LGBTQ+ People

Gender identity and sexual-affectional identity diversity are recorded by scholars throughout human history and manifest in culturally specific ways around the globe. The focus of this text is on describing LGBTQ+ affirmative counseling in the practice context of the United States; Chapter 15 covers international perspectives on LGBTQ+ affirmative counseling. A recent survey by Gallup found that up to 20% of individuals in the United States aged 16–25 identify as nonheterosexual or as having a noncisgender identity; estimates of the general population on average suggest that between 3% and 10% of adults identify with a LGBTQ+ identity (Reference JonesJones, 2022). As individuals continue to report fear related to disclosing their LGBTQ+ status, accurate estimates of the LGBTQ+ and other gender and sexual-affectional diverse populations are difficult to determine. In addition, the self-reflection, community support, and identity development associated with gender and sexual-affectional diversity involve engagement with nonlinear and lifelong processes that are influenced by social and environmental context (ALGBTIC LGBQQIA Competencies Task Force, 2013; APA, 2021). Discrimination and other forms of marginalization remain common features of LGBTQ+ people’s lives. Accessing mental health care and identifying practitioners who are affirming of LGBTQ+ identities remain common challenges for LGBTQ+ people seeking counseling and psychotherapy services (National Academies of Sciences, Engineering, and Medicine, 2020).

Key Terms

For the purposes of defining LGBTQ+ affirmative counseling, it is important to explain key terms for describing LGBTQ+ people and related populations. Gender identity refers to an individual’s sense of being female, male, nonbinary, and/or transgender and can be experienced as both static and enduring and/or fluid (APA, 2017). The term “sex” refers to physical characteristics such as reproductive organs, genitalia, and the chromosomes associated with the development of these characteristics. The gender binary paradigm is based on the perspective that there are only two normal or desirable modes of gender and sex: man/male and woman/female. Rigid adherence to the gender binary paradigm is used to justify antitransgender prejudice, sexism, and anti-LGBTQ+ prejudice in society. The term “intersex” refers to people who possess both male and female physical characteristics. A customary practice in the United States is to assign a gender to a person either in utero or at birth based on superficial visual inspection of their external genitalia. A person whose birth-assigned gender aligns with their gender identity is referred to as “cisgender,” and a person whose gender identity does not align with their birth-assigned gender may identify as transgender, nonbinary, or agender (someone who expresses no gender identity). Someone who identifies as gender fluid experiences changes in their gender identity and expression. Current perspectives on lifelong gender identity development are explored in depth in Chapters 5 and 7.

“Sexual orientation” refers to a pattern of romantic and sexual behavior, identity, experiences, and expression and encompasses asexuality or the experience of little to no sexual and romantic attraction to other people (National Academies of Sciences, Engineering, and Medicine, 2020). “Sexual-affectional identity” refers to an individual sense of sexual orientation that is inclusive of both sexual attraction and emotional and romanticaffinity. Both sexual orientation and sexual-affectional identity can be experienced as enduring or fluid, like gender identity. Current thinking and historical perspectives on sexual orientation and sexual-affectional identity are explored in Chapters 6 and 8. The word “lesbian” refers to women who are primarily to exclusively attracted to persons of the same sex and gender, and the word “gay” can refer to cisgender, transgender, and nonbinary people who are similarly same-sex and same-gender attracted, although is more commonly used by male-identified people. The word “bisexual” refers to the experience of being sexually and/or romantically attracted to people of both sexes, and the related word “pansexual” implies attraction to all sexes and genders.

“Queer” can refer to people who identify as LGB or to people who prefer to not identify with any sexual orientation label. Similarly, “genderqueer” may refer to people who prefer to not identify with any dimension of male or female. “Questioning” refers to people who are unsure about their gender identity and sexual orientation. The phrase “gender and sexual orientation diversity” is an inclusive umbrella term that refers to people and communities whose gender identity and sexual-affectional identity do not conform to the heterosexual and cisgender norm. It is important to emphasize that sexual orientation and gender identity are two related but distinct phenomena. People who identify as gay or lesbian, for example, may also identify as transgender but may also identify as cisgender. Transgender and gender-nonbinary people may identify as gay, lesbian, bisexual, or heterosexual. We use the acronym LGBTQ+ in this text to refer to the spectrum of gender identity and sexual-affectionally diverse people. Practitioners of LGBTQ+ affirmative counseling are intentional about the use of these and related terms in a respectful manner and acknowledge that self-identity is constantly evolving. The phrase “LGBTQ+ affirmative counseling” refers to a comprehensive practice framework for promoting the health and well-being of LGBTQ+ people based on valuing LGBTQ+ identities as normative manifestations of human experience and development. The following section takes a deeper dive into the development and principles of LGBTQ+ affirmative counseling.

The History of LGBTQ+ Affirmative Counseling

Professionals and advocates have discussed behavior that does not conform to gender-binary and heterosexual norms since the origins of psychology and psychiatry in the late 1800s in Europe and the United States (Reference Byer, Vider and SmithByers et al., 2019). The first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published in 1952 listed homosexuality as a mental disorder, reflecting the prevailing psychoanalytic perspective that sexual orientation diversity was inherently pathological (Reference Byer, Vider and SmithByers et al., 2019). The developers of the DSM omitted gender identity until 1980, when transsexualism was listed as a mental disorder. The American Psychiatric Association (APA) replaced transsexualism with gender identity disorder in the DSM-IV in 1994 and gender dysphoria in 2013 with the publication of the DSM-5 (APA, 2017). Efforts to change sexual orientation and gender identity diversity to encourage conformity to heteronormative and cisnormative values were considered the standard of care across the mental health professions. Advocates for gender and sexual orientation diversity and liberation engaged in a multidecade effort to resist discrimination that predominated in the mental health professions and to depathologize LGBTQ+ identities and experiences. One of the main arguments made by advocates for gender and sexual orientation diversity was that the pathologizing of LGBTQ+ people reflected social mores and not professional and scientific standards. Scholar-practitioners like Evelyn Hooker contributed to this effort by conducting practical research with populations of LGBTQ+ people, frequently finding that there were no inherent links between LGBTQ+ identities and mental disorder (Reference Byer, Vider and SmithByers et al., 2019). The precursor to the World Professional Association for Transgender Health (WPATH) developed standards for medical professionals to adopt when working with people seeking gender reassignment (i.e., gender affirming care) that supported the desire of transgender people to live congruently in their gender identities.

In 1973, advocates for LGBTQ+ diversity realized success in having homosexuality removed as a mental disorder from the DSM; however, gender dysphoria and ego-dystonic homosexuality remained in the DSM-III as diagnosable conditions. By the mid-1980s, other practice-based scholars began developing the framework termed “minority stress theory” (Reference MeyerMeyer, 2003), or the premise that the mental and physical health inequities experienced by LGBTQ+ people were primarily the result of social marginalization, discrimination, and oppression, especially as these occurred in the health care systems. The HIV/AIDS crises of the late 1970s and 1980s illustrated the impacts of discriminatory practices and policies on the health and well-being of LGBTQ+ populations. By 1987, the APA had removed all references to homosexuality from the DSM, though many practitioners still engaged in efforts to promote client conformity to heteronormative or cisnormative identities and behaviors (commonly referred to as “conversion” or “reparative therapy”).

In the early 2000s, codes of ethics in counseling and psychology began to reflect a more affirming perspective regarding nondiscrimination toward LGBTQ+ people, and the practice of LGBTQ+ affirmative counseling and psychotherapy began to be discussed more prominently in the literature base (Reference Byer, Vider and SmithByers et al., 2019). The APA changed its diagnosis of gender identity disorder to gender dysphoria in the DSM-5. The intent of this change was to focus on the distress people experience when their gender identity does not align with their biological sex and/or the distress experienced from marginalization of their gender identity rather than transgender or nonbinary identities themselves being diagnoses. Advocates continue to push for the depathologizing of transgender and nonbinary identity development, though gender dysphoria remains in the DSM-5 Text Revision (DSM-5-TR) today (APA, 2017).

Beginning in the mid-2000s and continuing today, the mental health professions appear to have reached a consensus that sexual orientation change efforts and gender identity change efforts aimed at promoting conformity to heterosexual and cisgender identities are inherently harmful, unlikely to be effective, and not in agreement with professional values. Frameworks for gender affirming counseling and for counseling that is affirming of LGB people have been developed by the American Counseling Association (ACA) and APA, reflecting adherence to multicultural-social justice counseling principles. Today, advocates for LGBTQ+ liberation are infusing an inherently intersectional perspective into their efforts that seeks to center the needs and experiences of historically marginalized groups within LGBTQ+ populations such as Black, Indigenous, and people of color (BIPOC), transgender and nonbinary people, and people with marginalized ability status issues (ALGBTIC LGBQQIA Competencies Task Force, 2013; APA, 2021).

Provider competence to work with LGBTQ+ and related gender- and sexual-affectional-diverse populations continues to be an urgent need across mental and physical health care systems. Professional associations prohibit discrimination or acting on personal biases and prejudices directed at LGBTQ+ and related populations, as specified by the authors of the ACA Code of Ethics (2014), the Ethical Principles and Code of Conduct put forth by the APA (2020), and in position statements published by the APA (2021). The Code of Ethics (2017) of the National Association for Social Workers states that social workers should develop cultural competence and understanding of sources of sociocultural diversity, including sexual orientation and gender identity, and proactively advocate for the elimination of discrimination against marginalized groups. While the major mental health professional associations have all endorsed best practice guidelines for work with and on behalf of LGBTQ+ clients, these guidelines do not carry the weight of ethical mandates. Little to no standardized training on LGBTQ+ affirmative counseling is available for experienced professionals finished with their own entry-level education, creating a gap in competence between new graduates and those who have been working in the field, which is one of the main reasons why we sought to create this text.

