Presented by Lisa A. Schimmel Ph.D Staff Psychologist, OHSU Student Health Services

1. Developing Clinical Competence in Working withLesbian, Gay, Bisexual and/or Questioning Patients Presented by Lisa A. SchimmelPh.D Staff Psychologist, OHSU Student Health Services

2. Learning Objectives This initial lecture will provide you with the information to: 1. Describe specific external factors and internal processes impacting the lives and mental health of Lesbian, Gay, Bi-sexual & Questioning patients/clients. 2. Discuss the nature of cohorts and ongoing coming out processes. 3. Develop awareness of your role as buffer in managing LGBQ patients’ external and internal stressors. 4. Incorporate specific actions to enhance rapport and connection with LGBQ patients. 5. Provide essential LGBQ/LGBT community resources to patients and colleagues.

3. LGBQ Sexual Orientations Lesbian -- primary sexual attraction of women toward women Gay Male– primary sexual attraction of men to men Bi-Sexual – primary gender not necessarily a factor in attraction Questioning – someone in process of identifying their sexual orientation Bi-Curious –one who might explore the same and other-sex attractions MSM – Men who have sex with men, but do not consider themselves to be gay Gay – overarching term used by many non-heterosexual persons

4. LGBQ Relevant Issues/Terms Heterocentrism/Heterosexist Bias LGBQ-sensitivity/Gay Affirmative Clinicians Multiple Minority Status Issues Family of Choice (F.O.C.) & “Family” “Friendly” Cohorts & Coming Out Bisexuality issues

5. Heterocentrism/Heterosexist Bias Belief in superiority of heterosexuality over things non-heterosexual… • May be part of conscious belief system • May be overtly or subtly expressed • May be also be an unconscious process

6. LGBQ-Sensitive/Gay-Affirmative Clinicians These clinicians are conscious of: • Impact of societal stigma on well-being of sexual minorities • Impact of hetero-centrism on LGBQ stress levels & • self-soothing attempts • Normalizing sexual diversity • Importance of acting as external buffer • Gently following shifts in identity with questioning and newly coming out persons • Acknowledging authentic life and relationship rituals of LGBQs • Ongoing stressful processes of coming out and synthesis of identity

7. The Road from Discovery… to Acceptance Discovery of one’s sexual self may appear much earlier in life than acceptance of it depending upon the number and type of hurdles one has to navigate. Buffers Cohort HeterocentrismLGBQ Community Access Political & Social Climate Work/Life Pressures to Pass Cultural/Racial Variables Fear of Physical/Emotional/Spiritual Harm Fear of loss of F.O.O. Limited F.O.C. Access to Affirmative Clinicians IPV Rural vs. City Status Sexual Diversity Awareness Fear of loss of community (friends, religious, community) “Minority” Status Access to GSAs Access to Role Models Access to Positive Media Portrayals Resilience _______________________________________________________________________________________________________________________ DiscoveryAcceptance

8. When working with a LGBQ populations it is essential to consider the complexity of minority status 8 • Be conscious of multiple stigmatizing variables for the LGBQ patient related to race, gender, financial limitations, disability, age, etc… • 2. Work to assess and navigate these identities with your patient by: • Educating self about the impact of ethnocentric, andro-centric and • heterocentric privilege on persons of multiple minority status • b. Teaching patient healthy self-soothing techniques Multiple Minority Status & Privilege

9. Family of Choice & “Family” LGBQs develop their own rituals, communities, and ways of relating: “Family of Choice” • People/communities created to function as “family” support • May be in lieu or in addition to families of origin “Family” • Refers to someone who is also LGBQ “Queer” • Umbrella term used by members of LGBTIQG-Q community to describe themselves. • Negative connotation when used by non-friendly persons. • Positive connotation when used by someone LGBITQG-Q “Friendly” • Refers to persons/providers/institutions deemed to be safe and supportive

10. Cohorts & Coming Out Cohort = of a specific time period or generation LGBQs express variability in comfort levels in coming out based on safety/political/social climate Present period Same-sex marriage/Civil Unions/Repeal DADT/Bullying exposed 1997-2000s Affirmative media portrayals of LGBQ life/Civil Unions 1990s Limited TV/Media exposure to positive LGBQ role models – NARTH/Reparative/Conversion Organizations/DOMA/DADT 1980s Reagan Era /GRID/AIDS /Closeted Time /Major losses /Rock Hudson/ An Early Frost /Gay Straight Alliances (GSAs) Late 60s/1970s Stonewall Riot/ Homosexuality Dx removed from DSM by APA Gay/Lesbian Identity -- Pride Parades Commemorate Stonewall /1stEx-Gay Ministry (Love in Action) 1960s & earlier Homosexuality = Mental Disorder **Attend to cohort /coming out differences when working with LGBQ couples

