Patients need doctors who look like them. Can medicine diversify without affirmative action?

Kat Stafford

apnews.com

Originally posted 11 September 23

Here are two excerpts:

But more than two months after the Supreme Court struck down affirmative action in college admissions, concerns have arisen that a path into medicine may become much harder for students of color. Heightening the alarm: the medical field’s reckoning with longstanding health inequities.

Black Americans represent 13% of the U.S. population, yet just 6% of U.S. physicians are Black. Increasing representation among doctors is one solution experts believe could help disrupt health inequities.

The disparities stretch from birth to death, often beginning before Black babies take their first breath, a recent Associated Press series showed. Over and over, patients said their concerns were brushed aside or ignored, in part because of unchecked bias and racism within the medical system and a lack of representative care.

A UCLA study found the percentage of Black doctors had increased just 4% from 1900 to 2018.

But the affirmative action ruling dealt a “serious blow” to the medical field’s goals of improving that figure, the American Medical Association said, by prohibiting medical schools from considering race among many factors in admissions. The ruling, the AMA said, “will reverse gains made in the battle against health inequities.”

The consequences could affect Black health for generations to come, said Dr. Uché Blackstock, a New York emergency room physician and author of “LEGACY: A Black Physician Reckons with Racism in Medicine.”

(cut)

“As medical professionals, any time we see disparities in care or outcomes of any kind, we have to look at the systems in which we are delivering care and we have to look at ways that we are falling short,” Wysong said.

Without affirmative action as a tool, career programs focused on engaging people of color could grow in importance.

For instance, the Pathways initiative engages students from Black, Latino and Indigenous communities from high school through medical school.

The program starts with building interest in dermatology as a career and continues to scholarships, workshops and mentorship programs. The goal: Increase the number of underrepresented dermatology residents from about 100 in 2022 to 250 by 2027, and grow the share of dermatology faculty who are members of color by 2%.

Tolliver credits her success in becoming a dermatologist in part to a scholarship she received through Ohio State University’s Young Scholars Program, which helps talented, first-generation Ohio students with financial need. The scholarship helped pave the way for medical school, but her involvement in the Pathways residency program also was central.

The info is here.

More than a quarter of U.S. adults say they’re so stressed they can’t function

American Psychological Association

Press Release

Originally posted 19 OCT 22

Americans are struggling with multiple external stressors that are out of their personal control, with 27% reporting that most days they are so stressed they cannot function, according to a poll conducted for the American Psychological Association.

A majority of adults cited inflation (83%), violence and crime (75%), the current political climate (66%), and the racial climate (62%) as significant sources of stress.

The nationwide survey, fielded by The Harris Poll on behalf of APA, revealed that 70% of adults reported they do not think people in the government care about them, and 64% said they felt their rights are under attack. Further, nearly half of adults (45%) said they do not feel protected by the laws in the United States. More than a third (38%) said the state of the nation has made them consider moving to a different country.

More than three-quarters of adults (76%) said that the future of our nation is a significant source of stress in their lives, while 68% said this is the lowest point in our nation’s history that they can remember.

Various disparities in stressors emerged among population subgroups. For example, 72% of the members of the LGBTQIA+ community reported feeling as if their rights are under attack, which is a higher proportion than non-LGBTQIA+ adults (64%). Younger adult women (ages 18 to 34) were more likely to report that most days their stress is completely overwhelming, in comparison with older women (62% vs. 48% 35–44; 27% 45–64; 9% 65+) and men ages 35 or older (62% vs. 48% 35–44; 21% 45–64; 8% 65+). Seventy-five percent of Black adults said that the racial climate in the U.S. is a significant source of stress, while 70% of Latino/a adults, 69% of Asian adults and 56% of white adults reported the same.

Furthermore, Latinas were most likely, among racial/ethnic groups, to cite significant sources of stress related to violence, including violence and crime (89% Latinas; 80% Black women; 79% Asian women; 77% Latinos; 75% Black men; 73% white women; 72% white men; 70% Asian men), mass shootings (89% Latinas; 78% Latinos; 77% Black women; 77% Asian women; 73% white women; 71% Black men; 67% Asian men; 66% white men) and gun violence (87% Latinas; 83% Black women; 77% Asian women; 76% Latinos; 75% Black men; 69% white women; 68% white men; 63% Asian men).

