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LGBTQ Issues

Counseling survivors of human trafficking

By Lamerial McRae and Letitia Browne-James October 9, 2017

Millions of human trafficking victims exist across the globe. In the United States, hundreds of thousands of victims experience trafficking. As society expands and evolves, human trafficking perpetrators find new ways to recruit and victimize others. The evolution of perpetration ensues because of increases in accessing technology, shifting state and federal laws, and changing criminal investigation methods within communities. Human trafficking continues to evolve into a new way of enslaving human beings, stripping individuals of basic rights and freedoms, while skirting the legal issues of slavery and ownership.

Human traffickers often recruit individuals by offering the fantasy of increased happiness, stability, relationship success and financial freedom. Human traffickers, often referred to as “pimps” or “playboys,” may recruit a female or male victim with promises of a better quality of life, including, but not limited to money, security and safe shelter. These perpetrators often present as charming and recruit their victims using lies and manipulation. They prey on victims from vulnerable populations, including those with low socioeconomic status (SES), biological females, children and adolescents, immigrants and LGBTQ+ youth. The fact that these vulnerable populations often remain dependent on others or experience institutionalized marginalization allows for perpetrators to paint the picture of a better life, both in terms of finance and social support. Thus, counselors must understand the cycle of perpetration and victimization to pinpoint potential victims among clients.

As a starting point, counselors must understand the nature of the phenomenon and seek ways to identify potential risk and protective factors. Counselors must learn to assess and address possible victimization with effective rapport building and intervention. For example, youth may display delinquent behavior (e.g., truancy, sexual misconduct, drug use) as a symptom of coercion and threats by a perpetrator. Perpetrators often experience greater ease when recruiting teenagers because of their tendency to be influenced by others. Sadly, when teenagers fall victim to a human trafficker, they are subjected to the victim-blaming phenomenon.

Thus, to build therapeutic rapport from a nonjudgmental framework, counselors need to understand the true source of teenagers’ behavior rather than labeling them as inappropriate or delinquent. As counselors increase their understanding of risk and protective factors, the profession may be able to conceptualize human trafficking as a systemic problem from a broad perspective.

 

Risk and protective factors

Several risk and protective factors exist for those falling victim to human trafficking. Risk factors include the following demographics and experiences. Risk factors, which are not limited to the list provided, may change over time with the help of counselors.

  • Low SES
  • Previous or current substance abuse
  • Social vulnerability (e.g., children, females, LGBTQ+ individuals)
  • Limited education.

Protective factors, referred to as strengths in counseling, include the following demographics and experiences. Counselors must foster protective factors and strengths in clients to reduce the risk of falling victim to trafficking.

  • Education
  • Family stability
  • Strong social support networks
  • Mental and emotional health

Counselors should understand these risk and protective factors to assess potential risks for human trafficking and to focus on increasing protective factors in counseling. For example, counselors may use a family counseling approach when working with survivors to increase their connections to loved ones and family. Throughout the process of recruiting and selling human trafficking victims, counselors may notice several risk and protective factors playing a role in the process.

 

Human trafficking business model and counseling implications

Human trafficking remains a mysterious and misunderstood phenomenon. Because of a lack of understanding about the effects of human trafficking on our society, counselors are charged with educating themselves to best address and assess individuals for victimization.

Counselors should recognize that survivors of sex trafficking require additional techniques (to those used with other clients) to build rapport with them and to reduce the mistrust that they commonly have about people. To best serve survivors, treatment approaches need to remain centered on survivors, empower them, provide safety and involve a multidisciplinary approach. In addition, professional counselors working extensively with sex trafficking survivors hold legal and ethical responsibilities to provide appropriate services and identify strategies to overcome barriers to their treatment, including specialized and intensive training.

To begin, counselors must understand the human trafficking business model to conceptualize the systemic issue and the moving parts that contribute to the continuing cycle. To highlight some of the societal and professional impacts, consider the parallel of the human trafficking business model to the process of manufacturing goods. The human trafficking business model includes the following stages of grooming and distribution:

1) The supplier recruits the victim.

2) The manufacturer grooms the victim.

3) The retailer determines price and then markets the victim.

4) The retailer sells and the consumer purchases the victim.

The human trafficking business model is a sophisticated process, not always linear in nature, and it functions as a well-established industry. Thus, the need exists to explore each of the model to better understand how to help victims and break the cycle.

Stage 1: Supplying victims. The supplier, also known as the initial human trafficking perpetrator, displays high levels of mental health concerns (e.g., antisocial personality traits) and shows little concern for the basic human rights of others. When victims enter this stage, counselors may find that these individuals report troubles at home, low SES, depression, anxiety and truant behavior. These factors contribute to their need to survive. Unfortunately, this may result in a perpetrator using charm or manipulation to attract the victims. Perpetrators remove victims’ identification, passports and other valuables to trap them in the world of human trafficking.

Clinical assessment is vital at this stage and remains an ongoing process. Counselors may want to ease survivors into telling their stories, paying special attention to the therapeutic relationship. Thus, the most valuable interventions at this stage include active listening and reflection. When administering specific assessment instruments, counselors will want to measure attitudes about victimization and perpetration and prevalence rates of violence. Counselors must use both open- and closed-ended questions to directly address potential victimization. Nonverbally, counselors will want to avoid direct eye contact and limit their use of touch because of victims’ trauma and abuse history.

Stage 2: Grooming victims. This stage involves moving human trafficking victims from the supplier to the manufacturer. Perpetrators continue to display high levels of antisocial behaviors and major mental health concerns; survivors present with mental health concerns such as depression, anxiety and addiction. Substance abuse concerns usually present when perpetrators force their victims to engage in substance use to coerce and control their behaviors, often resulting in addiction.

Counselors must use clinical assessment and maintain that ongoing process. In addition, because survivors have been manufactured as a human trafficking product, their levels of abuse and mistrust often appear high when they present to counseling. Therefore, counselors must focus on the therapeutic relationship as victims provide information about their experiences in trafficking. Counselors should pay special attention to reducing the stigma of substance use and mental health concerns, especially considering that victims develop these concerns because of coercion and violence.

Stage 3: Marketing victims. This stage involves moving survivors from the manufacturer to the retailer. At this stage, human trafficking perpetrators focus on the marketing and sales aspect of their exploitation. For example, based on the quality of their goods (i.e., victim age, appearance) and market demand, perpetrators determine the price for selling each of their victims. At this stage, survivors present with major depressive, dissociative and addiction disorders.

At this stage, counselors again use clinical assessment to understand the survivor’s story while maintaining a trustworthy therapeutic relationship. As previously stated, severe mental health concerns present because of the violence and abuse that victims experience. Thus, counselors need to use evidenced-based practices to treat depression and dissociative symptoms. Some of the most helpful interventions to treat these mental health concerns include grounding and relaxation techniques.

When focusing on grounding, counselors must engage the client’s physical world to assist the person in becoming present in the moment. For example, counselors may ask clients to locate an object in the room and provide an in-depth description. Relaxation techniques to practice include deep breathing and mindfulness meditation. Both types of techniques allow clients to practice coping skills during sessions that can translate to their everyday life experiences.

Stage 4: Selling victims. As retailers push survivors toward the consumers, the perpetrators continue to focus on marketing strategies and targeting potential consumers. Perpetrators often target large events (e.g., the Super Bowl, national political conventions) to take advantage of the crowds and high demand for paid sexual services. Those paying for the sex services, the consumers, exhibit low levels of depression and anxiety. These consumers often report avoiding relationship concerns or other mental health concerns, resulting in a desire to seek out sexual activity.