11. Sexual Prejudice

12. Bisexuality Issues • Bisexuals experience marginalization from heterosexual & lesbian/gay communities. • Lesbians & Gays view Bisexuals as “on the fence” about sexual orientation. • Heterosexual communities are often uncomfortable with bisexual fluidity. • Fewer visible role models than L & Gs • Limited information/research regarding their sexual orientation • Less awareness of Bi-sexual peers than L&Gs

13. Deepening Connection & Rapport Enhancing rapport with LGBQ patients involves: • Eliminating hetero-centrist language and assumptions • Creating a sense of safety for and acceptance of LGBQ patients • Fostering an inclusive environment • Educating yourself about and providing appropriate LGBTQ resources

14. Managing Hetero-centric Language & Assumptions USE LANGUAGE OF CONNECTION& EMPLOY AWARENESS • Utilize affirmative language Sexual orientation vs. Sexual preference Gay, Lesbian, Bi-sexual, Questioning (Identity) vs. Homosexual (Sexual Behavior) Partner/Significant Other/Spouse vs. Friend • Use terminology that resonates with the patient – (e.g., family, family of choice, top, stone butch, gay woman) • Feel free to ask them to define what you do not know and/or take time to access this information on your own. • **Listen for and attend to the language of “internalized homophobia/internalized homo-negativity” USE ASSESSMENT RATHER THAN ASSUMPTION Avoid assuming patients are coming to you with a hetero-sexual orientation Investigate the way patients understand their own sexual orientation Assess for IPV (Intimate Partner Violence) issues within same-sex relationships

15. Creating Safety & Acceptance • Assess extent to which external supports and • buffers exist for your patient • Take on role as buffer from societal/familial, • community disenfranchisement • Assess yourself and your own potential • conscious or unconscious hetero-centric biases and actions • Accept these biases. Work through these for yourself • in order to serve this population • Realize impact of external and internal LGBQ-prejudice/negativity on stress levels and self-esteem and the resulting acting or numbing out that may get expressed

16. Fostering an Inclusive Environment • People in LGB communities utilize therapy in larger numbers than non-LGBQs 2 • A sense of safety and connection is built, in part, through offering specific actions that promote LGBQ visibility and awareness. • Making a space for them and asking questions that mirror their experiences will aid in fostering an inclusive environment. Simple Steps You Can Take: • Waiting room: Diversity in magazines, books, art • Initial Intake forms & Interview • Eliminate items that may include • hetero-centrist bias on • intake forms and in interviews

17. Developing Competence Within & Beyond the Work Setting • Review your professional association guidelines for treating LGB/LGBT patients • http://www.apapracticecentral.org/ce/guidelines/index.aspx • http://www.psych.org/Departments/EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/200001.aspx • http://www.apa.org/pi/lgbt/resources/sexual-orientation.aspx • http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/glbt-advisory-committee/ama-policy-regarding-sexual-orientation.page • http://www.aamft.org/iMIS15/AAMFT/MFT_Resources/MFT_Resources/Content/Resources/Position_On_Couples.aspx • Join your professional association’s LGB/LGBT division, committee and/or listserv • http://www.aglp.org • http://www.apadivision44.org/ • http://www.socialworkers.org/governance/cmtes/nclgbi.asp • Keep abreast of socio-political and legal issues and/or changes that impact the life of your LGB patients • www.lambdalegal.org/ • www.glaad.org/ • www.nytimes.com

18. Developing Competence Within & Beyond the Work Setting (cont.) • Include study of LGB/LGBT populations in future research • Obtain clinical consultation for LGBQ patient care from LGBQ affirmative/competent therapists • Self-reflect on your hetero-normative/hetero-centric assumptions, hetero-sexual privileges, internalized homo-negativity, and sexual identity and the ways these may generalize to your life and work with your patients http:www.ndsu.edufileadminhdfsMcGeorge___Carlson_Deconstructing_Heterosexism.pdf • Be alert to organizations that promote reparative or conversion therapies aimed at “changing” sexual orientation.

