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Promoting Inclusivity in Mental Health: LGBTQIA+ Affirmative Approach in Therapy Setting

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LGBTQIA+ individuals still face significant inequalities in various areas around the world today. One area where these inequalities are evident is mental health (American Psychological Association, 2021). Lesbian, gay, bisexual, transgender, queer, and other individuals with non-heteronormative orientations and gender identities are exposed to various stress factors that can significantly affect their mental health (THealth, 2024). According to Meyer (2003) and Hatzenbuehler (2009), the higher rates of mental health issues among LGBTQIA+ individuals are not due to their sexual orientation or gender identity but rather to the exclusionary social conditions, discrimination, stigmatization, and minority stress they experience. For this very reason, developing affirmative approaches in mental health services that seek to understand and support the unique experiences of LGBTQIA+ individuals is both an ethical and scientific imperative.

The LGBTQIA+ affirmative therapy approach validates clients’ experiences related to gender identity and sexual orientation as valid, valuable, and normative. It also views LGBTQIA+ identities not as a ‘’problem’’ or ‘’condition to be treated’’ but as a healthy and natural variant of human experience (Craig et al., 2015; Pachankis & Goldfriend, 2004). For these reasons, affirmative therapy considers interventions aimed at changing an individual’s identity to be unethical (APA, 2021) and supports clients in freely exploring their identities, coming to terms with their identities, and coping with exclusionary experiences they encounter in social contexts (Bieschke et al., 2007). The LGBTQIA+ affirmative therapy approach is considered a comprehensive clinical approach that goes beyond merely demonstrating a positive and supportive attitude, incorporating scientific knowledge, cultural competence, and structural awareness. 

In the current therapy sketch, the theoretical foundations of the LGBTQIA+ affirmative therapy approach will be defined, therapeutic practices related to gender identity will be evaluated within the scope of scientific findings, and a comprehensive overview of the importance of the LGBTQIA+ affirmative therapy approach will be presented.

What is the LGBTQIA+ Spectrum?

To begin with a definition, emotional and sexual minority clients are a broad umbrella term for individuals who identify as LGBTQIA+ (Ellis & Cook, 2019). This umbrella term can be thought of as having two subcategories: 1. Gender Identity, and 2. Sexual Orientation.

Gender identity refers to how an individual feels about or defines their gender. A person’s gender may align with the gender assigned at birth, and a person assigned female at birth who identifies as female is considered cisgender; or a person whose gender identity does not align with the gender assigned at birth may be identified as trans, non-binary, or more generally as ‘’queer.’’ The concept of sexual orientation is divided into two categories: an individual’s emotional or sexual orientation toward others. Emotional attraction refers to the people with whom we form mental and emotional bonds, while sexual attraction refers to the people we find physically attractive. However, it is important to note that sexual orientation is not always linked to sexual behavior. For example, an individual may identify as a heterosexual man who is attracted to women, but may also have sexual experiences with men. This is precisely what the concept of ‘’identity’’ means. It is not based on an individual’s actions, behaviors, or categories determined by others; it is solely based on how the individual identifies themselves (Ellis & Cook, 2019).

In this context, some important terms are explained below:

  • Gay: People who identify as male and are attracted to other people who identify as male.
  • Lesbian: People who identify as female and are attracted to other people who identify as female. Trans women may also identify as lesbian. Identity statements are related to an individual’s self-definition (GLAAD, 2024).
  • Bisexual: Individuals who are attracted to both men and women. The term ‘’bi+’’ can also include pansexual and queer individuals (GLSEN, 2023).
  • Transgender: Refers to a situation where an individual’s self-identified gender identity does not match the gender assigned to them at birth. 
  • Queer/Questioning: Queer is an inclusive identity for individuals who reject traditional gender and sexuality norms and define themselves as not fitting into fixed categories. Questioning is used to describe individuals who are still in the process of discovering their sexual orientation or gender identity.
  • Intersex: Individuals who are born with a gender that does not fully fit into typical ‘’male’’ or ‘’female’’ categories in terms of chromosomes, hormones, or anatomy. Being intersex is not a gender identity; it is a biological diversity (UN Free & Equal, 2015).
  • Asexual: Refers to individuals who do not feel sexual attraction to others but may feel emotional attraction (Ellis & Cook, 2019).
  • + (Plus): Includes other identities not represented by the letters LGBTQIA+ (pansexual, non-binary, etc.).

