Updated guidelines for sexual minority people focus on resilience

Newly revised guidelines for psychologists working with sexual minority people aim to help practitioners understand the diversity of sexual minority identities, recognize patients’ resilience as well as their challenges, and broaden the focus of research to include participants from more diverse backgrounds.

Adopted by the Council of Representatives in February 2021, the APA Guidelines for Psychological Practice with Sexual Minority Persons (PDF, 1.5MB) opens in new window give psychologists a guide to clinical practice with lesbian, gay, bi+ (a term that includes people who describe themselves as bisexual, pansexual, and fluid), queer, and asexual orientations.

“Psychologists in all walks of life will encounter people who are sexual minorities,” said Nadine Nakamura, PhD, who cochaired the task force that created the new guidelines. “The guidelines give them a starting point so that their clients feel they are working with someone who has a general understanding of what their life is like.”

When it comes to sexual minority people, too often the focus is on the negative, even to the point of pathologizing this diverse population, Nakamura said. The revised guidelines aim to upend that perception.

“Because there is so much focus on stigma, we wanted to make sure that we presented the other side of the coin—resilience,” said Nakamura, a psychology professor at the California School of Professional Psychology at Alliant International University in San Diego. “Being a sexual minority person is not all doom and gloom.”

Since the last guidelines were adopted in 2012, there has been an explosion of research on sexual minorities, said Nakamura. Convened in 2018, the task force reviewed that literature, focusing especially on scholarship by researchers of color and sexual and gender minority researchers. The task force also met with a group of young people of color in Washington, D.C., to better understand their perspective. Reviewers with both research and clinical experience with sexual minority populations then provided feedback as the task force wrote and revised the guidelines.

The resulting guidelines use three conceptual lenses, said Nakamura and her task force cochair, Franco Dispenza, PhD, an associate professor of counseling and psychological services at Georgia State University.

First, the guidelines use the lens of affirmative psychological practice, which views sexual minority identities and sexual behavior as normal and nonpathological.

Second, the guidelines are grounded in sexual minority stress theory. The theory acknowledges the interpersonal and societal prejudice and stigma that sexual minorities face and the harm such stressors can have on their psychological and physical health. “We tried to bring issues related to stigma to the forefront so that psychologists realize how much heterosexism, monosexism, and other environmental stressors are having an impact on their clients,” said Nakamura.

Third, the guidelines use an intersectional approach that considers how other factors, such as race, gender, age, immigration status, and disability status, interact with each other. While those intersecting identities can result in multiple oppressions, said Dispenza, they are also sources of strength. “We all have intersectional identities that give us a source of pride, resilience, and ability to thrive,” he said. “These are all aspects that contribute to one’s well-being.”

All psychologists, whether they specialize in sexual minority issues or not, need some basic knowledge about this population, the guidelines emphasize. Psychologists should understand that people have diverse sexual orientations, and those orientations are normal variations and not mental illnesses needing treatment. Psychologists should also understand the multiple systems of oppression sexual minority individuals face, including the environmental, economic, and sociopolitical forces affecting their mental health.

The guidelines aim to clear up common misconceptions, such as conflating sexual orientation and gender identity. A person’s sexual orientation is whom that person is attracted to. That is distinct, the guidelines explain, from a person’s gender identity, or that person’s sense of their own gender.

The guidelines also call on psychologists to eradicate their monosexist bias and affirm bi+ identities. Bi+ women in the United States are a bigger population than lesbians, gay men, and bi+ men combined, the guidelines point out, yet bi+ individuals are often overlooked or subjected to harmful, inaccurate stereotypes that cast them as hypersexual people, cheaters, and spreaders of HIV and other sexually transmitted infections.

“We know that bi-erasure and bi-negativity are incredibly common and have really negative mental health effects,” said task force member Jennifer Vencill, PhD, an assistant professor of psychiatry and psychology at the Mayo Clinic in Rochester, Minnesota. Bi+ individuals, especially women, have the highest suicide rate of any sexual orientation group, for example. Bi+ young people are at higher risk of depression.

The updated guidelines urge psychologists to recognize the various types of stigma, discrimination, and sexual minority stress this population faces and advocate to eradicate them. Such stressors occur at all levels.

