Psychotherapy with Lesbian, Gay, and Bisexual Military Service Members
In September 2011 the US military’s ban on lesbian, gay, and bisexual (but not transgendered) service members was lifted. The repeal of Don’t Ask Don’t Tell (DADT) was a landmark step in the advancement of civil rights for sexual minorities in the United States. One of its effects was to open the door for military psychologists to begin to provide culturally sensitive services to a segment of the US military population whose treatment needs have until now been difficult to meet. The absolute number of Active Duty service members who (p. 153) are lesbian, gay, bisexual, or questioning their sexual orientation (LGBQSMs) is currently unknown. While estimations will by necessity wait for the Department of Defense’s relevant census initiatives, anecdotal reports suggest that the numbers are likely substantial and, due to the repeal of DADT, may be growing (e.g., National Defense Research Institute, 2010; Porter & Gutierrez, 2011).
Extensive literature already documents the long history of sexual minorities serving in the US military (e.g., Berube, 1990; Herek, 1993, National Research Institute, 2010). Essentially, gay men, lesbians, and bisexuals have always served in the US military. Until September 2011, these service members had been obliged to keep their identities, behaviors, and lifestyles as secret as possible. Failure to do so resulted in harassment, prosecution, or discharge from military service. The rationale for this has varied over the years. Before the 1940s, homosexual sexual behavior had been considered a criminal offense under the Uniform Code of Military Justice (UCMJ). During World War II, a more complete adoption of the medical model shifted the overall approach of US military toward homosexuals from the prior focus on criminal behavior to a newer focus on abnormal (or pathological) identity. This lasted until 1993, when with the passing of DADT the military’s approach shifted again. This time, suppositions of both criminality and pathology were explicitly avoided, in favor of a stated concern about a destabilizing, antisocial impact that the open presence of active duty LGBQSMs within the US military might possibly exert on unit cohesion and morale. Though DADT placed ostensible constraints on social or administrative enquiry into service members’ sexual behavior and orientation, sexual-orientation-related discharges escalated, totaling almost 14,000 during this 18-year period (National Defense Research Institute, 2010).
The September 2011 repeal of DADT allows LGMSMs to manage their privacy, including the concealment or disclosure of behaviors, identities, or attitudes related to sexual minority status, more freely than ever before in history. Yet the absence of administrative constraints on coming out has not yet clearly created an unequivocally affirming environment for sexual minorities serving within the US military.
While some generalizations can be made about the tendency toward socially conservative, heteronormative attitudes in US military culture, each unit or work environment is characterized by its own social norms and prevailing attitudes. At worst, disclosure (intentional or inadvertent) in socially dangerous environments within the military is believed to have already led to overt discrimination: increased targeting of LGBQSMs for verbal harassment, violence, military sexual trauma (MST), and even murder. At best, disclosure in a socially accepting environment can lead to improvements in mental health, social cohesion, task cohesion, commitment to the organization, and overall well-being. Somewhere in between lies the pernicious and difficult-to-identify territory of covert discrimination: disclosure that leads to social or professional exclusion (including, potentially, reduced opportunities for professional advancement or desirable work assignments) and loss of potential access to cultural capital, military camaraderie, and solidarity. In fact, as history has already demonstrated in the case of women and African Americans, integration of new sociocultural elements into US military culture takes time. DADT’s repeal has opened the door to a host of psychosocial concerns that may impinge on the mental health of LGBQSMs until true and universal acceptance is reached.
Furthermore, while the Department of Defense’s efforts to reduce discrimination of LGBQSMs are, over time, likely to reduce overt discrimination, they are less likely to be successful at reducing covert discrimination or at improving frank cultural acceptance of sexual minorities. This is particularly unfortunate, as social inclusion, access to cultural capital, and (p. 154) military camaraderie can exert important buffering effects on the high levels of stress and trauma often involved in military service. Even partial exclusion from these important aspects of military life may place some LGBQSMs at greater risk for developing symptoms as a result of military service, deployment-related stress, or trauma exposure.
