Evidence has consistently shown that lesbian, gay, bi+, trans+, and queer (LGBTQ) people generally experience greater mental health disparities and tend to utilize mental health services at higher rates than cisgendered heterosexual people do (Freeman-Coppadge & Langroudi, 2021).
These higher rates of utilization are due to the accumulated, multilayered effects of minority stress and not because of innate dysfunction or pathology (Freeman-Coppadge & Langroudi, 2021). However, traditional therapeutic modalities have not been designed with LGBTQ people in mind. The field especially lacks modalities that utilize an intersectional lens to apply to sexual and gender minorities (SGMs) with multiple marginalized identities at individual, interpersonal, and institutional levels (Freeman-Coppadge & Langroudi, 2021).
In particular, when it comes to supporting LGBTQ clients with coming out, clinicians need to be aware of additional factors that can specifically affect their SGM clients. This level of understanding not only fosters an effective therapeutic environment, but it also can help keep their clients safe as they navigate this process.
The Challenge
While LGBTQ-affirmative therapeutic practices have been increasing, there are additional clinical considerations to be made when working with clients possessing multiple marginalized identities. First, the overwhelming literature on queer psychology has focused on data and narratives for and about Western, White, cisgender, LGBT, middle- to upper-middle-class, highly educated, able-bodied individuals. Religion and spirituality studies of LGBTQ populations largely center on Christian sects, with much less attention to Judaism, even less to Islam, and still less to other spiritualities (Buddhism, Sikhism, earth- spirited faiths, etc.) (Freeman-Coppadge & Langroudi, 2021).
Little is empirically known about LGBTQ people with other marginalized intersectional identities such as race, ethnicity, class, ability, religion/spirituality, nationality, and culture. This often leaves these individuals with the heavy burden of educating the very therapists they’ve enlisted to help them address their problems.
In the process of educating their therapists, SGMs with multiple marginalized identities often endure microaggressions from them, which has the potential to disrupt rapport, lead to early termination, and worsen therapy outcomes. All of these consequences can foment further distrust of mental health and medical fields within marginalized communities.
Considerations for Practice
Therapists should endeavor to learn the complex history of gender constructs and their functional nuances within the LGBTQ community, all of which have implications for identity, self-empowerment, connection, and safety. Clinicians must understand how multiple-marginalized identities affect their clients, starting with acknowledging that LGBTQ clinical competence is not synonymous with intersectional LGBTQ clinical competence. Common “best practices” in the culturally competent care of LGBTQ individuals may prove ineffectual, or even harmful, to LGBTQ people with multiple marginalized identities.
For example, encouraging clients to embrace their gay identity and come out is culturally, and often therapeutically, considered the sine qua non process for healthy development and well-being. However, coming out in various cultural contexts (at family and community levels) can be psychologically, emotionally, and/or physically dangerous to some clients with multiple oppressions. Healthy internal integration and external compartmentalization strategies may be preferred ways of assisting such clients in their identity development.
For QBIPOC, connection to family, local community, and religion/spirituality may be more salient than for White SGMs. Therefore, coming out may risk important aspects of self-identification and connection to their ethnic, family, and religious roots, which can be destabilizing.
QBIPOC may be less likely than their White counterparts to come out to their parents; for example, Filipino American queer people tend to struggle with religious (Catholicism) and cultural barriers to coming out, as well as with bringing shame to their families in the process. At the same time, cultural values like collectivism and closeness of family (e.g., familismo within Latin@ culture) can provide strengths for helping families of QBIPOC to accept their SGM loved ones. (Freeman-Coppadge & Langroudi, 2021).
Clinicians therefore should be careful to factor in these important cultural considerations when working with QBIPOC and not assume that disclosure to loved ones is necessarily beneficial. They should also be careful not to assume that coming out to a racial/ethnic minority family will be disastrous, as many such communities exhibit fewer long-term rejections of their QBIPOC family members than do White families.
There is a difference between nondisclosure of SGM identity in particular environments, which is not thought to impact mental health, and the shame-based concealment of identity that does negatively affect well-being. Emerging evidence suggests that resilience is just as important as coming out and garnering social support. QBIPOC people may be able to mitigate psychosocial distress through developing a greater sense of agency and adaptive ways of coping with stressors rather than coming out to family.
A therapist with a solid case conceptualization will be able to explore, understand, and shape a treatment plan that includes all the aspects of the client’s life. Various aspects of intersectionality may be highlighted or may emerge in treatment based on different environments or contexts.
Further, a therapist who understands their own intersectionality, power, and privileges— and how they interact in the therapist-client dyad — has an opportunity to create and foster a safe space to transform both clinician and client.
Reference:
Freeman-Coppadege, D.J., & Langroudi, K.F. (2021). Beyond LGBTQ-affirmative therapy: Fostering growth and healing through intersectionality. Queer Psychology, 159-179.
