Counseling LGBTI Clients

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Kevin Alderson

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    Preface

    Whether you are a student, a mental health practitioner, an LGBTI person, or a person who wants to learn about this community, keep reading. This book is based on more empirical research than any other that exists on the topic of LGBTI individuals. Furthermore, the issues identified in the text that LGBTI clients bring to counselors are based on what we know to be their common concerns. The same holds true for the counseling interventions aimed at ameliorating the distress caused by these issues.

    We expect mental health counselors of all backgrounds to be competent in their practice. When it comes to the focus of this book about counseling LGBTI clients, however, this is rarely the case. Most counselors have never received training in working effectively with LGBT clients (Eubanks-Carter, Burckell, & Goldfried, 2005). While counseling students feel ill prepared to work with LGBTI clients, practicing counselors have expressed a lack of adequate levels of self-awareness and knowledge concerning their issues (Dillon et al., 2004).

    What Pearson (2003) wrote is still echoed today: Ignorance and prejudice about LGBTI issues are present in the counseling profession yet seldom discussed. Keppel (2006) noted that even in training programs that provide competent training regarding gay and lesbian issues, the training around working with bisexual clients is inadequate.

    The American Counseling Association's Code of Ethics under section C.2.a (i.e., Boundaries of Competence section) states, “Counselors gain knowledge, personal awareness, sensitivity, and skills pertinent to working with a diverse population” (American Counseling Association, 2005, p. 9). Yet most counselors today are going to have one or more LGBTI clients on their caseload. Lesbian, gay, and bisexual clients seek out counseling services at five times the rate (i.e., 50%) of heterosexual clients (i.e., 10%; Palma & Stanley, 2002; Rutter, Estrada, Ferguson, & Diggs, 2008). The increased need of LGBTI individuals to receive counseling should come as no surprise: These individuals have been subjected to “marked prejudice and discrimination in society” (Palma & Stanley, 2002, p. 86). The cumulative effects of homophobia, biphobia, transphobia, and heterosexism on one's psychological, emotional, and physical health are often substantial.

    The increasing visibility of the LGBTI community as well means that counselors will become more likely to have them as clients, and in turn, they will need to demonstrate competence in working with them. LGBTI training programs can teach counselors to work effectively with this population (Dillon et al., 2004; Eubanks-Carter, Burckell, & Goldfried, 2005; Rutter et al., 2008).

    Logan and Barret (2005) recently developed standards for LGBT counseling competency to aid counselors and counselors in training in the examination of biases and values as well as the implementation of appropriate intervention strategies. These standards have been adopted by the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC), a division of the American Counseling Association. This textbook incorporates these standards while at the same time paying particular attention to the multicultural competencies of beliefs and attitudes, knowledge, and skills as outlined by several experts in the field (Arredondo et al., 1996; Sue, Arredondo, & McDavis, 1992; Sue et al., 1982; Sue et al., 1998).

    Wherever possible, the text incorporates material from evidence-based peer-reviewed journal articles. In some cases, the lack of research in a specific area is indicated. In this regard, this book speaks to what we know based on the available research, and it is relatively silent on those topics that still require empirical study.

    You will notice that in Chapters 3 through 10, most of the opening vignettes begin with a counselor who is lacking competence in one or more areas. The intent is to help you begin thinking about appropriate interventions with this particular group within the LGBTI community. After reading the chapter, I recommend you return to the opening vignette to look at where counseling the individual could be improved based on what you have learned. Not even experts are perfect with their interventions; if we were, we would never face the painful realization of our limitations and of our own humanness. People are complex, and even people who believe they have come to understand themselves are still unaware or nonaccepting of some aspects of their selves. We are constantly reminded as counselors of how fallible human beings really are, both in who we work with and in ourselves. This alone should humble us as we continually strive to become still better counselors and even better persons.

    There are other pedagogical features of this text that will assist you in your learning. These are highlighted in Chapter 1. By the end of Chapter 11, you will have gained an excellent foundation upon which to provide counseling to the LGBTI community.

    The groups within the LGBTI community included in this text will be refreshing to many professionals in the field. Chapter 1 provides an introduction to terminology and to some of the ongoing debates within the field of LGBTI studies and, more generally, within all research endeavors.

    Chapter 2 provides a brief history of the LGBTI community. The intent is to provide some context for how this community rose in visibility, and in doing so, how it simultaneously began developing its own cultural norms and mores.

    Chapters 3 through 10 are the “meat and potatoes” of the text with their focus on gay men, lesbian women, bisexual men, bisexual women, fetishistic crossdressing individuals, male-to-female transsexual clients, female-to-male transsexual persons, and intersex individuals, respectively. Chapter 11 is the conclusions chapter, which offers a brief synthesis and evaluation of where we are and where we are headed.

    Throughout Chapters 3 through 10, while the focus is on one particular subgroup of the LGBTI community, the research done sometimes includes more than one subgroup in its sampling. For example, while discussing bisexual men in Chapter 5, some research may have drawn conclusions not just for bisexual men but also for gay men and lesbian women. In these instances, these additional groups (gay men and lesbian women in this example) will be mentioned here as well. To do otherwise would be to dismiss some of the findings of these particular studies.

    As a final preface, some American reviewers of an earlier draft of this text wondered why there was a separate section focused on Canada when the two societies are similar in so many respects. The reason is that our Canadian students lament their desire for a text that addresses the contributions made by researchers in Canada. This contribution is particularly salient as we move into Chapters 7 through 9 with their focus on transgender clients. As professor Kathy Lahey and I (and many others, I might add) noted in the title of our book about same-sex marriage, the personal is political (Lahey & Alderson, 2004). Part of the political is in acknowledging our neighbors, and part of the personal is in knowing that we stand together in our need to honor universal human rights and to provide equality and protection to all.

    I would now like to thank the individuals who helped breathe this book idea into life. First and foremost, I am deeply indebted to Paul Pedersen. I remember the day well when I received his email asking if I knew of anyone who would be well equipped to write a text that would fit his Multicultural Aspects of Counseling and Therapy series. After hearing a promising word a day later from Sage, the arduous work behind this text began.

    I must also thank my husband, Manuel Mendoza Montes de Oca. When I look in your eyes and see the joy inside, I know that everything I have done in the field of LGBTI studies has been worth it. You remind me of why this work is so important.

    I also thank my ex-wife, Bess Alderson, and my two children, Troy and Shauna, who have never stopped believing in me. You inspire me to keep moving forward. Your unconditional love helps me accept the reflection I see in the mirror each day. Thank you.

    Without the wonderful support of people working at SAGE, this book would not have come to fruition, either. Kassie Graves helped me to accept the times when I could not meet the deadlines that continually hovered above my head. That meant a great deal to a person who sometimes forgets to smell the flowers when they first bloom. You helped change my spring.

    I also thank Eve Oettinger at SAGE for her attention to the details that help move a book from the ordinary to the exemplary. I appreciate your efforts enormously.

    —Dr. KevinAlderson

    Counselor referenCe Guide to the Common ConCerns of LGBTI Clients inCluded in this text

    • Chapter 3: Gay Boys and Men
      • Internalized homophobia
      • Affectional orientation confusion and self-identifying as gay (i.e., coming out to self)
      • Fragmentation of identity
      • Religious conflicts
      • HIV/AIDS
      • Relationship problems
      • Disclosing to others
      • Managing the consequences of external homophobia
    • Chapter 4: Lesbian Girls and Women
      • Career concerns
      • Identity concerns
      • Major depression and suicide risk
      • Weight problems
      • Substance abuse problems
      • Relationship problems
      • Parenthood issues
    • Chapter 5: Bisexual Boys and Men
      • Identity confusion and labeling issues
      • Internalized biphobia
      • Relationship strain and fidelity concerns
      • Finding support networks
      • Invisibility and its sequelae
    • Chapter 6: Bisexual Girls and Women
      • Identity confusion and fluidity of sexuality
      • Poor mental health and suicidality
      • Drug and alcohol problems
      • Specific relationship strains
      • Lack of community and isolation
    • Chapter 7: Fetishistic Crossdressing Children and Adults
      • Marital discord
      • Ego-dystonic crossdressing and/or compulsiveness
      • Mild to moderate gender dysphoria
    • Chapter 8: Transsexual Boys and Transwomen
      • Child and adolescent challenges
      • Gender dysphoria
      • Wanting to transition
      • Relationship and family problems
      • Transitioning at work
      • Need for social support
    • Chapter 9: Transsexual Girls and Transmen
      • Uncertainty about SRS
      • Learning new gender scripts
    • Chapter 10: Intersex Children and Adults
      • Bereavement
      • Posttraumatic reactions
      • Shame and guilt
      • Loneliness, secrecy, and feelings of isolation
      • Developing an intersex identity
      • Family issues
      • Family support
      • Social support

    Note: Not all of the concerns listed below apply to all subgroups within the LGBTI community. Nonetheless, the list is provided here to assist counselors working with LGBTI clients find the section(s) they are looking for quickly.

