F Ken Freedman







Articles by F ken Freedman

Gay and Lesbian Mental Health (Part 1)
F. Kenneth Freedman

"When one is invisible he finds such problems as good and evil, honesty and dishonesty, of such shifting shapes that he confuses one with the other, depending upon who happens to be looking through him at the time. Well, now I’ve been trying to look through myself, and there’s a risk in it. I was never more hated than when I tried to be honest. Or when, even as just now I’ve tried to articulate exactly what I felt to be the truth. No one was satisfied--not even I. On the other hand, I’ve never been more loved and appreciated than when I tried to ‘justify’ and affirm someone’s mistaken beliefs; or when I’ve tried to give my friends the incorrect, absurd answers they wished to hear. In my presence they could talk and agree with themselves, the world was nailed down, and they loved it. They received a feeling of security. But here was the rub: Too often, in order to justify them, I had to take myself by the throat and choke myself until my eyes bulged and my tongue hung out and wagged like the door of an empty house in a high wind. Oh, yes, it made them happy and it made me sick. So I became ill of affirmation, of saying ‘yes’ against the nay-saying of my stomach-- not to mention my brain" (Ellison, 1947, p. 573).

"Whence all this passion toward conformity anyway?--diversity is the word. Let man keep his many parts and you’ll have no tyrant states" (Ellison, 1947, p. 577).

These quotes, taken from Ellison’s "Invisible Man" share a common ground with Gays and Lesbians in the phobic response to otherness. Homophobia, whether institutionalized, socialized, or internalized wreaks havoc on all those connected with it, and particularly the Gay or Lesbian person. What "they" prefer is that "we" speak nothing of our Gayness, perhaps in the mistaken belief that our talk will be only about sex, whereas when "they" talk of their straightness (kids, husband, wife, going places together, sharing), it’s acceptable, and, oddly, not about just sex. Our invisibility is the same as Ellison’s. We can sit in front of "them" and "they" can talk with "us" and never see "us."

This paper (as will the next) seeks to analyze a number of issues critical to Gay and Lesbian mental health as well as the effects of homophobia, stigmatization, AIDS phobia, and internalized oppression; and to discuss the awareness counselors need to have in order to deliver good, if not Gay affirmative, mental health support--to Gays, Lesbians, and straights alike. The main references in this paper will be to Gay and Lesbian issues, with occasional thought given to issues of bisexuality and transgenderism--the fields are too broad to be all inclusive at this level of research.

Youth and Young Adults

There is a growing sentiment that any deviation from strict heterosexual real-male-penis-penetrates-real-female-vagina sex should be considered transsexualism, simply because sexual and affectional proclivities in any form can span a wide variety of emotional and physical activities:

The Klein Sexual Orientation Grid (Klein et al., 1985) provides a comprehensive approach to assessing sexual orientation by including scales for emotional preference, social preference, heterosexual-bisexual-homosexual lifestyle, and self-identification as well as for sexual attractions, fantasies, and behavior. Individuals are asked to rate themselves on a seven-point heterosexual-bisexual-homosexual scale for each variable for past, present, and ideal time frames (Cabaj, 1996, p. 151).

This grid posits a wide range of sexual and affectional possibilities, perhaps heralding transsexualism which would include anything that isn’t heterosexual, procreative, sexual relations. This and other studies have their antecedents in the studies of Magnus Hisrchfeld in the early 1900s, the Kinsey reports in the late 1940s and numerous studies since then. In dealing with gender identity issues a well informed if not Gay affirmative counselor will be aware that clients presenting with gender identity or sexual orientation issues will not be easily slotted into categories of straight, Gay, or Lesbian. Or even Bisexual. Or Transgender. Or Transsexual. There are cross-dressers, transvestites, and a new (to me) category, bi-curious, which, I assume, means the person is curious about Bisexuality which may or may not be an entry point to a Gay or Lesbian identity or any of the variations. Ronald C. Fox1 in Cabaj (1996) talks about Bisexuality and points to a broader understanding of sexual orientation:

Gender, age, social class, ethnicity, sexual and emotional attractions, fantasies, and behavior affect the experience and presentation of bisexual identities. Furthermore, although many men and women develop a Bisexual identity after first considering themselves heterosexual, others arrive at a bisexual identity from an established Lesbian or Gay identity. This suggests that sexual identity is not as immutable for all individuals as some theorists and researchers have assumed (p. 158).

I believe that the important issue is for the counselor to be sensitive to a client’s self-representation, particularly with young adults (13 to 20 years of age), and to help them understand that immediate and permanent identity with one group or another is not urgent. Exploration in a safe environment would be ideal, though impossible in U.S. society today. I think the next best offer a counselor can make is to encourage the client to self-identify (as Gay, Lesbian, etc.) only when he or she is comfortable and not under pressure from peers or society. For myself, it would have been of tremendous benefit to have been told in the early 1950s when I knew I was not wired as a straight person that there were well-adjusted homosexuals and I could be one, too. (Of course, in the early 1950s that might have been a stretch.)

Self psychology addresses the issue of mental health for Gays and Lesbians from a different perspective:

As contrasted with more traditional views within psychoanalysis, self psychological perspectives assume that we continue to use others psychologically across the course of self as a source of sustenance and support. Central to self psychological perspectives, as first portrayed by Fairbairn (1952), Winnicott (1953/1958, 1960, 1965), and Kohut (1959/1978, 1971, 1977, 1984) is increased recognition of the importance of experiencing integrity and congruence for continued mental health throughout life. Problems arise only when persons are unable to take advantage of available support or when this support is not sustaining or fulfilling (Cabaj, 1996. pp. 212-213).

The counselor’s role, in this environment, would focus on healthy mirroring, as well as the client’s sense of personal integrity, goals, vitality, and well-being rather than choosing or rejecting an identity. "The important factor in understanding the significance of sexuality for personal adjustment is less concerned, for example, with the fact of an evening spent in a dance bar than with the patient’s experience during that evening" (Cabaj, 1996, p. 209).

It is important to remember that homosexuality isn’t per se a script for mental problems.

Contemporary contributions to self psychology recognize that sexual orientation and mental health must be understood as independent dimensions; there is little evidence that sexual orientation is related in any way to adjustment except as a consequence of stigma (Herdt and Boxer, 1992; Hooker, 1957 in Cabaj, 1996, p. 208).

As Herdt and Boxer’s (1992) report of the study of a group of Gay and Lesbian adolescents has shown, young people who feel sufficiently safe not to hide or be ashamed of their sexual orientation are able to adjust in the same way as their nonhomosexual counterparts (Cabaj, 1996, p. 208).

It sounds as if our role as counselors, should we accept the implications of the above citation, would be to address homophobia (whether institutionalized, socialized, or internalized), and not the client’s sexual orientation. There is some controversy around how to deal with a client who presents as Gay or Lesbian and wants to change, meaning stop being Gay or Lesbian. And most of the ex-Gay organizations have pretty bad reputations, not to mention a 70% failure rate. What is important, I think, is to help the client understand and accept his or her orientation and its complex ramifications; and homophobia; and then make choices around how to act on or not act on one’s homosexuality. (This is an extremely complex issue and merits its own paper if not its own books.)

As an openly Gay counselor, I see one role I might be well situated to enact, especially in Anchorage, AK: that of an identity transference model. Cabaj (1996) clarifies with the following:

One such transference-like enactment (Kohut, 1971), expressed through particular concern with the analyst’s admiration, affirmation, and approval, has been portrayed by Kohut (1977, 1984) as a mirroring transference. However, particularly among Lesbians and Gay men in treatment with openly Gay or Lesbian therapists who have successfully negotiated coming out and are comfortable with their sexual orientation, the analysand may be more likely to develop an idealizing transference. These patients look up to their therapists as a model and find renewed strength from basking in their glow. A third type of transference, twinship (alter-ego) transference (Kohut, 1984), may be expressed in the desire to spend time with the analyst or to be as much like the therapist as possible. (Although issues of tact and timing are critical in making interventions, a successful outcome of psychoanalysis or psychotherapy requires that the meaning of these enactments be made explicit within the relationship of therapist and patient and resolved in a manner similar to the more familiar "oedipal" transference associated with the nuclear neurosis) (pp. 213-214).

One of the most difficult paths to walk is the one with no apparent peers. Certainly in the case of Gay and Lesbian youth, these types of transference enactments could be helpful and reassuring. Considering that the effects of homophobia can inhibit healthy identity formation, having even one Gay affirmative person off of whom to bounce one’s identity issues could be a great boon. With effective counseling around issues of grieving (the loss of a normal homosexual childhood) and reconciliation with that loss, the client might embrace change more openly, and make bolder strides in self-actualization and the building/rebuilding of his or her personal integrity.


Midlife issues are often overlooked in Gay and Lesbian mental health discussions as are issues around aging and the older Gay and Lesbian communities. At this particular time in history there is a fairly clear psychological split between people of the "Stonewall generation" (I will move into a discussion of the implications of AIDS in a later section of this paper) and those who came of age in the 1980s.

