Psychosocial Issues and Health Risks of LGBT Youth

ORIGINAL ARTICLE
Curretit health c&e delivery sites’: Ii,’
are examined, and recommenda- ’
tions are given for improvement
of both practitioner skills and
health care programs targeting
these youth. J Pediatr Health
Care. (1997). 11, 266-274.
Psychosocial Issues in
Primary Care of
Lesbian, Gay,
Bisexual, and
Pansgender Youth
Jennifer L. Kreiss, MN, RN, and
Diana L. Patterson, DSN
T he passage through puberty, peer group acceptance, and
the establishment of a personal identity are all developmental
tasks of the adolescent years. For the youth who is lesbian, gay,
bisexual, or transgender, self-acceptance and identity forma-
tion in the face of a heterosexist society are difficult tasks asso-
ciated with many risks to physical, emotional, and social

health. Gay and bisexual males are at particularly high risk for
acquiring sexually transmitted diseases, including human
Jennifer L. Kreiss is a Pediatric Nurse Practitioner at Children’s
Hospital & Medical Center in Seattle,
Washington.
Diana L. Patterson is an Assistant Professor in Family and Child
Nursing at the University of Washington and is
Nursing Discipline Head at Adolescent Clinic at the University
of Washington in Seattle, Washington.
Reprint requests: Jennifer Kreiss, MN, RN, Children’s Hospital
Medical Center, 4800 Sand Point Way NE, P.O.
Box 5371, Seattle, WA 98105-0371.
Copyright 0 1997 by the National Association of Pediatric
Nurse Associates & Practitioners.
0891.5245/97/$5.00 + 0 25/l/79212
266 November/December 1997
Kreiss & Patterson
immunodeficiency virus and ac-
quired immunodeficiency syn-
drome (Zenilman, 1988). Lesbian,
gay, bisexual, and transgender
youth are also at increased risk for
low self-esteem, depression, sui-
cide (Remafedi, Farrow, & De&her,

1991), substance abuse, school
problems, family rejection and dis-
cord, running away, homelessness,
and prostitution (Kruks, 1991;
Remafedi, 1990; Savin-Williams,
1994). The psychosocial health con-
cerns faced by sexual minority
youth are primarily the result of
societal stigma, hatred, hostility,
isolation, and alienation (American
Academy of Pediatrics Committee
on Adolescence, 1993). One of the
roles of the primary health care
provider is to recognize adoles-
cents who are struggling with sex-
ual orientation issues and support
a healthy passage through the spe-
cial challenges of the teen years.
In recent years homosexuality
has become increasingly main-
stream. Images of lesbians and gay
men are visible in every venue of
popular culture, from television
shows and films to famous sports
stars and musicians. Presidential
speeches and national debates
occur on questions of gays in the
military, gay marriage and parent-
ing, domestic partnerships, and the
acquired immunodeficiency syn-
drome epidemic. The heightened
public awareness makes it easier
for adolescents to recognize the
meaning of same-sex attractions
and to self-identify as lesbian, gay,

bisexual, or transgender (hereafter
referred to as LGBT) at younger
ages than ever before (Savin-
Williams & Rodriguez, 1993). What
,this means for health care pro-
viders is that all health histories
must include questions about sexu-
al preference and practices without
making heterosexist assumptions.
This is considered standard assess-
ment to be covered with all adoles-
cent clients.
POPULATION AND
PREVALENCE
Homosexuality is defined as the
persistent sexual and emotional
attraction to person(s) of one’s own
sex. The American Academy of
Pediatrics’ Committee on Ado-
lescence (1993) has twice issued a
policy statement on homosexuality
and adolescence, stating that it is a
part of the continuum of sexual
expression. Homosexuality is not a
mental disorder, nor is it a choice
for individuals. The American
Psychiatric Association removed
homosexuality from its list of men-
tal disorders in 1973 (American
Academy of Pediatrics’ Committee
on Adolescence, 1993). People do
not choose to be attracted to per-
sons of their own sex, nor can peo-
ple choose not to be attracted to
persons of their own sex if they are

homosexual. Bisexual persons are
attracted to both their own and the
opposite sex. Transgender persons
identify as being members of the
opposite of their biologic sex, as,
for example, a man who feels that
he is actually a woman trapped
inside the body of a man. Most
transgender persons are biological-
ly male but have internalized a
female identity. Transgenderism is
described in the Diagnostic and
Statistical Manual of Mental Dis-
orders as a gender identity dis-
order (American Psychiatric Asso-
ciation, 1994). The incidence of
transgenderism in adolescents is
unknown but is presumed to be
very low because it has not been
captured in demographic studies
of adolescent sexual orientation.
Most research on sexual minority
youth does not include transgen-
der youth as part of the sample
because of the difficulty of finding
subjects in this tiny subset of the
population. Therefore inclusion of
the transgender population when
discussing health concerns of sexu-
al minority youth is a considered
appraisal of the health needs of a
heretofore unstudied group.
Projections of homosexuality in
adult men and women range from

1% to 10% (Remafedi, Resnick,
Blum, & Harris, 1992). Among ado-
lescents, the 1992 survey by
Remafedi and colleagues of 35,000
Minnesota junior and senior high
school students found that 1.4%
described themselves as having a
homosexual or bisexual identity.
The prevalence of bisexual and
homosexual experiences and be-
havior was higher than the per-
centage of youth who self-identi-
fied as gay or bisexual, supporting
the idea that many adolescents
who experiment with same-sex
behavior later identify as hetero-
sexual in adulthood. Similarly, 54%
of gay males and 81% of lesbians
between the ages of 14 and 23 years
reported engaging in heterosexual
sex. The number of heterosexually
and homosexualIy identified ado-
lescents who engaged in heterosex-
ual sexual behavior was nearly
identical, at 65% (Remafedi et al.,
1992). Both homosexual and het-
erosexual attractions, behaviors,
and identities increased with age.
Adolescents in general tend to
become more sexually active with
the increasing physical and emo-
tional maturity that accompanies
the later teen years.
The age at which youths self-
identify as gay or lesbian may be

younger today than in previous
decades. In the past the average
age of self-disclosure of LGBT sex-
ual identity to non-gays (i.e., “com-
ing out”) has been reported to be in
the early to mid 20s. Current re-
search shows that age to be falling
rapidly, and it is now estimated to
be in the late teen years. The
younger age of coming out may
be attributable to the increased visi-
bility of homosexuality in our pop-
ular culture (Savin-Williams &
Rodriguez, 1993).
JOURNAL OF PEDIATRIC HEALTH CARE
November/December 1997 2 6 7
ORIGINAL ARTICLE Kreiss & Patterson
SEXUAL IDENTITY
DEVELOPMENT AND THE
COMING OUT PROCESS
Many gay and lesbian adults say
retrospectively that they knew
from early childhood that they “felt
different” from their peers and that
they were able to recognize that
their primary attractions were to
people of their same sex. Troiden
(1988) has constructed a model of
individual homosexual identity
development (Figure 1). Age pro-
gression through the stages of

the model varies by individual.
Other theorists have expanded on
differences in identity develop-
ment between gay males and les-
bians. Browning (1987) believes
that young women develop lesbian
identities within a relational con-
text and that the establishment of a
same-sex intimate relationship en-
hances identity formation. Differ-
ences have been noted between
males and females in the coming-
out process (Gonsiorek, 1988). For
males the process seems to be more
abrupt and more likely to be asso-
ciated with symptoms such as de-
pression or suicide attempts. For
women the process is character-
ized by greater fluidity and am-
biguity, perhaps because histori-
cally women have been allowed
a broader range of emotional ex-
pression and behavior with other
women. Coming out is always an
individual choice, and some people
never make this choice. Others
come out, establish same-sex rela-
tionships, and reach the stage of
identity commitment while still in
their teen years. For youths there
is a greater risk of psychosocial
problems associated with earlier
age of self-identification. Younger
youth seem developmentally least
equipped to deal with the com-
plex social and behavioral con-