  • Appendix A: Glossary

    • Affectional orientation: Refers to a person's attraction, erotic desire, and philia for members of the opposite gender, the same gender, or both.
    • Affectional orientation confusion: A confusion that results when there is perceived disparity and felt conflict (cognitive dissonance and/or outside influences) among sexual affect, cognition, and behavior.
    • Affirmative therapy: Therapy offered by an LGBTI-affirmative therapist. Such therapists view LGBTI status as equal to heterosexual status and they emphasize a nonpathological view in their work with these clients.
    • Alexithymia: A condition whereby a person has a difficult time identifying and/or actually feeling a plethora of emotions.
    • Autoandrophilia: A male's propensity to be sexually aroused by the thought of himself as a male.
    • Autogynephilia: A male's propensity to be sexually aroused by the thought of himself as a female.
    • Biphilia: The propensity to fall in love romantically with members of either sex or gender.
    • Biphobia: The fear, dislike, or intolerance of bisexual individuals and/or rendering them invisible by denying their existence.
    • Bisexual individuals: People who self-identify as having primarily bisexual cognition, affect, and/or behavior.
    • Circuit parties: Large raves frequented mostly by gay men. They are known as venues where substantial drug usage and sometimes unprotected sex occurs.
    • Collectivist society: A society whose members are expected to strive for familial interconnected-ness, familial responsibility, and family heritage. Mexico, China, Japan, and India are examples.
    • Coming out:Coming out can mean one of two things, and usually the context provides the appropriate connotation. First, coming out can be used to refer to the process of self-identifying as LGBTI. Second, coming out can refer to disclosing one's LGBTI identity to others.
    • Conversion therapy: Therapy directed at changing a homosexual or bisexual orientation into a heterosexual orientation. Also known as reparative therapy.
    • Core gender identity: One's sense of being male, female, or indeterminate; it is usually established between 18 and 30 months.
    • Crossdressing individuals: People who dress in the clothing of the opposite gender with the intent of displaying cross-gender characteristics.
    • Disclosing: A more specific term than coming out. This refers to telling other people that he or she identifies as LGBTI.
    • Disorders of sexual development (DSD): An expression that refers to people with “congenital conditions in which development of chromosomal, gonadal, or anatomical sex is atypical” (Vilain, 2008, p. 330). They are referred to as intersex individuals in this text.
    • Drag king: A woman who crossdresses for fun and/or money.
    • Drag queen: A gay man who crossdresses for fun and/or money.
    • Ecological model of LGBTI identity: A new holistic theory intended to identify all influences affecting the person's sexual identity development, including internal factors (physical and psychological) and external factors (social and environmental). The development of a positive gay identity represents the final achievement in the model.
    • Essentialists: People who believe that those with homosexual orientations have always existed, regardless of whether they could give themselves a sexual identity label. Essentialists usually support their position with evidence from biologic and genetic studies.
    • Female-to-male transsexual (FTM): Biological females who have a male gender identity and who want sex reassignment surgery, whether preoperative or postoperative.
    • Fetishistic crossdressing (FC) individuals: Men who crossdress, at least during adolescence, because of the sexual arousal and often climactic release it provides. Most of these men define as heterosexual.
    • Gay identity: An identity status denoting those individuals who have come to identify themselves as having primarily homosexual cognition, affect, and/or behavior and who have adopted the construct of “gay” as having personal significance to them.
    • Gay men: Males who self-identify as having primarily homosexual cognition, affect, and/or behavior and who have adopted the construct of “gay” as having personal significance to them.
    • Gender benders: People (male or female) who intentionally “bend,” or transgress, traditional gender roles.
    • Gender dysphoria: Feeling varying degrees of discomfort with one's biological sex and/or one's expression of gender roles.
    • Gender identity: May refer to core gender identity, but it can also refer to one's current sense of seeing oneself as male, female, or indeterminate.
    • Gender identity disorder (GID): The official diagnosis for those individuals who meet the DSM-V or DSM-IV-R criteria.
    • Genotype: Refers to the entire genetic constitution of an individual.
    • Gonadal sex: Refers to the type of gonads present within an individual (i.e., testis and/or ovary).
    • Heterophilia: The propensity to fall in love romantically only with members of the opposite sex or gender.
    • Heterosexism: This term refers to the many ways individuals in our society consciously or unconsciously minimize gay, lesbian, or bisexual people, either by assuming that they don't exist or by projecting a belief that they are somehow inferior compared with their heterosexual counterparts.
    • Homonegativity: A more specific term than homophobia. This refers to having negative views of gay and/or lesbian people, regardless of the reason.
    • Homophilia: The propensity to fall in love romantically only with members of the same sex or gender.
    • Homophobia: The fear, dislike, or intolerance of gay and/or lesbian individuals.
    • Homosexual orientation: A sexual orientation created through the interaction between affect and cognition such that it produces homoerotic attraction, homoaffiliative desire, and ultimately homophilia.
    • Individualistic society: A society whose members are expected to strive for individuality, and such qualities as independence, autonomy, and personal freedom are espoused. The United States, Canada, Europe, and Australia are examples.
    • Internalized biphobia: This refers to bisexual individuals fearing, disliking, and/or hating themselves. The term also applies to bisexual individuals fearing, disliking, and/or hating other bisexual people or those who they perceive as bisexual.
    • Internalized homophobia: This refers to gay and lesbian individuals fearing, disliking, and/or hating themselves. The term also applies to gay and lesbian individuals fearing, disliking, and/or hating other gay/lesbian people or those who they perceive as gay/lesbian.
    • Intersex individuals: People with congenital conditions in which development of chromosomal, gonadal, or anatomical sex is atypical.
    • Karyotype: Refers to the individual's chromosomal pattern. Most people have a karyotype of 46,XY (male) or 46,XX (female).
    • Lesbian women: Females who self-identify as having homosexual cognition, affect, and/or behavior and who have adopted the construct of “lesbian” as having personal significance to them.
    • LGBTI individuals: People with nonheterosex-ual identities (e.g., lesbian, gay, bisexual) and/or those with transgender identities (e.g., fetishistic crossdresser, transsexual, intersex).
    • Male-to-female transsexual (MTF) individuals: Biological males who have a female gender identity and who want sex reassignment surgery, whether preoperative or postoperative.
    • Minority stress: The emotional stress experienced by being a member of a disenfranchised minority group.
    • Mosaic individuals: People that have a variety of cells containing XX and XY chromosomes.
    • Multicultural framework: A theoretical framework that purports that having culturally sensitive beliefs and attitudes, knowledge, and skills is necessary to become a multiculturally competent counselor.
    • Passing: Includes all attempts made by LGBTI individuals to not let others know about their LGBTI identity.
    • Pederasty: In ancient times, it was the practice whereby a man took a boy under his tutelage for purposes of educating him in exchange for sexual favors of one sort or another.
    • Phenotype: Refers to the observable characteristics or traits of an individual.
    • Phenotypic sex: Refers to the individual's primary and secondary characteristics.
    • Philia: The propensity to fall in love romantically with members of a particular sex or gender (or both, as in the case of biphilia).
    • Queer identity: Refers to those people who refuse to be classified on the basis of sexuality.
    • Queer theory: A theory evolving out of social constructionism. Its basic tenet is that all aspects of our sexuality are socially constructed and therefore flexible and malleable. Queer theorists avoid labeling people regarding their sexuality or gender due to this flexibility.
    • Same-sex passionate friendship: An intense friendship that does not include sexual contact.
    • Sexual identity: Refers to the label individuals use to define their sexuality (i.e., heterosexual or “straight,” gay, lesbian, bisexual, or queer).
    • She-male: A man who has achieved a female chest contour with breast implants or hormonal medication but still retains his male genitals.
    • Social constructionists: People who believe that homosexual orientations are environmentally determined and that they require certain socio-political-historical conditions to exist in order to find expression. Consequently, a homosexual orientation needs to be created within an environment that allows it at some level. Social con-structionists usually support their position with evidence from the social sciences.
    • Stealth: Refers to transgender people, usually transsexual, who live fully in their chosen gender without revealing their biological sex to others.
    • Transgender individuals: People who present unconventional gender expressions (e.g., cross-dressers, drag queens, drag kings) and/or those who present unconventional gender identities (e.g., transsexual, transwoman, transman).
    • Transgenderist individual: A male or female who crossdresses most if not all of the time and who may or may not experience gender dyspho-ria. A transgenderist individual with gender dys-phoria usually experiences it in a less severe form compared to transsexual individuals and has resolved (or has had it decided for him or her) not to proceed with gender reassignment surgery.
    • Transitioning: Refers to the process by which many transsexual individuals begin and continue physical steps to alter their body morphology. This includes cross-sex hormone therapy, top surgery (e.g., chest recontouring for female-to-male, breast augmentation for male-to-female), and bottom surgeries (e.g., vaginoplasty—creation of a vagina; clitoroplasty—creation of a clitoris; vulvoplasty—creation of the vulva; hysterectomy—surgical removal of the uterus; oophorectomy—surgical removal of the ovaries; metaoidioplasty—a procedure in which the clitoris is released from its hood, providing it greater length; phalloplasty—construction of a penis using skin grafts from the forearm or elsewhere). It is important to clarify that not all transsexual individuals elect to transition, and those that do might only transition in a partial sense (e.g., hormones only, top surgery only, bottom surgery only).
    • Transman: A postoperative transsexual female-to-male (FTM) individual. Not all FTM individuals will use this term to define themselves.
    • Transphobia: The fear, dislike, or intolerance of transgender individuals. This may include rendering transsexual individuals invisible by denying the existence of differing gender identities.
    • Transsexual individuals: People who believe their gender is dissonant with their morphology.
    • Transwoman: A post-operative transsexual male-to-female (MTF) individual. Not all MTF individuals will use this term to define themselves.
    • Two-spirited: A relatively new term used by many American Indian and Canadian First Nations LGBTI individuals to describe their sense of having both a male and a female spirit. The term has a positive connotation, as many such individuals historically were revered by their tribes.

