At the completion of this module, the participant will be able to take sexual orientation/sexual identity into account in making a psychiatric assessment and designing a plan for psychotherapy.  


In order to reach this goal, the participant will have:


  1. Which of the following statements is most accurate concerning a therapist's self-disclosure of sexual orientation to a LGBT patient:
    1. Therapists should never self disclose.
    2. Only a gay or lesbian therapist should disclose this information.
    3. The decision to disclose depends on the needs of the particular patient.
    4. A heterosexual therapist should disclose this at the outset of treatment.

  2. Considering "coming out of the closet":
    1. LGBT clients should be encouraged to come out as quickly as possible
    2. Clients who are ambivalent about their sexual orientation should be helped to understand that they are resisting coming out to themselves
    3. Teenagers should be discouraged from coming out to their parents
    4. Therapists should not pressure an LGBT client to come out

  3. Reparative therapy:
    1. Utilizes electroshock and pharmacological aversion treatment
    2. May be harmful to patients
    3. Has been endorsed by the American Psychoanalytic Association
    4. Has been proven to be effective in highly-motivated Christian clients

  4. Gay-affirmative therapy:
    1. Assumes that GLB identity is normal
    2. Encourages clients to come out to friends and family
    3. Requires that the therapist be gay or lesbian
    4. Encourages clients to promptly explore all forms of homosexual sex

General Issues in Working with GLBT Patients

GLB people enter therapy for help with the same clinical and life issues that heterosexuals do - depression, anxiety disorders, grief, relationship difficulties, work dissatisfaction, etc. Some of the presenting issues of GLB people have little to do with their sexual orientation while others will be intimately connected to their GLB identity. Even when a patient's chief complaint seems apparently unrelated to being GLB, issues of sexual orientation are likely to play a role in how treatment may unfold. Consequently, a therapist will need some specialized knowledge in order to be most helpful to the patient.

Gay-affirmative therapy assumes that GLB identities are normal and that changing a patient's sexual identity should not be a goal of treatment. Gay-affirmative therapy has two important underpinnings:

  1. The therapist needs to be willing to examine anti-homosexual attitudes in him- or herself and in the patient as they emerge in treatment. Anti-homosexual attitudes include homophobia, heterosexism, anti-gay violence, and moral condemnations of homosexuality. For example, a patient describes a relationship ending and the therapist thinks "Isn't this inevitable? Gay relationships never last." This stereotypical misconception on the therapist's part represents a judgmental homophobic countertransference that can threaten his or her potential to be helpful to the patient.

  2. The therapist needs to become familiar with issues specific to being GLB, and in particular the issue of coming out. The assumption that GLB identities are normal need not lead to "cheerleading," nor should the therapist encourage patients who are questioning their identities to come out prematurely or to simply reassure them that "it is ok to be gay." Therapists can be most helpful if they have no agenda as to how patients resolve complex issues of identity, affiliation, and openness, and do not push for premature resolution in these areas.

The Therapist's Sexuality

In the past, all therapists were presumed to be heterosexual. If they were not, they had to pretend that they were or risk professional ostracism. In addition, psychoanalytically oriented therapists frowned upon revealing personal details to a patient. Being an openly gay therapist was viewed as a countertransference problem.

Today, many lesbian, gay, bisexual or transgendered (LGBT) therapists have found that such disclosures can be helpful, as in the case of patients who may be struggling with the question of whether to come out. They argue that revelation of a therapist's LGBT identity need not be more disclosing than a heterosexual therapist's decision to wear a wedding ring.

Heterosexual therapists may see no need to directly declare their sexual identities and assume that without direct disclosure, a patient cannot determine the therapist's sexual identity. However therapists always provide indirect clues about their own identities, even when they do not provide direct confirmation. Because LGBT people grow up in a world where revealing their sexual identity is fraught with dangers, some develop an acute sensitivity--sometimes referred to as "gaydar"--regarding the sexual identities of others.

