really happened: A validation study of rape survivors’ help-seeking experiences with the legal and medical systems. Violence and Victims, 20, 55–68. Campbell, R., Dworkin, E., & Cabral, G. (2009). An ecological model of the impact of sexual assault on women’s mental health. Trauma, Violence, and Abuse, 10, 225–246. Chapman, E. N., Kaatz, A., & Carnes, M. (2013). Physicians and implicit bias: How doctors may unwittingly perpetu­ ate health care disparities. Journal of General Internal Medicine, 28 (11), 1504–1510. Crisp, C. (2006). The Gay Affirmative Practice Scale (GAP): A new measure for assessing cultural competence with gay and lesbian clients. Social Work, 51 (2), 115–126. Dovidio, J. F., & Fiske, S. T. (2012). Under the radar: How unexamined biases in decision making processes in clin­ ical interactions can contribute to health care disparities. American Journal of Public Health, 102 (5), 945–952. Edwards-Leeper, L. A., Leibowitz, S., & Sangganjanavanich, V. F. (2016). Affirmative practice with transgender and gender nonconforming youth: Expanding the model. Psychology of Sexual Orientation and Gender Diversity, 3 (2), 165–172. Fallin-Bennett, K., (2015). Implicit bias against sexual minori­ ties in medicine: Cycles of professional influence and the role of the hidden curriculum. Academic Medicine, 90, 549–552. doi:10.1097IACM.0000000000000662. Gemberling, T. M., Cramer, R. J., Miller, R. S., Stroud, C. H., Noland, R. M., & Graham, J. (2015). Lesbian, gay, and bisexual identity as a moderator of relationship function­ ing after sexual assault. Journal of Interpersonal Violence, 30, 3431–3452. doi:10.1177/0886260514563834. Greenwald, A. G., & Krieger, L. H. (2006). Implicit bias: Scien­ tific foundations. California Law Review, 94 (4), 945–967.

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Griner, D., & Smith, T. B. (2006). Culturally adapted mental health interventions: A meta-analytic review. Psychother­ apy: Theory, Research, Practice, Training, 43 (4), 531–548. doi:10.1037/00.33-3204.43.4.531. Hamby, S., & Koss, M. P. (2003). Shades of gray: A qualitative study of terms used in the measurement of sexual victim­ ization. Psychology of Women Quarterly, 27, 243–255. Hays, P. A. (2008). Addressing cultural complexities in practice: Assessment, diagnosis and therapy, 2nd edition. Washing­ ton, DC: American Psychological Association. doi:10. 1037/11650-000. Herman, J. H. (1992). Trauma and recovery. New York: Basic Books. Hunter, S., & Hickerson, J. (2003). Affirmative practice: Under­ standing and working with lesbian, gay, bisexual, and trans­ gender persons. Baltimore: NASW Press. McPhail, B. (2015). Feminist framework plus: Knitting feminist theories of rape etiology into a comprehensive model. Trauma, Violence and Abuse, 17, 314–29. doi:10.1177/15 24838015584367. Munson, S., & Cook, C. (2016). Lesbian and bisexual women’s sexual healthcare experiences. Journal of Clinical Nursing, 25, 3497–3510. National Association of Social Workers (NASW). (2017). Code of ethics of the National Association of Social Workers. https://www.socialworkers.org/about/ethics/code-of-ethics. National Center for Transgender Equality. (2015). The report from the 2015 U.S. Transgender Survey. http://www. ustranssurvey.org/. Neville, S., & Henrickson, M. (2006). Perceptions of lesbian, gay and bisexual people of primary healthcare services. Journal of Advanced Nursing, 55, 407–415. Payne, D. L., Lonsway, K. A., and Fitzgerald, L. F. (1999). Rape myth acceptance: Exploration of its structure and its measurement using the Illinois Rape Myth Acceptance Scale. Journal of Research in Personality, 33 (1), 27–68. Peterson, Z. D., & Muehlenhard, C. L. (2004). Was it rape? The function of women’s rape myth acceptance and defi­ nitions of sex in labeling their own experiences. Sex Roles, 51 (3), 129–144. Rothman, E. F., Exner, D., & Baughman, A. L. (2011). The prev­ alence of sexual assault against people who identify as gay, lesbian, or bisexual in the United States: A systematic review. Trauma Violence Abuse, 12 (2), 55–66. doi:10.117 7/1524838010390707. Rothschild, B. (2000). The body remembers: The psychophysi­ ology of trauma and trauma treatment. New York: W. W. Norton. Ruckle, V. (2013). Gay affirmative practice: Clinical social workers’ perspectives. Master’s thesis, St. Catherine Uni­ versity. https://sophia.stkate.edu/cgi/viewcontent.cgi? article=1257&context=msw_papers.

Sigurvinsdottir, R., & Ullman, S. E. (2015). The role of sex­ ual orientation in the victimization and recovery of sexual assault survivors. Violence and Victims, 30 (4), 636–648. doi:10.1891/0886-6708.VV-D-13-00066. Smith, M. E., & Kelly, L. M. (2001). The journey of recovery after a rape experience. Issues in Mental Health Nursing, 22, 337–352. Süssenbach, P., Albrecht, S., & Bohner, G. (2017). Implicit judg­ ments of rape cases: An experiment on the determinants and consequences of implicit evaluations in a rape case. Psychology, Crime and Law, 23 (3), 291–304.

Ullman, S. E. (2010). Talking about sexual assault: Society’s response to survivors. Washington, DC: American Psycho­ logical Association. Van der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New York: Viking. Walters, M. L., Chen, J., & Breiding, M. (2010) The National Intimate Partner and Sexual Violence Survey (NISVS) 2010–2012 state report: 2010 findings on victimization by sexual orientation. Atlanta: National Center for Injury Pre­ vention and Control, Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/ pdf/NISVS-StateReportBook.pdf.

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WORKSHEETS FOR GROUP EXERCISE

FACILITATOR WORKSHEET This worksheet includes the full vignettes that the facilitators will use to engage the larger group in a discussion about the differences between assumptions recorded by participants on their worksheets and the actual details of the vignette. Instructions: Read the modified vignette to the group and allow time for them to record their assumptions on the Participant Worksheet. Record the group’s assumptions on a large sheet of paper or a board. The facilitator will read the full vignette provided below and use the reflection questions below to open up a dialogue. Repeat for each vignette. Note: These vignettes are based on composites of several clinical cases. The composite is intended to preserve the privacy and confidentiality of victim-survivors. Modified Vignette 1 (Jane): Jane is a thirty-four-year-old medical student. She identifies as Caucasian and female. She experienced childhood sexual abuse from the ages of eight to ten. She had a substance abuse history from ages ten to eighteen. She lived in a rehab and halfway house. Jane sought therapy after becoming pregnant and feeling activated by the pregnancy. Full Vignette 1 (Jane): Jane is a bisexual, genderqueer woman who was consistently sexually assaulted by her fourteen-year-old cismale neighbor. Jane was very fond of her neighbor and wanted to please him. Jane was orally penetrated over a period of one year by her neighbor. She believed as a ten-year-old that the ejaculation in her mouth could result in pregnancy. She was terrified of becoming pregnant at the time. She did not realize until the abuse ended that something was wrong with the abuse. The abuse took place in the backyard of her neighbor’s house. While in rehab and during family therapy, Jane’s parents blamed her for the abuse and her subsequent alcohol dependence. At the age of thirty-four, Jane was impregnated by her male partner. As Jane became connected to the life she was carrying, she was activated by memories of herself as a child sexual-abuse victim-survivor. Questions What are your assumptions about the alleged offender? What are your assumptions about Jane’s family of origin? What are your assumptions about Jane’s substance abuse? What are your assumptions about why Jane is seeking support now? What are your assumptions about the type of abuse Jane experienced? What are your assumptions about where the abuse took place? What are your assumptions about Jane’s sexual orientation? What are your assumptions about Jane’s gender identity?

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Modified Vignette 2 (Jamal): Jamal is a nineteen-year-old, African American male. He was raped at a party. He was raised with strong religious beliefs and expectations that he would marry and have children. He has been questioning his sexuality. Full Vignette 2 (Jamal): Jamal identifies as heterosexual. Jamal also questions his sexual orientation. He does not drink alcohol. Jamal’s strict religious beliefs as a Jehovah’s Witness are associated with his intention to marry a cis-identified woman. Jamal attended the party with peers from his college dorm. Jamal was anally raped. Jamal is the child of an intact family of married, heterosexual parents. Jamal came to therapy to talk about how to tell his future partner about this experience. Questions What are your assumptions about Jamal’s sexual orientation?

What are your assumptions about Jamal’s religious background?

What are your assumptions about Jamal’s behavior at the party?

What are your assumptions about nineteen-year-old African American males?

What are your assumptions about Jamal’s family?

What are your assumptions about what Jamal wants from therapy?

What are your assumptions about the nature of Jamal’s rape?

What are your assumptions about Jamal’s gender identity?

Modified Vignette 3 (Deborah): Deborah is an eighteen-year-old female. She was sexually assaulted from the ages of twelve to eighteen. She grew up in foster care. She took a leave of absence from college one month after she arrived. Full Vignette 3 (Deborah): Deborah is a Caucasian cisgender female. The offender was her cisgender foster mother. Deborah’s biological parents were substance abusers. Her father was incarcerated. Deborah was in foster care from the time she was ten years old. Deborah reports dealing with the childhood sexual abuse in her previous therapeutic experiences, which she found helpful. When she presented for therapy this time, it was because she became activated when showering with her boyfriend. She was consistently molested in the shower by her foster mother. Questions What are your assumptions about Deborah’s racial identity?

What are your assumptions about the offender’s identity?

What are your assumptions about Deborah’s family of origin?

What are your assumptions about children who grow up in foster care?

What are your assumptions about Deborah’s leave of absence from college?

What are your assumptions about Deborah’s experience with therapeutic support?

What are your assumptions about the details of Deborah’s molestation?

What are your assumptions about Deborah’s gender identity?

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SAMPLE COMPLETED WORKSHEET VIGNETTE 1: Jane Jane is a thirty-four-year-old medical student. She identifies as Caucasian and female. She experienced childhood sexual abuse from the ages of eight to ten. She had a substance abuse history from ages ten to eighteen. She lived in a rehab and halfway house. Jane sought therapy after becoming pregnant and feeling activated by the pregnancy.

What are your assumptions about the alleged offender? • The offender was a male drug addict. • The offender was an adult male-identified person. • The offender was a heterosexual. What are your assumptions about Jane’s family of origin? • Parents were misattuned to their daughter. • Parents were substance abusers. • Jane had unmarried parents; Jane was probably raised by a single parent.

What are your assumptions about Jane’s substance abuse? • There is a family history of substance abuse. • Jane was using when she became pregnant. • Jane was addicted to heroin.

What are your assumptions about why Jane is seeking support now? • Jane was arrested and mandated for treatment. • Jane is upset about and may want to terminate the pregnancy. • Jane’s partner insisted that she start therapy.

What are your assumptions about the type of abuse Jane experienced? • Jane was abused by a parent. • Jane was abused by an adult. • Jane experienced forcible, penetrative rape by a male.

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What are your assumptions about where the abuse took place? • The abuse occurred in Jane’s home. • The abuse occurred in the offender’s home. • The abuse took place in secret.

What are your assumptions about Jane’s sexual orientation? • Jane is heterosexual. • Jane is asexual. • Jane is poly.

What are your assumptions about Jane’s gender identity? • Jane is a woman.

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PARTICIPANT WORKSHEET 1 VIGNETTE 1: Jane Jane is a thirty-four-year-old medical student. She identifies as Caucasian and female. She experienced childhood sexual abuse from the ages of eight to ten. She had a substance abuse history from ages ten to age eighteen. She lived in a rehab and halfway house. Jane sought therapy after becoming pregnant and feeling activated by the pregnancy.

What are your assumptions about the alleged offender?

What are your assumptions about Jane’s family of origin?

What are your assumptions about Jane’s substance abuse?

What are your assumptions about why Jane is seeking support now?

What are your assumptions about the type of abuse Jane experienced?

What are your assumptions about where the abuse took place?

What are your assumptions about Jane’s sexual orientation?

What are your assumptions about Jane’s gender identity?

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PARTICIPANT WORKSHEET 2 VIGNETTE 2: JAMAL Jamal is a nineteen-year-old African American male. He was raped at a party. He was raised with strong religious beliefs and expectations that he would marry and have children. He has been questioning his sexuality.

What are your assumptions about Jamal’s sexual orientation?

What are your assumptions about Jamal’s religious background?

What are your assumptions about Jamal’s behavior at the party?

What are your assumptions about nineteen-year-old African American males?

What are your assumptions about Jamal’s family?

What are your assumptions about what Jamal wants from therapy?

What are your assumptions about the nature of Jamal’s rape?

What are your assumptions about Jamal’s gender identity?

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PARTICIPANT WORKSHEET 3 VIGNETTE 3: DEBORAH Deborah is an eighteen-year-old female. She was sexually assaulted from the ages of twelve to eighteen. She grew up in foster care. She took a leave of absence from college one month after she arrived. What are your assumptions about Deborah’s racial identity?

What are your assumptions about the offender’s identity?

What are your assumptions about Deborah’s family of origin?

What are your assumptions about children who grow up in foster care?

What are your assumptions about Deborah’s leave of absence from college?

What are your assumptions about Deborah’s experience with therapeutic support?

What are your assumptions about the details of Deborah’s molestation?

What are your assumptions about Deborah’s gender identity?

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71 ADDRESSING ANTI-TRANS PREJUDICE: DECODING THE GENDER MATRIX Soumya Madabhushi Suggested Use: Activity Objective

This chapter outlines an outreach workshop designed to enhance empathy for the experience of gender dis­ sonance and for trans-identified individuals. The set of activities described can be used with members of any community. The goals of the activities are (1) to increase the participants’ awareness of gender as nonbinary and as a complex, intricate code written into the fabric of our lives, (2) to encourage exploration of participants’ own gender as opposed to an unquestion­ ing living out of gender expectations, and (3) to allow for exploration of privileges and marginalizations asso­ ciated with different gender identities and expressions. Rationale for Use

Gender has been perceived in our society as a binary construct with mutually exclusive categories of male or female, man or woman, boy or girl (Benjamin, 1966; Tanis, 2003). Such dichotomization of gender misses the rich variety of experiences that exist somewhere along the continuum and pressures people to exist at these poles (Egan & Perry, 2001; Witten & Eyler, 1999). Transgender and gender-nonconforming (TGNC) people are individuals who have a gender identity that is not fully aligned with the sex they were assigned at birth (APA, 2015). TGNC people may experience and express gender outside the binary, and the degree to which these individuals’ gender identity differs from their sex assigned at birth varies. The adherence of mainstream society to the gender binary and anti-trans prejudice adversely affect TGNC people within their families, schools, neighborhoods, workplaces, reli­

gious traditions and communities, and health-care and legal systems (Grant et al., 2011). Research has documented the extensive experi­ ences of stigma and discrimination that TGNC indi­ viduals encounter (Grant et al., 2011; Lombardi, Wilchins, Priesing, & Malouf, 2001; Mizock & Mueser, 2014). A national study (Grant et al., 2011) that sur­ veyed 6,450 TGNC individuals reported that discrim­ ination was pervasive throughout the sample: indi­ viduals faced a combination of anti-transgender bias and structural discrimination leading to devastating outcomes for them. For instance, 63 percent of the par­ ticipants had experienced a serious act of discrimi­ nation such as loss of employment, eviction, denial of medical services, incarceration, bullying, or assault that was due to bias, and about 23 percent of respon­ dents experienced a catastrophic level of discrimina­ tion, having been affected by at least three of the above major life-disrupting events because of bias. According to Stotzer (2009) a majority of trans people are likely to be victims of violence in their lifetimes. GLAAD, a U.S. advocacy group that tracks murders of TGNC individuals, reported that in 2016 twentyseven transgender people were killed in the United States, and nearly all of the victims were transgender women of color; and by mid-2017 at least six transgender people had been fatally shot or killed by other violent means. Besides physical danger and systemic discrimina­ tion, TGNC individuals encounter several forms of mistreatment and exclusion. Nadal, Skolnik, and Wong (2012) identified twelve categories of microaggressions faced by TGNC individuals: (1) use of transphobic or incorrectly gendered terminology, (2) assumption