    Appendix B: Handling the Roleplay Situations

    Roleplay #1, Chapter 3, Counseling Gay Men

    John, age 36, has come to see you for help. John has been out for 12 years and everyone knows he is gay. He has become entirely comfortable with himself and who he is. He has been dating Marco, age 32 from Mexico, for the past 2 years and they have lived together for a year. Marco has only been out to himself for 3 years. Marco has not disclosed his identity to anyone, including his family. Now his mother and father have decided to visit for 6 weeks, and they will be staying with John and Marco. John is beside himself not knowing what to do. He respects Marco but does not respect his dishonesty in not disclosing his identity to others. John will need to hide a lot of things at their home, especially his feelings and attachment to Marco.

    • Help John develop empathy—have John remember what it was like before he came out.
    • Help John explore his feelings—what is he most concerned about, hiding feelings from family or that Marco is unwilling to disclose their relationship? How does Marco's stance reflect upon John?
    • Discuss his concerns and feelings with Marco.
    • Multicultural awareness—might not be wise for Marco to come out to his family. John should learn more about culture.
    • Learn more from Marco—is it possible that family already knows despite everyone's unwillingness to label it? Is his family typical or unique in Mexican culture?
    • Explore options and compromises—parents leave house for an evening, couple rents hotel room periodically or goes out on dates. Might it be appropriate for Marco to disclose to his family after they get to know John?
    • Consider couples counseling.
    • Look at bottom lines. What if this situation never changes—what will be each partner's response?
    • Discuss family/values, supports, their relationship history, discuss the different stages of gay identity development of both parties.
    • Consider offering counseling to Marco.
    • Do not make assumptions; instead, ask questions.
    • Normalize John's feelings.
    • Bibliotherapy for John to understand Marco.
    • Explore coping strategies with John.
    • Explore John's assumptions about Marco—how does he know this to be true?
    • Explore the respect aspect (i.e., he says he does not respect Marco's dishonesty).

    Roleplay #2, Chapter 3, Counseling Gay Men

    Roger, age 45, has come to see you for help. He has been married to Jane for 20 years and they have two children, ages 15 and 13. Jane recently found him in their garage trying to asphyxiate himself by keeping the car running. After spending several weeks in a psychiatric ward, Roger has since been released. He hates himself because he has always had very strong attraction to men, and now he is aware these feelings are getting stronger. He has already decided to leave Jane and the kids but wants to feel better about himself.

    • Assess current suicide risk.
    • Get history from him. Explore life circumstances—what led him to attempt suicide?
    • Assess for reasons underlying internalized homophobia.
    • Help client reduce internalized homophobia—bibliotherapy, including Internet resources.
    • Help client reduce internalized homophobia—exposure to other gay men and community.
    • Help client reduce internalized homophobia—counseling focus, such as challenging his beliefs and normalizing being gay.
    • Self-esteem work.
    • Explore his affectional orientation and determine if he wants to pick an identity label.
    • Impart hope.
    • Encourage Roger not to make significant life changes at this time—especially do not leave wife until further counseling work is done.
    • Defer telling Jane about his attractions to men until he is in a more stable state emotionally. Assess his readiness for change.
    • Assess his support system—who is behind him and will be nonjudgmental?
    • Suggest couples and/or family counseling.
    • Normalize his attractions for men.
    • Explore potential marriage consequences.
    • Encourage Jane to receive counseling.

    Roleplay #3, Chapter 3, Counseling Gay Male Youth

    Peter, age 14, has come to see you for help. Peter has been sexually active with other boys for the past year. Although he has had a great time sexually, he wonders if he is prematurely settling down sexually with guys and wonders if he might also have interest in girls. Peter tells you that he had tried to ask girls for sex last year, but none of them felt either ready for it or they wanted something more than casual sex. Peter is only interested in casual sex right now.

    • Informed consent—From mom or dad, but if parents are separated or divorced, do parents have joint legal custody? If so, you need permission from both to counsel Peter.
    • Normalize his feelings and behavior.
    • Avoid labeling his behavior—possibly just sexual release.
    • Explore his affectional orientation—is he developing strong feelings for any of these guys?
    • Explore his sexual practices. Safer sex? If not, provide education.
    • Explore problems he is having becoming sexual with girls. Perhaps he needs assertiveness training or simply needs to change the way he approaches girls.
    • Is Peter in denial? Assess if internalized homophobia is operating.
    • Empathy assessment—ask him how he would feel if the situation was reversed and he was being used for sex.
    • History—what led him to become sexual with boys from such a young age?
    • Training may be indicated—(e.g., social skills, assertiveness).
    • Bibliotherapy.
    • Inquire about sexual identity.
    • What type of sex is he engaging in with boys?
    • Risk assessment—is he engaging in other risky behaviors when he has sex (e.g., alcohol, drugs)?
    • Explore self-concept, self-esteem, body image, and appearance.

    Roleplay #4, Chapter 3, Counseling Gay Male Youth

    Donald, age 18, has come to see you for help. Although Donald is aware that his interest is almost exclusively in men, he finds that whenever he gets together with men for sex, he has trouble maintaining an erection during anal sex and never seems able to cum. Donald doesn't want to assume the passive role in anal intercourse but wonders if he will need to if this problem is not soon resolved. There is nothing wrong with Donald physiologically.

    • Check if he is on antidepressants or other meds that could interfere with sexual performance.
    • Inquire about performance with other sexual behaviors, such as oral sex, vaginal sex, etc. Does it look any different regarding erection and ejaculation?
    • Inquire about performance during masturbation.
    • Assess for reason—internalized homophobia or other psychological reason, such as performance anxiety. Does he have this problem with women as well? Maybe he is just not interested in anal sex? Is he in a relationship or only having one-night stands? (May be that his morals and values are opposed to one-nighters.)
    • Will be helpful if he is with a consistent partner who is understanding and willing to assist in overcoming this problem.
    • Use behavioral technique called “shaping”—closer and closer approximations to the desired behavior.
    • May need more practice with this sexual behavior.
    • His views on taking the “passive” role—why the aversion? Probably internalized homophobia.
    • Sexual risk assessment—using condoms consistently? If yes, using shaping technique noted above.
    • Affectional orientation assessment.
    • Sexual identity assessment—how does he define himself?
    • Take history of where he is living, relationship with family, and so forth. Cultural, spiritual, and familial influences.
    • There are a variety of sexual practices to choose from—anal sex is only one of them.
    • Reassure him that many gay men do not enjoy anal sex (about one third).
    • Normalize his feelings.

    Roleplay #1, Chapter 4, Counseling Lesbian Women

    Debbie, age 25, has come to see you for help. She started dating guys when she was 16, and since then has probably dated and slept with more than 40 guys. Her boyfriends have lasted anywhere from 2 weeks to 9 months, and she has usually been the one to end it. She is concerned that despite liking many of these guys, she has never felt a special connection or feeling of romantic love for any of them. Recently she has met Karen, and she notices that her heart seems to beat faster every time they get together. She can hardly keep her mind from thinking about Karen, and she is beginning to wonder what sex would be like with her. Although the idea of being intimate with a woman is not frightening to Debbie, she is surprised by her feelings and questions whether she could develop an actual relationship with another woman.

    • History—explore Debbie's past relationships with men. What was missing?
    • Affectional orientation exploration—help her examine her feelings for Karen.
    • Sexuality for women is often fluid—possible that Debbie will still fall in love with a man someday? Does it matter to her that much?
    • Internalized homophobia—To what extent is Debbie homophobic? What would a lesbian identity mean to her?
    • Reciprocation—Questions about Karen—does she define as lesbian or bisexual? Will she be receptive to advances?
    • Encourage exploration—Lesbian erotica? Bibliotherapy regarding lesbian women or community?
    • Associate with lesbian women and community.
    • Normalize her experience.
    • Assess social support—How much support does Debbie have in her life? Will these individuals support her if she takes on a lesbian identity or if she begins a relationship with Karen?
    • No need to label her feelings toward Karen, but certainly an option for Debbie.
    • Explore her feelings and the importance she places on relationships in general.
    • Explore sexual identity and its meaning.
    • Establish her counseling goals.
    • Help her explore her options for being in relationship with Karen.
    • Are there any cultural differences to consider?

    Roleplay #2, Chapter 4, Counseling Lesbian Women

    Susan, age 46, has come to see you for help. She has been in a relationship with Ellen, age 42, for the past 10 years. Susan was previously married to a man and she has two teenage boys (Mark and Shane) from that marriage, ages 14 and 16. The boys live with Susan and Ellen, and it has become difficult for them to take Mark and Shane out with them. Mark and Shane feel embarrassed to be seen with them. Many people assume Susan and Ellen are lesbian because they fit many of the stereotypes, not to mention they are somewhat demonstrative in public. In addition to this, Susan tells you that she has not been sexually intimate with Ellen for 2 years and she wants to re-establish a sex life with her.