19. Self-Exploration of Hetero-normative Assumptions, Heterosexual Privilege/Identity Source :http://www.ndsu.edu/fileadmin/hdfs/McGeorge___Carlson_Deconstructing_Heterosexism.pdf 1. How did I learn about my sexual orientation and other sexual orientations? 2. What kinds messages did I receive from my family/friends/society about mine and other sexual orientations? How do my actions reflect these messages in my life today? 3. Do I tend to assume a particular sexual orientation upon first meeting another person? 4. Do I respond to expression of affection, regardless of sexual orientation, the same way? If not, how do I respond? What informs me to respond in that way? 5. How might it be to live in a society that may be hostile toward my sexual orientation? How might this impact my wellbeing and mental health? How might it impact my comfort in getting help from others? 6. How does living in a hetero-centrist society impact my sense of self, my connections to others and my ease in navigating life and work challenges? 7. What was the cause of my sexual orientation? 8. Looking back, when did I decide to make heterosexuality my preference? 9. How does my sexual orientation inform my work with patients of same or other sexual orientations? 10. How often do I worry that my heterosexuality might cause me to lose my job or status? 11. How often am I concerned about losing my life solely as a result of my heterosexual orientation? 12. How often am I worried about being perceived as unsafe to work with children because of my heterosexual preference? 13. Do I think it is possible to change my sexual orientation? 14. How do I feel about folks who consider themselves to be bi-sexual? What informs my feelings?

20. Consider researching these and other resources to provide to your patients

21. References 1 APA Task Force on Appropriate Therapeutic Responses to Sexual Orientation. (2009). Report of the Task Force on Appropriate Therapeutic Responses to Sexual Orientation. Washington, DC: American Psychological Association. 2 Fassinger, R.E., & Richie, B.S. (1997). Sex matters: Gender and sexual orientation in training for multicultural counseling competency. In D. B. Pope-Davis & H.L.K. Coleman (Eds.), Multicultural counseling competencies: Assessment, education, training, and supervision (pp. 83-110). Thousand Oaks, CA: Sage. 3 Goldberg, A.E. (2010) Lesbian and gay parents and their children: Research on the family life cycle. Washington, D.C: American Psychological Association. 4 Greene, B. (1994). Lesbian and gay sexual orientations: Implications for clinical training, practice and research. In Greene B & Herek, G.M. (Eds.), Lesbian and gay psychology: Theory, research and clinical applications(pp. 1-21). Thousand Oaks: Sage. 5Herek, G. M., Gillis, J. R., & Cogan, J. C. (2009). Internalized stigma among sexual minority adults: Insights from a social psychological perspective. Journal of Counseling Psychology, 56, 32-43. 6McGeorge, C. & Carlson, T.S. (2011). Deconstructing heterosexism: Becoming an LGB affirmative heterosexual couple and family therapist. Journal of Marital and Family Therapy, 37 (1), 14-16. 7 Omotto, A.M. & Kurtzman, H.S. (Eds.), (2006). Sexual orientation and mental health: Examining identity and development in lesbian, gay and bisexual people. Washington, D.C.: American Psychological Association. 8 Perez, R.M., DeBord, K.A. & Bieschke, K.J. (Eds.), (2000). Handbook of counseling and psychotherapy with lesbian, gay, and bisexual clients. Washington, D.C.; American Psychological Association.

22. References (cont.) 9Reynolds, A.L. & Hanjorgiris, W.F. (2000). Coming out: Lesbian, gay, and bisexual identity development. In R.M. Perez, K.A. Debord & K.J. Bieschke (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, and bisexual clients (pp.35-55). Washington, D.C.; American Psychological Association 10 Ritter, K.Y. & Terndrup, A. I. (2002). Handbook of affirmative psychotherapy with lesbians and gay men. New York: Guilford Press. 11Rust, P. C. R. (2002). Bisexuality: The state of the union. Annual Review of Sex Research, 13, 180–240

23. Readings 1 Balsam, K. F., Mohr, J. J. (2007). Adaptation to sexual orientation stigma: A comparison of bisexual and lesbian/gay adults. Journal of Counseling Psychology, 54(3), 306-319. doi: 10.1037/0022-0167.54.3.306 Barbosa, P., Torres, H., Silva, M. A., & Khan, N. (2010). Agapé Christian reconciliation conversations: Exploring the intersections of culture, religiousness, and homosexual identity in Latino and European Americans. Journal of Homosexuality, 57(1), 98-116. doi:10.1080/00918360903445913 Barker, M., & Langdridge, D. (2008). Bisexuality: working with a silenced sexuality. Feminism & Psychology, 18(3), 389-394. Doi:10.1177/0959353508092093 Bettinger, M. (2002). Sexuality, boundaries, professional ethics, and clinical practice: The kink community. Journal of Gay & Lesbian Social Services: Issues in Practice, Policy & Research Special Issue: Issues in Practice, Policy & Research, 14(4), 93-104. doi:10.1300/J041v14n04_06 Birkett, M., Espelage, D. L., & Koenig, B. (2009). LGB and questioning students in schools: The moderating effects of homophobic bullying and school climate on negative outcomes. Journal of Youth and Adolescence, 38(7), 989-1000. doi:10.1007/s10964-008-9389-1 Borgman, A. L. (2009). LGB allies and Christian identity: A qualitative exploration of resolving conflicts and integrating identities. Journal of Counseling Psychology, 56(4), 508-520. doi:10.1037/a0016691 Braun-Harvey, D. (2009). Fundamental principles of sexual health for group psychotherapists and their groups.Group.Special Issue: Group Therapy with Lesbian, Gay, Bisexual, and Transgender Populations, 33(3), 257-271. Retrieved from www.csa.com Burckell, L. A., Goldfried, M. R. (2006). Therapist qualities preferred by sexual-minority individuals. Psychotherapy: Theory, Research, Practice, Training, 43(1), 32-49. doi: 10.1037/0033-3204.43.1.32

