GUIDELINES FOR PSYCHOLOGICAL PRACTICE WITH LESBIAN, GAY, AND BISEXUAL CLIENTS

Transcription

1 GUIDELINES FOR PSYCHOLOGICAL PRACTICE WITH LESBIAN, GAY, AND BISEXUAL CLIENTS

2 Contents Page No. Preamble 4 The Code of Ethics 5 Broad Statement of Practice 5 Section A Guideline A 1. Psychologists understand that homosexuality and bisexuality are not indicative of mental illness 5 Guideline A 2. Psychologists are encouraged to recognise how their attitudes and knowledge about lesbian, gay, and bisexual issues may be relevant to assessment and treatment and seek consultation or make appropriate referrals when indicated 6 Guideline A 3. Psychologists strive to understand the ways in which social stigmatisation (i.e., prejudice, discrimination, and violence) poses risks to the mental health and well being of lesbian, gay, and bisexual clients 6 Guideline A 4. Psychologists strive to understand how inaccurate or prejudicial views of homosexuality or bisexuality may affect the client's presentation in treatment and the therapeutic process 7 Guideline A 5. Psychologists strive to be knowledgeable about and respect the importance of lesbian, gay, and bisexual relationships 8 Guideline A 6. Psychologists strive to understand the particular circumstances and challenges facing lesbian, gay, and bisexual parents 9 Guideline A 7. Psychologists recognise that the families of lesbian, gay, and bisexual people may include people who are not legally or biologically related 9 Guideline A 8. Psychologists strive to understand how a person's homosexual or bisexual orientation may have an impact on his or her family of origin and the relationship to that family of origin 10 Guideline A 9. Psychologists are encouraged to recognise the particular life issues or challenges experienced by lesbian, gay, and bisexual members of racial and ethnic minorities that are related to multiple and often conflicting cultural norms, values, and beliefs 10 Guideline A 10. Psychologists are encouraged to recognise the particular challenges experienced by bisexual individuals 10 Guideline A 11. Psychologists strive to understand the special problems and risks that exist for lesbian, gay, and bisexual youth 11 Guideline A 12. Psychologists consider generational differences within lesbian, gay, and bisexual populations, and the particular challenges that may be experienced by lesbian, gay, and bisexual older adults 11 Guideline A 13. Psychologists are encouraged to recognise the particular challenges experienced by lesbian, gay, and bisexual individuals with physical, (and/or) sensory, 2

3 and/or cognitive/emotional disabilities 12 Guideline A 14. Psychologists support the provision of professional education and training on lesbian, gay, and bisexual issues 12 Guideline A 15. Psychologists are encouraged to increase their knowledge and understanding of homosexuality and bisexuality through professional development, training, supervision, and consultation 13 Guideline A 16. Psychologists make reasonable efforts to familiarise themselves with relevant mental health, educational and community resources for lesbian, gay, and bisexual people 13 Guideline A 17. Psychologists must avoid the use of psychological tests that are biased against lesbian, gay, and bisexual people 13 Section B Ethical Issues for gay, lesbian and bisexual psychologists when working with gay, lesbian and bisexual clients 14 Guideline B 1. Psychologists working within a small community strive to be especially vigilant around issues of privacy for the psychologist 14 Guideline B 2. Psychologists are encouraged to be particularly aware of confidentiality and privacy issues for clients from within their own community 14 Guideline B 3. Psychologists working with clients from their own community need to be aware of issues which may impact on the therapeutic process 15 Guideline B 4. Psychologists are aware that they may be part of a community with special circumstances 16 3

4 GUIDELINES FOR PSYCHOLOGICAL PRACTICE WITH LESBIAN, GAY, AND BISEXUAL CLIENTS Preamble The Australian Psychological Society (APS) recognises that gay, lesbian, and bisexual clients are often the subjects of discrimination in our society. This discrimination has frequently been based on an attitude that any deviation from the most common form of sexual orientation is indicative of psychological disturbance and there have been attempts to change a person s sexual orientation through various forms of psychological treatment. The Australian Psychological Society believes that homosexuality and bisexuality are normal variants of human sexuality and that attempts to change a person s sexual orientation are rarely appropriate. (See APS Policy statement on the use of Therapies that Attempt to Change Sexual Orientation). Sexual orientation is not the same as sexual behaviour. (Refer APS pamphlet Answers to your questions about sexual orientation and homosexuality). Psychological intervention might be appropriate in circumstances where the sexual behaviour seeks to exploit children or other vulnerable members of society e.g. Paedophilia, exhibitionism and rape, and is therefore considered to be unethical or is illegal. The decision of the American Psychiatric Association in 1973 to remove homosexuality from its list of mental disorders together with a widening community acceptance have brought a more enlightened attitude toward issues of sexuality and sexual orientation. A wide range of alternative lifestyles and sexual expression is considered acceptable in current Australian society. Within the various cultural groups of Australian society, there is a considerable range of attitudes towards issues of sexuality and sexual orientation. In some cultures, there may be considerably less or more tolerance of these issues than is common in mainstream Australian society. Cultures vary in the behaviours that they perceive as being indicative of homosexuality. The marginalisation of gay men, lesbians and bisexuals in our society leads to many social problems that should be tackled by social change rather than by psychological treatment of the victim. However, gay men, lesbians and bisexual people encounter the same range of psychological issues as the rest of the society and may seek the services of a psychologist to help them deal with these issues. Psychologists are expected to respect the sexual orientation of the client and to treat all clients with dignity. (See APS Charter for Clients of Psychologists ) Education and training of psychologists in the area of psychological practice with bisexual, gay and lesbian clients is needed. Psychologists are encouraged to seek and utilise appropriate education and training in their psychological practice with lesbian, gay, and bisexual clients. Many gay, lesbian and bisexual clients will specifically seek the services of a gay or gay friendly psychologist with the expectation of receiving this respect and dignity, but this may raise particular ethical issues for such psychologists. For example, partly because of the small community in which many bisexual, lesbian and gay psychologists practise, there is often a need for both psychologist and client to be particularly vigilant about maintaining professional boundaries, especially around confidentiality and privacy for both the psychologist and the client. Section B of these guidelines addresses some of these ethical issues. The specific goals of these guidelines are to provide practitioners with a frame of reference for psychological practice with lesbian, gay, and bisexual clients. These guidelines build on the Australian Psychological Society's Code of Ethics, other policies of the APS, and policies of other mental health organisations. 4