“It’s clear that the impacts of uncontrollable stressors are profound for most Americans, but psychological science shows us that there are effective ways to talk about and cope with this type of stress,” said Arthur C. Evans Jr., PhD, APA’s chief executive officer. “Focusing on accomplishing goals that are in our control can help prevent our minds from getting overwhelmed by the many uncertainties in life. From using our breathing to slow racing thoughts, to intentionally limiting our social media consumption, or exercising our right to vote, action can be extremely empowering.”

Adults reported that stress has had an impact on their health; 76% of adults reported they had experienced at least one symptom in the last month as a result of stress—such as headache (38%), fatigue (35%), feeling nervous or anxious (34%) and feeling depressed or sad (33%). Seven in 10 adults (72%) experienced additional symptoms in the last month, including feeling overwhelmed (33%), experiencing changes in sleeping habits (32%), and/or worrying constantly (30%).

The pressor is here.

I See Color

Khama Ennis

On The Flip Side

Original date: February 13, 2020

9 minutes worth watching: Patient biases versus professional obligations

Letting tech firms frame the AI ethics debate is a mistake

Robert Hart
www.fastcompany.com
Originally posted November 2, 2018

Here is an excerpt:

Even many ethics-focused panel discussions–or manel discussions, as some call them–are pale, male, and stale. That is to say, they are made up predominantly of old, white, straight, and wealthy men. Yet these discussions are meant to be guiding lights for AI technologies that affect everyone.

A historical illustration is useful here. Consider polio, a disease that was declared global public health enemy number one after the successful eradication of smallpox decades ago. The “global” part is important. Although the movement to eradicate polio was launched by the World Health Assembly, the decision-making body of the United Nations’ World Health Organization, the eradication campaign was spearheaded primarily by groups in the U.S. and similarly wealthy countries. Promulgated with intense international pressure, the campaign distorted local health priorities in many parts of the developing world.

It’s not that the developing countries wanted their citizens to contract polio. Of course, they didn’t. It’s just that they would have rather spent the significant sums of money on more pressing local problems. In essence, one wealthy country imposed their own moral judgement on the rest of the world, with little forethought about the potential unintended consequences. The voices of a few in the West grew to dominate and overpower those elsewhere–a kind of ethical colonialism, if you will.

The info is here.

Philosophy of Multicultures

Owen Flanagan
Philosophers Magazine
Originally published August 19, 2018

Here is an excerpt:

First, as I have been insisting, we live increasingly in multicultural, multiethnic, cosmopolitan worlds. Depending on one’s perspective these worlds are grand experiments in tolerant living, worlds in which prejudices break down; or they are fractured, wary, tense ethnic and religious cohousing projects; or they are melting pots where differences are thinned out and homogenised over time; or they are admixtures or collages of the best values, norms, and practices, the sociomoral equivalent of fine fusion cuisine or excellent world music that creates flavours or sounds from multiple fine sources; or on the other side, a blend of the worst of incommensurable value systems and practices, clunky and degenerate. It is good for ethicists to know more about people who are not from the North Atlantic (or its outposts). Or even if they are from the North Atlantic are not from elites or are not from “around here”. It matters how members of original displaced communities or people who were brought here or came here as chattel slaves or indentured workers or political refugees or for economic opportunity, have thought about virtues, values, moral psychology, normative ethics, and good human lives.

Second, most work in empirical moral psychology has been done on WEIRD people (Western Educated Industrialised Rich Democratic) and there is every reason to think WEIRD people are unrepresentative, possibly the most unrepresentative group imaginable, less representative than our ancestors when the ice melted at the end of the Pleistocene. It may be the assumptions we make about the nature of persons and the human good in the footnotes to Plato lineage and which seem secure are in fact parochial and worth re-examining.

Third, the methods of genetics, empirical psychology, evolutionary psychology, and neuroscience get lots of attention recently in moral psychology, as if they can ground an entirely secular and neutral form of common life. But it would be a mistake to think that these sciences are superior to the wisdom of the ages in gaining deep knowledge about human nature and the human good or that they are robust enough to provide a picture of a good life.

The info is here.