Midlife psychology for any population is strongly influenced by contemporary culture and history; this may be particularly true for the generation of Gay men and Lesbians in their 40s and early 50s, men and women who were in their teens and 20s during the era of social change leading up to Stonewall2. This generation also experienced many of the first casualties of the HIV epidemic and has arguably sustained the greatest cumulative mortality rates attributable to AIDS....

...the current generation of Gay men and women in midlife is arguably different, or will be different, from past and future cohorts of midlife Gay men and Lesbians (Cabaj, 1996, p. 290).

An important historical footnote is in order here. In the 1970s, the catch phrase was more "Gay license" than "Gay Liberation." It was a time when public sex was put (in some cases literally) on a pedestal and touted as the new sexual consciousness for Gays and straights alike to embrace. Sexual license was indeed de rigeur and promiscuous sex was on everybody’s lips (pun intended). What we couldn’t know at that time was that AIDS was coming and along with it the end of that kind of sexual license. And that changed the face of Gay culture forever. Suddenly, the real meaning of liberation was significant. There was a need to have "safer sex" and more emphasis was put on relationships and support groups. Lesbians, traditionally not very interested in Gay men’s issues, stepped up to the plate and got so intensely involved that the two usually separate communities began talking in a way they never could before. Men were learning from these angels in Lesbian clothing that they, too, could have feelings, accept help, be supported, get into the process of their own issues. Liberation for men was beginning, ironically (but not unexpectedly), in the midst of a tragedy.

The post-Stonewall generation, having missed the tumult of the early 1970s and the onset of AIDS in the early 1980s, will have an entirely different midlife (those that survive to that age), and it will be marked indelibly by AIDS, grieving, support groups, and a whole different type of Gay Liberation--one in which long-term relationships, civil rights and marriage and job/housing discrimination are dominant. Sexual experimentation will still be uppermost in the genital stage of development but with a safer sex twist. And that attitude, whether heeded or not, forces changes in identity formation patterns and consequently those midlife issues will perforce be different from the Stonewall generation’s issues.

It is with those caveats in mind that I discuss midlife Gay and Lesbian issues, knowing that they will change, probably radically, for the next generation.

...a middle-aged businessman may realize that he is no longer competitive with younger colleagues and thus feels threatened by the change in his social status. Gay men and Lesbians, however, are likely to experience a profound social crisis much earlier in life when they disclose their sexual orientation to families. Kimmel (1978) describes a "crisis competence" forged by the coming out process and argues that this may buffer Gay men and women from crises in later life. Gay men and Lesbians prepare for self-reliance during later years by developing self-created friendship networks and social supports (Cabaj, 1996, p. 293).

Given the unique issues of homosexual identity formation, such as the frequently delayed consolidation of sexual identity, the sequence of developmental tasks for a large number of Lesbian and Gay adults may differ from that of heterosexual adults. Some Gay men and Lesbians, for example, have resolved issues of generativity more fully than those of intimacy

(R. M. Kertzner, unpublished observations, 1994 in Cabaj, 1996, p. 293).

The implications for counseling may involve identity issues. But for many Gays and Lesbians these issues have already been (at least partially) processed, and when the midlife crisis comes on, if it does, the focus may be more on the quality of peer support than identity on the job, or on extended family restructuring, rather then on the usual "who-am-I-and-what-am-I-doing-now-with-my-life?" type questions that might otherwise (or additionally) be asked.

In my own case, the issue in my early 50s was how do I get out of computers and into something I really want to do, such as counseling? I don’t recall having a crisis of identity or self-worth in terms of work or even in terms of type of career. I knew I didn’t want to stay in the computer industry (lucrative as it was) and the "crisis" was how to give myself permission to drop that and get into something that I felt would give me more fulfillment--a strategy issue rather than an identity issue. There never was any worry about what would happen if I lost my computer identity and didn’t gain a counseling identity. It wasn’t a matter of who I was or what I might become or what anyone would think of my career change; rather it was a need to reach deeper into my psyche and craft my life so that it would satisfy what Erikson might term ego integrity v. despair. While I can’t say definitively that I avoided a midlife crisis by going through the coming out "crisis" repeatedly from an early age, I can say that I’ve never questioned my ability to survive in the world, find some sort of work, and be relatively happy (my issues are around intimacy, which, according to some Gay theorists, is a function of a stigmatized identity during identity formation, and homophobia, inculcated from my early experiences).

Finally, optimal midlife development occurs in lives unhampered by discrimination (Erikson, 1959), a condition that is not applicable to many Gay men and Lesbians. Indeed, the experience of stigmatization and discrimination may overlay the spectrum of adult development for Gay men and Lesbians (Cohen and Stein, 1986). Whether one is able to participate openly in Gay community life, teach younger generations, or adopt children is subject to the vagaries of law and social tolerance (Cabaj, 1996, p. 294).

The difficulties that older Lesbians have in mentoring younger people are legion. Any group that forms in support of Gay and Lesbian youth, whether in schools or the private sector are assailed by a barrage of publicity, mostly negative, about how the children shouldn’t learn about sex and older Gays and Lesbians are just trying to recruit. Contrast that with Big Brothers, Big Sisters, an organization that encourages intergenerational contact, men helping young men and women helping young women (older male "brothers" may not mix with young women, etc.), and nary a worry about sexual contact. Even in spite of the fact that 95% of child molestation cases are shown to be perpetrated by older straight family members against their own offspring (many times same-sex offenses), older Lesbians and Gay men are nonetheless the targets of accusations of recruiting. (One wonders if straights are so worried about this "recruiting" why do they not believe that when a straight, older relative molests his or her own same-sex child that the child isn’t then recruited into a Gay or Lesbian "lifestyle" [sic].)

So, tragically, we stay away from those areas, for the most part, and mentor to those who are "of age," and it is satisfying. This does not protect us from discrimination, and that is the subject, often, of counseling, even in midlife: homophobia in another guise.

Another issue that plagues many midlife Lesbians, in particular, is health, or the lack of knowledge and accessibility to Lesbian affirmative care.

The most significant health issues for Lesbians and bisexual women in midlife (as with younger and older Lesbians) result from invisibility, ignorance of medical professionals about Lesbian health concerns, and lack of access to health care. Little is known about Lesbian health in midlife (Cabaj, 1996, p. 295).

An additional difference between heterosexual women and Lesbians is that Lesbians must put more emphasis on work and financial security, absent the promise of a husband to "bring home the bacon." Too, Lesbians are more apt to build a social network of support rather than the extended families on which their heterosexual counterparts rely.

The counseling issues that may come up, given this particular theorizing, might center on negotiating the politics of extended chosen family, or coming out, or homophobia, or issues of self-esteem in a homophobic society, rather than what one might expect from a middle-aged heterosexual woman coming to the same counselor. It is important to at least discuss such issues in addition to the presenting problems, because homophobia can be insidious and so ingrained that neither the therapist nor the client is aware of its effects.

For Gay men, arriving at midlife can be stressful, but for different reasons than for Lesbians. For Gay men there is the problem of ageism, meaning that older is not better (or at least as good) as it is generally in the Lesbian community. Middle-aged men are susceptible to increased stress because of the loss of physical attractiveness (Gay "looks-ism"), mistaking that state (youth) for personal desirability. For the astute Gay affirmative counselor that issue could lead to fairly deep work on self-esteem, ageism, and a rethinking of how Gay culture condones marginalization of its elders. Which might include getting involved with organizations that might address those issues in different ways:

...the expanding range of self-definition and life choices available to many Gay men in midlife provide an opportunity for ongoing personal growth during adulthood. Thus, Gay men in their 40s and 50s may find themselves raising children or assuming important roles in an array of political, social, or community organizations (Cabaj, 1996, p. 297).

Gay men in midlife, as do Lesbians, find their generativity at its peak and often

cite the quality of friendships they cultivate and provide to others as a major source of pride and personal meaning in their lives. Intergenerational commitments also may be developed during this time. In a study of middle-age Gay men without children, Farrell (1992) found that many of his subjects had strong feelings of loss concerning their childlessness and in response had strengthened kinship ties, established "fictive kin" relationships, served as mentors or "big brothers," or pursued foster or adoptive parenthood (Cabaj, 1996, p. 297).

When I was in my late 30s, I met and fictively adopted my son Paul (1980). In 1983, I met and fictively adopted Joe. These were two young Gay men who had been literally kicked out of their homes and were learning how to survive on their own. I helped Paul find an apartment and a job, and I hired Joe to work in my computer software company. Since then we have remained close, and with Joe in particular, I have maintained a very close father/mentor relationship. Several years after moving to Alaska I met a young, Gay, born-again Christian man. My relationship with him, as with Joe and Paul, has been one of mentor, counselor, foil, guide, and mother. All very fulfilling relationships which satisfy, to my way of thinking, the generativity of which Erikson speaks. I never wanted to have children of my own; have never felt the "dynastic impulse," as one friend/philosopher/Gay-historian calls it; have never cared about carrying on the family name in my own flesh and blood. But caring for and being a mentor to these three young men has been enlightening for me. And while I don’t pretend to know what it’s like to raise children from infancy, I know the satisfaction of passing along what wisdom I could. And they’ve taken those words and thoughts and my extremely warm caring for them into their own lives and, in their own ways, have tried to do the same for others. They are children of my heart.