5 The Code of Ethics Several sections of the APS Code of Ethics and a number of APS Guidelines may also be relevant to working with gay, bisexual and lesbian clients, in particular Guidelines for Psychotherapeutic Practice with Female Clients, Guidelines on the Proscription of Sexual Relations with Clients and Managing Professional Boundaries and Multiple Relationships. All members of the APS are required to be familiar with the APS Code of Ethics and the Ethical Guidelines. Psychologists are expected to treat lesbian, gay and bisexual clients with respect. Psychologists are advised to avoid of the use of stereotypes or other forms of bias, including the use of sexist or homophobic language, sexist or homophobic jokes and derogatory or demeaning labels. It is advisable to negotiate with the client appropriate and comfortable language for both parties. It is important that the psychologist demonstrate respect for the client, in face to face contact, in written reports, and in discussion with colleagues. The intersection of sexual orientation with cultural differences deserves special consideration. Broad Statement of Practice In accordance with General Principle I, II, and III b of the Code of Ethics, the member should recognise the right of the gay or lesbian client to develop as an autonomous and psychologically healthy person and should seek to foster such development. This includes enabling the client to have roles and relationships that are chosen without restriction by cultural bias or discrimination. Section A The following areas warrant special vigilance by all psychologists Some of these guidelines are applicable to therapeutic work with clients in a variety of situations and are not confined to working with gay, lesbian and bisexual clients. There are some areas that warrant special vigilance because of the issues around sexual orientation. Guideline A 1. Psychologists understand that homosexuality and bisexuality are not indicative of mental illness. Homosexuality and bisexuality once were assumed to be mental illnesses. There is, however, no evidence of disproportionate psychopathology in non-clinical studies of gay and bisexual men and women. Further, an extensive body of literature has failed to identify significant differences between heterosexual, homosexual, and bisexual people on a wide range of variables associated with overall psychological functioning. When studies have noted differences between homosexual and heterosexual participants with regard to psychological functioning, these differences have been attributed to the effects of stress related to stigmatisation based on sexual orientation. This stress may lead to increased risk of suicide attempts, substance abuse, and emotional distress. The literature that classifies homosexuality and bisexuality as mental illness has been found to be methodologically unsound. The flaws include unclear definition of terms, inaccurate classification of participants, inappropriate comparison of groups, discrepant sampling procedures, an ignorance of confounding social factors, and questionable outcome measures. The results from these flawed studies have been used to support theories of homosexuality as mental illness and/or arrested psychosexual development. These studies have no valid empirical support and yet serve as the basis for inaccurate representations of lesbian, gay, and bisexual people. Psychologists are expected to be aware that there is a wide field of individual difference in the quality, frequency and expression of sexual behaviour, and that sexual orientation is not related to psychopathology. Thus, psychologists affirm that a homosexual or bisexual orientation is not a mental illness. Furthermore, psychologists should assist clients in overcoming the effects of stigmatisation that may lead to emotional distress. 5