24. Readings 2 Buxton, A. P. (2006). Counseling heterosexual spouses of bisexual men and women and bisexual-heterosexual couples: Affirmative approaches. Journal of Bisexuality, 6(1-2), 105-135. doi:10.1300/J159v06n01_07 Cochran, S.D., Mays, V. M., Alegria, M., Ortega, A. N., Takeuchi, D. (2007). Mental health and substance use disorders among Latino and Asian American lesbian, gay, and bisexual adults. Journal of Consulting and Clinical Psychology, 75(5), 785-794. doi: 10.1037/0022-006X.75.5.7 Coolheart, D., Provancher, N., Hager, A., & Wang, M. (2008). Recommending transsexual clients for gender transition: A therapeutic tool for assessing readiness. Journal of GLBT Family Studies, 4(3), 301-324. Doi:10.1080/15504280802177466 Drescher, J. (2010). Queer diagnoses: Parallels and contrasts in the history of homosexuality, gender variance, and the diagnostic and statistical manual. Archives of Sexual Behavior, 39(2), 427-460. doi:10.1007/s10508-009-9531-5 Erich, S., Tittsworth, J., & Kersten, A. S. (2010). An examination and comparison of transsexuals of color and their white counterparts regarding personal well-being and support networks. Journal of GLBT Family Studies, 6(1), 25-39. doi:10.1080/15504280903472493 Fredriksen-Goldsen, K. I., & Muraco, A. (2010). Aging and sexual orientation: A 25-year review of the literature. Research on Aging, 32(3), 372-413. doi:10.1177/0164027509360355 Greene, B. (2009). African American lesbians and gay men: Life between a rock and a hard place. In H. A. Neville, B. M. Tynes & S. O. Utsey (Eds.), Handbook of African American psychology (pp. 311-331). Thousand Oaks, CA, US: Sage Publications, Inc. Retrieved from www.csa.com