Today, in search of safe psychotherapeutic spaces, many patients seek treatment with openly LGBT therapists. This is a viable option where therapists are willing to come out to their professional communities. When openly LGBT therapists are not available, patients may seek out a heterosexual therapist who is LGBT-friendly--someone comfortable with and knowledgeable about LGBT people's lives. In training settings, a curious, beginning therapist who knows little about the lives of LGBT people will sometimes encounter patients willing to share that information. Other patients may feel uncomfortable educating a naive therapist.

An LGBT therapist does not automatically have greater insights into issues that bring LGBT patients into treatment. Furthermore, an LGBT identity is not a substitute for rigorous psychotherapy training and undergoing a personal psychotherapy or analysis. A therapist need not be LGBT to treat LGBT patients any more than a therapist needs a heterosexual identity to treat heterosexual patients. Therapy's effectiveness is not necessarily determined by presumed similarities between a patient and therapist. A better way to evaluate effectiveness is how similarities and differences are handled in the therapeutic dyad.

Therapists, regardless of their own sexual identity, should evaluate a patient's need for the therapist to come out on an individual basis, and be prepared to do so when necessary. [Also see Ethics unit]

Transference and Countertransference

In psychotherapy with LGB clients, there can emerge both generic and specific transferences and countertransferences. Generic transferences might include the usual ways clients can experience their therapist, like "maternal" as in caring, or "paternal" as in protective or judgmental.

Several specific transferences and countertransferences have been identified in the psychotherapy of GLB clients. Here are just a few that have been described:

Transferences of GLB clients:

Expectation of Judgment or Labeling

"My therapist judges my orientation as 'bad' or 'wrong'."

The client may have experienced and then internalized negative views of him or herself from important figures in his or her life. The client may then expect others, particularly authority figures, to feel the same way. Bisexual clients may anticipate that their orientation will be judged as unstable or indecisive rather than a equally valid endpoint. Some clients may fear the therapist is eager to have the patient accept a limiting label to control or categorize them.

Idealization of a gay or gay-friendly therapist

"My therapist understands me completely and sees nothing wrong with who I am."

The GLB client may wish to believe that a therapist with experience in gay/lesbian issues will spontaneously understand their specific life experiences, without the usual history taking and relating of life stories with all their inherent contradictions. This assumption may limit the therapist's deeper understanding of the client and his or her conflicts. Alternatively, a GLB client may defensively assume that a therapist who is perceived as not knowledgeable about GLB issues couldn't possibly understand him or her.

Romantic feelings toward therapist

"I love my therapist" or "My therapist loves me."

GLB clients can develop romantic feelings for the therapist or fall in love with an imagined perception of the therapist. This may be confusing for the client if the gender or orientation of the therapist does not correspond to what their orientation might predict. A therapist should learn to explore and tolerate a wide range of romantic feelings from clients, even feelings that may be incongruent with of their own orientation or gender. Alternatively, a client may come to feel that the therapist is developing strong romantic feelings for him or her.

Sexual feelings toward therapist

"I have sexual feelings or dreams about my therapist."

Sometimes LGB clients develop intense sexual feelings for a therapist. These feelings may present as sexual images in dreams or daytime thoughts, or as a preoccupation with the therapist. Exploring the meanings of these feelings in expressive therapies can lead to treatment gains. In supportive therapies, boundary setting and reassurances that sex will not take place between therapist and client is useful. Therapists may need supervision in these situations, especially if a therapist is personally upset or offended by a patient's sexual desires or feelings.


Over identification/Over protectiveness

"My client has been through a lot of pain due to their sexual orientation; I can be the one to help them heal."

An empathic understanding of a client's life is an important part of a therapeutic alliance. However, an overly close identification with a client's struggle or suffering can lead to over protectiveness or inability to explore less than admirable aspects of a client.


"I feel anxious and uncomfortable when my client talks about the sex he/she is having."

If a therapist is made uncomfortable with hearing about sex, this may be conveyed to the GLB client, "shutting down" further sharing of information and feelings. Some therapists are more comfortable with abstract notions of sexual orientation or identity than they are discussing the actual details of sexual acts. Some therapists may wish to limit their work with GLBT clients if they are particularly bothered by sexual details and supervision is not helpful in resolving this. Some therapists can be made uncomfortable by clients with bisexual behavior or orientation, particularly if they do not believe that a bisexual orientation is a stable one, or if they feel that a client has to choose either homosexuality or heterosexuality.  

