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Introduction

Affirmative Practice

Understanding and Working with Lesbian, Gay, Bisexual, and Transgender Persons

Following the removal of “homosexuality” as a diagnostic category from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders in 1973 (see Chapter 8), the views of human services professionals about “homosexuals” began to change. In 1975, the Delegate Assembly of the National Association of Social Workers passed a resolution supporting the civil rights of these persons, and in 1977 adopted a policy statement opposing discrimination against them. In 1979, NASW formed a National Task Force on Lesbian and Gay Issues. The task force issued a position statement recommending that social workers hold nonjudgmental attitudes toward lesbian and gay persons, offer optimal support and services, and advocate for supportive environments (Gramick, 1983). NASW created the National Committee on Lesbian and Gay Issues in 1982, and in 1993 a change in the bylaws made the committee mandatory, to provide guidance and direction to NASW on gay and lesbian issues and represent lesbian and gay members of NASW and the social work community at large (National Association of Social Workers, 1999). In 1999, the NASW Board of Directors approved an affirmative action goal of 10 percent representation of lesbian, gay, and bisexual members in the association’s national leadership (“Sexual orientation goal,” 1999). The NASW Code of Ethics (1996) also has clear expectations regarding sexual orientation—practitioners cannot discriminate against clients because of their sexual orientation. Nor, can they refuse to provide services for a person solely because of their sexual orientation.

A former editor-in-chief of NASW’s journal Social Work urged educators, students, and practitioners to be more proactive on behalf of lesbian and gay persons on individual, organizational, and educational levels. At the individual level, we are challenged to examine the effects of a heterosexist society, and put aside assumptions about lesbian and gay persons, and hear their own understandings of themselves and their lives. We must familiarize ourselves with oppression and its effects on lesbian and gay persons, couples, families, and communities, and become advocates on their behalf. At the organizational level, we must examine our educational programs, agencies, and organizations for oppressive policies or heterosexist biases. We must work to change nonaffirmative policies and educational content. At the national level, we must push our professional organizations to be proactive in supporting affirmative policies, laws, and political candidates (Hartman, 1993).

The Council on Social Work Education (CSWE), the accrediting body of social work education programs, also has a committee that focuses on lesbian and gay, and also bisexual and transgender issues. The CSWE Commission on Sexual Orientation and Gender Expression advocates for inclusion of educational material on lesbian, gay, bisexual, and transgender (LGBT) persons in social work programs. Not until 1991, however, did CSWE require content on sexual orientation in social work programs as part of its nondiscrimination standard.

Currently, CSWE requires that social work programs make “specific and continuous efforts to provide a learning context in which respect for all persons and understanding of diversity…are practiced” (CSWE, 2002, p. 17). This standard on “nondiscrimination and human diversity” includes sexual orientation (http:://www.cswe.org/). Nevertheless, some of the actions of this organization reflect incompatible ideologies (Van Soest, 1996). For example, CSWE exempts religious institutions from the nondiscrimination standard related to sexual orientation. In a debate on this action between two social work educators, R. G. Parr claimed that religious institutions have codes of conduct for faculty and students limiting sexual conduct to heterosexual marriages. Exempt programs are not required to provide affirmative knowledge about gay and lesbian persons. This situation is troubling in a profession that seeks social justice for all persons. L. E. Jones contended that Parr’s view in stating that the issue is not sexual conduct but discrimination against a particular group of persons (Parr & Jones, 1966). The NASW board passed a motion regarding this exemption. It opposed “any effort which could diminish the profession’s commitment to and support of nondiscrimination in educational or professional arenas as explicated in NASW’s Code of Ethics” (“CSWE standard,” 2001, p. 8).