At the societal level, institutional discrimination such as same-sex marriage bans and religious exclusion is associated with poorer mental, behavioral, and physical health outcomes. In states with hate crime statutes and nondiscrimination policies in place to protect sexual minorities, the prevalence of psychiatric disorders is much lower. Psychologists themselves can perpetuate this kind of discrimination through seemingly innocuous acts like defaulting to the terms “mother” and “father” on intake forms instead of using the term “parent” or “guardian,” which does not imply assumptions about family composition.

Sexual minorities experience interpersonal discrimination, too, ranging from microaggressions to physical abuse. A psychologist could commit a microaggression by seeming to endorse heteronormativity, for example. At the other extreme, sexual minorities of all ages face higher rates of victimization than their heterosexual peers.

These stressors can lead sexual minorities to internalize heterosexism and other forms of stigma, another guideline points out. That might mean feeling anxious or trying to conceal one’s identity. These stressors can result in reduced psychological well-being, increased risk-taking, and worse physical outcomes.

But psychologists should not just focus on the negative. Another guideline urges psychologists to recognize the positive aspects of being a sexual minority and the individual and collective ways this population resists stigma and oppression.

“Because oppression toward this community is so prevalent, we are often unable to see beyond disparities,” said task force member Roberto Luis Abreu, PhD, an assistant professor of counseling psychology at the University of Florida. “We wanted to recognize that this population is not just coping with adversity, but many are thriving.”

Another set of guidelines focuses on relationships. The guidelines urge psychologists to respect diverse relationships and recognize the complexity of sexual health for sexual minorities.

Polyamorous relationships are one example. While research suggests that heterosexual and sexual minority people engage in consensually nonmonogamous relationships at similar rates, mental health practitioners often stigmatize such behavior among sexual minorities. In addition to lacking knowledge about this relationship structure, they may claim nonmonogamy is inferior to monogamy or even push patients to renounce these relationships.

“Both socially and clinically, there are many different types of relationship structures that are healthy, normative, and appropriate,” said Dispenza. “These relationship structures should not be pathologized.” Intake forms might just have one line for spouse or partner when a patient may have multiple partners, for example.

Psychologists may hold similarly stigmatizing views about sexual health. “There is a long history of pathologizing sex in this community, connecting it with HIV and other sexually transmitted infections, high-risk behaviors, and bad relationships,” said Dispenza. While rates of new HIV infections are highest among sexual minority men, that narrow focus has meant a lack of attention to other aspects of sexual health. Sexual minority women, for instance, experience much higher rates of sexual assault than heterosexual women.

Other guidelines urge psychologists to understand sexual minority people’s families—both their families of origin and families of choice. Coming out to families of origin can result in conflict, internalized stigma, and adverse psychological outcomes, with acceptance and rejection influenced by the family’s racial and ethnic background and religious beliefs. Psychologists should respect a patient’s decision not to disclose their identity to their families. Psychologists should recognize that sexual minority patients may have other forms of close relationships and inquire about significant relationships beyond biological family. While research shows there are no disadvantages for children raised by sexual minority parents and there are associated strengths, sexual minority parents face stigma, adverse policies, and other challenges that psychologists should strive to understand.

Psychologists also need to understand the educational issues sexual minorities face. At the high school level, for example, sexual minority students report higher levels of in-person and online bullying, violence, and sexual violence than their heterosexual peers. The victimization does not stop once students head to college. Sexual minority college students, especially those who have other forms of oppressed identities, report more isolation, drug use, depression, and suicidal ideation.

In addition, psychologists need to understand the unique issues sexual minorities face on the job. Discrimination and other factors lead to higher overall rates of poverty for this population.

The guidelines push psychologists to educate themselves about sexual minority people, then use that knowledge to improve education and training programs.

The final guideline urges researchers to take an affirming stance toward sexual minorities in all aspects of their work as a way of reducing health disparities and promoting well-being.

“At minimum, that means asking people about their sexual identities,” said Vencill. “That is still not routine in the psychological research that we do, and that is a huge demographic variable that is being overlooked.”

Researchers should also broaden their research population beyond upper-middle-class White urbanites and be careful not to lump all sexual minorities together, added Vencill, pointing to the unique experiences and needs of bi+ people in particular. The guidelines also identify several gaps in the research, such as research on asexuality and interracial relationships—a type of relationship more prevalent among sexual minority populations.

“The guidelines go beyond clinicians,” said Nakamura. “Every psychologist should find some kind of usefulness in the guidelines.”