Accurately understanding the identities of LGBTQIA+ individuals and the concepts related to these identities forms the cornerstone of an ethically and culturally competent therapeutic process. Another dimension of providing appropriate therapeutic support involves recognizing and being aware of the inequalities, difficulties, and exclusionary experiences that LGBTQIA+ individuals encounter in a social context. The following section will address the various challenges that LGBTQIA+ individuals face in their daily lives.

What are the Challenges Faced by LGBTQIA+ Clients?

As is well known, LGBTQIA+ individuals face structural challenges not only when expressing their identities but also in accessing social systems, family structures, education, and healthcare services. Below are some of the significant challenges faced by LGBTQIA+ clients:

Discrimination and Stigma: LGBTQIA+ individuals often face discrimination, stigma, and prejudice in many areas of life. This discrimination can manifest as overt harassment or exclusion and covert forms of prejudice (e.g., microaggressions) and can lead to feelings of isolation or rejection (Meyer, 2003; Nadal, 2011). 

Identity Acceptance: Confronting one’s sexual orientation or gender identity can be a complex and emotionally exhausting process. Internalized homophobia, transphobia, and social pressure can lead to significant psychological distress, such as anxiety, depression, and low self-esteem (Szymanski, 2009; Newcomb and Mustanski, 2010). 

Minority Stress: This concept refers to the chronic stress experienced by individuals in stigmatized minority groups. For LGBTQIA+ individuals, minority stress encompasses coping with societal expectations, hiding their true identities, and navigating a world that is often unwelcoming or unsafe. This chronic stress significantly negatively impacts mental health (TavaHealth, 2024; Meyer, 2015).

Social Rejection and Family Dynamics: Support from their families is of great importance for the mental well-being of LGBTQIA+ individuals. However, it is common for many LGBTQIA+ individuals to be rejected by their families because of their sexual orientation or gender identity. The absence of family support has been associated with low self-esteem and increased mental health issues (TavaHealth, 2024; Ryan et. al., 2010).

Lack of Inclusive Healthcare: Access to affirming and knowledgeable healthcare services is a major barrier for many LGBTQIA+ individuals. The scarcity of LGBTQIA+ knowledgeable service providers leads to inadequate care and overt discrimination. This situation can result in individuals missing out on healthcare services, avoiding medical care, and worsening both mental and physical health issues (TavaHealth, 2024).

What is the LGBTQIA+ Affirmative Approach?

The LGBTQIA+ affirmative approach is a clinical orientation that views various sexual orientations and gender identities not as problems or disorders, but as natural and healthy variations of human experience (Bieschke et. al., 2007). Drescher (2015) notes that this approach emerged in direct opposition to historical perspectives that pathologized LGBTQIA+ individuals, such as the classification of homosexuality as a mental illness in the DSM until 1973. At its core, the LGBTQIA+ affirmative approach is based on the belief that LGBTQIA+ individuals are not ‘’dysfunctional’’ or ‘’confused,’’ but rather possess valid, meaningful, and worthy identities (APA, 2021). The approach involves intentional, culturally competent, and identity-affirming clinical work that resists assumptions based on cisnormativity and heteronormativity (Singh and Dickey, 2017).

The basic principles of the LGBTQIA+ affirmative approach are as follows:

Respecting Self-Identified Gender and Sexual Identities: Affirmative therapists prioritize the client’s understanding and expression of their identity, avoiding labeling, pathologizing, or imposing normative expectations (Israel et al., 2008). This includes respecting the use of chosen names and pronouns, and acknowledging the fluidity and range of identity. 

Challenging Internalized Stigma and Minority Stress: Many LGBTQIA+ individuals may internalize societal messages of shame, inferiority, or deviance. The affirmative approach aims to help clients dismantle these internalized messages and understand their distress within a sociocultural context (Meyer, 2003; Pachankis & Goldfried, 2004).

Promoting Resilience and Identity Integration: The LGBTQIA+ affirmative approach encourages adaptive coping mechanisms while supporting both the client’s acceptance of themselves as they are and their ability to express themselves openly (Singh et al., 2011).

Addressing Systemic Barriers to Well-being: The affirmative approach acknowledges that mental health challenges often stem not from identity itself but from chronic exposure to discrimination, rejection by family and friends, barriers to accessing healthcare, and social exclusion (Craig et al., 2021).