Content Considerations: Culturally Salient Areas of Potential Clinical Concern
The sociohistorical and current heteronormativity within the US military discussed earlier is likely to impact the willingness and readiness of the LGBQSM client to discuss sensitive clinical issues in psychotherapy. Psychologists (military and otherwise) working with LGBQSMs (active duty and otherwise) need to be aware of several important areas of potential clinical concern.
Clinicians working with this population can learn to balance an appreciation of the client’s developing readiness to discuss sensitive issues with the therapeutic goal of including culturally important issues in the treatment. Other than in cases of potential high risk, prematurely introducing sensitive LGB-relevant topics may risk rupturing a fragile therapeutic relationship. Our recommendation is that psychologists focus first on developing trust and rapport, allowing the client an opportunity to develop his/her disclosure progressively and cumulatively within the treatment. Nevertheless, when appropriate, demonstrating knowledge and concern about culturally relevant areas of potential concern can strengthen the LGBQSM client’s confidence in both the psychologist and the treatment, improving both working alliance and treatment outcomes. Such dialogues can unroll fruitfully over the entire course of the treatment, returned to as needed, given the ongoing nature of most LGBQSMs’ negotiation of the following issues.
For the estimated 50% of potential LGBQSM clients who are between the ages of 17 and 24, issues concerning identity development are likely to need attention. For many sexual minorities, this is the age when sexual or affective tendencies toward same-sex relationships may be first noticed, or when tendencies noticed previously become too strong to continue ignoring. Furthermore, for younger LGBQSMs, this may be their first extended period of time away from the influence of a potentially constraining family environment. Positive development of mature gender and sexual orientation identities during this age range is crucial for a successful transition to adulthood and sustainable, long-term mental health.
For young recruits, military service is a precious opportunity to become adult men and women. This process may be more complicated for the young LGBQSM, for whom healthy development of an adult gender role identity is likely to be constrained on one end by the military’s valuation of stereotypical masculinity and on the other by their recognition of their own inherent differences from that stereotype. Certainly, not all men who are interested affectively or sexually in other men necessarily exhibit other stereotypically feminine behaviors or interests, nor do all women interested in women exhibit other stereotypically masculine behaviors or interests. Nonetheless, affective or sexual tendencies toward same-sex relationships transgress mainstream gender norms. Furthermore, outside the military, many lesbian and/or gay communities establish cultural capital on the basis of transgression or exaggeration of mainstream gender stereotypes. Young LGBQSMs may become confused or distressed by these conflicting social forces. This can lead to isolation, maladaptive coping styles, psychopathology, and, in a minority of cases, high-risk behaviors or suicide.
Feelings of discomfort regarding one’s tendencies toward affective or sexual relationships with same-sex partners are a normal part of adjusting to a potential change in self-concept and its related social implications. The mere presence of such feelings does not indicate the use of “reparative therapy” to attempt to change the tendencies. Such therapies (p. 155) remain ethically controversial, lack empirical support, and are generally repudiated by mainstream psychological and psychiatric associations. Rather, psychotherapists can help clients investigate a range of profound and crucial identity developmental questions that are likely to underlie any immediate social or professional concerns brought to treatment by the LGBQSM. These may include variants on “What kind of man/woman am I?”, “If I have ‘fooled around’ with other men in the service, does it mean that I am ‘gay’?”, “How can I feel good about being an adult man/woman when I transgress core elements of normative masculinity/femininity?” and “What kinds of future can I envision for myself within the US military, as I increase my autonomy, personal power, and cultural capital as a LGB person?” Through investigation and clarification of these questions, the psychotherapy will assist in authentic self-development and self-determination, rather than proscriptive behavioral changes of dubious durability or psychological merit.