6 Guideline A 2. Psychologists are encouraged to recognise how their attitudes and knowledge about lesbian, gay, and bisexual issues may be relevant to assessment and treatment and seek consultation or make appropriate referrals when indicated. The APS Code of Ethics General Principle II urges psychologists to maintain appropriate skills and learning in their areas of professional practice. Without a high level of awareness about their own beliefs, values, needs, and limitations, psychologists may impede a client s progress. The assessment and treatment of lesbian, gay, and bisexual clients can be adversely affected by psychologists' explicit or implicit negative attitudes. For example, when homosexuality and bisexuality are consciously regarded as evidence of mental illness, a client's homosexual or bisexual orientation is apt to be viewed as a major source of the client's psychological difficulties even when sexual orientation has not been presented as a problem. When psychologists are unaware of their negative attitudes, the effectiveness of assessment and treatment can be compromised by heterosexist bias. Heterosexism has been defined as "the ideological system that denies, denigrates, and stigmatises any nonheterosexual form of behaviour, identity, relationship or community (Herek, 1995). When heterosexual norms for identity, behaviour, and relationships are applied to lesbian, gay, or bisexual clients, their thoughts, feelings, and behaviours may be misinterpreted as abnormal, deviant, and undesirable. Psychologists strive to avoid making assumptions that a client is heterosexual even in the presence of apparent markers of heterosexuality (e.g., marital status, since lesbian, gay, and bisexual people can be heterosexually married). Another manifestation of heterosexism is approaching treatment with a perspective that claims to be uniform for people regardless of their sexual orientation and hence denies any difference. When psychologists deny culture-specific experiences in the lives of lesbian, gay, and bisexual people, heterosexist bias is also likely to pervade that work and be unhelpful to clients. When psychologists are uninformed about the unique issues of lesbian, gay, and bisexual people, they may not understand the effects of stigmatisation on individuals and their intimate relationships. Because many psychologists have not received sufficient current information regarding lesbian, gay, and bisexual clients, psychologists are strongly encouraged to seek training, experience, consultation and/or supervision to ensure competent practice with these populations when necessary. Key issues for practice include an understanding of human sexuality; the "coming out" process and how variables such as age, gender, ethnicity, race, disability, and religion may influence this process; same-sex relationship dynamics; family of origin relationships; struggles with spirituality and religious group membership; career issues and workplace discrimination; and coping strategies for successful functioning. Psychologists can work more effectively when they have an honest evaluation of their own attitudes with regard to sexual orientation. Psychologists are encouraged to use appropriate methods of self-exploration and self-education (e.g., consultation, study, and professional development) to identify and ameliorate preconceived biases about homosexuality and bisexuality. If they doubt their ability to act in a way that is free of overt or covert prejudice, they are advised to avoid entering into a professional relationship with a gay, lesbian or bisexual client. Guideline A 3. Psychologists strive to understand the ways in which social stigmatisation (i.e., prejudice, discrimination, and violence) poses risks to the mental health and well-being of lesbian, gay, and bisexual clients. Many lesbian, gay, and bisexual people face social stigmatisation, violence, and discrimination. Living in a heterosexist society may precipitate stress for lesbian, gay, and bisexual people, many of whom may be tolerated only when they are "closeted. Sexual minority status increases risk for stress from chronic daily hassles (e.g., hearing anti-gay jokes, always being on guard) to more serious difficulties from negative life events, especially gay-relevant events (e.g., loss of employment, home, and custody of children due to sexual orientation; loss of partner; anti-gay violence and discrimination). The cumulative effects of heterosexism, sexism, and racism may put lesbian, gay, and bisexual racial/ethnic minorities at special risk for social stressors. Lesbians and gay men are at risk for mental health problems and emotional distress as a direct result of discrimination and negative experiences in society. Social stressors affecting lesbian, gay, and bisexual older adults, such as a lack of legal rights and protection in medical emergencies and lack of acknowledgement of couples' relationships, particularly following the loss of a partner, have been associated with feelings of helplessness, depression, and disruption of grieving. For lesbian, gay, and bisexual youth, social vulnerability and isolation are prominent concerns. Anti-gay verbal and physical harassment are significantly more 6

7 common among adolescent gay and bisexual males who have attempted suicide. These stressors have also been associated with high-risk sexual behaviour. Lesbian, gay, and bisexual people who live in rural communities may experience stress related to the risk of disclosure because anonymity about their sexual orientation may be more difficult to maintain. Fears about loss of employment and housing may be more significant because of the limited opportunities within a small community. In rural communities, lesbian, gay, and bisexual people are more closeted and therefore less visible and there are fewer lesbian, gay, and bisexual support groups which may intensify feelings of social isolation. Furthermore, lesbian, gay, and bisexual people may feel more vulnerable to acts of violence and harassment because rural communities may provide fewer legal protections. Given the real and perceived social and physical dangers faced by many lesbian, gay, and bisexual clients, developing a sense of safety is of primary importance. Stigmatisation, prejudice, and discrimination (e.g. the murders of lesbian, gay, and bisexual individuals) can be sources of stress and create concerns about security for these clients. Physical safety and social and emotional support are central to stress reduction among lesbian, gay, and bisexual people. In addition to external stressors, many lesbian, gay, and bisexual people internalise negative societal attitudes. This internalisation may result in self-image problems ranging from a lack of self-confidence to overt self-hatred, depression, and/or alcoholism and other substance abuse. Some gay men with internalised homophobia may experience sexual dysfunction, relationship instability, and to blame themselves for anti-gay victimisation. Psychologists working with lesbian, gay, and bisexual people are encouraged to assess the client's history of victimisation as a result of harassment, discrimination, and violence. This enables the psychologist to understand the extent to which the client's worldview has been affected by these abuses and whether any post-traumatic concerns need to be addressed. Further, the psychological consequences of internalised negative attitudes toward homosexuality and bisexuality are not always obvious or conscious. Therefore, in planning and conducting treatment, psychologists are encouraged to consider more subtle manifestations of these consequences, such as shame, anxiety and/or low self-esteem, and to consider the differential diagnostic implications of such stressors, both historically and in a client's ongoing psychosocial context. It is important that psychologists recognise and actively acknowledge of sexual harassment, sexual and physical abuse, and all forms of violence, as crimes that are the responsibility of the perpetrator. These are never justified by a so-called provocative behaviour on the part of the victim. Potential action would include taking complaints seriously, reinforcing the client s awareness of their legal rights, referring to appropriate legal and protective services, supporting moves towards independence, while acknowledging social and other constraints and respecting the client s choice of survival strategy. Guideline A 4. Psychologists strive to understand how inaccurate or prejudicial views of homosexuality or bisexuality may affect the client's presentation in treatment and the therapeutic process. Bias and misinformation about homosexuality and bisexuality continue to be widespread in our society. Due to the stigmatisation of homosexuality and bisexuality, it is to be expected that many lesbian, gay, and bisexual people will feel conflicted or have significant questions about aspects or consequences of their sexual orientation (see Guideline 3). Fear of multiple personal losses including family, friends, career, and spiritual community, as well as vulnerability to harassment, discrimination, and violence, may contribute to an individual's fear of self-identifying as gay, lesbian, or bisexual. These factors have been identified as central in creating a lesbian, gay, or bisexual person's discomfort with his or her sexual orientation. Many clients who are conflicted about or are questioning the implications of their sexual orientation seek psychological assistance to resolve their concerns. Psychologists who harbor prejudice or are misinformed about sexual orientation may offer responses to the questioning or conflicted client that may exacerbate the client's distress (see Guideline 2). For example such a response might agree with the notion that the only effective strategy for coping with such conflict or discrimination is to seek to change the lesbian, gay, or bisexual person's sexual orientation. Psychologists working with gay, lesbian, and bisexual clients must note sections of the Code of Ethics which include prohibitions against discriminatory practices (e.g., basing treatment upon pathology-based views of homosexuality or bisexuality), a prohibition against the misrepresentation of scientific or clinical data (e.g., the unsubstantiated claim that sexual orientation can be changed); and requirements for informed consent. Psychologists should discuss the treatment, its theoretical basis, reasonable outcomes, and alternative treatment approaches with clients. In providing the client with accurate information about the social stressors 7

