Running head: SEXUAL MINORITY COUNSELING CONSIDERATIONS

Sexual Minority Counseling Considerations

Catherine E. Hommer
Frostburg State University

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Literature Review

When working with sexual minority clients, unique considerations must be taken into
account. Research by Liddle (1996) examined how sexual minority clients rated therapists
helpfulness based on therapist sexual orientation, gender, and counseling practices. This study
replicated and extended previous research on therapist attributes (Liddle, 1996). Past studies
were outdated and did not examine perceived helpfulness of therapists (Liddle, 1996).
Participants were 392 lesbians and gay men who completed a survey developed by the
researcher (Liddle, 1996). The survey included items pertaining to therapist practices, therapist
gender, therapist sexual orientation, and the number of sessions attended by the client. The
researcher sent 867 surveys to graduate students across the United States and Canada. Threehundred and ninety-two useable surveys were received over the course of a year (Liddle, 1996).
Statistical analyses included a three-way analysis of variance (ANOVA) between
therapist helpfulness rating as the dependent variable and client sex, therapist gender, and
therapist sexual orientation as the independent variables (Liddle, 1996). In the second ANOVA,
the researcher analyzed risk factors of therapy into two outcomes: therapist rated as unhelpful
and termination after first session (Liddle, 1996).

Last, the researcher completed a post hoc

analysis of covariance (ANCOVA) for therapist gender and sexual orientation with perceived
helpfulness (Liddle, 1996).
The findings supported that sexual minority clients perceived greater helpfulness from
therapists that matched on sexual orientation and gender (Liddle, 1996). However, heterosexual
female therapists were perceived as just as helpful as sexual minority therapists (Liddle, 1996).
On the other hand, heterosexual male therapists were rated lower than heterosexual female
therapists (Liddle, 1996). The researcher contributed this difference to female therapists being

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more informed about tailoring therapy for sexual minority clients. When therapists did not
reveal sexual orientation, perceived helpfulness was rated lower than both male and female
heterosexual therapists (Liddle, 1996).
The next article investigated internalized homophobias effect on sexual minority clients
relationships (Frost & Meyer, 2009). Internalized homophobia can lead a client to repress their
sexual orientation, impact his or her mental health in a negative way, and lead to a negative selfview (Frost & Meyer, 2009). The researchers conceptualized internalized homophobia in terms
of the stress theory, where the minority stressor of internalized homophobia was specific to
minority groups who have to adapt to hostile social environments (Frost & Meyer, 2009).
Internalized homophobia and other minority stressors were placed along a continuum that ranges
from stressors closest to the person to the furthest away from the person (Frost & Meyer, 2009).
Internalized homophobia was linked to several adverse outcomes in sexual minority
romantic relationships (Frost & Meyer, 2009). These included decreased satisfaction with
relationships, negative relationship quality, decreased length of relationship, reduced sexual
desire and depression. The researchers examined the relationship between internalized
homophobia and quality of romantic relationships (Frost & Meyer, 2009). Three hundred and
ninety-six subjects from the New York area were chosen to be sampled between February 2004
and January 2005 (Frost & Meyer, 2009). Participants that were recruited were surveyed using
different measures, which included the Internalized Homophobia scale (IHP scale), the Center
for Epidemiological Studies Depression Scale (CES-D), Outness, The Urban Mens Healthy
Study cohesion scale, Turners Relationship Strain items, Positive Relations with Others scale,
and The Sex Problems subscale of Psychiatric Epidemiology Research Interview (PERI) (Frost
& Meyer, 2009).