Contrary to the ‘’neutral’’ stance often encouraged in general clinical ethics, the LGBTQIA+ affirmative approach requires a proactive and participatory therapeutic stance. Therapists who adopt an LGBTQIA+ affirmative approach should not merely avoid causing harm; they must actively challenge oppressive dynamics both within the therapeutic relationship and in the broader social systems that impact clients’ lives (Shelton and Delgado-Romero, 2011). This involves advocating for equal treatment in healthcare, schools, legal systems, and society at large (Mallory et al., 2016). Furthermore, affirmative therapists acknowledge the intersectionality of LGBTQIA+ identities; they understand how race, ethnicity, disability, immigration status, and other dimensions of identity intersect to create marginalization (Crenshaw, 1991; Moradi, 2019). This intersectional awareness among therapists is essential to avoid a one-size-fits-all approach and provide culturally sensitive care.

Understanding the basic principles of the LGBTQIA+ affirmative approach is essential; however, translating this theoretical knowledge into clinical practice requires purposefulness, cultural humility, and informed practice. The following section will examine how the LGBTQIA+ affirmative approach is implemented in a therapeutic setting and highlight ways in which therapists can create safe, validating, and empowering environments for LGBTQIA+ clients.

How is the LGBTQIA+ Affirmative Approach Applied in a Therapeutic Setting?

The implementation of an LGBTQIA+ affirmative approach goes beyond simply accepting identity; it requires a systematic, consistent, and values-based approach at every stage of the therapeutic process. Therapists should integrate affirmative principles into their attitudes, communication, assessment methods, interventions, and ethical decision-making processes; they should ensure safety, participation, and psychological empowerment for clients (Craig et al., 2015).

Assessment Practices within the LGBTQIA+ Affirmative Framework: In an LGBTQIA+ affirmative approach, assessment involves more components than standard diagnostic assessment. Clients are assessed using a culturally competent approach and a narrative-based method, taking into account all aspects of the client’s unique history. Assessment may include understanding the client’s experiences of discrimination, trauma, and othering; identity development and emergence processes; and internalized homophobia, transphobia, etc. (Newcomb & Mustanski, 2010).

Treatment Planning and Goals: The affirmative approach focuses on affirming and supporting the client’s identity rather than changing it. The goals of the approach may include:

  • Facilitating the client’s exploration of their sexual and gender identity (Budge et al., 2013)
  • Promoting self-compassion and pride by eliminating internalized stigma (Moradi, 2019)
  • Addressing minority stress and trauma related to family rejection, religious condemnation, or institutional discrimination (Craig et al., 2021)
  • Developing collaborative safety planning for clients with suicidal thoughts (Haas et al., 2011)

While the common goals of an LGBTQIA+ affirmative approach are as outlined above, it is important to remember that each client’s identity is assessed within the context of their unique story, and that approach goals are determined based on the client’s specific needs.

Therapeutic Attitude and Communication: Creating a safe and inclusive therapeutic environment is essential for effectively supporting LGBTQIA+ clients. Clinicians should provide this environment by demonstrating an accepting attitude in both verbal and nonverbal communication. In this context, it is important to use inclusive language that respects clients’ identities and preferred pronouns. The implementation of positive communication strategies helps therapists promote openness and trust, while approaches tailored to various LGBTQIA+ identities ensure that each client’s unique experience is respected. Creating a safe and inclusive therapeutic environment begins with creating a space where LGBTQIA+ individuals feel free to express their identities. Therapists use an affirming language, display inclusive materials, and openly discuss issues related to sexual orientation and gender identity to help clients feel free.

  • Validating Client Experiences: Therapists’ strong efforts to understand the various challenges faced by LGBTQIA+ clients strengthen the therapeutic environment. By actively listening, showing empathy, and integrating cultural awareness into the process, therapists can build connections that validate clients’ experiences, empower them to share their stories, and increase their sense of belonging and acceptance.
  • Respecting Client Confidentiality: As with any approach, confidentiality is extremely important in the LGBTQIA+ affirmative approach. A consistent and genuine commitment to confidentiality is the foundation for building trust in the therapeutic relationship. Therapists prioritize open communication, ensuring that clients feel sufficiently safe to comfortably share their personal challenges, knowing that their identities and experiences will be respected and protected throughout the therapeutic process.
  • Client-Centered and Inclusive Support: Therapists are well-versed in the different identities within the LGBTQIA+ community and tailor their approaches accordingly. Recognizing the unique challenges faced by the client is the first step in an effective therapeutic process. Therapists customize therapeutic techniques to meet the client’s specific needs, encouraging validation and developing a sense of belonging that is vital for mental health support. On the other hand, therapists also focus on intersectionality, examining how different aspects of identity, such as race and gender, shape the client’s experience. This person-centered approach, tailored to the client’s needs, strengthens the therapeutic alliance and ensures that clients feel valued and understood on their journey toward self-acceptance.