8 that may lead to discomfort with sexual orientation, psychologists may help to offset the effects of prejudice and inoculate the client against further harm. If psychologists are unable to provide this or other relevant information due to lack of knowledge or contravening personal beliefs, they should obtain the requisite information or make appropriate referrals. Further, when a client presents with discomfort about sexual orientation, it is important for psychologists to assess the psychological and social context in which this discomfort occurs. Such an assessment might include an examination of internal and external pressures on clients to change their sexual orientation, the presence or absence of social support and models of positive lesbian, gay, or bisexual life, and the extent to which clients associate homosexuality or bisexuality with negative stereotypes and experiences. These and other dimensions of sexual orientation discomfort are important for psychologists to explore, as the meanings associated with them are invariably complex. It is important for the psychologist to facilitate the client s understanding of, and efforts to free his/herself from, the effects of negative or confining social influences. The role of psychologists, regardless of therapeutic orientation, is not to impose their beliefs on clients but to examine thoughtfully the clients' experiences and motives. It is important for the psychologist to be aware of the power imbalance in treatment, which might replicate, for gay, lesbian and bisexual clients, similar imbalances in other areas of their lives. Psychologists may also serve as a resource for accurate information about sexual orientation (e.g., by providing clients with access to empirical data on such questions as the development of sexual orientation or the relationship between mental health and sexual orientation). Guideline A 5. Psychologists strive to be knowledgeable about and respect the importance of lesbian, gay, and bisexual relationships. Lesbian, gay, and bisexual couples are both similar to and different from heterosexual couples. They form relationships for similar reasons and express similar satisfactions with their relationships. The differences derive from several factors, including different patterns of sexual behaviour, gender role socialisation, and the stigmatisation of their relationships. Lesbian, gay, or bisexual people in relationships may seek treatment for reasons common to many couples or for reasons that are unique to those in same-sex relationships. Common relationship problems such as communication difficulties, sexual problems, dual career issues, and commitment decisions can be affected by societal and internalised negative attitudes toward same-sex relationships. Problems presented in treatment specific to lesbian, gay, and bisexual couples include disclosure of sexual orientation as a couple to family, work colleagues; health professionals and caregivers; differences between partners in the disclosure process; issues derived from the effects of gender socialisation in same-sex couples; and HIV status. External issues such as pressure from families of origin and/or current or former heterosexual partners may also arise. Parenting may present unique issues for lesbian, gay, and bisexual people (e.g., possible challenges to child custody from previous heterosexual partners or grandparents, lack of legal rights for one of the parents). Changes in physical health may present unique issues, especially to older lesbian, gay, and bisexual couples (e.g., possible separation and loss of contact for partners in nursing homes and other in-patient settings). Psychologists are expected to validate the capacity of a client to define his/her own problems, and to show willingness to help the client explore both traditional and non-traditional relationship and lifestyle options without prejudice to the client s sexual orientation. For some clients, relationships are important to their psychological well-being, but may not be essential to others. Psychologists might assist the above by negotiating the therapeutic contract with explicit attention to the client's expressed needs and preferences. Psychologists are encouraged to consider the negative effects of societal prejudice and discrimination on lesbian, gay, and bisexual relationships. It is important for psychologists to understand that, in the absence of socially sanctioned forms and supports for their relationships, lesbian, gay, and bisexual people may create their own relationship models and support systems. Therefore, psychologists strive to be knowledgeable about the diverse nature of lesbian, gay, and bisexual relationships and value and respect the meaning of these relationships. Guideline A 6. Psychologists strive to understand the particular circumstances and challenges facing lesbian, gay, and bisexual parents. Research has indicated no significant differences between the capabilities of lesbian, gay, and bisexual parents when compared to heterosexual parents. However, lesbian, gay, and bisexual parents face challenges not encountered by most heterosexual parents because of the stigma associated with 8