    • Normalize Susan's plight with teenagers' embarrassment.
    • Normalize children's reactions to not wanting to be with their parents at their age.
    • Empower Susan to talk to her children about how she feels when they do not want to be seen with her and Ellen in public.
    • Consider family counseling to deal with Mark's and Shane's embarrassment. How do they feel about mom and Ellen?
    • Explore reason behind embarrassment—homophobia or developmental? How did they react in the past?
    • Explore possible options or compromises regarding family outings. Perhaps less demonstrative in public?
    • For family counseling, ensure biological father does not have joint legal custody (if so, you need his permission to do counseling involving the boys).
    • History of what happened to their sex life. Is the chemistry between them still there?
    • Consider couples counseling.
    • Sex therapy—help them re-establish a sex life. Can do some work with Susan alone if Ellen won't come in for counseling as well.
    • Bibliotherapy.
    • Explore Susan's feelings about her sons' behavior and her relationship with them. Is she feeling guilty or hurt? Are they close?
    • History of how Mark and Shane have reacted in the past. Has this been a consistent problem or is it recent?
    • Help Susan to prioritize her issues.
    • Clarify what Susan (and Ellen) mean when they refer to “having sex.”
    • Clarify counseling goals.

    Roleplay #3, Chapter 4, Counseling Lesbian Youth

    Kyla, age 15, has come to see you for help. Her mother has recently become aware that Kyla is having a sexual relationship with Sharon, a 22-year-old open lesbian woman. Kyla tells you that her mom hasn't told her dad because she is concerned about his reaction. Kyla's mom believes Sharon has “recruited” Kyla into this lifestyle, and she wants their relationship to end immediately. If Kyla doesn't act, she will be told to leave home. Although Kyla could live with Sharon, she doesn't want to because of what her peers at school will think. Kyla hasn't told anybody at school about her relationship.

    • Informed consent—From mom or dad, but if parents are separated or divorced, do parents have joint legal custody? If so, you need permission from both to counsel Kyla.
    • Is Kyla safe at home right now? Assess for safety.
    • Avoid labeling Kyla or her relationship—may well be an exploration.
    • Help her explore her relationship with Sharon—what meaning does it have for her?
    • Consider family counseling with mom involved at least. Is mom really going to kick her out? Perhaps she can be helped to understand the situation better. If Kyla won't end relationship and mom is adamant, may need to look at other living arrangements for Kyla.
    • Assess affectional orientation—look at crushes, attractions, and so forth.
    • How does Kyla define herself? Is she aware that her sexuality may be fluid and changeable?
    • Legal—Note: The age of consent for engaging in sexual relations in all U.S. states is between 16 and 18. See http://www.ageofconsent.us/ for state-specific details. Some states and all Canadian jurisdictions also have age gap provisions for those under the age of consent. In Canada, the age of consent is 16. Age of consent in some places is higher for individuals engaging in same-gender as opposed to opposite-gender sexual relations (e.g., age of consent in Canada regarding consensual anal sex is 18). Consult to find out if there is a duty to report. See http://www.cbc.ca/canada/story/2008/05/01/crime-bill.html.
    • Issue of not telling her friends—what does this represent (internalized homophobia, confusion, or anticipated reaction)?
    • What social supports does Kyla have outside of immediate family?
    • Explore options.
    • Look for signs that there may be cultural or spiritual conflicts.
    • Normalize that female sexuality is fluid and changeable.
    • Find out everyone's bottom lines and help them negotiate.
    • Normalize and reassure Kyla's parent(s).

    Roleplay #4, Chapter 4, Counseling Lesbian Youth

    Malani, age 16, has come to see you for help. She is really struggling with her deep attractions to girls and her absence of attraction to boys. Malani is Muslim, and her faith is not accepting of homosexual activity. Malani's parents have already got eyes on Ahmed, a guy they want her to marry eventually. Malani has met him, but she is not attracted to him. She is attracted to Ellen, a Caucasian 16-year-old in her class at school. Ellen has already shown interest in Malani and wants her to come over to her home when her parents aren't there. Malani is pretty sure that Ellen wants sex because she has told Malani that she has had sex with girls before. Malani's feelings of guilt are eating her up and she feels desperate.

    • Informed consent—From mom or dad, but if parents are separated or divorced, do parents have joint legal custody? If so, you need permission from both to counsel Malani.
    • Assess physical and emotional safety—Is she potentially suicidal?
    • Learn more about her family—What if her parents find out? How traditional are they?
    • What does her faith mean to her? Explore this. Perhaps consult with someone of Muslim faith.
    • Multicultural sensitivity—Learn more about her culture and its influence in her life.
    • Help her to avoid labeling—her attractions may shift. Adolescents are highly impressionable.
    • Normalize—Help her accept her feelings regardless of whether she decides she can act upon them.
    • Explore her guilt—is it faith based or coming from other sources?
    • Exploration of her affectional orientation. Previous crushes/relationships?
    • Encourage Malani to defer having sex with Ellen because of the conflict she feels between her opposing values.
    • Explain that there are often differences in what the scriptures say and in the adopted practices.
    • What is Malani's bottom line? Is Malani able to compartmentalize her life and keep her orientation quiet from her family?
    • Assess and treat for internalized homophobia.
    • Explore options—Look at whether it is best for Malani to wait until she is of age to move out before disclosing.
    • How much support does Malani have in her life?
    • Explore her sexual identity.
    • Encourage Malani to come back for another session regardless of what she does or does not do with Ellen.

    Roleplay #1, Chapter 5, Counseling Bisexual Men

    Robert, age 28, has come to see you for help. He has been in a relationship with Sara, age 24, for the past 4 years, and although he loves her, he craves sex with men periodically and goes out and gets it. Sara believes they are monogamous, as this has always been their understanding. Robert doesn't want to lose Sara, but he knows she will not accept his outside sexual behavior. The longest Robert has been able to hold off on having sex with men is about 2 weeks. If he doesn't get it, he starts feeling depressed and deprived.

    • Cheating—Robert is cheating—should he stay with Sara or leave? When does he intend to tell her about this behavior? Perhaps he needs to end relationship because of “a conflict with his personal values.”
    • Affectional orientation exploration—what does his sex with men represent? Is it just sex or is it fulfilling other emotional needs? Is being with Sara simply disguising a same-sex affectional orientation? Why isn't he having sex with other women?
    • Exploration of his identity—What does he define as? Does the self-definition cause him conflict?
    • Explore compulsive nature—emphasize he has choice over his sexual behavior. Help him realize that sex is not a need. Explore his depression in this context.
    • Explore his relationship and sexual history. Has he cheated on previous partners? Explore relationship with Sara—what is not working?
    • Sexual risk assessment. Explore his sexual practices with men—what type of sex is he engaging in? What precautions is he taking?
    • Encourage STD testing and explore risk to Sara re STDs.
    • Decide on whether you will continue working with Robert if his intent is to continue cheating.
    • Consider couples counseling.
    • Normalize bisexuality as an identity and affectional orientation but that behavior is still a choice.
    • Empathy assessment—does Robert have empathy for Sara? What would it be like if the situation were reversed?
    • What is the bottom line for Robert?
    • Values clarification—What does it mean for Robert to be in a committed relationship? What place does monogamy have in what he values about long-term relationships?
    • Influences—explore the influence of family and peers (who are the boys he is having sex with; ages)?
    • Explore options.
    • Education—(e.g., teach Robert that open relationships can work if they are honest and consensual).
    • Explore for internalized homophobia.
    • What is his goal(s) for counseling?
    • What social supports does Robert have?

    Roleplay #2, Chapter 5, Counseling Bisexual Men

    Adam, age 45, has come to see you for help. He has been with James for 6 months, a 40-year-old gay man who has been out for nearly 20 years. Adam used to be married to Nancy, but their marriage ended 8 years ago after Adam told Nancy that he wanted to start having sex with other people, including both men and women. As Adam dealt with his issues in a mature, responsible, and honest manner, Nancy and he maintained a good friendship following their marriage dissolution.

    James, however, has started telling Adam how jealous he is of the time he spends with Nancy and some of his other female friends. James believes Adam will have sex with these women because Adam defines himself as bisexual. In fact, there are times when he has had sex with women behind James's back. You find out that Adam does want an open relationship with James but doesn't know how to broach the subject.

    • Sexual risk assessment. Is he practicing safer sex ALL of the time? Emphasize it as he may be putting James at risk.
    • Explore Adam's feelings toward his cheating behavior. Does he feel guilty? Help Adam to see James's point of view—is he able to empathize with James?
    • Encourage Adam to stop having sex outside the relationship until or unless James agrees with it.
    • Explore Adam's previous relationships. Have they been open? Has he cheated in the past?
    • Suggest that Adam bring James in for couples counseling.
    • Explore James's knowledge of and feelings toward open relationships.
    • Explore whether either scenario (open or closed) is a deal-breaker for either Adam or James.
    • Options—Explore whether Adam still wants to have a relationship with James.
    • What is Adam's goal for counseling?
    • Explore Adam's relationship with James.
    • Social-skills training may be needed.
    • Education—(e.g., teach Adam about open relationships).
    • Work with Adam focused on building integrity.
    • Help him find a support system (e.g., perhaps a bisexual support network).

