Coming Out:
Considerations and clinical implications
Sixto Muñoz, LICSW
Developed with help by Rhonda Linde,
PhD, Ana Maldonado, PA-C, MPH, DHSc
& Melissa Savage, LICSW, LADC
Cultural Competence
“a heightened consciousness and analytic grasp
of how race and ethnicity, gender and sexual
orientation, social class and status, religion and
spirituality, age, and development stage, as well
as physical or mental abilities affect the lives of
people and their environments” (NASW, 2001)
6 themes in an LGBTQ-affirming practice
approach:
Attitudes
1. Same gender sexual desires and behaviors
are viewed as a normal variation in human
sexuality
2. The adoption of a LGBTQ identity is a positive
outcome of any process in which an
individual is developing a gender or sexual
identity.
6 themes in an LGBTQ-affirming practice
approach:
Knowledge
3. Service providers should not automatically assume a
client’s sexual orientation or gender identity.
4. It is important to understand the coming out process
and its variations.
Skills
5. Practitioners need to be able to deal with their own
racism, sexism, biases and queerphobia.
6. When assessing a client, practitioners should not
automatically assume that the client is heterosexual,
male or female.
LGBTQ Sensitive Therapy:
Creating a non-judgmental atmosphere
• Photos, pictures in office: who do they
include/exclude
• Explore own feelings that might result in
unconscious bias
• Use neutral language eliminate assumptions
of heterosexuality
Sexual Orientation/Gender Identity may
not be the presenting problem
• Do not over-treat or under-treat their
sexuality
• Do not assume that sexual orientation/gender
identity is the presenting problem
• Do not assume that it has no impact on their
mental health
Impact of Stigma & Discrimination on
Mental Health
• Constant concealment of true identity (“Covering”)
• Fear of, or actual victimization by, verbal or physical
attack
• Social isolation/ lack of social supports
• Problems with self-acceptance
• Stigma and pressures to be gender-conforming may
affect personality development
• Social determinants of health may shape one’s
developmental processes, self-esteem, and selfconcept.
Impact of Stigma & Discrimination on
Mental Health, Cont
• Stressors that are physical, emotional, cultural, spiritual
and/or other stressors (e.g., financial problems as a result
of employment discrimination) interfere with ability to
achieve goals.
• Insensitive, inattentive, uninformed, and inadequately
trained and supervised care providers compound stigma
• Stigma, oppression and discrimination contribute to
psychological symptoms, but do not necessarily indicate
pathology
• Elevated rates of depression, smoking, drug and alcohol
abuse among LGBTQ people
Coming out: 3 models
Sexual Identity: The Cass Model (1979)
• One of foundational theories of gay and
lesbian development
• Sequential theory of development with 6
stages
Coming out: 3 Models
The Cass Model (1979)
Identity
Awareness
Identity
Comparison
Identity
Tolerance
Identity
Acceptance
Identity
Pride
Identity
Synthesis
Coming out: 3 models
Anthony D’Augelli: “Homosexual Lifespan Development
Model”
• Developed in 1994, this model does not use a stages
perspective, but rather is focused on processes that could
occur repeatedly or not at all. Acknowledging that LGBTQ
people are coming out process repeatedly across their
lifespan. This model also recognized that LGBTQ identity
development could stop, then start again—or begin when a
person perceives that it would be safe to come out.
Coming out: 3 models
Coming out: 3 models
Arlene Istar Lev “Transgender Emergence Model”
• Developed in 2004, this 6 stage model is written not
only from the point of view of the individual, but also
of the clinician and describes ways trans people
come to view their identity.
Coming out: 3 Models
Lev – Transgender Awareness
Model
Awareness
Seeking
Info/Reaching
Out
Exploration
(Identity and
Self-labeling)
Disclosure to
Significant
Others
Exploration
(Transition
Issues &
Possible Body
Modification)
Integration
(Acceptance
& PostTransition
Issues)
LGBTQ Development:
Adolescence/Youth
• Lack of opportunity to experiment with LGBTQ identity
due to antipathy of peers, family & society
• May be few age-appropriate activities/institutions
available to LGBTQ youth
• Stress of homophobia/transphobia can lead to
increased risk/self destructive behaviors (suicidality,
substance abuse, tobacco use, pregnancy) when
compared to their heterosexual/cisgender peers
https://www.youtube.com/watch?v=IRLSgPQG0c4
LGBTQ DEVELOPMENT: Young
Adulthood/Middle Age
• Many LGBTQ people develop a positive sense
of self and form satisfying relationships
• Some are distressed by being LGBTQ and may
repress/suppress it
• Delay of interpersonal tasks from adolescence:
Challenges for Older LGBTQ People
• May revisit some of the conflicts from
adolescence if need to retire to straight
retirement/nursing homes where
homo/transphobic stigma may again isolate &
inhibit them
• May retreat into safety of invisibility
• May be vulnerable to decisions of blood family
members who may have legal power.
• Ageism in the LGBTQ community
Helping a Client decide about Coming Out
• Evaluate possibility for negative reactions
– rejection, harassment, discrimination, anti-LGBTQ violence
• Evaluate possible gains
– feeling more authentic, not having to hide a major part of
oneself, increase of intimacy via self-disclosure/sharing of
life events, receiving support, finding community,
consolidating identity
• Explore: internalized transphobia, homophobia, sexism,
consequences of bending traditional gender roles, loss
of acceptance, and lack of societal support
Factors to consider during an evaluation
or treatment
Presenting Problem
Is it LGBTQ-related or not?