Another issue that might come up in counseling is Gay men in the work place. Whereas Lesbians are more likely to be discriminated against because they’re women first and Lesbians second,

Gay men with advanced degrees from colleges and universities may not promote themselves at work or may hold themselves back from advancement, fearing an exposure of their homosexuality. As such, a "lavender ceiling" may be just as much self-imposed as it is a reality of discrimination in the workplace (Horn, 1994 in Cabaj, 1996, p. 298).

Here is a dilemma for the Gay affirmative counselor. In order to develop and maintain integrity one must be out of the closet. Why must one be out? Because self-esteem is considerably damaged when one must constantly edit one’s comments before making them, and hide significant portions of one’s emotional life when talking with colleagues or when in social situations. Self-disclosure is an intimate part of sharing, even if on a superficial level. Many well-intentioned but nonetheless homophobic people ask why Gays and Lesbians can’t just slide over that part of their lives and make it "easier" for themselves and the listeners. Which is the same as asking a heterosexual person to have a relationship with friends or co-workers without ever mentioning their spouse, their children, their wedding, the house they share, or the functions they’ve been to with their spouse. These well-intentioned folks try to convince themselves that being Gay or Lesbian is only about the sexual act, as if their heterosexual lives were only about the fact that they are sexual with people of the opposite sex. This is how homophobia invades the social arena, as well as the institutional arena, and, naturally, the personal arena. And it is the subject of some serious Gay affirmative counseling, meaning that the counselor must help the client see the damage they do to themselves by remaining in the closet, which probably means that the client needs to consider how high a price they realistically think they can pay by trading job security for personal marginalization. When one compartmentalizes one’s life, danger is right around the corner. Additionally, by compartmentalizing, one uses up a lot of energy maintaining those compartments and consequently loses time and focus on being a completely creative, zestful, compassionate, and connected person. My opinion is that the counselor must help the closeted client to shed the homophobia that convinces them that they must be closeted in order to maintain their lives as they currently are, and make changes that are self-affirmative and that allow the client to fully be themselves, even if it means changing jobs, moving, or shifting careers. I recognize it’s not the counselor’s job to convince the client to make those changes, rather it is, I believe, the counselor’s job to help the client toward a Gay affirmative self-actualization so that he or she can live fully.

Senior Gays and Lesbians

Another overlooked segment in the Gay and Lesbian community is the 65 and older population. Negative stereotypes abound including man-hating Lesbians and lecherous Gay men. While there are man-haters and lechers, their sexual orientation knows no limits and the myth that they are all same-sex oriented has been thoroughly debunked. The real-life concerns of the senior Gays and Lesbians are complex and deserving of further study.

Compared with younger Gay men, older Gay men worried less about disclosure or discovery of their homosexuality, were less likely to desire psychiatric treatment, and had more stable self-concepts.

To date, the most comprehensive study of older Gay men is Berger’s (1984) survey of 112 Gay men aged 41-77. None of the men in this study fits the stereotype of extreme social isolation. Rather than preying on younger men, these older men preferred to socialized with age peers, particularly other Gay men. Only about one-third lived alone, and almost one-half lived with a lover. About one-third had been heterosexually married. Almost three-fourths described themselves as "well accepted" or "popular" among other Gay men. However, their participation in Gay community institutions such as bars, social clubs, and organizations was low.

Berger (1984) also measured older Gay men’s self-acceptance, depression, and psychosomatic symptoms. On average, his respondents scored well within the healthy range. Eighty-four percent of Berger’s respondents said they were "very happy" or "pretty happy," and only a few reported that the knowledge that they were homosexual "weighed on their mind" (Cabaj, 1996, pp. 306-307).

As discussed earlier in this paper, coming to terms with one’s homosexuality and coming out in one’s early years may contribute to easier midlife and over 65 adjustments.

Francher and Henkin (1973) suggested that early life experiences of older Gay men led them to develop skills and attitudes that helped them adapt to growing older. For example, one of the tragedies of growing older in our culture is that old people are stigmatized: they are treated as useless and incompetent. However, many Gay men and Lesbians learned how to cope with a stigmatized identity early in life and are able to insulate themselves from the worst effects of societal stigma by developing self-affirming attitudes and by seeking support from others.

A closely related idea is that Gay people also experience a "crisis of independence" in early adulthood. Because they cannot take family and other social supports for granted, they learn self-reliance skills that become crucial in old age as friends and lovers die and as social roles become constricted (Cabaj, 1996, pp. 308-309).

The good news, from a counseling standpoint, is that coping skills learned early in the coming out process often bode well for adjusting later in life to changing social climates and personal needs. Additionally, since gender roles are not as rigidly set for homosexuals as for heterosexuals, it is often easier to make adjustments regarding aging, self-care, asking for help, and relying on service and support networks.

The bad news is that "social service agencies and helping professionals often fail to recognize the needs of their older Gay and Lesbian clients" (Cabaj, 1996, p. 309). One survey (discussed by J. J. Gerhardstein in a 1984 personal communication) pointed out that of 13 agencies in a medium-sized midwestern city that provided services to the elderly, none of them had any outreach to the Gay and Lesbian population. Five of the agencies said they had non-discrimination clauses and the rest were hostile to or ignored the question. What this means is that there may be a presumption that the senior citizen who does go to an agency for help is heterosexual. The point is that while they could remain closeted, and they could cope in an alien environment, it isn’t the optimal condition for anyone’s well being. And coming out may lead to abuses and ostracism.

Another, more critical problem, is that of hospital care and visitation.

Most intensive care units allow visits by blood relatives and spouses only, excluding lifelong same-sex partners. When the older person is incompetent or otherwise unable to make decisions, the patient’s lover must often stand by helplessly while relatives (who may be distant or hostile to the patients’ homosexuality) make life-and-death decisions (Cabaj, 1996, p. 311).

This discrimination pervades in other areas, as well, including housing, jobs, and insurance. Job-related benefits for same-sex (or unmarried opposite-sex partners) are available only in a small number of progressive corporations. For the counselor, these issues sometimes call for a deeper involvement than might be normally expected, including, advocacy and intervention where the client may not be able to defend themselves.

There is much more material to cover regarding this population. Time and space don’t permit it here, but it will be referred to throughout my studies. Earlier in this paper, I referred to midlife Gays and Lesbians of today as being of the "Stonewall Generation." The Post-Stonewall Generation, however, is likely to come at midlife and aging from a different perspective. As Cabaj (1996) states:

Although today’s older Gay men and Lesbians have often adapted to societal oppression, the more activist cohort of current "twenty-something" Gays and Lesbians may bring greater levels of political activism to tomorrow’s older homosexual population. Whatever the future brings, Gay men and Lesbians will continue to be an important part of the elderly population (p. 315).


My intent in this next section is to take a brief look at some mental health considerations for four minority-within-a-minority populations, which are Gays and Lesbians who are also African American, Asian, Latino/a, and Native Two-Spirit. This will be a generalized survey and no attempt will be made to be all-inclusive, or exhaustive.


As with Asians and Latino/a Gays and Lesbians (and curiously, not with Native Two-Spirit people), African Americans teeter precariously between two cultures: it is difficult being generally accepted as Gays or Lesbians (because they’re African American), and equally difficult being part of the African American culture (because they’re Gay or Lesbian). Stereotypes run from Lesbians being "man-hating, masculine butches preying on naive and unsuspecting heterosexual women" to "Gay men...as finger-snapping, wig-wearing, drag queens who work in beauty parlors" (Cabaj, 1996, p. 550). These stereotypes are hard to break and often, when one hears the discriminatory words often enough and long enough, the oppression becomes internalized, both as African-Americans and as Gays or Lesbians.

[I]t is particularly troubling for African Americans. It inhibits a person’s ability to combat a frequently hostile, homophobic, and racist environment.

"Closeted" African American homosexual individuals are viewed as socially immature, inept at relationships, and overly secretive and devious. Their suicide rate is significantly higher than that of their African American heterosexual counterparts (Bell and Weinberg, 1978 in Cabaj, 1996, p. 550).