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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of universal transgender experience, (3) exoticization, (4) discomfort with or disapproval of transgender experience, (5) endorsement of gender-normative and binary culture or behaviors, (6) denial of existence of transphobia, (7) assumption of sexual pathology or abnormality, (8) physical threat or harassment, (9) denial of individual transphobia, (10) denial of bodily privacy, (11) familial microaggressions, and (12) sys­ temic and environmental microaggressions. Encoun­ tering such harassment, mistreatment, discrimina­ tion, and violence can take a significant toll on TGNC individuals. Bockting and colleagues (2013) invoked the minority stress model and found that the stress asso­ ciated with stigma, prejudice, and discrimination increases rates of psychological distress in the transgender population. Their sample of 1,093 TGNC respondents had a high prevalence of clinical depres­ sion (44.1 percent), anxiety (33.2 percent), and soma­ tization (27.5 percent). One estimate of the incidence of major depression among transgender individuals was three times that of the general population (54 percent; Nuttbrock et al., 2010). In another study, more than half of transgender participants met criteria for clinical depression (56 percent, n = 16) (Reisner, Perkovich, & Mimiaga, 2010). Increased rates of sui­ cidality (61 percent), serious mental illness (43 per­ cent), medical and psychiatric disabilities (>50 per­ cent), and depression (20 percent) were noted in a study of transgender veterans (McDuffie & Brown, 2010). Higher rates of substance abuse, sexual risk taking, and suicidality have also been found among transgender individuals compared to their cisgender counter­ parts (Mustanski, Garofalo, & Emerson, 2010; Reisner et al., 2010). Suicidality has been noted in one-third to one-half of some samples (Clements-Nolle, Marx, & Katz, 2006; Grant et al., 2011; Reisner et al., 2010). High rates of suicidal ideation (54 percent), suicide plans (35 per­ cent), and suicide attempts (28 percent) have also been found (Nuttbrock et al., 2010). In the recent National Transgender Discrimination Survey (Grant et al., 2011) 41 percent of respondents reported attempting sui­ cide, compared to 1.6 percent of the general popula­ tion; rates rose for those who lost a job because of bias (55 percent), were harassed or bullied in school (51

percent), or were the victim of physical assault (61 per­ cent) or sexual assault (64 percent). These findings reflect the need for additional study of the effect of prejudice and discrimination on transgender individ­ uals and also highlight the public health and social justice implications for understanding and reducing such prejudice and discrimination. In keeping with the general principles of justice and equality articulated in the APA ethics code (2017), it is incumbent on psychologists to examine their beliefs regarding gender, gender stereotypes, and TGNC identities as well as their own gender identity and gendered experiences of privilege, power, or margin­ alization in order to ensure that their actions and practices are just, respectful, and affirming of all peo­ ple from all backgrounds. Clinicians adopting and making known an affirming clinical position that recognizes all experiences of gender as equally healthy and valuable, and allowing for an authentic articula­ tion of gender identity and gender expression, can improve TGNC people’s health, well-being, and qual­ ity of life (Austin & Craig, 2015; Lev, 2004; Witten, 2003). The APA (2015) highlighted the role that psy­ chologists can play in reducing stigma surrounding gender nonconformity and challenging anti-trans prej­ udice, thereby developing safer environments for TGNC individuals by examining their own gender identity and gendered experiences of privilege, power, or marginalization; by assessing their work settings and making appropriate changes to create welcoming spaces; by providing training to support staff on ways to respectfully interact with TGNC individuals; and by assisting TGNC individuals and their communities to challenge gender norms and stereotypes through trainings about the healthy variation of gender iden­ tity and gender expression. Singh and Burnes (2009) note the value of psychologists’ providing trainings on anti-trans prejudice to administrators, teachers, and school counselors in an attempt to develop safer school environments for TGNC students. To reduce anti-trans prejudice in public attitudes and social policies, it is critical to have a greater under­ standing of the underlying factors and key correlates of such prejudice. In an analysis of a trans communi­ ty’s experiences, Hill (2002) suggested that three key constructs can be used to conceptualize hate against

Addressing Anti-Trans Prejudice: Decoding the Gender Matrix 625

trans persons: transphobia, genderism, and gender bashing. Hill explains that transphobia, like homopho­ bia, is an emotional disgust or revulsion toward indi­ viduals who do not conform to society’s gender expec­ tations. Genderism, which is similar to heterosexism (Hill, 2002), is an ideology that reinforces the negative evaluation of gender nonconformity or an incongru­ ence between sex and gender. Genderism leads to negative judgment of people who do not conform to sociocultural expectations of gender as less worthy, less normal, or pathological. Finally, gender-bashing refers to the assault or harassment of persons who do not conform to gender norms. Thus, genderism is the broad negative cultural ideology, transphobia is the emotional disgust and fear, and gender-bashing is the fear manifest in acts of violence (Hill, 2002). These three elements reflect the traditionally triadic model of attitudes consisting of affective, cognitive, and behavioral elements. Hill and Willoughby (2005) created the Genderism and Transphobia Scale (GTS), which is intended to measure these three constructs. Factor analysis done by the creators of this scale revealed a strong two-fac­ tor solution: genderism/transphobia and gender-bash­ ing. Using this scale with a Hong Kong sample, Winter, Webster, and Cheung (2008) identified a five-factor solution composed of (1) anti-sissy prejudice (i.e., “antipathy toward gender variant men,” p. 675), (2) anti-trans violence (i.e., “violent antipathy extending to cross-gendered behaviors in both sexes,” p. 675), (3) trans unnaturalness (i.e., the extent to which gender variance is seen as “violating either a divine or natural order,” p. 676), (4) trans immorality (i.e., immorality of how trans people present to others and of surgery to alter genitalia), and (5) background genderism (a mis­ cellany of items on the survey that seem to capture the negative evaluations of gender nonconformity). This articulation of underlying factors helps determine directions for addressing anti-trans prejudice. Given the conflation of sex, sexual orientation, and gender identity and expression, it may be difficult to distinguish between homophobia and transphobia. It may be difficult to determine whether an effeminate gay man is feared or hated for his gender or sexuality. Correlations between the Homophobia Scale (Wright, Adams, & Bernat, 1999) and the Transphobia Scale 626 Madabhushi

(Nagoshi et al., 2008), as well as the GTS, bear out this hypothesized connection between homophobia and transphobia (Hill & Willoughby, 2005; Nagoshi et al., 2008; Tebbe & Moradi, 2012; Tebbe, Moradi, & Ege 2014). Anti-trans prejudice has further been found to be correlated with traditional gender role attitudes (Hill & Willoughby, 2005; Nagoshi et al., 2008; Tebbe & Moradi, 2012; Tebbe et al., 2014). Anti-trans prej­ udice was also found to be correlated with right-wing authoritarianism and religious fundamentalism (Nagoshi et al., 2008) as well as a social-dominance orientation and a need for closure (Tebbe & Moradi, 2012; Tebbe et al., 2014). Men express greater anti-trans prejudice than women do (Nagoshi et al., 2008; Tebbe & Moradi, 2012; Tebbe et al., 2014; Winter, Webster, & Cheung, 2008). Winter and colleagues (2008) also noted that antipa­ thy toward gender variance was especially strong in relation to gender-variant boys and men as compared to gender-variant girls and women. The strong associations between anti-LGB preju­ dice and anti-trans prejudice across various studies lends credence to Fassinger and Arseneau’s (2007) con­ ceptualization that LGB and trans individuals’ shared experience of prejudice may reflect their shared sta­ tus as perceived gender transgressors. Nagoshi et al. (2008), citing the significant and strong correlation of both transphobia and homophobia with right-wing authoritarianism, religious fundamentalism, and hos­ tile sexism for both sexes, note that a large part of what drives these prejudices was possibly socialization into “conservative,” “traditional” social values and that men and women are influenced by conventionalism to hold negative attitudes toward any socially nonconforming groups, including homosexuals and transsexuals. A second source of prejudice in men only is a hypermasculinity that seems to reflect a proneness to aggression in order to maintain power (Nagoshi et al., 2008). Men’s anxieties of loss of social power seem to get activated when confronted with nontraditional gender manifestations, whether of gender identity, gen­ der roles, or sexual preferences. This anxiety, in turn, seems to promulgate both transphobia and homopho­ bia in men. This finding was also supported by Egan and Perry (2001), who demonstrated the motivated nature of gender dichotomization by establishing that

men, but not women, dichotomize more strenuously when reminded of the precariousness of their gender status. Men also report stronger motivation to restore their gender status upon learning that their in-group is becoming less dichotomized. These findings are also consistent with Bettcher’s (2007) idea that transphobia in men arises from the anger felt by straight men over being “deceived” by male-to-female transgen­ der individuals about the latter’s actual sexed body and the subordinate power relationship that a female body implies. A third source of prejudice against transgender individuals, particularly for women, is the fear of loss of social power specifically associated with deviations from traditional gender roles. The current field of knowledge on the key cor­ relates of anti-trans prejudice points to traditional gen­ der-role ideology as well as ideas of male superiority and hypermasculinity as potentially valuable targets in interventions aiming to reduce anti-trans preju­ dice. Understanding and challenging anti-trans prej­ udice may involve not only the exploration of one’s attitudes toward the other (i.e., TGNC individuals) but also the exploration of one’s own gender-role attitudes and their interpersonal and intrapersonal manifesta­ tions. Also necessary might be an exploration of male privilege, the attendant anxieties of losing male priv­ ilege, and the constraints that result from hanging on to this privilege. Other targets of intervention seem to be homophobia, rigidity in adherence and submis­ sion to social conventions and norms, a predisposition toward anti-egalitarianism within and between groups, and need for closure. Research has found that personal acquaintance with a TGNC individual mediates discriminatory responses and attitudes (Harvey 2002; Hill & Wil­ loughby, 2005). No research is available that evalu­ ates programs addressing anti-trans prejudice. A comprehensive prevention program might need to address all the above-mentioned factors. For activi­ ties addressing sexism and heterosexism, see Adams, Bell, and Griffin (1997). Research also indicates that increased self-esteem and increased empathy might lower right-wing authoritarianism and social domi­ nance orientation (Greenberg et al., 1992; Pysz­ cynski, Solomon, & Greenberg, 2002). The activity in

this chapter focuses on addressing the exploration of one’s own gender-role attitudes with a particular focus on increasing empathy for the experience of gender dissonance. Instructions

To achieve our goal of enhancing empathy for TGNC individuals, modeling empathy is important, but we must do so without validating intolerance. A process goal for the workshop is to reduce defensiveness and encourage lateral thinking. A trigger warning along with information about available resources may also be in order. Icebreakers. Starting workshops with an ice­ breaker often is standard practice. An icebreaker is described here for use with this particular workshop. Ask participants to pair up with a person they do not know and take a minute each to respond to the fol­ lowing question: Which superpower would you like to have and why? This specific activity can be fun and can get peo­ ple actively engaged in a nonthreatening conversa­ tion with fellow participants whom they did not pre­ viously know. In a subtle way, this question gets people thinking about which rules of the physical world they find constraining and would like to break. This activ­ ity allows for outside-the-box thinking. It also gets participants connected to feelings about rules. Present­ ers might switch up the icebreaker to suit their per­ sonalities and their audience’s characteristics, but they are encouraged to keep the key features in mind while selecting an activity. At the end of the two minutes, depending on the size of the audience and amount of time available, presenters may choose to hear from all the participants or just seek out one or two volun­ teers to share their responses. Agenda and guidelines. Discuss the following goals for the workshop: • Know the differences between sex, gender, and gender roles • Know that gender identity is on a spectrum and not a dichotomy • Explore one’s own gender-role expectations • Gain greater empathy for the experience of gender dissonance

Addressing Anti-Trans Prejudice: Decoding the Gender Matrix 627

Establish some community guidelines in collab­ oration with participants to allow for safety and cre­ ation of an exploratory space. • Share one’s own reactions from one’s own perspec­ tives: “I” statements • Listen respectfully to different perspectives • Share air time (step up/step down) Presenters should set the space by recognizing differ­ ences in the room and how we all come to our differ­ ent perspectives on the basis of our different lived experiences. This workshop is about pushing and chal­ lenging ourselves to see if we can understand a per­ spective different from our own. Information. Using a PowerPoint presentation or a poster board, take fifteen minutes to share some information about sex, gender, gender roles, and the trans experience (see Lev, 2004). Include scientific information about gender’s not being a dichotomy and the many factors that play into people’s experience of their own gender. Activity. Presenters now introduce the workshop’s main activity. Start by asking the participants if they remember the movie The Matrix (1999). Give a quick synopsis of the movie. Below is the synopsis of the movie from the IMDb website: Thomas A. Anderson is a man living two lives. By day he is an average computer programmer and by night a hacker known as Neo. Neo has always questioned his reality, but the truth is far beyond his imagination. Neo finds himself targeted by the police when he is contacted by Morpheus, a legendary computer hacker branded a terrorist by the government. Morpheus awakens Neo to the real world, a ravaged wasteland where most of humanity have been captured by a race of machines that live off of the humans’ body heat and electro­ chemical energy and who imprison their minds within an artificial reality known as the Matrix. As a rebel against the machines, Neo must return to the Matrix and confront the agents: super-pow­ erful computer programs devoted to snuffing out Neo and the entire human rebellion. (redcom­ mander27, IMDb, Storyline section) Talk to the participants about how the Matrix is the artificial reality in which most of the humans in this 628 Madabhushi

movie exist. They live by this computer code and never realize that they are in an artificial reality. Most people inside the world cannot see the code. Even powerful characters in the movie, like Morpheus and Trinity, are able to flex and bend the code when in it, but they cannot actually see it and fully break free from it. As his character evolves, Neo is inside the Matrix and is able to see the artificial reality as lines of code. Discuss how the Matrix can be a good analogy for understanding gender-role expectations. The code for how gender is to be played is well established, but it is hard to see the code. We are subject to this code con­ stantly and live by it but cannot see it. The complex programming that goes into shaping male and female behaviors can be difficult to decode. Invite the par­ ticipants to engage in a game to see if they can work toward decoding this gender matrix. Give the following instructions to participants. Imagine that you are in a sci­fi movie. You realize that you have suddenly been transported into a matrix. All the rules of the world apply. If you fall down in the matrix, you will hurt. If you die in the matrix, you die. The only thing that is different, however, is that gender­ role expectations have been reversed. Rules, norms, and expectations associated with femininity now apply to men, and vice versa. Pair up with a partner and take five minutes to discuss the following questions: • What adjustments, if any, would you make to meet those expectations? • What would be easy and what would be difficult? • What would be lost and what would be gained? Come back to the larger group. What were some thoughts that came up in response to these questions? Allow some time for a large-group conversation. Guide the conversation to a discussion of societal gen­ der-role expectations as well as aspects of these expec­ tations that feel easy for participants and the ones that feel constraining or difficult. Encourage further reflection on questions such as how the adjustments that participants came up with would be different depending on race, ethnicity, religion, or if the matrix was stuck in their grandparents’ generation or was set in a different country. Continue with the follow­ ing instructions.

Let’s now try an improv exercise. Leave inhibitions at the door. We know that most of you are not actors, but see if you can lean in and try this out for a bit. Feeling uncomfortable is part of the deal. Pick out one of these cards from the box. The cards say Male, Female, or Agender. Imagine you are at a cocktail party. Talk to people as if you are the gender that you picked. It might feel unnatural, silly, uncomfortable, exaggerated. It’s okay. Just see what it feels like. After two to five minutes, bring the group back to a larger group discussion. Facilitate a conversation deal­ ing with the following questions: What was that expe­ rience like? What feelings came up? If you had to play a gender that is different from the way you iden­ tify, what did you do? If you had to play a gender that is the same as the gender you identify as, what did you do? What was easy? What was difficult? Through facilitating this conversation, bring out themes of gender as performance. Cue participants to the discomfort they may have felt in performing a gender different from the way they identify. Make connections to how their experience might be similar to the gender dysphoria that TGNC individuals might feel when they are boxed into living out gender-role expectations that do not fit them. End the workshop with introducing some trans narratives (videos, audios, written word) that speak to the felt identity of a TGNC person (www.transnarratives.org has many interviews to choose from). End the presentation by normalizing any difficult feelings that might have come up. Offer information on available mental health resources should anyone experience difficult feelings that persist. Vignette 1

Facilitator: What was that experience of performing a certain gender like? Participant 1: You know, initially I just felt it was really silly and awkward. I identify as a woman and my card said Male. I found myself trying to make my voice sound lower and walked more stiffly, with my chest puffed out a little bit. I introduced myself to my part­ ner as a mechanical engineer. The minute I did that I found myself wondering about that, you know . . . I am a teacher and I could have just said that. It was as if I

couldn’t be a teacher if I was a man and somehow being

an engineer was more masculine!

Facilitator: It sounds like you surprised yourself

with that.

Participant: Yeah. I think of myself as a fairly open-

minded person, and when we started this exercise I

felt this was a bit silly and trying to act like a man,

when we are talking also about how gender is nonbi­ nary felt very reductive. As we were starting the activ­ ity I figured I am going to pick the most stereotyped

ideas of maleness to act out. The voice and the walk—

those I guess I had already thought of. The job—I

didn’t think about it before I said it.

Facilitator: Some of these ideas of what is masculine

and what is feminine can be operating in us at a very

subconscious level. Our hope with this activity is to

make us more aware of some of these notions.

Vignette 2

Participant 1: I have always been a girly girl and it has always worked for me, and trying not to be one, even for just a few minutes, was just weird. Facilitator: So you are comfortable being the girly girl, and it was uncomfortable to be asked to act in ways that are counter to your usual way of being. Could you say more about being a girly girl? Participant 1: Sure. I just am very feminine. I like my hair long. I wear dresses most of the time . . . jewelry, makeup always. I have been told I have a gentle, soft voice. My mannerisms tend to be soft, fluid . . . I don’t know how best to explain it. And I noticed in the activity that I was trying not to be those things. I was trying to talk louder, more assertively. I was holding myself more stiffly. Participant 2: That’s interesting to hear. I didn’t have much difficulty trying to act male. I identify as a woman, but I wouldn’t say I am a girly girl. Never have been. I like dresses but only rarely wear them. I tend to be a bit more brusque in my manner. I grew up with three brothers, you know. I learned quickly to hold my own with them. Facilitator: It sounds like both of you identify as women but have some different ways of expressing your gender. Also, both of you seem to have some

Addressing Anti-Trans Prejudice: Decoding the Gender Matrix 629

specific ideas about what is or is not masculine and feminine. Participant 2: Oh, definitely! The number of times I was told growing up that I needed to wear a dress, or be a little less rowdy, or stay in and help my mom with the cooking! I suppose I wasn’t enough of a girl for them. Facilitator: So not fitting the norms for your gender identity gets you some pushback. Suggestions for Follow-up

Presenters may encourage participants to continue reflection by leaving them with the following questions: • What are some questions regarding gender identity that feel salient to you? • How might you go about finding answers? (High­ light the importance of approaching these question from a place of “I don’t quite understand, help me,” as opposed to an aggressive challenging of some­ one’s truth.) • How might you in the future allow for more vari­ ability in experience and expressions of gender? Contraindications for Use

This workshop is suitable for any group of adult partic­ ipants. One issue might be that the movie used to set up the analogy and the activity might not be known to all the participants, and the analogy might feel less powerful for those who have not seen the movie. While you may never have a group in which all participants have seen the movie, our hope is that a good percent­ age will have seen it. Using the synopsis, or perhaps even a trailer, might clarify the issue a bit. The Matrix was an iconic movie from the 1990s. If the partici­ pants are largely in the twenty-or-below age range, it would be better not to use The Matrix as the analogy. Perhaps a more current movie could be substituted and used with similar effect. For instance, Divergent (2014) has many relevant themes of societal pressures forcing individuals into playing narrowly defined roles. In addition, appropriate accommodations would need to be made for those with any auditory or visual impairments. Another consideration for presenters is knowing the group’s receptiveness to being challenged along these lines. If the group is in any way mandated 630 Madabhushi

to attend, the facilitator could encounter a greater amount of resistance, which can manifest itself in participants not fully engaging in the activities or even actively challenging the presenters or being overtly microaggressive. Presenters may need to adapt accord­ ingly. If overtly challenged, presenters may need to engage directly in sharing feedback with participants about the effects of their microaggressions on the presenters and others. Professional Readings and Resources Adams, M., Bell, L. A., & Griffin, P. (1997). Teaching for diversity and social justice: A source book. New York: Routledge. American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. http://www.apa.org/practice/guidelines/ transgender.pdf. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. http:// www.apa.org/ethics/code/index.aspx. Bornstein, K. (1994). Gender outlaw: On men, women, and the rest of us. New York: Routledge. Nadal, K. (2013). That’s so gay! Microaggressions and the lesbian, gay, bisexual, and transgender community. Washington, DC: American Psychological Association. Singh, A. A., & dickey, l. m. (eds.). (2017). Affirmative coun­ seling and psychological practice with transgender and gender nonconforming clients. Washington, DC: Ameri­ can Psychological Association.