Presenting Problem- Substance Abuse
• Substance Abuse & Coming Out:
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Does client frequent bars?
Are they part of the party circuit or find hook ups on-line?
Do they use substances to engage in sex?
Are they involved with AA/NA?
Factors to consider during an evaluation
or treatment
Social History & Functioning
• History of friendships: same/opposite sex
• Participation in group activities: sports, other
Assess sex role stereotypes of activities & in friendships
(identified with same or opposite-gender sex roles?)
• Sense of isolation: was there any
scapegoating/teasing/ harassment/beating because of
perception the client was LGBTQ?
• Any relationship that was a support or a safe haven?
• Any LGBTQ role models growing up?
Factors to consider during an evaluation
or treatment
Social History & Functioning
• Current social networks: LGBTQ groups/activities
• Who are they out to? At work, friends, family?
• Do they have LGBTQ friends? Straight friends?
History of primary romantic relationships:
• With cismen/women (natal), transmen/women?
• Assess patterns and themes in relationships, role of
substances, sex.
• Were they satisfying or abusive relationships?
Factors to consider during an evaluation
or treatment
Vocational/Educational History
• Ask to whom are they out at work
• How trans/homophobic is the work
environment?
• Any other LGBTQ people at their place of work?
• Was/is there pressure to date heterosexually in
school?
• Was/is school work affected by struggles re:
coming out or by society's homo/bi/transphobia?
Factors to consider during an evaluation
or treatment
Sexual History & Functioning
• First sexual attractions, fantasies and encounters:
same/different gender:
– How comfortable were they with these?
• Were sexual experiences:
–
–
–
–
In the context of an on-going relationship?
One night stands or anonymous?
Were substances involved?
How did they feel after?
Factors to consider during an evaluation
or treatment
Sexual History & Functioning
• Sexual behavior:
– Assess degree of safer sex
– Knowledge of STD transmission
– Use of substances?
• Assess presence/degree of sexual compulsivity
• Role of sex/sexuality in life and in sense of self
Factors to consider during an evaluation
or treatment
Impact of Stigma/Discrimination on Gay Male Sexuality
• Due to historical stigma and fear:
– contact with other gays had to be a furtive act
– Few non-sexual institutions before AIDS
– Sex was first contact point to meet others
Psychological Functions of Casual/Anonymous Sex for some gay men
For some it is a recreational part of well-adjusted life
For some it is:
• Compulsive
• For some men who lead a closeted, split life (married
heterosexually), anonymous sex is the only way to be with men
without risking social exposure
Factors to consider during an evaluation
or treatment
Medical History
• Experience with transphobia/homophobia in
healthcare
– Uncomfortable revealing gender identity/sexual
orientation/behavior to a medical provider?
– Avoidance of medical care or withholding of
information from a provider for fear of
harassment/discrimination?
Helping a Client decide about Coming Out
Online Resources:
• It Gets Better Project: http://www.itgetsbetter.org/ created by Dan Savage in 2010 as a response to LGBTQ
youth suicide
• RUComing Out: http://www.rucomingout.com – created in
2012 as an online support for closeted people to read
stories from other’s across the world about their coming
out experience
• Human Rights Campaign, Resource Guide:
http://www.hrc.org/resources/resource-guide-to-comingout - nation’s largest LGBTQ civil right’s organization
Questions?
References
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Cass, V. C. (1979). Homosexual identity formation: A theoretical model. Journal of Homosexuality, 4, 219-235.
D'Augelli, A.R. (1994). “Identity development and sexual orientation: Toward a model of lesbian, gay, and bisexual development.”
Diplacido, J. (1998). Minority stress among lesbians, gay men, and bisexuals: A consequence of heterosexism, homophobia, and
stigmatization. In G. Herek (Ed.), Psychological Perspectives on Lesbian and Gay Issues: Stigma and sexual orientation: Understanding
prejudice against lesbians, gay men, and bisexuals. (pp. 138-160). Thousand Oaks, CA: SAGE Publications, Inc. doi:
http://dx.doi.org/10.4135/9781452243818.n7
Lev, A.I. (2004). Transgender Emergence: Therapeutic guidelines for working with gender-variant people and their families.
Binghamton, NY: Haworth Press.
National Association of Social Workers. (2001). NASW standards for cultural competence in social work practice. Social Work Speaks.
1996 NASW Delegate Assembly.
Savin-Williams, Ritch C. (1994). Verbal and physical abuse as stressors in the lives of lesbian, gay male, and bisexual youths: Associations
with school problems, running away, substance abuse, prostitution, and suicide. Journal of Consulting and Clinical Psychology, 62(2),
261-269.
https://safezone.uncc.edu/allies/theories
http://www.hrc.org/resources/resource-guide-to-coming-out
http://www.itgetsbetter.org/
http://www.rucomingout.com/
References
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https://safezone.uncc.edu/allies/theories
http://www.hrc.org/resources/resource-guide-to-coming-out
http://www.itgetsbetter.org/
http://www.rucomingout.com/