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The American Journal of Family Therapy, 37:159–168, 2009
Copyright © Taylor & Francis Group, LLC
ISSN: 0192-6187 print / 1521-0383 online
DOI: 10.1080/01926180701441429
Marriage and Family Therapists’ Comfort Level
Working With Gay and Lesbian Individuals,
Couples, and Families
MARY S. GREEN, MEGAN J. MURPHY, and MARKIE BLUMER
Department of Human Development & Family Studies, Iowa State University, Ames, Iowa, USA
DEVON PALMANTEER
Non-Profit Agency, Hillsboro, Oregon, USA
As professionals, therapists should be prepared to work with a di-
verse population. The purpose of this study was to explore predictors
of American Association of Marriage and Family Therapy Clinical
Members’ comfort level in working with gay and lesbian individu-
als, couples, and families. Results indicated that therapists’ scores
on the Support for Lesbian and Gay Human Rights Scale predicted
their comfort level in working with gay and lesbian individuals,
couples, and families. The challenge for training programs is to as-
sist therapists-in-training and supervisors with self-exploration and
to increase opportunities for interactions with gays and lesbians.
As the number of diverse family forms continues to increase and as the
general population continues to increase their use of mental health services,
mental health providers will undoubtedly have more contact with cultur-
ally diverse families (Plummer, 1995). The number of lesbian and gay men
turning to therapy for help is increasing (Malley & McCann, 2002). This
is not surprising considering the inherent tensions and dilemmas gay and
lesbian persons face in the context of family relationships, as the internal
dynamics of the family vie with larger socio-political agendas (Malley &
Devon Palmanteer was previously a graduate student at Iowa State University. This study
was made possible by a Professional Advancement Grant through the Graduate College at
Iowa State University. This paper was previously presented at the National Council on Family
Relations 2005 Annual Conference in Phoenix, AZ.
Address correspondence to Mary Sue Green, Department of Human Development &
Family Studies, 4380 Palmer Bldg., Iowa State University, Ames, IA 50011-4380. E-mail:
greenm@iastate.edu
159
160 M. S. Green et al.
McCann, 2002). In fact, 72 percent of American Association of Marriage and
Family Therapy (AAMFT) Clinical Members indicate that approximately one-
tenth of their practice is with lesbian and gay clientele (Long & Serovich,
2003). Furthermore, roughly 80 percent of Marriage and Family Therapists
(MFTs) report working with gay and lesbian clients in practice (Bernstein,
2000). Despite this widespread practice, many mental health clinicians feel
under-trained in providing proper treatment for their increasingly diverse
client base. Doherty and Simmons (1996) reported that only about 54 per-
cent of MFTs felt competent in treating lesbians or gay men. Furthermore,
in a review of major family therapy journals from 1975–1995, Clark and
Serovich (1997) found that less than 1 percent of published articles focused
on lesbian, gay, or bisexual issues. Indeed there is concern over the ex-
tent to which therapists are equipped to meet the needs of lesbian and gay
families.
Family therapy has been slow to address gay and lesbian needs in prac-
tice, theory, and research. There has been a lack of awareness in working
with the lesbian and gay population as evidenced by the fact that there are
still few family therapy publications or papers on gay or lesbian sexuality
(Malley & McCann, 2002). Many therapists have failed to explicitly attend to
the social context of their gay and lesbian clients, which has lead to inad-
equate, homophobic, and potentially abusive practices (Malley & McCann,
2002). Currently, many practitioners and training institutions are challenging
the field to think outside of their comfortable and familiar heterosexist con-
structions of family life, thereby hoping to promote a more gay and lesbian
affirmative therapeutic stance (Malley & McCann, 2002).
In order to be effective in their work with gay and lesbian clients, MFTs
must continuously examine and challenge their beliefs and feelings and avoid
imposing them on their clientele (Bernstein, 2000). It is also recommended
that MFTs be sufficiently comfortable with lesbians and gays to be able to
engage in therapy warmly and supportively (Bernstein, 2000). There is one
common element in every training and therapy model—the “person” of the
therapist in a social relationship with the client (Aponte & Winter, 1987).
In therapy sessions, what the therapist ultimately utilizes is her expertise,
knowledge, and personal experiences, including her culture and value sys-
tem, in order to improve the quality of clients’ lives (Aponte & Winter, 1987).
Therapists have a responsibility and professional obligation to become aware
of their own culture (including beliefs, stereotypes, etc.) and how interven-
tions used with clients are impacted by their culturally based perceptions
(Plummer, 1995). This is particularly true of straight therapists working with
lesbian and gay clients, who must be willing to examine themselves and their
own privileged experiences as heterosexuals to be able to effectively work
with gay and lesbian clients (Bernstein, 2000). Self-awareness on the part of
the family therapist when working with lesbian and gay families is key, as
often times what is exhibited in the therapeutic setting is based on norms of
Marriage And Family Therapists’ Comfort 161
the dominant culture, which is predominately a culture of homophobia and
heterosexism (Malley & McCann, 2002).
