SEXUAL MINORITY CLIENTS

Sexual minority clients are persons whose sexual orientation and/or modes of consensual sexual and/or gender expression differ from the majority of the surrounding society. Initially the term sexual minorities referred primarily to homosexual men and lesbians. It has come to include bisexuals and the spectrum of transgendered people; these four groups are categorized under the rubric LGBT (Lesbian, Gay, Bisexual, Transgender).

Sexuality Factoid

In a national survey, 90% of men aged 18-44 considered themselves to be heterosexual, 2.3% as homosexual, 1.8% as bisexual, and 3.9% as 'something else'

Mosher WD, Chandra A, Jones J. Sexual behavior and selected health measures: Men and women 15–44 years of age, United States, 2002. Advance data from vital and health statistics; no. 362. Hyattsville, MD: National Center for Health Statistics. 2005.

Others referred to as sexual minorities include fetishists, practitioners of BDSM (see below) and people in nonmonogamous relationships, e.g. polyamorists (see below).

Members of sexual minority groups are often ridiculed, stigmatized, marginalized, feared, and even hated. As a healthcare professional, an important aspect of addressing sexuality concerns has to do with answering for yourself questions such as, “What types of clients am I comfortable with/willing and able to provide services for?” “Are there practices I can not condone/accept or that make me too uncomfortable to be effective in a therapeutic role?” “How much do I know or need to know about nontraditional practices, relationships, lifestyles?”


Homosexuality

Homosexuality is the sexual and romantic attraction between two individuals of the same gender. While the term can be used as an umbrella that encompasses both males and females, it is generally used, along with the term gay, to refer to males. The topic of homosexuality can stir passionate debate and intensely heated reactions.

While many believe that sexual orientation is purely biological and inborn, others believe that social and environmental factors intersect with biology to produce sexual orientation. Both nature and nurture may play complex roles in this process. The American Psychological Association (2008) notes that most people experience little or no sense of choice about their sexual orientation.

Despite the prevailing view of scientists toward a biological basis for homosexual orientation, there are adversaries, particularly those who believe it to be a grievous sin, whose approach is to say, “Even if they’re born this way, they don’t have to act on it.”

Reparative or Conversion therapy techniques aimed at changing homosexual orientation to heterosexual attraction have been touted as effective “treatment” by opponents of homosexuality, even though the mainstream health and mental health organizations who have a position on this therapy have condemned it, and most medical professionals warn that attempts to change one’s sexual orientation are potentially psychologically harmful (American Psychological Association, 2008).

Sexuality Factoid

4% of men and 2% of women consider themselves homosexual while 5% of men and 3% of women consider themselves bisexual

Source: Janus, S., and Janus, C. The Janus Report on Sexual Behavior. 1993. New York: John Wiley & Sons.


For over three decades the consensus of the mental health community has been that homosexuality is not an illness and therefore not in need of a cure, and many believe that claims by certain groups that they can change homosexual orientation create an environment in which prejudice and discrimination can continue to flourish.

Lesbianism

Lesbianism is same-sex desire and sexuality among females. In Western societies explicit prohibitions on women's homosexual behavior have been much weaker than those on men's homosexual behavior, and in general lesbianism arouses less intense emotional reactions in opponents.

Sexuality Factoid

Among women aged 18-44, 90% said they were heterosexual, 1.3% homosexual, 2.8% bisexual, and 3.8% as 'something else'

Mosher WD, Chandra A, Jones J. Sexual behavior and selected health measures: Men and women 15–44 years of age, United States, 2002. Advance data from vital and health statistics; no 362. Hyattsville, MD: National Center for Health Statistics. 2005.

Bisexuality

Bisexuality is the human sexual orientation that refers to the aesthetic, romantic, or sexual desire for people of either gender or of either sex. Some view this as a parallel attraction along with homosexuality and heterosexuality, while for others the term expresses a blend of the two.

In 1948 Alfred Kinsey, stating that “the living world is a continuum in each and every one of its aspects”, developed a 7 point scale to measure sexual orientation from 0 (exclusively heterosexual) to 6 (exclusively homosexual). This scale helps in understanding variations in sexual attraction (The Kinsey Institute, 1999).