Ethical Practice and Boundaries: The LGBTQIA+ affirmative approach, which is deeply committed to ethical practices, is based on non-discrimination, informed consent, cultural competence, and ongoing self-evaluation. The basic guidelines are as follows:

  • APA’s Ethical Principles of Psychologists and Code of Conduct (APA, 2017): APA’s ethical principles emphasize respect for human rights and dignity, particularly in the context of marginalized groups.
  • WPATH Standards of Care (Version 8): Informed consent models provide clinical guidance for working with transgender and gender-diverse individuals.
  • Continuous Education and Professional Development: Affirmative therapists engage in continuing education, undergo supervision processes, participate in peer consultation, and conduct self-evaluations to ensure that their practices are current, competent, and aligned with affirmative values (Bidell, 2012). Moradi and Grzanka (2017) explain this as follows: ‘’Ethical affirmative therapy is not static; it evolves as our understanding of gender, sexuality, and intersectionality deepens.’’

Takeaways:

  • Individuals’ identities are determined more by how they define themselves than by their behavior, which forms the basis for ethical and cultural competence in the therapeutic process.
  • LGBTQIA+ individuals face structural challenges such as discrimination, stigmatization, and social exclusion, which make it difficult for them to express their identities and access basic services.
  • The LGBTQIA+ affirmative approach accepts gender identities and sexual orientations not as pathologies but as natural and healthy variations of human experience and respects these identities.
  • The LGBTQIA+ affirmative approach requires an identity-affirming, culturally sensitive, and client-centered attitude throughout all stages of the therapeutic process; this attitude encompasses assessment, communication, intervention, and ethical decision-making.

References

  • American Psychological Association. (2021). Guidelines for Psychological Practice with Sexual Orientation and Gender Diverse People (2nd ed.).
  • Supporting LGBTQ+ clients: A guide for therapists. (2024). https://www.tavahealth.com/resources/support-lgbtq-clients-therapists-guide 
  • Ellis, A. E., PhD, & Cook, J. M., PhD. (2024, September 25). Five Things Therapists Can Do When Working with LGBTQ+ Individuals – Society for the Advancement of. Society for the Advancement of Psychotherapy. https://societyforpsychotherapy.org/five-things-therapists-can-do-when-working-with-lgbtq-individuals/ 
  • Admin. (2025, March 4). LGBTQIA+ Therapy Ethics: Essential Practices for Affirmation. Resilient Mind Counseling. https://resilientmindcounseling.com/lgbtqia-therapy-ethics-essential-practices-for-affirmation/ 
  • Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674‑697.
  • Hatzenbuehler, M. L. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychological Bulletin, 135(5), 707–730. https://doi.org/10.1037/a0016441 
  • Craig, S. L., Austin, A., & Alessi, E. J. (2015). Affirmative cognitive-behavioral therapy with LGBTQ+ youth: Evidence and future directions. Journal of Clinical Child & Adolescent Psychology, 44(5), 895–909. 10.1016/j.psc.2016.10.003 
  • Pachankis, J. E., & Goldfried, M. R. (2004). Clinical Issues in Working With Lesbian, Gay, and Bisexual Clients. Psychotherapy: Theory, Research, Practice, Training, 41(3), 227–246. https://doi.org/10.1037/0033-3204.41.3.227 
  • Bieschke, K. J., Perez, R. M., & DeBord, K. A. (Eds.). (2007). Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients (2nd ed.). American Psychological Association. https://doi.org/10.1037/11482-000 
  • GLAAD. (2024). GLAAD Media Reference Guide – LGBTQ Terms. https://www.glaad.org/reference 
  • GLSEN. (2023). Key LGBTQ+ Terms. https://www.glsen.org  
  • UN Free & Equal. (2015). Fact Sheet: Intersex. https://www.unfe.org 
  • Nadal, K. L., et al. (2011). Microaggressions toward lesbian, gay, bisexual, transgender, queer, and genderqueer people: A review of the literature. Journal of LGBT Issues in Counseling, 5(3-4), 234–258. https://doi.org/10.1080/15538605.2011.612968 
  • Szymanski, D. M., & Gupta, A. (2009). Examining the Relationship Between Multiple Internalized Oppressions and African American Lesbian, Gay, Bisexual, and Queer Persons’ Self-Esteem and Psychological Distress. Journal of Counseling Psychology, 56(1), 110–118. https://doi.org/10.1037/a0013317 
  • Newcomb, M. E., & Mustanski, B. (2010). Internalized homophobia and internalizing mental health problems: A meta-analytic review. Clinical Psychology Review, 30(8), 1019–1029. https://doi.org/10.1016/j.cpr.2010.07.003 
  • Ryan, C., Russell, S. T., Huebner, D., Diaz, R., & Sanchez, J. (2010). Family Acceptance in Adolescence and the Health of LGBT Young Adults. Journal of Child and Adolescent Psychiatric Nursing, 23(4), 205–213. https://doi.org/10.1111/j.1744-6171.2010.00246.x 
  • Meyer, I. H. (2015). Resilience in the Study of Minority Stress and Health of Sexual and Gender Minorities. Psychology of Sexual Orientation and Gender Diversity, 2(3), 209–213. https://doi.org/10.1037/sgd0000132 
  • Drescher, J. (2015). Out of DSM: Depathologizing homosexuality. Behavioral Sciences, 5(4), 565–575. https://pmc.ncbi.nlm.nih.gov/articles/PMC4695779/  
  • Singh, A. A., & dickey, l. m. (2017). Affirmative counseling with transgender and gender nonconforming clients. In K. A. DeBord, A. R. Fischer, K. J. Bieschke, & R. M. Perez (Eds.), Handbook of sexual orientation and gender diversity in counseling and psychotherapy (pp. 157–182). American Psychological Association. https://doi.org/10.1037/15959-007 
  • Israel, T., Gorcheva, R., Burnes, T. R., & Walther, W. A. (2008). Helpful and unhelpful therapy experiences of LGBT clients. Psychotherapy: Theory, Research, Practice, Training, 45(1), 102–110. https://pubmed.ncbi.nlm.nih.gov/18815981/ 
  • Singh, A. A., Hays, D. G., & Watson, L. S. (2011). Strength in the face of adversity: Resilience strategies of transgender individuals. Journal of Counseling & Development, 89(1), 20–27. https://doi.org/10.1002/j.1556-6678.2011.tb00057.x 
  • Craig, S. L., Eaton, A. D., McInroy, L. B., Leung, V. W. Y., & Krishnan, S. (2021). Can affirmative cognitive-behavioral therapy decrease minority stress for LGBTQ+ youth? A randomized controlled trial. Journal of Youth and Adolescence, 50(5), 870–880.
  • Shelton, K., & Delgado-Romero, E. A. (2011). Sexual orientation microaggressions: The experience of lesbian, gay, bisexual, and queer clients in psychotherapy. Journal of Counseling Psychology, 60(1), 34–43. https://pubmed.ncbi.nlm.nih.gov/21463031/ 
  • Mallory, C., Brown, T. N. T., & Sears, B. (2016). The Economic Impact of Stigma and Discrimination Against LGBT People in Georgia. The Williams Institute.
  • Budge SL, Adelson JL, Howard KA. Anxiety and depression in transgender individuals: the roles of transition status, loss, social support, and coping. J Consult Clin Psychol. 2013 Jun;81(3):545-57. doi: 10.1037/a0031774. Epub 2013 Feb 11. PMID: 23398495. 
  • Moradi, B. (2019). Discrimination, internalized stigma, and health. In C. M. Moradi & Y. J. Yeh (Eds.), Affirmative Counseling with LGBTQI+ People (pp. 103–124). American Counseling Association.
  • Haas, A. P., et al. (2011). Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations. Journal of Homosexuality, 58(1), 10–51. https://pubmed.ncbi.nlm.nih.gov/21213174/ 
  • American Psychological Association. (2017). Ethical Principles of Psychologists and Code of Conduct.
  • World Professional Association for Transgender Health. (2022). Standards of Care for the Health of Transgender and Gender Diverse People (Version 8). https://www.wpath.org/ 
  • Bidell, M. P. (2012). Examining school counseling students’ multicultural and sexual orientation competencies. Journal of Counseling & Development, 90(3), 305‑313.
  • Moradi, B., & Grzanka, P. R. (2017). Using intersectionality responsibly. The Counseling Psychologist, 45(3), 501–512. https://pubmed.ncbi.nlm.nih.gov/29048196/
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