Because survivors have been a part of ongoing abuse and a cycle of victimization that they cannot break, counselors must use a systemic approach to providing services. For example, counselors need to provide information on shelters and building connections with family. Counselors may incorporate the use of technology and location services, safety words and discussing location with loved ones at all times.

 

Case example         

Toney, an 18-year-old multiracial, cisgender male, moved away from his caregivers’ home about one year ago and currently lives with a friend. He moved because of safety issues in his home and within the nearby neighborhood. When Toney was 16, his father died during a gang-related shootout at their home. Thus, Toney often felt afraid of engaging in a similar lifestyle and enduring similar consequences. Toney’s mother suffered from a severe substance use disorder that led to eviction from their rental home because she could not afford the rent. Toney and his mother became homeless.

While Toney was homeless, Kevin, a childhood friend, suggested that Toney come live with him temporarily as long as Toney obtained a job and contributed to the rent and utility bills. One day, Toney answered the front door, and a young adult male appearing to be about Toney’s age attempted to sell him a magazine subscription. Toney disclosed to the salesman that he was financially strapped. The young man told Toney about the large sums of money he made while selling magazine subscriptions and offered to put him in contact with the owner. Toney was intrigued by the idea of alleviating his financial troubles, and the young male immediately scheduled a meeting with the owner for later that night.

That evening, Toney met with the young salesman and the business owner in an abandoned parking lot, bought their sales pitch and decided to go to work. The business owner told Toney that he would need to move six hours away to another state because there was a high demand for work there and he would not have to pay any rent or utility bills. The business owner promised Toney the opportunity to travel and see many areas of the country while working in the job.

Thus, Toney left a day later to live in a weekly hotel in a new city with his new manager and several others. Upon arriving, the manager took them to a warehouse to pick up the product. They all began working the next day.

After a few weeks, Toney began grasping the reality of his situation. The job of trying to sell magazine subscriptions was strenuous and exhausting. He often worked 10- to 12-hour days while receiving limited rest and food. When Toney voiced concerns about the number of work hours he put in each day, his manager threatened him. The threats later escalated to physical assault when Toney again voiced his concern and when the manager perceived him to be underperforming at the job.

No matter how hard Toney tried, he could not meet the daily sales goal that the manager set for employees. When Toney failed to meet the daily sales quota, the manager either denied him his nightly meal or forced him to sleep outside of the hotel on the streets. As a result, Toney rarely ate and often did not receive the money he had earned while working. He was told that he would receive the money once the team had completed its sales goals for the area and had moved on to another city.

One day, while trying to sell magazines to a homeowner who declined to buy anything, Toney became agitated and started crying. He told the homeowner that he was in trouble and begged her to help him get home, across state lines. The homeowner had recently watched a documentary on human trafficking and invited Toney to use her phone to call the authorities.

The police arrived and took Toney’s statement about his work experiences. Fortunately, the responding officer had recently attended a departmental training on human trafficking, and she took Toney to the police station for further questioning and support. The officer connected Toney with a local nonprofit organization that provided multidisciplinary services, including professional counseling, to survivors of human trafficking. The organization offered shelter and provided Toney with career development services to help him obtain legitimate work. The shelter’s ultimate goal was to move Toney back to his hometown.

In counseling sessions with Toney, the counselor focused on direct questions to assess the nature of the human trafficking Toney had experienced. For example, “Did anyone threaten you or your loved ones?” and “Did you have difficulty leaving the work that you did selling door-to-door merchandise?” While initially reluctant, Toney eventually responded with answers that indicated his victimization. For example, he reported that his manager used threats and power and control tactics (such as denying Toney food, money and shelter) to force him to work.

Following assessment, Toney received counseling services focused on recovering from the abuse he had endured. Toney felt validated because he was not alone while accepting that he had fallen victim to human trafficking. The counselor and Toney focused on crisis intervention and stabilization in the beginning, which included discussions about adjunct services and basic needs assessments (e.g., food and clothing, job obtainment). Next, the counselor and Toney addressed the trauma, focusing on decreasing anxiety-provoking cues and scaffolding into addressing more severe cues and triggers. All the while, Toney and the counselor developed several grounding and relaxation techniques to use both in their sessions and in Toney’s real-world experiences.

One of the most valuable grounding techniques made use of a rock that Toney could hold whenever he felt distressed. The counselor taught Toney how to become present, while holding the rock, through discussions about the texture, shape and weight of the rock. Discussing these tactile experiences allowed Toney to focus on the here-and-now rather than attempting to escape feelings and thoughts.

Toney and the counselor also used a breathing method in which Toney would take a deep breath through his nostrils for at least three seconds and exhale through his mouth for three seconds. They determined that he needed to take at least three deep breaths during the exercise so that he could calm down.

In the final stages of counseling, Toney and the counselor developed an action plan to help him avoid falling victim to trafficking. That does not mean, however, that Toney took responsibility for the actions of others. Toney and the counselor reviewed the different needs he may have and how to meet those needs in a helpful manner.

While focusing on the trauma from human trafficking victimization, the counselor worked with Toney on obtaining a job at a local fast food restaurant. They chose this restaurant so that he could easily transfer to another store in his hometown once he felt comfortable with the transition. After three months, Toney finally returned home and moved back in with his friend, Kevin. He remained employed as a fast food line cook and began seeking education at a local culinary institute.

 

 

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Lamerial McRae is an assistant professor at Stetson University and a licensed mental health counselor in Florida. Her research and clinical interests include counselor identity development and gatekeeping; adult and child survivors of trauma, abuse and intimate partner violence; marriages, couples and families; LGBTQ issues in counseling and human trafficking. Contact her at ljacobso@stetson.edu.

Letitia Browne-James is a licensed mental health counselor, clinical supervisor and national certified counselor. She is a clinical manager at a large behavioral health agency in Central Florida and is in the final year of her doctoral program at Walden University, where she is pursuing a degree in counselor education and supervision with a specialization in counseling and social change. She has presented at professional counseling conferences nationally and internationally on various topics, including human trafficking.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Counseling transgender persons and their families

By Al Carlozzi August 1, 2017

For the past several years, I have provided and supervised counseling services for transgender persons and their family members and conducted workshops for mental health professionals, school counselors and educators on optimal ways for responding to the needs of transgender youth and adults. The purpose of this article is to share information for understanding transgender persons and describe current practices for treating transgender persons and their families.

A person’s gender typically is assigned at birth and is determined primarily by external genitalia but also can be confirmed by gonads, chromosomes, hormones and internal organs. Newborns are usually designated male or female and, on rare occasions, intersex. Gender identity refers to the subjective sense of who one is as far as male, female or other. Gender identity is determined more by the brain than by sexual anatomy. It is not something that any of us choose. Most people have a sense of their gender identity by age 4, although this sometimes happens earlier and sometimes later in life.

Cisgender persons are those whose gender identity and expression are aligned with the cultural and social expectations of the gender they were assigned at birth. The majority of persons are cisgender. Gender-nonconforming persons are those whose gender identity or expression are inconsistent with societal expectations typically associated with males and females. Some gender-nonconforming persons do not fit into the gender binary (male or female) as others do and may consider themselves to be gender fluid, gender queer or gender nonbinary. Transgender persons (about 0.6 percent or more of the U.S. population) have a strong inner sense that their bodies and the gender assigned to them at birth are incongruent with their gender identity. They may be assigned-at-birth males who identify as female (male to female or MTF) or assigned-at-birth females who identify as male (female to male or FTM).