Tenets of LGBTQ+ Affirmative Counseling

The main tenets of LGBTQ+ affirmative counseling have evolved over time (Reference Byer, Vider and SmithByers et al., 2019). In professional psychology, the cultivation of affirming and inclusive attitudes was considered both necessary and sufficient for counselors and psychotherapists, asserting that LGBTQ+ affirmative counseling is a general orientation and not necessarily a comprehensive framework (Reference BidellBidell, 2017). Over time, the paradigm of multicultural-social justice competence became more prominent in both professional psychology and counseling fields. The multicultural-social justice competence framework is based on counselors and psychotherapists intentionally cultivating the awareness, knowledge, and skills to support marginalized and oppressed populations; the awareness–knowledge–skills–advocacy model is itself based on social-cognitive and self-efficacy theory (Reference BidellBidell, 2017). In applying the awareness–knowledge–skills–advocacy model to work with LGBTQ+ clients, scholars and practitioners developed supporting frameworks that are based on the lived experiences of LGBTQ+ people in terms of supporting mental health and well-being across the lifespan. The practice of LGBTQ+ affirmative counseling today is based on a synthesis of theory, evidence-based models, and ethical principles that helps operationalize nondiscrimination and the awareness–knowledge–skills–advocacy paradigm when working with LGBTQ+ clients.

The basis for modern LGBTQ+ affirmative practice is the framework termed “minority stress” (or “marginalization stress”; Reference Hope, Holt, Woodruff, Mocarski, Meyer, Puckett and ButlerHope et al., 2022; Reference Pachankis, Soulliard, Morris and van DykPachankis et al., 2023). The minority stress paradigm asserts that the higher rates of mental and physical health issues seen in LGBTQ+ groups are not due to inherent pathology but rather are a function of their development within a prevailingly hostile social environment (Reference MeyerMeyer, 2003). From exclusionary and oppressive laws to negotiating negative attitudes directed at them in their day-to-day lives, LGBTQ+ people continue to face a host of obstacles that negatively affect their ability to negotiate their developmental needs (Reference Kassing, Casanova, Griffin, Wood and SteplemanKassing et al., 2021). A key aspect of minority stress theory involves how LGBTQ+ people internalize negative attitudes about their LGBTQ+ identities, leading to internalized prejudice, lower self-esteem, and self-loathing, which also frustrates the efforts of LGBTQ+ people to realize optimal mental and physical health. Minority stress and internalized prejudice are described more fully in Chapter 3.

Originally focused on minority stress associated primarily with LGBTQ+ identities and experiences, LGBTQ+ affirmative counselors and psychotherapists should infuse intersectionality into their work. Intersectionality theory was primarily developed by Kimberly Reference CrenshawCrenshaw (1989) from critical racial theory and legal studies, and recently scholars have integrated intersectionality into LGBTQ+ affirmative counseling more specifically. Intersectionality theory is based on the premise that individuals espouse and inhabit multiple identities, such as ethnic and racial, gender, sexual orientation, ability status, nationality, and religion, and that these multiple sources of identity intersect with each other and interact dynamically with the environment to create distinct and often compounding experiences of social marginalization. The diverse and distinct communities that comprise LGBTQ+ populations are not a monolith; historically, the needs of middle-class and affluent, White gay and lesbian people dominated cultural awareness of LGBTQ+ groups. While LGBTQ+ people continue to demonstrate mental and physical health disparities, these disparities are influenced by experiences of sexism, racism, ableism, and antitransgender prejudice. Currently and historically, transgender and nonbinary people of color demonstrate the worst outcomes over the lifespan stemming from their experiences of discrimination directed at their multiple minoritized identities. An intersectional understanding of minority stress helps to explain these persistent disparities and fosters a nuanced understanding of the needs of distinct populations of LGBTQ+ people. Racism and sexism also occur within LGBTQ+ communities and spaces, and groups such as bisexual people and transgender people continue to report experiencing discrimination within LGBTQ+ spaces. The importance of intersectionality is discussed in Chapter 2.

In addition to ethnicity and race, gender, sex, and other salient intersections of personal identity, issues related to age and lifespan development are vital for conceptualizing the needs and aspirations of LGBTQ+ people. Suicide continues to be the leading cause of death for LGBTQ+ youth, compounded by adverse childhood experiences such as school-based bullying and rejection from both peer groups and families of origin (The Trevor Project, 2022). LGBTQ+ adults face unique challenges in forming social relationships, accessing economic resources, and engaging in career development. Housing, isolation, and difficulty accessing affirming health care are common issues faced by LGBTQ+ elders, conditions that are themselves made worse by lifetimes of coping with trauma and discrimination at earlier life phases (Reference Hope, Holt, Woodruff, Mocarski, Meyer, Puckett and ButlerHope et al., 2022). The importance of negotiating lifelong identity development and forming affirming social relationships for LGBTQ+ people is explored in Chapter 9.

Another important feature of modern LGBTQ+ affirmative counseling is an express emphasis on social advocacy as a key mode of intervention for practitioners. Research continues to demonstrate that health disparities experienced by LGBTQ+ people are mitigated by affirming social environments, including laws that affirm the civil rights of LGBTQ+ people and their relationships (ALGBTIC LGBQQIA Competencies Task Force, 2013; APA, 2021). Challenging discriminatory practices at the places where they work, serving as community educators, and lobbying for the development of affirming and inclusive laws are all considered to be best practices for counselors seeking to fully implement the LGBTQ+ affirmative counseling model. The importance of advocacy is further explained in Chapter 4. Finally, a key component of LGBTQ+ affirmative counseling is the intentional infusion of a strength-based approach when working with and on behalf of members of these historically and currently marginalized populations. This involves radical valuing of the inherent worth and resilience of every LGBTQ+ client as a dynamic and continually evolving human being. Given the history of pathologizing of LGBTQ+ people – often engaged in and promoted by mental health practitioners – viewing LGBTQ+ people as being inherently capable of well-being, life satisfaction, innovation, and happiness is a vital counterbalance to past and current oppression and discrimination.

Summary of Key Techniques

Conclusion

As a reader of this text, we commend you for wanting to expand your own ability to engage in LGBTQ+ affirmative counseling. Whether a student, new practitioner, or experienced practitioner, the information provided here will help attune your work with LGBTQ+ clients to the standards, research evidence, and ethical philosophy of LGBTQ+ affirmative counseling. Providers of LGBTQ+ affirmative counseling are part of an international community of practice, and we encourage you to connect with and support other practitioners on their own journeys of becoming ever more fully affirmative of LGBTQ+ people. Teaching, supervision, and consultation help to foster future generations of LGBTQ+ affirmative counselors, and we hope that you will feel the calling that we and the contributors feel toward advocating for the provision of LGBTQ+ affirmative counseling across all levels of the health care system in support of LGBTQ+ wellness, well-being, and liberation.

Assessing Intersectional Dynamics

Current standards of LGBTQ+ affirmative counseling emphasize the need for practitioners to consider the complexities of intersecting identities by examining how salient each identity is to the client, what relationships and potential conflicts exist among these identities, and levels of emotional distress related to these aspects (Reference Shurts, Kooyman, Rogers and BurlewShurts et al., 2020). The framework of intersectionality theory helps us to conceptualize how multiple sources of oppression and marginalization related to different social identities interact to inform clients’ lived experiences. Coined by Reference CrenshawCrenshaw (1989) to focus on the failings of employment nondiscrimination law when applied to the needs of Black cisgender women, over time intersectionality theory has grown to encompass the individual, local, institutional, and societal dynamics that can influence and compound LGBTQ+ individuals’ experiences of stress and marginalization. Applied specifically to counseling and psychotherapy, intersectionality serves as an important standard for practitioners ensuring that within-group diversity among LGBTQ+ populations is respected. In addition, intersectionality facilitates assessment of the specific barriers individual clients must navigate to meet their developmental and wellness needs. In this chapter, we will apply intersectionality to illustrate sources of stress at the level of individual identity and within systems and institutions. Though we do not address all potential sources of stress arising from multiple identities, the information in this chapter will help counselors build awareness on how individual identity and institutional dynamics may intersect with different sources of oppression.

LGBTQ+ Black, Indigenous and People of Color

Holding multiple marginalized identities, such as a sexual/gender and racial/ethnic minority, makes navigating society particularly complex and is inherently connected to experiences of chronic oppression (Reference Aguilera, Barrita and GarcíaAguilera & Barrita, 2021). This interweaving of oppression comes with many challenges that are often specific to the individual and their various identities. The concept of minority stress clarifies how oppression and stigma impact individuals. Minority stress (Reference MeyerMeyer, 2003) is explained as the stressors that occur in addition to day-to-day stressors experienced by anyone that are specific to having an identity with minority status. The literature provides clear evidence that individuals who hold multiple minority statuses (or who have intersecting oppressions) are more likely to experience stigma and oppression (Reference CyrusCyrus, 2017). Additionally, we know that people who experience minority stress have an increased risk for negative mental health outcomes (Reference Aguilera, Barrita and GarcíaAguilera & Barrita, 2021), including a consistent high rate of suicide and self-harm (Reference Haas, Eliason, Mays, Mathy, Cochran, D’Augelli, Silverman, Fisher, Hughes, Rosario, Russell, Malley, Reed, Litts, Haller, Sell, Remafedi, Bradford, Beautrais and ClaytonHaas et al., 2011). However, because of the varied nature of how specific identities (both privileged and oppressed) interact, there are mixed results on the exact impacts on mental health of individuals with intersecting minority-status identities (Reference Ching, Lee, Chen, So and WilliamsChing et al., 2018). Issues such as what sources of discrimination are perceived as salient, the timing or recency of microaggressions, and the relative direction,frequency, intensity and severity of microaggressive experiences all influence the degree to which individuals are impacted by their multiple minority identities (Reference Ching, Lee, Chen, So and WilliamsChing et al., 2018). When thinking about this issue, the identities we hold matter to what our exact experience might be. There are also large gaps in the literature addressing the specific pathways for how microaggressions directed at multiple identities are related to LGBTQ+ Black, Indigenous, and people of color (BIPOC) mental health (Reference Fattoracci, Revels-Macalinao and HuynhFattoracci et al., 2021).