25. Erich, S., Tittsworth, J., & Kersten, A. S. (2010). An examination and comparison of transsexuals of color and their white counterparts regarding personal well-being and support networks. Journal of GLBT Family Studies, 6(1), 25-39. doi:10.1080/15504280903472493 Fals-Stewart, W., O'Farrell, T. J., & Lam, W. K. K. (2009). Behavioral couple therapy for gay and lesbian couples with alcohol use disorders. Journal of Substance Abuse Treatment, 37(4), 379-387. doi:10.1016/j.jsat.2009.05.001 Fredriksen-Goldsen, K. I., & Muraco, A. (2010). Aging and sexual orientation: A 25-year review of the literature. Research on Aging, 32(3), 372-413. doi:10.1177/0164027509360355 Graham, S.R., & Liddle, B.J. (2009). Multiple relationships encountered by lesbian and bisexual psychotherapists: How close is too close? Professional Psychology: Research and Practice, 40(1), 15-21. doi:10.1037/a0013904. Greene, B. (2009). African american lesbians and gay men: Life between a rock and a hard place. In H. A. Neville, B. M. Tynes & S. O. Utsey (Eds.), Handbook of African American psychology. (, pp. 311-331). Thousand Oaks, CA, US: Sage Publications, Inc. Retrieved from www.csa.com Greene, B. (2009). The use and abuse of religious beliefs in dividing and conquering between socially marginalized groups: The same-sex marriage debate. American Psychologist, 64(8), 698-709. doi: 10.1037/0003-066X.64.8.698 Halkitis, P. N., Mattis, J. S., Sahadath, J. K., Massie, D., Ladyzhenskaya, L., Pitrelli, K., Bonacci, M., & Cowie, S. E. (2009). The meanings and manifestations of religion and spirituality among lesbian, gay, bisexual, and transgender adults. Journal of Adult Development, 16(4), 250-262. doi:10.1007/s10804-009-9071-1 Hatzenbuehler, M. L. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychological Bulletin, 135(5), 707-730. doi: 10.1037/a0016441 Herek, G.M. (1991). Stigma, prejudice, and violence against lesbians and gay men. In J. Gonsiorek & J. Weinrich (Eds.), Homosexuality: Research implications for public policy (pp. 60-80). Newbury Park, CA: Sage. Herek, G.M. (2003). Evaluating interventions to alter sexual orientation: Methodological and ethical considerations (Comment on Spitzer, 2003). Archives of Sexual Behavior, 32(5), 438-439. Herek, G.M. (2004). Beyond "homophobia": Thinking about sexual stigma and prejudice in the twenty-first century. Sexuality Research and Social Policy, 1(2), 6-24. Herek, G. M., & Garnets, L. D. (2007). Sexual orientation and mental health. Annual Review of Clinical Psychology, 3, 353-375. doi:10.1146/annurev.clinpsy.3.022806.091510 Hill, N. L. (2009). Affirmative practice and alternative sexual orientations: Helping clients navigate the coming out process. Clinical Social Work Journal, 37(4), 346-356. doi:10.1007/s10615-009-0240-2 Israel, T., Gorcheva, R., Walther, W.A., Sulzner, J. M., & Cohen, J. (2008). Therapists' helpful and unhelpful situations with LGBT clients: An exploratory study. Professional Psychology: Research and Practice, 39(3), 361-368. doi: 10.1037/0735-7028.39.3.36 Readings 3 Greene, B. (2009). The use and abuse of religious beliefs in dividing and conquering between socially marginalized groups: The same-sex marriage debate. American Psychologist, 64(8), 698-709. doi: 10.1037/0003-066X.64.8.698 Hatzenbuehler, M. L. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychological Bulletin, 135(5), 707-730. doi: 10.1037/a0016441 Herek, G.M. (1991). Stigma, prejudice, and violence against lesbians and gay men. In J. Gonsiorek & J. Weinrich (Eds.), Homosexuality: Research implications for public policy (pp. 60-80). Newbury Park, CA: Sage. Herek, G.M. (2003). Evaluating interventions to alter sexual orientation: Methodological and ethical considerations (Comment on Spitzer, 2003). Archives of Sexual Behavior, 32(5), 438-439. Herek, G.M. (2004). Beyond "homophobia": Thinking about sexual stigma and prejudice in the twenty-first century. Sexuality Research and Social Policy, 1(2), 6-24. Herek, G. M., & Garnets, L. D. (2007). Sexual orientation and mental health. Annual Review of Clinical Psychology, 3, 353-375. doi:10.1146/annurev.clinpsy.3.022806.091510 Hill, N. L. (2009). Affirmative practice and alternative sexual orientations: Helping clients navigate the coming out process. Clinical Social Work Journal, 37(4), 346-356. doi:10.1007/s10615-009-0240-2