It is important for counselors to understand how their transgender and gender-nonconforming clients identify, especially given that gender identity is now considered to be more a spectrum between male and female and may indeed be a galaxy of possibilities. Some gender-nonbinary persons do not seek hormone or surgical treatment and are comfortable with a more nonbinary gender expression, whereas others do seek medical interventions. With some exceptions, transgender persons desire and, if at all possible, pursue hormone and surgical treatment to experience congruity between their bodies and their minds. In other words, most transgender persons desire and pursue transition to the gender with which they identify. Transgender persons are the focus of this article.

Counselors and the general public need to understand that there is a difference between gender identity and sexual orientation. Some people make the erroneous assumption that transgender and gender-nonconforming persons are gay. The truth is that they, just like cisgender persons, may be gay, straight, bisexual, pansexual or asexual. Stated simply, sexual orientation refers to who one wants to sleep with, whereas gender identity refers to who one wants to sleep as, meaning as male, female or some other gender identity in that galaxy of possibilities.

Etiology of transgender

Family members and the general public often want to know how this happens or why some people are transgender. The etiology of transgender may be understood as a complex interaction of social/cultural, cognitive and primarily biological factors, consistent with explanations of gender identity in general.

A growing body of evidence suggests that being transgender is a congenital condition caused by varying degrees of testosterone exposure in utero. Research also suggests that transgender persons possess brain characteristics more like the gender with which they identify than the gender they were assigned at birth. Furthermore, some genetic studies show a high concordance rate among identical twins, thereby adding further credence to a primarily biological explanation.

So, there is growing evidence that transgender persons are, as Lady Gaga says, “born this way.” Being transgender is not a function of socialization, improper parenting or exposure to traumatic events. Rather than playing a role in the etiology of being transgender, socialization tends to squelch transgender and gender-nonconforming identities. Besides, most transgender persons are less concerned with why they are and much more focused on being who they are. Contrary to prejudicial views held by some in the general public that transgender persons are mentally ill or merely pretending to be the opposite sex, being transgender is best considered a medical condition that can be treated successfully with hormonal and surgical treatments and psychosocial support.

Gender dysphoria

Although being transgender is not a mental illness, most transgender persons experience dysphoria at various times in their lives. The dysphoria experienced by transgender persons is likely attributable to having to live in a body (and social role) that does not feel congruent with their sense of self in a society that misunderstands and discriminates against them.

The gender dysphoria diagnosis (302.85) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) indicates that it may include symptoms of depression, anxiety, fear, guilt, low self-esteem, shame and self-hatred. For some transgender persons, these negative emotional experiences may lead to self-harm, substance abuse and eating disorders. A more detailed description of the criteria that must be met to assign this diagnosis is provided in the DSM-5.

It is our job as mental health professionals to treat the dysphoria and associated symptoms, not the person’s gender identity. The inclusion of any diagnosis in the DSM-5 specifically for transgender persons is controversial. Many view the diagnosis as stigmatizing, even if it was included in the DSM-5 to support access to and insurance coverage for mental health and medical services.

The effects of dysphoria are concerning. One statistic that is particularly startling is that 41 percent of transgender persons attempt suicide, compared with less than 2 percent of the general population. Other statistics derived from the 2011 National Transgender Discrimination Study of 6,456 transgender and gender-nonconforming adults:

  • 57 percent have experienced rejection by their families
  • 53 percent have been verbally harassed in public settings
  • 97 percent have been harassed or discriminated against in work settings
  • 28 percent have experienced harassment in medical settings
  • As many as 27 percent have been refused medical care in the past

One encouraging statistic from this study is that 78 percent of those who completed their transition felt more comfortable at work and improved their job performance, despite mistreatment at work. This suggests that completing transition engenders greater confidence and comfort with self and may strengthen the transgender person’s ability to cope with stressful environments.

The World Professional Association for Transgender Health (WPATH) Standards of Care (currently SOC-7) provide state-of-the-art guidelines for the proper treatment of transgender adults and children. Treatment involves an integration of medical interventions, social support and community building, and mental health care. Treatment is integrative and collaborative with other professionals and is most effective when it includes advocacy and education within family, school, work and community contexts.

Medical interventions

Medical interventions may include any or all of the following, depending on the age and gender identity of the transgender person:

  • Puberty blockers that suppress the physical signs of puberty, which transgender adolescents often experience as distressing
  • Hormone replacement therapy (testosterone for FTM and androgen blockers and estrogen for MTF transgender persons)
  • Gender confirmation surgeries, including top surgeries (mastectomy and male chest contouring for FTM and breast augmentation for MTF transgender persons) and bottom surgeries (phalloplasty, scrotoplasty, metoidioplasty with or without urethroplasty, and hysterectomy for FTM, and orchiectomy, vaginoplasty and labiaplasty for MTF transgender persons)

Cosmetic surgeries may also be performed, such as tracheal shave and facial feminization surgery to help feminize facial features in MTF persons. Electrolysis or other hair-removal methods may also be considered by MTF transgender persons to feel and appear more feminine.

Androgen blockers and estrogen help to feminize the body in a variety of ways but do not feminize the voice, so MTF transgender persons may seek voice training to feminize their voices. Testosterone will deepen the voice and promote growth of hair on the face and body, so there is typically little need for FTM transgender persons to seek voice training or cosmetic treatments.

Social support and community building

Social support is very important for reducing the sense of isolation that many transgender persons experience. Many report that they first sought information and support for themselves on the internet, describing how comforting it was to find out there were other people like them.

Such support can be enhanced by actual support groups like those provided at the Dennis R. Neill Equality Center in Tulsa, Oklahoma. The Equality Center offers several groups in support of transgender and gender-nonconforming persons, along with many other services for LGBTQQIA (lesbian, gay, bisexual, transgender, queer, questioning, intersex, asexual) people. There are support groups for transgender men, women, children and teens, and for parents of transgender children and teens. I have served as a co-facilitator of the support group for parents of transgender children and teens for the past six years and have placed three to six graduate students at the Equality Center each year to provide counseling services and help facilitate support groups.

Open Arms Youth Project is another agency in Tulsa that provides social support for LGBTQQIA youth, and my graduate students have co-facilitated a weekly support group there. Other community organizations such as PFLAG (Parents and Friends of Lesbians and Gays) provide social support for family members. Gay-Straight Alliance groups in schools, and support groups and student organizations on college campuses, can serve as safe zones for adolescents and young adults.

Such groups for transgender persons and their family members provide useful information about medical, cosmetic and legal steps in the transition process. These groups are also central to the community building that provides hope and support for dealing with unaccepting environments and other challenges that transgender persons may encounter. Fostering the development of support services and participating in community-building efforts are among the ways that professional counselors can make a positive difference in the lives of transgender persons and their families.

Community building can also be helpful in organizing or participating in efforts to challenge legislation that would be harmful to transgender persons. Under President Obama, the U.S. departments of Justice and Education established guidance and took steps to protect the rights of transgender persons in the workplace and the rights of transgender students in the schools to use restrooms consistent with their gender identity. However, some state legislators, attorneys general and governors resisted these actions. Several state attorneys general filed suit against the Justice Department in 2016, and some state legislators have succeeded in enacting state laws that restrict the restroom usage rights of transgender persons.

In the early weeks of the Trump administration, the Justice Department and the Education Department rescinded the guidance that served to protect the rights of transgender persons and students. However, this past May, the 7th U.S. Circuit Court of Appeals ruled that a school district in Wisconsin violated the rights of a transgender student and upheld a lower court injunction requiring that the district allow him to use a restroom that aligns with his gender identity. This federal court ruling has far-reaching implications and adds to the growing number of judicial decisions that protect transgender persons from discrimination.