9 homosexuality and bisexuality. Prejudice has led to institutional discrimination by the legal, educational, and social welfare systems. In some instances, lesbian, gay, and bisexual parents have lost custody of their children, have been restricted in visiting their children, have been prohibited from living with their domestic partners, and/or have been prevented from adopting or being foster parents, on the basis of their sexual orientation The primary difficulties facing children of lesbian, gay, and bisexual parents are associated with misconceptions about their parents that are held by society at large. Three areas of concern have been raised by those in the legal and social welfare systems about the impact a parent's lesbian, gay, or bisexual orientation may have on children. These concerns include the influence of a lesbian, gay, or bisexual parent on a child's gender identity, gender role conformity, and sexual orientation. The body of research on lesbian mothers is currently considerably larger than that on gay fathers. There is no evidence of gender identity or gender role behaviour difficulties among children of lesbian mothers. Furthermore, children of lesbian, gay, and bisexual parents appear to be no different from peers raised by heterosexual parents in their emotional and sexual development. Psychologists need to rely on scientifically and professionally derived knowledge and avoid discriminatory practices when conducting assessments for suitability for child custody, adoption, and/or foster parenting. Psychologists should provide accurate information and correct misinformation in their work with parents, children, community organisations and institutions (e.g., educational, legal, and social welfare systems). Guideline A 7. Psychologists recognise that the families of lesbian, gay, and bisexual people may include people who are not legally or biologically related. The recognition of diverse family forms, including extended and blended families, is central to effective psychological treatment of ethnically and culturally diverse clients. For many lesbian, gay, and bisexual people, the primary partner and/or a network of close friends constitute an alternative family structure. In the absence of legal or institutional recognition, and in the face of societal, workplace, and familial discrimination, these alternative family structures may be more significant than the individual's family of origin. The importance of alternative family structures to lesbian, gay, and bisexual adults and youth is not always understood. Social support is an important resource in a heterosexual couple's capacity to handle relationship distress. People in same-sex relationships tend to derive less support in adulthood and old age from their families of origin than do their heterosexual counterparts. Close relationships with a network of supportive friends are considered by lesbian, gay, and bisexual youth to be extremely important. A strong friendship network has been viewed as pivotal in sexual identity exploration and development. Given the importance of social support in overall relationship satisfaction and longevity, psychologists are encouraged to consider the importance of lesbian, gay, or bisexual alternative family relationships. Psychologists should also aware of the stress that clients may experience when their families of origin, employers, or others do not recognise their family structure. Therefore, when conducting an assessment, psychologists are encouraged to ask clients who they consider to be part of their family. 9

10 Guideline A 8. Psychologists strive to understand how a person's homosexual or bisexual orientation may have an impact on his or her family of origin and the relationship to that family of origin. Families of origin may be unprepared to accept a lesbian, gay, or bisexual child or family member because of familial, ethnic, or cultural norms and/or religious beliefs or negative stereotypes. The awareness of a family member's homosexuality or bisexuality may precipitate a family crisis that can result in the exclusion of the homosexual or bisexual member, rejection of the parents and siblings by the homosexual or bisexual member, parental guilt and self-incrimination, or conflicts within the parents' relationship. Even when reactions are more positive, adjustments may be necessary to accommodate a new understanding of the lesbian, gay, or bisexual family member. Many families are faced with their own "coming out" process when a family member discloses his or her homosexuality or bisexuality. Families may need to adjust to the loss of hopes, perceptions, or expectations associated with the presumption of heterosexuality. Families may also need assistance in developing new understandings of sexual orientation, in confronting the ways in which negative societal attitudes about homosexuality and bisexuality are manifested within the family, and in addressing difficulties related to societal stigmatisation. Psychologists also are sensitive to the cultural variations in a family's reaction and ways of adapting to a lesbian, gay, or bisexual member. Guideline A 9. Psychologists are encouraged to recognise the particular life issues or challenges experienced by lesbian, gay, and bisexual members of racial and ethnic minorities that are related to multiple and often conflicting cultural norms, values, and beliefs. Lesbian, gay, and bisexual people from minority groups must negotiate the norms, values, and beliefs regarding homosexuality and bisexuality of both mainstream and minority cultures. Cultural variation in these norms, values, and beliefs can be a major source of psychological stress. There may be no one group or community to whom a racial/ethnic minority lesbian, gay, or bisexual person can anchor his or her identity and receive full acceptance. This problem may be an even greater challenge for racial/ethnic minority youth who are exploring their sexual identity and orientation. In offering psychological services to racially and ethnically diverse lesbian, gay, and bisexual communities, it is not sufficient that psychologists simply recognise the racial and ethnic backgrounds of their clients. Clients may be affected by the ways in which their cultures view homosexuality and bisexuality. The effects of racism within lesbian, gay, and bisexual communities are also critical factors to consider. A sensitivity to the complex dynamics associated with factors such as cultural values about gender roles, religious and procreative beliefs, degree of individual and family acculturation, and the personal and cultural history of discrimination or oppression is also important. All of these factors may have a significant impact on identity integration and psychological and social functioning. Psychologists are advised to avoid of the use of simplistic or uni-dimensional interpretations of psychological problems that occur in relation to the client s sexual orientation. It is more helpful to take and encourage a view of the client as a whole and complex person, frequently operating in an adverse environment. This might include considering multiple level explanation and intervention, e.g. family, cultural and community attitudes as these frequently play a significant role in the client s issues. Guideline A 10. Psychologists are encouraged to recognise the particular challenges experienced by bisexual individuals. Bisexual adults and youth may experience a variety of stressors in addition to the societal prejudice due to same-sex attractions. One such stressor is that the polarisation of sexual orientation into heterosexual and homosexual categories invalidates bisexuality. This view has influenced psychological theory and practice as well as societal attitudes and institutions. Consequently, while bisexuality may be a transitional state for some individuals, it is inaccurate always to represent it in this way. Some married men and women choose a bisexual lifestyle. Although no evidence of psychological maladjustment or psychopathology has been found, bisexual individuals who do not adopt an exclusively heterosexual or homosexual identity may nevertheless be viewed as developmentally arrested or in other ways psychologically impaired. 10

