The Pennsylvania Psychologist
June 2012
One challenge of working with lesbian clients lies in never assuming all concerns relate to sexual identity issues, while also acknowledging the potential impact of sexual identity. Also important is understanding the intersection of our clients’ sexual orientation with other socio-cultural identities, including age, citizenship status, ability, ethnicity, gender, race, religion, and socioeconomic status. A client’s socio-cultural identities are at times independent, interdependent, and multiplicative, and are best understood individual by individual (Stanley, 2004).
A difference exists between a lesbian’s self-identification and behavior. For example a female client married to a man may not be heterosexual. A recent study found that 67% of “exclusively straight” women had questioned or were questioning their sexual orientation (Morgan & Thompson, 2011). Conversely, a client who identifies as lesbian may never have had a same-sex experience. Fifty percent of self-identified lesbian adolescents had not had same-sex contacts (Savin-Williams, 2005). It is therefore better to ask a client, “With what gender or genders are you sexually active, if you are so?” as well as how they identify themselves, rather than to focus solely on labels. For some women, sexual behavior or attraction is not the basis for their identification as lesbian. In this context, Klein, Sepekoff and Wolf (1990) were instrumental in helping psychologists broaden their understanding of sexual identity to include other factors, such as attraction, emotional connection, and community affiliation.
Coming out to oneself about one’s sexual identity can happen at any age. Sexual orientation may be static over a lifetime or more fluid (Diamond, 2008). I recently met with a 71-year-old client who described experiencing sexual attraction toward women for the first time. Assuming that sexual identity is static may lead mental health professionals to miss subtle comments by clients who may be reaching out for support regarding their orientation.
As they consider coming out for the first time, clients benefit from thorough exploration of the “why” and “how” of their communication. It is useful for clients to choose carefully whom to tell first, in order to identify those with whom they are likely to have a positive experience. Reviewing how particular people have handled potentially disconcerting information in the past may prepare the client.
Coming out is an ongoing, lifelong process. While clients may focus on the major coming-out events, such as telling parents, spouses, friends, and work colleagues about their sexual identity, the decision of whether to come out and the possible consequences may arise daily. Checking into a hotel as a same-sex couple and assuring the clerk that indeed you would like one queen-sized bed rather than two double beds, or receiving an invitation for one to a cousin’s wedding, even though you have been with your spouse for fifteen years, can take a toll on even the most “out” and empowered individuals. A high school reunion full of questions about relationship status may lead an otherwise “out” lesbian to retreat back into the closet for the night. It is especially important for mental health professionals to be able to normalize for clients the process of “recycling” through the coming-out process based upon life circumstances and to give them a place to discuss their present contexts without pathologizing their needs and decisions.
Facing subtle and more overt forms of discrimination leads lesbian, gay, bisexual, and transgender (LGBT) individuals to seek mental health support services on a higher average than their heterosexual counterparts (Israel, Grocheva, Burnes, & Walther, 2008). Lesbian clients are not more emotionally “flawed” than their heterosexual counterparts; rather the chronic, overt discrimination and prejudice they experience can lead to higher rates of depression, anxiety, and substance abuse. The importance of screening for depression, anxiety, addictions, self-harming behaviors, and suicidality is therefore essential in our initial and continued work with lesbian clients.
Support from family of origin and/or family of choice (i.e., friends and mentors) plays a crucial role for many lesbians. Therefore, it may be useful to connect lesbian clients to affinity groups related to their interests and their work, whether through local or national venues. LGBT psychologists may find support and recognition through membership in APA’s Division 44. Clients in non-urban areas may benefit from online support groups and other social networking sites. Support for lesbians is often found in their friendships, which may differ in important ways from heterosexual friendships. It is not uncommon for lesbians to work to maintain friendships with their ex-partners (Weinstock & Rothblum, 2004; Stanley, 1996).
Psychologists who see lesbian couples need to consider some of the unique aspects of working with them. If one member of the couple is out to family and friends but the other partner is not because of fear of losing her job or being rejected by her parents or siblings, the disparity may strongly impact their relationship. Domestic violence in lesbian couples may also manifest in unique ways: An angry member of the relationship might threaten to “out” the closeted partner, thereby using the knowledge of her sexual identity to exert control. Working with lesbians who are married to men may involve conflicted feelings about coming out to their husbands and/or children. Their own mixed feelings such as excitement, shame, joy, and fear may interact with the reactions of friends, parents, and neighbors. Support groups are often useful for married or recently divorced lesbians to gain affirmation in their lives.
Unique issues for lesbians considering children range from legal issues (some states do not allow same-sex couple adoptions), to refusals by hospitals to recognize the non-pregnant female partner, to deciding which partner will be the biological mother. Today’s psychologist needs to have at least a basic understanding of fertility, adoption, and donor options for lesbian clients. Lesbian parents may also experience homophobia from teachers, school districts, Boy Scout troops, and others. Psychologists must be aware of local, state, and national laws regarding the protection of LGBT clients in order to best meet their needs. For up-to-date resources for such information in Pennsylvania, see http://www.hrc.org/laws-and-legislation/state/c/pennsylvania.
Lesbian psychologists are also affected by the interconnected nature of the lesbian community (Kessler & Waehler 2005; Brown, 1988). It is not unusual for lesbians to recommend their own mental health provider to friends and colleagues or for a lesbian psychologist to become well known in the community. Given the limited number of lesbian gatherings, a lesbian psychologist may run into clients socially. Consequently, early in therapy a discussion of professional boundaries may be particularly useful.
Finally, all psychologists benefit from ongoing self-introspection and awareness in regard to their own internalized homophobia. None of us, regardless of orientation, are immune from it. Riddle’s (1990) scale, which ranges from repulsion to nurturance, is a useful measure to assess one’s level of personal comfort regarding sexual orientation. We are ethically bound to recognize our limitations and to refer lesbian clients or consult if our biases or ignorance of a culture may be barriers to treatment. PPA’s Multicultural Resource Guide as well as other online resources may assist you in finding LGBT-affirmative therapists in your area for your client and continuing education trainings for yourself. Since we never know whether we may be working with lesbian clients, we must ensure we are providing a supportive and affirming environment for clients of all sexual orientations.
References are available from the author at jstanley@gradschoolcoaching.com or on the PPA website, www.PaPsy.org.