Managing Disclosure and Concealment
Concealing sexual identity at work has generally been linked to lower job satisfaction, work cohesion, and task cohesion, as well as higher turnover rates and greater overall distress for sexual minorities. However, disclosing sexual identity (inadvertently or intentionally) in a hostile environment can also lead to difficulties. Fortunately, managing concealment and disclosure need not be an all-or-nothing affair. With the help of the clinician, LGBQSMs may be able to identify certain friendships, work relationships, or environments that seem likely to support full disclosure, and others that do not. If indicated, psychotherapists can begin a dialogue with their LGBQSM clients about the costs and benefits of coming out (disclosing their identity), as well as about what might be its potential gradations (partial or selective disclosure; intentional or inadvertent dissemination through social networks, including social media; managing sexual behavior on and off base).
Potential High-Risk Clinical Issues
1. Substance misuse: Extraordinary care should be taken in ongoing treatment to evaluate LGBQSMs for potential substance misuse. Both military service members and LGBQ people are at increased risk for substance misuse compared to the general population. LGBQSMs, subject to the stressors and social norms of both groups, may represent an even higher risk. Though the US military’s zero tolerance policy for illicit substance use is often effective at prevention, misuse of alcohol is likely to be high among LGBQSMs seeking treatment, and can lead to other problems, such as risky sexual behavior. Clinicians working in the United States should be aware of the high rates of methamphetamine use among gay men in the general population, and its potential combination with risky sexual behavior and promiscuity.
2. Unsafe sex and HIV/AIDS: Psychotherapists could help their LGBQSM clients, particularly sexually active men, by developing comfort around discussing the specifics of safer and risky sexual behavior, assessing their clients’ health behavior in this domain on an ongoing basis. Over 50% of the US military is currently under the age of 25. In this younger age bracket, which did not directly experience the most socially traumatic years of the AIDS epidemic, rates of risky sexual behavior are increasing. Where appropriate within the treatment, exploration of the client’s thoughts and feelings about HIV/AIDS, including the way it can impact careers within the US military (e.g., constraint on deployments) can be used to facilitate greater awareness and improve health behavior. LGBQSMs who are seropositive may be at higher risk for isolation and depression, and will need additional support within the therapy related to any potential feelings of shame, guilt, or fear regarding their condition.
3. Military sexual trauma (MST): Both lesbian and gay male service members may be at high risk of being targeted for MST, (p. 156) principally by male service members (e.g., Burks, 2011). LGBQSM clients should be screened for potential MST histories and treated as appropriate. Additionally, regardless of exposure history, the possibility of future MST may be a safety concern for LGBQSM clients, adding to their overall level of distress, and impacting the client’s management of concealment and disclosure.
4. Suicide: Both LGBQ and military populations are at higher risk for suicide compared to members of the general population. Sadly, suicide rates in the US Armed Forces have been increasing since 2008, a trend understood to be in part a function of distress related to multiple deployments to combat zones. Further, LGBQ people, particularly youth and young adults, have ended their own lives at high rates in response to social disenfranchisement and harassment and as a result of conditions of depression, low self-acceptance, and challenges within identity development. An initial screening for suicide risk should be supplemented by ongoing, informal assessments and support, when indicated.
Technical Considerations: Diagnosis, Treatment Approach, Ethics
Beyond the various categories for general Axis I psychopathology available in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM–IV–TR; American Psychiatric Association, 2000), any of which may apply to the LGBQSM client, current US psychiatric nosology offers little nuance with which to characterize sexual orientation identity-related distress. Adjustment Disorder (309.X) captures emotional and behavioral presentations of distress related to living as a sexual minority within a heternormative environment, such as the US military even after the repeal of DADT. Identity Problem (313.82) indicates significant distress related to self-questioning about sexual orientation and behavior. Though Sexual Disorder Not Otherwise Specified (302.9) can be used for cases of significant, long-lasting distress regarding sexual orientation, it risks pathologizing the orientation or behavior, rather than the heteronormative environment. This is an arguably unethical step as it could potentially cause further harm to an already fragile client.
