the Gay and Lesbian Client: Treatment Issues and Conversion
L. Heffner, Psy.D.
written for Diversity Education at the Lakeview Center,
on AllPsych August 12, 2003
Before beginning any treatment with a homosexual
client, a therapist has the responsibility of making
sure he or she is well versed on issues related
to sexuality, has the skills necessary to create
a positive and nonjudgmental environment, and will
not feel uncomfortable discussing issues related
to homosexuality. If a therapist believes homosexuality
is wrong, sinful, immoral, or a mental illness,
he or she should NOT work with gay clients. Refer
this client to someone who is able to provide the
necessary components of a therapeutic relationship.
If a therapist believes that a person can change
his or her sexual orientation (often referred to
as conversion, reparative, or reorientation therapy),
it is only ethical to do adequate research on the
topic before beginning such treatment. Understand
that the American Psychiatric Association, The American
Psychological Association, The American Academy
of Pediatrics, and others have denounced this type
of treatment due to the high incidences of negative
outcomes and very low and even questionable success
rates. Also understand that while you can help a
client change his or her behavior, it is much more
difficult, if not impossible, to change who they
are. Think about convincing a straight male attracted
to blonds that he must now be attracted only to
red heads. He would likely respond, “but I like
blonds, I can’t change that, it’s a part of who
Understanding the Client
When working with gays and lesbians, it is often
important to know where your client is in terms
of acceptance. If sexuality is a presenting issue,
understanding the stages is even more important.
Cass (1979) lists six stages that many homosexuals
go through when dealing with their own sexual orientation.
These stages have been widely accepted by professionals
and gay men and women alike. They include:
(1) Identity Awareness. The point when the child
or adolescent begins to realize he or she has feelings
that are different from others and different from
what they have been taught.
(2) Identity Comparison. The individual begins to
explore his or her feelings alone and to compare
them to the beliefs of society, parents, and peers.
(3) Identity Tolerance. During this stage, the individual
will often rebel against his or her feelings and
attempt to deny them. After all, nobody wants to
be gay in a straight world.
(4) Identity Acceptance. After realizing that sexuality
is a part of who they are, they begin to embrace
it, explore their feelings and desires, and start
to find a place in the world where they are accepted
(5) Identity Pride. Often involves anger toward
parents, society, religion, or other aspects of
the world that tells them that they are bad, wrong,
immoral, or mentally ill merely because their feelings
are directed toward the same sex. They embrace the
‘homosexual lifestyle’ and explore their newfound
sexuality. It is during this stage that the gay
or lesbian may start fighting against what society
has taught them.
(6) Identity Synthesis. The final stage in which
homosexuality becomes a part of who they are rather
than the defining factor. Instead of being a gay
man or lesbian, they begin to see themselves as
parents, employees, leaders, teachers, supervisors,
coaches, and volunteers who just happen to be gay.
In the final stage, they are able to accept themselves
more wholly rather than seeing their sexuality as
separate from the rest of who they are.
When counseling a homosexual client, it is important
to understand where they are in terms of their sexuality.
Those attempting to convert to a ‘straight lifestyle’
are likely in stage two or three. They have not
yet accepted themselves as gay and have not likely
experienced friendship and love from others who
know their sexual orientation. While conversion
therapists have reported limited success, this success
is often in terms of behaviors and not thoughts
and feelings. In other words, a gay man may be able
to avoid sexual contact with other men, but they
still have feelings and thoughts related to being
gay. And, since sexuality is often present at the
onset of adolescence, research has shown that it
is not real amenable to change. (Individuals who
return to a straight life after changing their sexual
behavior due to a trauma such as rape were likely
not gay in the first place. They merely engaged
in homosexual behaviors.)
Those in stages four and five are likely trying
to reinvent themselves with this newfound acceptance.
They may be seeking out gay friends, engaging in
sexual behaviors less discriminately, or ‘shouting
it from the mountain tops,’ so to speak. They have
accepted their sexuality but have not yet learned
to integrate this aspect of their life into their
sense of self. In treatment, the strength these
individuals feel should be embraced and treatment
should be focused on what they can do, not to make
the world accept them, but to show the world that
they are worthy of acceptance. In other words, gay
parades, demonstrations, email campaigns to congress,
are all worthy efforts, but so is living an honest
life, helping other people, sharing, loving, and
being a friend.
Individuals in stage six are often seen as no different
from most clients we see in therapy. They have accepted
their sexuality, have developed relationships, and
don’t see ‘gay’ as the issue, but rather as one
of the many issues they deal with in an imperfect
world. Being gay is often seen in a positive light.
They can now begin to give back to others, become
a mentor, volunteer, run for office, or otherwise
use their whole self as a means to make the world
a better place.
Aside from issues arising from the first five stages
above, treatment for homosexual clients should be
no different than any other client. In terms of
mood disorders, anxiety disorders, relationship
concerns, stress, and sexual issues, homosexual
clients present at about the same rate as their
counterparts and treatment should not be any different.
Research has, however, shown that depression is
significantly higher among gay adolescents and that
the suicide rate is double their straight counterpart.
Suicidal ideation, depression, and anxiety are also
higher among those who have not accepted their sexuality
or who struggle for acceptance with friends and
family because of their sexual orientation.
Couples therapy should be treated no different than
marital therapy, aside from the obvious legal and
social issues. Any bias a therapist has will be
very difficult to hide when dealing with relationship
issues with a gay or lesbian client. Their relationships
should be treated with the same legitimacy as any
committed relationship, and the therapist should
be aware that like any sexual relationship, their
may be intimacy concerns, fidelity issues, children,
parents, and other issues that may be a part of
treatment. Be prepared for this and once again,
refer out if you are not able to accept and respect
Below are a few websites that offer suggestions
on counseling with gay and lesbian clients.
(Answers to your questions about sexual orientation
and homosexuality. -American Psychological Association)
(Lesbian, Gay, and Bisexual Issues: What you need
to know. -American Psychological Association)
(The truth about ex-gay conversion therapy. -King
County [Seattle] government web page)
Consider the following statements released by professional
organizations regarding gay to straight conversion
therapy. If it is attempted, please do so with open
eyes and with a solid understanding of the likely
consequences. (Retrieved from the King County government
website, June 7, 2003)
"Confusion about sexual orientation is not unusual
during adolescence. Therapy directed at specifically
changing sexual orientation is contraindicated,
since it can provoke guilt and anxiety while having
little or no potential for achieving changes in
- American Academy of Pediatrics
"For nearly three decades, it has been known that
homosexuality is not a mental illness. Medical and
mental health professionals also now know that sexual
orientation is not a choice and cannot be altered.
Groups who try to change the sexual orientation
of people through so-called conversion therapy are
misguided and run the risk of causing a great deal
of psychological harm to those they say they are
trying to help."
-American Psychological Association
"Clinical experience suggests that any person who
seeks conversion therapy may be doing so because
of social bias that has resulted in internalized
homophobia, and that gay men and lesbians who have
accepted their sexual orientation positively are
better adjusted than those who have not done so."
- American Psychiatric Association