When looking at the intersection of race/ethnicity and sexual orientation/gender, different factors will matter for different groups/individuals. Factors such as immigration and documentation status, acculturation, refugee experiences, trauma, poverty, and subnational or regional identities may all vary in salience based on individual, group, and generational differences (Reference Ching, Lee, Chen, So and WilliamsChing et al., 2018). LGBTQ+ Asian American youth were found to have difficulty developing a sense of belonging and fully coming into their identity as they are marginalized by their White LGBTQ+ peers due to their race and by the Asian American community due to their LGBTQ+ identity (Reference Gorse, Bacolores, Cheung and De PedroGorse et al., 2021). Reference Gorse, Bacolores, Cheung and De PedroGorse et al. (2021) found that compared to White lesbian and gay students, Laotian lesbian and gay students experienced more suicidal ideation. LGBTQ+ students from several Asian cultural groups indicated experiencing more physical fights or being threatened with weapons as well as not experiencing a positive school climate compared to their heterosexual and cisgender counterparts (Reference Gorse, Bacolores, Cheung and De PedroGorse et al., 2021). Transgender Asian American youth had higher experiences of bullying (physical fights, property being stolen, being threatened with a weapon) than their lesbian and gay counterparts (Reference Gorse, Bacolores, Cheung and De PedroGorse et al., 2021). LGBTQ+ Asian American youth who feel supported at school or within their families reported lower rates of emotional distress as compared to those who felt alienated and unaccepted (Reference Gorse, Bacolores, Cheung and De PedroGorse et al., 2021). Further, attitudes within Asian communities regarding relationships within the LGBTQ+ community have been impacted by colonization and Western ideals (Reference Ching, Lee, Chen, So and WilliamsChing et al., 2018).

Native American communities were also impacted by colonization and forced assimilation practices, including beliefs and attitudes related to gender and sexual orientation identities (Reference Hoover, Jeffries, Thomas and LestonHoover et al., 2023; Reference Thomas, McCoy, Jeffries, Haverkate, Naswood, Leston and PlateroThomas et al., 2022). The Two Spirit movement within some Native communities, inspired by retention of the history and knowledge of a precolonial understanding of gender and sexual orientation, has created a space of support and affirmation for Native American LGBTQ+ people (Reference Thomas, McCoy, Jeffries, Haverkate, Naswood, Leston and PlateroThomas et al., 2022). Reference Hoover, Jeffries, Thomas and LestonHoover et al. (2023) found that Two Spirit and LGBTQ+ Indigenous individuals experienced several barriers to care, including affordability, a lack of service providers, and an absence of psychological support groups specifically for Two Spirit and LGBTQ+ communities. Like many LGBTQ+ people with other marginalized identities, discrimination and a lack of affirming providers contribute to the Two Spirit and transgender population having higher rates of sexually transmitted disease, mood disorder, and substance use disorder, along with other health conditions. One study found that half of the American Indian/Alaskan Native trans people surveyed reported being verbally harassed and/or sexually assaulted within the health care system relating to their gender identity (Reference Hoover, Jeffries, Thomas and LestonHoover et al., 2023). For Indigenous LGBTQ+ or Two Spirit people, finding quality care at the intersection can be particularly daunting. In fact, many health care workers may have some training on Indigenous culture or on LGBTQ+ issues, but they tend to not have both, thus replicating colonizing mindsets and missing the nuances of working with Two Spirit people (Reference Hoover, Jeffries, Thomas and LestonHoover et al., 2023). Additionally, LGBTQ+ Indigenous and Two Spirit people fear having their gender identity/sexual orientation known because of a lack of appropriate care, which is particularly problematic for gender-diverse people because of their specific health care needs.

An important consideration for people who are Latinae and LGBTQ+ involves the centrality of family dynamics, termed familismo, and how that pairs with acceptance/rejection of one’s gender/sexuality. For example, Latinae LGBTQ+ youth are greatly impacted by family rejection, which can include “familial gender policing” that enforces hypermasculinity and submissiveness based on the gender that the family has ascribed to the youth (Reference Schmitz, Robinson and SanchezSchmitz et al., 2020, p. 833). Family rejection can lead to higher rates of suicide among Latinae LGBTQ+ youth, and some Latinae youth when faced with daily anti-LGBTQ+ reactions from the family that they share a residence with decide to refrain from defending their identity (Reference Schmitz, Robinson and SanchezSchmitz et al., 2020).

Studies have found that Black gay, bisexual, and transgender (GBT) adolescents and emerging adults also experience various intersectional oppressions due to sexuality/gender and race (Reference Harper, LaBoy, Castillo, Johnson, Hosek and Jadwin-CakmakHarper et al., 2022). These experiences are paired with increased negative mental health outcomes, such as depression and suicidality (Reference Haas, Eliason, Mays, Mathy, Cochran, D’Augelli, Silverman, Fisher, Hughes, Rosario, Russell, Malley, Reed, Litts, Haller, Sell, Remafedi, Bradford, Beautrais and ClaytonHaas et al., 2011). To counter some of the isolation and lack of belonging in multiple spheres, Black GBT adolescents and emerging adults embraced the house and ballroom community (HBC) as well as the Kiki scene (Reference Harper, LaBoy, Castillo, Johnson, Hosek and Jadwin-CakmakHarper et al., 2022). These spaces provided safety, acceptance, and support related to the expression of gender identity and sexual orientation. The Kiki scene is based on creating spaces where GBT young people of color could socialize, vogue, and access services (e.g., HIV prevention, testing, food, shelter) (Reference Castillo and HosekCastello & Hosek, 2018) while also emphasizing youth leadership and deemphasizing the competitive nature of the HBC. Scholarship highlights how the Kiki scene improved participant executive functioning, confidence, creativity, sense of support, and achievement orientation (Reference Harper, LaBoy, Castillo, Johnson, Hosek and Jadwin-CakmakHarper et al., 2022).

LGBTQ+ and Religious and Spiritual Identities

Some LGBTQ+ individuals navigating the coming-out process in relation to their religious/spiritual identity may find that their coming-out process is influenced by several factors. These include but are not limited to the point in their lives when they acknowledged their LGBTQ+ identity, the length of time and level of involvement with a religious community, and how accepting this community is toward LGBTQ+ individuals (Reference Shurts, Kooyman, Rogers and BurlewShurts et al., 2020). If clients experience moderate to high conflict between their religious and LGBTQ+ identities, their religious/spiritual beliefs will become more central to the counseling process (Reference Shurts, Kooyman, Rogers and BurlewShurts et al., 2020).

Reference Shurts, Kooyman, Rogers and BurlewShurts et al. (2020) developed a traffic signal framework to assess intersectional dynamics as they relate to clients’ LGBTQ+ identity development and their religious identity/faith development. Within this framework, green indicates where one identity (e.g., religious) may help the client navigate another identity (e.g., LGBTQ+) and where the stage of faith development is not creating challenges to the coming-out process, though the client could still experience other barriers. Yellow indicates an area where counselors should approach cautiously when assessing potential challenges between a client’s religious and LGBTQ+ identity based on additional identities and contextual factors, such as the client’s stage of faith development. Red signals high conflict with a client’s LGBTQ+ identity development and religious development, indicating that religious or faith beliefs are creating barriers to the coming-out process, which in turn might result in negative feelings or views of the self (Reference Shurts, Kooyman, Rogers and BurlewShurts et al., 2020).

Counselors working with clients they deem to be in the green zone may find that they are able to integrate both their religious/spiritual identity and their LGBTQ+ identity. Often, this integration is a result of affirming support from their religious community, connecting with LGBTQ+ mentors and community elders, and accessing tools to aid them in LGBTQ+ identity development. It may also represent periods of healthy disengagement from their religious/spiritual community and/or family of origin (Reference Shurts, Kooyman, Rogers and BurlewShurts et al., 2020). Clients in the yellow zone may indicate that they have found some constructive ways to navigate these conflicts or that they are seeking guidance to reconcile these conflicts (Reference Shurts, Kooyman, Rogers and BurlewShurts et al., 2020). A client deemed to be in the red zone may exhibit behaviors such as engaging in substance use, engaging in reparative therapy, avoiding open interactions with LGBTQ+ people, and potentially engaging in anonymous interactions with LGBTQ+ people that could include risky sexual encounters. As this framework focuses on religious/spiritual identity and LGBTQ+ identity development, it is important for counselors to explore how additional identities (e.g., racial/ethnic, disability, nationality) intersect and the level to which they have been integrated with these identities based on their salience to the client in addition to the socialization and barriers they have experienced in different contexts.

Barriers to Care and Risk Factors

Multiple minority communities, including LGBTQ+ BIPOC people across the lifespan, cope with compounding minority stress experiences when attempting to seek help (Reference Currin, Hubach, Crethar, Hammer, Lee and LarsonCurrin et al., 2018). Providers are not uniformly trained in LGBTQ+ counseling, and training in diversity, equity, and inclusion has only become prominent within the past two decades. LGBTQ+ clients are more likely to be diagnosed with mental and substance abuse disorders and to report discrimination generally and specifically within health care and education systems (Reference Currin, Hubach, Crethar, Hammer, Lee and LarsonCurrin et al., 2018). Adding to the likelihood of negative mental health outcomes for LGBTQ+ BIPOC people is the fact that clients are often working with clinicians from dominant groups, which increases the likelihood of cultural misunderstandings and miscommunications (Reference DominguezDominguez, 2017; Reference HatzenbuehlerHatzenbeuhler, 2014). Demographics of clinicians from across professions and across communities within the United States consistently show that providers are more likely to White, heterosexual, cisgender, Christian, and usually professional or middle class (Reference DominguezDominguez, 2017; Reference Hulko and HovanesHulko & Hovanes, 2018).