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Structural equation modeling (SEM) tests were used to assess direct and indirect effects
of internalized homophobia (Frost & Meyer, 2009). Internalized homophobia led to greater
relationship problems because of increased depressive symptoms in participants interviewed
(Frost & Meyer, 2009). In addition, outness, connection to the LGB community, and depressive
symptoms were not directly related to internalized homophobia. Outness was negatively related
to internalized homophobia but was not related to relationship strains (Frost & Meyer, 2009).
Connection to the LGB (Lesbian, Gay, Bisexual) community was also independent of
internalized homophobia but did affect relationship quality in a negative way (Frost & Meyer,
2009). The researchers contributed this negative effect on relationships because they thought an
LGB individual may be giving more attention to community connections over his or her
romantic relationships (Frost & Meyer, 2009).
Another important consideration to examine when counseling sexual minorities is
whether or not the clinician is engaging in sexual orientation microaggressions (Shelton &
Delgado-Romero, 2013). Once overt, heterosexism has moved towards becoming more subtle
(Shelton & Delgado-Romero, 2013). Microaggressions are meant to be negative messages and
serve as discrimination towards sexual minorities (Shelton & Delgado-Romero, 2013).
Microaggressions do not happen at one time but over a period, which makes them hard to
challenge (Shelton & Delgado-Romero, 2013). In addition, the person using the
microaggressions might not realize what they are doing, or saying is harmful because their
prejudices are unconscious (Shelton & Delgado-Romero, 2013).
There are three types of microaggressions: microassaults, microinsults, and
microinvalidations (Shelton & Delgado-Romero, 2013). Microassaults are deliberate forms of
discriminatory behaviors or words that are meant to hurt the intended target (Shelton & Delgado-

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Romero, 2013). This type is closest to overt discrimination because they are not hidden
Microinsults are outside of consciousness and are rude verbal or nonverbal messages (Shelton &
Delgado-Romero, 2013). Microinvalidations are nullifications of the targets feelings, reality,
and thoughts (Shelton & Delgado-Romero, 2013). Microinsults and microinvalidations are more
dangerous than microaggressions because they are not in the communicators awareness (Shelton
& Delgado-Romero, 2013). Originally only to be thought to happen against racial minorities,
microaggressions are being observed in relation to sexual minorities as well (Shelton & DelgadoRomero, 2013).
The study aimed to explore sexual microaggressions occurring during psychotherapy
(Shelton & Delgado-Romero, 2013). Sixteen participants were recruited from a southeastern
University LGBQ center and website (Shelton & Delgado-Romero, 2013). Participants must
have identified as LGBQ (lesbian, gay, bisexual, queer) and have had at least one session with a
mental health professional (Shelton & Delgado-Romero, 2013). The subjects were split into two
separate focus groups of five and eleven members lead by sexual minority leaders. Researchers
pulled questions from Sue and colleagues study of racial microaggressions to use in the focus
groups (Shelton & Delgado-Romero, 2013).
Data was transcribed from each group and read multiple times by many people to gather
collective themes (Shelton & Delgado-Romero, 2013). Seven themes appeared when looking at
all of the data: sexual orientation as reason for treatment, avoidance of sexual orientation, overidentification with LGBQ clients, stereotypical assumptions about sexual minority clients,
heterosexism bias, assumption that LGBQ people need therapy, and warning about being LGBQ
(Shelton & Delgado-Romero, 2013). Microaggressions were transmitted through direct and
indirect channels that left clients feeling confused, hurt, and rejected among other negative

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feelings (Shelton & Delgado-Romero, 2013). In addition to microaggressions communicated by

the therapist, environmental microaggressions were also experienced by clients (Shelton &
Delgado-Romero, 2013). These included information available in therapists offices, such as
pamphlets and books (Shelton & Delgado-Romero, 2013). Despite being harmed by
microaggressions, clients noted that therapists were not being malicious and may not have
known they were conveying negative messages to clients (Shelton & Delgado-Romero, 2013).
The next two articles focused on counseling considerations specifically for bisexual
clients. Research was limited when it came to looking at therapists views and attitudes towards
bisexual clients (Mohr, Israel, & Sedlacek, 2001). Research supported that most people view
sexuality as dichotomous, leaving no room for bisexuality (Mohr et al., 2001). In addition,
bisexual clients experienced more stereotypes from counselors, such as bisexuality being viewed
as confusion or as immature sexuality (Mohr et al., 2001).
The first study examined counselors attitudes regarding bisexual clients psychological
health and the degree counselors attributed therapy needs to bisexuality (Mohr et al., 2001).
Ninety-seven masters and doctoral counseling psychology students read an intake about a
bisexual woman who was dealing with career issues, a recent long-term relationship break-up,
and a boyfriend not accepting of her sexuality (Mohr et al., 2001). The researchers had six
doctoral students read it for believability before using the scenario in the study (Mohr et al.,
2001).
In addition to reading the client scenario, participants completed the Attitudes Regarding
Bisexuality Scale (ARBS) and the Attitudes Toward Lesbians and Gay Men scale (ATLG-S)
(Mohr et al., 2001). For clinical assessment, participants rated the client using the Global
Assessment of Functioning (GAF) scale from the DSM and a shortened clinical intake