Resources for Clients Bornstein, K. (2013). My new gender workbook: A step­by­step guide to achieving world peace through gender anarchy and sex positivity. New York: Routledge. Erickson-Schroth, L. (2014). Trans bodies, trans selves: A resource for the transgender community. New York: Oxford University Press. GLAAD. An organization committed to working with the media to fairly and accurately tell the stories of transgen­ der lives. GLAAD also works closely with transgender people and transgender advocacy groups to raise aware­ ness about transgender issues and offers free trainings to empower transgender people to share their stories in the media. https://www.glaad.org/transgender/resources. I AM: Trans People Speak. A project to raise awareness about the diversity that exists within transgender communities. It gives a voice to transgender individuals, as well as their families, friends, and allies. www.transpeoplespeak.org/. Trans Narratives. An organization whose mission is twofold: to tell trans stories and, as a community, to build and pro­ mote trans history. The website offers hours of in-depth

interviews that demonstrate the diversity of the trans community. http://transnarratives.org/.

References Adams, M., Bell, L. A., & Griffin, P. (1997). Teaching for diversity and social justice: A source book. New York: Routledge. American Psychological Association (APA). (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. http://www.apa.org/practice/guidelines/trans gender.pdf. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. http:// www.apa.org/ethics/code/index.aspx. Austin, A., & Craig, S. L. (2015). Empirically supported inter­ ventions for sexual and gender minority youth. Journal of Evidence­Informed Social Work, 12 (6), 567–578. doi: 10.1080/15433714.2014.8849588. Benjamin, H. (1966). The transsexual phenomenon. New York: Julian Press. Bettcher, T. M. (2007). Evil deceivers and make-believers: On transphobic violence and the politics of illusion. Hypatia, 22 (3), 43–65. doi:10.1111/j.1527-2001.2007.tb01090.x. Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Ham­ ilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103, 943– 951. doi:10.2105/AJPH.2013.301241. Bornstein, K. (2013). My new gender workbook: A step­by­step guide to achieving world peace through gender anarchy and sex positivity. New York: Routledge. Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. Journal of Homosexuality, 51, 53–69. doi:10.1300/J082v51 n03_04. Egan, S. K., & Perry, D. G. (2001). Gender identity: A multi­ dimensional analysis with implications for psychosocial adjustment. Developmental Psychology, 37 (4), 451–463. doi:10.1037/0012-1649.37.4.451. Erickson-Schroth, L. (2014). Trans bodies, trans selves: A resource for the transgender community. New York: Oxford University Press. Fassinger, R. E., & Arseneau, J. R. (2007). “I’d rather get wet than be under that umbrella”: Differentiating the experi­ ences and identities of lesbian, gay, bisexual, and transgender people. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (eds.), Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients, 2nd edition, 19–49. Washington, DC: American Psychological Association. Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Kiesling, M. (2011). Injustice at every turn: A report of

the National Transgender Discrimination Survey. Wash­ ington, DC: National Center for Transgender Equality & National Gay and Lesbian Task Force. https://transequality. org/sites/default/files/docs/resources/NTDS_Report.pdf. Greenberg, J., Solomon, S., Pyszczynski, T., Rosenblatt, A., Burling, J., Lyon, D., Simon, L., & Pinel, E. (1992). Assess­ ing the terror management analysis of self-esteem: Con­ verging evidence of an anxiety-buffering function. Journal of Personality and Social Psychology, 63, 913–922. doi:10. 1037/0022-3514.63.6.913. Harvey, J. (2002). Attitudes of the general population toward transsexuals. PhD diss., Southern California University for Professional Studies. Hill, D. B. (2002). Genderism, transphobia, and gender bash­ ing: A framework for interpreting anti-transgender vio­ lence. In B. Wallace & R. Carter (eds.), Understanding and dealing with violence: A multicultural approach, 113–136. Thousand Oaks, CA: Sage. Hill, D. B., & Willoughby, B. L. B. (2005). The development and validation of the Genderism and Transphobia Scale. Sex Roles, 53, 531–544. doi:10.1007/s11199-005-7140-x. Lev, A. I. (2004). Transgender emergence: Therapeutic guidelines for working with gender­variant people and their families. New York: Haworth Clinical Practice Press. Lombardi, E. L., Wilchins, R. A., Priesing, D., & Malouf, D. (2001). Gender violence: Transgender experiences with violence and discrimination. Journal of Homosexuality, 42, 89–101. doi:10.1300/J082v42n01_05. McDuffie, E., & Brown, G. R. (2010). 70 U.S. veterans with gender identity disturbances: A descriptive study. Inter­ national Journal of Transgenderism, 12 (1), 21–30. doi:10. 1080/15532731003688962. Mizock, L., & Mueser, K. T. (2014). Employment, mental health, internalized stigma, and coping with transphobia among transgender individuals. Psychology of Sexual Orientation and Gender Diversity, 1, 146–158. doi:10. 1037/sgd0000029. Mustanski, B. S., Garofalo, R., & Emerson, E. M. (2010). Men­ tal health disorders, psychological distress, and suicidality in a diverse sample of lesbian, gay, bisexual, and transgender youths. American Journal of Public Health, 100, 2426–2432. doi:10.2105/AJPH.2009.178319. Nadal, K. L., Skolnik, A., & Wong, Y. (2012). Interpersonal and systemic microaggressions toward transgender peo­ ple: Implications for counseling. Journal of LGBT Issues in Counseling, 6 (1), 55–82. doi:10.1080/15538605.2012. 648583. Nagoshi, J. L., Adams, K. A., Terrell, H. K., Hill, E. D., Brzuzy, S., & Nagoshi, C. T. (2008). Gender differences in correlates of homophobia and transphobia. Sex Roles, 59, 521–531. doi:10.1007/s11199-008-9458-7. Nuttbrock, L., Hwahng, S., Bockting, W., Rosenblum, A., Mason, M., Macri, M., & Becker, J. (2010). Psychiatric

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impact of gender-related abuse across the life course of male-to-female transgender persons. Journal of Sex Research, 47, 12–23. doi:10.1080/00224490903062258. Pyszcynski, T., Solomon, S., & Greenberg, J. (2002). In the wake of 9/11: The psychology of terror. Washington, DC: American Psychological Association. redcommander27. (n.d.). The matrix (1999)—storyline. http:// www.imdb.com/title/tt0133093/. Reisner, S. L., Perkovich, B., & Mimiaga, M. J. (2010). A mixed methods study of the sexual health needs of New England transmen who have sex with nontransgender men. AIDS Patient Care and STDs, 24, 501–513. Silver, J. (producer), & Wachowski, L., & Wachowski. L. (direc­ tors). (1999). The matrix (motion picture). Warner Bros. Singh, A. A., & Burnes, T. R. (2009). Creating developmentally appropriate, safe counseling environments for transgen­ der youth: The critical role of school counselors. Journal of LGBT Issues in Counseling, 3, 215–234. doi:10.1080/ 155386009033794577. Singh, A. A., & Burnes, T. R. (2010). Shifting the counselor role from gatekeeping to advocacy: Ten strategies for using the Competencies for Counseling with Transgender Cli­ ents for individual and social change. Journal of LGBT Issues in Counseling, 4, 241–255. doi:10.1080/15538605.2 010.525455. Stotzer, R. L. (2009). Violence against transgender people: A review of United States data. Aggression and Violent Behav­ ior, 14, 170–179. doi:10.1016/j.avb.2009. 01.006. Tanis, J. E. (2003). Trans-gendered: Theology, ministry, and communities of faith. Cleveland: Pilgrim.

632 Madabhushi

Tebbe, E. N., & Moradi, B. (2012). Anti-transgender prejudice: A structural equation model of associated constructs. Journal of Counseling Psychology, 59 (2), 251–261. doi:10. 1037/a0026990. Tebbe, E. N., Moradi, B., & Ege, E. (2014). Revised and abbre­ viated forms of the Genderism and Transphobia Scale: Tools for assessing anti-trans* prejudice. Journal of Coun­ seling Psychology, 61 (4), 581–592. doi:10.1037/cou000 0043. Wick, D., Fisher, L., & Shabazian, P. (producers), & Burger, N. (director). (2014). Divergent (motion picture). Summit Entertainment. Winter, S., Webster, B., & Cheung, P. K. E. (2008). Measuring Hong Kong undergraduate students’ attitudes towards transpeople. Sex Roles, 59 (9–10), 670–683. doi:10.1007/ s11199-008-9462-y. Witten, T. M. (2003). Life course analysis—the courage to search for something more: Middle adulthood issues in the transgender and inter-sex community. Journal of Human Behavior in the Social Environment, 8, 189–224. doi:10.1300/J137v8no2_12. Witten, T. M., & Eyler, E. (1999). Hate crimes and violence against the transgendered. Peace Review, 11 (3), 461–468. doi:10.1080/10402659908426291. Wright, L. W., Jr., Adams, H. E., & Bernat, J. (1999). Develop­ ment and validation of the Homophobia Scale. Journal of Psychopathology and Behavioral Assessment, 21, 337–347. doi:10.1023/A:1022172816258.

A B OUT T H E ED I TO R S AN D CO N TR IBUTO R S

About the Editors

About the Contributors

Cyndy J. Boyd, PhD, is a licensed psychologist and

Eve M. Adams, PhD, is a Regents professor, director

Director of Training at the University of Pennsylva­ nia Counseling and Psychological Services. She has served on the Commission on Accreditation of the American Psychological Association, on the board of directors of the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC), the Supervision and Training Section of Division 17 of the American Psychological Associa­ tion, and the Association of Counseling Center Training Agencies. Dr. Boyd is a recipient of the ALGBTIC Service Award and served on the Educa­ tion and Training Committee of the Safe Schools Alliance in Chicago. Currently, she is a member of the LGBTQ+ Health Working Group at the University of Pennsylvania and the Education Task Force of Reclaim Philadelphia. Areas of particular emphasis in her research, training, and practice include clini­ cal supervision, social justice, and issues related to the LGBTQ community. She also maintains a private psychotherapy practice in Philadelphia.

Joy S. Whitman, PhD, is a licensed professional coun­ selor (LPC) in Missouri and a licensed clinical pro­ fessional counselor (LCPC) in Illinois. She currently is a clinical professor at the Family Institute of Northwestern University in the master’s Counseling@ Northwestern program. She was the president of the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling, the Governing Council representative for the division, and a member of the ACA Ethics Committee. Whitman is a founding mem­ ber of the International Academy for LGBT+ Psychol­ ogy and Related Fields and serves on the editorial board for the Journal of Lesbian, Gay, Bisexual, and Transgender Issues in Counseling. She is the coeditor of The Therapist’s Notebook for Lesbian, Gay, and Bisexual Clients, of Preparing the Educator in Counselor Education, and of Skill Development in Counselor Edu­ cation. She maintains a private practice in Missouri, where she counsels adults and couples and focuses her practice on working with the LGBTQ communities.

634

of training of the Counseling Psychology PhD Pro­ gram at New Mexico State University, and a fellow of the American Psychological Association and its Soci­ ety of Counseling Psychology. She received her doc­ torate in counseling psychology in 1988 from the Ohio State University. Adams has received over $5.5 million in federal grant funds, most of which has been used to expand the training of NMSU counsel­ ing psychology students to provide integrated behav­ ioral health services in primary care settings. She has been the principal investigator for a graduate psychol­ ogy education grant for thirteen years, has coordi­ nated the development of several interprofessional training experiences, and has helped create collabo­ rations with a local hospital and its family medicine residency clinic, area federally qualified health-care centers, and school-based health clinics. She has helped create interdisciplinary courses, which have allowed counseling students to work with nursing, MSW, and MPH students and family medicine resi­ dents to better understand the mind-body connec­ tion. Adams teaches mindfulness meditation to fac­ ulty, staff, and students and has focused on better understanding how mindfulness can help heal those suffering from oppression. Her research focuses on mindfulness, LGBT psychology, multicultural identity development, and gender-role beliefs.

Luke R. Allen, MA, LPC in the state of Missouri, is a

counseling psychology doctoral student candidate at the University of Missouri–Kansas City. He holds undergraduate degrees in psychology and philosophy and a certificate in ethics. He received a master of arts degree in counseling and guidance from New Mexico State University. Allen specializes in working with individuals and families on issues related to sex­ ual and gender diversity. Most recently, he completed a yearlong practicum at Children’s Mercy Hospital’s Gender Pathway Services Clinic. He currently serves as cochair of the World Professional Association for Transgender Health (WPATH) Student Initiative and

is the elected student representative to the WPATH Board of Directors. He has presented research inter­ nationally and has published qualitative, quantita­ tive, and theoretical articles on transgender health, ethics, and social justice. Nathaniel Amos, LICSW, is currently working in pri­

vate practice in the greater Seattle area. His profes­ sional work has centered on supporting the psycho­ logical well-being of adolescents and emerging adults. Before entering private practice, he held several agen­ cy-based positions at the Attic Youth Center, an agency organized to support the well-being of LGBT-identi­ fied youth in Philadelphia, and at the University of Pennsylvania’s student counseling center.

Wendy Ashley, PsyD, LCSW, is an associate professor

and the associate chair of the California State Univer­ sity at Northridge’s Masters of Social Work program. Ashley has a doctorate in clinical psychology and over twenty years of social work experience in micro, mezzo, and macro settings. She is the author of multi­ ple publications, speaks at conferences nationwide, maintains a private practice, and provides training for multiple community agencies. She specializes in antioppressive practice, trauma treatment, and the effects of power and privilege on marginalized populations. She is passionate about promoting social justice and infuses an intersectionality lens into her teaching, practice, and research. Randall L. Astramovich, PhD, is a faculty member in

the Department of Counseling at Idaho State Uni­ versity. His background includes experience in men­ tal health counseling and professional school counsel­ ing. He is the author of numerous articles and book chapters and the book Organizing & Evaluating DataDriven School Counseling Programs. His research has appeared in leading counseling journals, including Journal of Counseling & Development, Counselor Edu­ cation & Supervision, Professional School Counseling, Journal for Child & Adolescent Counseling, and Jour­ nal for LGBT Issues in Counseling. Astramovich has served in numerous national roles, most recently as founding president of the Association for Child & Adolescent Counseling.

Lori Barrett, MS, is a licensed counselor in the state

of Kentucky. During her time at Northern Kentucky University, she was part of the LGBT Council and continues to be an advocate for the community. She has a long history in early education and clinical research, and she possesses a particular interest in equine-assisted psychotherapy. She is committed to clinical work with children, couples, and families.

Hannah B. Bayne, PhD, LPC, is an assistant professor

of counseling at the University of Florida. In her clini­ cal practice she works with young adult and adult pop­ ulations on issues related to sexual identity as well as integration of religion and spirituality. Her research interests include empathy development, assessment, and application; integration of spirituality and religion in counseling; managing values conflicts; broaching racial and cultural dynamics; and counselor education and supervision. She is interested, both in research and in practice, in how counselors can connect with and deeply understand clients across diverse experiences.

Kandice H. van Beerschoten, PhD, LCSW, is a psycho­

therapist with a private practice in Raleigh, North Carolina. She specializes in working with members of the BDSM (“kink”) and polyamorous communities, as well as survivors of trauma. In 2017 van Beerschoten’s research into the kink community was published as The Meaning of BDSM Experiences: A Psychodynamic Perspective. She received her PhD from the Institute for Clinical Social Work.

Kristin N. Bertsch, PhD, is an assistant professor, NJ

director of Area Health and Education Centers (AHEC), course director of the Community Service Learning and Leadership Course (CSLL), and psychol­ ogist at Rowan University School of Osteopathic Med­ icine. She also runs a small private practice in Philadel­ phia. Previously, she worked at the Drexel University Office of Counseling and Health. Her clinical inter­ ests include working with individuals on adjustment issues, family relationships, LGBT identity, the inter­ section of identities (e.g., race, gender, sexual orien­ tation), and discrimination. In addition to individual therapy, Bertsch also has a strong interest in group therapy and has experience facilitating several types of About the Editors and Contributors 635

groups: interpersonal process groups, LGBTQ support groups, dialectical behavior therapy–informed skills groups, and international student support groups. Bertsch also has experience and a strong interest in training and supervision of medical and psychology students. Outside clinical work, she also has experi­ ence teaching graduate students and presenting at numerous national conferences, and she has coau­ thored several peer-reviewed journal publications. Lauren M. Bouchard, MS, is a graduate of the Clinical-

Counseling Psychology program at Illinois State Uni­ versity. She has conducted research on several differ­ ent topics, including barriers to meaningful work for individuals with disabilities and chronic illnesses and general issues in rehabilitation and psychology train­ ing. She also is extremely interested in LGBTQ issues in eldercare, especially those related to cultural com­ petency in health-care and housing settings. Currently, she is working clinically as a counselor for older adults affected by Alzheimer’s disease and their families, in addition to working on research, advocacy, and clin­ ical projects related to career counseling, gerontology, and LGBTQ issues.