Older LGBTQ+ BIPOC adults’ mortality rate increases due to layers of oppression (ageism, racism, genderism, heterosexism) and barriers to accessing care (Reference Chan, Frank, DeMeyer, Joshi, Vargas and SilverioChan et al., 2021). These factors also increase the prevalence of suicidality, anxiety, depression, and mental exhaustion and may also lead to substance use and addictions as forms of coping. Older LGBTQ+ BIPOC adults whose identity is affirmed and cultural identity is preserved are more inclined to seek help. While grief and loss are considered natural parts of aging, older LGBTQ+ BIPOC adults encountering racism, genderism, heterosexism, and other layers of oppression experience heightened levels of grief and loss, and these can contribute to isolation as well (Reference Chan, Frank, DeMeyer, Joshi, Vargas and SilverioChan et al., 2021). Additionally, discrimination and prejudice impede the ability of older LGBTQ+ BIPOC people to access housing, increase the likelihood of eviction, and can amplify feelings of displacement from communities and society (Reference Niemet and RiceNiemet & Rice, 2022). Older LGBTQ+ adults of color consistently contend with coming out across the lifespan (Reference Niemet and RiceNiemet & Rice, 2022). Experiences of coming out and self-disclosure can be complex because of the loss of connections, fear of rejection, and incivility from trusted communities of support (Reference Chan, Frank, DeMeyer, Joshi, Vargas and SilverioChan et al., 2021).

The overall well-being of LGBTQ+ BIPOC individuals and the level of resilience at the community and individual level are influenced by internalized oppression and phobias, trauma, and other stressors (Reference Aguilera, Barrita and GarcíaAguilera & Barrita, 2021; Reference HatzenbuehlerHatzenbeuhler, 2014). This is due to the overlapping epidemics of discrimination, poverty, classism, racism, genderism, heterosexism, and religious persecution (Reference Aguilera, Barrita and GarcíaAguilera & Barrita, 2021; Reference Chan, Frank, DeMeyer, Joshi, Vargas and SilverioChan et al., 2021). In addition, LGBTQ+ POC experience exclusion and racism within queer spaces and establishments, including deliberate targeting, discrimination, and sometimes harassment (Reference Felipe, Garrett-Walker and MontagnoFelipe et al., 2022). In addition, “Black and Native Americans TGNC [transgender and gender nonconforming] individuals report connecting with LGBTQ+ POC communities but do not find the same connection with the broader White LGBTQ+ community” (Reference Aguilera, Barrita and GarcíaAguilera & Barrita, 2021, p. 141). While racism within the LGBTQ+ community and internalized heterosexism negatively impact LGBTQ+ BIPOC individuals, multiracial individuals encounter additional barriers to connection and kinship due to potential invisibility along both their racial and LGBTQ+ identities (Reference Felipe, Garrett-Walker and MontagnoFelipe et al., 2022). Multiracial LGBTQ+ experiences of marginalization can be impacted by being invisible, invalidated, or not embraced when it comes to their multiracial identity, creating disconnection from the communities that they seek belonging with (Reference Felipe, Garrett-Walker and MontagnoFelipe et al., 2022). This means that when experiencing depression and anxiety they might retreat within themselves rather than reaching out to any community for support due to past experiences or the concern of potentially encountering alienation. Multiracial LGBTQ+ individuals have also been found to have higher levels of self-harm (Reference Felipe, Garrett-Walker and MontagnoFelipe et al., 2022).

LGBTQ+ youth experience more homelessness, are more likely to be in the foster system, and are more likely to be incarcerated than their cisgender and heterosexual peers, and these statistics are worse for LGBTQ+ youth who are also BIPOC (Reference RobinsonRobinson, 2018). Reference RobinsonRobinson (2018) found that LGBTQ+ BIPOC youth in child welfare systems experienced being institutionalized as well as gender segregation, which led to stigmatization and isolation. Some examples include being misgendered, not being provided with what they needed based on their gender identity, being bullied based on intersections, being locked in rooms, having their gender expression dictated, and being sent to a mental hospital by foster parents who want to bypass foster service policies that require a 30-day notice before discontinuing to foster (Reference RobinsonRobinson, 2018). Transgender and nonbinary youth of color continue to report the highest rates of negative health and social outcomes due to facing discrimination across communities and systems, particularly in rural communities (Reference Hulko and HovanesHulko & Hovanes, 2018).

Scholarship demonstrates that trans women of color are the most marginalized and experience the worst outcomes compared to the rest of their LGBTQ+ counterparts. This is perhaps most exemplified in the murder rates of trans women of color. When it comes to race-based harassment, it has been found that transgender and nonbinary BIPOC students experience more of this type of harassment than their cisgender BIPOC peers (Reference Zongrone, Truong and ClarkZongrone et al., 2022). Reference Zongrone, Truong and ClarkZongrone et al. (2022) found that Native American transgender and nonbinary youth had the highest experiences of gender-based violence as compared to their BIPOC and multiracial transgender and nonbinary peers. Black and Latinae transgender and nonbinary youth reported the highest rates of race-based discrimination and harassment (Reference Zongrone, Truong and ClarkZongrone et al., 2022). Transgender and nonbinary BIPOC youth who experience both racist and transphobic harassment rather than one or the other type of harassment alone experience worse impacts on their mental health (Reference Zongrone, Truong and ClarkZongrone et al., 2022).

Size and Body Image

Researchers have consistently demonstrated that some of the recurring health disparities facing LGBTQ+ people are issues related to eating disorders and body image issues (Reference Kalash, Harb, Zeeni, El Khoury and MattarKalash et al., 2023). To understand how discrimination, marginalization, and stereotypes regarding body image influence the mental, physical, and emotional health of LGBTQ+ individuals, it is important to examine their stories within a cultural context or through the intersection of identities (e.g., race, sex, gender, class, ability, spiritual tradition, affectional orientation). There is a large volume of research concerning the influence of body image on primarily heterosexual women and, in some cases, both heterosexual women and lesbians (Reference Donaldson, Hall, Neukirch, Kasper, Simones, Gagnon, Reich and ForcierDonaldson et al., 2018). These concerns are of particular importance to LGBTQ+ youth. According to The Trevor Project (2022), 54% of LGBTQ+ youth have reported being diagnosed with disordered eating, and 54% of those who did not receive a formal diagnosis suspect that they have an eating disorder. Among gender-diverse youth, heterosexual transgender youth were most likely to be diagnosed with an eating disorder (approximately 71%), with the highest prevalence of disordered eating in female-identified transgender youth (54%).

Of youth that identified as gender nonconforming and genderqueer, 40% have been diagnosed with an eating disorder. Additionally, according to The Trevor Project (2022), 39% who identified as transgender male reported being diagnosed with an eating disorder. Cisgender male, transgender male, and gender-nonconforming LGBTQ+ youth reported binge eating disorder as the most common eating disorder for which they had received a diagnosis. Cisgender female and transgender female LGBTQ+ youth have reported bulimia as the most common eating disorder for which they had received a diagnosis. Additionally, among those who identified as another gender identity, 60% had been diagnosed with an eating disorder, with “other eating disorder” being the most common. Also of importance, 57% of those who identify as female who had never been diagnosed with an eating disorder suspected that they had an eating disorder, with bulimia being the most common suspicion, and among those transgender females who had never been diagnosed an additional 41% suspected that they had an eating disorder, with anorexia being the most common. Equally important is that disordered eating has been shown to have comorbidity with suicidal ideation and homelessness in LGBTQ+ youth.

Conclusion

Intersectionality is now a core principle of LGBTQ+ affirming counseling with all clients, and counselors and other clinicians should assess how clients’ experiences of their intersecting identities create both areas of compounding marginalization and resistance to being marginalized. In this chapter, we highlighted scholarship that illustrates the impact of multiple minority stress for specific intersecting populations. It is important to note that while experiences of compounding stress are likely, counselors should not make assumptions about how clients’ identities interact and influence their social development. Counselors should also, as part of the reflexive questioning of personal biases that is considered best practice with LGBTQ+ people, consistently reassess how their own multiple social identities create distinct similarities and differences with the clients they work with.

Core Tenets and Constructs of the Minority Stress Model

Building on Brooks’ earlier model of minority stress in lesbian women, Ilan Reference MeyerMeyer (1995) identified three processes that cause men in the gay community to experience stress. First, environmental discrimination, threats, and violence all create stress. The second process, stigma, is when an individual anticipates or expects a stressful situation to occur due to their minority status (Reference MeyerMeyer, 1995). This leads an individual to be more vigilant to always protect themselves. The last and final process is when negative beliefs and prejudices are internalized (Reference MeyerMeyer, 1995). Reference Hendricks and TestaHendricks and Testa (2012) state that this could be the most damaging process as it can lead to a decreased ability to cope with stressful events. Reference MeyerMeyer (2003) expanded upon his original theory, applying it to LGB populations and emphasizing the role of proximal and distal stressors. Proximal stressors are internal experiences subjectively interpreted and leading to minority stress. Meyer described both internalized homophobia and threat anticipation (stigma) to be proximal stressors. Alternatively, distal stressors are external factors that cause stress, such as discrimination and prejudice. Distal stressors work hand in hand with proximal stressors as internalized negative experiences increase. Meyer also includes resiliency coping skills and social support in his theory, all of which are influenced by personal identity formation. Reference Hendricks and TestaHendricks and Testa (2012) later demonstrated how the minority stress model may be applied to transgender and gender-diverse populations, identifying both trans-specific stressors and forms of resilience. How stressful situations and resilience change an individual’s reaction to future stressors is important to note as these affect physical and psychological symptoms.