For counselors, there are several issues to consider even before starting sessions with an African American client. First, there is the issue of racial parity. Studies have shown that self-disclosure is easier and more forthcoming when an African American counselor works with the African American client. That would have to be discussed before either the counselor or client agreed to ongoing sessions, mainly because, as has been shown, therapy may take on the look of progress when the client is actually deceiving both him- or herself as well as the counselor, using the proper words and attitudes to simulate compliance and growth when it’s not really happening. Sexual orientation is another issue. Even if the counselor is Gay or Lesbian, the client may not identify as Gay or Lesbian in the same way the counselor does (assuming the counselor to be white). The gender roles are fairly clear in African American culture, with the penetrator being the "man" and the person being penetrated being the "woman" regardless of the gender of the participants. This might change the vocabularies and comprehension of both the counselor and client.

Despite a strong (and myth-based) belief in the African American churches and social structures that homosexuality is largely a white man’s disease, that it didn’t exist in African villages, and that slave owners imposed it on the African American population, strides have been made by visible Lesbian and Gay African Americans to be somewhat more accepted in the straight African American community.

Until the situation improves significantly, however, the probability of being unwelcome in their root community may push African American Gays and Lesbians to the white Gay and Lesbian venues. This may not always be an ideal fit:

In fact, because of discriminatory practices, participation by African Americans in the [white] Gay and Lesbian community may be anxiety-producing. This kind of stress may well be heightened because of alienation from the larger African American community. The resulting second-class, or perhaps third-class, citizenship is simply another contributor to low self-esteem and poor identity development (Cabaj, 1996, p. 556).

Counseling needs to take careful stock of the cultural differences before assuming that standard methods always apply.

[p]sychotherapy is largely based on a Eurocentric (white), Freudian model. In addition, considerable stigma is attached in the African American community to both being a patient and not being able to cope with one’s problems. When issues related to sexual orientation are added to these factors, the African American who could benefit from mental health services may experience overwhelming resistance.

Therapists must be prepared to assist patients in uncovering and recognizing the inherent and particular conflicts involved in making primary and secondary identity choices. Patients also need help in understanding the justifiable anger produced by having to make such choices. Resolving the conflicts resulting from this choice is a key part of the therapeutic process. With therapy, a patient can decide whether he or she is more comfortable with a primary definition as African American or as Lesbian, Gay, or Bisexual (Cabaj, 1996, pp. 558-559).

The challenge in counseling is to dull the blades of the double-edged sword or racism and homophobia: a daunting task.

Asian Americans

There is a long and well-documented history of homosexuality in Asian countries. In spite of that fact, many Asians still believe that homosexuality was imported from the West, and because of that, many young Asian Americans have rejected their culture in favor of their sexual orientation. Yet it is important to note that cultural construction may have a lot to do with the perception of homosexuality. For example, Asians in history were traditionally married and had homosexual relationships within that framework. Too, in the East, there is less prevalence of homosexuality as a core identity than in the West (Cabaj, 1996, p. 565). Sexual experiences can take place across the gender lines and still not result in self-identification in any particular category. This is important for a counselor to know (though the expressions of homosexuality are far more complex than depicted here), because the approach to resolving problems may not center around coming out or identity issues even though they might be the presenting problems.

East Asian men, for example, are expected to be married (though being in love or being happy isn’t so important) and make babies to carry on the family line. Affairs, heterosexual or homosexual, outside that family unit are not noticed. Even in North America, Asians are sometimes subject to arranged marriages, and acquiesce in order to not upset the family structure.

Confucian cultures generally place great importance on maintaining social harmony. Societal needs are elevated above individual needs. This emphasis creates pressure to conform to societal norms, and individual expression of sexuality is not tolerated. Lesbian and Gay Asian Americans must overcome the fear of breaking traditional societal boundaries that discourage "coming out." In accordance with the importance placed on social harmony, East Asian societies emphasize shame over guilt. As a result, not bringing disgrace to one’s family, kinship, or company is vital to people from East Asian cultures. Because of the importance of "keeping face" or maintaining dignity, East Asian Lesbians and Gay men frequently feel compelled to maintain secrecy about aspects of their personal life of which society would disapprove (Cabaj, 1996, pp. 567-568).

What is important for the counselor, I believe, is to remember that the Asian American who comes in to talk about sexual identity brings a host of values of which white North Americans probably are ignorant. Research and questioning the client will be tantamount to effective counseling.

Another phenomenon that must be guarded against is what I call internalized Asian-phobia. This is the situation in which Asian American Gays and Lesbians may identify so much with their sexual identity that they exclude or "forget" they are Asian American. What is important about that is simply that there is a vast cultural heritage that comes in the package, and forgetting about one’s birth culture isn’t as easily done as said. In fact when crisis strikes, such as AIDS or a relationship breakup, the issues of identity including culture and sexuality generally come to the fore and may be addressed in that context for the first time (Cabaj, 1996, p. 571).

Gay Asian American men who become HIV infected may start seeking support of other Asian Americans for the first time, possibly because their peers may be understanding of particular family issues that arise in the context of death and dying (Cabaj, 1996, p. 571).

Those "family issues" may have great import for the Asian American client, whether HIV+ or not, and it is useful for the counselor to be aware that such issues may need to be addressed.

It is also useful to know that there is a general stigma attached to mental health treatment in the Asian American community. So, in addition to bringing up the issue of race parity as well as Gay or Lesbian parity between counselor and client, there may be the question of whether the client is truly comfortable in session and whether they’ll be able to self-disclose, which is also an issue in the Asian American culture.

Finally, it is important for a non-Asian American counselor to realize that identity formation and development may not depend on coming out to family members. Because of the vast cultural and religious modern day prohibitions against homosexuality, the standards that make sense for white North Americans may not apply to Asian Americans.

Latino Men and Latina Women

The family, the Catholic church, and silence around matters of sex are the hallmarks of the Latino culture. Family is a "core cultural value that transcends nation of origin and to some extent the effects of acculturation" (Marín, 1989 in Cabaj, 1996, p. 585). The Catholic church roundly condemns homosexuality. And silence around sexual matters is typical of a Latino family. Sexual roles are set in stone which help to grease the wheels of the highly prized smooth social interactions.

Machismo is the "code of virility and masculine conduct that prizes honor, respect, and dignity, as well as aggressiveness, invulnerability, and sexual prowess" (Staples and Mirandé, 1980 in Cabaj, 1996, p. 586). Marianismo refers "to the Virgin Mary, to describe a generalized attitude that promotes women’s reticence on sexual matters as ‘purity’ while typifying sexually open women as putas or whores" (Espín, 1987; Marín and Gómez, 1994 in Cabaj, 1996, pp. 586-587). It is important to note that, in general, this dynamic plays out both in heterosexual and homosexual relationships.

As with Asian Americans and African Americans, the counselor (assuming him or her to be white North American) must be alert to the differences in cultural values.

One other important note is that in the U.S. and Mexico, at least, dabbling in bisexuality doesn’t make one Gay or Lesbian. In fact, the most important aspect of same-sex eroticism is the sex role played. Counselors need to be aware that the Latino/a talking about same-sex activity may not consider themselves Gay or Lesbian per se and care must be taken to not assume a common ground.

Another interesting discrepancy between Latino men and Latina women is the invisibility of the women. Because Latino society tends to see itself through masculine eyes, women, and consequently Lesbians, remain largely invisible (Cabaj, 1996, p. 589). It may be a touch more acceptable for Lesbians to remain single and go unnoticed (their job or education level precludes marriage) than for Gay men, who are expected to marry and procreate. This will have far-reaching implications for establishing a wholly Gay or Lesbian identity and life.

Similar to Asian Americans and African Americans, identifying with Gay culture in America "may come at the cost of losing cultural identity" (Almaguer, 1993 in Cabaj, 1996, p. 593). Since there is great importance placed on keeping things socially smooth in the family, the client trying to come out might have more issues around keeping that peace than on being rejected by the family and culture.

There is also a difference between traditional families and those that are more acculturated. In the former, a Gay identity is much more frowned upon, where in the latter there might be a little more acceptance. So, the coming out process has subtle and complex ramifications that must be brought out in counseling.

Given the multiple stresses described briefly here, it is easy to see that drug and alcohol abuse could be a greater risk than for non-two-culture Gays and Lesbians. And AIDS considerations become more complex considering the cultural stigma that comes with the disease, particularly if it was contracted as a result of Gay sex.

Acculturation issues will be a strong focus in negotiating the identity struggles of this group. Interventions should be appropriate to the degree of acculturation. A practitioner may want to encourage greater exploration of Latino identifications in a highly Gay-acculturated client, for example, while providing a sense of security and positive mirroring for a Latino-identified client who is not out (Cabaj, 1996, p. 596).

The counselor might also find him- or herself wanting or needing to get involved at the community level when it comes to AIDS awareness and culturally sensitive programs. Advocacy, once again, may need to be considered.

Native Two-Spirit People

"Gay," "Lesbian," and "Bisexual" are terms that

are felt to be culturally biased in favor of non-Native concepts, which focus more on sexual orientation. Two-spirit is a term that can encompass alternative sexuality, alternative gender, and an integration of Native spirituality.