Nevertheless, the rights of transgender persons to use restrooms consistent with their gender identity remains both a national- and state-level issue, when all transgender persons want is to feel safe and comfortable using a restroom for the same reason that anyone wants to use a restroom. Counselors can be helpful to transgender persons by advocating for their rights. Considering that many transgender students report being bullied in schools, counselors can support anti-bullying state legislation and intervene, as appropriate and with their clients’ consent, in school systems where transgender youth experience harassment. The importance of the counselor’s role as an advocate for social justice is strikingly evident in our efforts to help transgender and gender-nonconforming persons.

Mental health care

Professional counselors can be helpful to transgender persons by providing informed, competent and compassionate mental health care. According to WPATH SOC-7, minimum qualifications to provide mental health care to transgender persons include a master’s degree in a clinical behavioral science field; training and competence in the DSM-5; documented supervised training and competence in counseling/psychotherapy; and continuing education in the treatment of gender identity issues and WPATH SOC. The Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (a division of the American Counseling Association) and the American Psychological Association have also published guidelines for treating transgender and gender-nonconforming clients.

Transgender persons present several common concerns to counselors and other mental health professionals. They may present with symptoms associated with gender dysphoria, such as depression, anxiety and suicidal ideation. Some may need help with substance abuse or other harmful means of coping with distress. It is also important to attend to any co-occurring mental health issues that may require a referral to a psychiatrist for medication. Be aware that some transgender youth develop eating disorders, and others may be on the autism spectrum, so collaboration with providers with specialized expertise in these areas may be necessary. Counselors also may need to attend to traumatic experiences and symptoms of minority stress associated with discrimination, stigmatization and harassment.

Other commonly expressed concerns involve:

  • Disclosure to others (coming out)
  • The timing and extent of transition
  • The impact of transition on relationships with current partners/spouses/children (in adult transgender persons)
  • Support or nonsupport of parents and extended family
  • Concerns about passing as the gender with which they identify
  • Reactions from employers, school personnel, leaders and members of their religious groups, and their peers at work or school

It is important to recognize that our clients’ age, stage of life and stage in the transition process will likely influence the concerns and issues presented. A Tanner Stage 1 child (birth to onset of puberty) may have issues with family, school and peers, whereas a Tanner Stage 2 child (onset of puberty) may present with family, school and peer group concerns, as well as worries associated with the changes that accompany puberty that can be very distressing for transgender adolescents. Young transgender adults may have concerns about reactions and treatment by employers and fellow workers. Older adults may share these same concerns and have compounding issues with spouses and children (whether young children or adult children), depending on the person’s age of coming out and transitioning. Transgender persons at any age or stage of life may have issues with their parents, siblings, extended family members, friends, church or faith, and the larger political/social climate for transgender persons.

Regarding ethical responsibilities, it is crucial that counselors are aware of, confront and alter their own biases, fears (transphobia), discomfort, gender-normative assumptions and lack of information about transgender persons. One of the best ways to do this, as with overcoming any discomfort with people we perceive to be different from us, is to get to know persons who are transgender. This requires openness to learning about their experiences, listening with empathy to their life stories and demonstrating respect. One of the major ways we show respect when working with transgender and gender-nonconforming clients is by asking them about and consistently using their preferred pronoun (she, he, them, etc.), the name by which they prefer to be called and their self-defined gender identity (transgender, gender queer, gender nonbinary, etc.).

It is also important that we are respectful of our transgender clients’ sense of timing for coming out to others, and the pace and timing for steps they wish to take in their transition. Some transgender persons seek multiple surgeries (top, bottom, cosmetic), whereas others choose not to take all of these steps in their transition or simply cannot afford every surgical intervention that they might desire.

Furthermore, passing as the gender with which they identify may be more important to some transgender persons than it is to others. Passing should never be more important to the counselor than it is to the transgender client. A counselor should never say to a transgender client (as one counselor did), “If you are ever going to pass as female, you need to do something about your face and your voice.” That remark by a counselor left one client feeling degraded.

Instead, it is counselors’ responsibility to reduce the shame associated with self-stigmatization and internalized transphobia that transgender clients may experience and to help them replace that shame with pride. Knowing that the antidote to shame is self-esteem and pride, counselors must help these clients identify positive resources and strengths. It is our responsibility as counselors to cultivate a safe therapeutic environment for transgender clients — a safe zone where they feel supported, affirmed, respected and appreciated for their courage and resolve.

It is helpful for counselors to know that transgender clients are likely to want to take steps to change their names and gender markers on legal documents such as driver’s licenses, birth certificates, passports, academic/school records, medical records, Social Security cards, bank accounts, credit cards and other financial records such as trusts and wills. The ease or difficulty in making such changes depends on the jurisdiction and particular offices involved (and, if the transgender person is a minor, the support of parents or legal guardians). Ideally, counselors will know or learn enough about making changes to legal documents to be able to direct their clients to people and resources that will be helpful.

When mental health professionals work with transgender clients, they can expect that these clients will ask them to provide a support letter for medical treatment at some point. Such letters should include results of an assessment to determine if the diagnosis of gender dysphoria is warranted and if any co-occurring conditions are present (such as substance use or abuse, smoking, eating disorder, etc.) that could affect medical treatment. For more detailed information about letters to physicians and surgeons, counselors should consult WPATH SOC-7 and obtain continuing education to enhance their knowledge of the “gatekeeping” role of mental health professionals. SOC-7 makes clear that the role of mental health professionals involves much more than assessment and letter writing; it includes support, collaborative care, education, systems intervention and advocacy.

Families of transgender persons

Although family members vary in their degree and pace of acceptance, most struggle adjusting to the change in their identity as a family. When individuals come out as transgender in mid or late adulthood, cisgender spouses or children may be affected. Couples or family counseling may assist cisgender spouses and children in making accommodating adjustments to the changing gender identity of a spouse or parent.

Some couples work through the issues associated with such a change and maintain their love and commitments to stay together, whereas for others, such adjustments are too difficult. Some couples part amicably and the individuals remain friends, whereas others feel betrayed, and if minor children are in the home, custody battles sometimes transpire. Counselors can help spouses and children (whether younger or older) by providing information about being transgender, enlisting their empathy and caring for their transgender loved one, and empathizing with their feelings, which may include grief, shame, anger and worries about their family.

When a child, teenager or young adult comes out as transgender, parents and siblings also make accommodating adjustments in their identity as a family. Counselors can assist parents by supporting them in their grief and worry about the well-being of their transgender child. Counselors can also serve as a resource for information about gender identity and the coming out process, and they can assist parents and their transgender children in determining when and how to inform grandparents, extended family members, friends, school personnel and church personnel. Advising parents about books and articles to read and websites to educate themselves about their transgender child or teen can also prove beneficial. Two books I recommend as helpful resources for parents and professionals are The Transgender Child by Stephanie A. Brill and Rachel Pepper (2008) and The Transgender Teen by Brill and Lisa Kenney (2016).

Parents and other family members often struggle, at least temporarily, with the names and pronouns by which their transgender loved ones want to be referred. Counselors can encourage family members to be intentional about using these names and pronouns, while also recognizing that mistakes happen and that it will take practice to get everything right consistently.

Whether working with parents in counseling or in support groups, counselors can address parental concerns about medical and cosmetic interventions and procedures for changing legal documents. It is important for counselors to support and affirm appropriate action when parents of transgender youth express concerns about bullying or harsh treatment by peers or school personnel, their child’s depression or suicidal ideation, and negative reactions by extended family or others. I have witnessed parents and family members of transgender youth change from being grief-stricken to becoming empowered advocates for their transgender child. In our parent support group, it is common for parents to share their concerns, challenges and triumphs.