Health and Mental Health Implications

Like physical health, the mental health of individuals within the LGBTQ+ population is impacted by stress. Among LGBTQ+ youth, internalized heterosexism and concealment behaviors are associated with risky sexual behavior, depressive symptoms, anxiety, and lower self-esteem (Reference Bränström, Hatzenbuehler, Pachankis and LinkBränström et al., 2016). Neighborhoods with higher rates of LGBTQ+ hate crimes are associated with increased substance use and suicide among LGBTQ+ youth (Reference Bränström, Hatzenbuehler, Pachankis and LinkBränström et al., 2016). Reference Valentine and ShipherdValentine and Shipherd (2018) completed a systematic review on the mental health of transgender and gender-nonconforming individuals and found depressive symptoms, substance use, and suicidality were all increased among transgender and gender-nonconforming individuals. Building on the large body of research correlating proximal and distal stress to depression, Reference Borgogna and AitaBorgogna and Aita (2023) found both forms of minority stress to account for 15% of the variance in depression scores across the Big-5 personality traits and other recent stressors in a sample of LGBTQ+ individuals (n = 435). Reference Hall, Xavier, Harris, Burns, Girod, Yount and WongHall and colleagues (2023) conducted a latent class analysis study focusing on intersectional stigma and mental health outcomes for Black, Indigenous, and sexual minoritized women (n = 324). The results indicated that those who experienced higher levels of racial, gender, and sexual orientation discrimination together had higher levels of stress and depression than those who experienced high racial discrimination, moderate levels of gender discrimination, and low levels of sexual orientation discrimination. Both groups experienced worse stress and depression over LBTQ women of color with low levels of discrimination in all its forms. This study provides support for both the unique and intersectional nature of minority stress and how it might lead to worsened mental health outcomes. These stressors may be long-lasting and even change genetic functioning, lead to inflammation, and alter hormonal functions (Reference Flentje, Heck, Brennan and MeyerFlentje et al., 2020). In fact, LGB adults over 50 years of age are more likely to have diminished immune systems than their heterosexual counterparts (Reference Fredriksen-Goldsen, Kim, Shui and BryanFredriksen-Goldsen et al., 2017).

Given the substantial number of studies and amount of supporting evidence, the minority stress model serves as a useful way to understand and treat the mental and physical symptoms created or exacerbated by LGBTQ+ stigma, prejudice, and discrimination. However, there remain critiques. One criticism is how overreliance on minority stress theory may encourage a focus on pathology rather than on how individual and collective resiliency relate to positive coping and LGBTQ+ community support (Reference Frost and MeyerFrost & Meyer, 2023). The theory also fails to take the interacting and often reciprocal effects of economic circumstances and cultural intersectionality into full consideration.

Social Determinants of Mental Health

The social determinants of mental health (SDMH) are based on the earlier social determinants of health (SHD) framework, later adopted by the Word Health Organization (WHO) in its quest to address health disparities within and between countries with higher and lower economic means (Reference Johnson, Cunningham, Tirado, Moreno, Gillespie, Duyile, Hughes, Scott and BrookoverJohnson et al., 2023). Today, the WHO defines SDH more broadly as the contextual, nonmedical factors affecting health outcomes: “They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, and political systems” (World Health Organization, 2023, para. 1). Research suggests that between 30% and 55% of health outcomes are accounted for by SDH (WHO, 2023).

Reference Allen, Balfour, Bell and MarmotAllen and colleagues (2014) argued that mental health outcomes were similarly affected by the social gradient and other SDH. The authors emphasized the role of multiple stressors and their cumulative effects across the lifespan, which often lead to mental health concerns. The role of economic disparities remains primary, but it is not the only factor impacting mental functioning. Overcrowded living conditions, poor working conditions, unemployment, food insecurity, low family support, social isolation, and a lack of access to primary care services are all related to poor mental health outcomes (Reference Alegría, NeMoyer, Falgàs Bagué, Wang and AlvarezAlegría et al., 2018; Reference Allen, Balfour, Bell and MarmotAllen et al., 2014). More recently, the SDH framework was broadened to include other inheritable demographic factors, including race, ethnicity, and gender, and their social counterparts of racism, sexism, and heterosexism (Reference Alegría, NeMoyer, Falgàs Bagué, Wang and AlvarezAlegría et al., 2018). As such, the SDMH framework embodies elements of the minority stress model, recognizing the damaging mental health effects of discrimination toward sexual- and gender-minority individuals (Reference Alegría, NeMoyer, Falgàs Bagué, Wang and AlvarezAlegría et al., 2018). Furthermore, the SDMH framework reveals complex and reciprocal relationships between the SDH and mental health (Reference Alegría, NeMoyer, Falgàs Bagué, Wang and AlvarezAlegría et al., 2018). For example, queer youth who are barred from their families and left in a state of homelessness may lose economic, social, and health care access, thus removing support for emerging mental health crises. With poorer mental health outcomes, these youth may experience challenges when seeking employment, housing, and positive social networks.

Reference Henderson, Goldbach and BlosnichHenderson et al. (2022) conducted a comprehensive examination of 26 scientific literature reviews of sexual- and gender-minority mental health published since 2017 using the Healthy People 2030 framework (US Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 2023). Among the five categories, social and community context was the most reviewed, often using Reference MeyerMeyer’s (2003) minority stress model. Reference Henderson, Goldbach and BlosnichHenderson et al. (2022) found substantial evidence linking health care discrimination, child abuse, bullying, intimate partner violence, and internalized heterosexism and transnegativity to mental health concerns. Those subject to institutional systems such as foster care and incarceration were further marginalized by discriminatory attitudes and abuse (Reference Fish, Baams, Wojciak and RussellFish et al., 2019).

Economic stability remains an underlying factor for mental health concerns among LGBTQ+ individuals, with even higher poverty rates among transgender and bisexual POC. Reference Henderson, Goldbach and BlosnichHenderson et al. (2022) also suggested that poverty is a result and cause of mental health symptoms. Housing is a particular concern, as LGBTQ+ populations experience high rates of homelessness, and they often encounter housing discrimination, all of which may lead to diminished mental wellness. Henderson and colleagues also found little research connecting educational attainment to mental health outcomes, with the few studies examining suicidality showing mixed results. Neighborhood and built environment factors are not as well studied for this population; however, some evidence shows that an increased density of same-sex couples and perceived safety both served as protective factors against depression, nonsuicidal self-injury, and suicide attempts. In Henderson and colleagues’ review, they found that most studies on health and health care determinants focused on negative attitudes that LGBTQ+ individuals experience from health care providers. Access to health care insurance, which relates to economic marginalization and employment discrimination, is another important factor.

In total, the SDMH framework allows for a more detailed and intersecting analysis of the interpersonal and systemic forces that affect mental health among the LGBTQ+ population. It expands upon the minority stress model, giving clinicians and researchers alike a chance to broaden and nuance their conceptualization of individual clients and whole communities. When using this framework, it is important to note how these experiences are often not universal across all LGBTQ+ people and how other intersecting identities (race/ethnicity, socioeconomic status, rurality, gender) may mitigate or exacerbate these effects.

The Role of Multiple Minority Stress in LGBTQ+ Health

As we begin this section, we invite you to consider the following analogy. Imagine you have a canvas covered with multiple paint colors each bleeding into the others, with some colors being more visible than others. Living as an LGBTQ+ POC in the world is not necessarily easy, as one has to balance different identities and roles and decide how to present within various groups. People who hold both LGBTQ+ and racial/ethnic minority statuses are likely to be subject to new proximal and distal stressors over and above those experienced by those with any one of these statuses alone. This is known as “multiple minority stress.”

There is mounting evidence confirming that living as an LGBTQ+ POC within society leads to complicated ways of socializing in the world. Reference Balsam, Molina, Beadnell, Simoni and WaltersBalsam and colleagues (2011) detailed the challenges that LGBTQ+ racial and ethnic minorities face both within the LGBTQ+ community and within their racial and ethnic minority communities. Many LGBTQ+ bars and community centers have historically focused on White gay patrons, refusing service to other groups or engaging in fundraising and programming for this economically and socially privileged group alone. They also noted how African American, Latinx/Latinae, and Asian American LGBTQ+ individuals have also experienced higher rates and unique forms of heterosexism in their respective communities, often associated with specific cultural values and norms. What is unclear, however, is the extent to which the membership in multiple minority groups leads to worse mental health outcomes (Reference CyrusCyrus, 2017). Reference MeyerMeyer (2010) summarized the evidence showing that those with multiple minority identities experienced higher levels of stress; however, mental health outcomes did not differ between Black and White LGB individuals. He noted how this effect has been attributed to individual and community resiliency realized from prior racial discrimination.

In the minority stress model, resiliency is also theorized to come from LGBTQ+ community support and related to one’s identity formation. Unfortunately, racial and ethnic discrimination from within the LGBTQ+ community can shape the degree to which one affiliates with the LGBTQ+ community and finds it supportive. Reference McConnell, Janulis, Phillips, Truong and BirkettMcConnel and colleagues (2018) found LGBTQ+ community connection to serve as a stronger mediator between stigma and stress among White individuals than POC, an apparent result of racial and ethnic discrimination toward POC in LGBTQ+ spaces. Ethnic cultural affiliation is similarly revealing, as sexual-minority Latinx men with a stronger orientation to their ethnic culture experienced higher levels of intersectional discrimination and used alcohol at higher rates than sexual-minority Latinx with a stronger orientation to the US mainstream culture (Reference Zelaya, Rosales, Garcia, Moreno, Figuereo, Kahler and DeBlaereZelaya et al., 2023). Of further concern is the increased risk of health care avoidance among POC experiencing mental health issues resulting from higher levels of stigma and discrimination. In total, multiple minority stress creates additional challenges for LGBTQ+ POC seeking needed support for each of their intersecting identities.