[T]o be two-spirit means seeing through both sets of eyes, and therefore being able to see further, or more holistically, than someone who is only male or female. This concept suggests why the two-spirit person is often associated with power and spirituality--having this "double vision" gave a greater potential for one to exist on a more integrated level (Cabaj, 1996, p. 603).

Two-spirit people may also have been respected because they were good and valuable people (to the tribe), and not just because they were two-spirit. "The advantage of the two-spirit person was the greater flexibility and the position of being a bridge between genders, sacred and secular; and Native and non-Native communities" (Cabaj, 1996, p. 604).

Tragically, in the early 1500s European explorers, under the influence of the Spanish Inquisition, literally destroyed people who were known "sodomites" (read two-spirit people). The Natives learned early on not to discuss sexuality, and to this day, much of the history of these two-spirit people is lost. "Unfortunately, this has led in some cases to a Native internalization of the shame that non-Natives associate with sexuality, especially for those individuals who have lost their own language" (Cabaj, 1996, p. 605). The implications for a counselor and Native American two-spirit client are deep and complex, calling for information from the client about his or her cultural identity, and possible grief around the loss of a culture and history.

Current belief systems among Native Americans are quite different from the other three cultures discussed above.

In a study of interracial same-sex couples who had been together for at least 1 year, Native American partners reported a higher rate of heterosexual activity outside their primary relationships than any other ethnic groups (Tafoya and Rowell, 1988). This finding is significant because of the stereotype that bisexual individuals are married men who have homosexual affairs outside their marriage. The results of this study suggest bisexual activity can work in both directions, as Native respondents in primary Gay or Lesbian relationships engaged in heterosexual activities (Cabaj, 1996, p. 609).

For the white Gay- or Lesbian-identified counselor, this might pose an identity issue that could turn out to be more countertransference than a client problem.

Along those same lines, it is important to be aware of the fact that the gender of the partner isn’t as important as who the passive partner is. If the passive partner is a male, then he is homosexual, though his male partner may not identify as such.

For European-Americans, there is an emphasis on behavior determining identity, in contrast to the focus of many Native people on the core identity of a person. One engages in certain acts that confirm a European-American’s membership in the newly acquired category; for many Native people, one is a member of a clan, and extended family, a tribe, or nation. What one does is irrelevant on certain levels, since that can always change. One’s membership in the clan, family, tribe, or nation never changes, regardless of one’s sexual behavior (Cabaj, 1996, p. 612).

One other historical fact that can have an impact on counselors with this population is that of the boarding schools. In the 1930s Native children were forced to attend Federal boarding schools, where their spiritual, sexual, cultural, and language development was severely interrupted. Bereft of their elders to train them in the right ways to live, and at the mercy of the missionaries who thought it their duty to "civilize the savages," these children were often sexually abused by those very missionaries. Even now, with Natives attending public schools, "fully 25% of these students are still attending public boarding schools. Literally no community has escaped the impact of these schools" (Cabaj, 1996, p. 610).

Although the clinician must attend to the possibility of sexual abuse in Lesbian, Gay, and Bisexual clients of all ethnicities, the high incidence of sexual abuse among many Native populations suggests it may be more significant issue to explore in therapy with this population (Cabaj, 1996, p. 611).

As a counselor, one needs to be attentive to this historical legacy, and, as with Asian Americans discussed above, one also has to determine the extent to which the client identifies with his or her particular culture. The questions of ethnicity as well as self-identification are important, as much as is the denial of one or the other.

Using certain terms in the counseling setting may also be problematic. Words that describe emotional states that white European-Americans are accustomed to using may not exist in Native cultures. Additionally, insight therapy may not be the method of choice for many Native Americans, where "action-oriented interventions that match well with homework assignments" (Cabaj, 1996, p. 613) may be more acceptable and functional.

Another important consideration is what is called "pause-time," the space between one person’s finished sentence and the next speaker’s beginning. In Native culture this is longer than in non-Native cultures. This could lead to misinterpretations on the counselor’s part making it seem as if the client is reticent to answer. Questioning patterns might also be different. Direct questions may not be dealt with comfortably, and even what non-Natives consider a simple "yes" or "no" may be a matter of style that will be misinterpreted in therapy.

Much of the culture of the Lesbian, Gay, Bisexual, and Transgendered communities is based on non-Native values and principles, so Native people who are "different" may feel a strong sense of cognitive dissonance. For example, a person may ask, "Do I give up being a native for being a Lesbian?" For a number of European-American Lesbians, Gay men, and Bisexual individuals, sexual orientation becomes the primary basis for identity. For the majority of Native people (and for other people of color), the primary basis for identity may remain the ethnicity (Cabaj, 1996, p. 614).

The counselor, especially if he or she is Gay or Lesbian, must take into account the possibility that the two-spirit person may identify with their culture first and even though sexual identity issues may arise, the cultural pull is strong and meaningful. Ironically, it "should never be assumed that Native patients have had the opportunity to find out about their own traditions" (Cabaj, 1996, p. 615) especially since much history has been lost or destroyed for two-spirit people. That tragedy is homophobia on an historic scale that amounts to cultural genocide.

Nonetheless, the message is still loud and clear, as regards Native consciousness and spirit:

Perhaps the most important gift Native people offer is an opportunity to go beyond Western binary consciousness that operates on the basis of opposition. The existence of two-spirit people speaks to the possibility that difference from the "norm" is not automatically pathological (Cabaj, 1996, p. 615).

Childhood Sexual Abuse

Abuse of all stripes is widespread and is well documented (though probably still greatly underreported). For Gay and Lesbian youth and adults, however, the problem is far more pervasive. I can’t cover this broad a topic in this type of paper, but want to touch on the subject as a means of keeping a sensitivity to issues that may come up in counseling.

Gay men generally experience greater levels of anti-Gay verbal harassment by nonfamily members, threats, victimization in school and by police, and most types of physical violence and intimidation. Lesbians generally experience higher rates of verbal harassment by family members and report greater fear of physical violence and a greater degree of discrimination. The small number of studies examining racial and ethnic differences in anti-Gay violence show that Gay men and Lesbians of color, in particular Blacks and Hispanics, are at increased risk for violent attacks and other forms of victimization because of their sexual orientation (Berrill, 1992 in Cabaj, 1996, p. 803).

It is important to keep in mind that the violence described above is anti-Gay and anti-Lesbian violence, usually experienced in school or adulthood, which is to be distinguished from childhood abuse (sexual, physical, or emotional). The motivations of these crimes are rather different: anti-Gay hate crimes usually are perpetrated by a "young white male, often acting together with other males, who are strangers to the victim" (Comstock, 1991 in Cabaj, 1996, p. 803); whereas the child abuse crimes are usually perpetrated by older straight family members and they are generally abuses of power and violence rather than specifically anti-Gay or anti-Lesbian.

Being aware that one is the potential target of anti-Gay or anti-Lesbian violence (whether or not one has experienced it personally) creates an environment that "may include a heightened sense of vulnerability about and reluctance to disclose sexual orientation" (Cabaj, 1996, p. 804). Living in this kind of fear can lead to many other ways of dealing with the problem, from denial to symptoms typical of posttraumatic stress disorder (PTSD) to nightmares, depression, etc.

Victimization creates psychological distress; in addition, particular psychological effects of anti-Gay and anti-Lesbian violence result from the pervasive heterosexism and stigmatization of homosexuality in our society (Garnets et al, 1992). The internalized homophobia of the Gay, Lesbian, or Bisexual victim may be triggered and lead to the belief that being homosexual is the cause of the assault.... As with the victim of rape, many survivors of anti-Gay or anti-Lesbian violence have trouble seeking help because of their embarrassment about the incident, possibly fearing mistreatment by caregivers or concerns about disclosure of their sexual orientation (Cabaj, 1996, p. 804).

The counselor needs to be aware of the immediate needs of a client who comes to a session with an anti-Gay or anti-Lesbian incident, and to tend to the long-range needs, as well. Direct and immediate attention can help with the resolution of the present situation, and sometimes involvement in social and political activism can help in the longer term. This is not meant to be an in-depth look at how to handle a hate crime crisis. It is meant to acknowledge that there is a need on the counselor’s part to be open and nonjudgmental in dealing with these situations.

I can remember specifically in my adult years feeling that I was somehow responsible for the being raped and sexually abused (starting at age 7 and continuing until I was 33). Looking back, I realize that those early events conditioned me to expect more those events: I’d heard enough anti-Gay rhetoric to believe in some dim part of myself that that’s what happened to people like me who "flaunted" their homosexuality. In this case, "flaunting" referred to even telling someone that I was Gay, even mentioning it in conversation. Anyone else could talk about their wife, husband, and/or kids, mistress, girlfriend, boyfriend, etc., as long as the relationships were opposite sex; but any mention whatsoever of being Gay was "flaunting" and I "deserved" what I got. It took many years in therapy to get past that belief; and I’m not sure I’m totally past it yet. Partly with good reason. There are still a majority of folks in the world who believe that violence against Gays and Lesbians is justified, and one can’t know the provenance of the next attack. At the same time, I can’t live my life in a perpetual state of fear and hiding. This is an issue that any counselor needs to be sensitive to and deal with both on an historical and real-time basis.