The more I work with transgender persons, the more impressed I am with their courage and resolve to be genuinely who they are in a world that can be hateful. The more I work with their parents and family members — and with mental health professionals, educators and others who support transgender persons and stand up for their rights — the more I am encouraged that understanding and compassion will ultimately triumph over ignorance and hate.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Al Carlozzi is a professor of counseling and counseling psychology at Oklahoma State University (OSU) and serves as director of the OSU-Tulsa Counseling Center. He has provided counseling services and supervised the provision of services to transgender and gender-nonconforming clients, conducted numerous continuing education workshops on treating transgender persons and their families, and collaborated with the Dennis R. Neill Equality Center in Tulsa, placing graduate students there as counselors and co-leading a support group for parents of transgender children and teenagers. Contact him at al.carlozzi@okstate.edu.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Illuminate closing: Less talk, more action

By Laurie Meyers June 12, 2017

“We are well beyond just talking. We need to act,” said Cheryl Holcomb-McCoy during Saturday’s closing keynote address at the American Counseling Association’s Illuminate Symposium, a three-day conference that focused on the intersection of counseling and lesbian, gay, bisexual, transgender, questioning and queer (LGBTQ) issues that took place June 8-10 in Washington, D.C. She urged attendees to take the knowledge and strategies they had learned in the Illuminate sessions to empower and uplift their LGBTQ clients.

Holcomb-McCoy, an ACA fellow and dean of American University’s School of Education, told the audience of more than 200 attendees that certain forces in the United States would like to take

Cheryl Holcomb-McCoy gives the closing keynote address at ACA’s Illuminate Symposium June 10. Photos by Pruitt Allen.

the country backward to its darkest days of prejudice against LGBTQ people and other marginalized communities. She noted that in the Washington area alone, a huge surge in hate crimes has occurred.

“I’m not telling you anything you don’t already know,” Holcomb-McCoy acknowledged. “But I just want to remind us that we need to stand up for the rights of those who are disenfranchised, marginalized, stepped upon, silenced and victimized. … And most of all we have to stand up for what is right.”

Although tremendous gains have been made in the fight for LGBTQ rights, Holcomb-McCoy said that many challenges still exist, such as universal protection against discrimination at work, the high rate of suicide among LGBTQ youth, the fear many LGBTQ students feel at school, a lack of resources for transgender people and the need to protect LGBTQ prisoners. She noted, however, that she feels hopeful as she sees and hears the younger generations speaking out more frequently on such issues.

Holcomb-McCoy also spoke to the importance of intersectionality — the cumulative effect of overlapping forms of discrimination such as racism, sexism and homophobia. At the same time, she extended a warning. “We [marginalized populations] are pitted against each other,” she said. Groups such as those living in poverty, women, people of color, LGBTQ individuals, immigrants and people with disabilities are often made to feel that there are limited seats at the table, she explained.

“We become afraid of one another, we compete with one another, we judge one another and sometimes we betray one another,” Holcomb-McCoy said. “We must stop fighting. We must band together to reach the goal of full equality.”

Those in power often keep others powerless and disenfranchised by convincing them to fight against one another, Holcomb-McCoy noted. “Some in the black community believe that the messages of hate about LGBTQ individuals are not rooted in the same prejudices that have been used to discriminate against us as black people,” she said. “And I push back on that all the time. Our histories are different, but there is a shared experience of oppression.”

Holcomb-McCoy shared that sometimes her friends who are African American tell her that they don’t believe in gay marriage. “I immediately say, ‘You know, people used to say that about us and about our love.”

“The unshakable conviction that all people are equally endowed with fundamental and irrevocable rights has been central to this nation and in this capital,” Holcomb-McCoy continued. “The story of this country is one of striving to fulfill our ideals and only gradually expanding the circle of inclusion.”

However, history doesn’t always move forward. It can also move backward, she warned, noting that anti-LGBTQ movements across the country can be seen as a backlash.

Counselors must take action, Holcomb-McCoy said, urging attendees to stand up and speak out in multiple places and on multiple platforms. She noted that the Black Lives Matter movement traces its origins to Twitter.

She also encouraged counselors to create more forums in which they can work with others in the community, including the police, business leaders and other mental health professionals.

Holcomb-McCoy also advised the Illuminate attendees to be patient yet persistent. She pointed out that in the fight for equality, advocates may not win every race, but they can still win the marathon.

To bring about change, she said, counselors must ultimately be ready to make what civil rights icon Rep. John Lewis has called “necessary trouble.”

 

 

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Laurie Meyers is senior writer at Counseling Today. Contact her at LMeyers@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

ACA’s Illuminate kicks off with reflection, rally cry

By Bethany Bray June 9, 2017

“Look at us now! We’ve come so far.”

Colleen Logan, delivering Friday’s opening keynote address at the American Counseling Association’s Illuminate Symposium, broke into a wide smile when she noted that she didn’t even have to explain what the letters in the LGBTQ abbreviation meant to the packed room.

Illuminate, a three-day conference focused on the intersection of counseling and lesbian, gay, bisexual, transgender, questioning or queer (LGBTQ) issues, is taking place June 8-10 in Washington, D.C. More than 200 professionals are attending the sold out conference.

Colleen Logan gives the opening keynote at ACA’s Illuminate Symposium June 9. Photos by Pruitt Allen.

Logan, a past president of both ACA and one of its divisions, the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling, reflected on the progress made in recent decades within the counseling profession and in society as a whole. But she also called on her audience to continue the push forward.

“We can’t be complacent,” said Logan, the program coordinator for the marriage, couple and family counseling program at Walden University. “We need each other. We need to advocate. We need to learn from our younger generation. We need to care, we need to cry and we need to be here [at events such as Illuminate].”

Years ago, LGBTQ-focused sessions at counseling conferences were few in number and covered only the most basic of issues, recalled Logan, a licensed professional counselor and licensed marriage and family counselor who maintains a private practice. She noted the difference between those conferences and Illuminate, which features sessions on everything from microaggressions to the unique needs of transgender clients.

“Back in the day, we really didn’t think folks would come to our sessions,” Logan said. “We would leave these sessions hoping that we made one little bit of change, invoked one little bit of understanding and a little less hostility. We felt we had succeeded if people left our sessions knowing that everyone was not heterosexual.”

Current ACA President Catherine Roland, who spearheaded the concept and planning of Illuminate as one of her presidential initiatives, concurred with Logan’s observations about the progress realized over the past decades. She mused about what an Illuminate symposium would have looked like if ACA had hosted it 20 years ago. “I can tell you what it would have looked like — because there wasn’t one,” Roland said.

Logan cited the 2015 U.S. Supreme Court decision that legalized same-sex marriage in highlighting the progress that has been made. At the same time, she noted that America’s social climate and political landscape has shifted back over the past couple of years. From so-called “bathroom bills” to religious freedom issues, “this time is more frightening and disheartening than ever” for the LGBTQ community, Logan said.

“It’s two steps forward and 10,000 steps back,” Logan continued. “The vitriol is breathtaking, the hatred is palpable. … There is no such thing as homophobia. It is prejudice through and through. It matters because there is no such thing as a phobia toward another human being.”

Change is never linear; it is a process, Logan reminded the audience, adding that it is so “easy to quit when you hit snags, wall off and move on. … [But] there is no time to be weary, no time to be tired.”

Above all, counselors within the profession need to rely on each other, Logan said.

“Stay steadfast,” Logan urged the Illuminate attendees. “We can be our hardest critics. Give each other a break. If someone doesn’t know everything, it’s OK. Turn together, not on each other. Share, listen, lean in, lean on.”