Rush toward a stable identity

"My client's uncertainty about whether he/she is gay or straight has lasted a long time. I feel I want to move my client along faster toward self acceptance and a stable identity."

The process of coming out is complex and can take years. The process is not linear. In therapy, there can be times of great movement and change interspersed with long, seemingly quiescent periods. Therapists need to be patient, respectful and open to many possible end points - including a straight identity, a gay or lesbian identity, bisexual experiences and identity, or even the patient's rejection of a traditional identity label altogether.

Over pathologizing

"My client is borderline."

The coming out process can be a fast-moving, tumultuous time for both the client and the therapist. Clients can have a shifting sense of self and impulsivity, experimentation, and a quickly changing group of friends. These behaviors may overlap with some DSM criteria for personality disorders and traits, but often don't represent lifelong behavioral patterns. GLB clients, like any segment of the population, may have personality or character pathology, but the therapist should be vigilant not to overpathologize or jump to a diagnosis based on countertransference.

HIV and AIDS in Psychotherapy with GLBT Patients

When a GLBT patient discloses an unsafe sexual practice in psychotherapy, his or her therapist should strive to maintain a non-judgmental attitude that includes interest in exploring this behavior in an open, encouraging manner. This non-judgmental stance is a prerequisite for all patients but given the ubiquity of fear and shame in GLBT patients, is especially important. Some patients will disclose unsafe sexual practices spontaneously, but a thorough sexual history, including risk factors for HIV exposure, is essential to ensure that patients who are reluctant to talk about unsafe sex are encouraged to do so.

A thorough sexual history obtained in the context of a therapeutic relationship in which a patient feels comfortable may reveal surprises. Psychotherapists should not assume that GLBT patients only have sex with members of the same gender or that heterosexually identified patients only have sex with members of the opposite gender. A woman who identifies as lesbian may have sex with men occasionally. For example, some lesbians with substance related disorders might exchange drugs for sex. An African-American man may consider himself to be straight because he has a girlfriend even though he has sex with men (being "on the down-low" or "DL"). In fact, in many cultures outside the U.S., a man is not considered gay or bisexual if he has a girlfriend or wife and does not engage in receptive anal intercourse. The current term in the U.S. for such men who are heterosexually identified, but have sex with other men is MSM (Men who have sex with men). In general, as with all patients, all risk factors for HIV exposure should be reviewed with all GLBT patients. This includes unprotected anal or vaginal sex (in both cases, sex without a condom either as the insertive or receptive partner), unprotected oral sex (although the level of risk is more controversial), sharing of needles, breastfeeding, or blood transfusions prior to 1986 in the United States.

Discussions of sex without a condom may lead to the topic of "barebacking" (male unprotected anal sex). Why might patients bareback?   Nonjudgmental inquiries might yield a response.   Perhaps a patient is tired of the vigilance that safer sex requires or perhaps, in light of new treatments, he doesn't see HIV disease as a catastrophic condition. He may value the emotional intimacy of sex without condoms or feel that condoms impair the development of trust and closeness. He may be making what feel like educated guesses about who might be a source of infection and who might not.   He may be afraid to refuse a sexual partner's request for unprotected sex.   He may wish to become HIV infected (a "bug-chaser").  He may be using drugs that impair his judgment, or he may be involved in an abusive or coercive relationship. A psychotherapist needs to understand the many possible meanings of having sex without condoms in order to help a patient make rational decisions to better protect himself.

For the patient newly diagnosed with HIV, the psychotherapist may need to convey that HIV disease is not a death sentence nor is it a moral punishment. Referrals and encouragement to seek medical treatment may be needed, as well as tracking the patient's success at engaging with medical treatment. Psychotherapists need to be aware that not all patients will choose traditional Western treatments and be prepared to explore reasons for this. A patient may need help deciding whether to disclose his diagnosis to others, including his sexual partners, friends, and family. Important issues about health care and disability benefits, insurance, and estate planning may arise.