sequences of acquiring a gay iden-
tity (Remafedi, Farrow, & Deisher,
1991). (
49 years
oeeurs before puberty
1 2 - 1 8 years 1 5 - 2 2 years adulthood
opment (stages and ages variable).
The coming out process is not
solely applicable to the individual.
Once the individual discloses an
LGBT identity to his or her family,
the family faces a not dissimilar
process of adaptation to the news.
As with individuals, some families
choose never to complete or even
begin this process of adaptation,
and the youth is rejected by the
family. It must be pointed out that
individuals within the family usu-
ally have different time frames for
adaptation to the youths disclo-
sure, with some individuals mov-
ing to an acceptance stage before
others. A model of family adapta-
tion is shown in Figure 2.
SPECIAL HEALTH
CONCERNS
Youth who reach the identity as-
sumption stage of Troiden’s (1988)
model and come out to others dur-
ing the teen years have been identi-

fied as facing a number of special
health challenges. The primary
care provider can best assess the
needs of LGBT adolescents by con-
sidering the concerns frequently
encountered by these youth.
School problems. Contributing to
school difficulties are the friendship
loss and peer rejection usually asso-
ciated with the disclosure of an
LGBT identity to schoolmates. Peer
rejection and loss of friends is a dev-
FIGURE 1. Troiden’s model of individual lesbian and gay
identity devel-
astating event for the adolescent,
whose normal developmental tasks
involve a movement away from
parents and family and toward the
peer group as a growing source
of support. Peer group rejection
has a powerfully negative effect
on the self-esteem and coping of
the adolescent. Peers may engage
in name-calling and may ridicule,
ostracize, or physically abuse the
disclosed individual. Youths most
abused by peers are those with the
most gender-atypical appearance,
mannerisms, and behavior. Indi-
viduals who failed to incorporate
cultural ideals of gender-appropri-
ate behavior and roles were most
likely to experience peer rejection
(Savin-Williams, 1994). Verbal and

or physical harassment of the ado-
lescent at school along with in-
adequate support by teachers and
staff contributed to a school drop-
out rate of 28% in one study of gay
and bisexual boys, with 80% of re-
spondents reporting deteriorating
school performance (Smith & Mc-
Claugherty, 1994).
Family conflict and rejection. Pa-
rental rejection, at least initially,
is a common outcome of youth
self-disclosure (Borhek, 1988; Mat-
tison & McWhirter, 1995). Families
frequently hold antihomosexual
attitudes based on homophobia,
prejudice, and ignorance. .Family
2 68 Volume 11 Number 6 JOURNAL OF PEDIATRIC
HEALTH CARE
INITIAL REJECTION IDENTITY ACCEPTANCE
COMMITMENT
youth discloses homosexual *family gradually comes to family
able to disclose
identity to family accept youth’s identity (may not son or
daughter’s
*homosexuality msy be in conflict
extend approval) homosexual identity to

with family’s cultural or religious w-establishment of family
others
beliefs communication
wmmon parental reactions are
denial, confusion, guilt, anger,
fear, grief
*initial rejection of youth common
*stage may last months to years
*family-youthcommunication
disrupted
FIGURE 2. Kreiss’ model of family adaptation to a gay son or
lesbian
daughter (stages of family variable, usually lags behind youth’s
development).
difficulties are clearly linked to
stigmatization (Herrick & Martin,
1987). Just as individuals struggle
with the risks, pain, anguish, and
fear of coming out, so must fami-
lies face the same emotions when a
loved family member discloses a
homosexual identity. In the most
commonly recognized pattern of
coming out, the individual first dis-
closes his or her identity to a few

carefully chosen friends and only
later to family members. Thus by
the time a youth comes out to par-
ents and family, he or she has
already been involved in an in-
ternal identity acceptance process
that has occurred over months or
years. Families may require vary-
ing amounts of time to accept the
youth’s disclosure. For youth who
come out to parents and family
before attaining financial indepen-
dence, nonsupportive family re-
sponses can lead to the youth being
‘thrown out of the home either per-
manently or temporarily or to the
youth leaving home voluntarily
because of isolation, confusion,
shame, or family discord.
Homelessness. Once a youth is out
of the home, an additional set of
psychosocial risks is encountered.
Homeless youth face multiple prob-
lems including substance abuse, vic-
timization by violent hate crimes,
conflict with the law, participation
in survival sex, poverty and de-
creased access to health care ser-
vices (Kruks, 1991).
Out-of-home LGBT youth are
among the hardest to place of all
youth because of their older age at
admission to care (adolescents are
harder to place than younger chil-

dren), a genera1 lack of culturally
congruent foster homes, and the
difficulty of finding group homes
that can incorporate overt sexual
minority youth (Sullivan, 1994).
Substance abuse. The use of drugs
and alcohol is a common coping
mechanism of gay-identified youth.
Traditionally, one of the few social
gathering places for gays and les-
bians, both youth and adults, has
been in bars. Particularly in rural
areas, bars are the only place to see
other gay and lesbian people. Alco-
hol and drug use among LGBT
youth occur at considerably higher
rates than the general adolescent
population. Nearly 60% of gay and
bisexual males in one study were
currently abusing substances and
met psychiatric criteria for sub-
stance abuse (Savin-Williams, 1994).
Substance abuse occurs concurrent
to school dropout, homelessness,
and criminal activity and is asso-
ciated with higher rates of suicide
attempts (Remafedi et al., 1991;
Savin-Williams, 1994).
Depression and suicide. The in-
creased incidence of depression
and suicide has been well docu-
mented for LGBT youth (American
Academy of Pediatrics Committee
on Adolescence, 1993; Remafedi,
1991; Savin-Williams, 1994; Smith

& McClaugherty, 1994). Forty per-
cent of homosexual men and
women have seriously considered
or attempted suicide, with nearly
all of the reported attempts occur-
ring during the teenage years. Gay
adolescents are two to three times
more likely to attempt suicide than
non-gay peers, and attempts made
are more serious and lethal. It is
estimated that gay youth account
for 30% of completed youth sui-
cides each year. LGBT youth of
color face a double stigma and
have higher rates of suicide at-
tempts than white youth. Remafedi
and colleagues (1991) reported that
one third of first attempts occurred
in the first year that subjects identi-
fied their homosexuality or bisexu-
ality, and most other attempts oc-
curred soon thereafter. Compared
with LGBT peers, youths who at-
tempted suicide recognized same-
sex attractions and told others
about them at younger ages. At-
tempters were also younger at the
age of first homosexual experience
than peers. For each year’s delay in
homosexual self-labeling, the odds
of a suicide attempt decreased
by 80%. Remafedi and colleagues
(1991) concluded that, “Compared
with older persons, early and mid-
dle adolescents may be generally
less able to cope with the isolation

and stigma of a homosexual iden-
tity” (p. 874).
A perspective on health care for
LGBT youth. When thinking about
provision of health care to LGBT
November/December 1997 2 69
BOX 1 Survey of LGBT youth clinics
Method
Subjects: Directors of LGBT youth
clinics in the United States
Sample size: 5
Measure: Self-administered 21 -item
questionnaire (see appendix)
Response rate: 80%
Results
Average age of clients seen: 18.3 years
Sexual orientation of clients:
Gay male 50%-97% (average,
70.5%)
Lesbian I%-30% (average, 13%)
Bisexual 2%-l 5% (average, 9%)