Cheryl Holcomb-McCoy, an ACA fellow and dean of American University’s School of Education, will serve as the closing keynote speaker for Illuminate on June 10.

The event coincides with Washington, D.C.’s annual Capital Pride festivities. Logan noted that she will be marching in the Pride Parade on Saturday.

“I will not be complacent. I will not stay on the margins,” Logan said. “I march for those who can’t march. I march for those who won’t march. I march for those who don’t march. … I march for my children and my beautiful wife. I march for me, for all of you, with pride.”

 

 

 

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Find out more about Illuminate at counseling.org/illuminate.

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

 

LGBTQ issues across the life span

By Laurie Meyers March 24, 2017

The specific biological mechanisms that underpin how people develop as lesbian, gay, bisexual, transgender, questioning or queer (LGBTQ) are still undiscovered, but what many researchers have determined is that neither sexual/affectional orientation nor gender identity is a choice. Rather, they are innate, unchangeable parts of who a person is, much like skin color.

And like people of color, LGBTQ individuals regularly encounter significant prejudice throughout their lives. This stigma can make life’s typical slings and arrows all the more painful. Although tremendous progress has been made in LGBTQ rights in the past few decades, counselors must still work to understand the barriers that these clients face across all stages of the life span.

“Growing up in any marginalized group can cause issues surrounding identity,” says Misty Ginicola, the lead editor of the new book Affirmative Counseling With LGBTQI+ People, published by the American Counseling Association. “For LGBTQI+ persons” — referring to individuals who identify as lesbian, gay, bisexual, transgender, queer, questioning, intersex, asexual, ally, pansexual/polysexual or two-spirited — “the unique identity surrounds not only who they bond with and are attracted to, but very often also their own gender identity and expression. Rather than having their differences be celebrated, unfortunately, LGBTQI+ people commonly grow up in an environment where they internalize very early on that their differences are taboo or undesirable, particularly if they grow up in a disaffirming religious context. Being marginalized also puts a person at greater risk of experiences of trauma and bias incidents, which impacts how safe a person is in any given context.”

Growing up LGBTQ

In general, experts are finding that children and adolescents are growing more comfortable with coming out at an early age, according to Ginicola, a professor of counseling and school psychology and coordinator of the clinical mental health counselor program at Southern Connecticut State University. If this coming-out process transpires in a supportive and affirmative environment, it can help LGBTQ students to form a strong sense of self and establish healthy relationships, she notes. However, in many cases, these individuals face significant stigma from an early age.

“Being LGBTQ in school requires continuous negotiations between authenticity, connection, safety and health,” explains Colton Brown, a member of the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC), a division of ACA. “Students may find themselves in unsupportive or even hostile environments.”

ALGBTIC President Tonya Hammer notes that physical, emotional and verbal bullying of LGBTQ students begins as early as elementary school or even prekindergarten. “While physical bullying, particularly that which results in injury and at times death, is prevalent and probably the most talked about since it makes the news sometimes, the cyberbullying and the emotional and mental bullying that take place can often be just as harmful … if at times not more so,” she says.

LGBTQ individuals may be subject to bullying across the life span, but the experience of being bullied can be particularly devastating when it occurs early in a person’s life, says Hammer, an assistant professor of counseling and coordinator of the counseling program at Oklahoma State University. “The power of language and words to inflict damage — especially on children — is often dismissed,” she says.

Insults and taunts — long a staple of playgrounds and classrooms — have found an additional and often particularly vicious arena in cyberspace, warns Hammer, whose research focus includes both bullying and the intersection of gender and sexual/affectional orientation. “Cyberbullying — from Instagram to Snapchat — is only growing and, unfortunately, much harder to address and remedy,” she says. “If physical bullying takes place on school grounds, counselors, teachers and administrators have the capability to take action. However, much of cyberbullying takes place outside of their purview, as well as that of parents, and often goes unnoticed by adults.”

Transgender students are particularly at risk for bullying, stigma and rejection, says Brown, a counselor in the college clinic at the University of Central Oklahoma and a doctoral student in counseling psychology at Oklahoma State University. “Transgender students often face difficulty with coming out because their authentic selves are typically much more visible than [that of] LGBQ students,” he notes. “These students face bathroom and locker room barriers that may come from peers, teachers, administrators and even state policies.” Transgender students also may be excluded from participating in many extracurricular activities such as sports teams because of their gendered nature, he says.

Brown points out that these painful exclusions are happening during a crucial developmental period when adolescents are typically learning how to form various emotional bonds. Transgender and other LGBQ adolescents “may be looking for friendship or romance but can be met with rejection [instead],” he says.

Further complicating matters for many transgender adolescents is that they may not be able to fully establish their personal identities. Those who wish to transition medically need parental support until they are 18, Brown explains.

But transgender students are not the only members of the LGBTQ community who face unique barriers in coming out and finding community, Brown says. Bisexual youth also often find themselves struggling for acceptance and a sense of belonging, not just among heterosexual, cisgender students, but also within the greater LGBTQ community, he says.

“Bisexual people are generally defined by who they are dating at a given time,” Brown explains. “For example, if a male student is dating a female student, then [he is] assumed to be heterosexual. If that same male student is dating a male student, the script flips, and he is now considered gay. Students do not often consider that this student may actually be bisexual. These perceptions can result in these students not feeling ‘straight enough’ for the heterosexual kids or ‘gay enough’ for the gay kids.”

“Bisexual students are in this middle ground in which they may be left without a close-knit group unless they find other bisexual students,” Brown continues. “These students may also struggle more with coming out due to the continued pressure to define themselves outside of who they are or are not dating. Other students also internalize monosexist messages from adults, media and culture and may harass or discriminate against bisexual students. These factors can result in bisexual students feeling shame and may result in internalized biphobia.”

The potential rejection and lack of support may lead LGBTQ children and youth as a whole to be wary of being their authentic selves with friends, teachers, parents and counselors, Ginicola says. “They may also attempt to hide this identity from romantic partners before they have accepted their affectional orientation or come out to others,” she continues. “In this context, identity development in adolescence is disturbed, particularly if they experience rejection.”

A safe space

The good news is that counselors can help bridge the acceptance gap for LGBTQ youth.

“Counselors can create a safe space by a variety of means,” Hammer says. “It can be as simple as displaying an HRC [Human Rights Campaign] ‘equal’ sign in their office or a small rainbow flag somewhere. I know that sounds minor, but small symbols can signify something to students.”

“It is also a matter of having resources available,” she says. “GLSEN [formerly the Gay, Lesbian and Straight Education Network] has a resource called Safe Space Kit that provides curriculum, activities and also stickers that can be displayed which indicate that your office is a safe space. Additionally, counselors can provide programming that is LGBT inclusive or sponsor organizations like a Gay-Straight Alliance. There are activities or weeks that counselors can help organize, such as No Name-Calling Week, Ally Week and Day of Silence.”

When meeting with students, school counselors can create supportive environments by using language that does not assume a student is attracted to any particular sex, Brown says. “This can let students know that you are open to them sharing that information when they are ready,” he says. “School counselors can also be sure to have pamphlets and information sources that include LGBTQ issues and use these examples if they present to classes. Counselors can also include LGBTQ sensitivity training in any presentation they may give to faculty and staff so that the supportive environment may be spread.”