All human services professional associations now require their members to deliver knowledgeable and unbiased services to LGBT persons and to advocate against discrimination directed at them. Although transgender is a sexual identity, transgender persons experience the same range of sexual attractions and sexual orientations as any other group. Even if heterosexual, these persons also have issues in common with LGB persons such as prejudice and discrimination. Across the United States coalitions of LGBT communities recognize common goals of sexual freedom and sex–gender expression. Transgender persons also experience other common issues such as coming out and disclosing information about their sexual identity, sexual orientation, or both.

Knowledge of LGBT populations is the educational foundation from which unbiased human services practice begins (for example, Croteau & Kusek, 1992). The purpose of this book is to add to the contemporary resources of knowledge on LGBT persons. It is noted in this book, however, that practitioners are also required to not only demonstrate intellectual competency but emotional competency (for example, no attitudes and feelings that can impair capacity to effectively and compassionately offer services to LGBT clients). Reaching emotional competency and learning unbiased or affirmative practice skills depend on field placements and agencies with supervisors who can guide students and practitioners in attaining this competency and the skills to work with LGBT clients.

Contentious Issues: Causes, Choices, and Numbers

Many contentious issues surround nonheterosexual sexual orientations. Among the most fiercely heated issues are what causes differences in sexual orientations, whether or not sexual orientation is a choice, and what are the proportions of LGB persons. Scholars, scientists, and the lay public debate these issues, as well as LGB persons themselves.

Causes

Typically, various proposed causes of sexual orientation fall on either side of a dichotomy: nature–biological (essentialism) or nurture–social (social constructionism). Are same-sex or bisexual sexual orientations biologically caused, permanent, and found in every culture; or are they arbitrary and socially created and maintained phenomena (for example, Bailey, 1995; E. Stein, 1990)? So far, no sufficient evidence supports either biological causes (for example, Bailey & Pillard, 1991) or social–environmental causes (for example, Kitzinger, 1995). Many studies fail to find any associations between various proposed causative factors (for example, prenatal hormones, early psychosocial factors) and same-sex or bisexual sexual orientations.

Most likely, nonheterosexual sexual orientations result from a complex interaction of biological, psychological, and cultural factors. A discovery of either a definitive set of components or a single path to sexual orientation is unlikely (T. S. Stein, 1993). Different “causes” may operate not only across persons but also within subgroups of populations (for example, sex–gender, ages, social classes, racial and ethnic groups) (Bailey, 1996; Savin-Williams, 1998). Most likely, research will eventually identify a cluster of routes that lead to some forms of nonheterosexual sexual expression (Dynes & Donaldson, 1992).

Choices

The question of whether LGB sexual orientations are choices is central to the essentialist–constructionist debate. Essentialists assume that persons do not consciously choose their sexual orientation (Gonsiorek & Weinrich, 1991; Herdt, 1990). In distinct contrast to this view, one of the most basic tenets of social constructionism is that persons make a conscious, intentional choice of sexual orientation (for example, Vance, 1988; Weeks, 1991).

Even within LGB communities, opinions differ. Some LGB persons distinguish between sexual orientation, which they do not choose, and sexual identity, which they do choose. Many lesbians studied by Golden (1996, 1997) believed they had no control over their sexual orientation, but that they chose their sexual identification or the labels for it. Yet, these women appear to have chosen more than just their self-label. Some talked about deciding to become sexually attracted to and involved with other women. Though they had no previous same-sex sexual experience, they became “open” to attractions to women. Certain experiences, such as a specific film or TV program, lecture, article, or discussion with a lesbian, prompted their interest as well as more general experiences such as women’s studies classes or exposure to lesbians within feminist groups. Some “chose” to be lesbians because the feminist movement legitimated this choice. Women identifying as bisexual found it easy to move into this choice once they discovered bisexuality. Sometimes these women reinterpreted close female friendships and attachments as evidence that they had always had attractions to women but had not acknowledged them as having anything to do with being lesbian or bisexual. These various experiences could support either the constructionist or essentialist views.