Access:
100% arrive at clinics on foot/by
bike or by public or private trans-
port
Two clinics pick up youths at vari-
ous locations and transport them
Funding:*
100% of clinics provide all services
free of charge
Two clinics report private and grant
funding
One clinic reports private donations
and volunteers
One ciinic reports fundraising and
grants
*A// of the clinics providing physical
health care (3 of 4 clinics surveyed)
disagreed that their current funding
is adequate to meet their service
goals
Frequency of clinic operation:
Average 2.2 times per week
Type of health care providers:
Medical doctor-l 00% of the three

clinics providing physical health
care
Nurse practitioners-66%
Physician assistants-33%
Nurses-33%
Medical assistants-33%
Type of services provided:
Minor illness-ne clinic
Minor injury-one clinic
Sports medicine-one clinic
HIV testing-three clinics
STD testing/treatment-two clinics
Drug/alcohol counseling-two clinics
youth, it is useful to keep the fol-
lowing points in mind. One per-
cent to 10% of the adult population
is homosexual. The average age of
homosexual self-definition, based
on retrospective studies of adult
gays and lesbians, is between 19
and 21 years for males and 21 to 23
years for females (Troiden, 1988).
Only after self-definition occurs do
individuals begin the process of
disclosure to others, known as
coming out, which usually occurs
over several years during the third
decade of life. Therefore of all the
people who will eventually dis-
close a homosexual identity, less
than half will have done so by their
twenty-second birthday. Most will

come out as adults. This does not
mean that youth who have not yet
come out are insensitive to hetero-
sexist assumptions by health care
providers and others-quite the
opposite. The prevalence of the
youth’s exposure to these assump-
tions may be a contributing factor
to the youth’s delay in attaining
identity assumption. Health care
providers cannot know which of
the youth they see may one day
self-identify as LGBT; thus gender-
neutral language and avoidance of
gender stereotypes and heterosex-
ist assumptions for all persons seen
in the clinical setting are important.
CURRENT HEALTH CARE
DELIVERY TO LGBT YOUTH
Survey of LGBT Youth Health Clin-
ics. The authors conducted a study
of health clinics specifically target-
ing the LGBT youth population.
The purpose of the study was to (a)
identify clinics currently serving
LGBT youth and (b) evaluate the
effectiveness of the clinics currently
in existence (Box 1).
Currently only four major metro-
politan cities have clinics specifical-
ly designed to meet the health
needs of LGBT youth. Cities with

specialized LGBT youth clinics are
Seattle, Minneapolis, Los Angeles,
and New York. Other metropolitan
areas (Boston, Chicago, San Fran-
cisco, and Washington, D.C.) have
LGBT youth centers that coordi-
nate referrals to health services
familiar with LGBT youth issues.
The self-described mission of the
health clinics varies in focus, from
“human immunodeficiency virus
prevention and treatment” to “safe
supportive space” to “provision of
culturally sensitive care.” Special-
ized metropolitan free clinics ad-
dress the need for affordable, acces-
sible, culturally congruent services
in areas with significant popula-
tions of high-risk urban LGBT
youth, many of whom have multi-
ple risk factors including poverty,
homelessness, substance abuse,
and positive human immunodefi-
ciency virus status. However, most
of the health services needs of
LGBT youth can be provided in
general adolescent health care set-
tings by a primary care provider
who is familiar with adolescent
issues, sexual health, LGBT specific
issues, and community resources
for LGBT youth (Box 2).
Survey of LGBT Youth Regarding
Quality of Health Care Received.
Blanc0 (1995) surveyed LGBT
youth in Washington State to assess

their access to health care and the
quality of care they received. The
study found that 66% of youth stat-
ed that their health provider had
never brought up issues of sexual
orientation. Many received inap-
propriate treatment and health ed-
ucation based on their provider’s
heterosexual assumption and igno-
rance of their true sexual orienta-
tion. The youth also rated health
care provider qualities that were
important to them. Most important
HEALTH CARE
BOX 2 Coordination of
care for LGBT youth content
referral I ist
l Peer support groups (gay, les-
bian, transgender, youth of
color, HIV+)
l Counseling (individual and
family)
l Emergency housing
l Food assistance
l Clothing assistance
l Drug and alcohol recovery ser-

vices
l Legal assistance
l Education programs
l Job training
l Prostitution diversion
to youth were that the provider
be skilled, be supportive of the
youth’s sexual orientation, be the
same sex as the youth, and share
the same sexual orientation. Other
considerations were the provider’s
age and ethnic background, with
youth preferring providers that
were most like themselves.
Overcoming Barriers to Care De-
livery. Practitioners working with
teens must address access issues
relevant to all adolescent health
care. Services must be available,
visible, affordable, flexible, confi-
dential, coordinated, and of high
quality (Society for Adolescent
Medicine, 1992). Many LGBT youth
fear that the provider will tell their
parents about their sexual identity;
therefore health care providers
should inform the youth what in-
formation can and will be kept con-
fidential. Also, practitioners should
have LGBT resources to offer teens
and keep lists updated as new ser-
vices become available. In addition,
providers must keep their knowl-
edge current on issues affecting the

LGBT community including legis-
lation and health and actively dis-
pel myths and correct stereotypes
with clients and families. Providers
can advertise their services in gay
and lesbian publications and at
meeting places to encourage youth
to seek them out as a provider.
Many youth have difficulty making
and keeping appointments; drop-in
hours can add to the clinic’s flexibil-
ity. Barriers such as lack of trans-
portation can be addressed by of-
fering bus tokens or coordinating
with other local youth services to
provide a van service. A system-
atic outreach strategy is necessary
to bring adolescents into care. Ex-
amining barriers related to both
LGBT adolescents (client barriers)
and to the particular care setting
(institutional barriers) can result in
better access to care for this at-risk
population (Dilorenzo et al., 1993).
Institutional barriers include rais-
ing provider awareness of LGBT is-
sues, support for ongoing provider
training, solicitation of community
support for the clinic’s mission and
service goals, and adequate clinic
funding to provide cost-effective
yet comprehensive service.
ROLE OF THE PRIMARY
HEALTH CARE PROVIDER

The goal of health care provision to
LGBT youth is to provide care sen-
sitive to the unique needs of this
population within a safe, accept-
ing, and supportive environment.
To achieve this goal providers must
first, create a safe space for youth to
seek health care, second, incorpo-
rate knowledge of LGBT health
issues into designing a care plan
unique to the needs of the youth,
and third, coordinate comprehen-
sive service delivery (Box 3).
Creating a Safe Space for Care. Prac-
titioners working with children can
start early to create a safe, trusting,
and unbiased setting for care deliv-
ery. With only gender-neutral lan-
guage in history-taking and the
avoidance of gender stereotyping,
practitioners never assume any cli-
ent is heterosexual including and
especially children and adolecents,
who have yet to define their sexual
BOX 3 The role of the
pediatric nurse practitioner
in provision of health care
services for LGBT youth
l Health promotion
* Complete assessment
* Minor illness care
l Minor injury care
l Sports health care
l Dental care referral

l Mental health screening and
referral
l STD testing and treatment
l HIV testing, including partner
testing
l Risk reduction counseling
l Barriers and contraceptives
l Drug/alcohol counseling
l Crisis intervention
preference. Total avoidance of het-
erosexual assumptions during con-
versation with youth is a cue to
them that the provider is aware of
nonheterosexual options. For exam-
ple, few teenage lesbians will bother
to correct the practitioner who asks
only whether they have a boy-
friend; the question will only add to
the sense of isolation and different-
ness the teen already feels. The key
to quality service delivery for LGBT
youth is to ask the right questions
and to assess the known risk areas
of LGBT youth (Table). Health care
providers must assess their client’s
sexual preferences and practices to
give appropriate treatment and ed-
ucation. A relaxed attitude about
sexual development and an open-
ness to exploring issues of sexuality
with youth are essential for build-
ing the trust it will take for a youth
to discuss such personal matters