Clinical example

Andrew, a 26-year-old gay man, mentions in a psychotherapy session that he met someone through the Internet. With a slightly challenging tone, he says, "I fucked him without a condom. He didn't want me to use one, and it's not really that dangerous to be a top. I'd never do it as a bottom."

In this example, the therapist should be aware that Andrew might be bringing up this encounter for multiple reasons, not all of them necessarily within his awareness. He may want to be reassured by his therapist about his behavior. Alternatively, he may be hoping to be challenged. He may be testing to find out if his therapist responds with discomfort or disapproval. Andrew's disclosure of an unsafe sexual practice provides many opportunities for the psychotherapist. The therapist should try to learn more about the circumstances. Who was his partner? Perhaps Andrew didn't think he had to ask about HIV status because he thought his partner didn't "look" like someone with HIV. What is his understanding of safer sex? A non-judgmentally curious stance with such a patient may help him to better understand his own conflicts about this and is more likely to result in his choosing to practice safer sex than moralizing. This can be an opportunity to offer information regarding safer sex and strategies targeted to reducing risk. Were drugs or alcohol involved? An untreated substance-related disorder might be discovered. Are shame and internalized antihomosexual attitudes present that make the patient feel that his personal well being is unimportant? Similarly, are depression, suicidality, or psychosis present? Assessing for and treating psychiatric disorders such as Major Depressive Disorder may help patients practice safer sex.


The prevailing paradigms of sexuality,  derived from the illness model of homosexuality, splits sexual desire into two categories: homosexual and heterosexual. However, research indicates that a substantial number of people feel sexual attraction to both men and women. The word bisexual is used as an adjective to describe sexual attraction to both genders, as well as sexual behavior that includes sex with both genders. The word is also used as a noun to describe individuals with have a bisexual sexual orientation.

Issues common for bisexuals include confusion about how to understand their patterns of sexual attraction as well as feelings of isolation or alienation. One common difficulty that bisexuals face is a sense of alienation from both the heterosexual community and the GLBT community. If in a relationship with someone of the same sex, bisexuals face all the same issues as gays and lesbians in terms of coming out to family, friends, and community members. If a bisexual person comes out to family members as bisexual, he or she may feel pressure avoid or hide his or her same-sex attractions, e.g. parents may not recognize same-sex partners and may ask if the person has a "choice," why they would ever choose a same-sex partner? When looking for refuge in the gay community, bisexuals may feel ostracized as many gay and lesbian people assume that bisexuals are really homosexual but are too fearful to come out as gay. Alternatively, they may feel that bisexuals are going through a "phase" on their way to full homosexuality. Some gays and lesbians resent bisexuals for their choice to "pass" as heterosexual when they are in a relationship with someone of the opposite sex. In the interest of finding community, bisexuals may feel forced to present themselves as either gay or straight. [Further reading, see Fox 2003.]

Disorders of Sex Development (Intersex)

Therapists may encounter individuals with a Disorder of Sex Development (DSD) at any point in their lifespan, but most commonly at birth, in adolescence, and when newly diagnosed in their adult years. Unfortunately, mental health professionals are not included early or often enough in the care of individuals with a DSD. When called upon for consultation at the birth, the psychiatrist needs to work with the family of the infant with a DSD. The psychiatrist can help explain to the parents the nature of the DSD condition and the future implications for the child, as well as offering support to parents whose expectations have been changed and who are frightened and uncertain. Later on, it is important not to overlook other mental health issues for the child such as learning disabilities, anxiety disorders, depression and ADHD. Despite careful diagnostic consideration in making sex assignment at birth, it may become evident later that the sex assignment that was made conflicts with the individual's core gender identity. In adolescence, especially, issues of gender identity and sexuality may become more salient. Some individuals' DSD conditions may not be diagnosed until adolescent or adult years because of problems with delayed puberty, sexual dysfunction, and infertility. Many people with a DSD, especially those with early surgical intervention, have issues regarding body image and may postpone the development of intimate relationships. In the past the secrecy regarding DSD conditions led to feelings of shame, silence, and feelings of betrayal when individuals eventually learned their DSD history. Despite the somatic and physiological challenges, some  people with DSD make good psychosocial adjustment and are able to have partners, families, and lead productive lives. It is also important to remember that these individuals may have any of the sexual orientations or gender identities of their counterparts without a DSD.