Interventions Addressing LGBTQ+ Discrimination and Related Stressors

When addressing minority stress, counselors and other mental health professionals may employ a variety of interventions with LGBTQ+ individuals while advocating for community-based interventions that reduce stigmatizing attitudes and discriminatory behavior among the public. When working with sexual and gender minorities who encounter discrimination, counselors may select from a variety of interventions, many of which are evidence-based practices, adapted for this population. In the literature, these strategies are offered across individual, family, and group modalities, often with a concerted effort to address minority stress among youth, who face bullying and family stressors and are developing new social supports and coping strategies. When adopting a strengths-based collaborative approach it is important to recognize what individuals are already doing to manage these stressors.

Building on earlier research of racially and ethnically diverse LGBTQ+ youth, Reference Goldbach, Rhoades, Mamey, Senese, Karys and MarsigliaGoldbach et al. (2021) developed and tested Proud & Empowered, a 10-session group intervention designed to build voluntary (e.g., self-talk) and involuntary (e.g., adopting a sense of pride in their sexual orientation and gender identity) coping strategies and resources. In their randomized controlled trial funded by the National Institutes of Health (NIH), the researchers found the intervention to reduce the effects of minority stress on existing depression, suicidality, and post-traumatic stress disorder (PTSD) among a diverse sample of high school students (n = 44). Although the intervention has not been widely evaluated, these results are very promising. Other interventions for LGBTQ+ youth have shown positive results, including improved mental health and coping strategies, although few have been assessed with randomized controlled trials (Reference Lucassen, Núñez-García, Rimes, Wallace, Brown and SamraLucassen et al., 2022). Cognitive behavioral therapy (CBT) adapted for sexual and gender minorities remains a common approach. One such intervention, AFFIRM (Reference Craig, Austin and AlessiCraig et al., 2013), is an eight-module manualized CBT intervention designed to help LGBTQ+ youth recognize their strengths and practice coping behaviors. In addition to affirming LGBTQ+ client identities and experiences of discrimination, a key component of this model includes distinguishing problems based on dysfunctional thoughts from those caused by one’s environment (Reference Craig, Austin and AlessiCraig et al., 2013). Beyond cognitive and perspective changes, environmental changes are therefore encouraged, such as seeking support and directly confronting discriminatory behavior.

Adult evidence-based interventions for LGBTQ+ people are emerging as well. Reference Pachankis, Hatzenbuehler, Rendina, Safren and ParsonsPachankis et al. (2015) developed ESTEEM (Effective Skills to Empower Effective Men) for gay and bisexual men and subsequently EQuIP (Empowering Queer Identities in Psychotherapy) for sexual- and gender-minority women (Reference Pachankis, McConocha, Clark, Wang, Behari, Fetzner, Brisbin, Scheer and LehavotPachankis et al., 2020), focusing on positive and negative coping responses to minority stress. These 10-session individual counseling interventions include components to identify strengths, increase motivation, and educate clients about minority stress and its impacts while developing and practicing new coping strategies. Both interventions were evaluated in subsequent randomized controlled trials, and they demonstrated reductions in depression and anxiety. Gay and bisexual men in the ESTEEM program also experienced reduced alcohol use problems, sexual compulsivity, and post-90-day condomless sex with casual partners, all of which have been recognized as negative coping strategies for managing minority stress (Reference Pachankis, Hatzenbuehler, Rendina, Safren and ParsonsPachankis, 2015).

Reducing public stigma remains a priority for LGBTQ+ individual and allies alike. Since 2007, there has been a substantial increase in research on interventions that reduce prejudice (Reference Paluck, Porat, Clark and GreenPaluck et al., 2021). Among efforts to reduce stigma and discrimination against LGBTQ+ individuals, the most effective have been those using peer influence and interpersonal contact (Reference Paluck, Porat, Clark and GreenPaluck et al., 2021). Peer influence interventions are designed to encourage significant individuals to carry messages of tolerance. Contact-based interventions are designed to bring together individuals from different life experiences and identities so that they may see their commonalities and humanize each other. Many community-based interventions occur in middle school, high school, or university settings, and it is important that counselors advocate with and on behalf of their LGBTQ+ clients to offer these growth opportunities.

Barriers to Accessing Care

Although the LGBTQ+ population accesses treatment services at higher rates than the general population, substance use disorder treatment utilization rates are far lower among this population. Among the estimated 5.5 million LGB individuals with substance use disorders, only 6.7% received treatment (SAMHSA, 2022). Similarly, transgender individuals are over twice as likely not to receive mental health care compared to cisgender heterosexual women (Reference Steele, Daley, Curling, Gibson, Green, Williams and RossSteele et al., 2017). Treatment retention is an additional concern, likely influenced by economic barriers and health care discrimination (Reference Card, McGuire, Bond-Gorr, Nguyen, Wells, Fulcher, Berlin, Pal, Hull and LachowskyCard et al., 2021; Reference Steele, Daley, Curling, Gibson, Green, Williams and RossSteele et al., 2017). Lower individual economic means, which reduce health care access, may be rooted in LGBTQ+ employment discrimination, leading to underemployment, job loss, and displacement from one’s home and neighborhood. Even in Canada, where health care is provided universally, income remains a key factor, reaffirming how income levels may impact one’s ability to access care (e.g., transportation, childcare, ability to get time off work) as well as perceived respect from health care providers (Reference Card, McGuire, Bond-Gorr, Nguyen, Wells, Fulcher, Berlin, Pal, Hull and LachowskyCard et al., 2021). When health insurance is not available or does not provide adequate coverage, LGBTQ+ individuals may seek out services from LGBTQ+ health centers (Reference Martos, Fingerhut, Wilson and MeyerMartos et al., 2019). However, fears of being discriminated against make these centers less appealing for bisexual women and men (Reference Martos, Fingerhut, Wilson and MeyerMartos et al., 2019).

Should an LGBTQ+ individual access health care, they are often subject to discrimination and a lack of competent care – forms of minority stress that dissuade individuals from getting care. Stigmatizing attitudes in mental health care continue to be causes of concern. LGBTQ+ individuals experience anti-LGBTQ+ attitudes, systematic exclusion from services, and being ignored when receiving behavioral health care (Moagi et al., 2021). Balik et al. (2020) conducted a systematic review of general health care discrimination among sexual- and gender-minority individuals and found the most common forms to be discriminatory attitudes and being refused needed medication. As primary care providers are often a pathway to accessing mental health services (Reference Card, McGuire, Bond-Gorr, Nguyen, Wells, Fulcher, Berlin, Pal, Hull and LachowskyCard et al., 2021), nonstigmatizing primary care and mental health services are both needed.

Case Example: Responding to Multiple Minority Stressors

Judeé is a 63-year-old self-identified Black, heterosexual trans woman using she/her pronouns and living in rural Ohio. After growing up in Iowa, she moved to a large public university in the Appalachian region, where she found greater acceptance as a woman among other LGBTQ+ students. During that time, she also drank heavily and occasionally used ecstasy (MDMA) and poppers (inhalants) during dance parties. Other students physically and verbally harassed Judeé because of her racial and gender identities, which led to her dropping out of college. Having grown up in a religiously conservative home, she was rejected by both of her parents after she disclosed her gender identity to them. After forming a close relationship with another transgender friend, she found employment at a regional call center, which she described as “boring, but at least it paid the bills.” Since that time, she has pieced together a series of similar jobs but has never been promoted. For social support and entertainment, Judeé drives an hour to the city on Sunday evening to an LGBTQ+ club where a group of “drag” performers called the “Girls of Gospel” sing traditional church music. Now she is proud of her identity as a Black Christian woman and openly engages strangers with a positive and friendly attitude, especially if they show discomfort with her.

Judeé was recently referred to you after a screening at the local integrated health care center. She reports that she likes her nurse practitioner at the center after having had “bad” experiences with other medical and behavioral health professionals. The referring nurse noted how Judeé expressed an interest in gender affirming care, but she lacked the financial resources to obtain it. Judeé confirms that she has had symptoms of anxiety and depression throughout her life. Now they are even worse. “I don’t have any retirement, and many of my friends have already died. I’m not sure what is left for me in this world.” She denies suicidal ideation. She continues to drink alcohol but does not use other substances, and she often remains at home alone with her dog, Angel.

Conclusion

Minority stress has detrimental mental health outcomes and is a key concern when serving LGBTQ+ clients. When one holds additional marginalized racial and ethnic identities, minority stress becomes amplified. Multiple minority stress may include stigmatizing attitudes from society as well as from within the communities with which people identity. Individual and community resiliency may buffer these effects. As counselors employ evidenced-informed practices to address minority stress, they will need to consider adaptations to address these multiple stressors and advocacy strategies in order to overcome barriers to health care.

Traditional presenting problem

The client presents with symptoms of lifetime anxiety and depression, worsening as she approaches retirement age due to financial insecurity and a lack of social support. The client engages in negative coping strategies such as alcohol use, bar attendance, and isolation.

History of Advocacy for LGBTQ+ Communities

In many precolonial cultures across the globe, LGBTQ+ people were recognized and considered valuable parts of society (Reference Mattson and OddenMatson & Odden, 2022). More than 150 different Native American nations acknowledged third genders in their communities prior to being colonized (Reference FloresFlores, 2020). Additionally, there is documentation of spiritual leaders in West Africa who were assigned male at birth but presented as feminine, as well as third genders such as the Muxes in Zapotec culture in what is now Oaxaca, Mexico, the Bakla people in Philippines, and Kwaja Sira (formerly known as Hijra – an outdated term) in South Asia (Reference FloresFlores, 2020).

However, over the course of time, the process of colonization and the spreading of the Christian religion began to threaten the celebration and place of LGBTQ+ people in various societies, particularly through the promotion of the gender binary. In Native North America, Christian colonizers also condemned same-sex relationships and gender variance (Reference FloresFlores, 2020), and because this was a common occurrence in many nations, this meant that colonizers would hunt and severely punish Two Spirit people or drive them underground (Reference Mattson and OddenMatson & Odden, 2022). Two Spirit people represented a threat to the way of life that Europeans felt they were bringingto a people viewed as less civilized.