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assessment form borrowed from a university counseling center with questions regarding bisexual
stereotypes and the clients presenting problems (Mohr et al., 2001). After participants had
assessed client psychological functioning, they completed the Therapist Personal Reaction
Questionnaire (TRPQ) and Awareness of Values subscale from the Counseling Self-Estimate
Inventory (Mohr et al., 2001). These measures assessed how the counselors thought they would
react to the client.
Descriptive statistics were used to examine tolerance and stability (Mohr et al., 2001).
Canonical correlations were used to determine if therapists attitudes were connected to reactions
to the client and how the therapists judged the client clinically (Mohr et al., 2001). Researchers
found that counselors who viewed the bisexual client in a positive light were likely to rate the
client with high psychological functioning and anticipated not having an adverse reaction to the
client (Mohr et al., 2001). In addition, therapists who viewed bisexuality as stable were less
likely to associate stereotypical bisexual problems to the client (Mohr et al., 2001).
The next article examined when clinical bias was most likely to occur in relation to a
bisexual client (Mohr, Weiner, Chopp, & Wong, 2009). This study was an extension of the
previous study described above by Mohr, Israel, and Sedlacek (2001). Therapists often viewed
bisexual clients in a different way than heterosexual or homosexual clients, which influenced
clinical judgment (Mohr et al., 2009). However, female therapists were more hopeful in relation
to improvements in bisexual clients symptomology versus male therapists (Mohr et al., 2009).
The researchers investigated therapists clinical recommendations and reactions to
different male clients (Mohr et al., 2009). Participants read a clinical intake form of a man that
was either heterosexual, homosexual or bisexual (Mohr et al., 2009). One hundred and eight
therapists were recruited from psychological association membership lists (Mohr et al., 2009).

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The fictitious scenario involved a male client that was dealing with career problems, a long-term
relationship break-up, and problems with the current relationship (Mohr et al., 2009).
Participants were randomly assigned a clients sexuality (Mohr et al., 2009). A packet with
survey materials were sent to members that included rating the client on Global Assessment of
Functioning (GAF), assessing clinical issues from a university counseling center check-list,
Therapists Personal Reaction Questionnaire, Awareness of Values subscale, Concern for
Appropriateness Scale, Sources of Attitudes, validity check items, and demographic questions
(Mohr et al., 2009).
Researchers used analyses of covariance to determine statistical significance of client
sexual orientation in GAF, clinical areas, and therapist reactions (Mohr et al., 2009). A two-way
analysis of variance was used to look at how the clinical judgments were moderated by therapist
variables (Mohr et al., 2009). Client bisexuality did not affect clinical judgment but did have an
effect on judgments regarding bisexual stereotypes unrelated to the clients problems (Mohr et
al., 2009). Findings also supported that therapists who held stereotypes towards bisexual clients
were confused and conflicted about the stereotypes (Mohr et al., 2009). An interesting finding
was that compared to the heterosexual client situation, participants that received the bisexual
client scenario viewed the client in a more positive light (Mohr et al., 2009).
Summary
The first article examined therapist variables in relation to sexual minority clients rating
of helpfulness (Liddle, 1996). The researcher provided ample information regarding how sexual
minority clients can perceive helpfulness based on the therapists gender, sexual orientation, and
treatment practices. This study extended and replicated a previous study to provide more
evidence for the problem being examined (Liddle, 1996). The design of the study was

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appropriate for the problem being researched because the researcher gathered information
directly from sexual minority clients who were currently in therapy or had at least one session
with a counselor (Liddle, 1996). However, participants were not pulled from a random subject
pool but were chosen by the researcher sending survey packets to university and graduate
schools (Liddle, 1996). This means that these participants could have different views on
counseling due to their education versus participants who were not in college or graduate school
with less insight into counseling.
Surveys sent to the members were the best method the researchers could have used
because they were easily sent and returned (Liddle, 1996). If the researcher used in-person
interviews, she would not have gotten such a large amount of subjects. The instruments used
were also appropriate for the problem being examined because they covered all the relevant areas
that needed to be questioned (Liddle, 1996). The statistical analyses were clear, analyzing
matching therapist variables to helpfulness and analysis of therapist variables to counseling
practices (Liddle, 1996).
The conclusions were supported by the evidence that sexual orientation and gender were
important for sexual minority clients (Liddle, 1996). However, female therapists were perceived
as helpful no matter what their sexual orientation was (Liddle, 1996). This result was interesting
because sexual orientation did not play a factor in perceived helpfulness, meaning that therapists
can be helpful even if they are not part of the sexual minority (Liddle, 1996).
The researcher did provide limitations to the study, such as client bias toward an
individual therapist influencing the results and therapist practices not being thoroughly surveyed
(Liddle, 1996). This means that clients could have just not liked their therapists based on
personal variables. The results are confident, but could have been different or there might have

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been less of an effect if different subjects would have been used (Liddle, 1996). For example, a
less educated client may not have been focused on therapist sexual orientation and gender
because he was looking for social services, such as finding a job versus needing psychotherapy.
The article was clear and organized in a coherent manner, which made it easy to understand and
follow. It could have been strengthened by using participants from a larger data pool and using a
random sample, to get a comprehensive view of all different client types. Overall, the findings
are still important because they support the idea that therapists can learn to be sensitive in their
counseling practices when working with sexual minority clients (Liddle, 1996).
Internalized homophobia was the next phenomenon examined (Frost & Meyer, 2009).
Ample background information was given about the problems that internalized homophobia
caused in sexual minority clients relationships (Frost & Meyer, 2009). The researchers
conceptualized internalized homophobia in terms of stress theory as a minority stressor (Frost &
Meyer, 2009). The design of the research used data pulled from an extensive study completed in
New York, which surveyed several areas of sexual minority relationships, as well as independent
client factors (Frost & Meyer, 2009). The survey style was appropriate for the given problem
because it tapped into several variables that were associated with the research questions and was
able to reach several participants (Frost & Meyer, 2009).
The statistical analyses were appropriate and precise, tapping into all of the variables
investigated (Frost & Meyer, 2009). Conclusions were supported by data analyses, such as
sexual minority relationships being negatively affected by internalized homophobia (Frost &
Meyer, 2009). In addition, the researchers focused on direct and indirect effects of internalized
homophobia, which showed how each variable was related (Frost & Meyer, 2009). Alterative
explanations were not present in the conclusions, but the researchers cautioned against viewing

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internalized homophobia as a trait internal to an LGB individual (Frost & Meyer, 2009). They
stated that it was a social atmosphere of stigma that creates this phenomenon (Frost & Meyer,
2009).
The conclusions are relevant and stable, supported by the research done. The researchers
broke down several variables to examine many different facets of how internalized homophobia
affects sexual minority clients (Frost & Meyer, 2009). The report was organized in a clear
manner, making it easy to understand. Research is never going to be perfect or hit every area
that needs to be examined. This article could have been strengthened by using a national pool of
members to understand different client views instead of participants only from the New York
area (Frost & Meyer, 2009). In addition, the researchers could have explained more ways to
combat internalized homophobia when it is a problem for sexual minority clients.
Microaggressions have been examined in terms of racial minorities, but in this study they
were researched in terms of sexual orientation (Shelton & Delgado-Romero, 2013). They were
described in terms of how they can occur in therapy with sexual minority clients. The design of
the research made sense because the researchers used focus groups to talk about clients
encountering microaggressions (Shelton & Delgado-Romero, 2013). A survey may have been
able to cover more areas, but the researchers wanted personal examples of microaggressions, so a
focus group was best for that (Shelton & Delgado-Romero, 2013).
Data that was collected was not numeric but descriptive, which meant that analyses were
more complicated than using statistical analyses methods (Shelton & Delgado-Romero, 2013).
Transcriptions of the focus group were read by several people that kept bias in check (Shelton &
Delgado-Romero, 2013). In addition, the researchers described exactly how they analyzed data