with the health care provider.
Practitioners must be prepared to
articulate their philosophy of sexu-
al health care to parents, explaining
their use of gender-neutral lan-
guage and conscious avoidance of
gender stereotypes. Practitioners
IOURNAL OF PEDIATRIC HEALTH CARE
November/December 1997 2 7 1
‘34 ORIGINAL ARTICLE Kreiss & Patterson
TABLE Psychosocial interventions for gay, lesbian, bisexual
and transgender youth: A clinical path
Timeline: Initial Visit
Functional
health pattern Outcomes Assessment Intervention/Referral
Coping/stress
tolerance
1. Adolescent recognizes
that heterosexuality,
homosexuality, and
bisexuality are all nor-
mal expressions, and all
can be practiced within
the context of healthy,
normal lives

2. Adolescent can identify
sources of stress
3. Adolescent effectively
manages stress through
use of coping techniques
that promote health,
growth and develop-
ment
resources to assist in
coping/stress reduction
Roles/relation-
ships
1. Adolescent has the abil-
ity and opportunity to
form healthy relation-
ships with family, peers,
and community
Sexuality 1. Adolescent develops
positive feelings and ex-
periences satisfaction re-
garding sexual identity
2. Adolescent demon-
strates responsible deci-
sion-making re: sexual
behavior and health
1. Assess stereotypic ideas and
attitudes

2. Assess adolescent’s internal
concerns re:
l Comfort with perceived
identity
l Comfort in communicating
sexual-preference concerns
with health provider
3. Assess degree of isolation
4. Assess evidence of depression,
i.e. social withdrawal, declin-
ing school performance, sub-
stance abuse, disrupted family
relationships, runaway behav-
ior, health risk-taking (unsafe
sex, promiscuity, self-harm,
suicide ideation)
1. Assess adolescent’s external
concerns re:
l Family relationships and
family member’s knowledge
of sexual-orientation issues
l Interaction at school/job
. Peer friendships and peer
knowledge of sexual orienta-
tion
l Community involvement

1. Assess concerns re:
l Sexual experiences and
practices
l Experiences with uncomfort-
able touch or abuse
2. Assess awareness of options
related to sexual activity,
knowledge of reproduction,
disease transmission, and con-
traception/barrier methods
Interventions:
l Assure confidentiality
l Be supportive and nonjudgemental
l Avoid labels by discussing the spec-
trum of sexual orientation
l Provide accurate and unbiased infor-
mation-correct stereotypes
l Allow time for self-definition
l Validate homosexual, heterosexual,
and bisexual behaviors as compatible
with a healthy, normal life
l Assist in identifying stressors and
exploring coping strategies
. Teach a variety of coping strategies
l Provide sources of information and
support (keep a complete referral list of

gay and lesbian resources for your
area)
Referrals:
9 Youth LGBT support groups if youth
desires for evidence of depression,
refer to mental health counseling
Interventions:
l Assist youth to identify supportive
adult(s)
l Assist youth to identify supportive fam-
ily member(s) (explore extended family
if necessary)
peer(s)
community (i.e., youth groups/youth
centers/gathering places, books, news-
papers, internet resources)
interventions:
l Provide unconditional acceptance of
the youth
l Validate sexual preference as legiti-
mate
l Explore sexual decision-making and
assertiveness techniques

l Teach facts about safer sex practices,
disease transmission, reproductive bar-
rier/contraceptive choices
Referrals:
l Refer to counseling for unresolved
abuse issues
HEALTH CARE
Kreiss & Patterson
TABLE Psychosocial interventions for gay, lesbian, bisexual
and transgender youth: A clinical path-confti
Timeline: Follow-up visit(s)-Two weeks to two months
depending on risk profile
Functional
health pattern Outcomes Assessment Intervention/Referral
Coping/stress
tolerance
1. Adolescent can begin to
verbalize own process of
self-acceptance
2. Adolescent begins to
effectively manage stress
through use of coping

techniques that promote
health, growth and
development
Roles/relation-
ships
1. Adolescent has the abili-
ty and opportunity to
form healthy relation-
ships with family, peers
and community
supportive adult(s), fami-
ly member(s), peer(s)
and has knowledge of
available community
resources
Sexuality 1. Adolescent begins to
develop positive feelings
and verbalizes accep-
tance of sexual identity
of self and others
2. Adolescent begins to
demonstrate responsible
decision-making regard-
ing sexual decision-
making and sexual
health
1. Assess level of identity devel-
opment (seeTroiden, 1988),
i.e., sensitization, identity con-

fusion, identity assumption,
commitment
2. Assess coping techniques for
identified current stressors
3. Assess whether stressors ex-
ceed current coping strategies
1. Assess supportive and nonsup-
portive factors in current rela-
tionships
1. Continue ongoing assessment
of feelings, experiences, and
values regarding own sexuality
and that of others
2. Assess sexual knowledge and
behavior
Interventions:
l Assist youth to identify own goals for
personal physical and mental health
l Validate the youth’s process of identity
development, emphasizing that indi-
vidual timelines for acceptance vary,
that individual timelines for accep-
tance vary, and that the process is life-
long
l Assist in identifying coping strategies
Referrals:
9 Suggest appropriate community

resources for support (see referral list in
Box 2)
Interventions:
* Assist in identifying and improving
supportive relationships
* Offer to meet with parents/family to
facilitate family communication
Referrals:
l Individual counseling
l Family counseling (referrals to counsel-
ing agencies with philosophical con-
gruence to youth and family)
Interventions:
l Validate the individual and his/her
feelings
l Validate the youth’s experience
9 Identify progress the youth is making
toward achieving safe, satisfying rela-
tionships
* Assist in problem-solving ways to
make the youth‘s experiences healthier
and/or more satisfying
l Reinforce teaching of disease transmis-
sion and risk-reduction techniques
can explain the spectrum of sexual

orientation to families. As a pri-
mary care provider, speak openly
and matter-of-factly about sexual
health, incorporating age-appro-
priate discussion into al1 well-child
visits. “Creating a safe space” also
entails such efforts as having gay
and lesbian books on your shelf
and fliers on your wall. It includes
having office staff and colleagues
who are comfortable, friendly, and
accepting of LGBT youth in the
care setting.
The pediatric nurse practitioner
can be an ideal care provider for
this population and can function in
the role of case manager to ensure
appropriate, comprehensive, and
cost-effective care delivery. It is the
role of the practitioner to provide
accurate, unbiased information,
support, resources, and uncondi-
tional acceptance. It is not the role
November/December 1997 2 73
of the practitioner to “diagnose”
sexual orientation; sexual orienta-

tion is not a disease to diagnose.
Nor is it the practitioner’s role to
encourage the youth to come out to
self or others; only the adolescent
can decide what his or her sexual
orientation is and both when and
how much of that information will
be shared with others. The Table is
an example of a clinical path based
on selected functional health pat-
terns particularly relevant to the
health care of LGBT youth.
Steps to a Healthy Future. With in-
creasing visibility of LGBT persons
in our communities and an ongo-
ing societal dialogue regarding gay
and lesbian issues, the shame and
stigma of being lesbian, gay, bisex-
ual, or transgender in our society is
decreasing. A better awareness on
the part of health care providers of
LGBT youth health issues will im-
prove the quality of services of-
fered and may improve the health
status of LGBT youth. With the
growing acceptance of all types of
sexual expression as compatible
with a healthy lifestyle, an increase
in the quality and availability of
appropriate health services for
LGBT youth is now both a reason-
able expectation and a goal for both
the present and near future. Health
care providers acting as youth ad-
vocates in the health care and legal
arenas can make a positive con-