As time progressed, these homo/bi/trans/ace-phobic ideologies persisted. Before the start of World War II, scholarship started popping up in several places investigating medical assistance for and understanding of transgender people’s experiences, challenging some of the prominent ideologies of the time. An example of this is the work in Germany of Magnus Hirschfeld (Reference StrykerStryker, 2017). Throughout this time, gender clinics emerged, and the beginnings of the first gender confirmation surgeries were documented (Reference StrykerStryker, 2017). With the rise to power of the Nazis, Hirschfeld’s work was burned along with the Institute of Sexual Science in 1933, wiping out much of the knowledge of that time (Reference StrykerStryker, 2017) and restoring the anti-LGBTQ+ status quo.

In the 1960s, there was an increase of prejudice directed against LGBTQ+ people (Reference StrykerStyker, 2017). An example of this was the enactment of bans on LGBTQ+ people gathering in public. At the same time, police conducted raids of gay bars and nightclubs, where LGBTQ+ people were arrested for gathering or crossdressing or other laws created to make it a crime to be LGBTQ+ (Reference StrykerStryker, 2017). In response to more frequent police harassment and arrests, LGBTQ+ people began organizing and fighting back in what was known as the Homophile Movement (Library of Congress, n.d.). The Mattachine Society was formed by Harry Hay in 1950 to counter the ways in which LGBTQ+ people were pathologized through the inclusion of homosexuality as a mental disorder in diagnostic nosologies (Reference LeeLee, 2013). The term homophile was specifically used by advocates to counter this pathologization (Reference LeeLee, 2013). The Daughters of Bilitis, a lesbian activist organization, was formed shortly after this time as well to promote LGBTQ+ rights (Library of Congress, n.d.).

In 1964 in Philadelphia, there were 2 weeks of sit-ins in protest of crossdressing patrons being denied service at a local diner (Reference StrykerStryker, 2017). The establishment ultimately conceded, representing an important win for LGBTQ+ rights (Reference StrykerStryker, 2017). Meanwhile, in 1966 in San Francisco, ongoing police harassment (e.g., arrests for things like female impersonation and blocking the sidewalk) brought matters to a boiling point when a trans woman threw her coffee in the face of a police officer who was harassing her. The patrons of a local cafeteria collectively joined in to fight back in what came to be known as the Compton Cafeteria Riots (Reference LevinLevin, 2019). In 1969 in Greenwich Village in New York City, in another reaction to police brutality and targeting of LGBTQ+ people, patrons fought back during a raid of a common gathering place at Stonewall Inn, starting the Stonewall Riots (Reference StrykerStryker, 2017). Citywide protests continued for the following 5 days in response (Reference StrykerStryker, 2017). This event served as a tipping point that allowed for broader participation. At the Stonewall Riots, as in other movements, trans women of color lead the charge (Reference StrykerStryker, 2017). Women such as Marsha P. Johnson, a Black trans activist and drag queen mother, and Sylvia Rivera, a Puerto Rican and Venezuelan trans woman from New York, were at the forefront of the efforts at Stonewall (Reference StrykerStryker, 2017). A year after the Stonewall Riots, marches began popping up to commemorate these events. One such march was led in 1970 by bisexual activist Brenda Howard, who is considered the Mother of Pride because she is the one who renamed Liberation Marches as Pride Marches (Reference LeeLee, 2013). The impact of this is still seen today, as hundreds of pride parades are still held annually (Reference LeeLee, 2013). During this same period, gender clinics started appearing again to help understand and support transgender people (Reference StrykerStryker, 2017). In 1966, Harry Benjamin wrote The Transexual Phenomenon, which explored transexual experiences, and he also set the diagnostic criteria for transsexuality (Reference StrykerStryker, 2017). Additionally, in 1973, homosexuality was officially removed from the Diagnostic and Statistical Manual of Mental Disorders (DSM) after much debate in the field (Reference StrykerStryker, 2017).

While much was gained because of this activism in the 1960s and 1970s, there still was much work to be done. By the 1980s, this became painfully obvious with the governmental response to the AIDS epidemic, which was first labeled “gay-related immunodeficiency disorder” (GRID) or, more commonly, “gay cancer” (AIDS.gov, n.d.). This was an era led by misinformation, stigma, and homophobic and transphobic rhetoric against LGBTQ+ communities. In 1980, Gender Identity Disorder was added to the DSM, to be replaced by Gender Dysphoria in the 2010s, and the first standards of care for transgender patients were published by the Harry Benjamin Association (Reference StrykerStryker, 2017). These standards, now in their eighth edition, continue to set the bar in the field for appropriate care, and they are now known as the World Professional Association of Transgender Health (WPATH) Standards of Care (SOC; World Professional Association for Transgender Health, 2011). These changes in the field of mental health today represent positive gains; however, barriers remain. While historically there is much to thank our LGBTQ+ ancestors for, it is essential to continue advocacy efforts until full equity under the law and in practice is won. As counselors, it is especially important to advocate through a lens of social justice, particularly given how many of the continued challenges LGBTQ+ people face today can easily be tied to the systems of oppression impacting them.

LGBTQ+ Well-Being, Law, and Policy

Public policy informs community and societal norms as well as influences interpersonal interactions and maintains or creates structural barriers or supports (Reference Jackson, Stewart and FleeglerJackson et al., 2023). Thus, the use of legislation to disincentivize discrimination has the power to foster inclusion, acceptance, and equity within communities (Reference Jackson, Stewart and FleeglerJackson et al., 2023). For example, regarding the LGBTQ+ community, studies have noted that with the passage of same-sex marriage laws there were decreases in rates of antigay bias (Reference Ofosu, Chambers, Chen and HehmanOfosu et al., 2019), decreases in the rate of attempted suicides by LGBTQ+ students (Reference Raifman, Moscoe, Austin and McConnellRaifman et al., 2017), and reductions in medical and mental health care visits and the mental health costs of some patients within the LGBTQ+ community (Reference Jackson, Stewart and FleeglerJackson et al., 2023; Reference Ofosu, Chambers, Chen and HehmanOfosu et al., 2019). In addition to improving the health of LGBTQ+ individuals, the utilization and adoption of antidiscriminatory policies benefit all individuals economically (Reference Jackson, Stewart and FleeglerJackson et al., 2023). For example, research shows that harmful and problematic practices such as sexual orientation change efforts (SOCEs) can have a multibillion-dollar negative economic impact, whereas LGBTQ+ affirmative therapy (compared to no therapy) can save money and improve productivity (Reference Glassgold and HaldemanGlassgold, 2022). In addition, when states engage in creating and maintaining discriminatory policies and legislation, many LGBTQ+ individuals leave the area and move to more supportive states (Reference Jackson, Stewart and FleeglerJackson et al., 2023). This has been seen in examples such as North Carolina’s bill that denied transgender individuals the ability to use the bathroom that aligns with their gender, which cost the state of North Carolina approximately $3.76 billion (Reference Jackson, Stewart and FleeglerJackson et al., 2023). Businesses that have recognized the positive impact of LGBTQ+-positive bills and inclusive practices on their bottom line have joined over 290 companies signing the Business Statement Opposing Anti-LGBTQ+ State Legislation (Reference Jackson, Stewart and FleeglerJackson et al., 2023).

Positive Movements

In response to the growing concerns over legislation across the US that further threatens LGBTQ+ rights, advocates and allies are engaging in new strategies to resist anti-LGBTQ+ oppression. New groups and organizations dedicated to LGBTQ+ rights are often more intersectionally focused than previous groups and center the voices of LGBTQ+ people who are also Black, Indigenous, and people of color (BIPOC). One such example is the Undocuqueer Movement, which began in the late 2000s (Reference Cabas-MijaresCabas-Mijares, 2023; Reference Cisneros and BrachoCisneros & Bracho, 2019). The label Undocuqueer seeks to highlight the experiences of immigrants, especially Latinx youth, at the intersections of “racialized, gendered, sexualized, and xenophobic discrimination” (Reference Cabas-MijaresCabas-Mijares, 2023, p. 49). This movement centers the resistance toward respectability and acculturation that is found in immigrant and LGBTQ+ movements, thus challenging narratives about who represents worthy versus unworthy immigrants via advocacy, media, and art (Reference Cabas-MijaresCabas-Mijares, 2023). Many of the youth involved with this movement were instrumental in promoting new forms of protests such as the Coming Out of the Shadows strategies/events (Reference Cisneros and BrachoCisneros & Bracho, 2019). Additionally, many organizations such as Lambda Legal, the GSA Network, the Gay and Lesbian Alliance Against Defamation (GLAAD), the National Center for Transgender Equality, Parents, Families and Friends of Lesbians and Gays (PFLAG), the Trevor Project, and the Gay, Lesbian and Straight Education Network (GLSEN) have worked tirelessly to advocate for LGBTQ+ populations. These organizations (among others) serve as easy entry points for counselors to engage with advocacy efforts through providing education.

Banning Sexual Orientation and Gender Identity Change Efforts

Sexual orientation change efforts and gender identity change efforts (GICEs), still referred to today as “conversion therapy,” were seen as legitimate practices for several decades. These efforts have been enacted through religious organizations as well as by mental health practitioners. They have been shown not only to fail in their goals of changing the identities of those who are subjected to them but also to cause harm to individuals’ well-being (e.g., relational issues, increases in self-harm, increases in suicidal ideation, increases in substance abuse; Reference McGeorge, Coburn and WalsdorfMcGeorge et al., 2023). According to the Movement Advancement Project (MAP), 21 states and the District of Columbia have laws banning SOCEs and GICEs for minors, while five states and one territory have partial bans for minors. Conversely, one state prohibits local-level bans, and three states have a preliminary federal injunction currently preventing the enforcement of bans. Today, 20 states and four territories have no state laws or policies related to SOCEs or GICEs (Movement Advancement Project, 2023a). Additionally, counselors and many other physical and mental health professional organizations have spoken out against conversion therapy in public statements, citing it as harmful and unethical (Reference Harper, Finnerty, Martinez, Brace, Crethar, Loos, Harper, Graham, Singh, Kocet, Travis and LambertHarper et al., 2013).