Richard A. Brandon-Friedman, PhD, LCSW, LCAC, is an assistant professor in the Indiana University School of Social Work. As a clinician, he has worked with youth in schools and in the child welfare system for over ten years and has worked with youth who iden­ tify as sexual and/or gender minorities for over fifteen years. Brandon-Friedman currently serves as the social work services supervisor for the Gender Health Program at Riley Children’s Hospital at Indiana Uni­ versity Health and is a member of the Executive Board of GenderNexus (an organization that serves individ­ uals who identify as gender diverse), the chair of the Indiana Chapter of the National Association of Social Workers’ Sexual Orientation and Gender Identity Committee, and a councilor for the Council on Social Work Education’s Council on Sexual Orientation and Gender Identity and Expression. His research focuses on sexual-identity development, sexual orientation– identity development, gender-identity development, youth sexuality, youth sexual well-being, and the incorporation of sexuality into social work practice. 636 About the Editors and Contributors

Sara K. Bridges, PhD, is the codirector of the Coher­

ence Psychology Institute and a certified trainer and supervisor of coherence therapy. Bridges is also the director of training and an associate professor of counseling psychology at the University of Memphis. She is a recipient of the Distinguished Teaching Award from the University of Memphis and is an active scholar of constructivism, sexuality, and depth-focused approaches to psychotherapy. Her current research focuses on issues related to trans* clients, seduction, kink, and optimal sexual experiences. In addition to publishing extensively on constructivism and sexual­ ity, Bridges has coedited the five-volume Studies in Meaning series. She is a past president of both the Con­ structivist Psychology Network and the Society of Humanistic Psychology (Division 32 of the American Psychological Association). Bridges is also a licensed psychologist in Tennessee and New York with a distance-based private practice.

Theodore R. Burnes, PhD (he/his/him pronouns), is

a clinical psychologist, a licensed professional clinical counselor, and the director of Training and Continu­ ing Education at the Los Angeles Gender Center. He is also an affiliate faculty member in the graduate psy­ chology programs at Antioch University, Los Angeles. His professional interests include mental health and wellness for trans*, nonbinary, and gender-noncon­ forming people; sex-positivity and sexual expression; clinical supervision and training in mental health; antiracism and social justice; young adult development; mental health and wellness for LGBQ people; and adolescent and young adult development. He is an associate editor for Training and Education in Profes­ sional Psychology and is a fellow of the American Psychological Association. Batsirai Bvunzawabaya, PhD, is a counseling psychol­

ogist at the University of Pennsylvania’s Counseling and Psychological Services (CAPS) in Philadelphia. She graduated from Auburn University’s Counseling Psychology program in 2012. In addition to providing individual and group therapy, Bvunzawabaya enjoys participating in training and outreach and preven­ tion services at CAPS. Her clinical interests include exploring issues related to minority mental health,

body image concerns, sexual trauma, racial- and eth­ nic-identity development, and social justice counseling. She is strongly committed to promoting and explor­ ing how issues of equity and inclusion are incorporated in all aspects of our work. Rebekah Byrd, PhD, LPC, NCC, RPT-S, is an associate

professor of counseling, program coordinator, and School Counseling Concentration coordinator in the Department of Counseling and Human Services at East Tennessee State University. Her research spe­ cialization primarily involves issues pertaining to LGBTG-EQQIA+ advocacy, child and adolescent counseling, play therapy, school counseling, social justice and multicultural concerns, self-injury, wom­ en’s wellness, and Adlerian theory. Byrd has over fif­ teen years of experience in working with children and adolescents and maintains a client caseload spe­ cializing in children and adolescents and play ther­ apy. She serves on many nation- and statewide com­ mittees and was recently awarded Outstanding Teacher of the Year from the Clemmer College of Education and received a national best practice award for research conducted with her colleagues. Caroline Carter, PsyD, is a licensed clinical psychol­ ogist who works with transgender and gender-non­ conforming adults and children, adolescents and their families, in private practice and with the Los Angeles Gender Center (LAGC; www.lagendercenter.org). In 2014 Carter helped develop LAGC’s training program. LAGC has since provided education to hundreds of clinicians on trans-sensitive and trans-competent mental health care. Through LAGC’s training program, Carter helps facilitate and also personally provides trainings for mental health professionals in a variety of professional and community settings. She received her doctorate in clinical psychology from Azusa Pacific University and completed her predoctoral internship at the APA-accredited University of Kentucky (UK) Counseling Center. She also holds a master’s degree in women’s studies in religion from Claremont Grad­ uate University. Carter is strongly committed to gen­ der justice and celebrates the unfolding vastness of gender expression and identity in our world.

Cadyn Cathers, PsyD, is a bisexual transgender man,

an advocate, an educator, and a clinician. He has been serving as the interim codirector of the LGBT Specialization in the MA clinical psychology pro­ gram at Antioch University Los Angeles (AULA) since 2017. Before that, he served as an affiliate fac­ ulty member in the LGBT specialization, starting in 2012. In addition to teaching courses in LGBTQIA+-affirmative theory and practice, he teaches a wide variety of courses at AULA, from human sexuality to psychodynamic theories to research methods. He is the executive director of The Affirmative Couch, an online educational platform for therapists to gain competence in working with LGBTQIA+, consensually nonmonogamous, and kinky clients. He is a member of the adjunct faculty at Alliant International University, Mount Saint Mary’s University, and California State University at Los Angeles. As a psychological assistant in private practice under the supervision of Kenneth Scott, PsyD, he focuses on relational psychoanalytic treatment with sexual-, gender-, and relationship-expansive com­ munities. He loves bunnies.

Christian D. Chan, PhD, NCC, is an assistant profes­

sor in the Department of Counseling and Educa­ tional Development at The University of North Carolina at Greensboro and president-elect for the Association for Adult Development and Aging (AADA). His interests revolve around intersectional­ ity; multiculturalism in counseling, supervision, and counselor education; social justice; career develop­ ment; critical research methods; acculturative stress; intergenerational conflict; and cultural factors in identity development and socialization. His earlier professional experiences include case management with adolescents in foster care, career development, higher education administration, intensive outpatient counseling, and outpatient counseling, providing individual, couples, parent-child, group, and family counseling services. Within higher education, he has served as an instructor and co-instructor to master’s and doctoral students in clinical mental health coun­ seling; school counseling; marriage, couple, and fam­ ily counseling; rehabilitation counseling; and coun­ selor education and supervision. He is dedicated About the Editors and Contributors 637

particularly to mentorship for current and future professionals in counseling and counselor education. In addition to contributions to peer-reviewed jour­ nals, books, and edited volumes and over one hun­ dred refereed presentations at the national, regional, and state levels, he recently received the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC) Ned Farley Service Award. Michael P. Chaney, PhD, LPC, ACS, is an associate

professor in the Department of Counseling at Oak­ land University. He is past president of the Associa­ tion of LGBT Issues in Counseling, and currently serves as editor in chief for the Journal of LGBT Issues in Counseling. He has demonstrated compe­ tencies and expertise working with individuals deal­ ing with substance use and mood disorders, sexual compulsivity, sexual orientation, gender identity and expression, male body image, and past trauma. In addition, he has specialized training in counseling individuals who are infected or affected by HIV/ AIDS. He has published numerous articles in presti­ gious professional journals in the areas of substance use disorders, sexual compulsivity, sexual orienta­ tion, male body image, social justice, and advocacy in counseling.

Jessica Chavez, PhD, is a staff psychologist for Coun­

seling Services at Tulane University. She completed her internship and postdoctoral fellowship at the Counseling and Psychological Services at the Uni­ versity of Pennsylvania, and she obtained her PhD in clinical psychology at the New School for Social Research, where she was a member of Dr. Lisa Rubin’s Gender and Health Lab. Her research has explored the experiences of Spanish-preferring Latina women following mastectomy for breast can­ cer, the abortion experiences of low-income women in the United States, and psychologists’ attitudes about reproductive issues. Her recent interests include intrafamilial racism in multiracial families and psychodynamic perspectives on multiracial identity and experiences. She is a proud board mem­ ber for Section IX (Psychoanalysis for Social Responsibility) of Division 39 of the American Psy­ chological Association.

638 About the Editors and Contributors

Jeannine Cicco Barker, PsyD, ATR-BC, is a licensed

psychologist at the University of Pennsylvania’s Coun­ seling and Psychological Services (CAPS). She leads CAPS’s Eating Concerns Team and specializes in the areas of eating concerns, trauma recovery, sexual assault, and first-generation, low-income student con­ cerns. Cicco Barker is passionate about supporting and empowering individuals with marginalized iden­ tities. She earned a bachelor’s degree in fine arts from the University of Pennsylvania, a master’s degree in art therapy from Drexel University, and master’s and doctoral degrees in clinical psychology from Widener University. She is also a board-certified art therapist and spent several years as an adjunct art therapy pro­ fessor. Much of her clinical experience before going to Penn was working with underserved communities in the Philadelphia area, which in part informed her commitment to social justice advocacy as a psychol­ ogist. Outside her role at CAPS, Cicco Barker con­ ducts asylum and other related psychological evalua­ tions to support the immigrant community. Susannah C. Coaston, EdD, serves as an assistant pro­

fessor at Northern Kentucky University. She is an independently licensed professional counselor and supervisor in the state of Ohio, specializing in clinical work with adults with severe and persistent mental illness. In addition to her teaching and clinical respon­ sibilities, she serves as the executive director of the Greater Cincinnati Counseling Association (GCCA). A certified wellness counselor, she integrates a strong humanistic philosophy into her teaching, counseling, supervision, and research. Her research interests involve wellness, particularly occupational wellness, counselor development, and creative teaching and counseling interventions. Kathleen M. Collins, MA, is a doctoral student in clin­

ical psychology at the University of Massachusetts Boston. She earned her BA in psychology at Sarah Law­ rence College and her MA in clinical psychology at the New School for Social Research. Her research interests broadly include sexual orientation, gender identity, the effects of marginalization on mental health, the psychotherapy process, and mixed meth­ ods research designs.

Laura Kay Collins, MSS, LSW, is a social worker pro­

viding psychotherapy in the college counseling center at the University of Pennsylvania. Before college coun­ seling, she worked in various community mental health centers in Philadelphia, specializing in trauma recovery. Her clinical work and personal interests are grounded in intersectional feminist principles and relational approaches to therapy. She is a graduate of the Psychoanalytic Center of Philadelphia’s psychodynamic therapy training program. She is a member of an interdisciplinary working group with Student Health Services working to improve care for LGBT students on campus. She is also a member of the Sex­ ual Trauma Treatment Outreach and Prevention (STTOP) team at Penn, where she works with victimsurvivors of sexual assault and trauma. She also sup­ ports various outreach efforts on the wider campus to promote a healthy culture of consent. Pedro Alexandre Costa, PhD, is a clinical systemic

psychologist and a postdoctoral researcher at the Wil­ liam James Center for Research, ISPA (Instituto Uni­ versitário, Portugal), and Birkbeck University of Lon­ don, UK. He holds a master’s degree in the psychology of child development and a doctoral degree in psy­ chology in the field of psychosocial adjustment of gay-, lesbian-, and bisexual-parented families, and social attitudes toward these families. He is also a research team member of the longitudinal European survey on attitudes toward same-sex marriage and families. His research interests span developmental psychol­ ogy, family psychology, and social and community psychology. Costa has published several international papers on same-gender-parented families, sexual prejudice, social oppression, and their impact effects on the LGBT+ community. He organized and hosted the First International Conference on LGBT Psychol­ ogy and Related Fields in Lisbon, Portugal, in 2013, and he is a founding member of the International Academy of LGBT+ Psychology and Related Fields.

Vanessa Dabel, PhD, is a staff psychologist and the

outreach coordinator at Barnard College’s Furman Counseling Center. She also serves as an independent contractor for the Truman Group, providing virtual psychotherapy to U.S. expatriates living abroad. Dabel

completed her doctoral internship and postdoctoral fellowship at the University of Pennsylvania’s Coun­ seling and Psychological Services (CAPS). Her inter­ ests include trauma-informed care, adjustment diffi­ culties, issues of marginalization and oppression, and identity concerns. Dabel has provided individual and group therapy for survivors of sexual assault, and she strives to use a social justice framework in her clini­ cal work to support marginalized individuals. She is also passionate about working with adolescents and young adults in a college setting and has conducted research on post-trauma outcomes in college students with a focus on strategies to enhance post-traumatic growth. Sabina de Vries, PhD, is an assistant professor at Texas

A&M University–San Antonio. She is a licensed pro­ fessional counselor (LPC), LPC supervisor, and a national certified counselor. De Vries has an extensive background in clinical work in private practice as well as providing counseling services to the homeless and survivors of domestic violence. Her research inter­ ests include treatment of post-traumatic stress disor­ der and complex post-traumatic stress disorder. Spe­ cifically, she is concerned with the effects of trauma, including its influence on early childhood develop­ ment, and the occurrence of intimate partner violence, with special consideration for minorities and other marginalized clients.

Natasha Distiller, PhD, LMFT, is a therapist in pri­

vate practice in Berkeley and Oakland, California. She specializes in working with LGBTQ populations, including individuals, couples, children, their par­ ents, and queer families. She is a member of Mind the Gap, the mental health wing of the University of California at San Francisco’s Child and Adolescent Gender Center, and a trainer for the Pacific Center, Berkeley’s LGBTQ center. She has presented at numerous conferences around the Bay Area on work­ ing with LGBTQ clients, and she also speaks about the intersectionality of gender with race and nationality as a diversity presenter. You can find out more about her work and see her extensive publication list at www.natashadistiller.com.

About the Editors and Contributors 639

Suzanne M. Dugger, EdD, LPC-S, NCC, ACS, is a pro­

fessor and chair of the Department of Advanced Studies and Innovation at Augusta University. A sea­ soned counselor educator who has also provided coun­ seling services and career-development support in K–12, college, and private practice settings, Dugger is a passionate advocate for the LGBTQ population; she has expertise in counseling and career-development interventions with sexual minority students and cli­ ents. She currently serves on the Board of Directors for the Council for Accreditation of Counseling & Related Educational Programs and has held numer­ ous leadership positions in the counseling profession. She was a member of the American Counseling Asso­ ciation’s 20/20 Task Force, served as the ACA Human Rights chair, ACA Midwest Region chair, Michigan Counseling Association president, and chair of Mich­ igan’s licensure board for professional counselors. She has presented and published extensively on topics related to school counseling, career counseling, post­ secondary planning, and LGBTQ issues, all of which are addressed in her most recent textbook, Founda­ tions of Career Counseling: A Case-Based Approach.

Laura Boyd Farmer, PhD, is a licensed professional

counselor, certified substance abuse counselor, and certified Qoya instructor. Her research focuses on LGBTGEQ-affirming counseling practices and cre­ ative and expressive approaches to health and heal­ ing. She is an invited speaker on LGBTGEQ-affirma­ tive counseling, mental health, and mind-body wellness. Her background training and experience include mindfulness practices, expressive arts, play therapy, counseling survivors of gender-based vio­ lence, crisis intervention, and resilience. In addition to her teaching and research, Farmer maintains a pri­ vate counseling practice and facilitates a peer-based support group for LGBTGEQ youth in southwest Virginia.