[Also see DSD unit for clinical examples]

Internet Resources

Intersex Society of North America (closed 2008; site archived)

Consortium on Disorders of Sex Development

Sexual Compulsivity

Clinical Example

Edward is a 30-year-old gay man who came into therapy with complaints of feeling depressed and being unable to maintain meaningful relationships with sexual partners. As therapy progressed, he described sexual relations with multiple anonymous partners, sometimes several in one night, augmented by frequent masturbatory activity. He described the use of sexual-enhancing drugs such as methamphetamine ("crystal"). His performance at work showed signs of deterioration, leading to feelings of guilt and depression.

Sexual compulsivity, as illustrated above, refers to repetitive, intensely driven sexual behavior that often occurs at the expense of meaningful interpersonal relationships. It may, at times, expose the individual to significant risk both for injury and illness. The individual may feel out of control and may experience intense guilt or remorse, as well as shame over the loss of control and the sexual behaviors themselves. Sexually compulsive behavior may have different psychological underpinnings in different patients. It may be used to relieve feelings of anxiety or depression, or as a self-regulating mechanism to dispel painful affects or loneliness. The excitement and gratification of the activity can have an addictive quality, in that it can lead to the desire to repeat the behavior as well as a need for more intense stimulation.  Also, there may be a feeling of boredom or agitation upon abstaining. There is a common misconception that such sexual patterns characterize gay life in general. In reality, these problems are present in only a small subgroup of the GLBT community. In fact, compulsive sexual behavior is not rare in the general population.

Sexually compulsive behavior often is accompanied by substance use, most commonly alcohol, though one also can see use of marijuana, cocaine, crystal methamphetamine and "designer drugs," such as MDMA or GHB. Use of drugs is correlated with an increase in unsafe sex practices. The presence of a co-morbid substance use disorder makes treatment more difficult as both addictions need to be addressed.

There is no single underlying etiology for sexually compulsive behavior. A patient whose sexual experience is heightened by intense excitement and risk-taking behaviors will require a different approach than a patient who is using sexual behavior to relieve anxiety or repress intolerable affects. The therapist ideally will guide the patient in uncovering the specific underlying motivational factors involved as well as exploring risky or dangerous behaviors. The therapist's approach should avoid judgment or criticism as negative countertransferential reactions will block the patient's ability to explore his or her motivations for change such reactions can lessen the potential for lasting change. The patient's perception of either judgment or criticism may lead to the precipitous termination of treatment or deepening of depression, but is unlikely to stimulate curiosity or increasing self-awareness in the patient.

A realistic goal might be to help the patient address the self-destructive aspects of their behavior as well as the perceived value; in addition, it is vital to address co-morbid psychiatric disorders. The therapist should explore the patient's relationships, capacity for affect management, strategies for self-soothing. Not all patients with compulsive patterns of sexual behavior will respond to psychotherapy. Other approaches that can be valuable include behavioral modification, psychotropic medication, and Twelve Step programs such as Sexual Compulsives Anonymous or Sex Addicts Anonymous. Although the DSM does not classify sexual compulsivity as an addiction, some patients find an addiction model helpful in their efforts to control their behaviors.  

Kinky Sex and Kinky Love

In the course of evaluation and treatment of a GLBT patient, the therapist may discover that the patient engages in diverse sexual behaviors,  including bondage, dominance,  sadomasochism (BDSM), "water sports" (sex involving urine), “scat” (sex involving feces), sex involving animals, cross-dressing, or leather outfits, to name a few. Heterosexuals as well as GLBT people engage in these sexual practices. They may involve erotic role-playing with focus on power dynamics or a desire for intense erotic stimulation.  When these sexual practices are the only source of sexual satisfaction, they are diagnosed as paraphilic disorders in the DSM V. However, in many individuals, these practices do not warrant a psychiatric diagnosis.