26. Erich, S., Tittsworth, J., & Kersten, A. S. (2010). An examination and comparison of transsexuals of color and their white counterparts regarding personal well-being and support networks. Journal of GLBT Family Studies, 6(1), 25-39. doi:10.1080/15504280903472493 Fals-Stewart, W., O'Farrell, T. J., & Lam, W. K. K. (2009). Behavioral couple therapy for gay and lesbian couples with alcohol use disorders. Journal of Substance Abuse Treatment, 37(4), 379-387. doi:10.1016/j.jsat.2009.05.001 Fredriksen-Goldsen, K. I., & Muraco, A. (2010). Aging and sexual orientation: A 25-year review of the literature. Research on Aging, 32(3), 372-413. doi:10.1177/0164027509360355 Graham, S.R., & Liddle, B.J. (2009). Multiple relationships encountered by lesbian and bisexual psychotherapists: How close is too close? Professional Psychology: Research and Practice, 40(1), 15-21. doi:10.1037/a0013904. Greene, B. (2009). African american lesbians and gay men: Life between a rock and a hard place. In H. A. Neville, B. M. Tynes & S. O. Utsey (Eds.), Handbook of African American psychology. (, pp. 311-331). Thousand Oaks, CA, US: Sage Publications, Inc. Retrieved from www.csa.com Greene, B. (2009). The use and abuse of religious beliefs in dividing and conquering between socially marginalized groups: The same-sex marriage debate. American Psychologist, 64(8), 698-709. doi: 10.1037/0003-066X.64.8.698 Halkitis, P. N., Mattis, J. S., Sahadath, J. K., Massie, D., Ladyzhenskaya, L., Pitrelli, K., Bonacci, M., & Cowie, S. E. (2009). The meanings and manifestations of religion and spirituality among lesbian, gay, bisexual, and transgender adults. Journal of Adult Development, 16(4), 250-262. doi:10.1007/s10804-009-9071-1 Hatzenbuehler, M. L. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychological Bulletin, 135(5), 707-730. doi: 10.1037/a0016441 Herek, G.M. (1991). Stigma, prejudice, and violence against lesbians and gay men. In J. Gonsiorek & J. Weinrich (Eds.), Homosexuality: Research implications for public policy (pp. 60-80). Newbury Park, CA: Sage. Herek, G.M. (2003). Evaluating interventions to alter sexual orientation: Methodological and ethical considerations (Comment on Spitzer, 2003). Archives of Sexual Behavior, 32(5), 438-439. Herek, G.M. (2004). Beyond "homophobia": Thinking about sexual stigma and prejudice in the twenty-first century. Sexuality Research and Social Policy, 1(2), 6-24. Herek, G. M., & Garnets, L. D. (2007). Sexual orientation and mental health. Annual Review of Clinical Psychology, 3, 353-375. doi:10.1146/annurev.clinpsy.3.022806.091510 Hill, N. L. (2009). Affirmative practice and alternative sexual orientations: Helping clients navigate the coming out process. Clinical Social Work Journal, 37(4), 346-356. doi:10.1007/s10615-009-0240-2 Israel, T., Gorcheva, R., Walther, W.A., Sulzner, J. M., & Cohen, J. (2008). Therapists' helpful and unhelpful situations with LGBT clients: An exploratory study. Professional Psychology: Research and Practice, 39(3), 361-368. doi: 10.1037/0735-7028.39.3.36 Readings 4 Israel, T., Gorcheva, R., Walther, W.A., Sulzner, J. M., & Cohen, J. (2008). Therapists' helpful and unhelpful situations with LGBT clients: An exploratory study. Professional Psychology: Research and Practice, 39(3), 361-368. doi: 10.1037/0735-7028.39.3.36 Kelly, B.C., Bimbai, D.S., Nanin, J.E., Izienicki, H., & Parsons, J.T. (2009). Sexual compulsivity and sexual behaviors among gay and bisexual men and lesbian and bisexual women. Journal of Sex Research, 46(4), 301-308. doi:10.1080/0022449080266625. Kertzner, R. M., Meyer, I. H., Frost, D. M., & Stirratt, M. J. (2009). Social and psychological well-being in lesbians, gay men, and bisexuals: The effects of race, gender, age, and sexual identity. American Journal of Orthopsychiatry, 79(4), 500-510. doi:10.1037/a0016848 Kolmes, K., Stock, W., & Moser, C. (2006). Investigating bias in psychotherapy with BDSM clients. Journal of Homosexuality.Special Issue: Sadomasochism: Powerful Pleasures, 50(2-3), 301-324. doi:10.1300/J082v50n02_15 Kosciw, J. G., Greytak, E. A., & Diaz, E. M. (2009). Who, what, where, when, and why: Demographic and ecological factors contributing to hostile school climate for lesbian, gay, bisexual, and transgender youth. Journal of Youth and Adolescence, 38(7), 976-988. doi:10.1007/s10964-009-9412-1 Manners, P. J. (2009). Gender identity disorder in adolescence: A review of the literature. Child and Adolescent Mental Health, 14(2), 62-68. doi:10.1111/j.1475-3588.2008.00498.x