GLSEN has been tracking the school experience of LGBTQ students since 1999 through its National School Climate Survey. Although the survey has shown an improvement in awareness and acceptance of LGBTQ students in schools, significant harassment and discrimination still exist, particularly in relation to transgender students. The 2015 survey found that 85.7 percent of LGBTQ students heard negative remarks from their peers specifically about transgender people, whereas 65.3 percent heard negative remarks from teachers and other school staff members. The survey also found that 22.2 percent of transgender students had been prevented from wearing clothing considered inappropriate based on their legal sex, while 60 percent of transgender students had been required to use a bathroom or locker room of their legal sex.

In late February, President Trump rescinded a 2016 directive issued by President Obama that ordered schools to allow transgender students the use of bathrooms that match their gender identity. The battle reached the Supreme Court with G.G. v. Gloucester County School Board, in which Gavin Grimm, a transgender boy, filed suit against the Virginia school board alleging that it violated Title IX of the Education Amendments of 1972 by denying him the use of the boys’ restroom. On March 2, in a development indicative of growing support for transgender individuals, 53 major businesses signed on to a “friend of the court” brief in support of Grimm. However, the case ultimately was sent back to a lower court.

School counselors can play a critical role in supporting the rights of transgender students, Brown says. “School counselors can help advocate for and with transgender students through engaging in school policy discussions and promoting fair bathroom, locker room and athletic policies,” he urges. “They can also be outspoken against bullying of transgender students and assist other school professionals with stopping bullying. Importantly, school counselors can also support transgender students simply by using [these students’] identified names and gender pronouns. Although this seems small, many students are not supported in this way, and acknowledging [their] true selves can help foster their development.”

Brown also encourages school counselors to educate themselves about the multiple identities that fall under the transgender umbrella, such as gender-queer (individuals who do not identify with conventional gender distinctions, such as solely male or female, but instead identify with both or neither) and gender-fluid (individuals whose gender identification fluctuates over time).

Hammer adds that the Southern Poverty Law Center and its Teaching Tolerance program provides materials for schools that focus not only on LGBTQ identity issues but also ethnicity and racism. “It is important to remember that our cultural identity, no matter what our affectional/sexual orientation, is made up of so much more,” she says. “The intersection of our ethnicity, age, religious and/or spiritual orientation, gender, affectional/sexual orientation, where we live, etc., are all important factors to consider when working with a client. As a counselor, you should not ignore any aspect of a client’s culture. For example, the intersection of affectional/sexual orientation with a person’s religious and/or spiritual identity can either be a source of support and comfort for someone, or possibly a source of rejection and trauma.”

As always, Hammer says, the most important thing to focus on when working with LGBTQ students is the counselor-client relationship. “Listen to them with respect and treat them with dignity and not as if they are abnormal,” she says. “Let them know that they matter — to you, to their families and to the world.”

Working for a living

One of the hallmarks of adulthood is the ability to support oneself, which typically means going to work, notes ACA member Larry Burlew, whose research specialties include issues around adult development, gay men and career development. However, work can be an uncertain and sometimes hostile place for LGBTQ individuals, Burlew says.

For instance, those who are LGBTQ often have no legal protections against discrimination in the workplace, says Burlew, a counselor educator who is retired from full-time teaching and is currently an affiliate professor at the Chicago School of Professional Psychology in Washington, D.C. There is no federal anti-discrimination protection for LGBTQ individuals, and only 20 states and the District of Columbia prohibit discrimination on the basis of sexual orientation or gender identity.

“It’s easy for them to be dismissed from work without necessarily a good reason,” says Burlew, who was also a licensed professional counselor with a small private practice for almost 30 years.

Even if a workplace is not actively hostile, there may be what Burlew calls a “lavender ceiling” — an environment of subtle but pervasive anti-LGBTQ discrimination. So when LGBTQ individuals first enter the workplace or start a new job elsewhere, they are often dealing with a lot of unknowns, he says. As a result, some LGBTQ individuals decide not to come out or be out at work, choosing instead to keep that part of their identities very private, Burlew says. For LGBTQ individuals, this can require a delicate balancing act between developing and keeping social workplace connections and not fully revealing who they are, he continues.

Even those individuals who are fully out at work often still find themselves managing perceptions, Burlew says. “I think that LGBTQ workers get very creative about how to be successful. When you get to an organization, you get creative about how to present who you are in a way that is acceptable to fellow workers,” he says. “[The question becomes], how do you introduce it in conversation?”

LGBTQ workers also have to determine how they will handle microaggressions, Burlew says. He adds that he has been in situations in which he had to decide whether it was safe to address certain comments and jokes that disparaged the LGBTQ community.

Concerns about how they might be perceived can even influence professional choice for LGBTQ individuals. “I’ve had [clients] throughout the years such as gay men who wanted to go into, say, construction and had fears about that,” Burlew says. He would have these clients visualize going to work in the environment that they feared and imagine how they would be received. Then he would talk with these clients about their fears and explore possible scenarios to help them build skills for dealing with problematic situations.

Burlew uses the example of a gay man working in project management at a construction site who hears that some of the workers have been making fun of him when he isn’t around. What are this man’s options? He has to decide whether he feels safe trying to change the environment (a process called an active adjustment) or if he will choose to change himself instead (a reactive adjustment).

In the case of an active adjustment, Burlew and the client would discuss the potential consequences of trying to change the workplace. They would then work on how to use assertive communication to address the problem. This might include having a conversation with the men making the jokes and saying something such as, “I’ve heard that you don’t want to work with me, and I was just wondering if it has anything to do with me being gay?” Burlew would help the client develop assertive communication skills through role-play and practicing what he wanted to say. Burlew and the client would repeat these techniques until the client felt comfortable addressing the problem on his own.

In the case of a reactive adjustment, Burlew would help the client reduce his stress level through systematic desensitization. He would do this by having the client talk about the incident in which he experienced the most stress. They would continue to “practice” the incident until the client could imagine the situation without feeling an undue level of stress.

Burlew and the client would also talk about avoiding work scenarios, if possible, that caused the client the most stress. If avoiding these situations was not possible, Burlew would help the client evaluate how to move forward by asking questions. Did the client need to stay in the position for his career? If so, for how long? Were other alternatives possible, such as pursuing additional education or staying with the company but taking another position?

Relationships and family

Life isn’t just about work, of course, but also about personal connections and family.

Young adults can sometimes struggle to establish intimacy, and Burlew says this can be even more of a challenge for LGBTQ individuals because they are often still trying to sort out who they are. They may not be fully out, even to themselves, he explains, which can delay establishing relationships. Then, as these young adults begin making connections in the LGBTQ community and start dating as LGBTQ individuals, additional challenges can arise.

“In addition to the bountiful issues that face heterosexual, cisgender couples, LGBTQI+ couples face [other] stressors from being marginalized,” Ginicola says. “Experiencing bias incidents, trauma and rejection from loved ones can add incredible stress to a relationship. It can be particularly traumatic to have people who are supposed to unconditionally love you — parents, family and your closest friends — disapprove of or reject your partnership while celebrating heterosexual relationships with showers, weddings and family pride.”

Problems can also arise if partners have different degrees of “outness.” As Ginicola explains, “If one person in the relationship is fully out to others, and one partner is not, this can cause additional struggles within the relationship, where one person may feel invalidated.”

In such cases, it is important for counselors to explore the reasons that one partner prefers to remain in the closet or less out, she says, paying particular attention to how each partner’s coming-out experience may have differed. The partner who fears being fully out may have come from a culture in which being LGBTQ was not just taboo but also put the individual at high risk for violence. Or the person may have grown up in a religious background that stridently disapproved of LGBTQ individuals, Ginicola explains. Counselors should also encourage the out partner to talk about how it feels for the relationship to be “hidden,” Ginicola says. By improving communication, counselors can often help these couples resolve their conflict in a way that works for each partner, she says.