Using the content areas provided above as touchstones in the treatment, psychotherapists of LGBQSM clients can work effectively within any modality; no theoretical orientation is clearly better than any. Regardless of modality or theory, the approach to treatment can benefit from the following considerations: creating an LGBQ-affirming space, cultivating awareness of one’s own homophobia or heterosexism, and avoiding pigeonholing.
1. Creating an LGBQ-affirming space: When the LGBQSM client walks into the office, he or she scans it and looks for evidence that it is safe. In turn, the psychotherapist who has items, books, or objects that clearly are LGBQ-affirming communicates from before the first word is uttered that he or she is open-minded, welcoming of him or her, and accepting of who he or she is as a person.
2. Cultivating vigilance against one’s own homophobia: Avoiding heteronormative assumptions and using neutral language are steps toward greater inclusivity. Using terms such as “partner” or “significant other” rather than “girlfriend” or “spouse” can signal an openness to working with people of various sexual orientations and/or relationship arrangements. This stance requires constant attention and self-reflection. The APA has provided guidelines that can help psychotherapists understand their roles and have reasonable expectations in psychotherapy with LGBQSM clients (APA Div. 44, 2000). The authors of this chapter have also written on couple therapy with this population (Porter & Gutierrez, 2011).
(p. 157) 3. Avoiding pigeonholing: When LGBQSMs seek psychotherapy, their concerns do not necessarily hinge on their sexual or affective tendencies. Sexual orientation might be disclosed only later in the treatment, depending on the client’s readiness. Again, some feelings of discomfort regarding a potential shift in self-concept or social identity are developmentally normal, and do not indicate therapeutic attempts at “reparation.”
Psychotherapist lapses in cultural competence can result in therapeutic ruptures, diminished client engagement, or an impoverished alliance, any of which could lead to a potentially high-risk client prematurely terminating treatment. Psychotherapists newer to this population are advised to assess their own knowledge base, skills, attitudes, and awareness of issues related to sexual minorities using published self-report measures of cultural competency (e.g., Bidell, 2005). Given the high-risk behaviors (including suicide) in this population, psychotherapists with substantial heteronormative biases of their own should consider referring LGBQSM clients to someone able to provide more appropriate care. Yet, with appropriate training, clinical competence, and sensitivity, military psychologists can provide valuable and needed mental health services to LGBQSMs.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.Find this resource:
American Psychological Association Division 44, Committee on Lesbian, Gay, and Bisexual Concerns Task Force. (2000). Guidelines for psychotherapy with lesbian, gay, and bisexual clients. American Psychologist, 55, 1440–1451.Find this resource:
Berube, A. (1990). Coming out under fire: The history of gay men and women in World War Two. New York, NY: Free Press.Find this resource:
Bidell, M. P. (2005). The Sexual Orientation Counselor Competency Scale: Assessing attitudes, skills, and knowledge of counselors working with lesbian/gay/bisexual clients. Counselor Education and Supervision, 44(4), 267–279.Find this resource:
Burks, D. J. (2011). Lesbian, gay, and bisexual victimization in the military: An unintended consequence of “Don’t Ask, Don’t Tell”? American Psychologist, 66, 604–613.Find this resource:
Herek, G. M. (1993). Sexual orientation and military service: A social science perspective. American Psychologist, 48, 538–549.Find this resource:
National Defense Research Institute. (2010). Sexual orientation and U.S. military personnel policy: An update of RAND’s 1993 study. Santa Monica, CA: RAND Corporation. Retrieved from http://www.rand.org/pubs/monographs/MG1056
Porter, M., & Gutierrez, V. (2011). Enhancing resilience with culturally competent therapy for same-sex military couples. In B. Moore (Ed.), Handbook of counseling military couples (pp. 295–320). New York, NY: Routledge.Find this resource: