By Maggie Baisley, Ph.D.
Oct. 5, 2022

West Virginia National Guard's Sgt. Kristin Vannatter and her wife, former U.S. Army Reserve Sgt. Lori Thompson, have a 17-year relationship as a LGBTQ+ couple while serving in uniform. Their experience serving during the "Don't Ask, Don't Tell" period between 1994 and 2011 prevented them from being open about their sexuality without the threat of discharge, but today they see the open recognition of LGBTQ+ Pride month in the military as a victory for inclusion, acceptance, trust, and a blow to discrimination. (West Virginia National Guard Photo by Edwin Wriston)

This year marked the 34^th anniversary of LGBTQIA+ National Coming Out Day, which was celebrated on Oct. 11, 2022. In honor of this occasion, I write this blog as a queer person and with the privilege of being "out" in a space of relative personal, professional, and social safety.

While stationed with my partner in North Carolina, we flew a Pride Flag outside of our house. Soon after raising the flag, local teenagers yelled a homophobic slur outside. I attempted to assess whether this behavior was normal on the town social media page. Most members were supportive, while others asked, "Did you really have to fly a Pride Flag? I don't fly a straight pride flag." This response further conveys a message: maybe it's okay to be queer, if you do it privately; if you're not private about your identity, you've really invited this type of aggression yourself.

Historical attempts and policies to criminalize and then medicalize queerness may have served to fuel discriminatory beliefs among our broader communities and can make being out and queer overwhelming for some. For example, until 1973, the Diagnostic and Statistical Manual (DSM) included "homosexuality" as a mental illness.¹ Until 2011, military members who came out could be, and were often, discharged because of their sexual orientation. Until 2019, military members who committed "sodomy" could be court-martialed and even imprisoned according to the Uniformed Code of Military Justice.² Until 2021, service members discharged under Don't Ask, Don't Tell could not access full VA benefits due to the characterization of their discharge. Even now, our transgender community members experience continued public scrutiny regarding their ability to serve. This public scrutiny over transgender service members has many parallels to the public debate over whether "homosexuals" could serve that led to the compromise of the Don't Ask, Don't Tell policy. Against this historical and political backdrop, being out publicly and proudly is a meaningful act, and yet not being out can be an important survival strategy.

What does it mean to "come out"?

"Coming out" refers to expressing one's sexual orientation or gender identity openly (e.g., Human Performance Resources CHAMP, 2019). A related term is "passing" which refers to appearing to have a privileged identity³– for example, a transwoman might appear gender conforming and therefore have to verbally disclose or "come out" if she wants to share her trans identity. "Coming out" means something different for each individual person, but general involves disclosing a marginalized identity under potentially uncertain or even hostile circumstances. "Coming out" also can lead to different types of consequences, especially for individuals with multiple marginalized identities.⁴ National Coming Out Day is about respecting and celebrating our entire queer community, especially those members who are unsure or not ready to come out. "Coming out" is often a lifelong and repetitive process that ranges from pronouncements to simple corrections (e.g., "no, not my husband."). Many medical settings assume a gender binary (i.e., people are either male or female) and assume heteronormative relationships (e.g., people have a different gender husband or wife, if partnered). These assumptions can complicate the experience of coming out because queer patients must decide to be misidentified or correct the assumption. When medical settings remove these assumptions, then it equalizes the experience for all patients.

What does LGBTQIA+ affirming mean?

Affirmation means validation and advocacy for the needs of sexual⁵ and gender marginalized clients⁶ and requires an active engagement beyond tolerance on the part of the clinician. I personally experienced many instances of non-affirming or even hostile health care interactions, which reflected harmful and inaccurate underlying beliefs about sexuality expressed towards me. For example, when I was sorting out my own sexual and gender identity in my early 20s, I decided to see a therapist. I was met with lots of reassurances that I was "straight". These reassurances often come from a presumption that being "straight" is the preference. A few years later, in my psychology training, I overheard a military provider conceptualizing a patient as becoming a lesbian due to sexual assault, a comment that represented a presumption that a lesbian sexual orientation is trauma-induced or simply a result of negative experiences, rather than a pattern of sexual and romantic attraction.

During a search for a therapist near our family's next duty station, I asked the potential new therapist, "Are you LGBTQ affirming?" and she said, "Oh yes, I'm fine with it." For me, the subtextual answer, then, was "no". This therapist appeared to mistake affirmation with tolerance and may have thought her general acceptance was enough. Therapists who want to be affirming must engage in effortful dialogue and research to unlearn what may seem to once have been "common sense" concepts about sexuality and gender. Thankfully, there are many pathways to have these dialogues and helpful online resources. Affirming therapists understand that providing quality therapy for all individuals requires active effort and the ability to identify these harmful and inaccurate presumptions.

How do affirming providers practice in general?

For heterosexual and cisgender providers, one study suggests that an open and empathic approach is more important than having a similar identity to your client or patient⁷. Queer therapists must balance decisions related to "signaling" (comments that might implicitly reveal identity) versus outright disclosure of identity depending on the patient and the relationship. Affirming-therapist reflective practices will include consideration and understanding of.^4,5

• Basic differences between sexual orientation and gender identity
• Heterosexism and its negative impact on therapy
• Intersectionality⁸ and the complex ways multiple forms of marginalization affect mental health (e.g., the ways queer individuals of color might have different experiences than white individuals); please continue to check our website for an upcoming provider's guide to intersectionality clinical support tool
• The uniqueness of each person's story and diversity within the LGBTQIA+ community
• Positional power as a provider and obligations that creates to advocate for marginalized individuals within a health care system

Some helpful specific actions in the clinic might include:

• Take the time to learn past and current civil rights issues that LGBTQIA+ individuals face
• Thoughtfully create an inclusive environment of care, including having materials in the waiting room that include LGBTQ materials
• Encourage clinic leadership to update all paperwork that removes heteronormative assumptions (e.g., use of terms like "partner" rather than husband or wife)
• Engage colleagues who express discriminatory views and/or misgender patients in a dialogue

Some helpful clinical practices might include:

• Constructively address group members who express homophobic or transphobic ideas during group therapy
• Ask patient directly about pronouns and/or sexual identity in individual sessions
• Ensure you are educated about LGBTQIA+ cultures and do not rely too heavily on the person you're working with to give you a basic education
• Actively refer your LGBTQIA+ patient to LGBTQIA+-specific resources and community groups based on the individual's level of interest

What are practices to avoid?

The following behaviors are harmful practices to avoid, which are pulled from themes identified by a small sample of lesbian, gay, and queer clients⁹, with some additional considerations for trans and other gender expansive clients:

• Assuming that sexual orientation is the cause of all presenting issues
• Avoiding or minimizing sexual orientation
• Attempting to overidentify with the queer community (e.g., references to family members who are gay)
• Making stereotyped assumptions about LGBTQIA+ clients regarding masculinity/femininity
• Expressing heteronormative bias (e.g., therapist stating, "I am NOT gay")
• Assuming LGBTQIA+ individuals need psychotherapeutic treatment
• Encouraging any client to "re-discover" their masculinity or femininity or explaining gender exploration away as trauma or transient
• Blocking, obscuring, or slowing any client's gender transition efforts

When providers make an effort to understand LGBTQIA+ historical and current events, they can make a huge impact on the safety and quality of experience for queer patients. This impact is magnified when providers proactively translate their evolving understanding into advocating for systems-level and process change in their clinics. If you're reading this blog article now, you are already making this effort.

Resources:

• "'Coming out' in the Military" by the DOD's Human Performance Resources by CHAMP: https://www.hprc-online.org/social-fitness/couples-intimacy/coming-out-military
• "Do Ask, Do Tell: 5 Awkward Minutes to Better Patient Care" training by VHA: https://www.train.org/vha/course/1073854/
• Substance Abuse and Mental Health Services Administration (SAMHSA) training resources for work with the LGBT community: https://www.samhsa.gov/behavioral-health-equity/lgbt/curricula
• Annual VA/DOD Women's Mental Health Mini-Residency, which includes presentations on affirming care for gender marginalized service members: https://health.mil/Military-Health-Topics/Centers-of-Excellence/Psychological-Health-Center-of-Excellence/PHCoE-Clinician-Resources/Womens-Mental-Health/Womens-Mental-Health-Mini-Residency

References

1. Drescher, J. (2015). Out of DSM: Depathologizing homosexuality. Behavioral Sciences, 5(4), 565-575. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4695779/
2. Peterson, J. C. (2021). The Walking Dead: How the Criminal Regulation of Sodomy Survived Lawrence v. Texas. Texas (Feb. 11, 2021). https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3784093
3. Moriel, L. (2005). Passing and the performance of gender, race, and class acts: A theoretical framework. Women & Performance: A Journal of Feminist Theory, 15(1), 167-210. https://www.tandfonline.com/doi/abs/10.1080/07407700508571493?journalCode=rwap20&
4. McNamara, K. A., Lucas, C. L., Goldbach, J. T., Holloway, I. W., & Castro, C. A. (2021). You Don't Want to Be a Candidate for Punishment: a Qualitative Analysis of LGBT Service Member "Outness". Sexuality Research and Social Policy, 18, 144-159.
5. American Psychological Association (2021). Guidelines for psychological practice with lesbian, gay, and bisexual clients. Retrieved from, https://www.apa.org/pi/lgbt/resources/guidelines
6. American Psychological Association. (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70(9), 832-864.
7. Alessi, E. J., Dillon, F. R., & Kim, H. M.-S. (2015). Determinants of lesbian and gay affirmative practice among heterosexual therapists. Psychotherapy, 52(3), 298–307. https://doi.org/10.1037/a0038580
8. O'Reilly, H.N. (2020). Intersectionality and cultural competence: A quick introduction. Blogpost retrieved from, https://www.health.mil/Military-Health-Topics/Centers-of-Excellence/Psychological-Health-Center-of-Excellence/Clinicians-Corner-Blog/Intersectionality-and-Cultural-Competence-A-Quick-Introduction
9. Shelton, K., & Delgado-Romero, E. A. (2013). Sexual orientation microaggressions: The experience of lesbian, gay, bisexual, and queer clients in psychotherapy. https://psycnet.apa.org/record/2013-25652-006

Dr. Baisley is a contractor psychologist and scientific advisor in the Behavioral Health Clinical Management Team at Medical Affairs, Defense Health Agency. She served in the Army and has worked as a clinician in DOD and VA settings. She is an advocate for ensuring health care equity for historically marginalized communities and optimizing the health care system to provide proper care for all service members.