Leadership and Counseling Psychology: Dilemmas, Ambiguities, and Possibilities

Sandra Shullman
The Counseling Psychologist
First published November 28, 2017

Abstract

In this article, I introduce the scientist–practitioner–advocate–leader model as a strategy for addressing the rapidly changing context for psychologists and psychology. The concept of counseling psychologists as learning leaders is derived from the foundations and values of the profession. Incorporating leadership as a core identity for counseling psychologists may create new directions for science and practice as we increasingly integrate multicultural identities, training, and diverse personal backgrounds into social justice initiatives. The article presents six dilemmas faced by counseling psychologists in assuming leadership as part of professional identity, as well as eight learning leader behaviors that counseling psychologists could integrate in their management of ambiguity and uncertainty across various levels of human organization. The article concludes with a discussion of future possibilities that may arise by adopting leadership as part of the role and core identity of counseling psychology.

The article is here.

Bioethics and multiculturalism: nuancing the discussion

Chris Durante
Journal of Medical Ethics 
Published Online First: 11 August 2017

Abstract

In his recent analysis of multiculturalism, Tom Beauchamp has argued that those who implement multicultural reasoning in their arguments against common morality theories, such as his own, have failed to understand that multiculturalism is neither a form of moral pluralism nor ethical relativism but is rather a universalistic moral theory in its own right. Beauchamp’s position is indeed on the right track in that multiculturalists do not consider themselves ethical relativists. Yet, Beauchamp tends to miss the mark when he argues that multiculturalism is in effect a school of thought that endorses a form of moral universalism that is akin to his own vision of a common morality. As a supporter of multiculturalism, I would like to discuss some aspects of Beauchamp’s comments on multiculturalism and clarify what a multicultural account of public bioethics might look like. Ultimately, multiculturalism is purported as a means of managing diversity in the public arena and should not be thought of as endorsing either a version of moral relativism or a universal morality. By simultaneously refraining from the promotion of a comprehensive common moral system while it attempts to avoid a collapse into relativism, multiculturalism can serve as the ethico-political framework in which diverse moralities can be managed and in which opportunities for ethical dialogue, debate and deliberation on the prospects of common bioethical norms are made possible.

The article is here.

Culture: The Grand Web of Meaning

Chao, Melody Manchi and Kesebir, Pelin,
Found in The Experience of Meaning in Life: Perspective from the Psychological Sciences
(September 16, 2011).  J. Hicks, C. Routledge, eds., Springer Press, 2011.

Abstract:    

Meaning and culture mutually constitute each other. Culture rests on meaning, whereas meaning exists and is propagated in culture. The uniquely human quest for meaning transpires against the background of culture and is simultaneously recreating culture. The current chapter aims to explore different aspects of this dynamic relationship between meaning and culture. We begin by defining meaning and culture, and elaborating the nature of their intricate relationship. Then, we analyze the universal and relative aspects of meaning systems across cultures. Finally, we examine meaning in the backdrop of multiculturalism to illuminate how individuals navigate through different cultural webs of meaning and its implications to cultural competence.

The book chapter is here.

We need morality to beat this hurricane of anger

Jonathan Sacks

The Telegraph

Originally published July 1, 2016

Here is an excerpt:

Morality has been outsourced to the market. The market gives us choices, and morality has been reduced to a set of choices in which right or wrong have no meaning beyond the satisfaction or frustration of desire. We find it increasingly hard to understand why there might be things we want to do and can afford to do, that we should not do because they are dishonourable or disloyal or demeaning: in a word, unethical. Too many people in positions of public trust have come to the conclusion that if you can get away with it, you would be a fool not to do it. That is how elites betray the public they were supposed to serve. When that happens, trust collapses and a civilization begins to decay and die.

Meanwhile the liberal democratic state abolished national identity in favour of multiculturalism. The effect was to turn society from a home into a hotel. In a hotel you pay the price, get a room, and are free to do what you like so long as you do not disturb the other guests. But a hotel is not a home. It doesn’t generate identity, loyalty or a sense of belonging. Multiculturalism was supposed to make Europe more tolerant. Its effect has been precisely the opposite, leading to segregation, not integration.

The article is here.

