Cover Story

In the 32 years since patrons of the Stonewall Inn challenged police who raided the now-famous gay nightclub, lesbians, gays and bisexuals have grown in personal and political power, creating their own communities and finding acceptance in traditional ones as well.

Conversations taking place in today's therapy offices reflect this change. Although many lesbian, gay, bisexual and transgendered (LGBT) people still bring issues of discrimination and fear of rejection to their psychologists' offices, they are just as likely to discuss such mainstream issues as parenting and fears about aging.

Meanwhile, new trends have emerged in therapy, too, as younger generations of LGBT people wrestle with problems such as a resurgence of HIV infection among gay male youth and changing identity issues. Likewise, groups that have been more closeted, including transsexuals and transgendered people, are finding their voice and appearing more often in treatment to work on identity and relationship concerns.

"Some issues haven't changed much at all since Stonewall, and others have changed dramatically," comments Doug Haldeman, PhD, a clinical faculty member at the University of Washington and an APA Council representative for Div. 44 (Society for the Psychological Study of Lesbian, Gay and Bisexual Issues). "People still need help with coming out--when, how and to whom. Some cultures within our culture are still very homophobic."

At the same time, Haldeman says, psychologists are seeing "a whole host of other issues related to the creation of LGBT families, LGBT people in the workplace, generational differences and the reality of multiple-minority identities--issues that demand our best research and clinical skills."

Generation gaps

Psychologists working with LGBT clients are finding the need to tune in to generational differences, experts note--whether it's understanding young LGBT clients' new ways of thinking about their sexuality or assessing reasons for depression in older gay men.

Many LGBT youth, for instance, now call themselves "queer" as a blanket term for their community, and they're more likely to accept variations in their ranks than previous generations, says Beth Firestein, PhD, a private practitioner in Loveland, Colo., and editor of "Bisexuality: The Psychology and Politics of an Invisible Minority" (Sage, 1996), a compendium of research on bisexuality. In communities that include lesbians and bisexual women, for example, "there's more unity and community, cooperation and friendly relationships now than there was 10 or 15 years ago," she says.

Esther D. Rothblum, PhD, a professor of psychology at the University of Vermont, agrees it's more common for today's young LGBT people to express and accept fluid gender and sexual identities. "In the generation before mine, if you went to a lesbian bar and didn't identify as either butch or femme, they'd think you were an imposter," she says. "Now young lesbians are just as likely to say they feel butch one day and femme the next."

Another strong feature that distinguishes younger lesbians from their Baby Boomer counterparts is their lack of identification with the feminist movement, says sex therapist Suzanne Iasenza, PhD, a professor of counseling at the John Jay College of Criminal Justice in New York.

"Their attitude is, 'What does my sexuality have to do with politics?'" says Iasenza. "You're not likely to find them saying they're lesbian as a statement against patriarchy or because they don't like the way men take over their bodies or their lives."

Gay men, young and aging

Some young gay men are presenting a serious challenge for practitioners. Since protease inhibitors were introduced in the mid-1990s, researchers have reported a surge in the number of young gay men who practice unsafe sex, known these days as "barebacking," in part because they thought the drugs would protect them from HIV's worst effects.

The events of Sept. 11 seem to have escalated this trend, with the crisis adding a dose of fatalism and nihilism to impulsiveness, according to Haldeman. As a consequence, Haldeman finds himself taking a hard line with these clients, despite his therapeutic training. He fears that if he doesn't push them to change, he'll see more young men with HIV who need help managing the disease.

Columbia University HIV-prevention researcher and clinician Alex Carballo-Dieguez, PhD, says that in addition to barebacking, he's spotting a body-image problem among his young gay clients. "Twenty years ago, your body image was about what you wore, how you wore your hair and so on," Carballo-Dieguez says. "Now, it's about the transformation of the body itself. These guys want to reshape their bodies to make them look a certain way"--muscled and perfectly toned. "A lot of times that's achieved with chemicals, hormones and even surgery," he says.

This obsession becomes especially problematic when it comes to partner-shopping, with clients looking for Mr. Right only if he's also Mr. Buff, Carballo-Dieguez says.

To combat this problem, he has clients walk through their own sexual and emotional histories and take a realistic look at themselves.

"They get to see that they've never been satisfied with the guys they score with," he says. "They're never certain that they're attractive enough or that the other person's attractive enough." This insight can help them stop the appearance-obsessed merry-go-round, he says.

Gay men in their 40s and 50s also bring a "looks" challenge into therapy, says Haldeman.

"Middle-aged gay men face tremendous challenges because we grew up in such a youth-oriented gay culture," says Haldeman, who's 50. "Thirty-five is seen as old, and 50 is ancient! That's a blow to our narcissism. Not only are we not the pretty things when we walk into the bar, we're the age of the parents of the pretty things."