The literature reveals some factors that may reflect greater or lesser lev-
els of comfort when working therapeutically with gay and lesbian individuals
and their families. Self-awareness can help foster greater comfort in work-
ing with gay and lesbian clients. Being capable of negotiating multicultural
worlds when working with diverse populations is key to increasing com-
fort when coming into contact and working with someone from a different
culture (Plummer, 1995). In other words, more exposure and knowledge of
people of various cultures leads to greater feelings of comfort. A therapist’s
own position and politics influences his/her clinical work and feelings of
comfort in working with lesbian and gay clients as well (Herek, 1999; Malley
& McCann, 2002). Sexual prejudice refers to negative attitudes based on sex-
ual orientation, which can lead to antigay behaviors, and can be rooted in
discomfort with one’s own sexual impulses or gender conformity and for
others it reflects the influence of current in-group norms (Herek, 1999). It
has been suggested that we need to not only be able to competently treat
gay and lesbian clients, but we need to actively work to change societal
beliefs about the gay and lesbian population (McCann, 2001).
The purpose of this study was to explore MFTs’ attitudes about sexual
orientation and their comfort level in working with gay and lesbian clients.
Bisexual and transgender issues are outside the scope of this research and
the study will focus only on lesbians and gays. This study is considered to be
descriptive and exploratory by design. Predictor variables will be explored
for their influence on the comfort level of MFTs in working with gay and
lesbian individuals, couples, and families. It is hypothesized that therapist
support for legal recognition of civil unions for same-sex couples, liberal
political orientation, number of sources from which a therapist learns about
gays and lesbians, and support for gay and lesbian human rights will be
related to a higher comfort level in working with gay and lesbian individuals,
couples, and families.
METHOD
Participants
Participants were 208 Clinical Members of the AAMFT. AAMFT Approved
Supervisors comprised 13.5 percent of the total Clinical Members. Seventy-
five participants were male and 127 were female (36 percent and 64 percent,
respectively). The majority of participants were between the ages of 45–64
years (73 percent) (M=53.78 years), with 16 percent being younger than
45 years and 11 percent being older than 64 years. In regard to educa-
tion, 55 percent of the participants had obtained master’s degrees and 45
percent held doctorate degrees. The majority of participants were currently
employed in private practice (58.2 percent). The remaining participants were
162 M. S. Green et al.
employed in community agencies (13.9 percent), academic positions (13.0
percent), hospitals (2.4 percent), or other (11.5 percent). The race of partici-
pants was predominantly White/European descent (92 percent). The majority
(70.4 percent) of participants indicated they were exclusively heterosexual,
5.5 percent indicated they were exclusively homosexual, and 24.1 percent
indicated they were between these two indices.
Measures
A 50-question online survey was utilized in this study. General demographic
information was gathered, as was information about work setting, sexual
orientation, theoretical orientation, comfort level with reparative/conversion
therapy, location of practice, religious preference, and religious practices.
Control variables were age, sex, and highest level of education completed;
predictor variables were political orientation, support for civil unions, a com-
posite score for where a participant learned about gay and lesbian persons
(Learn Total), and a composite score for the Support for Lesbian and Gay
Human Rights Scale (Summed Score on SLGHRS). The 25-question SLGHRS
was utilized to measure the participants’ level of support for gays and lesbians
(Ellis, Kitzinger, & Wilkinson, 2002). The overall reliability of the SLGHRS
was .94. Six questions addressed the participants’ comfort level regarding
working with gay and lesbian individuals, gay and lesbian couples, and gay
and lesbian families with children.
Procedure
Participants were Clinical Members of the AAMFT from nine states. The states
were randomly selected based on their inclusion in one of the nine regions
as designated by the U.S. Census Bureau. A total of 1,012 AAMFT Clinical
Members from Vermont, Pennsylvania, Illinois, Kansas, Florida, Alabama,
Arkansas, Utah, and California were sent e-mails. A total of 137 surveys were
completed for a 15.6 percent response rate. Two months later a second
round of emails was sent. An additional 80 surveys were completed for a
21 percent overall response rate, for a final sample of 208 AAMFT Clinical
Members.