Therapeutic Harm and Cultural Oppression

By Derald Wing Sue
The Counseling Psychologist 
January 6, 2015 0011000014565713

Abstract

The divergent discourses between scholars from the potentially harmful treatment and multicultural psychology camps are accurately observed by Wendt, Gone, and Nagata. I argue that the differences in perspectives between the two groups are more about a clash of therapeutic worldviews, that they are often antagonistic to one another, that conversations have been a one-way process (with one side “not wanting to hear”), and that sociopolitical forces play a significant role in preventing a true dialogue from occurring. I conclude that the ultimate harm to groups of color is cultural oppression.

The entire article is here.

Who Should Decide What's in a Child's Best Interest?

By Robert MacDougall
Impact Ethics
Originally posted December 8, 2014

Here is an excerpt:

One might argue that state intervention would not constitute an imposition of Western values on First Nations families and children. Instead, one might claim that state intervention merely prevents First Nations Canadians from imposing their values on their children, who are not yet old enough to decide for themselves whether to follow the Western medical paradigm or the traditional aboriginal one. But this assumes that the default position of the state should be to treat children in accordance with the Western paradigm until the child is old enough to decide for him or herself. Rather than assume the Western paradigm when making treatment decisions for First Nations children, it makes more sense to treat them according to the values of their own parents.

The entire article is here.

Collaborating across cultures

Working with scientists from the Arab world improved my worldview, my career and my life. I urge you to collaborate with researchers from other cultures, too.

By Thomas Eissenberg, PhD
Monitor on Psychology
December 2014, Vol 45, No. 11
Print version: page 60

Working with scientists from the Arab world improved my worldview, my career and my life. I urge you to collaborate with researchers from other cultures, too.

One reason to collaborate across cultures is that many global problems — environmental degradation, disease, conflict and inequity — cannot be addressed comprehensively without global partnerships.
Yet crafting empirically based solutions with colleagues around the world involves ethical issues that extend beyond those typically considered by an Institutional Review Board (IRB). That is, rewarding and successful cross-cultural collaboration demands that partners re-dedicate themselves to basic ethical principles that involve interactions with research participants and also interactions among researchers themselves.

The entire article is here.

Multiculturalism & Comedy: If Asians Said the Stuff White People Say

"I Wish I Were Black" and Other Tales of Privilege

By Angela Onwuachi-Willig
The Chronicle of Higher Education
Originally published October 28, 2013

To be white is to not think about it," a white legal scholar named Barbara Flagg wrote two decades ago.

After the University of Texas at Austin denied Abigail Fisher admission, she made several statements that revealed just how little she had ever had to think about her race. Fisher, the petitioner in the Supreme Court's recently decided affirmative-action case, said in a videotaped interview made available by her lawyers: "There were people in my class with lower grades who weren't in all the activities I was in, who were being accepted into UT, and the only other difference between us was the color of our skin."

As decades of debates over affirmative action have revealed, many whites spend so little time having to think about, much less deal with, race and racism, that they understand race as nothing more than a plus factor in the admissions process. Like Fisher, they fail to see the many disadvantages that stem from simply existing as a person of color in this country—disadvantages that often hamper opportunities to achieve the badges that help students "win" in the admissions game.

The entire article is here.

Judging Moral Issues in a Multicultural Society: Moral Reasoning and Social Dominance Orientation

By Stefano Passini & Paola Villano
Swiss Journal of Psychology

Abstract

People’s reactions to crimes sometimes change depending on whether the perpetrators are members of their own ingroup or an outgroup. This observation results in questions concerning how moral reasoning works in intergroup situations. In this research, we analyzed the combined effect of the nationality of the protagonist in a moral dilemma and the participant’s social dominance orientation (SDO) attitudes on the participant’s level of moral reasoning. A total of 230 Italian participants responded to two moral dilemmas taken from the Defining Issues Test, which had been modified so that one was about an Italian and the other about a Romanian. The results showed a significant interaction between the dilemma, the protagonist’s nationality, and the participant’s SDO: The P scores (postconventional reasoning) of low-SDO participants were on the same level when they were judging people of either nationality, while high-SDO participants tended to have a higher P score when judging Italians as opposed to Romanians.