Another area in which LGBTQ individuals and couples face significant barriers is family planning. “In some states and in most international adoptions, same-sex couples cannot adopt,” Ginicola points out. “Therefore, they may have to utilize expensive alternatives, such as artificial insemination or IVF [in vitro fertilization] or surrogacy.”

“Again, counselors should employ affirmative counseling techniques to support these individuals and partnerships,” she says. “Acknowledging the realities and struggles of being an LGBTQI+ couple or relationship is important, as is providing nonjudgmental support and connecting clients to resources that can help them with family planning that is specific to LGBTQI+ couples.”

Taking a toll

As individuals face the various struggles that are unique to being LGBTQ throughout childhood and into adulthood, it can take a significant toll on the body.

“The LGBTQI+ person is under much greater stress than is typical for a heterosexual, cisgender person,” Ginicola says. “If the person has intersectional identities that are also marginalized — ethnic minority, immigrant, differently abled — this stress will be exponentially increased. Although anxiety, depression and suicidal ideation are common as a result of this increased stress across the LGBTQI+ spectrum, the research indicates that each subpopulation experiences different physical and mental health problems.”

“For example,” she continues, “lesbian and bisexual women are more likely to be obese and are more likely to smoke. Gay men are more likely to experience eating disorders, including anorexia, drink excessively and use substances to cope, which impact their physical health.”

In addition to all of this, medical doctors aren’t always cognizant of how LGBTQ health needs might be different from the needs of their other patients, says ACA member Jane Rheineck, a past president of ALGBTIC. For example, she notes, gynecologists often offer lesbians — even out lesbians — birth control.

In addition, LGBTQ individuals often feel uncomfortable or unsafe disclosing in doctors’ offices, Rheineck says, which means that they may delay or even altogether avoid seeking health care. Counselors can help by educating LGBTQ clients about some of the unique risks that they face, but also by providing them with validation, support and empathy for these difficulties, she says.

“Psychoeducation surrounding minority stress, understanding why these negative coping factors are there, [and] recognizing and validating the stress that they experience is crucially important,” Ginicola says. “Cognitive behavior therapy can be helpful in this regard. [It involves looking] at how their inner self-talk and coping skills are moving them more toward their goals or further away.”

Ginicola says counselors can also help clients find LGBTQ-friendly health care through resources such as the Gay and Lesbian Medical Association’s website (glma.org), which has a provider finder.

Being older in a youth-obsessed society is not always easy, but being older and LGBTQ can be even more difficult, Ginicola asserts. Older LGBTQ adults are not only discriminated against in general society but can often find themselves marginalized within the LGBTQ community, she explains. “Therefore, they may experience bias incidents both inside and outside of their community,” she says.

Older LGBTQ adults were more likely to have come out in a hostile societal environment, says Christian Chan, a former family counselor and current doctoral candidate in counseling at George Washington University in Washington, D.C. This history of intense stigma and marginalization puts older LGBTQ adults at even greater risk for mental health issues such as depression and substance abuse, he notes. In addition, at a stage in life when health care issues may necessitate the need for long-term care, older LGBTQ adults are more likely to have a difficult time securing it because retirement communities and nursing homes often discriminate against those who are LGBTQ, Chan and Ginicola say.

Counselors can help this client population, but only if they are aware of the issues, says Chan, who serves as the student trustee for ALGBTIC and the member at large for outreach and advocacy for the Association for Adult Development and Aging, a division of ACA. He emphasizes the need for further training in counselor educator programs and beyond.

“[We should] focus on extending training on how to discuss sexuality, affectional [orientation] and gender identity in conversations and meaning-making around self-disclosure and coming out,” says Chan, who is also president of the Maryland Counseling Association. “It appears to me that many counselors are unsure about how to navigate these questions at large in counseling, which makes the counseling less culturally responsive to older LGBTQ adults.”

Chan urges individual counselors to help their LGBTQ clients build social support networks. “This is especially important in the sphere of redefining family for older LGBTQ adults,” notes Chan, who adds that the concept of family may need to be extended beyond the traditional definition for these clients.

Chan also points counselors toward organizations such as Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (sageusa.org) and the National Resource Center on LGBT Aging (lgbtagingcenter.org) that specialize in helping older LGBTQ adults. AARP’s website (aarp.org) also contains a significant amount of information on LGBTQ issues.

Transgender individuals walk a particularly difficult and dangerous road throughout the life span, confronting widespread misunderstanding and discrimination and an extremely high likelihood of becoming victims of violence, Ginicola says.

“Trans persons, particularly trans women of color, face incredible bias both inside and outside of the LGBTQI+ community,” she says. “When a person transitions, their family and partner must transition with them, which may not always be possible. For example, a trans male, designated as female at birth, may have been in a relationship with a lesbian. When he transitions to male, his partner may experience identity issues and  difficulty in accepting a male as her partner. Transitioning can bring a transgender person such relief in terms of finally being able to be their authentic self, but at the same time, they are likely to experience rejection, bias incidents and discrimination within their personal and professional lives. This is why trans persons are also at the highest risk for suicide.”

Ginicola says that affirmative counseling is crucial to transgender — and, indeed, all LGBTQ — clients. “Affirmative counseling is truly about validating an identity,” she says, “while understanding the realities of being marginalized, building coping skills, connecting clients to affirming communities and making cultural accommodations.”

 

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ACA Illuminate

The American Counseling Association will be holding Illuminate, an innovative counseling symposium focused on serving the needs of the LGBTQ community and those who work with members of this community, from June 8 to 10 in Washington, D.C.

Illuminate is a passion project for ACA President Catherine B. Roland, who has made LGBTQ issues one of her presidential initiatives. “The inspiration [for Illuminate] occurred many years ago and became real right after I was elected ACA president,” Roland says. “I knew that the marginalized population of the LGBTQ community, and the diversity and multiple identities within it, should be a focus of mental health treatment.”

Roland’s goal for Illuminate is to help more counselors and counselor educators gain a greater awareness of the needs of the LGBTQ community and learn how to offer the best care. She also hopes that the symposium will generate additional specific strategies for working with the population, families and career aspirations of LGBTQ adults across the life span.

For more information, visit counseling.org/illuminate. The deadline for early bird registration is April 7.

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association.

Journal articles (counseling.org/publications/counseling-journals)

  • “Long-Term Outcomes of Lesbian, Gay, Bisexual and Transgender Recalled School Victimization” by Darrell C. Green, Paula J. Britton and Brian Fitts, Journal of Counseling & Development, December 2014
  • “I Am My Own Gender: Resilience Strategies of Trans Youth” by Anneliese A. Singh, Sarah E. Meng and Anthony W. Hansen, Journal of Counseling & Development, April 2014

Counseling Today (ct.counseling.org)

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Counseling People Living with HIV/AIDS” by Brandon Hunt
  • “LGBTQQ-Affirmative Counseling” by Anneliese Singh and Maru Gonzalez

Books & DVDs (counseling.org/publications/bookstore)

  • Affirmative Counseling With LGBTQI+ People edited by Misty M. Ginicola, Cheri Smith and Joel M. Filmore
  • Group Counseling With LGBTQI Persons by Kristopher M. Goodrich and Melissa Luke

Podcasts (counseling.org/knowledge-center/podcasts)

  • “Queer People of Color” with Adrienne N. Erby and Christian D. Chan
  • “Group Counseling With LGBTQI Persons” with Kristopher M. Goodrich and Melissa Luke
  • “Living Straight: Coming Out After 40” with Loren Olsen
  • “Counseling Queer* (LGBT) Youth” with Anneliese Singh

ACA divisions 

  • Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (algbtic.org)

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.