One case example of a blended attraction is a man who identifies himself to the world as gay. He states, “I am attracted to women, and I can be sexual with women and enjoy it. If I were giving a percentage, I’d say I’m 40% attracted to women and 60% attracted to men, but I feel more emotionally connected and comfortable with men, so I’ve chosen to be with men.” And a t-shirt worn by a college student says, “I’m bisexual--this doubles my chances of having a date on Saturday night.”

Sexuality Factoid

6.2% of men and 4.4% of women are attracted to people of the same sex

Source: Laumann, E., Gagnon, J.H., Michael, R.T., and Michaels, S. The Social Organization of Sexuality: Sexual Practices in the United States. 1994. Chicago: University of Chicago Press (Also reported in the companion volume, Michael et al, Sex in America: A Definitive Survey, 1994).


Interestingly, in the rapidly developing field of the study of animal sexuality, researchers have found a wide range of sexual behaviors in animals and have documented homosexual behavior in over 1500 species, including insects, birds, and mammals, particularly apes (Goudarzi, 2006; Owen, 2004; Smith, 2004).

Note: Same-sex sexual behavior and same sex orientation in humans can be distinct from one another. Many heterosexuals engage in same-sex behavior at times, and many homosexuals have heterosexual lifestyles. As a clinician you may have clients who are questioning their orientation and want to explore what is happening in this regard. There are excellent references on the resource pages. One particularly good book to help in this exploration is Eric Marcus 2005 book Is It a Choice? Answers to the Most Frequently Asked Questions About Gay & Lesbian People, 3rd Edition (Paperback).

Transgender

Transgender is an umbrella term that describes people who feel their anatomical sex and their gender identity do not match. In other words, transgender individuals identify with a physical sex different from the one they were born with, and many describe the feeling of being “trapped in the wrong body.” Their appearance and behavior often do not conform to society’s norms for their apparent gender.

Included in this group are transvestites, i.e. persons who dress in the clothing of the opposite gender (a.k.a., crossdressers) but do not want to change their anatomical sex, transsexuals, i.e. people who intend to live as a gender other than the one assigned to them at birth, and others with unconventional gender expressions (University of California at Santa Barbara, 2008a; Gender.org, 2001).

Experts estimate that transsexuals account for 1 in every 2,500 people, at least for male-to-female. Female-to-male transsexuals are roughly the same number as male-to-female (www.diversitycentral.com).

There are many forms of gender variance, making education on the subject beyond the scope of this module. Resources are provided for those who want to explore this in more depth. The Harry Benjamin International Gender Dysphoria Association (HBIGDA), named for one of the first physicians to work with gender dysphoric persons, is an international interdisciplinary professional organization whose mission is to further the understanding and treatment of gender identity disorders by professionals of many disciplines.

The name of the Association has been changed to The World Professional Association for Transgender Health (WPATH). It is not unlikely that healthcare providers will encounter transgendered individuals during medical/mental health assessments.

INTERSEXUALITY

Intersex conditions are those in which a person is born with a reproductive or sexual anatomy that doesn’t seem to fit with what is typically defined or recognized as female or male (Intersex Society of North America, 2008). According to Preves (2003), one in 2,000 infants is born with atypical genitalia, and as many as four in 100 individuals may be intersexed if one takes into account hormonal and chromosomal differences along with anatomy.
Sexuality Factoid

In hospitals with gender assignment teams, 1 in 2000 infants is born with genitalia that are so atypical that the attending physician requests the help of the specialists in the team to assign a sex.

Source: www.intersexualite.org


The Intersex Society of North America (ISNA), founded in 1993, was established to provide information and awareness about the many genital surgeries that may have been unwanted and that have been shrouded in secrecy and shame for the individual born with an anatomy “that someone decided” is not standard for male or female.

Their excellent website explains what intersex is, intersex conditions, recommendations for children with intersex, past treatment of intersex, the difference between being transgender or transsexual and having an intersex condition, and other very valuable information for individuals, families, professionals, and the general public (Intersex Society of North America, 2008). (http://www.isna.org ).

BDSM

BDSM is a an umbrella term that describes a number of consensual sexual behaviors performed for mutual enjoyment that in neutral or nonsexual contexts would be considered unpleasant, undesirable, or abusive. B & D is Bondage & Discipline, D & S is Domination and Submission, and S & M is Sadism and Masochism.