The patient's presenting problem may or may not be related to their preferred mode of sexual expression. It can be challenging for the therapist to accept the patient's view of their sexuality as non-problematic or even healthy if it stirs up anxiety, confusion or disgust in the therapist. On the other hand the patient may be distressed over desires or behaviors that feel shameful, degrading or dangerous. In these instances, it is all the more important for the therapist to maintain a nonjudgmental stance. The patient's sexual interests may represent an expression or adaptation to the sequela of sexual abuse or trauma, though this link remains speculative. It is most prudent to avoid presumptive formulations about any particular mode of sexual expression and instead, seek an understanding that is based on the patient's unique history presenting problem, transference manifestations and the expressed goals of treatment.

Conversion or Reorientation Therapies

"In general, to undertake to convert a fully developed homosexual into a heterosexual does not offer much prospect of success than the reverse, except that for good practical reasons the latter is never attempted"
-- Sigmund Freud

Sexual conversion therapy, also referred to as "reparative" or reorientation therapy refers to a number of psychotherapeutic techniques and "talking cures" aimed at changing a person's sexual orientation from homosexual or bisexual to predominantly or exclusively heterosexual. Underlying these approaches is the implicit or explicit belief that homosexuality or bisexuality represents abnormal, pathological development or a deficit that can be "repaired."

Since 1973, the American Psychiatric Association has not considered homosexuality to be a mental disorder. Implicit in this position is the belief that homosexuality is a normal variant of sexual expression. The APA also maintains that therapies aimed at changing homosexuality are based on unproven theories and that these "treatments" may be harmful to those who undergo them (see APA Position Statement on Reparative Therapy)

To date, the origins of homosexuality, like the origins of heterosexuality, are unknown. Mainstream scientific research sees evidence of both biological and environmental factors in the development of any sexual identity. However, conversion therapists offer interventions based on unproven assumptions about what "causes" homosexuality.    For example, some claim sexual molestation causes homosexuality.   Others assume that origins of homoerotic attraction lie in a young child's problematic relationship to the parent of the same sex. A hypothetical inability to form a close bond with this parent leads to lack of understanding or comfort with persons of the same sex, and an unfulfilled longing for non-sexual intimacy. This longing is supposedly eroticized and transformed into homosexual attractions. The "cure" lies in forming close bonds in a non-sexualized therapeutic frame with a person of the same sex, which then allows the hypothetically "natural," underlying tendency towards heterosexual attractions to emerge.

"Sexual conversion therapies" require that patients/clients avoid homosexual contact and encourage either heterosexual contact or celibacy. When patients/clients are unable to comply with these directives, threats to terminate therapy are often advocated as an appropriate response.

"Reorientation therapies" may be harmful and potentially destabilizing to patients and their families. There are anecdotal reports of worsening depression and attempted and completed suicide as a result. In the case of "ex-gay" ministries, which are akin to self-help groups, there is often limited professional oversight and significant issues regarding confidentiality. People who enter into conversion therapies may be encouraged to enter into heterosexual marriages that do not last when the homosexual partner does not change.   If there are children involved or if a couple does not believe in divorce for religious reasons, the tragedy of these marriages is further compounded.

GLBT Populations and Substance Use Disorders

Recent research on substance use problems in LGBT individuals offers useful guidelines and important factors that should be considered during evaluation and treatment. First, there appears to be a relatively high prevalence of alcohol and substance use disorders in this population. Several studies of data from the National Comorbidity Survey, a nationally representative household survey, revealed higher lifetime prevalences of anxiety, mood and substance use disorders in individuals who reported same-sex sexual partners than in those who did not (Gilman 2001, Cochran 2000, Cochran 2004). Cochran (2004) reported that both homosexually active men and women reported higher lifetime, recent and daily use of substances than men and women who identified themselves as exclusively heterosexual. Regarding gender differences within the GLBT population, homosexually active men reported higher rates of daily drug use than did homosexual women.