11 Negative individual and societal attitudes toward bisexuality in both the heterosexual and homosexual communities adversely affect bisexual individuals. Such attitudes may be due to a lack of information about or access to a visible and supportive community of other bisexual individuals. Information on community resources can facilitate the development and maintenance of positive bisexual identities. Psychological treatment of bisexual clients involves respect for the diversity of their experiences and relationships. Psychologists are encouraged to adopt a more complex understanding of sexual orientation rather than a dichotomous model in their approach to treatment. Guideline A 11. Psychologists strive to understand the special problems and risks that exist for lesbian, gay, and bisexual youth. It is important for psychologists to understand the unique difficulties and risks faced by lesbian, gay, and bisexual adolescents. Lesbian, gay, and bisexual youth may experience estrangement from their parents when revealing their sexual orientation and thus may be at increased risk of becoming homeless, may resort to prostitution and increase their risk for HIV and other STD infection. Youth who identify as lesbian, gay, or bisexual at an early age are also at increased risk to become victims of verbal and physical abuse including violence even within their families, to abuse substances, and to attempt suicide. Young gay, lesbian and bisexual students who are still at school may encounter extra difficulties with bullying and lack of acceptance by peers, with less than tolerant attitudes from teachers and lack of information relevant to exploring their sexuality. Such difficulties may also complicate the developmental tasks of adolescence. The social stigma associated with lesbian, gay, and bisexual identity may also complicate career development and choice issues. Perceived parental and peer acceptance has an important impact on lesbian, gay, and bisexual youths' adjustment. Although peers and educators may be helpful in improving the psychosocial environment for these youth, they may not be useful if they lack the appropriate information and experience. When these potential sources of support are heterosexist, they may cause additional conflict and distress. Appropriate therapeutic strategies for work with lesbian, gay, and bisexual youth have been described in the professional literature. Psychologists strive to create a safe therapeutic context for youth to explore sexual orientation issues. Psychologists should be aware of the ways in which psychological, ethical, and legal issues involved in working with minors are made even more complex when working with lesbian, gay, and bisexual youth. Guideline A 12. Psychologists consider generational differences within lesbian, gay, and bisexual populations, and the particular challenges that may be experienced by lesbian, gay, and bisexual older adults. Psychologists are encouraged to recognise that (1) lesbian, gay, and bisexual people of different generations may have had significantly different developmental experiences; and (2) older lesbian, gay, and bisexual people grew into adulthood with peers who share characteristics that may make them distinct as a generation. Examples of factors influencing generational differences include changing societal attitudes toward homosexuality, the AIDS epidemic, and the women's and gay liberation movements. These cohort effects may significantly influence gay identity development, as well as psychological and social functioning. Psychologists are encouraged to be aware of the special transitions and life tasks facing lesbian, gay, and bisexual older adults, such as normative changes in health, retirement, finances, and social support. In many respects, these issues are the same as those of heterosexual older adults. However, clients' multiple minority status may exacerbate problems, and their gender may compound the issues (see Guideline 9). Moreover, end of life span tasks for lesbian, gay, and bisexual older adults are often complex and can develop into crises due to psychosocial stressors and heterosexism. Older lesbian, gay, and bisexual couples lack legal rights and protection afforded to older heterosexual couples (see Guideline 5). Psychologists are encouraged to be aware that Commonwealth and State laws and regulations may affect the rights of their clients, and also to support clients in considering legal safeguards related to medical crises, financial crises, and death. 11

12 Older adults are a diverse group, and normative changes in ageing may be positive as well as negative and are not necessarily related to pathology or a client's sexual orientation. Positive adaptation to ageing among lesbian, gay, and bisexual older adults should be recognised by psychologists treating these clients. Having already addressed issues of being a stigmatised minority may help older gay men, lesbians, and bisexual people to address ageism and transitions in old age. Guideline A 13. Psychologists are encouraged to recognise the particular challenges experienced by lesbian, gay, and bisexual individuals with physical, (and/or) sensory, and/or cognitive/emotional disabilities. Lesbian, gay, and bisexual individuals with physical and/or sensory disabilities may experience a wide range of challenges related to the social stigmas associated with both disability and sexual orientation. One concern is the extent to which the individual's self concept is affected by social stigmas, which in turn may affect the individual's sense of autonomy and personal agency, sexuality, and self-confidence. For example, people with disabilities may be particularly vulnerable to the effects of basing social value on physical appearance and marginalising those who do not conform, for reasons of age, ability, or appearance, to socially constructed standards. Another area of concern relates to how physical disability affects the person's relationship with partners, family, caregivers, and health care professionals. Within partner relationships, there may be issues related to life management, including mobility, sexuality, and medical and legal decision making. Family support may not be available due to negative reactions to the person's sexual orientation. There may also be stress associated with a lesbian, gay, or bisexual person's need to "come out" to caregivers and health care providers. Lesbian, gay, and bisexual people with disabilities may not have access to information, support, and services available to non-disabled lesbian, gay, and bisexual people. Lack of societal recognition for lesbian, gay, and bisexual people in relationships affects those with ongoing medical concerns such as medical insurance coverage for domestic partners, family medical leave policies, hospital visitation, medical decision making by partners, and survivorship issues. People with disabilities are often inaccurately assumed to be asexual. It is recommended that psychologists inquire about the person's sexual history and current sexual functioning where appropriate and provide information and facilitate problem-solving in this area. Many lesbians and gay men with disabilities have experienced coercive sexual encounters and it may be important for psychologists to assess the extent to which the person may have experienced sexual or physical victimisation. Lastly, given the prejudice, discrimination, and lack of social support both within and beyond the lesbian, gay, and bisexual communities, it also may be important that psychologists recognise that when physical (and/or) sensory and/or cognitive/emotional disabilities are present, social barriers and negative attitudes may limit life choices. Guideline A 14. Psychologists support the provision of professional education and training on lesbian, gay, and bisexual issues. There remains a gap between policy and practice in the psychological treatment of lesbian, gay, and bisexual clients. Many post-graduate courses do not sufficiently address issues of diversity and postgraduate students in psychology often report inadequate education and training in lesbian, gay, and bisexual issues. Many post graduate students and novice psychologists feel unprepared to work effectively with lesbian, gay, and bisexual clients. The gap between policy and practice can be addressed by including information regarding these populations in all training programs. Psychology academics, supervisors, and consultants are encouraged to integrate current information about lesbian, gay, and bisexual issues throughout training for professional practice. Psychologists who have expertise in lesbian, gay, and bisexual psychology may be utilised on a full-time or part-time basis to provide training and consultation to psychology departments as well as course and clinical supervision to students. Academics and supervisors are encouraged to seek to develop an understanding of lesbian, gay, and bisexual issues. 12