    Roleplay #1, Chapter 6, Counseling Bisexual Women

    Maggie, a Black woman aged 20, has come to see you for help. She has been aware of her interest in both men and women for several years, and she has had sexual relations with both sexes as well. Her heterosexual friends and lesbian friends alike are threatened by her middle position and they pressure her to take one side or the other. Most of her lesbian friends they tell her she is really a lesbian and that she is just trying to hang on to some remnant of a heterosexual identity. On the other hand, she finds that most of her Black heterosexual friends refuse to believe her interest in women is real, and they tell her to grow up and find a man. Mostly Maggie is confused by her dual attractions. She is also seeing you because she feels rejected by both the heterosexual community and the lesbian community. She rarely gets invited to anyone's home.

    • Explore sexual identity confusion further. How does she define herself?
    • Explore affectional orientation confusion further. What components of affectional orientation go out to men and women (perhaps use Alderson's sexuality questionnaire here)?
    • Explore the meaning of her friendships—do none accept her as she is?
    • Encourage her to help her friends understand her better. Provide assertiveness training if necessary.
    • Reframe her problem as her friends being biphobic and its resultant feelings of isolation and rejection.
    • Resources for bisexual people, either in the community or online.
    • Help her find a bisexual community nearby or online.
    • Bibliotherapy.
    • Provide validation for a bisexual identity.
    • Romantic partner—Question Maggie about the person she would like to see herself with. Explore the person's characteristics that she falls in love with.
    • What supports are there in the Black community? In the lesbian community? What social supports does she have—friends and family—whether inside these communities or external to them?
    • Assess for whether there may be other reasons for why this is happening. Maybe Maggie is a very difficult person to be around.
    • Get her relationship history and friendship history.
    • Assess all influences affecting Maggie.
    • Normalize her experience.
    • Help her explore her options.
    • Discuss malleability/fluidity of female sexuality.
    • Explore internalized homophobia.

    Roleplay #2, Chapter 6, Counseling Bisexual Women

    Janis, age 35, has come to see you for help. She has been an active member of the lesbian community for the past 15 years. Her 12-year relationship with Emma (age 43) has been fairly positive and fulfilling, but like several long-term relationships, it has had its ups and downs.

    While Emma was away on a 2-week business trip, Janis went out dancing to a mixed (both gay and heterosexual) club and found herself being seduced by Clint, a handsome 40-year-old businessman. The two of them spent some time together every night together during Emma's absence, having sex following the third date. Shocking to Janis, she found herself developing strong feelings of attachment for Clint and craving more and more sex. After Emma returned, Janis has found herself making excuses why she is out some nights, spending that time secretively with Clint. She is seeing you because she doesn't know what to do.

    • Sexual identity confusion—how do her feelings for Clint threaten her identity?
    • Affectional orientation confusion—what components of affectional orientation are being expressed with Clint? Which ones are not? How would it matter if Clint were a woman instead?
    • Explore options—leave Emma or stay with her? If she wants to stay, what will she do about Clint?
    • Explore history of her lesbian identity.
    • Explore her relationship with Emma, including sex life and their history together. What are the issues that explain why she has sought another relationship?
    • Consider couples counseling.
    • Cheating and the problem of continuing to deceive Emma. How would she feel if the situation were reversed? What values are in conflict for Janis? Is this a time she should be confiding in her long-term partner?
    • Is she practicing safer sex with Clint?
    • Normalize that women's sexuality tends to be more fluid than men's. Also that it is common to develop feelings for others.
    • In what ways is her identifying as lesbian or being a part of the lesbian community being challenged?
    • Gather more information about Clint. Why is he in this?
    • Help her find a support network (e.g., bisexual community).
    • What are Janis's goals in counseling?
    • Normalize bed death as common with lesbian couples.

    Roleplay #1, Chapter 7. Counseling Crossdressing Individuals

    George, age 48, has come to see you for help. George has crossdressed since he was 12 years old. No one has ever caught him doing this, despite the fact that he used to go out in public when he was single. The problem began 4 years into his marriage with Claire (age 41) after she discovered his female clothing in their basement closet. That was 6 years ago. Although Claire got her head around the fact that George would dress up when she was away from home, George began insisting that he wear female clothing whenever he is at home and that she would have to get used to it. Claire did, and for the past 2 years, George often dresses as a woman at home.

    George tells you that he has taken this a step further. For the past year, he has insisted that he have sex with Claire while dressed as a woman. Claire reluctantly complied but declared 2 weeks ago that she married him as a man and that she only wants to have sex with him as a man from now on. She will not tolerate any more of his crossdressing at home or while they have sex. He is quite distraught about her “change of heart.”

    • Get a history of George's crossdressing behavior. Have any other previous partners known about his desire to crossdress? Does his cross-dressing always involve masturbation? Does he crossdress in public?
    • Does he have anyone in his life who is supportive of his behavior? If not, encourage involvement in the crossdressing community.
    • Normalize his behavior.
    • What does George want? Explore if he has ever been interested in ideally being a woman.
    • Consider couples counseling.
    • Explore relationship history. Is crossdressing about taking control over his partner's wishes?
    • Give-and-take. Claire has been supportive of George's desire to crossdress, even while he has escalated his behaviors without any negotiation with her. Present George with Claire's perspective—how does she feel about all of the changes in her husband? Help George have empathy for Claire's feelings.
    • What is the bottom line for both George and Claire? Assess if there is a possibility of negotiation of boundaries around crossdressing. Discuss options.
    • Help George develop empathy for Claire.
    • Assess that George is not a nonhomosexual male-to-female transsexual individual.
    • Is he still capable of having sex without crossdressing?
    • What are the goals of counseling?
    • Education—(e.g., crossdressing behavior increases with stress).
    • Bibliotherapy.
    • Explore if George's feelings of stress are his own or if they are associated with Claire's demands regarding his crossdressing.

    Roleplay #2, Chapter 7. Counseling Crossdressing Individuals

    Herb, age 39, has come to see you for help. He is having terrible feelings of guilt because he finds that he only gets sexually aroused when he is dressed as a woman. Herb is disgusted by this, but he feels compelled to dress up nonetheless before he masturbates. He is single and would love to be in a relationship with a woman but fears that he could not get involved with someone while this is going on in his life. Besides this, he wonders if he should consider getting a sex change to “make things right.”

    • Assess whether there is substance to wanting to transition—more likely that he does not have a stable and persistent desire to become a woman. More a stress reaction to crossdressing. Does he have obsessive-compulsive disorder—if not, why is he “compelled”?
    • Educate him about difference between crossdressing and transsexuality. Consider bibliotherapy.
    • Explain the behavior is a fetish—it is associated with sexual excitement for him.
    • Choice is his—attempt to eliminate fetish or own it? Some women will not mind he has this fetish (important to be honest about it, however).
    • Normalize his experience. Reduce guilt about fetish, regardless of what he wants to do about it. This may involve reducing transphobia.
    • Take history of his crossdressing behavior. Was it always associated with sexual excitement?
    • If eliminating fetish, attempt shaping (perhaps begin with reducing amount of female clothing worn during masturbation, then looking at female clothing while masturbating without wearing it, etc.). Have him work on changing his sexual fantasies (less and less clothing focus). Try sex toys.
    • Assess for medication or drug use that may be affecting his sexual ability.
    • Consider a support group, online or in person.
    • Does Herb have other relationship issues besides crossdressing? One might suspect so given that he is 39. What is his relationship history?
    • Diagnose. Does Herb have obsessive-compulsive disorder or another mental disorder? Why does he feel compelled?
    • Assess if Herb is a fetishistic crossdressing individual or a nonhomosexual male-to-female individual.
    • Bibliotherapy.
    • What is Herb's relationship with his penis? Does he want it removed?
    • Assess Herb's sexual identity.
    • Ask him to explain the consequences of transitioning (e.g., hormones) to you.

    Roleplay #1, Chapter 8. Counseling MTF Individuals

    Scott, age 23, has come to see you for help. Scott is very feminine in his mannerisms and his gender role, and you soon discover he has thought of himself as predominantly a girl since age 10. His sexual interest is in other men. He tells you he wants to become a woman. He confides in you that he always hated his penis and often wishes it were gone. Your inner sense is that Scott is quite unstable at this time and you have concern that he may self-injure.