As for childhood sexual abuse, there are many surveys that substantiate numbers ranging from 50% to 95% of perpetrators being straight, older family members, regardless of the sexual orientation of the child (if he or she is aware of it). It is equally important to process these historical events in counseling as it is to address the present time issues that accrue because of childhood sexual abuse.

Loulan (1988) reported that Lesbian survivors are more likely to have difficulties with adult sexual relationships in terms of feeling vulnerable and having memories of sexual abuse reemerge during sexual contact. Loulan also reported a 27% incidence of adult rape among the Lesbians who were abuse survivors versus 8% in those not sexually abused. This finding also has been reported in the general population and may be attributable to the difficulty of the survivor in recognizing and protecting themselves [sic] in potentially dangerous situations (Cabaj, 1996, p. 807).

I can attest to that statement, even though the survey was done with an all-Lesbian cohort. Whether or not my ability to discern danger was a direct result from the childhood sexual abuse I suffered, the fact remains that in later years in therapy when I described these incidences, it took the therapist some time to explain to me that I had been raped and abused repeatedly from that first sexual abuse incident when I was 7 years old. It never occurred to me that those highly frightening incidences were anything but normal sexual encounters, and if I got hurt into the bargain, well, that was just the way things were.

Courtois (1988) noted that, because the sexual abuse or incest occurs during the course of maturation and development, it can get integrated into the personality to cause maladaptive personality traits and personality disorders (Cabaj, 1996, p. 808).

Again, I cite my own case. Whether or not the childhood sexual abuse caused me to compartmentalize my sexual life and my "real" life, or fail at intimate relations, or have fear around sexual encounters, or grow up thinking I was somehow to blame for what happened to me, it nonetheless remains a fact to this day that I cannot even contemplate a sexual situation without some of the same fears assailing me that did when I was 7 years old. Treatment of these disorders are legion, but a brief mention of one method is worth some space.

The initial goals of treatment are usually symptom relief and memory retrieval. In midphase the therapy often deals with relationships in the here and now. Ideally, in the endphase the sexual abuse survivor is able to achieve a healthy relationship with a partner.

In the case of Gay men and Lesbians, internalized homophobia may complicate adult adjustment to childhood sexual abuse. This may come to the forefront when a crisis, such as HIV diagnosis, occurs (Cabaj, 1996, p. 809).

As a counselor I know I can use my own woundedness to help others work through their issues. I still have work to do, however, and need to keep myself warned about countertransference. Sexual abuse is a complex issue that I can’t devote the warranted time or space to here. It wants much more research.


It is a well-known fact that mainstream religious institutions shun Gays and Lesbians. With the exception of the Unitarian Universalists, the Quakers, and the United Church of Christ, no religion openly welcomes and accepts Gays and Lesbians. They might be tolerated, but not sought after, and certainly not if they "flaunt" (as previously described) their homosexuality. A few churches and some isolated ministers, priests, and rabbis have made efforts at including and even ordaining homosexuals, but those are islands. The point is that the religious marginalization of Gays and Lesbians continues. Yes, we have our own church, the Metropolitan Community Church (MCC), a Christian denomination, and Dignity, for Gay and Lesbian Catholics. And there are several Gay synagogues. Nonetheless, we are denied access to the mainstream spiritual life that everyone else at least has an option for, and that sends a powerful message to us about our spiritual lives: don’t have one in my back yard! The combination of social and religious stigmatization is a powerful double edged sword, with both sides cutting deeply and causing much damage. Whether or not one wishes to participate in religious life, the option is the important factor. It is hard to assimilate the hatred and still nurture a spiritual life when you find yourself asked to leave a church or temple because you’re Gay or Lesbian.

But we make do with our ghettoized churches and temples, large though they may be, and develop our own spiritual life and even thrive in many parts of the world.

But what is different about the soul of the Lesbian or Gay man is that it is forged out of pain and struggle. New Age theologian Andrew Harvey (1992) described the wound experienced by Lesbians and Gay men as a result of stigmatization and its consequent role in spiritual development. In Harvey’s view, examination of the wound leads to a confrontation with all of its elements: shame, terror of abandonment, rage, and self-loathing. Embracing and reexperiencing these emotional elements become a mystical journey that purifies the soul, ultimately leading to a transcendent state. Harvey theorized that this mystical journey is the means by which the psychic wounds of Lesbians and Gay men become healed (Cabaj, 1996, p. 883).

The challenge, as I see it, is for the counselor to help the client work through the issues of social and religious stigmatization and homophobia and come to a place of healing as described by Harvey, above. It is not so simple as knowing cognitively that one was abused, or stigmatized, or shunned, or the victim of homophobia, and thereby healing because of that knowledge. The process is tortuous. To me, it involves naming the problem, which isn’t always easy to begin with. There follows the reliving of the hate or the abuse, and the physical "knowledge" of the event(s). Sometimes that takes repeated attempts before full acknowledgment and awareness can occur. There is a need to find safety from those events which often involves inner child work. There is the assimilation of that knowledge into what I call heart knowledge--something beyond cognitive knowing. The process is far more complex than I’m describing, but it has to lead to a sense of current-day safety, where a client can feel comfortable in a social or religious setting, getting what he or she needs from the situation and the people around without being adversely affected by the knowledge that acceptance and welcome isn’t universal.

To find one’s way "back to God" (or whomever or whatever the external forces may be called) takes a leap of faith that is forbidden to most Gays and Lesbians. It seems to me that the safety factors in matters of spirituality are quite similar to those of psychology. One has to find one’s way to the comfort zone before taking chances on being out--as a Gay man or Lesbian, or a spiritualist.

In many ways, the tasks of spiritual identity development ... parallel the tasks of identity development presented in Gay-affirmative psychotherapy. The former seeks to heal the wounded spirit, permitting the individual to move forward in whatever spiritual path seems appropriate. The latter seeks to soothe the effect of sociocultural injuries, enabling the individual to release the pain and move on. Obviously, the two are not mutually exclusive. Quite the opposite is true: attentiveness to both of these overlapping processes facilitates the repair and growth of the whole person (Cabaj, 1996, p. 884).

The therapist’s task, overall, is not to develop an agenda to guide the process, but to accompany the individual on a journey (Cabaj, 1996, p. 885).

It is ironic, but not unexpected, that many young men and women who hide their sexual orientation while members of their family’s church or temple, and then come out, are not necessarily welcomed into the Gay or Lesbian communities either. Especially if they bring their religious talk with them. The phobic reaction of may Gays and Lesbians only points more strongly to the need for healing around spirituality. While I won’t take the time here to describe the details, there have been numerous books written about the Bible and the homosexual. Historically it seems there is ample evidence that the homosexuality condemned in the Bible isn’t the same homosexuality that abounds today. In fact, it seems in some interpretations, the Bible might actually be encouraging same-sex relationships. It may not be as well known, but it is true, that from the 6th to the 12th centuries, the only marriage ceremonies performed in Churches were homosexual unions, due to the fact that they were spiritual unions, where heterosexual unions were considered an exchange of property and those ceremonies were held usually in the town squares or town halls, as civil and legal ceremonies and contracts: the man takes the woman and a dowry and she now belongs to him. I’ll document these statements and go into more detail in the course and paper on Spiritual & Sacred Psychology.

Ultimately, the therapist must be able to facilitate the patient’s ability to discern the function of spirituality in identity and thus its appropriate place in his or her life. Lesbian and Gay psychotherapy patients with spiritual concerns need to be treated with the respect they often do not receive, either in their churches or in the Gay community.

Spirituality is complex and requires attentiveness to affective, cognitive, and existential features (Cabaj, 1996, p. 893).

Counselors might consider helping clients who wish to pursue their spiritual roots to the knowledge that "numerous Gay-affirmative theologians [speak] to the creativity involved in living a life that includes a full expression of both sexuality and spirituality" (Cabaj, 1996, p. 894). The client may need to change religions, which is not always easy, but similar faiths and congregations can be found. It is also important to be out in an effort to combat "ecclesial homophobia" (Goss, 1993 in Cabaj, 1996, p. 894).

All varieties of spiritual practice may serve to strengthen a positive sense of self. It is when spiritual practice engenders shame, fear, and self-loathing, or when it leads to a fragmentation of identity, that the therapist needs to consider the patient’s spiritual path critically and assist her or him in loosening bonds that may be tied to the past (Cabaj, 1996, p. 895).

Deaf Gays and Lesbians

It is not my intent to cover the wide body of literature there is extant about Deaf culture, much less Gays and Lesbians within it. I hope to cover the subject more thoroughly at some point, whether in my course on multicultural issues, or on my own, I’m not sure3.