Second, it has also been suggested that differences in social norms and/or cultural practices may increase the likelihood for consistent alcohol use to become problematic for gay men and lesbians. McKirnan and Peterson (1989) hypothesized that differences in social and sex-role norms (e.g., homosexual men and women being less likely to enter traditional "marriages" and have children) and in cultural life (e.g., the importance of bars, clubs and other non-stigmatizing venues) might be factors responsible for some differences observed between heterosexual and homosexual populations. Such differences are:

  1. The persistence of heavier drinking and drug use later into life for gay men and lesbians when compared to heterosexuals;
  2. The higher rates of problematic drinking, especially among gay women and older gay men;
  3. The smaller gender difference between gay men and lesbians than seen between heterosexual men and women.
Third, Amadio (2006) hypothesized that alcohol use and problematic drinking are increased by a higher degree of "internalized homophobia", which is "a set of negative attitudes and affects towards homosexuality in other persons and oneself" (Shildlo 1994). In a study using questionnaires in a convenience sample to measure internalized homophobia and alcohol use and alcohol related problems, Amadio (2006) found some evidence of a predictive relationship between higher degrees of "internalized homophobia" and pathological drinking behavior.

Keeping the above in mind, therapists should be mindful of differences in prevalence and presentation of substance use problems in the LGBT population as well as differences in the nature of the psychotherapeutic relationship. Points of the treatment process needing particular attention include:

  1. The initial consultation when the "doubly closeted" patient is called upon to disclose activities that he/she may consider shameful or embarrassing but a strong therapeutic alliance has not yet been achieved ("If I reveal my methamphetamine addiction, you'll know I'm gay.");
  2. Aspects of transference and countertransference that are different for gay men and lesbians in the early stages of treatment;
  3. The emergence of previously suppressed emotions, once the patient is sober: ("Now that I am sober, I feel depressed and feel guilty all the time about being gay.")
  4. Working through of the need to change "people, places and things" that requires the LGBT individual to be find sober supportive environments ("I'll be all alone if I can't go to bars.");
  5. The possibility that referral to specialized substance abuse treatment services may be required, such as inpatient or outpatient rehabilitation and/or Twelve-Step programs. At this point, it may be helpful, for some LGBT individuals, to refer to services that are "gay-friendly" or "gay affirmative". Programs such a The Pride Institute or Twelve-Step meetings with a LGBT focus, if such resources are available.

It should be noted, however, that, for most LGBT individuals with substance use issues, the physiological and psychological issues are quite similar to heterosexuals. The establishment of a therapeutic alliance, exploration of ambivalence about abstinence, detoxification, and recovery are as vital for the LGBT population as the heterosexual population and require the same thoughtful assessment, treatment planning and long term care.

Couples therapy with Lesbian or Gay Couples

In most ways, couples therapy is the same for lesbian or gay couples as it is for heterosexual couples and involves improving communication, exploration of conflicts and teaching conflict resolution. Gay couples may have some issues, though, that are unique. Some issues that may be encountered include:

  1. Conflicts around differences in degree of closetedness and public affection
  2. Coping with serodiscordance (when one member of a couple is HIV negative and the other is HIV positive
  3. Conflicts around dealing with extended families who are homophobic
  4. Conflicts around getting married in jurisdictions where same sex marriage has been legalized, especially in couples who have been together longer
  5. Complexities in parenting including possibly negotiating complex nuclear families which may include sperm/egg donors outside the primary couple and dealing with public ostracism of both gay parents and their children
  6. Addressing conflicts around monogamy and, when non-monogamy is agreed upon, negotiating terms which respect the primacy of the couple (this may be an issue in heterosexual couples as well, but may be more common in lesbian and gay couples)

In working with lesbian and gay couples, sensitivity to the unique challenges of making a relationship work in a culture that has yet to fully welcome and support such couples is important. As in all therapy with LGBT individuals, couples therapy should originate in a position that respects the couple and leaves judgment at the door.