    • Risk assessment—how likely is he to hurt himself? Is he suicidal?
    • Explain process to him: 3 months minimum therapy, hormone therapy (either by your referral to a physician or wait until assessed by psychiatrist), 12 months real-life test, sex reassignment surgery.
    • Assess for other possibilities—schizophrenia, bipolar, dissociative identity disorder. Assess that he is not simply gay with extreme internal homophobia.
    • Gather a complete history regarding his desire to become female. Check for signs of cross-gender interests and persistent cross-gender identity. To qualify, he needs to show a persistent and stable desire to transition. How often does he masturbate while crossdressed?
    • Consider talking to those who know him to confirm a long-stated desire to transition (especially if you are recommending hormone therapy yourself).
    • Review relationship history.
    • Why does he hate his penis? Explore.
    • Recognize that often transwomen are very persistent and want everything to change NOW.
    • Bibliotherapy.
    • Normalize his feelings. Many others have felt this way.
    • Assess psychosocial supports. Regardless of current support, refer to a support group or online resources for transpeople. Community connection is important.
    • What does he see his transition looking like when it comes to his feelings, his outward appearance, and his transitioning around friends and family? Does he see that going smoothly? Plan around how he will start the transition.
    • Ask him to explain the consequences of transitioning (e.g., hormones).
    • Rule out intersex conditions.
    • Work within your areas of competence—outsource assessment (i.e., the gatekeeper function) if needed or desired.
    • What is his sexual identity?
    • What is his affectional orientation?
    • Help Scott get in touch with the emotional component of wanting to be a woman.

    Roleplay #1, Chapter 8. Counseling MTF Individuals

    Tina, age 65, has come to see you for help. Tina had sexual reassignment surgery 10 years ago and soon after discovered she was HIV positive. Now that she has retired, she has decided that she wishes to pursue a long-term relationship with Julio, a 70-year-old man she has known platonically for a few months. She wonders if she should tell him that she is both a transsexual and HIV positive. She believes her chance of giving Julio the virus is very low.

    • Normalize her feelings. Many others have not wanted to tell their partners, either.
    • Gather a complete relationship history from Tina. Has she been dishonest in major areas of her life with previous partners—why or why not? As a transwoman, does Tina live stealth, or is she honest about being trans with most people?
    • Explore with Tina the pros and cons of telling and not telling Julio her transsexual status. Recall that most experts believe it is better to tell the partner.
    • Education—Help Tina to see that she still poses a risk to Julio and he can indeed become infected with HIV from her.
    • Know the law in this area—in some jurisdictions, it is illegal to not inform a sexual partner if you are HIV positive.
    • Why is she now looking for a long-term relationship? Has anything changed in her life to make this switch? What is her idea of a long-term relationship, and is being honest part of that? What type of relationship is she wanting to develop: platonic or sexual?
    • If the relationship she desires is sexual, what types of sexual activities is she interested in? Why does she believe the chance of giving Julio the virus is low? Discuss safer-sex practices.
    • Help Tina develop empathy for Julio. Has he done anything to make her think that she couldn't tell him? How would you feel if you ended up transmitting the virus to Julio? If the situation were reversed, would you want him to tell you if he was HIV positive? What are Julio's values? What kind of culture is he a part of? Sexism, racism, and political leanings may give more insight on how he might react.
    • What is Tina's support system like? Will she have people to fall back on if things do not work out the way she is hoping?
    • Refer Tina to her HIV clinic or specialist for information about the impact that viral loads and CD4 counts can have on increased/decreased risk of transmission of the HIV virus.
    • Explore if Tina's anxiety is partly related to her own internalized transphobia.

    Roleplay #1, Chapter 9. Counseling Transmen

    Becky, age 31, has come to see you for help. She has felt more like a boy ever since she can remember. However, she has some doubt whether she should pursue sex reassignment surgery. She knows that the surgery to construct a penis is difficult and that many transmen are unhappy with the common complications and the surgical result. She is interested sexually in women only. Nonetheless, she is desperately unhappy as a woman and constantly thinks about how much she hates her breasts and her vagina.

    • Explain process to her: 3 months minimum therapy, hormone therapy (either by your referral to a physician or wait until assessed by psychiatrist), 12 months real-life test, sex reassignment surgery.
    • Assess for other possibilities—schizophrenia, bipolar, dissociative identity disorder.
    • Gather a complete history regarding her desire to become male. Check for signs of cross-gender interests and persistent cross-gender identity. To qualify, she needs to show a persistent and stable desire to transition.
    • Consider talking to those who know her to confirm a long-stated desire to transition (especially if you are recommending hormone therapy yourself).
    • Review relationship history.
    • Bibliotherapy or online resources.
    • Normalize her feelings. Many others have felt this way.
    • Assess support system—refer to a support group or online resources for transpeople regardless.
    • Affirm her concern about the surgery—many are waiting for this reason.
    • She could consider hormone replacement therapy and having breast reconstruction (making breasts look like male pecs).
    • Suicide risk assessment.
    • Explore if Becky ever wants to have a child. Will this affect her desire to transition in any way? Should she consider having her eggs stored?
    • Affectional orientation change. This may occur, but it is more commonly experienced by male-to-female transsexual individuals.
    • Enhance current comfort—ask what she is doing right now to make her feel more comfortable in her body (for example, binding her breasts, wearing certain clothes).
    • Ask her to explain the consequences of transitioning (e.g., hormones) to you.
    • “COM”: Work within your areas of competence—outsource assessment (i.e., the gatekeeper function) if needed or desired.
    • Assess sexual identity.
    • Assess affectional orientation.
    • Find out is she is currently assuming the male role in aspects of her life—which aspects?
    • What is it that she hates about her breasts and her vagina?
    • What is her goal(s) for counseling?
    • Explore options—look at the pros and cons of having surgery.
    • What does she believe her life would be like following surgery?

    Roleplay #2, Chapter 9. Counseling Transmen

    Laura, age 21, has come to see you for help. Laura has always known that she was supposed to be born a boy, but it didn't happen that way. She is desperate to be in a relationship and cannot imagine a life of remaining single. She believes she would rather be dead than spend the rest of her life devoid of a long-term committed relationship. Laura wants to pursue sex reassignment surgery. Her sexual interests are exclusively toward men—heterosexual men, that is.

    • Major problem—she is only interested in heterosexual men, but she will become a man if she transitions! Explore Laura's vision of how it would work to be a man and yet attract a heterosexual man.
    • Another major problem—alas, gay men will not be that interested, either.
    • Encourage her to get to know gay men, perhaps by going to the gay bar.
    • Explain process to her: 3 months minimum therapy, hormone therapy (either by your referral to a physician or wait until assessed by psychiatrist), 12 months real-life test, sex reassignment surgery.
    • Assess for other possibilities—schizophrenia, bipolar, dissociative identity disorder.
    • Gather a complete history regarding her desire to become male. Check for signs of cross-gender interests and persistent cross-gender identity. To qualify, she needs to show a persistent and stable desire to transition.
    • Consider talking to those who know her to confirm a long-stated desire to transition (especially if you are recommending hormone therapy yourself).
    • Review relationship history.
    • Bibliotherapy or online resources.
    • Refer to a support group or online resources for transpeople.
    • If she cannot face a life without a romantic relationship, she may not be a good candidate for sex change.
    • Suicide risk assessment. Why is she desperate? Why would she rather be dead? How serious is she?
    • What is her bottom line?—transitioning or a relationship?
    • Has she ever wanted children? How will she reconcile this with transitioning?
    • Affectional orientation change. This may occur, but it is more commonly experienced by male-to-female transsexual individuals.
    • Normalize her experience and her confusion.
    • Assess affectional orientation.
    • Ask her to explain the consequences of transitioning (e.g., hormones) to you.
    • What does she believe life will be like following surgery?
    • What will sex look like postsurgery?

    Roleplay #1, Chapter 10. Counseling Intersex Individuals

    Tabitha, age 18, has come to see you for help. Most of the other grade 12 girls in her school have started dating, and Tabitha feels desperate to start herself. She is very self-conscious, however, as she has tells you she has a significantly enlarged clitoris and is lacking labia because of a “birth defect.” She makes it clear that she does not want to talk further about her physical condition.

    • Respect Tabitha's desire to not talk about her physical condition.
    • Normalize DSD. Explain to her that you are somewhat knowledgeable about DSD and you know that divergent individuals often enjoy stable and enduring adult relationships.
    • Normalize the dating experience. Explain that many people, especially when younger, experience many short relationships as they learn about themselves. Many desire to not settle down with one person early in the dating process.
    • Is Tabitha interested in boys, girls, or both?
    • Look at her parent's view of dating—are they supportive of her beginning dating?
    • Explore her history regarding her reactions to her physical differences. How has she coped up until this point?
    • Help Tabitha see the range of potential dating behaviors: which ones would be okay for her in the initial stages of dating?
    • As dating progressed to the point where her physical differences would become obvious, roleplay with her ways that she could inform her boyfriend/girlfriend.
    • Help her develop coping strategies for whatever the outcome of this conversation.
    • Help her develop coping strategies for engaging in sexual activity and the possible outcomes.
    • If relevant, explore with her possibilities for plastic surgery eventually.

    Roleplay #2, Chapter 10. Counseling Intersex Individuals

    Mannix, age 55, has come to see you for help. He tells you that he has never had a relationship before and feels extremely lonely. He blurts out that he is interested in men but that he does not define as gay. Mannix believes he ought to have been born a woman and was even assessed when he was in his mid-20s at a gender clinic for trans-sexuality. He was told then that he was not a candidate for sex reassignment surgery, although the details were never explained to him. It strikes you that he if did transition, he would likely be a physically unattractive woman. As you ask about his medical history, you find out that he has Klinefelter syndrome.