Introduction

Although multiculturalism is on the rise in public opinion and politics, people sometimes judge criminal and deviant actions differently depending on the group membership of the person involved. For instance, the Italian media regularly report people being run over and even killed by drunk drivers. People's reactions to such events, however, differ depending on whether the perpetrators are members of their own ingroup or members of an outgroup. Moreover, when the aggressors are immigrants, the media do not consider these events to be related to the problems of road safety and alcohol alone. They often also relate these events to issues of immigration and national security, and they tend to judge the event more harshly than when the aggressors are ingroup members (see van Dijk, 2000). This shift of attention from the event itself to the person involved - in terms of his/her nationality - poses new questions concerning how moral reasoning works in intergroup situations.

The entire article can be found here, hiding behind a paywall.

Comedy & Multiculturalism: What Kind of Asian are You?

Racial And Ethnic Diversity Goes Local

By Barrett A. Lee, John Iceland, and Gregory Sharp

September 2012

During the last three decades, the United States has become more racially and ethnically diverse. We examine this trend at the local level, where the consequences of increased diversity for the economy, education, and politics regularly prompt debate, if not rancor. Decennial census and ACS data spanning the 1980-2010 period allow us to determine (a) the pervasiveness of diversity across America, focusing on metropolitan, micropolitan, and rural areas and places, and (b) the community characteristics that correlate with diversity.

We nd that almost all communities—whether large immigrant gateways or small towns in the nation’s heartland—have grown more diverse. However, the data show a wide range of diversity proles, from predominantly white communities (a shrinking number) to minority-majority and no-majority ones (an increasing number). The pace of local diversity gains, as well as shifts in racial-ethnic composition, has similarly varied.

While surging Hispanic and Asian populations often drive these patterns, other groups, including African immigrants, Native Americans, and multi-racial individuals, contribute to the distinctive mixes evident from one community to the next.

As for the correlates of diversity, communities with large populations, abundant rental housing, and a range of jobs are more diverse. So are those where the government and/or the military is a key employer. Locationally,diversity tends to be higher in coastal regions and along the southern border. 

In short, a growing number of Americans now live in communities where multiple groups—Hispanics, blacks, and Asians as well as whites—are present in signicant proportions.

The entire report is here.

A Chance to Walk the Talk at the Ethics Educators Conference

By Jeff Sternlieb, PhD
The Pennsylvania Psychologist
June 2012

During the 2011 annual PPA Ethics Educators Conference, an exchange occurred that could, met with the right attitude, guide our organization in creating safe learning spaces. Here’s what happened:

The exchange

The chair of the Ethics Committee began by identifying the content of the program for the day and then introduced the “luminaries” present: past presidents of PPA and significant contributors to ethics education. He ended with a specific request to be respectful of each other in our exchange of ideas and then introduced the morning’s presenters.

When the first pair of presenters described their roles, the second made a comment about being a longtime sidekick – Robin to the first one’s Batman. Immediately, someone in the audience remarked, “Oh, I guess that means you’re gay,” chuckling as though it were a joke. A ripple of laughter from the audience quickly subsided as the presenters moved on without any comment about the “joke,” even though it occurred minutes after the Ethics chair requested sensitivity.

My thoughts

Immediately I struggled. I wondered whether anyone would respond to the remark. I believed we were all, through our silence, colluding with the “joke” and placing in an unfair position anyone who was gay or simply cognizant of the impact of such comments on any minority member.

I shared my concern with a colleague next to me, who did not seem to consider it nearly as significant. I was considering what I should do, but doing or saying nothing was not an option. Two choices occurred to me: say something to the entire group, potentially embarrassing the person who made the remark, or say something to him at the break. The former had the potential to interfere with the ethics program; the latter might determine the speaker’s awareness of the remark’s impact and intent to address it in the larger group. I chose the latter.

The conversation

When I asked the quipster whether he was aware of the possible impact of his comment, he indicated that not only was he aware, but that he had already addressed it during a small-group discussion. He said he regretted it the minute it came out of his mouth, and that he worked with a number of gay clients in a setting in which his comment would have been heard differently. It struck me as a justification rather than an understanding of its potentially negative impact in the current context. He said he appreciated that I brought the concern to him but made no offer to discuss it with the larger group. He had not heard the term “microaggression” when I used it. Included in his small discussion group had been the Ethics chair, who approached while we were talking and asked whether I would be willing to share my experience with the larger group. I agreed.