tribution to achieving this goal.
Homosexuals are among the last
groups in our society to still suffer
legal discrimination. The support
of equal rights and antidiscrimina-
tion legislation for all people will
ease the burden of stigma and help
the young people of today to be-
come healthy, contributing mem-
bers of society.
REFERENCES
American Academy of Pediatrics, Com-
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sexuality and adolescence. Pediufuics, 92,
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American Academy of Pediatrics, Com-
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sexuality and adolescence. Pediatrics, 72,
249-250.
American Psychiatric Association. (1994).
Diagnostic and Statistical Munuul(4th ed.).
Washington, DC: Author.
Blanco, V. (1995). QuuIity of cure of lesbian, bi-

sexual und guy youth. Unpublished manu-
script.
Browning, C. (1987). Therapeutic issues and
intervention strategies with young adult
lesbian clients: A developmental ap-
proach. Journal of Homosexuality, 14,
45-52.
Borhek, M.V. (1988). Helping gay and les-
bian adolescents and their families. Jour-
nal of Adolescent Health Cure, 9, 123-128.
Dilorenzo, T.A., Abramo, D.M., Hein, K.,
Clare, G.S., Dell, R., & Shaffer, N. (1993).
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Gonsiorek, J.C. (1988). Mental health issues
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Herrick, E.S., & Martin, A.D. (1987). Devel-

opmental issues and their resolution for
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Kruks, G. (1991). Gay and lesbian home-
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Mattison, A.M., & McWhirter, D.P. (1995).
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Remafedi, G. (1990). Fundamental issues in
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(1991). Risk factors for attempted suicide
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Remafedi, G., Resnick, M., Blum, R., &

Harris, L. (1992). Demography of sexual
orientation in adolescents. Pediatrics, 89,
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Savin-Williams, R.C. (1994). Verbal and
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ning away, substance abuse, prostitution
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Savin-Williams, R.C., & Rodriguez, R.G.
(1993). A developmental, clinical per-
spective on lesbian, gay male, and bisex-
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cent Sexuality (pp. 77-101). Newbury
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Journal of Adolescent Health, 13,162-170.
Smith, S., & McClaugherty, L.O. (1994). Ado-
lescent homosexuality: A primary care
perspective. American Family Physician,
48,33-36.
Sullivan, T.R. (1994). Obstacles to effective
child welfare service with gay and les-
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Troiden, R.R. (1988). Homosexual identity
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HEALTH CARE
Counselling Psychology Review, Vol. 31, No. 1, June 2016 67

T
his Year’s diVision oF Counselling
Psychology conference theme, Positive
Approaches, Challenging Contexts,
provides perspective on the substantive
professional gains we have achieved in creat-
ing lesbian, gay, bisexual, and transgender
(lGBt) affirmative psychological theory,
practice, and education. it also exposes how
our professional past interconnects with
present psychosocial problems that continue
to vex lGBt people. lGBt individuals in
both the united kingdom and united states
share strikingly similar types and rates of
mental health disparities and psychosocial
problems. moreover, applied psychologists
(i.e., counselling, clinical, education/school,
and health) and other mental health profes-
sionals can be one piece of the puzzle when
trying to redress lGBt mental health dispar-
ities. research conducted in the united
Research Paper
Mind our professional gaps: Competent
lesbian, gay, bisexual, and transgender
mental health services1
Markus P. Bidell
Applied psychology has a complex relationship with lesbian,
gay, bisexual, and transgender (LGBT) matters. As
part of the religious, legal, and scientific triumvirate, we played
a central part in developing discriminatory, biased,

and stereotypic perspectives castigating LGBT individuals as
immoral, deviant, disordered, and even dangerous.
Such perspectives not only begot and reinforced legal and social
oppression, but also fuelled the creation of LGBT
psychological theories and malevolent treatments – since
discredited. In a historic and perhaps even redemptive
reversal, professional psychological bodies now reject the
notion that being LGBT is representative of a mental
disorder, immorality, or social deviancy and affirm that LGBT
people have a sexual orientation or gender identity
that is normal, healthy, and legitimate. In fact, applied
psychologists have become ardent advocates for LGBT
human rights. In our post-triumvirate role, we might reason that
our LGBT work is done or nearing completion
with the proffering of LGBT-affirmative professional ethics,
public policies, standards, and treatment guidelines.
Yet LGBT individuals on both sides of the Atlantic continue to
be negatively affected by alarming and
disproportionate rates of serious mental health and psychosocial
problems. These disparities are compounded by
practitioner and trainee concerns regarding their competence
with LGBT clients. Moreover, complex issues arise
when applied psychologists’ personal beliefs run contrary to our
professional LGBT standards of care. Based on a
keynote address (Bidell, 2015) and research paper presentation
(Bidell, Milton, Chang, Watterson, & Deschler,
2015) - both given at the annual conference of the British
Psychological Society Division of Counselling Psychology
- this paper juxtaposes our troubled past with current LGBT
psychosocial issues. It weaves past with present as well
as personal with professional to underscore the continued need
to advance LGBT-affirmative psychological services.
Keywords: sexual orientation, gender identity, LGBT counsellor
competence, religious conservatism,
applied psychology.

1 this paper is based on an invited keynote address (treating
transgressors: our complicated relationship with
lesbian, gay, bisexual, and transgender issues) and research
paper presentation (examining positive patterns
and current challenges: lGBt affirmative counsellor competency
and training in the united kingdom) given
at the annual conference of the British Psychological society
division of Counselling Psychology, harrogate,
uk., June 2015.
68 Counselling Psychology Review, Vol. 31, No. 1, June 2016
AuthorMarkus P. Bidell
states documents critical concerns with
lGBt counsellor competence and profes-
sional training. it is not uncommon for
mental health providers and trainees in the
united states to report being poorly trained
and feeling minimally competent to work
with lGBt clients (Bidell, 2014a; Bidell &
Whitman, 2013; Graham, Carney, & kluck,
2012; Grove, 2009; hope & Chappell, 2015;
mcGeorge, Carlson, & toomey, 2013a;
o’hara, dispenza, Brack, & Blood, 2013;
rock, Carlson, & mcGeorge, 2010). and
those in the mental health professions can
and do hold prejudicial attitudes towards
lGBt people, most often based on conser-
vative socio-political and religious beliefs
(Bidell, 2012, 2014b; Bidell & Whitman,
2013; henke, Carlson, & mcGeorge, 2009;
mcGeorge et al., 2013a; o’shaughnessy &
spokane, 2013; o’hara et al., 2013).