Haldeman urges such clients to take a life inventory, to look at the past and see what's valuable there. "They need to ask themselves, 'Am I on a path where, when I look back, I'll be satisfied with my life?'" he says.

The silver lining to their aging regrets: "Thank God we're aging," Haldeman adds. "We buried so many of our generation years ago. So we have a special joy and appreciation of life that we might not otherwise have had."

Coming out, parenting

LGBT clients of all ages are still likely to face coming-out issues, clinicians report. Young people, though, are more likely to face a host of post-coming-out problems, since many are likely to already have come out to their parents, says Marny Hall, PhD, a psychotherapist and researcher in the San Francisco Bay area. While that's often good news, she observes, often their parents' acceptance is conditional.

"Parents tend to display a sort of limited tolerance for their 'queer' kids--what I call tolerance without equality," Hall says. "The clients I see are constantly confronted with issues like this."

LGBT clients are also dealing with the flip side of that equation: being parents themselves. Many lesbians and gay men are the first generation of homosexuals to have children who are becoming teens. Some have found that while as younger children they had no problem accepting their gay parents, as they move into adolescence, some teens start to feel embarrassed by their parents' homosexuality, says Haldeman.

"Some young people are really conflicted and may try to hide the fact they have two same-sex parents by having the parents pick them up from school in some secret location," he says--dynamics that affect the child's relationship with parents and peers and the parents' relationship.

Another spin on the parenting issue is that today, gays and lesbians have children not only from dissolved heterosexual marriages, but from broken-up gay relationships as well, Hall adds. Conflicts involving children of same-sex unions present particular difficulties because the legal ground for same-sex couples and their child-custody rights "is shifting all the time," she says.

"When there are no clear guidelines, what often substitutes are conflicts within the couple," Hall says. "Relationship problems can really get played out in this arena."

Psychologists are helping these clients separate parenting problems from relationship problems and devising solutions that don't require legal structures to implement, she says.

Gender-blending and fluid identities

A final theme clinicians report in their practices is more questioning and fluidity around gender identity and sexual attraction. While these issues are central in the lives of transsexuals or transgendered people, others are questioning these elements of identity and expression too, therapists report.

"I'd put a fifth category on the end of 'LGBT'--a 'Q' for 'questioning,'" says Hall. "Gender identity and sexual identity issues have frayed more and more around the edges."

On one hand, there's a push for LGBT young people to come out at earlier ages, she notes; on the other, more young people are pausing indefinitely in what she calls the "lingering" category. "There are no more givens about gender identity," she says. "Young people don't take sexual identity for granted."

Bisexuals represent another group that turns conventional thinking on its head, says Firestein.

"Often bisexuals want to label themselves as lesbian or gay because occupying a middle ground is so difficult in a culture that dichotomizes sexual orientation and gender identity," she says. Conventional thinking has it that if bisexuals are attracted to people of both sexes, they must have more than one partner, and that defies society's value on monogamy. Bisexuals tend to internalize this social tension, Firestein says, so a common therapeutic question is, "If I identify as bisexual, what does that mean about my choice of partners?"

To help bisexual clients face this concern, Firestein conducts an exercise demonstrating that the number of partners you have and your sexual orientation exist on different dimensions. As two examples, you can be monogamous and bisexual, and you can be heterosexual and have more than one sexual partner.

For transsexuals--people who have nontraditional gender identity or expression--issues include coming to terms with their feelings about their true gender and then deciding whether and how to act on those feelings. In her work with transgendered people, New York City private practitioner and gender expert Katherine Rachlin, PhD, notes that transgendered people struggle not so much with who they are as with finding ways to fit into a society that doesn't understand them. She says that transgendered people, who do not identify as either male or female, sometimes work on accepting a fluid gender identity. More often, Rachlin says, they choose to identify as one gender or the other because it's too challenging to live in a gender-dichotomous society otherwise.

Therapy with transgendered people requires extra education and perception, Rachlin believes. She spent hundreds of hours with this community before she had a good understanding of how to work with "trans" clients, she says. For clinicians who want to work with trans people, she recommends reading the Harry Benjamin Foundation's "Standards of care for the treatment of gender identity disorders," available on the Web at www.HBIGDA.org. The document outlines the role of the therapist and describes the qualifications needed to be a gender specialist.

In her 15 years of being involved with the trans community, Rachlin has appreciated learning a new and different way of looking at gender.

"There's a great mystery that underlies transgenderism, and it does change the way you see the world," she says. "I had to redefine male and female, man and woman, for myself. These concepts are now disproven to me."

Tori DeAngelis is a writer in Syracuse, N.Y.