27. Erich, S., Tittsworth, J., & Kersten, A. S. (2010). An examination and comparison of transsexuals of color and their white counterparts regarding personal well-being and support networks. Journal of GLBT Family Studies, 6(1), 25-39. doi:10.1080/15504280903472493 Fals-Stewart, W., O'Farrell, T. J., & Lam, W. K. K. (2009). Behavioral couple therapy for gay and lesbian couples with alcohol use disorders. Journal of Substance Abuse Treatment, 37(4), 379-387. doi:10.1016/j.jsat.2009.05.001 Fredriksen-Goldsen, K. I., & Muraco, A. (2010). Aging and sexual orientation: A 25-year review of the literature. Research on Aging, 32(3), 372-413. doi:10.1177/0164027509360355 Graham, S.R., & Liddle, B.J. (2009). Multiple relationships encountered by lesbian and bisexual psychotherapists: How close is too close? Professional Psychology: Research and Practice, 40(1), 15-21. doi:10.1037/a0013904. Greene, B. (2009). African american lesbians and gay men: Life between a rock and a hard place. In H. A. Neville, B. M. Tynes & S. O. Utsey (Eds.), Handbook of African American psychology. (, pp. 311-331). Thousand Oaks, CA, US: Sage Publications, Inc. Retrieved from www.csa.com Greene, B. (2009). The use and abuse of religious beliefs in dividing and conquering between socially marginalized groups: The same-sex marriage debate. American Psychologist, 64(8), 698-709. doi: 10.1037/0003-066X.64.8.698 Halkitis, P. N., Mattis, J. S., Sahadath, J. K., Massie, D., Ladyzhenskaya, L., Pitrelli, K., Bonacci, M., & Cowie, S. E. (2009). The meanings and manifestations of religion and spirituality among lesbian, gay, bisexual, and transgender adults. Journal of Adult Development, 16(4), 250-262. doi:10.1007/s10804-009-9071-1 Hatzenbuehler, M. L. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychological Bulletin, 135(5), 707-730. doi: 10.1037/a0016441 Herek, G.M. (1991). Stigma, prejudice, and violence against lesbians and gay men. In J. Gonsiorek & J. Weinrich (Eds.), Homosexuality: Research implications for public policy (pp. 60-80). Newbury Park, CA: Sage. Herek, G.M. (2003). Evaluating interventions to alter sexual orientation: Methodological and ethical considerations (Comment on Spitzer, 2003). Archives of Sexual Behavior, 32(5), 438-439. Herek, G.M. (2004). Beyond "homophobia": Thinking about sexual stigma and prejudice in the twenty-first century. Sexuality Research and Social Policy, 1(2), 6-24. Herek, G. M., & Garnets, L. D. (2007). Sexual orientation and mental health. Annual Review of Clinical Psychology, 3, 353-375. doi:10.1146/annurev.clinpsy.3.022806.091510 Hill, N. L. (2009). Affirmative practice and alternative sexual orientations: Helping clients navigate the coming out process. Clinical Social Work Journal, 37(4), 346-356. doi:10.1007/s10615-009-0240-2 Israel, T., Gorcheva, R., Walther, W.A., Sulzner, J. M., & Cohen, J. (2008). Therapists' helpful and unhelpful situations with LGBT clients: An exploratory study. Professional Psychology: Research and Practice, 39(3), 361-368. doi: 10.1037/0735-7028.39.3.36 Readings 5 Moser, C. (2009). When is an unusual sexual interest a mental disorder? Archives of Sexual Behavior, 38(3), 323-325. doi:10.1007/s10508-008-9436-8 Mueller, J. A., & Cole, J. C. (2009). A qualitative examination of heterosexual consciousness among college students. Journal of College Student Development, 50(3), 320-336. Retrieved from www.csa.com Parrott, D. J., Zeichner, A. (2005). Effects of sexual prejudice and anger on physical aggression toward gay and heterosexual men. Psychology of Men & Masculinity, 6(1), 3-17. doi: 10.1037/1524-9220.6.1.3 Parsons, J. T., Kelly, B. C., Bimbi, D. S., Muench, F., & Morgenstern, J. (2007). Accounting for the social triggers of sexual compulsivity. Journal of Addictive Diseases, 26(3), 5-16. doi:10.1300/J069v26n03_02 Pope, A. L., Mobley, A. K., & Myers, J. E. (2010). Integrating identities for same-sex attracted clients: Using developmental counseling and therapy to address sexual orientation conflicts. Journal of LGBT Issues in Counseling, 4(1), 32-47. doi:10.1080/15538600903552749 Pope, A. L., Murray, C. E., & Mobley, A. K. (2010). Personal, relational, and contextual resources and relationship satisfaction in same-sex couples. The Family Journal, 18(2), 163-168. doi:10.1177/1066480710364501 Rutter, P. A., Leech, N. N., Anderson, M., & Saunders, D. (2010). Couples counseling for a transgender-lesbian couple: Student counselors' comfort and discomfort with sexuality counseling topics. Journal of GLBT Family Studies, 6(1), 68-79. doi:10.1080/15504280903472816