as the 2014–2015 regent’s university
london Fulbright scholar (Bidell, 2014c), i
am drawing on methodology i’ve employed
in the united states. over the past year, i
have been examining lGBt competence
and training in the British isles amongst
mental health practitioners and trainees. an
initial look at the data indicates that defi-
ciencies and problems with mental health
practitioners’ lGBt competence and train-
ing are not dissimilar to those i’ve witnessed
in the united states. Preliminary findings
show that lGBt counsellor competence is
significantly lower among more religiously
conservative British mental health practi-
tioners and students (Bidell, milton, Chang,
Watterson, & deschler, 2015). Comparable
to clinicians in the united states, i’ve found
that the overwhelming majority of British
trainees and practitioners (n = 196; 76.1 per
cent) reported their professional education
either incorporated minimal lGBt training
or none at all (Bidell et al., 2015). Clearly
existing research and my initial Fulbright
data underscore an imperative need for
applied psychologists on both sides of the
pond to improve lGBt clinical competence
and training.
The triumvirate: Religion, state, and
science
across the developmental spectrum, lGBt
people in the united states and united
kingdom have disproportionally high rates
of serious psychosocial and mental health

problems such as depression, anxiety, smok-
ing, substance abuse, suicidality, discrimina-
tion, and violence (Chakraborty, mcmanus,
Brugha, Bebbington, & king, 2011; elliott et
al., 2015; haas et al., 2010; institute of medi-
cine, 2011; king et al., 2003; king et al.,
2008; Warner et al., 2004). applied psychol-
ogists are starting to understand these
higher rates of psychosocial problems within
the framework of minority stress (meyer,
2003). the minority stress model views
‘stigma, prejudice and discrimination as
producing a hostile and stressful social envi-
ronment that leads to poor mental health,
and eventually, physical health’ (elliot, et al.,
2015, p.14). lGBt minority stress is not
static or isolated and can be hard to avoid.
impacted broadly by psychosocial factors, it
can wax and wane depending on develop-
mental issues, environment, and social
support. Furthermore, minority stress ‘may
be complicated by additional dimensions of
inequality such as race, ethnicity, and socioe-
conomic status, resulting in stigma at multi-
ple levels’ (iom, 2011, p.1.2).
the shared moral, legal, cultural, and
scientific heritage between the united king-
dom and united states likely explains why
we see such common types of lGBt oppres-
sion along with resultant forms of lGBt
psychosocial disparities. For lGBt people in
both countries, a powerful, interconnected,
and synergistic structure links past to pres-
ent. an omnipotent triumvirate, consisting
of religious, state, and scientific institutions,

has castigated lGBt people as immoral,
criminal, and disordered for well over a
thousand years. the roman Catholic
Church was one of the earliest Western insti-
tutions which not only morally condemned
lGBt people, but also developed ecclesias-
tic law punishing them as well. Penalties
changed over ensuing centuries, ranging
from social to physical and included capital
punishment.
as nation states in europe formed,
strengthened, and even broke from rome,
ecclesiastic law became the basis for anti-
lGBt common law. the first British sodomy
law, the Buggery act of 1533, was written
when henry the Viii split from the roman
Church during the english reformation.
Buggery became a felony punishable by
death. attempted buggery was a lesser crime
with penalties ranging from imprisonment
to pillory. the punishment of hanging for
buggery was not lifted until 1861 with the last
two British executions occurring in 1835. at
the turn of the century, lGBt Britons were
prosecuted using the labouchere amend-
ment (Criminal law amendment act, 1885)
stating lGBt behaviours were immoral and
represented gross indecency.
american anti-lGBt laws have primarily

been regulated through state criminal
statutes under various forms of sodomy legis-
lation and criminal punishments. as a
former colony, america based its early lGBt
legislation on British law. in most states,
homosexuality was initially categorised as a
felony and later re-codified as crimes against
nature or acts of gross indecency. social
changes starting in the late 1960s ushered in
processes that began the repeal of anti-
lGBt laws in the united kingdom and
united states. these repeals started with the
1967 sexual offences act that decrimi-
nalised homosexuality in england and Wales
and continued until 2003 when the united
states supreme Court in lawrence v. texas
repealed the remaining 14 state sodomy stat-
ues.
Classifying lGBt people as mentally
disordered provided the final component
to the triumvirate. influenced by social,
cultural, and moral discriminatory views
about lGBt people, Bayer (1987) argues
that mental health professionals started
‘serving as guarantor of social order, substi-
tuting the concept of illness for that of sin’
(p.10). Prevailing lGBt moral strictures
and public policies largely shaped emerg-
ing theories and clinical treatments devel-
oped by psychologists. lGBt people were
not only immoral in the eyes of religion and
criminals in the eyes of the law, but now also
viewed as mentally ill by our profession.
Psychiatrists and psychologists drew on

their tools of nomenclature to diagnosis
lGBt people as mentally disordered. in the
first edition of the Diagnostic and Statistical
Manual of Mental Disorders (dsm; american
Psychiatric association, 1952), homosexual-
ity was codified as a mental illness and cate-
gorised within the sociopathic personality
disturbances.
Codification of homosexuality within
sociopathy strongly reinforced a view that
lesbian, gay, and bisexual individuals were
not only highly pathological but also
extremely dangerous to society. this type of
categorisation justified the development and
utilisation of cruel measures to extinguish a
person’s homosexuality. Psychiatrists drew
on medical procedures such as electrocon-
vulsive therapy (i.e., electroshock treat-
ment), frontal lobotomies, and chemical
hormonal castration to beat back the
dangerous scourge homosexuality was
thought to present. our professional prede-
cessors employed psychoanalytic, behav-
ioural, and cognitive psychological theories
and treatments in their misguided, ill-fated
attempts at curing homosexuality. Psychoan-
alytical practitioners and researchers were
largely responsible for the idea that same-sex
attraction was an outcome of exposure to
highly pathological parent-child relation-
ships in early development. (Bieber, dain, &
dince, 1962; socarides, 1965). they also
developed psychoanalytic therapies, albeit
ineffectual, to attempt curing same-sex
sexual orientations (British Psychological

society, 2012b).
Cognitive and behavioural psychologists
transformed homosexuality from a distor-
tion of the normal pattern of psychosexual
development into the maladaptive behav-
ioural consequence of inappropriate learn-
ing and irrational fears of the ‘opposite’ sex
(Bayer, 1987; Freund, 1977). the technique
TitleMind our professional gaps
behaviourists employed most often was the
coupling of same-sex thoughts and fantasies
with emetics, electric shock, or other aversive
conditions, followed by desensitisation
procedures (i.e., termination of negative
aversion stimulus with the appearance of
heterosexual stimuli). in a later reflection
atypical for most behaviourists engaged in
conversion therapies, Freund stated:
i started a therapeutic experiment,
employing aversion therapy combined
with positive conditioning toward females.
approximately 20 per cent of the homo-
sexual males married and founded fami-
lies. For some time, there seemed to be
reason for guarded optimism. however,
this was a long-term study, and these
marriages were followed for many years.
Virtually not one cure remained a cure. i

am not happy about my therapeutic
experiment which, if it has helped at all, it
has helped clients to enter into marriages
that later became unbearable or almost
unbearable. Virtually all the marriages of
these clients had become beset with grave
problems ensuing from their homosexual-
ity (Freund, 1977, p.237).
dr evelyn hooker was one of the first
psychologists to conduct empirical research
on nonclinical lesbian women and gay men.
her landmark study (1957) examined results
from three projective tests administered to
30 gay and 30 heterosexual male study
participants matched along age, education,
and intelligence dimensions. after blinded
analysis of subjects’ responses, experts rated
each participant on a 5-point adjustment
scale. the independent evaluators found no
differences in the adjustment levels between
the two groups. Furthermore, they were not
able to accurately identify which participants
were gay or heterosexual. From her results,
hooker concluded that homosexuality did
not represent a clinical entity nor was it asso-
ciated with pathology. the work of psycholo-
gists like dr evelyn hooker coupled with
lGBt civil rights activism forced mental
health professionals to re-examine their
socially constructed and biased notions
regarding the conceptualisation and treat-
ment of lGBt individuals. in 1974, the
american Psychiatric association voted to
declassify homosexuality as a mental disor-