One book I found (Luczak, 1993), isn’t a scholarly work; rather it contains contributions from Deaf Gays and Lesbians in the form of essays, poems, photographs, and interviews. I present a few comments here as a window into a truly different culture. Keep in mind that ASL is the third most used language in the U.S., or at least that’s what I was led to believe.

This is for every Deaf Gay high school student still in the closet: "I really want you to work hard and to come out as soon as possible, because it will make your life a lot easier in the long run. Allow yourself to experience all kinds of things by going to Gay bars, reading books about Gay people, and making Gay friends. It’s important to realize that being Gay doesn’t mean that you should have only Gay friends, and it’s important to get along with everyone, including straight people. Through a variety of such experiences, you’ll learn so much about yourself (from "Different from the Others" by Philip J. Gorton in Luczak, 1993, p. 30)


In my research on Deaf Gay men, I’ve asked this question of them: Suppose there are two candidates running for president, the first one for rights of the handicapped and the second one for Gay rights. All said they would much rather vote for the one supporting the rights of the handicapped than for the one for Gay rights. Which means, the Deaf Gay person is more concerned with Deaf rights than with Gay rights.

This is also true of us in the Deaf community. We think of ourselves as Gay first, then Deaf second; but in the hearing world we think of our deafness first, our gayness second.

We switch back and forth depending on where we are (from "Men in Pink Spacesuits" by Tom Kane in Luczak, pp. 35-36).

The above two quotes speak to issues I’ve raised in this paper and in previous ones. The importance, at least to some, of coming out is a matter of learning, personal growth, and connections in the world. The cultural issue of deafness or Gayness (as a concept) has been discussed before, also. The cultural values that have to be addressed in a counseling session will depend largely on the client but their perception of their place in the world will need to be taken into account.

There is a big need for role models. Back when I was young in the sixties and the seventies, the older Deaf Gay men were my role models. They were often emotionally negative and unstable, and I thought, "Oh, that’s what I have to do."

No, that has to change.

I have no respect for anyone who stays and stays and stays in the closet. That’s his problem, and that’s sad (from "Men in Pink Spacesuits" by Tom Kane in Luczak, pp. 36).


Rejection by Dragonsani Renteria

Society rejects me for being Deaf.

The Deaf community reject me for being a Lesbian.

The Lesbian community reject me for not being able to hear them.

The Deaf-Lesbian community reject me for being into S&M.

The S&M community reject me for being Deaf.

Society rejects me for being Chicana.

The Hispanic community reject me for being a Lesbian.

Patriarchal society rejects me for being a woman.

I am rejected and oppressed,

Even by those who cry out readily

Against rejection, oppression, and discrimination.

When will it end?


However, I have found Gay hearing men to be more sensitive to Deaf Gay men--they know the feeling of being part of a small group, a minority.

I asked Charlie if he would change if he suddenly could hear. He looked at me a long time and then said, "I don’t know. I have a Deaf soul, a feeling that binds me with other Deaf people, because we all know what it’s like to be in a hearing world. I’m happy being me (from "Dancing Without Music: Moments with Deaf Gay Men" by James Mackintosh in Luczak, pp. 95-96).

Interesting to note that there’s a loyalty to the culture, even if one could change. Which brings up an argument that will crop up in counseling more often, probably, than one might suppose. Which is the question of change. Change one’s deafness? Change one’s sexual orientation? Heterosexism has been defined as the belief that heterosexuality is inherently superior to any other orientation. Besides the homophobia in that attitude is the belief that one ought to want to be heterosexual, just because it’s more "normal." Counselors should be warned that choice is not the issue. There is even danger in the argument that being Gay or Lesbian is biological. If it is, is that the only reason to grant equal rights? Is that the reason Blacks were granted voting privileges and equal rights? Because they couldn’t help being Black? I don’t think so. People choose a religion, if they wish, whether they were born into one or not. Yet their rights of religious expression are protected by law. Seems to me a counselor needs to be wary of the client who wants to change because of the perception that life would be easier were they straight. They will still have a Gay or Lesbian soul and that cultural heritage will always be with them regardless of their chosen behavior. I would opt for discovery around living creatively as a Gay man or Lesbian, working on shame issues, and self-esteem issues, and homophobia, to name a few, before attempting to change a client’s orientation or even encouraging them to try.

Knowing that two lovers share the same cultures, such as Deaf culture and Gay culture, is a very special gift. I’ve always claimed that being Deaf and Gay is a double pleasure, not a double handicap (from "Double Pleasure" by Gregg Brooks in Luczak, pp. 147).


This discussion about HIV and AIDS is not meant to be complete or exhaustive. I want to discuss several areas, including mourning and grief, and empathic challenges for the counselor. There isn’t time to cover each area in detail, so this overview will suffice, I hope, and engender further research.

Care must be taken when dealing with grief (which refers "to the affective experience that accompanies a loss" and mourning (which "refers to the process of integrating the meaning of the loss") (Cadwell, et. al., 1994). In the Gay and Lesbian communities enormous losses have accrued and the potential is there for overload, meaning, too many lives lost, too many funerals to attend, and no way to integrate the losses upon losses. It is a tough place for a Gay or Lesbian counselor to be, as one has to address the issue of meaning and spirituality in the lives and deaths of young men and women who should still be alive, who died in their prime while an epidemic swept the nation, and that nation, for the most part, stood by without lifting a finger to help.

In the 1980s the Gay community developed agencies to care for its ill when no one else would. Also during this decade, Gay men had to learn to mourn their dead. Many of the people who had contributed to the evolution of Gay culture were now dying. The culture that evolved in the 1970s suddenly seemed to be in danger of slipping away. One could argue that developing rituals for mourning and honoring the dead represents the ongoing evolution of a culture. Unfortunately, the massive loss of lives came rather early and suddenly in the Gay movement. Considering this, the Gay community has done reasonably well in honoring its dead and validating the enormity of its loss (Cadwell, et. al., 1994, pp. 57-58).

What is amazing is that we have circled the wagons and protected ourselves. "The rapid creation, maintenance, and expansion, of institutions whose role is to tend to the needs of people living with human immunodeficiency virus (HIV) has been unprecedented in the history of social welfare in the United States" (Cadwell, et. al., 1994, pp. 58). That we did that and continued to care for our dying and press for education and public outreach and, simultaneously, launch demonstrations and sit-ins and civil disobediences that brought AIDS to the attention of the Federal Government and forced it to change its policies around identifying and treating the disease, not to mention developing and releasing new drugs is a monument to the resiliency of Gays and Lesbians worldwide. But that does not remove the savage sting of the abandonment we felt both from straight culture and from our own ill and dying. It is a counselor’s responsibility to address these issues and not be fooled into thinking that depression is simply a matter, for example, of difficulties in a relationship, or, perhaps, the feeling that somehow the client hasn’t accomplished in life what they thought, by now, they should or could. AIDS phobia and homophobia and "ecclesial homophobia" are the major players in this arena, and must be carefully considered in dealing with any client who has been affected, directly or indirectly, by this pandemic.

A more ardent seriousness about being Gay is also evident in our culture. AIDS and the effects of loss are ultimately humanizing. As men mourn the loss of a partner or friend, their narcissistic defenses lose some of their power. Gay men often become less afraid and less tolerant of homophobic bigotry (Cadwell, et. al., 1994, p. 58).

Certainly, anger can lead us to that sense of "we’re mad as Hell and we’re not going to take it any more!" It seems that it’s as important to address those activist outlets as a way of mourning as much as it is to address the loss and mourning itself.

Another mourning touchstone is the NAMES Project AIDS Memorial Quilt. People dealing with AIDS deaths are able to put together a 3’ x 6’ panel (the size of a grave) and decorate it with an incredible array of artifacts, poems, artwork, quilting, photos, and more. The process of creating the panel can be as much a community event as a private one. But the result is the same: mourning with friends or family near, remembering, talking, crying, creating, sharing.

The individual mourner first encounters the enormity of the Quilt as a validation of the enormity of his loss. He must search for the panel of his partner, friend, or friends as he wanders through the symbols of the losses of others--just as he may search and yearn for the lost experience of the relationship. Finally he finds the panel. He created it, sent it on, and may have seen it go all over the country, but once again he finds it. The memories flood, the tears well up, the sadness and pain return. Gradually the mourner’s intense affects subside. It is time to move on, time to go on living (Cadwell, et. al., 1994, p. 61).

Another way to deal with the loss is ritual. Some clients may find that creating their own rituals, or participating in a memorial service is useful. Meaning is derived from the steps of the ritual; perhaps even a reconnection with a spirituality that had been momentarily lost. Groups are another way to deal with the enormity of the losses. Somehow, the connection with other people who have been through or are going through similar stresses helps ease the process. The counselor dealing with HIV+ clients needs to keep these possibilities in mind.