28. Erich, S., Tittsworth, J., & Kersten, A. S. (2010). An examination and comparison of transsexuals of color and their white counterparts regarding personal well-being and support networks. Journal of GLBT Family Studies, 6(1), 25-39. doi:10.1080/15504280903472493 Fals-Stewart, W., O'Farrell, T. J., & Lam, W. K. K. (2009). Behavioral couple therapy for gay and lesbian couples with alcohol use disorders. Journal of Substance Abuse Treatment, 37(4), 379-387. doi:10.1016/j.jsat.2009.05.001 Fredriksen-Goldsen, K. I., & Muraco, A. (2010). Aging and sexual orientation: A 25-year review of the literature. Research on Aging, 32(3), 372-413. doi:10.1177/0164027509360355 Graham, S.R., & Liddle, B.J. (2009). Multiple relationships encountered by lesbian and bisexual psychotherapists: How close is too close? Professional Psychology: Research and Practice, 40(1), 15-21. doi:10.1037/a0013904. Greene, B. (2009). African american lesbians and gay men: Life between a rock and a hard place. In H. A. Neville, B. M. Tynes & S. O. Utsey (Eds.), Handbook of African American psychology. (, pp. 311-331). Thousand Oaks, CA, US: Sage Publications, Inc. Retrieved from www.csa.com Greene, B. (2009). The use and abuse of religious beliefs in dividing and conquering between socially marginalized groups: The same-sex marriage debate. American Psychologist, 64(8), 698-709. doi: 10.1037/0003-066X.64.8.698 Halkitis, P. N., Mattis, J. S., Sahadath, J. K., Massie, D., Ladyzhenskaya, L., Pitrelli, K., Bonacci, M., & Cowie, S. E. (2009). The meanings and manifestations of religion and spirituality among lesbian, gay, bisexual, and transgender adults. Journal of Adult Development, 16(4), 250-262. doi:10.1007/s10804-009-9071-1 Hatzenbuehler, M. L. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychological Bulletin, 135(5), 707-730. doi: 10.1037/a0016441 Herek, G.M. (1991). Stigma, prejudice, and violence against lesbians and gay men. In J. Gonsiorek & J. Weinrich (Eds.), Homosexuality: Research implications for public policy (pp. 60-80). Newbury Park, CA: Sage. Herek, G.M. (2003). Evaluating interventions to alter sexual orientation: Methodological and ethical considerations (Comment on Spitzer, 2003). Archives of Sexual Behavior, 32(5), 438-439. Herek, G.M. (2004). Beyond "homophobia": Thinking about sexual stigma and prejudice in the twenty-first century. Sexuality Research and Social Policy, 1(2), 6-24. Herek, G. M., & Garnets, L. D. (2007). Sexual orientation and mental health. Annual Review of Clinical Psychology, 3, 353-375. doi:10.1146/annurev.clinpsy.3.022806.091510 Hill, N. L. (2009). Affirmative practice and alternative sexual orientations: Helping clients navigate the coming out process. Clinical Social Work Journal, 37(4), 346-356. doi:10.1007/s10615-009-0240-2 Israel, T., Gorcheva, R., Walther, W.A., Sulzner, J. M., & Cohen, J. (2008). Therapists' helpful and unhelpful situations with LGBT clients: An exploratory study. Professional Psychology: Research and Practice, 39(3), 361-368. doi: 10.1037/0735-7028.39.3.36 Readings 6 Pope, A. L., Mobley, A. K., & Myers, J. E. (2010). Integrating identities for same-sex attracted clients: Using developmental counseling and therapy to address sexual orientation conflicts. Journal of LGBT Issues in Counseling, 4(1), 32-47. doi:10.1080/15538600903552749 Pope, A. L., Murray, C. E., & Mobley, A. K. (2010). Personal, relational, and contextual resources and relationship satisfaction in same-sex couples. The Family Journal, 18(2), 163-168. doi:10.1177/1066480710364501 Shildo, A. (1994). Internalized homophobia: Conceptual and empirical issues in measurement. In B. Greene & G.M. Herek (Eds.), Lesbian and gay psychology: Theory, research and clinical applications (pp.176-205). Thousand Oaks, CA: Sage. Vrangalova, Z., & Savin-Williams, R. C. (2010). Correlates of same-sex sexuality in heterosexually identified young adults. Journal of Sex Research, 47(1), 92-102. doi:10.1080/00224490902954307 Willging, C. E., Salvador, M., & Kano, M. (2006). Unequal treatment: Mental health care for sexual and gender minority groups in a rural state. Psychiatric Services, 57(6), 867-870. doi:10.1176/appi.ps.57.6.867

29. Contact Information Lisa A. Schimmel, Ph.D. Psychologist & Clinical Consultant License Numbers: Psy15072 (CA) 1709 (OR) Phone: 503.381.9524 Email: schimmli@ohsu.edu

30. Thoughts?Questions? Thoughts? Questions? Thoughts? Questions? Thoughts?Questions? Thoughts? Questions? Thoughts?Questions?