Fiona D. Fonseca, MB, BCh, BAO, MS, is a psychiatry

resident at St. Mary Mercy Hospital in Livonia, Michi­ gan, a doctoral student in counseling, on hiatus, at Oakland University in Rochester, Michigan, and an associate editor for the American Journal of Psychia­ try Residents’ Journal. They enjoy working with indi­

640 About the Editors and Contributors

viduals across the life span, using an integrative approach to well-being. They value their role as a holistic scientist-practitioner and are passionate about LGBTQIA+ mental health and advocacy. As an early career mental health professional, they find deep fulfillment in learning and are privilaged to be able to instruct and supervise future clinicians. Jayleen Galarza, PhD, LCSW, CST, is an associate pro­

fessor within the Department of Social Work & Ger­ ontology at Shippensburg University. She identifies herself professionally as a clinical social worker who specializes in sexuality social justice issues. In addi­ tion to her clinical social work license, she is a certified sex therapist through the American Association of Sexuality Educators, Counselors, and Therapists (AASECT). She completed her PhD in human sexual­ ity at Widener University with a focus on exploring the intersections of queer and Latina identities and experiences. Before holding an academic position, she worked as a sex educator and mental health therapist, providing individual and group services to adoles­ cents and young adults. Galarza’s research and prac­ tice are firmly rooted in her passion for sexuality social justice, and her areas of interest include inter­ sectionality, Latinx sexuality, sexual/gender identities and experiences, and use of narrative and feminist therapeutic approaches in addressing sexuality-related concerns. She is also coeditor of Taking Sides: Clashing Views of Human Sexuality. Jean Georgiou, EdD, LPC, NCC, ACS, is an assistant

professor in the Department of Counselor Education at New Jersey City University, where she teaches group process, group theory and practice, and internship courses. She also teaches a unique multicultural coun­ seling course that incorporates an immersion experi­ ence with a traveling component. In 2016 she and another professor took students to Japan and in the summer of 2018 took students to Kenya. On a recent mission trip to Kenya, she was invited to assist in developing and implementing mental health services in a local community center in a rural area of west­ ern Kenya. She is also a licensed professional counselor in private practice, in which she specializes in assist­ ing those struggling with depression, anxiety, PTSD,

trauma, grief and loss, sexuality issues, gender issues, and change-of-life and/or transitional issues. She uses a cognitive behavioral model while integrating both eclectic and holistic strategies, as she recog­ nizes the importance of treating the whole person. In addition, she is a certified clinical trauma profes­ sional, is certified in disaster mental health by the American Red Cross, is an LGBTQ Safe Zone ally, and has served as the vice president of New Jersey Association for Child and Adolescent Counseling. Her research interests include graduate group work, multicultural issues, the development of a codepen­ dency scale (adult and children), and various areas of trauma work. Jennifer M. Gess, PhD, LMHC, LCPC, is a core faculty member in the School of Counseling at Walden Uni­ versity. Her commitment to empowerment and social justice for lesbian, gay, bisexual, transgender, and queer (LGBTQ+) communities is central to her ped­ agogy, clinical engagement, scholarship, and service. She has worked as a licensed counselor for over seven years specializing in LGBTQ+ children, youth, and families. Her research focuses on LGBTQ+ compe­ tence in counseling and counselor education. In addi­ tion to teaching, research, and counseling, she is an advocate for equality, demonstrated by her facilitating trainings for schools and agencies to increase LGBTQ+ inclusivity and safety. She is also committed to ser­ vice that promotes LGBTQ+-affirmative practice, such as starting the Idaho Association of LGBT Issues in Counseling (2015–2016) and infusing such practices as the past president of Idaho Counseling Association (2017–2018). Laura R. Haddock, PhD, has been a counseling profes­ sional for over twenty-five years in both clinical and academic settings. She received her PhD in counselor education and supervision from the University of Mississippi and currently serves as a faculty member at Southern New Hampshire University. Her clinical practice includes work with a variety of populations; her focus is on identity issues and women experienc­ ing significant life transitions. She is a licensed pro­ fessional counselor-supervisor, national certified coun­ selor, and approved clinical supervisor. Dr. Haddock

is an active counseling professional and has served on the Mississippi Licensed Professional Counselors Board of Examiners and the executive boards of Mississippi Counseling Association and Mississippi Licensed Professional Counselors Association. She maintains an active research agenda and was the 2017 recipient of the Association of Counselor Education and Supervision Distinguished Service Award—Coun­ selor Educator. Her research interests include coun­ selor wellness and secondary trauma, spirituality, sex­ uality, cultural diversity, and supervision. John J. S. Harrichand, PhD, LPC, NCC, CCMHC,

CCC, is an assistant professor of counselor education at the College at Brockport State University of New York. He actively engages in program review, advo­ cacy, mentorship, research, writing, and professional service, and he frequently presents at local, state, regional, and national conferences. He publishes in the areas of counselor education leadership and burnout, group counseling, doctoral student research development in counselor education, emotional intelligence and counselor burnout, LGBTQ+ issues in counseling, professional and social justice advo­ cacy, and international counseling students’ education and retention. He serves Chi Sigma Iota International as a committee member on the Leadership and Advo­ cacy Committee, the Association for Spiritual Ethical and Religious Values in Counseling as a committee member on the Ethical Values Committee, the Asso­ ciation for Multicultural Counseling and Develop­ ment as chair of the Ethics Committee, and the American Counseling Association as a member of the Professional Standards Committee. His teaching and research interests include counselor leadership and wellness, professional advocacy, multicultural counseling, counseling theories, diagnosis and treat­ ment planning, emotional intelligence, resilience and post-traumatic growth, and addictions. His clinical experience encompasses working in community mental health and college and university counseling settings. He is a 2017 Association for Counselor Education and Supervision (ACES) Emerging Leader, 2018–2019 Counselor Education & Supervi­ sion Journal fellow, and 2018–2020 Southern ACES Emerging Leader. About the Editors and Contributors 641

Yuhong He, PhD, is a licensed psychologist at the

University of Pennsylvania’s Counseling and Psycho­ logical Services (CAPS). She leads CAPS’s interna­ tional student outreach and prevention initiatives and coordinates career counseling services. She spe­ cializes in mental health and multicultural counsel­ ing with international and Asian American students in higher education. She provides multilingual coun­ seling, workshops, and consultation in Mandarin and Cantonese. She serves on several committees at Penn and of professional organizations such as the Society of Counseling Psychology. She is a founding and lifetime member of the Association of Chinese Helping Professionals and Psychologists—Interna­ tional. She grew up in China and received her mas­ ter’s degree in college counseling and a doctorate in counseling psychology in the United States. Her research areas include international students’ and immigrants’ mental health, coping, and career development.

Cara Herbitter, MA, MPH, is a clinical psychology

doctoral candidate at the University of Massachusetts Boston (UMB). They received their BA with honors from Wesleyan University in women’s studies and com­ pleted their MPH at Columbia University, focusing on sexuality and health. At UMB their current research focuses on emerging sexual minorities (e.g., consen­ sually nonmonogamous people, asexual individuals). Their general research interests include sexual minority stress and resilience, sexual health and health-care access, behavioral medicine, as well as applied femi­ nist and queer theory, and their current research focuses on how sexual and gender minority individ­ uals experience and cope with social stressors. They have presented their research at numerous professional conferences and published their findings in academic journals. Herbitter’s clinical placements have included the UMB Counseling Center, the Behavioral Medi­ cine Clinic at the Boston VA, and the Dauten Family Center for Bipolar Treatment Innovation at Massa­ chusetts General Hospital, and The Fenway Institute (TFI) at Fenway Health. In 2019–2020 they will be a clinical psychology intern at the Alpert Medical School of Brown University in the behavioral medi­ cine track. As a clinician, they seek to integrate cog­

642 About the Editors and Contributors

nitive behavioral therapy, feminist-multicultural approaches, and humanistic therapy. Carlos Hernández, PhD, is a clinical assistant profes­ sor at the University of Florida’s Counseling and Well­ ness Center (CWC), a licensed mental health coun­ selor, and coordinator of the CWC LGBTQ+ Services Committee. He worked for ten years at the Career Resource Center at the University of Florida before starting at the CWC in 2001. He received his doctoral and education specialist degrees in mental health counseling from the Department of Counselor Edu­ cation at the University of Florida, specializing in mental health and multicultural counseling. His clin­ ical and research interests include multiculturalism, sexual orientation and gender identity, and vocational issues. He is also involved in the training and super­ vision of practicum and specialist interns and provides seminars on counseling sexual minorities. He serves as the CWC leader in coordinating and providing staff training and supervision on LGBTQI issues and con­ cerns. He has guest-lectured at numerous graduate counseling courses and has presented at local, state, and national conferences working with the LGBTQI pop­ ulation. Hernández cocreated and cotaught the first graduate course in the Counselor Education Depart­ ment titled “Counseling the Lesbian, Gay, Bisexual, and Transgender Client.” He is currently working on a community project to unite those health-care pro­ fessionals, both medical and mental health, from within campus and in the community, who work with transgender and gender-nonconforming-identified individuals to facilitate access to services in Alachua County. Tracie L. Hitter, PhD, is an assistant professor in the Counseling Psychology PhD Program at New Mexico State University. She has a master’s degree in marriage and family therapy from San Diego State University and received her doctorate in counseling psychology in 2012 from New Mexico State University. She com­ pleted her doctoral internship with Iowa State Uni­ versity’s Student Counseling Service and served as a staff psychologist at Idaho State University’s counsel­ ing center. Hitter teaches coursework on personality assessment, ethics and professional issues, supervi­

sion, and family therapy. Her research interests are mindfulness, resilience, sexuality, supervision, and training issues. Sharon G. Horne, PhD, is professor of counseling

psychology and the director of training for counsel­ ing psychology at the University of Massachusetts Boston. She received her BA in journalism and Slavic languages and literature from Indiana University and her PhD in counseling psychology at the University of Georgia. Horne has worked on international and transnational sexual orientation and gender-identity psychology concerns, primarily in post-Communist countries, including Russia, Uzbekistan, and Kyrgyz­ stan. She is an elected American Psychological Asso­ ciation representative to the International Psychology Network for Lesbian, Gay, Bisexual, Transgender and Intersex Issues (IPsyNet). She was an Open Society Foundation academic fellow with the Psychology Department of American University of Central Asia in Kyrgyzstan for ten years. She is a licensed psychologist.

Bayley A. Johnson is a masters-level psychotherapist

currently practicing at Columbia River Mental Health Services in Vancouver, Washington. Johnson earned her master’s in the art of counseling in 2014 at Multnomah University in Portland, Oregon. She went on to work with adolescents struggling with eating disorders in a partial hospitalization program at the Eating Disorder Recovery Center of Washing­ ton in Bellevue, Washington. Following this posi­ tion, Johnson relocated to Phoenix, Arizona, where she worked in two different treatment milieus. The first was Community Medical Services, which served individuals with opiate addictions. Then she gained experience at the inpatient level at Aurora Behav­ ioral Healthcare East. In this position, she estab­ lished her own movement-therapy group. Johnson started her own psychotherapy/group therapy prac­ tice in 2018 and looks forward to expanding her knowledge in the areas of neuropsychology and mind-body wellness. M. Killian Kinney, MSW, LSW (they/them), is a doctoral candidate and associate faculty in the School of Social Work at Indiana University in

Indianapolis. Kinney is actively engaged in LGBTQ practice and research, maintaining their license and serving as an expert on transgender and nonbinary topics. They have provided presentations, training, and consultation on LGBTQ-affirming health care at the local, national, and international level. Their primary research explores identity development, health disparities, resilience, and corrosive and pro­ motive factors of well-being. Their scholarship advances a holistic theory of well-being and a thriv­ ing-based approach to exploring gender-diverse experiences. Another line of inquiry is advancing social work education through peer mentoring, interprofessional education, scholarship of teaching and learning, and program evaluation. They are committed to translational research, community practice, and pedagogy that value diversity and social justice. Throughout their academic career, they have continued to work within the community, facilitating groups, completing intakes, presenting training, evaluating programs, and volunteering at a free clinic. In the classroom, Kinney leverages these rich and varied experiences to teach about the bene­ fits of interprofessional collaborations and the importance of diversity in social work, communi­ ties, and society. They are the recipient of the Wil­ liam M. Plater Civic Engagement Award and the Chancellor Bantz’s Award for Excellence. Veronica M. Kirkland, PhD, has served as a licensed clinical professional counselor in Maryland for over six years. She is also interested in researching issues of social justice, counselor education, and counselor professional identity. Although clinical practice and research are areas of focus for Kirkland, she is most passionate about her work as a clinical supervisor and counselor educator. She recently began her journey as a counselor educator teaching as a full-time faculty member in the online counseling program at Lindsey Wilson College. Kirkland graduated with a doctoral degree in counselor education and supervision from Walden University. Her dissertation focuses on counselor competence with gender-diverse clients. She lives and serves in the Montgomery County area of Maryland. About the Editors and Contributors 643

Dorian Kondas, PhD, is a counseling psychologist cur­

rently with a private group practice, Affirmations Psychological Counseling, LLC, in Columbus, Ohio, which has historically served the LGBT community. He received the honor of postdoctoral training for LGBT veteran care through the Yale School of Medi­ cine and its affiliates with the Veterans Administra­ tion Healthcare System of Connecticut. He is pub­ lished in the field of same-sex intimate partner violence and has developed research scales for the measure­ ment of lesbian and gay male spiritual conflict.

Heather Kramer, MA, is a behavioral specialist work­

ing with families in crisis. She recently graduated with an master’s in clinical mental health counseling from Loyola University Maryland, where her mas­ ter’s project focused on working with transgender and gender-nonbinary children and adolescents and their families. Her wider research scope includes ado­ lescent and family work throughout the LGBTQ­ QIAA community. Jennifer Lancaster, PhD, is the founder and clinical

director of New York Cognitive Therapy and Well­ ness Center, a private practice clinic serving clients from all walks of life. She is a New York State licensed psychologist who specializes in the treatment of anx­ iety and depression in adolescents and adults. Lan­ caster is also vice president of academic affairs and professor of psychology at St. Francis College, where she has organized initiatives focused on creating wel­ coming and safe academic settings for young adults. Lancaster’s primary research interests are in the use of film and metaphor in therapeutic work, the effective­ ness of group interventions, and the therapeutic inte­ gration of identities, specifically religion and spiritu­ ality in clients who identify as LGBTIQA. She super­ vises doctoral students from Hofstra University and Teachers College at Columbia University.

Amanda Lawson-Ross, PhD, is a clinical assistant pro­

fessor at the University of Florida’s counseling psy­ chology doctoral program and is a licensed psychol­ ogist. She is a proud Latinx member of the LGBTQ+ community and is an advocate for social justice. Her areas of professional interest include strength-based

644 About the Editors and Contributors

psychology (e.g., bolstering resilience), supervision and training, diversity and multiculturalism, and help­ ing people work toward self-awareness, growth, and acceptance. She received the Society for the Psycho­ logical Study of Social Issues fellowship and partici­ pated in the Minority Fellowship Program through the American Psychological Association. She also received the University of Florida’s Division of Stu­ dent Affairs Superior Accomplishment Faculty Award. Matthew LeRoy, PsyD, is clinical psychologist at the

University of Pennsylvania’s Counseling and Psycho­ logical Services (CAPS). At CAPS he treats a diverse student body, processing experiences of painful rejec­ tion and isolation, particularly as it relates to mar­ ginalized identities. He also has an interest in and focus on prevention of sexual violence, including engaging with those found responsible for sexual violence to help them understand and prevent prob­ lematic behavior. Additionally, LeRoy is heavily involved in Division 39 of the American Psychological Association, focused on psychoanalysis, particularly as the editor of a publication addressing the intersec­ tion of social justice and psychoanalysis, the Psycho­ analytic Activist (psychoanalyticactivist.com), in which a range of topics related to social justice are discussed and explored.

Heidi M. Levitt, PhD, is a professor of clinical psy­

chology at the University of Massachusetts Boston. The American Psychological Association (APA) has awarded her fellow status in Divisions 5 (Quantita­ tive and Qualitative Methods), 29 (Psychotherapy), 32 (Society of Humanistic Psychology), and 44 (Society for the Psychology of Sexual Orientation and Gender Diversity). She has been associate editor for the jour­ nals Qualitative Psychology and Psychotherapy Research. In 2017–2018 she was president of the Society of Qualitative Inquiry in Psychology, which is a section of Division 5 of the APA. Levitt has developed a twen­ ty-year multi-method program of research that has studied the construction and evolution of gender iden­ tities within lesbian, gay, bisexual, transgender, and queer (LGBTQ) cultures. This body of work has been concerned with studying the historicity of these com­

munities—examining how gender identities arise over time in relation to evolving social realities, sex­ ual and gender stigma, and social representations of gender. In addition, her LGBTQ research has been focused on the correlates of minority stress and inter­ ventions to reduce this stress, especially as they relate to gender expressions and sexual identities. Her other lines of work are directed at psychotherapy process and outcome and the use of qualitative and mixed methods methodologies. Carina Lindsey, EdS, lives in Jackson, Mississippi, and serves as the Career & Technical Counselor for Vicksburg Warren School District Career & Technical Center at Hinds Community College and as the direc­ tor of student success at Belhaven University. Lindsey is no stranger to counseling, having spent eight years as a college counselor and a school counselor. She now directs college access programs to expose tradi­ tionally underserved students to the college process and teaches them skills to be successful in college. Lindsey was named the College Counselor of the Year by the Mississippi Counseling Association in 2017. A big believer in equal access and equity, Carina Lind­ sey currently holds a Board of Directors chair in the Southern Association for College Admission Counsel­ ing (SACAC). She is a National Board Certified coun­ selor and holds a master’s degree in counselor educa­ tion from Mississippi State University and an education specialist degree in counseling from Mississippi College. Allen Eugene Lipscomb, PsyD, is an assistant profes­

sor in the Social Work Department at California State University Northridge. Lipscomb is a clinical psy­ chologist and a licensed clinical social worker in the state of California. He received his doctorate in psy­ chology with a clinical emphasis in marriage, family, and child psychotherapy from Ryokan College and his MSW from the University of Southern California. Lipscomb specializes in providing anti-oppressive mental health services to individuals, children, youth, and families of color. His area of research is psychi­ atric epidemiology among racialized and marginalized individuals who have experienced trauma (i.e., com­ plex trauma, traumatic grief, and race-based trauma).

Virginia Longoria, PhD, is an assistant professor in the

Counseling and Educational Psychology Department at New Mexico State University, involved mostly in offering courses and clinical supervision to students pursuing graduate training in Spanish-language coun­ seling. She obtained a master’s in clinical psychology from the University of Texas at El Paso and a PhD in counseling psychology from New Mexico State. Lon­ goria currently provides clinical services at a schoolbased health center in Las Cruces, New Mexico. Her research and clinical interests include mind-body psychology, mindfulness-informed interventions, mul­ ticultural and social justice issues, and the use of alter­ native and indigenous approaches to healing.