der (Bayer, 1987). however, a new diagnosis,
sexual orientation disturbance, was added
and then replaced with ego-dystonic homo-
sexuality in the dsm iii (american Psychi-
atric association, 1980); both diagnostic
categories described those individuals
conflicted with having a same-sex sexual
orientation. the diagnostic category was
completely removed with the publication of
the dsm-iii-r (american Psychiatric associ-
ation, 1987).
For transgender people, a diagnostic
category remains. introduced relatively late
in the diagnostic statistical manual’s history,
Gender identity disorder was added with the
publication of the dsm-iii (american
Psychiatric association, 1980). the diagnosis
was revised and renamed Gender dysphoria,
with the publication of the dsm-5 (ameri-
can Psychiatric association, 2013). the
continued inclusion of a transgender-based
dsm diagnosis remains controversial. some
advocates of the diagnostic category argue
that needed medical treatments for trans-
gender individuals might be jeopardised
with a complete removal of the diagnosis
from the dsm. others like myself believe the
continuation of categorising non-cisgender
people within a psychiatric diagnosis rein-
forces and even maintains the longstanding
prejudicial views that lGBt people are
fundamentally abnormal and diseased. i
believe healthcare policy can simply be
developed to address insurance and medical
coverage issues potentially resultant from

the complete elimination of a non-cisgender
diagnostic category from the dsm.
Mind the professional gap
For those of us born in america during the
1960s, an intact religious, legal, and scien-
tific triumvirate was still largely in place that
socially constructed lGBt people as
immoral, criminal, and mentally disordered.
For example, the socially conservative state
where i grew up criminalised homosexuality
until a 1972 legislative repeal. and the first
edition of the dsm (american Psychiatric
association, 1952) was still in use, categoris-
ing homosexuality as a serious mental illness
within the sociopathic personality distur-
bances. Coming to terms with my sexual
orientation in such an environment was chal-
lenging to say the least.
By the time i entered graduate training
in the early 1990s, lGBt social attitudes
and policies were in flux as the old triumvi-
rate began faltering and struggled to
remain a cohesive front against emerging
lGBt civil rights activism. it was not
uncommon to be confronted with past prej-
udices alongside emerging lGBt advocacy
and public policy gains. so as a graduate

counselling student at sonoma state
university in the early 1990s, i didn’t find it
odd that my professors expressed caution
about potential problems i might have as an
openly gay counsellor working with youth
in schools. they were concerned that preju-
dicial stereotypes about gay men coupled
with the existence of discriminatory laws
could make my work in public schools
uncertain at best. Consider that it wasn’t
until 2003 that the united states supreme
Court in lawrence v. texas ruled that state
sodomy laws were unconstitutional. said
another way; i had been an assistant Profes-
sor for three years by the time the supreme
Court made this ruling.
Perhaps the most defining moment of my
professional career happened when i began
my doctoral training in combined applied
psychology (counselling/clinical/school) at
the university of California, santa Barbara.
at the time, i couldn’t have known this expe-
rience would profoundly shape not only my
dissertation, but also my future scholarship
and professional work. my efforts to opera-
tionalise lGBt counsellor competence can
be directly traced back to this pivotal experi-
ence. a professor with ardent beliefs that
being lGBt was morally wrong taught my
first doctoral course. Furthermore, he
supported using reparative or conversion
therapy typically based on conservative and
fundamental religious beliefs about lGBt
people. these pseudo-treatments claim out-

dated psychoanalytic, cognitive, and
behaviour principles can be utilised to
convert lGBt people to be heterosexual
and cisgender. in response, the american
Psychological association and the British
Psychological society have issued strong
position statements condemning such
pseudo-treatments as unethical and highly
damaging to lGBt clients (american
Psychological association, 2009; 2012;
British Psychological society, 2012a, 2012b).
however, when i was enrolled in dr Brown’s
course at the university of California, santa
Barbara in the autumn of 1996, the ameri-
can Psychological association or British
Psychological society had yet to issue these
ethical edicts.
For one of the assignments in this profes-
sor’s class, i needed to write a research paper
on a topic and population of my choice. my
proposal focused on lGBt adolescent career
development. after i submitted my topic, the
professor pulled me aside, outlined his reli-
gious fundamentalist beliefs about lGBt
individuals, rejected my proposal topic, and
prohibited me from selecting any lGBt
issues for the assignment. What i found most
disquieting was witnessing how some
students’ beliefs were bolstered by the profes-
sor’s declaration of his conservative religious
views about lGBt issues. my concerns gener-
ated questions regarding the role of educa-
tion and training in addressing lGBt mental
health disparities. in response, i created and
psychometrically established the sexual

orientation Counselor Competency scale
(soCCs, Bidell, 2005) for my dissertation
research. drawing on the ternary multicul-
tural counsellor competency model (sue,
arredondo, & mcdavis, 1992), the soCCs is
a self-assessment of counsellors’ lGBt-affir-
mative attitudinal awareness, clinical skills,
and knowledge.
Post-triumviratism: The emergence of
LGBT social science, public policy, and
equality
in over 20 peer-reviewed research papers, the
soCCs has been a basis for not only my
scholarship, but also for other researchers
(Bidell & Whitman, 2013). Based on findings
from these studies, important and often obvi-
ous relationships regarding lGBt compe-
tence have emerged. moreover, lGBt
clinical and counselling competency has
developed into a viable, reliable, and valid
psychological construct based on the resolute
rejection of the historic and biased notions
stigmatising lGBt people as immoral,
mentally disordered, inferior, socially
deviant, or aberrant (american Psychological
association, 1975; 1991; 2009; 2012; British
Psychological society, 2012a; 2012b). instead,
it asserts the fundamental legitimacy and
equality of lGBt people. Based on this foun-

dation, lGBt competent psychologists exam-
ine and advance their: (a) self-awareness of
personal and societal lGBt biases, stereo-
types, and prejudices; (b) understanding and
knowledge of lGBt life stage development,
intersectionality, mental health disparities,
theories, and psychosocial issues; and, (c)
clinical, counselling, and psychotherapeutic
skills grounded in professional ethics and
lGBt psychological standards of care (Bidell
& Whitman, 2013).
While it is beyond the scope of this paper
to review the body of soCCs-based research
(see, Bidell & Whitman, 2013), i’d like to
highlight one key area, namely the relation-
ship between lGBt counsellor competence
and clinicians’ conservative lGBt beliefs.
not surprising, mental health professionals
with more conservative socio-political and
religious beliefs consistently report lower
levels of sexual orientation counsellor
competence (Bidell, 2012, 2014b; mcGe-
orge, Carlson, & toomey, 2013b; o’shaugh-
nessy & spokane, 2013). in one study
(Bidell, 2014b) i examined over 200 mental
health practitioners, supervisors, and
students to explore the impact of clinicians’
religious beliefs. my findings showed;
that significantly lower levels of lGB-affir-
mative counselor competence were
related to more religiously conservative
counselors, even when the effects of
education level, political conservatism,
and lGB interpersonal contact were

controlled…[and] one in three coun-
selors, educators, supervisors, and trainees
in this study demonstrated a significant
connection between their conservative
religious beliefs and sexual orientation
counselor competency. (p.175)
results from my study highlight both the
ongoing nature and scale of the problem. For
practitioners holding beliefs that lGBt indi-
viduals are immoral or sinful, tension exists
between the personal and professional (Whit-
man & Bidell, 2014). While this can be an
ethical dilemma for clinicians, it’s quite worri-
some for lGBt clients seeking mental health
services. lack of sensitive, affirmative, and
competent clinical services has been identi-
fied as a major structural barrier that can
negatively impact lGBt individuals’ health-
care experiences and clinical outcomes
(iom, 2011). in the united kingdom, elliot
and colleagues (2015) found that lGBt indi-
viduals reported significantly lower health-
care provider satisfaction compared to their
heterosexual counterparts. the researchers
concluded that, ‘discrimination may affect
the quality of care that sexual minorities
receive…and some healthcare workers may
be uncomfortable communicating with
sexual minority patients and insensitive to
their needs’ (p.10).
Personal and professional conflicts
regarding ethical lGBt psychotherapy
services are at the centre of legal cases involv-
ing the dismissal of two united states gradu-