13 Guideline A 15. Psychologists are encouraged to increase their knowledge and understanding of homosexuality and bisexuality through professional development, training, supervision, and consultation. Unfortunately, the education, training, practice experience, consultation, and/or supervision regarding lesbian, gay, and bisexual issues have often been inadequate, outdated, or unavailable to psychologists and therefore prejudice and insensitivity from psychologists is commonly reported by lesbian, gay, and bisexual clients. Preparation for the provision of psychological treatment to lesbian, gay, and bisexual clients may include additional education, training, experience, consultation, or supervision in such areas as (a) human sexuality (b) lesbian, gay, and bisexual identity development (c) the effects of stigmatisation upon lesbian, gay, and bisexual individuals, couples, and families (d) ethnic and cultural factors affecting identity; and (e) unique career development and workplace issues experienced by lesbian, gay, and bisexual individuals. Guideline A 16. Psychologists make reasonable efforts to familiarise themselves with relevant mental health, educational and community resources for lesbian, gay, and bisexual people. Knowledge of community resources is often a factor considered by lesbian, gay, and bisexual clients in their selection of psychologists. The availability of lesbian, gay, and bisexual community resources varies dramatically according to location; thus it is helpful for psychologists to know what sources of information and support can be found at the local, regional, and national levels. It is useful for psychologists to be aware of the nature and availability of lesbian, gay, and bisexual community resources for clients and their families. Of particular use are organisations that provide support to the parents, young and adult children, and friends of lesbian, gay, and bisexual clients (e.g., Parents, Family, and Friends of Lesbians and Gays); programs that provide special attention to the victims of crimes; programs for lesbian, gay, and bisexual youth; and groups that focus on parenting issues, relationships, or "coming out". There are also professional organisations and groups for lesbian, gay, and bisexual people of specific ethnic and cultural backgrounds, groups for people with HIV issues, groups for socialising and networking in business, and groups that can provide spiritual assistance. Electronic resources such as Internet news groups, mailing lists, and web pages can be used by both clients and psychologists as valuable sources of information and support. In addition, there are businesses that cater to lesbian, gay, and bisexual clientele. Psychologists unfamiliar with local lesbian, gay, or bisexual resources may obtain consultations or referrals from local agencies, and the A P S. For example each state has a local AIDS Council, most capital cities have free gay newspapers which list local groups and gay groups in most states produce a gay business directory. Psychologists should take responsibility for their own education about gay, lesbian or bisexual issues and should not expect their clients to educate them. Guideline A 17. Psychologists must avoid the use of psychological tests that are biased against lesbian, gay, and bisexual people. Psychologists must be vigilant against the use of psychological assessment tools and measures with a biased view of homosexuality as indicative of pathology. This is particularly true of some of the older psychological tests or tests that have been developed from psychological theories which have been superseded. Furthermore psychologists must not use the results of psychological assessment tests and measures to discriminate against lesbian, gay, and bisexual people on the basis of their sexual orientation. 13

14 Section B Ethical Issues for gay, lesbian and bisexual psychologists when working with gay, lesbian and bisexual clients. The issue of relationships with clients is covered by the Code of Ethics Section B: In particular B7 Members must avoid dual relationships that could impair their professional judgement or increase the risk of exploitation. Examples of such dual relationships include, but are not limited to, provision of psychological services to employees, students, close friends or relatives. The definition of close friends and relatives should be considered in its broadest context and lesbian, gay and bisexual psychologists working in their own community should pay special attention to the APS Guidelines Managing Professional Boundaries and Multiple Relationships. B8 states Members must not exploit their professional relationships with clients sexually or otherwise. And B9 states in part Sexual relationships between members and current clients must not occur. And B10 states No member may engage in a sexual relationship with a former client when less than two years have expired since the ending or termination of the professional relationship. Paragraphs B11 and B12 are also relevant to this situation. See also APS Guidelines on the Proscription of Sexual Relations with Clients Guideline B 1. Psychologists working within a small community strive to be especially vigilant around issues of privacy for the psychologist. The gay, lesbian or bisexual psychologists who work with lesbian, gay or bisexual clients are often working and living within a small subgroup of the wider community. This has many of the features and difficulties of working in a small community. In a small community it is likely that most people will know someone who knows the psychologist or the client, knows about the psychologist or the client, or knows of the psychologist or the client. This can result in difficulties regarding privacy and confidentiality for both the psychologist and the client. Referral is often by word-of-mouth from current or ex-clients, gay or lesbian doctors or other professionals, or through advertisements in gay or lesbian media, which means that psychologists are sometimes a known figure in the community and this may have an adverse impact on a potential client. Clients who feel they have access to possible detrimental information about a particular psychologist may be deterred from seeking assistance from that psychologist. Psychologists may have concerns about the client s knowledge of their social network, of their sexual / personal / financial activities, or of their relationships (past and present). It is important that psychologists protect their own privacy carefully and maintain an awareness of the nature of gossip and informal communication networks in small communities. Psychologists are advised to maintain professional boundaries both in the treatment room and outside, to ensure confidentiality, and to avoid dual relationships. If gay, lesbian or bisexual psychologists are to maintain a positive image within the community, they may need to be vigilant in managing their own personal issues. Good supervision is an excellent way to maintain awareness of these issues. Guideline B 2. Psychologists are encouraged to be particularly aware of confidentiality and privacy issues for clients from within their own community. Clients often feel a stigma associated with seeing a psychologist, and some clients wish to avoid being seen seeking treatment or being known to seek treatment. This may be so especially for gay, lesbian and bisexual clients because in the past their sexual orientation has been a source of discrimination and harassment. Whereas clients in the broader community can often seek psychological invention in a reasonably anonymous manner, such anonymity can be difficult to maintain in a small community and special attention needs to be directed at protecting the clients' confidentiality and privacy. There is a need therefore for special vigilance around client records, appointment books, scheduling of appointments and waiting room privacy. Where psychologist and client are from the same community, clients often have concern about the psychologist s knowledge of their social network and whether such knowledge would impact on either their social life or their treatment. While the Code of Ethics addresses provision of psychological services to "close friends", the issue of social contact in a small community is not addressed and this may be more problematic. Therefore gay, lesbian or bisexual psychologists particularly are advised to avoid entering a 14