The organic process

After the morning break, one psychologist, new to the Ethics Educators Conference, questioned how the earlier comment had impacted the learning, sharing environment. This opened the opportunity to share these issues in a natural way, and the Ethics chair publicly invited me to share what we discussed during break. This person’s independent concern supported my belief that such comments have an impact. Save for those who speak out, we cannot know how many others have been affected.

I shared my reaction, thought process, and conversation. I then invited the quipster to share his perspective, and he did, explaining that he worked with a largely gay clientele, apologizing to anyone he might have offended, and repeating that he had regretted his remark immediately after making it.

Audience reactions

Some participants thanked the new attendee for her courage in raising this issue, while others commended the quipster for his apology. One asked what the fuss was about, saying she did not recall hearing any offensive remarks. One person rejected the idea that he was collusive, having heard the remark less negatively. Another asked how this had become Jeff Sternlieb’s issue. Others expressed discomfort at censoring comments that might be seen as offensive to any one person, resisting “political correctness.” One participant noted a significant bias toward calling on male participants to the exclusion of women.

Analysis

All comments struck me as introductory and reactive. No one sought clarification. We did not converse. While no time was scheduled to explore these issues, I was surprised at the lack of informal discussion during lunch or break. These issues seemed too hot to handle and we seemed too uncomfortable to talk about them. Though the exchange introduced the opportunity to learn, our inability to talk effectively stopped us from naming our experience and the concepts involved, including:

·         Privilege. Those of us with privilege – especially we who are white, male, heterosexual, and relatively financially secure ­– tend to minimize the perspectives of those who are marginalized. While none of us want an environment in which we cannot talk about race, sexual orientation, or gender because we are afraid of offending others, we seem to do the opposite: fail to take others seriously when insensitivity is identified. Just because clients or friends are gay does not give us the freedom to make jokes about being gay, particularly among those we may not know well. When any group is singled out, it impacts all groups who have been marginalized.

·         Collusion can be active or passive. Active collusion involves direct participation in the offense, and might involve adding to an initial insult or joke, thus amplifying the impact. This “joining in” sanctions the remark, making it easier for others to “pile on” with similar comments and more difficult for anyone to object. Passive collusion consists of saying or doing nothing, thereby lending tacit support to an unacceptable statement. To object may be seen as a personal affront, discomfiting, or unnecessarily confrontational.

·         Microaggressions are comments that may seem innocent, harmless, or even complimentary but contain demeaning implications or hidden messages. They “...are the brief and everyday slights, insults, indignities and denigrating messages” sent to minorities in subtle, unintended discrimination (Sue, 2010). Sue describes three types: micro-assaults, micro-insults, and micro-invalidations. A useful website, http://microaggressions.com, lists many examples of such comments.

·         Political correctness. The primary reason we should not joke about people’s race, gender, or sexual orientation is that these characteristics are personal. In the context of a professional exploration of issues, a reference might not be microaggressive, but a joke about a minority made as an aside is a personal affront, and to not recognize it as such IS to collude.

·         Misapplication of Golden Rule. The Golden Rule, “Do unto others as you would have others do unto you,” does not address individual and group preferences; we cannot assume that because a remark might not offend us that it won’t offend others. An alternate rule, the “Platinum Rule,” can be helpful: “Treat others as they want to be treated,” which would require asking rather than assuming.

The fact that one seemingly simple comment raises so many questions, issues, and reactions suggests we in PPA have a lot more to learn. Having a Committee on Multiculturalism and a host of resources (including a CE program) is not a guarantee of progress. Having this experience in vivo can teach more than any didactic exercise.

The comment one person made could have been made by any of us. The real challenge, in my view, is how we respond.

Reference

Sue, D. W. (2010). Microaggressions in everyday life:  Race, gender and sexual orientation. New York, NY: John Wiley and Sons.

Clinical Considerations When Working With Lesbian Clients

By Jeanne L. Stanley, PhD
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.

The Application of Virtue Ethics to the Practice of Counseling Psychology

Virtue Ethics in Counseling Psych

This dissertation can be found in the public domain here.