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The data supported the conclusion that sexual orientation microaggressions did occur in
therapy sessions (Shelton & Delgado-Romero, 2013). Alternative explanations were not
explained, but limitations were included, such as data being analyzed by heterosexual allies,
unknown therapist sexual orientation, and small focus group size (Shelton & Delgado-Romero,
2013). This means that microaggressions could have occurred more or less intensely if those
variables were different (Shelton & Delgado-Romero, 2013). However, this does not mean
sexual orientation microaggressions did not occur during treatment. These results are important
because it means that therapeutic alliances are being ruptured even though counselors may not be
conscious of this phenomenon (Shelton & Delgado-Romero, 2013). The research was clearly and
concisely presented, leaving no significant questions unanswered. The article could be
strengthened by using a bigger participant size to obtain more examples and a survey in
conjunction with the focus group to gain more information about microaggressions that occurred.
Bisexual clients deal with a double-edged sword, facing oppression from both
heterosexual and homosexual groups (Mohr et al., 2001). The problem of viewing sexuality as
dichotomous was thoroughly described by researchers and how this view can influence
clinicians judgments and opinions about bisexual clients (Mohr et al., 2001). The methods used
were appropriate for this particular research because several variables were tapped into by the
survey (Mohr et al., 2001).
Data analyses were clear and fitted the research problem (Mohr et al., 2001). Analyses
examined how each of the surveyed variables were related (Mohr et al., 2001). Findings were
supported by the data and how the views of the therapist affected judgments of the client either
positively or negatively (Mohr et al., 2001). Limitations cautioned readers that these findings
may not be generalizable to real life counseling practices because only a female bisexual client

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was used in the scenario (Mohr et al., 2001). In addition, anything different about the client may
have changed the views of therapists.
Despite these limitations, these results are important because counselors must be aware of
their biases and ideas regarding bisexual clients (Mohr et al., 2001). The report was organized in
a coherent fashion that made it easy to understand and gain information about therapists views
of bisexual clients. The article could have been strengthened by using a male bisexual client
scenario to see if gender impacted clinical judgment (Mohr et al., 2001). In addition, a
heterosexual and homosexual client could have also been used in the study to draw comparisons
between sexualities of clients.
The last article was an extension and replication of the article described above.
Researchers extended information about bisexual client oppression (Mohr et al., 2009). The same
methods were used as the original study, which covered several areas of therapist opinions and
judgments (Mohr et al., 2009). This time, the client scenarios included a heterosexual,
homosexual and bisexual male (Mohr et al., 2009).
Analyses of data were appropriate and precise, which explored the relationships between
therapists opinions and judgments to clients sexuality (Mohr et al., 2009). Conclusions that
were drawn were supported by the data that showed stereotypical bisexual problems were more
relevant to therapists for the bisexual client even though these problems were not part of the
presenting problem (Mohr et al., 2009).
Limitations of the research included the way client sexuality was operationalized, the use
of a male client, and nonrandom missing data (Mohr et al., 2009). Operationalization of clients
sexuality may have been interpreted differently depending on the participant, which might have
led to different judgments and opinions by the therapist (Mohr et al., 2009). Like before, if the