For the HIV+ client, there is today a whole different set of issues to address. A few short months ago, the counselor was faced with a client who, if HIV+, was pretty sure to die sometime within a 10 year period after having contracted HIV disease. There were instances of long-term survivors, but not many. With the advent of protease inhibitors, some change is occurring. Now, about 70% of the HIV-infected people who use these new drugs (called cocktails when in combination with some of the standard ones, such as 3TC and AZT, for example), are able to stop much of the disease where it is. This is a double-edged sword and must be approached with the help of the client’s doctor(s). The new drugs don’t reverse the disease, just arrest it--in those who can tolerate it. So, this means that some people will respond and have a whole different set of issues to work on in therapy, where others still will have to deal with the prospect of death. If the patient responds well to the new drugs, he or she must now figure out how to reintegrate into life whose end was imminent and being prepared for. The alternative is to mourn one’s own death even before it happens (some friends of mine have even made panels for the Quilt (see below) before their own death). Attendant with the latter is the problem of determining which problems are counseling issues and which are somatic, such as AIDS-related dementia, etc. For those that are able, however, groups seem to offer a good deal of solace.

As HIV+ men join groups and establish relationships with other HIV+ men, they often find that their terror, isolation, and confusion diminish. Men also form friendships that strongly reflect the sentiment "we are in this together." A great deal of comfort, reassurance, and hope can come through these relationships (Cadwell, et. al., 1994, pp. 62-63).

Another area to consider occurs when a client presents with self recrimination for having gotten AIDS.

When the early family failed to adequately mirror the self, the vulnerable self may have rationalized that caregivers "legitimately" failed to affirm him because he was fundamentally "bad." AIDS can then feel like a present-day retribution or confirmation that the self is bad, defective, unworthy, and unlovable. This belief may be the core dynamic of internalized homophobia, in which certain Gay men experience AIDS as a punishment for being homosexual (Cadwell, et. al., 1994, p. 215).

The counselor must be particularly sharp around such issues. The complexity is in the combination of early childhood memories and events along with present day worries about self-esteem, health, proper care, friends, and a good support network. "The therapist’s mirroring, alterego, and idealizing functions are crucial, as is his or her commitment for a long-term presence" (Cadwell, et. al., 1994, p. 216). It seems to me the counselor may choose to cross boundaries when needed to help insure the care and well-being of the client.

Working with Persons With AIDS (PWAs) requires expanding the frame of the therapy. The therapist often must work with the patient’s support system via family and couple’s [sic] work, or conversations with the patient’s physician, to enable others involved with the patient to better mirror, accept, protect, and strengthen the PWA’s threatened self. The isolation, alienation, and stigma of AIDS requires that mobilization of interpersonal resources be a part of the therapeutic process (Cadwell, et. al., 1994, p. 216).

Countertransference is definitely an issue when working with HIV and AIDS clients.

Working with a terminally ill patient confronts the therapist with her or his own mortality and challenges her or his healthy grandiosity. The fears aroused can then impair the therapist’s ability to support or allow an idealized transference. As the patient grows more ill, angry, and frustrated, he may want to devalue the therapist. The therapist’s own sense of powerlessness might collude with this devaluation, instead of the therapist remaining empathically [sic] neutral and interpretive (Cadwell, et. al., 1994, p. 219).

If a Gay male therapist cannot separate his own grief from the experience of resonating with the patient’s feelings, or if he overidentifies with the patient, he will not remain attuned to the patient’s unique experiences. At the other extreme, if the therapist represses or disavows his own grief, he will affectively become distanced from his patient--a common consequence for burned-out Gay therapists who have large caseloads filled with HIV patients (Cadwell, et. al., 1994, p. 220).

I am aware that my own grief and mourning processes may come into play when I deal with HIV and AIDS clients. Personally, I have lost over 40 close friends and one lover to this disease. My anger and sense of helplessness constantly war with each other, and then I direct it toward the Reagan and Bush administrations which, in the early part of the pandemic, did absolutely nothing. It would be easy for me to collude with a client’s anger and I must guard against that. My sense of it is that if the issues does come up and I sense myself in a countertransference situation, it would be well, assuming my client has the strength to deal with it, to tell him or her that that is what is going on for me. With some honesty and deep discussion, the issue might be resolved and help us both along the way.

Another issue is survivor guilt. Again, this is an area that deserves more time than I can afford right now. But I want to touch on it briefly as a reminder to myself to study more about it, and to alert the reader to the problem.

If a man feels guilt for having had the good fortune to survive when another has not, it seems clear that he will be resistant to recognizing his own distress and doubly resistant to talking about it. Denial separate from survivor guilt may include denial of the personal and social impact of the AIDS epidemic on the Gay community in general, denial about the complexity of feelings surrounding safer and unsafe sex, and denial of the likelihood that the epidemic may take an irreparable psychological toll from many survivors, especially those with multiple losses (Cadwell, et. al., 1994, pp. 455-456).

An astute counselor can pick up on this guilt and direct the client’s attention to it. Often, these men engage in high-risk behaviors partly as a wish to join those who are sick or have died, believing that’s the only way they can "atone" for having remained HIV-. Some people put themselves on the front lines of the AIDS service institutions and so completely immerse themselves in their work that they burn out. This "‘acting out’ is [a] common--and not entirely pathological--expression of life in the epidemic" (Cadwell, et. al., 1994, p. 468).

When it is understood that guilt about surviving those who are lost to AIDS is irrational and unrealistic, and that it is compelling because it connects so powerfully to earlier conflicts characterized by guilt, the patient may then begin to feel that he has a right to have the best life he can--at any rate a decent one--and that trying to do so is not violence against, betrayal of, or abandonment of those less fortunate. "To a degree not generally recognized, psychopatholgies are pathologies of loyalty" (Friedman, 1985, p. 530 in Cadwell, et. al., 1994, p. 469).

Empathic challenges are especially apt to arise for the Gay or Lesbian counselor. Cadwell, et. al. (1994) discuss four levels on which a counselor might find him- or herself vulnerable. First, if the therapist is HIV-positive there would be the potential for immediate conflict. Second, is homophobia, or, as I call it, AIDS-phobia. The third is the counselor’s vulnerability to grief caused by multiple losses to AIDS. And, fourth, the counselor "is socially and politically vulnerable because of the loss of a powerful portion of his community" (p. 477).

Empathy, as I understand it, is the ability to hear and feel another’s pain but not merge with it; to remain differentiated from it. If any of the four issues listed above were to impair true empathy, the counselor would either have to bring it up in session, work it out with a colleague or supervisor, or refer the client to another counselor. I believe it could be damaging for a counselor to countertransfer and not either bring it up immediately or resolve it before the next session.

Other possibilities for dealing with empathy issues include meetings with other therapists, or conferences, or peer support groups. The counselor could get involved in other activities such as research, personal writing, and so on. Other ways to shore up an empathic overload include a well-developed social life, hobbies, exercise, spiritual pursuits, and real do-nothing down-time (Cadwell, et. al., 1994, pp. 486-487).

Empathy walks a fine line between two worlds:

To be too rigid about boundaries can also be to avoid through distancing, which can be experienced by the patient as lack of caring or even as hate. To be too identified can also be to join and lose vital differentiation. It is right at the boundary that the therapy is done. Tracking the therapy to this extraordinary permeable membrane of relatedness takes us to that place where self and other mix. To return to this inchoate place and come away clear and strong is the essence of identity. In this place, the therapist navigates, using multiple ways of knowing: joining and distancing, and identification and detachment (Cadwell, et. al., 1994, p. 492).

As I typed that paragraph my excitement grew. I see my work taking place on that very membrane and want a client load that appreciates that level of work. Alas, that will not be the reality for all of my work. But what I want to communicate to my clients is my earnest desire to "be present" for them and to work at our optimum best. There is an excitement working close to one’s raw feelings, which is equal parts dread and high arousal: you know you’re in dangerous territory but can’t resist the thrill of the danger.

Vital aspects of generativity are also inherent in the work.

One therapist says he is passing along what previous patients taught him to his next patients. This sense of "passing along" speaks to a sense of legacy that is critical to the success of many survivors of trauma (Lifton, 1979). This "telling of the story" is the same witnessing function in which Holocaust survivors found affirmation. This dimension captures some of the Eriksonian stage of generativity versus stagnation (Cadwell, et. al., 1994, p. 493).

I can only agree.


1 Ronald C. Fox, Ph. D. is a Psychotherapist in private practice in San Francisco, California. He is Cochair of the Task Force on Bisexual Issues in Psychology of the Society for the Psychological Study of Lesbian and Gay Issues, American Psychological Association Division 44.

2 New York's Stonewall Inn riot launches a "gay rights" movement as homosexuals protest a June 27, 1969 police raid on a Greenwich Village dance club and bar on Christopher Street. The People's Chronology is licensed from Henry Holt and Company, Inc. Copyright © 1992 by James Trager. All rights reserved.

3 It is a dream of mine to be able to counsel in American Sign Language (ASL) one day. It depends on time and the motivation to learn ASL well enough to understand all the psychological nuances, and then to find and develop a clientele.


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