Recent Social Events and LGBTQ+ People

The American Civil Liberties Union (ACLU) is currently tracking 501 anti-LGBTQ+ bills in the United States (American Civil Liberties Union, 2023). The broad categories of these bills include: (1) limiting the ability to update gender information on congruent birth certificates and other forms of ID or records; (2) undoing civil rights policies and laws such as those that protect LGBTQ+ people from discrimination; (3) limiting free speech related to the ability of LGBTQ+ individuals to outwardly be themselves and access resources about their community; (4) blocking affirming care for transgender people; (5) preventing the use of facilities like bathrooms in a gender affirming manner and other public accommodations; (6) censoring discussions within schools about LGBTQ+ people and issues; (7) excluding LGBTQ+ student from sports and clubs; and (8) instituting the outing of students (American Civil Liberties Union, 2023). Marriage bans are also another area that anti-LGBTQ+ bills are targeting (American Civil Liberties Union, 2023). Along with marriage bans, anti-LGBTQ+ activists are also advocating for the banning of same-sex couples from adoption services. These bans all represent ongoing and ever-changing or new threats to LGBTQ+ rights. This highlights the importance of counselors getting involved in advocacy efforts affecting LGBTQ+ communities, particularly the most marginalized when intersectional identities are considered. As counselors, working toward LGBTQ+ advocacy keeps us in touch with the real issues affecting LGBTQ+ people and families.

Strategies for Social and Political Advocacy

The American Counseling Association (ACA) Advocacy Competencies provide a framework for counselors to address systemic barriers and sociopolitical challenges. The ACA Advocacy Competencies consist of six domains of advocacy (empowerment, client advocacy, community collaboration, systems advocacy, collective action, and social/political advocacy) and are based on the expectation of counselors adhering to relevant ethical and multicultural concerns when engaging in advocacy work (Reference Toporek and DanielsToporek & Daniels, 2018). Advocacy in the client/student empowerment domain consists of aiding clients/students in identifying the systemic barriers and sociopolitical challenges or factors impacting them, identifying their strengths and resources, developing self-advocacy skills, and acknowledging the positionality of the counselor and the client/student and their communities (Reference Toporek and DanielsToporek & Daniels, 2018). The client/student advocacy domain involves counselors intervening on behalf of the client/student to confront barriers impacting the client’s/student’s well-being, including consultation with all relevant stakeholder groups. Advocacy in the community collaboration domain includes being mindful of context, developing alliances that address the issues/concerns of the community or organization, identifying community strengths and resources, and utilizing counseling that aid advocacy/collaboration efforts (Reference Toporek and DanielsToporek & Daniels, 2018). The systems advocacy domain is centered on systems change for groups of clients/students in educational systems, organizations, or communities through identifying stakeholders and accomplices regarding the issues/concerns of the group of focus as well as sources of social and political power in the system. Systems change is based on utilizing data and research to highlight the necessity for change and on creating a vision and plan that inform the needed change and address resistance (Reference Toporek and DanielsToporek & Daniels, 2018).

In the collective action domain, advocacy is centered on addressing public policy and public perception through identifying factors that are protective and those that interfere with overall healthy development. At this level, counselors are encouraged to create and disseminate materials that highlight how different factors impact community development and can be used to educate as well as influence decision-makers/policymakers (Reference Toporek and DanielsToporek & Daniels, 2018). The final domain – social/political advocacy – centerscounselors engaging in advocacy in the public arena for client/student groups and communities. Utilizing appropriate channels/structures to address problems identified by communities, building a coalition of stakeholders to address policy change and development, and the provisionof mutual support are all aspects of advocacy at this level (Reference Toporek and DanielsToporek & Daniels, 2018).

Recent examples of counselor advocacy to create change include banning of GICEs and SOCEs at the municipal, state, and federal levels of government as well as for professional mental health associations (Reference McGeorge, Coburn and WalsdorfMcGeorge et al., 2023). Professional mental health associations have engaged in various types of actions to address GICEs and SOCEs, including releasing statements, adding statements to their code of ethics, advocating for legislation that makes GICEs and SOCEs illegal, and providing education to all levels of clinicians as well as families and the community at large about the dangers of GICEs and SOCEs (Reference McGeorge, Coburn and WalsdorfMcGeorge et al., 2023). Additionally, the ACA has a Government Affairs and Public Policy (GAPP) department that tracks legislation as well as offers members resources to provide guidance regarding writing to legislators and requesting meetings with legislators. This entity produces a legislative agenda that outlines the ACA’s priorities regarding the counseling profession and promoting the ACA’s mission through advocacy at federal and state levels. In the ACA 2023 legislative agenda, conversion therapy bans are listed, stating “ACA will support states in their efforts to align local practices with ACA’s ethical code and current best practices. We will monitor bans of the discredited method referred to as conversion or reparative therapy throughout the U.S. and provide strategic resources to advance state goals for these bans” (ACA, 2023, p. 3).

The American School Counseling Association (ASCA) in their The School Counselor and Transgender and Nonbinary Youth position statement, which was adopted in 2016 and revised in 2022, highlights that school counselors understand and honor that gender identity is determined by the student and not “medical practitioners, mental health professionals or documentation of legal changes” and that school counselors engage in collaboration “to address district operations, programs, policies and activities that may put the well-being of transgender and nonbinary youth at risk.” Although the guidelines within this statement provide important suggestions, they cannot anticipate every situation that might occur. In The School Counselor and LGBTQ+ Youth position statement (adopted in 1995, revised in 2022), the ASCA emphasizes that school counselors are responsible for assisting students in navigating different stages of identity development and that they must not try to influence a student’s gender identity, gender expression, or sexual orientation. It also highlights the importance of school counselors understanding the harm of therapies that attempt to change the gender identity or sexual orientation of students and advocating against them, in addition to providing a safe and affirming school. School counselors remain vital allies and advocates given their level of involvement in the lives of LGBTQ+ youth and how much time youth spend in school (Reference Asplund and OrdwayAsplund & Ordway, 2018). Youth are some of the most vulnerable members of the LGBTQ+ population because they are so often dependent upon adults to protect them, and many adults in their lives may reinforce homo/bi/trans/ace prejudice. “In its present state, the field of school counseling has more to offer LGBTQ+ students, by embracing this definition of advocacy and by applying more advocacy language to the ASCA Model (2012)” (Reference Simons, Chan, Beck and AsplundSimons et al., 2019, p. 463).

It is important to evaluate the efforts that professional mental health organizations are putting forward, as it has been recognized that when they remain silent around the institution of GICEs and SOCEs tremendous harm is done to the LGBTQ+ community at large (Reference McGeorge, Coburn and WalsdorfMcGeorge et al., 2023). There are numerous LGBTQ+-centered organizations, with some being large, such as COLAGE (https://colage.org/), which was created to support youth in LGBTQ+ families, and LGBTQ+ Victory Fund (https://victoryfund.org/), which centers increasing the number of LGBTQ+ individuals in elected offices (Movement Advancement Project, n.d.). Other organizations such as Immigration Equality (https://immigrationequality.org/), GLAAD (https://glaad.org/), GLSEN (www.glsen.org/), and Soulforce (https://soulforce.org/) center on specific issues (Movement Advancement Project, n.d.).

Conclusion

Counselors engage directly with the impacts of oppression on LGBTQ+ people because of its impact on their mental health. While many gains have been made by advocates throughout history, the current challenges facing LGBTQ+ people, particularly youth and BIPOC, are considerable. Advocating effectively requires counselors to engage outside of the counseling office and often with laws and policies directly. By joining with existing advocacy organizations and their resources, counselors can be important contributors to a more safe and inclusive future.

Case Example: Responding to Anti-LGBTQ+ Legislation

Laila has been seeing you in counseling for a month after a referral from her school. She has been suspended on two separate occasions when she was sent to the office to change her clothing for going against school codes that require her to dress as her assigned gender. When sent to the office, the situation escalated, as she refused to comply. The school has mentioned that this has interrupted her learning, and they are concerned with her grades and her growing number of absences. She has come out at school and at home as trans; however, you are in a state that recently passed a bill against trans affirming care, which has also meant that there is little legal protection in the school regarding dress codes being developed according to gender. You sit with the family as they confide in you that they know their child would be successful and happy if they were just able to provide affirmative care, but they fear losing custody for what is now legally considered abuse. They cannot afford to move in order to leave the state, and they also feel concerned that, even if they did, similar new laws would just pop up elsewhere.

In this situation, the counselor is in a difficult position because their ethical responsibilities are in direct conflict with current laws and policies. This is why advocacy can be so important in the work of counselors. This family is supportive, which is helpful in this case. However, they are scared and do not want to do anything that could threaten their family remaining together. When considering your options as a counselor, you must ask yourself what you believe to be the most ethical route, and then also how that interacts with the legal requirements in front of you. When considering advocacy efforts, seeking out stakeholders who will be supportive of the client and their family can be one of the most important steps. In this case, seeking legal representation may be necessary, and perhaps this might be a case that a bigger advocacy organization, such as Lambda Legal or the ACLU, would be willing to take on if legal action is required. You also may need to consider the policies and support you would or would not have within the agency you work for and to consider the school’s position. There are no easy answers in this situation, but counselors sometimes must do the brave thing by doing what they feel is right, even when this does not align with what current laws require. Change often comes through the legal battles that can come about because of such action.