    • Fully explore Mannix's history, including medical. What is the closest he has come to having a relationship? Has he at least dated others, and if so, men, women, or both?
    • Look further at his not defining as gay. Is internalized homophobia a factor? If so, it should be worked on in counseling.
    • What has prevented him from dating and/or attempting to establish a relationship? Are there behavioral interventions that might help him date and/or establish a relationship?
    • Assess for whether Mannix fits the criteria for gender identity disorder. If he does, how severe is the gender dysphoria? Does his GID warrant referral to a gender clinic? Are you qualified to work with individuals who have GID?
    • Normalize his feelings. There is evidence suggesting that gender dysphoria is more common with those who have Klinefelter syndrome.
    • Has he ever dressed as a woman? How convincing does he believe he looks? How attractive does he view himself to be? What could be done to increase his attractiveness (e.g., makeup, clothing style, hairstyle)? If he qualified for transitioning and wanted to do so, what surgical procedures could improve his attractiveness?
    • Can he afford sex reassignment surgery?
    • What resources are there in the community?

    Appendix C: Sexuality Questionnaire

    KevinAlderson, Ph.D. © 2012

    1. TODAY'S DATE:

    2. AGE:

    3. BIOLOGICAL SEX: Male ____ Female ____ Intersex

    4. GENDER (i.e., aside from your biological sex, this refers to the extent you actually view yourself as a male or a female):

    7. GENDER ROLE (i.e., this refers to what extent you see yourself as behaving in traditionally masculine and/or feminine ways):

    10. EDUCATIONAL LEVEL COMPLETED (circle or check whichever answer is closest):

    11. RELIGION:

    12. CITIZENSHIP:

    13. ARE YOU:

    Please answer the following two questions BEFORE turning the page.

    The following questions pertain to the magnitude of your opposite-gender and same-gender interests. To what extent have you experienced the following during the two time periods indicated?

    SEXUAL ATTRACTION—This refers to feeling sexually aroused by someone you find attractive.

    SEXUAL FANTASIES—This refers to your sexual fantasies experienced during either masturbation or during sex with a partner.

    SEXUAL PREFERENCE—This refers to your preference for having male and/or female sexual partners.

    PROPENSITY TO FALL IN LOVE ROMANTICALLY—This refers to your natural inclination to have crushes and fall in love romantically with males and/or females.

    BEING IN LOVE ROMANTICALLY—This refers to how often you have actually felt romantic love (liking the person, having chemistry or feelings of lust toward this person, and feeling some degree of commitment toward this individual).

    SEXUAL PARTNERS—This refers to how often you have had sexual partners who are male and/or female. [NOTE: “sexual partner” refers to anyone you have engaged in penetrative sexual acts with, including oral, vagina, and anal sex.]

    SELF-IDENTIFICATION—This refers to your own self-identification.

    To what extent do you, and did you, think of yourself using the following terms?

    Use the following ratings for the next seven questions:

    0 = Zero or none 1 = Unsure 2 = Low 3 = Moderate 4 = High

    Graphing Affectional Orientation

    Appendix D: The Sexual Orientation Counselor Competency Scale

    Markus P. Bidell

    The need for mental health professionals to provide culturally competent psychotherapeutic services is now well established. Multicultural counselor competency (MCC) initially focused on defining and assessing awareness, skill, and knowledge competencies specific to ethnic/racial minority populations (Sue, Arredondo, & McDavis, 1992). Drawing on the tridimensional MCC model, Bidell (2005) developed the Sexual Orientation Counselor Competency Scale (SOCCS) to assess the attitude, skill, and knowledge of counselors working with LGB clients. The SOCCS focuses on sexual orientation and not gender identity. Because sexual orientation and gender identity present important differences, counselors and psychologists need to develop distinctive competencies regarding transgender clients. To date, no instrument has been published specifically focusing on transgender counselor competency, and the lack of such research is a serious problem (Bidell, 2005; Carroll & Gilroy, 2002).

    Sexual orientation counselor competency includes attitudinal, knowledge, and skill competencies needed to work effectively with LGB clients. The attitudinal component consists of personal beliefs about LGB individuals that include heterosexist, biased, and stereotypic assumptions regarding individuals that are LGB. Knowledge competencies include social, political, and legal issues facing this minority group. LGB clinical skills include experience with assessment and LGB-affirmative supervision and counseling as well as case conceptualization and treatment planning. The establishment of the SOCCS addresses the relative absence of LGB theory-based research and instrumentation (Bidell, 2005).

    Development and Psychometric Assessment of the SOCCS

    Examining previous multicultural counselor competency instrumentation literature (see Dunn, Smith, & Montoya, 2006), the sampling procedures and psychometric evaluations of the SOCCS were developed. More than 300 (N = 312) mental health professionals were included in the sample (235 women, 77 men, mean age = 31.9 years). Participants included counseling and psychology students (64.5 %) as well as doctoral-level counselor educators and psychologists (35.5%) recruited from 13 public and 3 private universities across the United States. Recruiting participants across the United States ensured a diverse sample with regard to sexual orientation (12.2% identified as LGB), and more than 30% were ethnic/racial minorities. All participants were given a demographic questionnaire, three instruments (Attitudes toward Lesbians and Gay Men Scale [ATLG], Multicultural Counseling Knowledge and Awareness Scale [MCKAS], and Counselor Self-Efficacy Scale [CSES]), and the initial 42-item SOCCS.

    The original item pool for the SOCCS was developed from a comprehensive review of LGB and multicultural research and literature utilizing the rational-empirical approach (Dawis, 1987). A pool of 100 test items was produced that measured various competencies of counselors working with LGB clients. In addition, a focus group and two separate card-sort procedures were also conducted to develop and sort test items. This process reduced the original pool of 100 test items to 42 questions. Factor analysis and reliability testing, as well as criterion, convergent, and divergent validity assessment, were used to assess the standard psychometric properties of the SOCCS.

    An exploratory factor analysis was conducted on the 42 original SOCCS items using principal-axis factoring procedures and oblique rotation. A priori decision rules included a minimum .35 item loading to be included in a factor, and each factor needed a minimum of four items. The factor analysis with the a priori decision rules yielded 29 questions and a three-factor solution that accounted for 40% of the total variance. The initial factor consisted of 11 test items that dealt with specific LGB counseling skills. It was labeled Skills and accounted for 24.91% of the variance (eigenvalue = 11.21). Comprising 10 items, the second factor was labeled Attitudes and examines a counselor's biases about LGB clients; it accounted for 9.66% of the variance (eigenvalue = 4.34). The final factor consisted of eight items and examined specific issues regarding LGB clients and mental health care. It was labeled Knowledge and accounted for 5.41% of the variance (eigenvalue = 2.43).

    The factor analysis produced a final SOCCS instrument consisting of 29 questions, of which 11 are reverse scored. The SOCCS uses a seven-point scale ranging from 1 (Not At All True) to 7 (Totally True), with higher scores indicating greater levels of sexual orientation counselor competency. The overall SOCCS mean score (of the final 29 items) was 4.64 (SD = 0.89), with scores ranging from 2.52 to 6.90. The Skills sub-scale had a mean score of 2.94 (SD = 1.53), ranging from 1.00 to 6.91. The Attitudes subscale had scores ranging from 3.10 to 7.00 and an overall mean score of 6.49 (SD = 0.79). For the Knowledge subscale, the mean was 4.66 (SD = 1.05), with scores ranging from 1.63 to 6.88. The intercor-relations between subscales were relatively weak (.29 between Attitudes and Skills, .29 between Knowledge and Attitudes, and .45 between Knowledge and Skills). The coefficient alphas for the overall SOCCS as well as the Attitude, Skills, and Knowledge subscales were .90, .88, .91, and .76, respectively. Test–retest reliability (1-week) correlation coefficients were .84 for the overall SOCCS, .85 for the Attitudes subscale, .83 for the Skills subscale, and .84 for the Knowledge subscale.

    Criterion validity for the SOCCS was established using participants' education level and sexual orientation, as these criteria would be expected to correlate with scores on the SOCCS. Compared with heterosexual respondents, LGB participants scored significantly higher on the overall SOCCS, F(1, 301) = 30.14, p < .001; on the Attitudes subscale, F(1, 301) = 8.27, p < .005; on the Skills subscale, F(1, 301) = 29.12, p < .001; and on the Knowledge subscale, F(1, 301) = 8.80, p < .005. The mean score for LGB respondents on the overall SOCCS was 5.33 (SD = .96) compared to 4.53 (SD = .82) for heterosexual participants. Education levels also established criterion validity. Compared to those with less education, participants who had higher levels of education scored significantly higher on the overall SOCCS, F(3,308) = 75.10, p < .001; on the Attitudes sub-scale, F(3, 308) = 5.33, p < .001; on the Skills subscale, F(3, 308) = 107.82, p < .001; and on the Knowledge subscale, F(3, 308) = 25.62, p < .001. The overall mean SOCCS score was 4.03 (SD = .39) for undergraduates, 4.63 (SD = .74) for master's-level students, 4.85 (SD = .72) for doctoral-level students, and 5.84 (SD = .61) for doctoral-level psychologists and counselors.