Emily M. Lund, PhD, CRC, is an assistant professor of rehabilitation and addiction counseling in the Depart­ ment of Community Psychology, Counseling, and Family Therapy at St. Cloud State University. She holds a PhD in disability disciplines with emphases in spe­ cial education and rehabilitation counseling from Utah State University and was a postdoctoral fellow at the Center for Psychiatric Rehabilitation at Boston University. She has worked with individuals and fami­ lies with developmental and learning disabilities and mental health concerns in a variety of clinical and educational settings. Her primary research interests include interpersonal violence, trauma, and peer vic­ timization in people with disabilities and suicide and nonsuicidal self-injury in people with disabilities. She also researches the experiences of psychology trainees with disabilities and LGBTQ+ issues as they relate to disability. She has published over fifty peer-reviewed articles and was a coeditor of the recent book Religion, Disability, and Interpersonal Violence, published by Springer. Soumya Madabhushi, PhD, is a licensed counseling

psychologist and the outreach training coordinator at University of Pennsylvania’s Counseling and Psycho­ logical Services (CAPS). She is originally from India. She came to the United States for graduate school, has lived in the United States since, and feels very much connected to both cultures. She is psychodynamically trained and infuses her work and life with multicul­ tural and social justice values and principles. She is a About the Editors and Contributors 645

clinician who enjoys individual, group, and commu­ nity work, as well as training. She approaches her work with individuals and communities with endless curi­ osity and deep reverence for the human condition. She believes in the value of meeting people where they are, individually or in their communities, and build­ ing on natural resilience, strengthening resources, removing obstacles blocking natural tendencies toward healing and growth, and working toward conscious­ ness raising and culture change where necessary. At CAPS she teaches a yearlong seminar for the doctoral interns on outreach and prevention, and she has also taught an eight-week seminar on social identities and a twelve-week seminar on social justice. At Penn she has delivered a variety of trainings on stress manage­ ment, cultivating wellness, suicide prevention, stigma reduction, and trauma-informed care and has facili­ tated dialogues addressing social identities, social justice, and sexual violence prevention. She is a member of the Association for University and Coun­ seling Center Outreach and serves on its Diversity Equity and Inclusion Committee as well as the Research and Assessment Committee. Maeve Malley, DPsy, is a consultant systemic psycho­

therapist in the National Health Service (NHS) in London, working with individuals, couples, and fam­ ilies with mental health difficulties. She trains and supervises other clinicians in systemic psychotherapy in the NHS and other sectors, with a focus on work­ ing beyond the individual, beyond diagnoses, and in considering the life context of individuals and their wider systems. Malley has published a number of papers on training systemic psychotherapists for work­ ing with sexual minority clients and their families, on the experiences of lesbian and gay psychotherapists in working with sexual minority clients, and on that of LGBT clients in psychotherapy. She maintains an abiding interest in working with LGBT+ populations and individuals and a deep admiration for her clients and colleagues, particularly for those who continue to innovate and research in this area. Vincent M. Marasco, PhD, LPC, received his doctorate in counselor education and counseling from Idaho State University and his master’s in counseling from 646 About the Editors and Contributors

the University of Nebraska at Omaha. He has a variety of clinical experiences, including work with children and adolescents on the autism spectrum, college-aged populations, and adults with co-occurring diagnoses. He hold professional counseling licenses in both Idaho and Nebraska, and he is a strong advocate for the development of sexuality-based competencies for best practices in the counseling profession. His clini­ cal and research interests include issues and con­ cerns related to sexual health and wellness, LGBTQ+ populations, social justice and advocacy, multicul­ turalism, as well as ways to enhance counselor edu­ cation. In addition to his clinical and scholarly pur­ suits, Marasco maintains a strong commitment to education. He has taught courses related to health and wellness, sexual health and education, and men­ tal health across developmental levels, and he works to incorporate practices of mindfulness with stu­ dents and clients. Marilia S. Marien, PhD, is a psychologist at Counsel­

ing and Psychological Services at the University of Pennsylvania. There she coordinates the Psychology Externship program, is the founding chair of the Integrative Treatment Committee, and worked to develop a program of mindfulness-based offerings. She has a PhD in counseling psychology from the State University of New York at Buffalo. She is a certified teacher of mindfulness-based stress reduc­ tion and has been trained in mindfulness-based cognitive therapy. Nationally, she has held leader­ ship positions in the American College Personnel Association Commission for Counseling and Psy­ chological Services and received the ACPA Distin­ guished Commission Directorate Member Award for her work within the organization. In addition to her clinical work, she has taught undergraduate courses in the psychology of women and graduatelevel courses in career counseling and multicultural counseling. Meredith R. Maroney is a doctoral student in counsel­

ing psychology at the University of Massachusetts Boston. She received her BA in psychology at Loyola University Maryland, and her master’s in mental health counseling at the University of Massachusetts Boston.

Her research and clinical interests are focused on sexual orientation and gender identity concerns, autism, and psychotherapy. She is working on projects focused on the intersection of autistic and LGBTQ identities. Hilary Meier, MS, received her undergraduate degree

in psychology from the University of Mississippi and her master’s in mental health counseling from Lip­ scomb University. Meier is a licensed professional counselor and a national certified counselor. She is currently the director of Allied Health of Delta Health Alliance. She enjoys working with underserved pop­ ulations, women’s issues, and children on the autism spectrum.

Eva Mendes, MA, LMHC, NCC, is an Asperger’s and

autism expert, author, psychotherapist and couples’ counselor in private practice in the Boston area, and she is sought out by clients nationwide and globally. Mendes’s clients include adults with Asperger’s or autism, ADHD, nonverbal learning disability, and social communication disorder, gifted individuals, cou­ ples in which one or both partners have Asperger’s syndrome or are on the autism spectrum (diagnosed or suspected), and LGBTQIA folks with Asperger’s or autism. She began training in autism spectrum dis­ order and related profiles from the beginning of her career at the Asperger/Autism Network in Watertown, Massachusetts. She is the author of Marriage and Lasting Relationships with Asperger’s Syndrome (Autism Spectrum Disorder): Successful Strategies for Couples or Counselors (Jessica Kingsley Publishers). Mendes’s most recent book, Gender Identity, Sexuality and Autism: Voices from across the Spectrum is available on Amazon.com. She also authors the blog Heart of Autism on psychologytoday.com. You can read her paper “‘Labels Do Not Describe Me’: Gender Identity and Sexual Orientation among Women with Asperger’s and Autism” and other works on her website, www. evmendes.com. In addition to autism, Eva’s interests include Nichiren Buddhism and yoga. Crystal Morris, MA, LPHA, is an associate marriage and family therapist currently working with at-risk youth and families in the foster and probation systems.

She has spent the last several years working with youth and adults who have experienced trauma and severe mental health challenges in both inpatient and out­ patient community health settings and values oppor­ tunities to engage and learn from individuals of all backgrounds. She has trained in and is interested in furthering her knowledge and study of complex trauma, particularly the experiences of culturally diverse pop­ ulations, including those who identify as LGBTQ. She has contributed to studies focusing on the expe­ riences of individuals who identify as LGBTQ and has been invited to present at Columbia’s queer Q-LLAGE conference. Sarah Mountz, PhD, is an assistant professor of social

work at the University at Albany, SUNY. Her research focuses on the experiences of LGBTQ youth in childwelfare and juvenile-justice systems and among home­ less youth populations. Her most recent research project, From Our Perspectives, used a communitybased participatory research (CBPR) framework to look at the experiences of LGBTQ former foster youth in Los Angeles County through qualitative interview­ ing and photovoice methods. Mountz’s previous research used life history interviewing to explore the experiences of queer, transgender, and gender-expan­ sive young people in girls’ juvenile-justice facilities in New York State. She is particularly interested in LGBTQ and other youth activism and organizing. Her work has been featured in Affilia: Journal of Social Work, the LGBTQ Policy Journal at the Harvard Kennedy School, and the Sage Encyclopedia of LGBTQ Studies.

Julie M. Mullany, PsyD, MFA, is a licensed clinical psychologist on staff at the University of Pennsylvania. She also works in private practice in Philadelphia. Mullany has an interest and specialized training in group process and works, in general, with marginal­ ized populations, including transgender and other gender minorities or nonbinary-identifying individ­ uals. She has additional experience and training in the treatment of eating disorders, providing dialecti­ cal behavioral therapy, facilitating groups, and work­ ing from a psychodynamic, feminist, relational, and multicultural framework. In particular, struggles per­ taining to identity formation, life transitions, interAbout the Editors and Contributors 647

personal relationships, and social justice issues are areas of clinical focus. Other research interests include narcissism and its effects on both one-on-one rela­ tionships and society. She is a member of the LGBTQ Health Working Group, a collaboration with Penn’s Student Health Services and Penn’s LGBT Center, and serves as a liaison to the Kelly Writers House at Penn. She also provides ongoing supervision to psychology clinicians in training, and she has taught both the social identities seminar and the activism seminar to interns at CAPS. Mullany is a member of the Ameri­ can Psychological Association (APA), Pennsylvania Psychological Association (PPA), and Philadelphia’s Society for Psychoanalytic Psychology (PSPP), the local chapter of APA’s Division 39 (Psychoanalysis). She also completed a fellowship at Chicago’s Center for Psychoanalysis (CCP). Michelle M. Murray, PhD, LP, earned her doctorate

in counseling psychology from the University at Albany, SUNY. She has a private practice in Philadel­ phia, where she provides individual therapy from a relational, psychodynamic, and multicultural-femi­ nist perspective. She specializes in working with marginalized populations, with identity develop­ ment, and with survivors of sexual-, combat-, racial-, or gender-based trauma. She is dedicated to provid­ ing LGBTQ-affirmative care and educating health­ care providers on best practices for providing ser­ vices to the LGBTQ community and survivors of trauma. Currently, she is an adjunct professor at Lehigh University. She has taught courses and pro­ vided workshops to college students, military veter­ ans, and therapists-in-training on the effects of social identities and cultural implications for coun­ seling, healthy relationships and sexual health, supervision from a relational-multicultural approach, and understanding trauma reactions and PTSD. Previous areas of research include social jus­ tice approaches to primary prevention, post-deploy­ ment readjustment of survivors of military sexual trauma, and the unique experiences of women in the STEM fields.

Michelle M. Murray is a doctoral candidate in human

development and family science with a concentration

648 About the Editors and Contributors

in marriage and family therapy at Virginia Tech. Her research interests include family communication about sexuality and sexual-identity development. She has experience working with individuals, couples, and groups in therapy and hopes to continue working with these populations. Kiahni Nakai, EdD, LPC, is a fully licensed profes­ sional counselor in the state of Georgia. She provides mental health outreach to military members and their families at military bases in various parts of the United States and abroad. She previously worked as a professor at the American University in Cairo and as a master’s level dissertation adviser and recognized teacher at the University of Liverpool/Laureate Edu­ cation, where she enjoyed working with interna­ tional students. She is particularly interested in researching the range of contemporary sexual per­ spectives of the African diaspora. Mary R. Nedela, MS, LMFT, is a doctoral candidate

in the Human Development and Family Science Department at Virginia Tech, specializing in mar­ riage and family therapy. Currently, she is employed as a visiting lecturer at the University of Nevada Las Vegas in the Couple and Family Therapy program. She holds a license in marriage and family therapy in the states of Michigan and Nevada, and is an AAMFT–approved supervisor candidate. Her clinical experiences have focused largely on adolescents and their families from a broad range of backgrounds. She is a member of the American Association for Mar­ riage and Family Therapy as well as the National Council for Family Relations. Her research interests include LGBTQ+ experiences, particularly those of nonbinary sexual orientations and gender identities.

Anita A. Neuer Colburn, PhD, LPC-S, is a core fac­ ulty member and clinical training director with Northwestern University’s Counseling@Northwest­ ern program, a digital master’s in counseling pro­ gram in which students and faculty meet synchro­ nously on a weekly basis. She has provided full-time or part-time counseling services since 1998 and clin­ ical supervision to licensure-bound counselors since 2005. As an educator, she has taught in face-to-face

and online programs, at both the doctoral and mas­ ter’s levels. Her own master’s degree was in rehabili­ tation counseling, and she worked in private practice as a career counselor for over ten years. Neuer Col­ burn’s counseling experiences have included work primarily with women, sexual minorities, couples, and teens and parents in foster care systems. Before becoming a counselor, she worked as an indepen­ dent executive recruiter and personnel consultant. She presents frequently on LGBTQQIA issues, and her research interests include online counselor edu­ cation pedagogy, LGBTQQIA counseling and super­ vision competencies, spiritual integration in coun­ seling and supervision, and social justice issues. Mia Ocean, PhD, MSW, worked as a clinical social

worker for over a decade before moving into her roles of educator, researcher, and advocate in higher education. Most recently, she served as a professor of addictions studies at Bakersfield College, and cur­ rently she serves as an assistant professor of graduate social work at West Chester University. She is a National Institute of Alcohol Abuse and Alcoholism (NIAAA) fellow, and much of her research focuses on the preparation of addiction counselors, in addi­ tion to the sometimes competing open-access and gatekeeping functions of community colleges. Accordingly, she has developed and refined sub­ stance abuse counseling credentialing programs at multiple community colleges throughout the United States. In all her work, her passion for empowering individuals, challenging inequitable policies, and engaging in an anti-oppressive practice is evident.

Deborah (Di) O’Neill, DSW, MSW is a clinical social

worker providing psychotherapy in the college coun­ seling center at the University of Pennsylvania. After focusing her doctoral research on sexual violence within the college community, O’Neill created the Sexual Trauma Treatment Outreach and Prevention (STTOP) team. The team is an identity-diverse, mul­ tidisciplinary team of mental health clinicians invested in providing treatment specific to the needs of survivors of sexual trauma. The team offers an educative and supportive function to team clinicians in addition to meeting the goal of providing imme­

diate support to victim-survivors. O’Neill is a mem­ ber of a campus Sexual Assault Response Team (SART), a member of a countrywide Sexual Assault Program Coordinators (SAPC) association, has cre­ ated a group prototype for supporting survivors of campus sexual and interpersonal violence, and is regularly engaged in community education and out­ reach initiatives on the University of Pennsylvania campus. Jason A. Owens, EdS, LPC, NCC, is currently the direc­

tor of Pupil and Personnel Services for the Cabrillo Unified School District in Half Moon Bay, California. Owens is passionate about sexual identity within tra­ ditionally marginalized minority populations as it relates directly to development, education, and career. His current research is focused on minority popula­ tions with a lens specifically looking at transgender individuals and ethical counseling of those groups. He works diligently to continue in the creation of a culture centered on safety, encouragement, and posi­ tivity in education for all our students.

Tracy Peed, PhD, PEL, is an assistant professor of counselor education and supervision in the Depart­ ment of Counseling and Student Personnel at Minne­ sota State University–Mankato. She is currently a licensed school counselor in Illinois, where she served as a secondary school counselor for seven years, is a member of the Illinois School Counselor Association Executive Board, and was acknowledged as the 2014 Secondary School Counselor of the Year. She is strongly committed to leadership, social justice, advocacy, and culturally aware best practice with and on behalf of marginalized individuals, groups, and communities. She puts practice to action in her Multicultural Coun­ seling and Counseling in a Diverse Society courses. It is here that she facilitates students’ understanding, knowledge, and skills related to their own intersec­ tional cultural identities, fostering intentional work with clients who are culturally different and face advo­ cacy and agency concerns and systemic and institu­ tional oppression. Kathryn L. Pozniak, MA, LLPC, NCC, is a doctoral

student in counseling at Oakland University in RochAbout the Editors and Contributors 649

ester, Michigan. She is the lead counselor at Honey Space for Moms, where she focuses primarily on peri­ natal mental health and couples counseling. She works with counselors-in-training through teaching and supervision and explores evidence-based prac­ tices in the counseling profession to fill the gap between research and clinical practice. Jane E. Rheineck, PhD, LPC, is an associate profes­

sor in the Department of Counseling at Mount Mary University in Milwaukee. Rheineck has taught both master’s and doctoral students in clinical skills, coun­ seling ethics, multicultural counseling, counseling the LGBTQ community, and leadership and advocacy. She has an ongoing program of research and schol­ arship that focuses on a variety of LGBTQ and gender issues. Rheineck is a licensed clinical professional counselor (LCPC) in the state of Illinois; she has a clinical background that reflects a broad range of experiences that include adolescent inpatient residen­ tial treatment, outpatient counseling with adults, and mental health counseling in the schools. In addition to her clinical background, Rheineck has experience in higher education and student affairs with an emphasis on student development and counseling. Alexandra M. Rivera, PsyD, is a licensed psychologist

who specializes in culturally informed treatment and outreach and advocacy for multiply marginalized communities, particularly queer and trans people of color. She is currently a psychologist at Stanford Counseling and Psychological Services as well as the program manager for Stanford’s Weiland Health Initiative, a partnership between Vaden Health Center and the Queer Student Resources Center on campus. Rivera received her doctoral degree in clinical psy­ chology from the PGSP-Stanford Psy.D. Consortium. She is an active member of the Asian American Psy­ chological Association as well as the American Psycho­ logical Association (Divisions 27 and 44) and is on the Editorial Board for the Counseling Psychologist, the official journal of APA Division 17. She has pub­ lished numerous journal articles and book chapters on multicultural mental health and actively conducts research in this area.

650 About the Editors and Contributors

Zully A. Rivera Ramos, PhD, is a clinical assistant pro­

fessor at the University of Florida’s Counseling and Wellness Center (CWC); a licensed psychologist; and the coordinator of Outreach and ASPIRE, a diversity and inclusion program within the CWC. She is very passionate about multicultural concerns, particularly in regard to the intersections of gender, sexual, and Latinx identities. Being originally from Puerto Rico, she is fluent in both Spanish and English. She has experience doing research and outreach to promote awareness and understanding of diverse sexual orien­ tations and gender identities. She is a member of the National Latinx Psychological Association (NLPA) and served as membership chair for over two years. Rivera Ramos has presented nationally and published in peer-reviewed journals. She currently serves as an editorial board member for the academic journal Counseling Psychologist. She received a Presidential Citation at the 2018 NLPA conference for her service as membership chair. She was accorded the 2018 Uni­ versity of Florida’s Division of Student Affairs Supe­ rior Accomplishment Faculty Award. She received the 2017 Wise Latina Faculty/Staff Award from the Uni­ versity of Florida’s Hispanic-Latinx Affairs and the 2015 Faculty/Staff Member of the Year at the Univer­ sity of North Florida’s LGBTQ Resource Center Lav­ ender Graduation.