  1. Gay-affirmative therapists needs to have the following specialized knowledge:
    1. The clinical symptomatology of depression that is different for GLBT patients when compared to depressed heterosexual patients.
    2. Techniques to make GLB patients come out of the closet as quickly as possible.
    3. An understanding of the developmental process of coming out.
    4. Gay-affirmative therapy is no different that any other psychotherapy so therapists need no specialized knowledge or skills.

  2. A therapist disclosing his or her sexual identity to a patient is:
    1. Inevitable
    2. Illegal
    3. Always harmful to the treatment
    4. Sometimes helpful in treating LGBT patients

  3. Which of the following would likely be an ineffective strategy for a therapist with a patient who is engaging in unsafe sexual behaviors?
    1. Ask about the patient's sexual partners.
    2. Review safer and unsafe sex guidelines with the patient.
    3. Determine whether alcohol or drugs were involved with the patient's unsafe sexual behavior.
    4. Inform the patient that treatment will be interrupted if the unsafe sexual behavior continues.

  4. A patient reluctantly reveals a pattern of unsafe anonymous sexual activity especially when under the influence of methamphetamine. The therapist should:
    1. Insist that the patient stop all such activity.
    2. Report the patient to the local health department, provide a supportive environment, and encourage the patient to explore the reasons for the behavior.
    3. Explore issues of dual diagnosis and evaluate extent of substance abuse.
    4. All of the above.

  5. A client presents requesting reparative therapy. What is the best response?
    1. Refer them to a reparative therapist.
    2. Explore family dynamics that may have contributed to this behavior.
    3. Explain to the patient the APA position that homosexuality is a normal variant of sexual behavior and reassure them it should not be considered a problem.
    4. Explain the lack of evidence regarding efficacy and potential harm of reparative therapies. Explore in a non-judgmental way the client's feelings about sex and their unique sexual history.


Amadio DM. 2006. Internalized heterosexism, alcohol use, and alcohol-related problems among lesbians and gay men. Addictive Behaviors 31:1153-1162.

Cochran SD, Ackerman D, Mays VM, et al. 2004. Prevalence of non-medical drug use and dependence among homosexually active men and women in the US population. Addiction 99:989-998.

Cochran SD, Keenan C, Schober C, et al. 2000. Estimates of alcohol use and clinical treatment needs among homosexually active mend and women in the US population. Journal of Consulting and Clinical Psychology 68(6):1062-1071.

Fox RC. 2003. Bisexual identities. In Psychological Perspectives on Lesbian, Gay, and Bisexual Experiences, ed. LD Garnets and DC Kimmel, 86-129. New York: Columbia University Press.

Gilman SE, Cochran SD, Mays VM, et al. 2001. Risk of psychiatric disorders among individuals reporting same-sex sexual partners in the national comorbidity survey. American J Public Health 91(6):933-939.

McKirnan DJ, Peterson PL. 1989. Alcohol and drug use among homosexual men and women: epidemiology and population characteristics. Addictive Behaviors 14:545-553.

McKirnan DJ, Peterson PL. 1989. Psychosocial and cultural factors in alcohol and drug abuse: an analysis of a homosexual community. Addictive Behaviors 14:555-563.

Shidlo A. 1994. Internalized homophobia: conceptual and empirical issues in measurement. In Lesbian and Gay Psychology: Theory, Research and Clinical Applications, Greene B, Herek GM, editors, 176-205. Sage: Thousand Oaks, CA.

Selected Bibliography on Psychotherapy with LGBT Clients

Cabaj RP, Stein TS, eds. 1996. Textbook of Homosexuality and Mental Health. Washington, DC: American Psychiatric Publishing.

Domenici T, Lesser RC, eds. 1995. Disorienting Sexuality.   New York: Routledge.

Drescher J. 1998. Psychoanalytic Therapy and the Gay Man.   Hillsdale, NJ: Analytic Press.

Drescher J, D'Ercole A, Schoenberg E, eds. 2003. Psychotherapy with Gay Men and Lesbians: Contemporary Dynamic Approaches. New York: Harrington Park Press.

Group for Advancement of Psychiatry (GAP), Committee on Human Sexuality. 2000. Homosexuality and the Mental Health Professions: The impact of bias. Hillsdale, NJ: Analytic Press.

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