Although sexuality is not experienced as a choice by all women, or even by most, Golden (1997) thought it is a choice for a significant minority of women. Such does not seem to be the case, however, for gay and bisexual men (for example, Diamond & Savin-Williams, 2000; Kitzinger, 1995). Biology may play a larger role for them (Golden, 1997; Veniegas & Conley, 2000). A question posed by Bohan and Russell (1999a) was why choice is debated at all. If LGB identities are healthy variations, why not choose them? Many persons choose these identities and experience happy and satisfying lives.

A related issue is the stability–fluidity of one’s sexual identity (Savin-Williams, 1998). But, the longitudinal stability or instability of sexual orientation or identity over one’s adult life is an open question because essentially of the lack of research on this topic (Gonsiorek, Sell, & Weinrich, 1995).

Numbers Question

Pursuit of the numbers question started with the Kinsey reports in 1948 and 1953 and continues to date (for example, Laumann, Gagnon, Michael, & Michaels, 1994; Sell, Wells, & Wypij, 1995). Despite many definitional and measurement difficulties in these pursuits, Gonsiorek et al. (1995) concluded that the approximate prevalence of predominantly same-sex sexual orientation in the United States ranges from 4 percent to 17 percent. Exclusive same-sex sexual behavior or substantial same-sex attraction is probably in the middle of this range.

Estimates of the prevalence of lesbian and gay persons are simply guesses—what the actual figures are remains unknown. The exact prevalence of bisexual behavior and attraction is also unknown (Stokes, McKirnan, Doll, & Burzette, 1996) as is the prevalence of transgender persons, although one estimate is that they make up .01 percent of the U.S. population (Gainor, 1999).

Unsettled Terminology

Terminology is also unsettled; it varies across geographical areas, across cultures, across time periods (American Psychological Association [APA], 1991; Donovan, 1992), as well as from inside and outside LGBT populations. In the second half of the 1860s, K. M. Benkert, writing under the noble name of his family, Ka’roly Ma’ria Kertbeny, invented the term homosexual for persons who felt attractions to others of the same sex–gender (Herzer, 1985). Later, others such as Krafft-Ebing (1892), Havelock Ellis (1942), and Magnus Hirschfeld (1948) adopted and popularized this term. Though other terms were in use such as “homophile”—meaning “loving the same” in Greek (Dynes, 1990)—homosexual was by far the most predominant term applied to persons with same-sex attractions for more than a century (Herdt & Boxer, 1992).

Community Terms

Before the turning point of the rebellion at the Stonewall bar in Greenwich Village in 1969 (see Chapter 1), few used the terms “lesbian” and “gay.” When opportunities for collective organizing and socializing increased, the phenomenon of self-identification as lesbian or gay also began to appear (Cohler, Galatzer-Levy, Boxer, & Irvin, 2000).

Gay. Gay and lesbian persons dismissed the term homosexual after the 1969 Stonewall Rebellion because of the link between this term and negative stereotypes as well as its use as a pathological diagnosis. Though its origins are unknown, an alternate term—“gay”—was in widespread use by the late 1960s. The group itself chose this term “as a sign of its refusal to be named by, judged by, or controlled by the dominant majority” (Cruikshank, 1992, p. 91). Gay and lesbian persons no longer identified with sin or sickness (homosexual) but with a social status (gay). Though not accepted by everyone, this term was the standard community term by the 1980s (Herdt & Boxer, 1992) although primarily it applied to males. Unless noted otherwise, in this book, “gay” means males.

Lesbian. The term “lesbian” was not in wide use in the United States until the 19th and 20th centuries. The historical record of who introduced this term apparently no longer exists but the source for it was probably the name of the home of the poet Sappho who lived on the Greek island of Lesbos around 600 bc (Money, 1998; Nakayama & Corey, 1993). Because of the primary identification of the term gay with men, women wanted a label of their own. By the late 1980s, groups for both women and men usually included lesbian in the group identity (Cruikshank, 1992). Lesbians wanted a name to represent women’s distinct and separate experiences and culture (Jeffreys, 1994; T. S. Stein, 1993). In the 1940s and 1950s, before the consistent usage of the term lesbian, women had no concept of a cohesive lesbian community (Kennedy & Davis, 1993).

Bisexual. Though not a term chosen by its community, “bisexual” seems to be an acceptable term to contemporary bisexual men and women. Current affirmative books, networks, and other resources on bisexual men and women use this term or sometimes the shorter version “bi.” Another related term is “bisexualities” which reflects the wide diversity among bisexual persons (Stokes & Damon, 1995).

Intersex. “ Intersex” is a clinical term applied to persons born with varying degrees of both male and female sexual reproductive organs (Feinberg, 1996). This term, which emerged in the 19th century, has largely replaced an older term, “hermaphrodite.” In the 19th century, “intersex” was also applied to persons who sexually desired others of the same sex-gender (Epstein, 1990; Hekma, 1994). As with transgender persons, intersex persons may or may not be lesbian, gay, or bisexual.

Transgender. The medical establishment also imposed clinical terms on transgender persons that implied pathology such as “transvestite” and “transsexual” or “sexual dysphoria” (Denny, 1999). In 1966, The Transsexual Phenomenon by New York endocrinologist Harry Benjamin popularized the term “transsexual,” although this term has largely been rejected by transgender persons. The use of “transgender” began in the 1990s (coming into widespread use in 1994) as a new way to think about sex–gender. This term fits almost anyone who resists gender stereotypes or who transgresses sex–gender norms through sexual orientation—gay, lesbian, and bisexual persons—and sex–gender—women who are not stereotypically “feminine” or men who are not stereotypically “masculine” (Denny, 1999).

Terms for Racial and Ethnic LGBT Persons

Racial and ethnic LGBT persons contend not only with the terms that signify sexual identity or sex–gender expression but also their racial and ethnic groups. Most of the research findings on LGBT persons in racial and ethnic groups include those who are African Americans, Asian Americans, Latinos, and Native Americans. In this book, the ethnic and racial terms generally used are those recommended by the APA Publication Manual (2001). These include black or African American, Latino, Asian American, and Native or Native American. Yet, racial and ethnic persons may prefer other terms based on differences in region, age, culture, and philosophies. Examples include Latina/Latino, Chicana/Chicano, Mexican American, or person of color (Martinez, 1998).

Minority cultures may or may not use the same terms as the white gay and lesbian communities. Many Latino men in same-sex relationships, for example, do not identify as gay but as homosexual. No term fits the diversity of motivations, behaviors, and identities of Latino men (Gonza’lez & Espin, 1996), so Manalansan (1996) suggested using the phrase “men who have sex with men.” Many Native American persons identify powerfully with the labels of lesbian, gay, bisexual, transgender, or queer—depending on their social–economic, regional, generational locations, or on their political attitudes (Tofoya, 1996). Other Native American persons, though, find these categories too confining. They may prefer instead one of several “sex–gender styles” that exist among Native Americans: women, men, not-men (biological women who perform some male roles), not-women (biological men who perform some female roles), lesbian, and gay. Not-men and not-women may seem bisexual because they experience sexual attractions to both men and women (Brown, 1997). In addition, the term “two spirit” is used among some Native Americans because it represents more of a spiritual–social identity or an integration of alternative sexuality, alternative sex–gender, and Native American spirituality (Tofoya, 1996, 1997).

Emerging Terms

The terms gay, lesbian, bisexual, and transgender are currently the standard terms in use, but terms used by community members rise and fall in popularity (Champagne, 1993) and vary in different social and political situations (Rust, 1996b). Along with queer politics and queer activism, the term “queer” recently reemerged as a label within some LGBT communities. Yet, it is a controversial term because of politically radical associations (for example, “Queer Nation”), past use as a taunt by heterosexuals (Jeffreys, 1994), and particularly derogatory definitions such as something unusual, abnormal, worthless, or counterfeit (Bryant & Demian, 1998). Queer is also a generic word applied to both males and females and, as argued by Jeffreys (1994), generic words typically only refer to men.

Terms also develop and change with socially available sexual identities. Today among bisexual women the most common identities not only include bisexual and queer but “lesbian-identified bisexual” and “bisexual lesbian” or “bi dyke” and “byke.” Some bisexual women include the term lesbian in their current identification because of a previous lesbian identification or a political commitment to women or to the lesbian community (Rust, 1995). Some women identify as bisexual lesbians because of sexual involvements with women and identification as lesbians, but this does not exclude the possibility that they might also experience sexual desire for men. Other women identify as “transient lesbians” because although at some point they identified as lesbians and sexually involved themselves with women, they subsequently became sexually involved with men (Golden, 1996). “Gay bisexual” is a recent identification among men. Other identifications among both men and women include “bisensual” (indicating a sensuality that expresses human connecting more accurately than genital sex does), “polysexual” or “polyamorous” (indicating separation of sexuality from sex–gender and sexual dichotomies), and “polyfideltious” (indicating fidelity to a group of three or more persons) (Rust, 1996a).

The transgender movement continues to define itself beyond the existing terminology (Maurer, 1999). Many transgender persons are creating words or terms to describe their own experiences including two spirit (from Native American traditions), “genderblend,” “androgyne,” “drag king,” and “drag queen” (Cole, Denny, Eyler, & Samons, 2000; Maurer, 1999).

We must be sensitive to what persons want to be called. The terms used among transgender persons and persons attracted to the same sex, including terms used among racial and ethnic persons with same-sex attractions, vary and change. Language sensitivity also applies to intersex persons although little discussion of their preferred terms appears in the literature.

Another important perspective on terminology is the use of nonbiased terms that do not perpetuate old stereotypes (Bernstein, 1992). The Committee on Lesbian and Gay Concerns of the APA identified acceptable terminology in 1991, and some of these terms are now in the APA Publication Manual (2001) such as “lesbian and gay” instead of “homosexual.” The terms “homosexual(s)” or “homosexuality” sometimes appear in this text but usually only in the context of historical discussions and past research. They appear with quotation marks to indicate that these terms are not currently acceptable unless, as observed earlier, persons prefer them. Quotation marks are also used with the term “transsexual” to indicate its decreased acceptance in the transgender community. The terms “preoperative,” “postoperative,” and “nonoperative” are also used because they make sexual reconstruction surgery (SRS) the primary event in the lives of transgender persons, overshadowing everything else (Denny, 1997).

Additional Clarifications about Terminology

Several other terms in this book also require clarification. The terms “link” or “linkup” are sometimes used for relationship. The terms “coming out” and “disclosure” represent different processes. Coming out refers to the internal process of same-sex identity development in this book, whereas disclosure refers to the declaration of one’s identity to others (Strommen, 1989). More recently, Savin-Williams and Diamond (1999) used “sexual questioning” instead of coming out. A concept recommended by Longres (2000), “subordinated group(s),” is used as a replacement for “minority group(s).” The terms “problem” and “problems” are often replaced with the terms “difficulty” or “difficulties” to indicate that problem-oriented terminology is less acceptable now because of more emphasis on the strengths of persons. Also the terms “therapy” and “therapist (s)” are rarely used because they signify a narrow approach to what clients may require. The terms “practitioner (s)” and “practice” are more often used.

Uses of the terms “gender” and “sex” also require clarification because sometimes these terms appear as if they are the same. In its standard usage, sex distinguishes males and females mostly by biological characteristics (Rutter & Schwartz, 2000). Biological aspects such as genitalia, chromosomes, reproductive organs, gametes, and hormones assign a person to the distinct categories of male or female. Gender is what society expects people to be, based solely on sex (Maurer, 1999), including roles, characteristics, and stereotypes (E. Stein, 1999). But, gender can be imposed (feminine–masculine) on experiences that may have no relation to the sex (male–female) of a person (Bohan & Russell, 1999b; McKenna & Kessler, 2000).

Many of the biological factors used to classify persons as male or female do not divide persons into two distinct groups (Coombs, 1998). Persons raise this issue because they are born with different combinations of genitals, chromosomes, and secondary sex characteristics (for example, body hair, breasts) not classifiable as male or female (E. Stein, 1999). The sex–gender assignment for others may come into question later, such as an XY (chromosomal) baby who has external female genitals but will never fully develop internal female sexual organs (Maurer, 1999). Some cultures recognize more than two sexes (for example, Blackwood, 1984).

Because our current views about what biological features distinguish males from females might be inaccurate and controversial, E. Stein (1999) used the term sex–gender to encompass the standard usage of both sex and gender. Sex–gender includes all the characteristics (for example, biological, psychological, cultural) that distinguish males–men from females–women. In this text, we also use the term sex–gender to indicate the complex and unsettled issues surrounding sex and gender. Sometimes the terms masculine and feminine and “butch” and “femme” are used, indicating that these terms are often unclear because what differentiates a male from a female is unclear.

What Readers Can Expect

This book will lead the teacher, student, and practitioner through many contexts of the lives of LGBT persons, including the oppressive responses of the heterosexual world and the psychological and social development of primarily lesbian and gay persons across the life course. We also identify various practice issues related to the topics we address. The initials LGB or LGBT are often used in this book but, as noted earlier, being transgender does not imply a connection with any particular sexual orientation (Lee, 1998). These initials also do not imply that material on these all of these groups of persons is available in any equivalent way. Far more material is currently available on lesbian and gay persons.

Part 1 addresses the development of communities among LGBT persons (Chapter 1), and then discusses cultural, social, political, and legal issues and advances (Chapter 2). Finally, sexual orientation, sexual identities, and evolving identifications are examined (Chapter 3). In Part 2 of the book, we present a knowledge base on individuals, with a focus on coming out and disclosure across the life course (Chapters 4 and 5), couples (Chapter 6), and families and children (Chapter 7). In Part 3 of the book, the history of practice with LGBT persons, contrasting the former, highly oppressive “conversionist” practice with the newer affirmative practice, is reviewed (Chapter 8). The requirements of affirmative practitioners and social agencies are then addressed (Chapter 9). Some ideas for practice with individuals, couples, and families, and institutions and communities are presented in Part 4 (Chapters 10, 11, and 12). Part 5 focuses on knowledge and interventions with LGBT persons in special groups including adolescence, middle age, and old age (Chapters 13 and 14). The epilogue looks at research issues. The Appendix is a more general review of the values and principles of practice and pointers on assessment, intervention goals, and various practice approaches.

Because of space limitations, some topics in this book are not addressed as fully as others or not at all. Examples of topics not addressed include physical violence in some LGBT couples and alcoholism. Although there are discussions of HIV/AIDS in almost every chapter, they are not extensive except in the chapter on youth. Numerous materials on HIV/AIDS are available elsewhere.

The reader can also expect a positive or affirmative approach to the lives of LGBT persons. After the major modification made by the American Psychiatric Association in 1973, approaches to treatment of lesbian and gay persons changed from approaches focused solely on changing sexual orientation to those that focused on helping these clients to accept and value their sexual identities. These new approaches become known as affirmative (see Chapters 8 and 9).

The book is intended for use by both undergraduate and graduate students. It can serve as a required main text in courses on oppressed populations and as a supplemental text for many courses that prepare students to practice in applied human services fields (for example, social work, counseling, mental health, nursing, psychology, sociology, and education). In social work, where content on LGBT persons is required, the book can be used in several of the core courses: human behavior, direct practice, and oppressed populations.

Practicing professionals, such as social workers, clinical psychologists, policy planners, and human resource providers in the human services, can also use the book. It can be used for in-service training and workshops—also, it should be of interest to LGBT populations and to the organizations and agencies, both public and private, servicing these populations.

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