Tangela S. Roberts, PhD, received her counseling psy­

chology doctorate from the University of Massachu­ setts Boston. She is currently an assistant professor in the Counselor Education and Counseling Psychol­ ogy Department at Western Michigan University. Her research focuses on the experience of individu­ als whose identities lie at the intersection of race, ethnicity, and sexual orientation. Her aim is to develop a better understanding of critical theories and focus on intersectional identities, resilience, and community support. Her scholarly works include analyses of the effects of racial justice activism on the mental health of black activists, as well as the influence of the con­ cept of monosexism on the sexual orientation–identity development process of bisexuals.

Sorrel Rosin (pronouns: they/them/theirs), originally

from Chicago, is a trans/queer student at the Univer­

sity of Oregon. They are studying for a bachelor of education in family and human services with a minor in queer studies. They are an avid trans/queer activist. In the summer of 2017 they started Welcome Queer (WelcomeQueer.com), an online database of consumer reviews for places that are safe for queer people—and those that are not safe. Along with founding and managing Welcome Queer, they were a 2017–2018 GLAAD campus ambassador. GLAAD campus ambassadors are a volunteer network of LGBTQ and ally college and university students who work with GLAAD and within their local communities to build an LGBTQ movement that accelerates acceptance and ends hate and discrimination. Angela Schubert, PhD, LPC, CCMHC, is an assistant

professor and program director of clinical counsel­ ing at the Central Methodist University. She is a coleader of the Sexual Wellness in Counseling Inter­ est Network of the American Counseling Associa­ tion. She recently retired as Missouri state chair for the American Association of Sexuality Educators, Counselors, and Therapists, a position she held for six years. Her research interests focus on intersec­ tionality in relation to gender, age, and sexuality through a relational cultural theoretical lens. She is principal investigator for a qualitative research study looking at how societal messages of gender influence academic self-concept and work-life balance. She is strongly involved in the LGBT+ community in Kan­ sas City and rural areas of Missouri. She has contin­ ued to act as expert consultant on sexuality-related topics such as sexual wellness, aging sexuality, sexual consent, sexual assault, and body image.

Matthew R. Shupp, EdD, is an associate professor and

coordinator of the College Student Personnel spe­ cialization in the Department of Counseling and College Student Personnel at Shippensburg Univer­ sity. Before his work as a faculty member, Shupp was a student affairs professional for twelve years in a variety of institutional settings. He is both a national certified counselor (NCC) and board-certified tele­ mental health provider (BC-TMH). He received both his BA in psychology and his master’s in coun­ seling from Shippensburg University, and his EdD in

higher education administration from Widener Uni­ versity. He also holds a post-master’s certificate in clinical counseling from Messiah College. He has presented at numerous local, regional, national, and international higher education conferences on a variety of topics. His research interests include exploring inclusive supervision strategies and social justice topics related to equity, access, and inclusion. Christina M. Sias is a PhD candidate in curriculum and instruction at Utah State University. Her research has focused on engineering education and Navajo edu­ cation. She is committed to producing research that seeks to create equity for all students. She is currently working on her dissertation, which focuses on Navajo student access, enrollment, and participation in post­ secondary education. Anneliese Singh, PhD, is professor and associate dean

of the Office of Diversity, Equity, and Inclusion in the College of Education at the University of Georgia. She cofounded the Georgia Safe Schools Coalition to work on the intersection of heterosexism, racism, and other oppressions, and she founded the Trans Resil­ ience Project to translate two decades of her research on trans and nonbinary (TNB) persons’ resilience to trans prejudice. Singh is the author of The Queer and Transgender Resilience Workbook and The Racial Heal­ ing Handbook, and she has co-authored TNB coun­ seling texts (A Clinician’s Guide to Gender-Affirming Care, Affirmative Counseling and Psychological Prac­ tice with Transgender and Gender Nonconforming Clients), American Counseling Association Transgen­ der Counseling Competencies, and American Psy­ chological Association Transgender Psychological Practice Guidelines. Singh strives to live by the ideals of Dr. King’s beloved community, as well as Audre Lorde’s reminder that “without community, there is no liberation.” Brandy L. Smith, PhD, is the assistant director for clin­

ical training at Auburn University’s Student Coun­ seling & Psychological Services. She started working more directly with diversity while pursuing her under­ graduate degree at Mississippi University for Women through an honors project related to sexual orientaAbout the Editors and Contributors 651

tion. While studying for her master’s and doctoral degrees, Smith was an active member of a University of Memphis research team that focused on sexual orientation and gender identity. She carried the pas­ sion for diversity, broadly defined, through her intern­ ship year at University of Oregon, completing the multicultural rotation and then, after her internship, served as a staff clinician for three years, including time as the diversity coordinator, at New Mexico State University. She joined the Auburn University family in August 2011 and has been working with the uni­ versity’s Safe Zone program since her first year there. For the past several years she has been the sole Safe Zone facilitator and has worked to get as many fac­ ulty, staff, and students Safe Zone–trained as is possible. Diane Sobel, PhD, is a licensed counseling psychologist

and the assistant director and training director at the University of Kentucky Counseling Center (UKCC) in Lexington, Kentucky. She started the Trans* and Gender-nonconforming Support group at UKCC in 2014, and she annually coleads the group with a doc­ toral psychology intern in training at UKCC as part of her commitment to training clinicians competent to work with transgender clients. She is a member of University of Kentucky’s Transform Health Clinic Patient Care Working Group (www.uky.edu/lgbtq/ transformhealth). She served as a HOPE regional trainer of psychologists for twelve years through the APA’s HIV/AIDS Office for Psychology Education. She has served on the boards of directors of a num­ ber of professional organizations over the years, including the Kentucky Psychological Association (KPA), Kentucky Board of Examiners of Psychology (KBEP), and the Association of Counseling Center Training Agencies (ACCTA).

Shannon Solie, MA, LMHC, is a therapist in private

practice in Seattle, Washington. They believe in cre­ ating an “equal healthcare for all model” and set up a practice based on a pay-by-need-and-means basis. They have thrived with clients feeling empowered to engage in therapy that works for them at costs that allow for a holistic caring for the self. Solie focuses their practice on working with folks who consider

652 About the Editors and Contributors

themselves oppressed by sexuality and gender roles. In addition to clinical work, Solie is an adjunct pro­ fessor at Seattle University, where they teach courses on counseling along the gender spectrum and sexual phenomenology. Solie teaches workshops around the country on inclusive health care for gender- and sex­ ually diverse people and works as a clinical specialist on asylum cases for individuals who identify as LGBTQIA. Alaina Spiegel, PsyD, is a licensed clinical psycholo­

gist and the coordinator of prevention programs at the University of Pennsylvania’s Counseling and Psy­ chological Services (CAPS). Spiegel is passionate about enhancing college student well-being through clini­ cal care and community outreach and prevention. To this end, she helps coordinate and facilitate CAPS’s I CARE program, a gatekeeper training that provides Penn faculty, staff, and students the skills and resources to intervene in student stress, distress, and crisis. Spie­ gel also assists in outreach coordination; engages in program development; delivers workshops, presenta­ tions, trainings, and orientations across campus; and serves as a CAPS liaison to various departments, pro­ grams, and student groups at Penn. She is committed to outreach and prevention efforts aimed at social jus­ tice, stigma reduction, self-care, social support, suicide prevention, and mindfulness.

Jeanne L. Stanley, PhD (she, her, hers), is the execu­ tive director of Watershed Counseling and Consulta­ tion Services, LLC, and a national trainer and con­ sultant. She is a licensed psychologist in private practice in the Philadelphia area and founder of Grad School Coaching. Stanley has been on the graduate faculty of the University of Pennsylvania since 1994 and has received the Outstanding Educa­ tor of the Year Award from the University of Penn­ sylvania’s Graduate School of Education. Her clinical, training, and research specialties focus on the inter­ section of sociocultural identities (including gender, gender identity, sexual orientation, race, ethnicity, class, religion or spirituality, social class, and disabil­ ity); supporting and affirming LGBTQIA individuals; assisting school districts, academic institutions, and businesses in creating policies and implementing

best practices for supporting gender-expansive and transgender (GET) students and personnel. She also works with individuals and work teams regarding the expansion of their talents and strengths. Her research and trainings have led to several publica­ tions in professional journals and books. Her coed­ ited book, Teaching LGBTQ Psychology: Queering Innovative Pedagogy and Practice (2017), was pub­ lished by APA Books. George Stoupas, PhD, is a professor of human ser­

vices in the addiction studies program at Palm Beach State College and adjunct instructor in Florida Atlantic University’s clinical mental health counseling program. He is a licensed mental health counselor and Florida board-certified addiction professional, with over a decade of clinical experience in the treat­ ment of substance use disorders for a variety of pop­ ulations. His publications include book chapters and journal articles related to addiction, ethics, spiritual­ ity, and case conceptualization. His current research examines the relationship between counselor and trainee beliefs about addiction, recovery status, and job function expectations. As an educator, he emphasizes the role of cultural sensitivity and knowledge in providing individualized, ethical, and effective care for people with substance-related prob­ lems. He is the 2018 recipient of the Stewart Award for Distinguished Teaching.

Andrew Suth, PhD (pronouns: he/him/his), is an

associate professor at Illinois School of Professional Psychology (ISPP). He earned his doctorate from the Department of Comparative Human Development in human development and psychology at the Uni­ versity of Chicago, subsequently taught clinical courses in that department, and served as the assis­ tant director of the mental health track. He has a postdoctoral certificate in clinical neuropsychology. He teaches in and has chaired the neuropsychology concentration at ISPP and has served as a clinical consultant to the Psychological Services Center at Argosy University and to several private assessment practices. He previously served as a national cochair for APA’s Division 39 (Psychoanalytic Psychology) 2010 annual conference in Chicago and currently is

the associate director of the Palombo Center for the Study of Neuroscience and Psychoanalytic Social Work at the Institute for Clinical Social Work. He maintains a private practice in psychotherapy and neuropsychological assessment. Patia Tabar, JD, MS, MAPH, MSEL, is a licensed men­

tal health counselor in Indiana, a licensed profes­ sional clinical counselor in Ohio, and a general prac­ tice attorney in Kentucky, Washington state, and Ohio. She is passionate about counseling underserved populations, focusing on sufferers of trauma and the LGBTQ+ population. In addition to her counseling skills, she has a background in both his­ tory and theology, and extensive experience teaching college-level courses in history and law.

Fiona Tasker, PhD, is a reader in psychology at the

Department of Psychological Sciences, Birkbeck University of London (www.bbk.ac.uk/psychology/ our-staff/fiona-tasker). Tasker has specialized in family psychology and systemic family therapy and is on the editorial boards of several journals. She has published widely on the psychological implications of both nontraditional and new family forms (cre­ ated through foster care, adoption, and assisted reproductive technologies) for parents and children, in heterosexual- and LGBTQ-parented families. Currently, she is working on several studies employ­ ing narrative analysis techniques to explore and appreciate aspects of the individual and family-re­ lated life course histories of LGBTIQQA people and has developed a range of family-mapping exercises for use with both adults and children in families.

K. Jod Taywaditep, PhD, is a staff psychologist at

Northwestern University Counseling and Psycholog­ ical Services. His past research includes the sexual and affectional behavior of bisexual men, HIV risks, and alcohol and substance use among men who have sex with men. His dissertation examined gay and bisexual men’s prejudice against other men’s gender nonconformity, and how this attitude is linked to their defeminization history and patriarchal attitude. He has worked as a clinician in college mental health settings since 1999, and among his areas of interest About the Editors and Contributors 653

are issues related to gender, sexuality, and racial or ethnic identity development, evidence-based prac­ tice, and LGBTQ-affirmative psychotherapy. In his role as the director of a doctoral internship and post­ doctoral fellowship, his professional interests are clinical training and supervision in psychology, and the development of clinical trainees’ multicultural competence. He has been an active member of the Association of Counseling Center Training Agencies (ACCTA) and has served as the chair of the Stand­ ing Committee for Training Resources and as a member of its Board of Directors. Angelica Terepka, PsyD, New York Presbyterian/ Columbia University, New York Cognitive Therapy and Wellness Center. Terepka is a New York State– licensed psychologist trained in cognitive behavioral therapy (CBT), trauma-focused CBT, and accep­ tance and commitment therapy. She specializes in working with diverse populations, particularly with LGBTQIA+ and religious populations, and she received the New York State Psychological Associa­ tion Diversity Award for her clinical and research contributions to the field of therapy. Terepka has specialized training in providing therapy to young adults and has held appointments at several univer­ sity counseling centers, where she developed and facilitated numerous workshops and therapy groups focused on LGBTQIA+ support. She currently works as a psychologist for a hospital where she provides individual and group therapy to teens and young adults and their families; she also sees clients in pri­ vate practice. In addition, Terepka is an assistant clinical professor of medical psychology at Columbia University Medical Center, and she maintains adjunct faculty appointments in Fordham Universi­ ty’s Graduate School of Education Counseling Psy­ chology program and Long Island University’s Counseling and School Psychology program. M. Evan Thomas, MS, is a PhD student at Virginia

Tech in the Human Development, Marriage and Family Therapy program. His research interests include rural mental health, adolescents, and cultur­ ally adapting interventions for minority populations. He obtained his MS from Purdue University, and 654 About the Editors and Contributors

there he gained much of his experience working with LGTBQ groups. Jenae Thompson, PhD, LPC, BC-TMH, is an assis­

tant professor in the Clinical Mental Health Program at Adler University and the owner of Synergy Coun­ seling Services. She is passionate about systemati­ cally addressing issues of marginalization that many clients experience, especially those related to racial and ethnic minorities, children, the LGBT commu­ nity, and women. Her research interests include counselor educator cognitive development, clinical applications of the multicultural and social justice competencies, intersectionality pedagogy, and cul­ turally sensitive gatekeeping.

Brianna M. Wadler is a doctoral student in counsel­

ing psychology at the University of Massachusetts Boston. She earned her BA in psychology and wom­ en’s studies at Wesleyan University and her master’s in society, human development, and health (health inequities) from Harvard School of Public Health. Before starting her doctoral studies, she worked for the Harvard Program in Refugee Trauma. She has both clinical and research interest in the experiences of sexual and gender minority people. Recently her research has focused on the effects of policy and political climate on sexual and gender minority people. Matthew J. Wright is the Title IX coordinator for

Idaho State University. In that capacity he oversees all investigations regarding discrimination, sexual harassment, and sexual assault, and he educates stu­ dents, faculty, and staff about civil rights issues. He speaks to students about sexual assault and consent, and he makes presentations at human resources con­ ferences on civil rights investigations in higher edu­ cation institutions. He has worked as a Title IX investigator and is certified as a civil rights investiga­ tor by the National Center for Higher Education Risk Management (NCHERM). Previously he was a law librarian and research attorney for the University of Nevada, Las Vegas, and regularly researched issues related to sexual orientation and the law. He has a JD from the University of Utah College of Law.

Anthony Zazzarino, PhD, LPC, ACS, CPRP, is a full-

time faculty member at Rutgers University in the Department of Psychiatric Rehabilitation and Coun­ seling Professions, where he currently provides instruction for professional education courses for New Jersey Supportive Housing agencies imple­ menting community support services (CSS), the master’s program in rehabilitation counseling, and the doctoral program in counselor education and supervision. Zazzarino completed his PhD in coun­ selor education and supervision at Walden Univer­ sity, where he focused on improving the lives of sex­ ual minorities with serious mental illness. Zazzarino is actively presenting at local, state, and national conferences related to psychiatric rehabilitation methods, counseling services, and supervision prac­ tices. In addition to the professional education courses, Zazzarino is a suicide prevention trainer, facilitates group therapy for adolescents and adults at an intensive outpatient program, provides outpa­ tient counseling services at his private practice, and

provides clinical supervision for counselors needing supervised clinical hours in New Jersey. Matt Zimmerman, PsyD, ABPP, is a board-certified clinical psychologist who serves as an assistant direc­ tor and director of training at the University of Vir­ ginia’s Counseling & Psychological Services. In those roles, he supports the functioning of the center and doctoral interns in an American Psychological Asso­ ciation–accredited training program. He has served as the president of the Broward County Mental Health Association and the Association of Counseling Center Training Agencies. His authorship is in the areas of client-therapist goodness of fit and enhanced integra­ tive health care. Zimmerman provides counseling to a wide range of university students, and he practices and trains in the areas of multicultural counseling, brief therapy, integrated care, and supporting individ­ uals with eating and body image concerns. Zimmer­ man has a long-standing interest in organizational development for health agencies, collaborative health care, addressing barriers to mental health access for traditionally underserved and marginalized popula­ tions, and intersecting identities.