Many of these behaviors have become increasingly accepted. Diagnostically, for sexual sadism or masochism to be considered a disorder, the fantasies, sexual urges, or behaviors must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (American Psychiatric Association, 2000).

Sexuality Factoid

14% of men and 11% of women have had some sexual experience with sadomasochism

Source: Janus, S., and Janus, C. The Janus Report on Sexual Behavior. 1993. New York: John Wiley & Sons

POLYAMORY

Polyamory involves the practice or lifestyle of sustaining multiple, open, honest, sexual and loving relationships. It can involve any network of multiple partners who have primary relationships with each other, and each set of polyamorous (aka poly) people must decide what their boundary conditions are and how their relationships are going to be conducted (Anapol, 1997).

Polyamory – at least in theory - is separate from the "swinger" culture in that the primary emphasis in on multiple loving relationships that exist over time, not simply the gathering of groups for casual sex.

To date, reliable statistics have not been compiled that show the incidence of polyamory in the United States; however a brief survey of web sites dedicated to the subject of polyamory seems to show a burgeoning culture for this practice.

TREATING SEXUAL MINORITY PATIENTS

Therapists who are considering treating sexual minority patients must first answer the question of whether they really wish to treat such patients. Not all therapists (even those who are themselves sexual minority therapists) are able to overcome their own issues about alternative sexual behaviors and treat patients non-judgmentally. In these instances, patients should be referred (Moser, 1999).

Dr. Charles Moser (1999) has written an excellent article that 1) guides therapists in making the decision about treating sexual minority patients, 2) discusses specific considerations in treating these patients, and 3) provides specifics of interviewing and a glossary of sexual minority terms. The article can be accessed online at http://www.ejhs.org/volume2/Moser/moser1.htm

Because the interview techniques included in this article are applicable to virtually all interview situations, they are included here.

Interviewing

Better ways of asking questions:

Rather than asking "marital status?"
Ask, "Are you single, married, divorced, separated or partnered?" The next question is, "With whom do you live?"

Rather than "What form of birth control do you use?"
Ask, "Do you use birth control?" If the patient says no, then ask "Do you need birth control?"

Rather than "Do you have any sexual problems?"
Ask, "Do you have any sexual concerns?" There is research showing that this question, however, will not uncover sexual dysfunctions. You have to ask about each specific dysfunction. For example, "Do you have difficulty having an orgasm, getting an erection, maintaining an erection, with pain during sex, lubricating enough or long enough, with the amount of desire you have for sex?"

Rather than "With how many partners did you have sex?"
Ask, "Are you sexually active?" Note: The author has found that this particular question can generate very concrete responses such as, “No, I just lie there,” etc., so please word this in a different way.

Rather than, "Who beat you up?"
Ask, "How did you get those marks/bruises/welts?"

Rather than, "What is your sexual orientation?"
Ask, "Do you have sex with men, women or both?" (Moser, 1999).

SEX SURROGATES

Sex Surrogates (a.k.a., surrogate partner therapy), a therapeutic modality introduced by Masters and Johnson, have sometimes been recommended for people with physical disabilities and other conditions that have impacted and/or inhibited their sexual development.

Since its inception in the 1970s, the practice has been controversial in the business of sex therapy. There are complex legal, moral, ethical, professional, and clinical implications.

According to the International Professional Surrogates Association (IPSA), a surrogate is a member of the three-way therapeutic team (an accredited or licensed supervising therapist, the client, the surrogate) who acts as a nurturing partner to the client, helping him build his skills in the areas of physical and emotional intimacy achieved through experiences involving communication, relaxation, sensual and sexual touching, and social skills training. (International Professional Surrogates Association Website, n.d.).

Sex surrogacy differs from prostitution in that the prostitute’s intent is immediate sexual gratification, while the surrogate’s intent is long-term therapeutic re-education and re-orientation of inadequate capabilities of sexual functioning. Data gathered for a research project in 1983 seemed to support strongly Noonan's hypothesis that sex surrogates provide more than sexual service for their clients and that they spend almost 90% of their professional time doing nonsexual activities (Noonan, 1984/1995).

The extent of sex surrogacy involvement in sex therapy today is unknown. Its use in many states is prohibited at the outset by legal constraints.

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