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client would have been female, therapists may have viewed the client differently, leading to
different results (Mohr et al., 2009). In addition, bias might have occurred because of
nonrandom missing data, which might have skewed the results in either direction (Mohr et al.,
2009). The results are confident despite limitations and are necessary for the field of counseling.
Like before, therapists need to be aware of their opinions and biases (Mohr et al., 2009). The
article could be strengthened by using a larger sample pool instead of getting participants from
psychological associate member lists (Mohr et al., 2009). This would have led to varying views
of the bisexual client.
Conclusions
The five articles studied had several common themes. These included sexual minority
clients experiencing discrimination during therapy (Liddle, 1996) (Shelton & Delgado-Romero,
2011), exacerbated relationship problems due to social stigma (Frost & Meyer, 2009), and more
biases toward bisexual clients (Mohr et al., 2001) (Mohr et al., 2009). All but one of the articles
used surveys as the main methods of gathering data. Surveys seemed to be the method of choice
because they were able to gather information on several variables. To help delineate these issues,
counselors can spend extra time during training to understand sexual minorities and concretely
formulate views and opinions that will help clients (Shelton & Delgado-Romero, 2011).
Concerning how this research relates to the field of counseling psychology, several ideas
are prevalent. In relation to sexual minorities as a whole, clinicians need to make sure to be
aware of their biases and judgments when in therapy. Microaggressions and other judgments that
occur below the consciousness of therapists can harm therapeutic alliance, making sexual
minority clients not get the help they need and being afraid of counselors (Shelton & DelgadoRomero, 2011) (Liddle, 1996).

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One of the major areas that are hard for sexual minority clients is relationships (Frost &
Meyer, 2009). Counselors can help clients work through internalized homophobia to form a
healthy relationship in the outside world (Frost & Meyer, 2009). Like all clients who suffer from
oppression, building positive self-regard and working towards positive relationships are
important in combatting internalized homophobia (Frost & Meyer, 2009). Minority stressors are
a major part of any minority group members life because they are extra stress added to everyday
problems (Frost & Meyer, 2009). A therapist should help clients deal with these stressors if they
are part of the clients presenting problem (Frost & Meyer, 2009).
Bisexual clients often are discriminated by homosexual and heterosexual group members
because of their sexuality not being viewed as stable (Mohr et al., 2001) (Mohr et al., 2009).
When working with bisexual clients, a counselor must keep his or her biases and judgments in
check because they can differ from biases of homosexual clients (Mohr et al, 2001) (Mohr et al.,
2009). These biases can influence clinical judgments, leading to unhelpful practices and
negative impacts on therapeutic alliance (Mohr et al., 2001) (Mohr et al., 2009).
Although these articles were not perfect in the sense of research methodology, they are
still very informative for the field of counseling psychology. A therapist might not think that they
are harming a sexual minority client, but the therapist might be ignorant to the fact that this
particular population faces greater adversity than heterosexual clients. However, just because a
client is part of sexual minority does not mean that all problems that are considered to be
relevant to sexual minorities are part of his or her personal problems. It is the job of the
counselor to determine what the client needs, just like any other client. It is not ethical to force a
client to work on internalized homophobia if they seem to be having relationship problems that
are due to some other external factor, such as differing views of how to live life or even small

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things, like fighting over who has to do the dishes. Counselors who have sexual minority clients
must treat their clients with openness and respect, as well as to keep these special considerations
in the back of their minds. This does not mean that these issues will arise during counseling.
During training, therapists should take time to learn about all minorities, not just sexual
minorities, to thoroughly understand all types of clients.

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References

Frost, D. M., & Meyer, I. H. (2009). Internalized homophobia and relationship quality among
lesbians, gay men, and bisexuals. Journal Of Counseling Psychology, 56(1), 97-109.
Liddle, B. J. (1996). Therapist sexual orientation, gender, and counseling practices as they relate
to ratings on helpfulness by gay and lesbian clients. Journal Of Counseling Psychology,
43(4), 394-401. doi:10.1037/0022-0167.43.4.394
Mohr, J. J., Israel, T., & Sedlacek, W. E. (2001). Counselors' attitudes regarding bisexuality as
predictors of counselors' clinical responses: An analogue study of a female bisexual
client. Journal Of Counseling Psychology, 48(2), 212-222. doi:10.1037/00220167.48.2.212
Mohr, J. J., Weiner, J. L., Chopp, R. M., & Wong, S. J. (2009). Effects of client bisexuality on
clinical judgment: When is bias most likely to occur?. Journal Of Counseling
Psychology, 56(1), 164-175. doi:10.1037/a0012816
Shelton, K., & Delgado-Romero, E. A. (2013). Sexual orientation microaggressions: The
experience of lesbian, gay, bisexual, and queer clients in psychotherapy. Psychology Of
Sexual Orientation And Gender Diversity, 1(S), 59-70. doi:10.1037/2329-0382.1.S.59