ate school counselling students from their
mental health training programs (keeton v.
anderson-Wiley, 2010; Ward v. Wilbanks,
2010; Ward v. Polite, 2012). in the federal
lawsuits, the former students cited their
conservative Christian beliefs and argued
their freedoms of religion and speech were
violated when faculty upheld professional
ethics regarding lGBt-affirmative clinical
standards of care. Both cases not only
connect directly to my personal experiences
and professional work, they also illuminate a
fundamental transformation fuelling recent
advancements in lGBt equality.
in the united states and united king-
dom, conservative politicians, pundits, and
pastors have steadfastly drawn on the moral,
legal, and scientific triumvirate to oppose,
often successfully, lGBt civil and human
rights. as we move into a post-lGBt triumvi-
rate era where lGBt people are no longer
considered immoral, mentally disordered, or
criminal; opponents to lGBt equality can
no longer effectively utilise the tripartite
arguments of past generations. adopting
different tactics, conservative individuals and
organisations are trying to claim they
become victims of lGBt equality, arguing

infringement of their religious freedom
when lGBt-affirmative laws, policies, and
professional standards are adopted. as the
new lGBt paradigm tilts toward equality,
such objections and arguments are becom-
ing untenable and ultimately unjustifiable.
this progression is not confined to lGBt
rights. throughout history, the strictures of
the triumvirate have also been utilised in the
subjugation and dehumanisation of other
oppressed groups. as minoritised groups
have sought civil and human rights, advance-
ment must occur in the social justice
discourse making it impossible to withhold
human rights based on prejudicial and
biased moral, legal, scientific, and social
mores.
the two unsuccessful lawsuits brought by
the school counselling students and the
recent united states supreme Court ruling
(obergefell v. hodges, 2015) legalising
same-sex marriage are examples of the shift-
ing landscape for lGBt equality. in the
majority opinion, united states supreme
Court Justice antony kennedy provides an
eloquent exemplar of this paradigm shift,
writing:
until the mid-20th century, same-sex inti-
macy long had been condemned as
immoral by the state itself in most West-
ern nations, a belief often embodied in
the criminal law. For this reason, among
others, many persons did not deem

homosexuals to have dignity in their own
distinct identity. a truthful declaration by
same-sex couples of what was in their
hearts had to remain unspoken…[and]
the argument that gays and lesbians had
a just claim to dignity was in conflict with
both law and widespread social conven-
tions. same-sex intimacy remained a
crime in many states. Gays and lesbians
were prohibited from most government
employment, barred from military serv-
ice, excluded under immigration laws,
targeted by police, and burdened in their
rights to associate…[and]…for much of
the 20th century, moreover, homosexual-
ity was treated as an illness…the nature
of marriage is that, through its enduring
bond, two persons together can find
other freedoms, such as expression, inti-
macy, and spirituality. this is true for all
persons, whatever their sexual orienta-
tion…there is dignity in the bond
between two men or two women who
seek to marry and in their autonomy to
make such profound choices…as the
state itself makes marriage all the more
precious by the significance it attaches to
it, exclusion from that status has the
effect of teaching that gays and lesbians
are unequal in important respects.
nodding to the past wrongs wrought by the
moral, legal, and scientific triumvirate,
Justice kennedy moves us forward and away
from the viability of denying lGBt individu-
als the dignity of human rights and equality

based on out-dated prejudicial justifications.
this ruling, along with similar historic legis-
lation in the united kingdom (marriage act,
2013) and ireland (thirty-fourth amend-
ment of the Constitution Bill, 2015), under-
scores the profound change occurring today.
Conservative religious beliefs or morally
based reasoning can no longer substantiate
lGBt inequality. a paradigm shift of this
magnitude has the power to change hearts,
minds, and deeds. in the case of marriage
equality, acts of lGBt transgression are
rightly transformed into acts of love.
Primum non nocere: First, do no harm
it’s important to acknowledge that many
deeply religious applied psychologists do not
harbour beliefs that lGBt individuals are
sinful or immoral nor do they have any
conflicts between their faith and the provision
of competent lGBt psychological services.
however, emerging research indicates discor-
dance between personal beliefs and lGBt-
affirmative counselling is not as uncommon
as we might hope (Bidell, 2012, 2014b; mcGe-
orge et al., 2013b; o’shaughnessy & spokane,
2013). Whilst we are now crossing a major
societal and professional threshold in the
advancement of lGBt equality, lGBt biases

and prejudices are still reaching into today’s
counselling sessions and psychological consul-
tation rooms. the stakes for lGBt clients are
high and even potentially catastrophic.
recent research examining lGBt health
disparities exposes how vulnerable lGBt
people can be to minority stress and resultant
mental health problems, with suicide being
the most tragic consequence (Chakraborty et
al., 2011; elliott et al., 2015; haas et al., 2010;
iom, 2011; king et al., 2003; king et al., 2008;
Warner et al., 2004).
i have contemplated my possible
response if either of the aforementioned
counselling students were enrolled in one of
my classes. When first learning of these
cases, i was torn about the decision to
dismiss them. after all, expulsion is the ulti-
mate action educators can take against any
student. and i believe ardently in the sanc-
tity of religious and speech freedoms.
however, the paradigm shift fuelling historic
advancements in lGBt rights is advancing
my own certainty that freedom of religion
and speech does not mean freedom to
discriminate. more importantly, no legal or
professional protections exist for applied
psychologists that justify the abdication of
our principle duty: first, do no harm. as
such, freedom of speech and religion can
never justify rejecting our ethical duty
regarding lGBt clinical and professional
competence.

We remain at a professional crossroads
where paradigm shifts and removal of
students from programs will not eliminate
dilemmas that happen when conservative
personal beliefs conflict with our profes-
sional lGBt ethical standards. While we
cannot, and should not, dictate the personal
beliefs applied psychologists hold about
lGBt issues and individuals; applied
psychologists must search for ways to redress
our past lGBt wrongs by addressing current
lGBt mental health and psychosocial
disparities. multicultural training is a power-
ful tool in our professional arsenal, yet its
potential has not been fully realised for
lGBt clinical competence. the majority of
clinicians and trainees report that their
professional training has not prepared them
to work competently and ethically with
lGBt issues and my Fulbright data under-
scores this fact for practitioners and students
in the united kingdom (Bidell et al., 2015;
Bidell & Whitman, 2011).
We mustn’t let professional gains and
societal progress regarding lGBt equality
obfuscate lGBt psychosocial and mental
health problems that stubbornly remain, nor
our professional responsibility to do no harm.
important work remains for applied psychol-
ogists regarding competent and ethical lGBt
psychological services – the health and well-
being of our lGBt clients depend on it.
Markus P. Bidell,
department of educational Foundations &

Counseling Programs, hunter College of the
City university of new York.
the author thanks Charles donovan for
editorial support. Correspondence concern-
ing this article should be addressed to markus
Bidell, department of educational Founda-
tions & Counseling Programs, hunter
College of the City university of new York,
new York, nY 10065.
email: [email protected]
Title
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Markus P. Bidell
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