15 professional relationship with clients where outside knowledge of or social contact with the client might impair the provision of psychological services. Some clients may fear possible future interactions with their psychologist in work, social, relationship, political, or other spheres. Gay, lesbian and bisexual psychologists may need to consider negotiating with clients concerning appropriate limits in these situations. Lesbian, gay and bisexual clients often have concern about confidentiality, in particular the possibility of the psychologist s knowledge of the client s issues escaping into the broader gay community (especially for higher profile gay figures). While all psychologists are advised to take special care to avoid inadvertent breaches of confidentiality, gay, lesbian and bisexual psychologists need to exercise particular care around these issues. Guideline B 3. Psychologists working with clients from their own community need to be aware of issues which may impact on the therapeutic process The following are some areas where boundary issues may occur for the psychologist and warrant particular vigilance. Because lesbian, gay and bisexual people are aware of their minority status in many areas of life, they often have a strong need to form significant bonds with other gay, lesbian and bisexual people when they come across them. Hence both gay, lesbian and bisexual clients and lesbian, gay and bisexual psychologists are at greater risk of moving into a personal as opposed to a professional relationship. Psychologists sometimes feel an inappropriate identification with the client or feel sexually attracted to client. It is important that the psychologist avoid working with clients where such difficulties might arise and take steps to refer the client to another psychologist if the issue impairs their professional practice. Clients who are in the process of coming out, progress at different rates and have different levels of comfort with the process as a whole and with the various stages of the process. Psychologists should be alert to the level of comfort for the client with his/her sexual orientation, and to respect the pace and progress for the client while coming out. In particular gay, lesbian and bisexual psychologists should be aware of the attachment that some clients may develop towards the psychologist as part of the process of being understood and supported. Gay, lesbian and bisexual psychologists should also be aware that they often wittingly or unwittingly provide a role model for their gay, lesbian and bisexual clients, especially young clients or clients who are coming out. This may be particularly intense, as the psychologist may be one of the few lesbian, gay or bisexual people the client has ever met. Clients sometimes feel sexually attracted to their psychologist, especially those clients who are young or inexperienced with their sexuality. It is important for the psychologist to assist the client to distinguish between friendship and professional relationships. Psychologists may sometimes gain outside knowledge relating to a client from community sources either before or during the period of work with the client, which may influence the intervention. Special difficulties may arise when a current client enters a relationship with someone known to psychologist. It is important for the psychologist to attempt to partition such knowledge and to prevent such knowledge from impairing the professional relationship. It is important for any psychologist to form a positive therapeutic relationship with their client and still maintain appropriate professional boundaries. This is an important distinction for the gay or lesbian psychologist to maintain. Non-sexual touching and intimacy (i.e. hugs) are common among members of the gay, lesbian and bisexual community as forms of greeting between friends and acquaintances. Gay, lesbian and bisexual psychologists should remain aware that their relationship with a client is a professional one and not one of friendship, so that in most cases touching is not appropriate. Those psychologists who use physical touch in their treatment should discuss this with the client so that both are clear about the purpose of physical touch. (See APS Ethical Guidelines relating to Procedures/ Assessments that Involve Psychologist-client Physical Contact ) Guideline B 4. Psychologists are aware that they may be part of a community with special circumstances Gay, lesbian, or bisexual psychologists should address the issue of meeting clients in a social situation, taking into consideration the clients level of comfort, and the psychologists need to maintain a professional boundary and some personal privacy. The situations might include meeting clients or ex-clients at a gay 15

16 social event (gay festival, dance party, dinner party) or meeting clients or ex-clients at a non-gay event (public lecture, private dinner party, conference, work event). There is a special need for vigilance around maintaining professional boundaries when psychologists are involved in activities which might involve meeting a client or ex-client (anonymously or not) at a telephone chatline, Internet chat room, newspaper personal advertisement, sex-on-premises venue, etc. Gay, lesbian and bisexual psychologists are encouraged to consider how best to maintain their own privacy and how to negotiate the limits of their professional and personal relationships with a priority for the best interests of the client. The authors of these guidelines acknowledge the assistance of Div 44 of the American Psychological Association for providing their guidelines, which form the basis of section A of these guidelines. October