About the Editors and Contributors 655

IN DE X Page numbers in italics refer to illustrations, homework, handouts, and activities.

ableism, 581–587

abusers, intimate partner, 195–196, 197, 200

Acceptance and Commitment Therapy (ACT), 178, 437

adaptive integration, 62

addiction. See substance use disorders (SUDs)

ADDRESSING framework, 101

affinities, sexual, 328, 331

ageism, 14, 69, 133–135, 438

agender, 276, 368, 385

aging, 436–443

Allport, Gordon, 62, 66

ally-training

brainstorming strategies and, 558–564, 563, 564

for general audiences, 596–603

amnestic heterosexism, 82

animal-human bonds, 6–7

anticipatory stress, 93, 96, 98

anti-sissy prejudice, 626

anti-trans prejudice, 624–627

aphobia, 451

Apple Tree Family (ATF), 256, 259, 260, 263

aromantic, 376, 563

art therapy

body issues and, 464–471, 471

expressive, 392–399, 398–399

and gender dysphoria, 385, 386–389

and trauma, 349

asexuality, 220, 368, 376–382, 381–382

Asperger’s syndrome, 158

assertiveness training, 425–426

assessment forms, nonbinary, 354–365, 359–365

asylum seekers, 168–175, 174–175

authenticity, 23

authoritarianism, 626, 627

autism spectrum disorder (ASD), 158–167, 163–164,

165–166, 167

autobiographical photography, 402

autonomy, and pet-assisted therapy, 7–8

aversive heterosexism, 82

BDSM Communication Tool, 235–237, 239

belonging, 91

656

beneficence, 7, 8, 171

bias

implicit, 566–573, 570–573

internalized, 82, 91, 411, 449–450, 473, 610–613

personal, 580–587

Bible, interpretations of, 63

binary thinking, 264–269, 269

biphobia, 152, 195, 219, 451, 474

body dysphoria, 464–471

body image, 464–471

body mapping, 387–389

body scan, 408–416, 414–416

bondage and discipline/dominance and submission/

sadism and masochism (BDSM), 234–241, 239,

240–241

“Both/And” concept, 597

boundaries, clinician-client relationship, 226–227

branched sexualities, 330

Buddhism, 83, 85

campus climate assessment worksheet, 594–595

campus climate checklist, 522–533, 524, 526, 530–533

Campus Pride survey, 523

career-construction theory, 514

career decision-making self-efficacy (CDMSE), 534–542,

540, 541, 542

career issues

decision making, 534–542

and job searches, 492–497

personal values and, 514–521, 519, 520–521

resources, 492–497, 497

sexual identity and, 498–507

workplace discrimination strategies, 508–512

charting, 451–453, 472–480, 480

cinematherapy, 52–58, 57, 58

circles of outness, 314–319

cisgenderism, 70–73, 436, 438

cognitive behavioral therapy (CBT), 2, 15, 84, 394, 446,

474

co-incident sexualities, 330

collaborative safety and treatment planning, 140–148,

145–148 collages, 393–394, 395, 404

collective action, 68, 124–131, 129, 130, 131

colleges

campus climate checklist, 522–533, 524, 526, 530–533

climate assessment and, 588–595, 594–595 outreach workshops and, 552–557 coming-out process, 4, 5–6

and empowerment, 5, 15, 24, 30

older adults and, 14–20

pet-assisted intervention and, 4–12

religious identity and, 31, 60–66

stages of, 4, 400–401

and transgender teens, 22–29

common humanity, 83

communication

and BDSM, 234–241, 235, 239, 240–241

and implicit bias, 566–573

and sexual desire, 186–193

community

and addiction recovery, 451, 452, 453, 482–488,

487–488 college outreach and, 552–557 power and privilege within, 604–609

concealment, sexual identity, 5, 124

confidentiality

and group workshops, 208

ICTs and, 225–227

connection

and addiction recovery, 482–488

family-of-choice, 254

ICTs and, 224–226

conscientization, 109

consent, in BDSM, 235

control, partner abusers and, 195–196, 200

cost-benefit analysis (CBA), 15–17, 19–20

countries of origin, 168–171

covering, 169

Crisp, Catherine, 612

critical lyric analysis, 41–42, 45, 49

C3PO substance use intervention, 451–453

cultural identity, 5–6

cyberbullying, 225, 226

cyberstalking, 226–227

cycle of violence, 195–196, 199

deadname, 248

Desire Spectrum Map, 368, 371, 375

desisting gender dysphoria, 306

digital footprints, 185, 226

disabilities, 580–587, 586, 587

disclosure

and the family unit, 280–287 in mixed orientation relationships, 314–319

and parents of transgender teens, 270–279

disconnection, community, 124

discrimination

forms of, 624–625 perceived, 83, 84

distal stressors, 91

distress management, 438–439, 441

Divergent (movie), 630

Domestic Violence Personalized Safety Plan, 201–205

eating disorders, 464–471

ecomaps, 30–39, 38, 39

emotion-focused therapy (EFT), 289

emotion regulation, 438

employment

discrimination and, 498–500, 508–512

searching for, 492–497

empowerment

addiction recovery and, 457–458

and body issues, 466

coming out and, 5, 15, 24, 30

and Latinx clients, 109–110

mapping exercises and, 367–369

and people of color, 77

pronoun use and, 247, 250, 427

resilience and, 125

and workplace discrimination, 508–509

empty-chair work, 288–296

eroticism, 366

experimentation, sexual, 235–236, 240–241

expressive art therapy, 392–399, 398–399

external (distal) stressors, 91

Family Acceptance Project, 141

family mapping exercises (FMEs), 254–263, 258, 259, 260,

263

family-of-choice connections, 254

family portraits, 395

family therapy

for blended family and trauma issues, 298–305, 305

empty-chair work and, 288–296

and expanding binary thinking, 264–269

and the family unit, 5, 280–287, 283

intervention for parents of gender-nonbinary chil­ dren, 306–312 and LGBTQ parents, 254–263 transgender-affirmative parenting, 246–253 and transgender teen disclosure process, 270–279, 277–279 Index 657

fidelity, 7, 8, 171

Fifty Shades trilogy, 234

film therapy, 52–58

financial discrimination, 15, 271, 342, 459, 510, 512

fluidity, of sexuality, 326–327

formal discrimination, workplace, 498

Four Cs, 235

Gay Affirmative Practice Survey, 612

Gay, Lesbian, and Straight Education Network (GLSEN),

224, 226, 227–228, 514

gender-bashing, 82, 626

gender dysphoria (GD), 306, 384–391

gender identity disorder (GID), 306

gender identity exploration matrix, 326–339

gender identity terms, 276

genderism, 82, 264–265, 626

Genderism and Transphobia Scale (GTS), 626

Gender Spectrum Map, 370, 374

Gender Terms Discussion Exercise, 308, 311–312

genograms, 254, 300–303, 305

Gerasimo, Pilar, 404

Gestalt therapy, 289

GLBT Power and Control Wheel, 195, 196, 200

global identity, 36

GLSEN National School Climate Survey, 514

goals

and aging, 438–439, 440, 442

career, 494, 534–535, 540

educational, 526

in outreach workshops, 553–554, 598, 605, 606

relapse-prevention and, 452, 453

hate violence, 2, 22–23, 207

health-care injustice, 70–71 Health Equity Promotion Model, 355

heterosexism, 82, 150–157 internalized, 449–450, 473, 611–613 heterosexist events, 151–155, 157

Holonic System of Sexual Desire Meanings, 188, 192–193 honesty, 456–463 host country, 168–171 hostile heterosexism, 82

hypermasculinity, 626, 627

identities

group exploration of, 400–408, 408

intersecting, 546–551, 550–551

labels, 328–329, 332, 366–368

658 Index

understanding personal, 596–603, 602, 603

See also multiple marginalized identities

identity abuse, 60–61

imagery, guided, 403–404

imagery rescripting, 474

immigration officials, 168–169

implicit bias, 566–573, 570–573

Inclusive Safety Plan of Care (ISPOC), 140–148

informal discrimination, workplace, 498

information and communication technologies (ICTs),

224–232, 230–231, 232

injustice, structural, 70–75

intake forms, 354, 357

internalized stigma, 82, 91, 411, 449–450, 473, 610–613

internal (proximal) stressors, 91, 93, 96, 98

Internet use, 224–232

Intersectionality Activity, 524, 524, 526–527, 526

intersectionality theory, 70, 132–133

intersectional spaces, power and privilege within,

604–609

intimate partner violence (IPV), 194–205, 199, 200,

201–205

isolation

and addiction, 451, 457, 475

asylum seekers and, 169, 170

autism and, 159

and collective action, 68, 125

on college campuses, 523, 552, 556, 588

coming out and, 5, 7

employment search and, 499

and intimate partners, 196

minority adolescents and, 283

minority stress and, 91

older adults and, 132, 133, 436

sexual minority parents and, 298

journaling, 8, 458, 461–463 Kelly, George, 188

Killermann, Sam, 599

kink-identified people, 234–236

Klein Sexual Orientation Grid (KSOG), 326–330

Knowdell Career Values Card Sort, 515

labels, identity, 328–329, 332, 366–369 language

in ally-training, 559–560, 563

asylum seekers and, 171, 172

client assessment and, 354–365

and human desire, 366

name-change process and, 426–435, 433–435

and social technologies, 224, 226, 227

transgender-affirmative parenting and, 23–24,

246–253

Latinx community cultural values, 108–123, 114–121,

122–123

letter-writing activities, 22–29, 29, 403

“LGBT Job Search and Career Resources,” 493–494, 497

LGBT People of Color Microaggressions Scale, 596

LGBTQ-parented families, 254–263

LGBTQ Workplace Discrimination Checklist, 508–509,

512

liberation psychology, 108–109

lovingkindness, 82–89

lyrics, song, 41–42, 404

mapping

age acceptance and, 436–443

desire and gender, 366–375, 370, 371, 374, 375

ecomaps, 30–39

family, 254–263, 258, 259, 260, 263

and gender dysphoria, 384–391

and relationship disclosures, 314–318

markers, 290, 330

Martín-Baró, Ignacio, 108

Matrix, The (movie), 628, 630

Matrix for Sexuality and Gender (MSG), 326–339, 335,

336–337, 338–339

meditation, 82–89, 403–404, 408, 410–412

mental health care injustice, 70–75

metaphor, in film, 52, 54

Metzl, Jonathan, 71

microaggressions, 605

categories of, 624–625

on college campuses, 556

effects of, 574–578

and people of color, 100, 596

social privilege and, 605–606

milestone events, 330

mindfulness, 83–89, 410–418, 416–418

minority stress experiences, 90–98, 93, 96–97, 98, 125

mixed orientation relationships, 314–319

Motion Picture Association of America (MPAA) film

rating, 53

movies, 52–58

multiculturalism, 109

multicultural model of the stress project, 101

multiple marginalized identities

and addiction, 472–480

collective action and, 124–131

people of color and, 100–107

privilege within, 604–609

Musical Autobiography Assessment Activity, 41–42, 44,

47, 48

music therapy, 40–50

name-change process, 426–435, 433–435

narratives

addiction charting and, 475

and mixed orientation relationships, 314–319

multiple oppressions and, 76–81, 81

narrative exposure therapy (NET), 170

and photo diaries, 341–347

National Center for Transgender Equality, 611

National Center on Domestic and Sexual Violence, 196

National Institute of Justice, 227

National Transgender Discrimination Survey, 246, 625

National Violence Against Women survey, 194

Nightingale, Florence, 7

nonmaleficence, 7–8, 171

Nursing Home Reform Act, 132

nursing homes, 133–139

nurturance, 366

Obama, Barack, 522

Occupational Outlook Handbook, The, 537

older adults

and acceptance, 436–443

advocacy roles for, 132–139, 138, 139

coming out as, 14–20

oppression

coping with multiple forms of, 70–75, 75

intersectionality and, 546–548

narrative management of, 76–81

structural, 70–75, 108–109, 624

outreach workshops

ally-training, 558–564, 563, 564

college campus, 552–557, 588–595, 594–595

general audience, 596–603

papercut exercise, 574–578

parenting

and binary thinking, 264–269, 269

and family mapping, 254–263

sexual and gender minority parents, 298–305, 305

transgender-affirmative, 246–253, 253

and transgender teen disclosure, 270–279

Index 659

paternalistic heterosexism, 82 peer support

and college campuses, 552–557

and minority stress, 91, 92

and relationships, 207–209

social media and, 224, 225

people of color

cinematherapy and, 52

multiple marginalized identities and, 100–107,

106–107 narratives of, 76–81

perceived discrimination, 83, 84

persisting gender dysphoria, 306

personal bias, 580–587

pet-assisted coming-out therapy, 4–12, 12

photo diary, 340–347

photography, autobiographical, 404

Pierce, Chester, 574

police violence, 22–23, 169

polyamorous relationships, 218

positive stereotypic heterosexism, 82

power dynamics, sexual, 234–235

predators, sexual, 225

privacy

addiction recovery and, 456–463

ICTs and, 225–227

privilege

intersectionality and, 546–548

in marginalized communities, 604–609

understanding, 596–603, 603

problematization, 109

problem-saturated narratives, 315

prompts, addiction recovery, 456–463, 461–463

pronouns

affirmative parenting and, 246–253, 253

asserting one’s, 428–430, 434–435

in initial assessment forms, 354–365, 359–365

proximal (internal) stressors, 91, 93, 96, 98

psychological distress, 91, 93, 97, 98

Pulse massacre, 108

“Reach Higher” initiative, 522 refugees, 168–175 relapse-prevention intervention, 448–455 relational cultural theory (RCT), 132–135 relationships asexual, 368, 376–382

and BDSM, 234–241

ecomaps and, 30–39

forming and maintaining, 218–222, 222

and information and communication technologies,

224–232

and intimate partner violence, 194–205

mixed orientation, 314–319

polyamorous, 218

romantic, 328, 329, 376–378, 382

sexual desire in, 186–193

termination of, 212–216, 216

transgender youth skills in, 206–211

relaxation techniques, 8

religious fundamentalism, 626

religious identity

coming out and, 31, 60–66, 66

expression of, 177

intersection management and, 420–425, 425

and LGBTQ clients of color, 101–102

and lovingkindness meditation, 85

personal values and, 176–182, 181, 182

stages of, 62, 66

Religious Tolerance website, 63

resilience

collective action and, 124–131, 129, 130, 131

minority stress and, 91, 93, 97, 125

themes of, 170–171

respeto (respect), 110

reverse-covering, 169

right-wing authoritarianism, 626, 627

role-playing

empty-chair work and, 288–296

pet-assisted intervention and, 6, 7, 8

romantic attraction, 328, 329, 376–378, 382

Quadrant Exercise, 219–220, 222

safety

and BDSM, 235–237, 239, 240–241

ICTs and, 224–228

intimate partner violence and, 196, 197, 201–205

in nursing homes, 133–134

and youth of color, 140–148, 145–148

safe words, 235, 236–237

sanctuary status, 168

racism

health care and, 70–71

internalized, 102, 151

and multiple marginalized identities, 100–107

narrative approach to managing, 76–81

raw credulity, 62

660 Index

satisfying rationalism, 62

secrecy, addiction recovery and, 456–463

self-characterization sketch of sexual desire, 188

self-compassion, 83–89

self-portraits, 393, 394–395

sexual affinity ratings, 328, 331

sexual attraction, asexuality and, 368, 376–382

sexual configurations theory (SCT), 366–367

sexual desire

communicating, 186–193, 192–193

fluctuations in, 186

intersectional mapping of, 366–375, 370, 371, 372, 373

meanings of, 187, 188–189, 192–193, 366

and older adults, 135

and popular culture, 186–187

self-characterization sketch of, 188

sexual experimentation, 235–236, 240–241

sexual-identity management, 498–507, 505, 506, 507

sexuality, multidimensional, 326–327

sexual orientation and gender identity (SOGI), 280

“Sexual Orientation Microaggressions: ‘Death by a Thou­ sand Cuts’ for Lesbian, Gay, and Bisexual Youth” (Nadal et al.), 574–575

sexual predation, 225

sexual sociability, 450

sexual violence

intimate partner, 194–205 victim-survivors of, 610–622, 612, 616–619, 620, 622

Shepard, Matthew, 589

Shore, Stephen, 160

SIFT acronym, 85, 89

social belonging, 451, 452, 453

social cognitive career theory (SCCT), 498, 534

social identity, 330, 604–609, 609

social media, 224–232

social privilege, 605–606

social sexuality, 450

song activity, 402

stereotypes, 24, 71, 566, 567, 625

stigma, internalized, 82, 91, 411, 449–450, 473, 610–613

storytelling, 76–81, 81

stress inoculation training (SIT), 170

Stronger Together: Best Practice Guide for Supporting LGBT Asylum Seekers in the U.S., 168

Strong Interest Inventory (SII), 537

structural competency, 71

structural oppression, 70–75, 108–109, 624

substance use disorders (SUDs)

body image and, 464–471

charting and, 472–480, 480

and community membership, 482–488

honesty in recovery from, 456–463

relapse-prevention intervention, 448–455

Sue, Derald Wing, 605

technology, 224–232 teens

disclosure process and, 22–29

and disclosure to parents, 270–279

ecomaps for, 30–39

isolation and, 283

See also youth

termination, relationship, 212–216

therapeutic alliance, 125–126, 284–285, 351, 436–438

thin description, 315

three-minute breathing space, 412, 418

time, visual transitions of, 341

time frames, 330

time lines, 451–453

trait mindfulness, 83–84

transgender and gender-expansive (TGE) youth, 264–269

transgender and gender-nonconforming (TGNC) people

addressing prejudice against, 624–632

identity exploration for, 400–408, 408

minority stress group intervention for, 90–98

and name-change process, 426–435

teen disclosure letter-writing exercise, 22–29, 29

and youth of color safety planning, 140–148

and youth relationship skills, 206–211

and youth trauma interventions, 348–353

transitional name, 428

transphobia, 82, 427, 626–627

trauma-focused cognitive behavioral therapy (CBT), 170

trauma-informed art therapy, 347

trust

in BDSM relationships, 235–237

and pet-assisted intervention, 5–7

in therapy, 125–126, 284–285, 351, 436–438

twelve-step model, 457

“Two Stars and a Wish,” 213, 216

United Nations High Commissioner for Refugees

(UNHCR), 168

U.S. Transgender Survey, 611

values

aging and, 438, 440

career exploration and, 514–521, 519, 520–521

Index 661

personal exploration of, 176–182, 181, 182

veracity, 7, 8

violence

cycle of, 195–196, 199

hate, 2, 22–23, 169, 207

intimate partner, 194–205

victim-survivors of, 610–622, 612,

616–619, 620, 622

visualization, 403–404

volunteering, 451, 452, 453

Whosoever website, 63

workplace discrimination, 498–500

strategies for addressing, 508–512, 512

workplace sexual-identity management (WSIM), 498–500

662 Index

World Values Survey, The (2011), 60 writing and healing heterosexist experiences, 150–157, 157

and identity exploration, 403

multiple oppression navigation and, 77–78, 79

transgender teen disclosure and, 22–29

youth

definition of, 224

and ICTs, 224–232, 230–231, 232

parents of TGNC, 264–269

and TGNC safety planning, 140–148

TGNC trauma interventions and, 348–353

transgender relationship skills, 206–211

See also teens