    The three subscales on the SOCCS demonstrated excellent convergent validity through strong correlation coefficients with established psychology instruments assessing similar constructs. The ATLG (Herek, 1998) assesses LGB bias and was used to validate the Awareness subscale of the SOCCS. Of the three subscales, the Attitudes subscale correlated the strongest with the ATLG scale, r(312) = -.78, p < .01. The MCKAS (Ponterotto et al., 2002), a scale that measures multicultural counselor competency with an emphasis on knowledge competencies, correlated the strongest with the MCKAS Knowledge subscale, r(312) = .63, p < .01. To validate the SOCCS's Skills subscale, the CSES (Melchert, Hays, Wiljanen, & Kolocek, 1996) was used, which measures counselors' perceptions regarding specific skills needed to be effective counselors. The SOCCS's Skill sub-scale correlated the strongest with the CSES, r(312) = .65, p < .01. In addition, divergent validity was explored by including three social desirability questions that examined impression management (see Paulhaus, 1991). A bivariate correlation between SOCCS scores and the mean social desirability cluster questions (M = 1.19, SD = .59) showed a weak association between the social desirability cluster and total SOCCS scores (r = 27).

    The Utilization and Limitations of the SOCCS

    Since its publication in 2005, the SOCCS has been utilized in plentiful dissertation research as well as national and international peer-reviewed studies. Doctoral students have utilized the SOCCS to examine the LGB competency of college counselors (Day, 2008), school counselors (Andrews, 2004), and graduate counseling students (Graham, 2009; Roberts, 2005), as well as examined the efficacy of counselor training programs (Frank, 2004) and LGB mental health professional workshops (Lewis, 2008). Graham's (2009) dissertation research explored LGB competency using the SOCCS with an impressive sample of 235 counseling and psychology graduate students from across the United States.

    The reliability data reported by Graham (2009) is consistent with Bidell's (2005) coefficient alphas. The researcher reported Cronbach's Alpha for the overall SOCCS and the Awareness, Skills, and Knowledge subscale as .87, .91, .86, and .71, respectively. Graham (2009) reported mean scores on the overall SOCCS, Attitude, Skill, and Knowledge subscales (5.01, 6.52, 3.88, 4.67, respectively) that were consistent with those reported by Bidell (2005). Also similar, Graham (2009) found participants' Skill subscale scores to be the lowest overall. Bidell (2005) noted “skill competencies were over one third lower than knowledge and one half lower than awareness competencies” (p. 277). Graham's (2009) data support the beneficial role of education and training regarding sexual orientation counselor competency. She reported that students in her study reporting higher education levels or attendance at LGB workshops had significantly higher SOCCS scores. Also noteworthy, Graham (2009) found that counseling psychology students had higher SOCCS scores compared to counselor education participants.

    The SOCCS is also gaining use as an outcome variable in peer-reviewed research. The SOCCS has been utilized to show the effectiveness of various forms of training, including LGB workshops for postgraduate psychology students (Fell, Mattiske, & Riggs, 2008); a British integrative counseling program (Grove, 2009); a counselor education program in the United States (Rutter, Estrada, Ferguson, & Diggs, 2008); and a study comparing school and community/agency counselors (Bidell, 2012). Utilizing the SOCCS, Henke, Carlson, and McGeorge (2009) explored the connection between homophobia and counselor competency. The researchers examined more than 700 couple and family clinicians, concluding that counselors with higher self-reported levels of LGB bias and prejudice had lower levels of sexual orientation counselor competency. In another study (Rock, Carlson, & McGeorge, 2010), 190 couple and family therapy students reported receiving limited to no LGB training and felt only somewhat competent to work with this population of clients. The SOCCS is also elucidating how counselor specialization can impact GLB competency. A recent study (Bidell, 2012) showed that school counseling students had significantly lower SOCCS scores compared to general community/agency students.

    Limitations are being identified with multicultural counselor competency self-report instruments that include the tri-component model, reliance on self-report answers, and assessment of explicit attitudes versus implicit bias, as well as their lack of attention to clinical outcome, case conceptualization, and client perspective (Dunn, Smith, & Montoya, 2006). Since the SOCCS is fashioned on the MCC scales, it is probable that similar issues apply. Despite these limitations, the SOCCS has been shown to be a psychometri-cally sound assessment of LGB attitude, knowledge, and skill competencies and is increasingly being utilized as an outcome variable in social science research.

    References
    Andrews, B. V. (2004). An examination of the factors affecting school counselors' competency to address the needs of children of same-sex parented families. Dissertation Abstracts International: Section A. Humanities and Social Sciences, 65(12A), 4471.
    Bidell, M. P. (2005). The Sexual Orientation Counselor Competency Scale: Assessing attitudes, skills, and knowledge of counselors working with lesbian, gay, and bisexual clients. Counselor Education and Supervision, 44(4), 267–279.
    Bidell, M. P. (2012). Examining school counseling students' multicultural and sexual orientation competencies through a cross-specialization comparison. Journal of Counseling and Development, 90, 200–2007.
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    SEXUAL ORIENTATION COUNSELOR COMPETENCY SCALE

    Using the following scale, rate the truth of each item as it applies to you by circling the appropriate number.

    1 2 3 4 5 6 7

    Not at all True Somewhat True Totally True
    • I have received adequate clinical training and supervision to counsel lesbian, gay, and bisexual (LGB) clients.
    • The lifestyle of a LGB client is unnatural or immoral.
    • I check up on my LGB counseling skills by monitoring my functioning/competency via consultation, supervision, and continuing education.
    • I have experience counseling gay male clients.
    • LGB clients receive “less preferred” forms of counseling treatment than heterosexual clients.
    • At this point in my professional development, I feel competent, skilled, and qualified to counsel LGB clients.
    • I have experience counseling lesbian or gay couples.
    • I have experience counseling lesbian clients.
    • I am aware some research indicates that LGB clients are more likely to be diagnosed with mental illnesses than are heterosexual clients.
    • It's obvious that a same sex relationship between two men or two women is not as strong or as committed as one between a man and a woman.
    • I believe that being highly discreet about their sexual orientation is a trait that LGB clients should work towards.
    • I have been to in-services, conference sessions, or workshops, which focused on LGB issues in psychology.
    • Heterosexist and prejudicial concepts have permeated the mental health professions.
    • I feel competent to assess the mental health needs of a person who is LGB in a therapeutic setting.
    • I believe that LGB couples don't need special rights (domestic partner benefits, or the right to marry) because that would undermine normal and traditional family values.
    • There are different psychological/social issues impacting gay men versus lesbian women.
    • It would be best if my clients viewed a heterosexual lifestyle as ideal.
    • I have experience counseling bisexual (male or female) clients.
    • I am aware of institutional barriers that may inhibit LGB people from using mental health services.
    • I am aware that counselors frequently impose their values concerning sexuality upon LGB clients.
    • I think that my clients should accept some degree of conformity to traditional sexual values.
    • Currently, I do not have the skills or training to do a case presentation or consultation if my client were LGB.
    • I believe that LGB clients will benefit most from counseling with a heterosexual counselor who endorses conventional values and norms.
    • Being born a heterosexual person in this society carries with it certain advantages.
    • I feel that sexual orientation differences between counselor and client may serve as an initial barrier to effective counseling of LGB individuals.
    • I have done a counseling role-play as either the client or counselor involving a LGB issue.
    • Personally, I think homosexuality is a mental disorder or a sin and can be treated through counseling or spiritual help.
    • I believe that all LGB clients must be discreet about their sexual orientation around children.
    • When it comes to homosexuality, I agree with the statement: “You should love the sinner but hate or condemn the sin.”

    Thank you for completing this scale.

    © Markus P.Bidell, Ph.D.

    Scoring the SOCCS: Instructions: First, reverse score those questions in parentheses (so 1 = 7, 2 = 6, 3 = 5, 4 = 4, 5 = 3, 6 = 2, 7 = 1). Note. Scoring information was not provided to research study participants.

    Total SOCCS Scoring

    To calculate total SOCCS scores, add up all items (remembering to add the reverse score for questions in parentheses) and divide by 29. So, 1 + (2) + 3 + 4 + 5 + 6 + 7 + 8 + 9 + (10) + (11) + 12 + 13 + 14 + (15) + 16 + (17) + 18 + 19 + 20 + (21) + (22) + (23) + 24 + 25 + 26 + (27) + (28) + (29) = Your Raw Score/29 (Divide Your Raw Score by 29 – number of SOCCS questions)

    Subscale Scoring

    For each subscale, add up the scores of the question listed (remembering to add the reverse score for questions in parentheses) and divide by the number of questions in each subscale.

    Awareness: (2) + (10) + (11) + (15) + (17) + (21) + (23) + (27) + (28) + (29) = Your Raw Score/10 (Divide Your Raw Score by 10 – num ber of Awareness questions)

    Skills: 1 + 3 + 4 + 6 + 7 + 8 + 12 + 14 + 18 + (22) + 26 = Your Raw Score/11 (Divide Your Raw Score by 11 – number of Skills questions)

    Knowledge: 5 + 9 + 13 + 16 + 19 + 20 + 24 + 25 = Your Raw Score/8 (Divide Your Raw Score by 8 – number of Knowledge questions)

    Author Note

    Markus P. Bidell, Associate Professor in the Department of Educational Foundations & Counseling Programs, Hunter College, 695 Park Ave. W1017, New York, NY 10065. E-mail: mbidell@hunter.cuny.edu; (212) 772-1474 (O); (212) 650.3198 (F).

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