Results
The majority of the sample described themselves as extremely or mostly lib-
eral (59.8 percent), whereas 12.8 percent described themselves as extremely
or mostly conservative (M=2.83). In addition, 73.5 percent strongly sup-
port legal recognition of civil unions (M=1.58). Only 7.2 percent reported
that they learned about gay and lesbian persons in one place, whereas
TABLE 1 Hierarchical Regressions for Comfort Level Working With Lesbian Individuals, Couples, and Families
Lesbian Lesbian Lesbin
Idividuals Couples Families
Variables BSEB βR2BSEB βR2BSEBβR2
Step 1 .16 .19 .19
Sex (0 =Male) –.76 .136 –.41∗∗∗ –.97 .17 –.42∗∗∗ –1.01 .18 –.42∗∗∗
Age .01 .007 .06 .02 .01 .13 .02 .01 .12
Education .20 .128 .11 .28 .16 .13 .26 .16 .12
Step 2 .27 .37 .35
Sex –.43 .121 –.23*** –.44 .13 –.19** –.44 .14 –.18**
Age .00 .006 .00 .01 .01 .07 .01 .01 .07
Education .11 .107 .06 .15 .12 .07 .11 .13 .05
Political .04 .052 .07 .03 .06 .04 .02 .06 .03
Orientation
(1 =mostly
liberal)
Support for –.29 .09 –.36∗∗∗ –.17 .09 –.04 .10 –.04 –.38
Civil Unions
(1 =strongly
agree)
Learn About .07 .04 .11 .04 .04 .05 .01 .05 .01
Total
SLGHRS Total .01 .01 .24∗.03 .01 .53∗∗∗ .04 .01 .63∗∗∗
∗p<.05; ∗∗ p<.01; ∗∗∗ p<.001.
163
164 M. S. Green et al.
approximately 78 percent reported that they learned about gays and lesbians
in 3 or more places. The majority (95.5 percent) reported that they learned
about gay and lesbian persons through clinical experience, yet less than 65
percent reported learning in graduate school and only 46 percent report
they learned through supervision during graduate training. Aside from clin-
ical experience, 89 percent learned about gay and lesbian persons through
personal experience from such sources as gay and lesbian friends, commu-
nity involvement, or professional articles. Mean scores for comfort level in
working with gay and lesbian individuals, couples, and families ranged from
5.18 (gay families) to 5.46 (lesbian individuals).
T-test analyses indicate that females in this sample were more politically
liberal (t=3.89, p<.001), more supportive of civil unions (t=4.15, p<
.001), more comfortable working with gay individuals (t=2.76, p<.01),
couples (t=3.34, p<.01), and families (t=3.29, p<.01), more comfort-
able working with lesbian individuals (t=4.91, p<.001) couples (t=5.04,
p<.001), and families (t=5.08, p<.001), and more supportive of gay and
lesbian human rights (t=4.08, p<.001) than males.
The overall relationship between the predictor variables and comfort
level working with lesbian individuals was significant (R2=.433, F =17.99,
p<.001). Significant predictor variables for comfort level working with
lesbian individuals were support for civil unions (β=.36, p<.001), sex of
the therapist (β=.23, p<.001), and support for gay and lesbian human
rights (β=.24, p<.05). The overall relationship between the predictor
variables and comfort level working with lesbian couples was significant
(R2=.56, F =30.02, p<.001). Significant predictors included support for
gay and lesbian human rights (β=.53, p<.001) and sex of the therapist
(β=.19, p<.01). The relationship between predictor variables and comfort
level working with lesbian families was significant (R2=.54, F =26.41, p<
.001). Support for gay and lesbian human rights was the most significant
predictor (β=.63, p<.001) followed by sex of the therapist (β=.18, p<
.01). See Table 1 for hierarchical regression models for comfort level working
with lesbian individuals, couples, and families.
The overall relationship between predictor variables and comfort level
working with gay individuals was significant (R2=.36, F =13.35, p<.001).
Support for gay and lesbian human rights (β=.35, p<.01), along with
support for civil unions (β=.32, p<.01), was a significant predictor of
comfort working with gay individuals. The overall relationship between pre-
dictor variables and comfort level working with gay couples was significant
(R2=.48, F =21.37, p<.001). Support for gay and lesbian human rights
was the most significant predictor of comfort (β=.60, p<.001). Educa-
tion was also shown to predict comfort level in working with gay couples
(β=.14, p<.05). This is the only client configuration in which educa-
tion was significant as a predictor. The overall relationship between pre-
dictor variables and comfort level working with gay families was significant
TABLE 2 Hierarchical Regressions for Comfort Level Working With Gay Individuals, Couples, and Families
Gay Gay Gay
Individuals Couples Families
Variables BSEBβR2BSEB βR2BSEB βR2
Step 1 .07 .13 .09
Sex (0 =Male) –.450 .142 –.243** –.702 .168 –.310*** –.693 .188 –.281***
Age .003 .007 .034 .013 .009 .107 .009 .010 .068
Education .274 .133 .159* .394 .158 .187* .242 .177 .105
Step 2 .29 .35 .37
Sex –.098 .127 –.053 –.218 .140 –.096 –.167 .156 –.068
Age –.003 .006 –.029 .007 .007 .057 .002 .008 .015
Education .197 .112 .114 .298 .124 .141* .124 .139 .054
Political .064 .054 .117 .050 .060 .074 .030 .068 .041
Orientation
(1 =mostly
liberal)
Support for –.249 .090 –.319** –.090 .099 –.094 –.047 .111 –.045
Civil Unions
(1 =strongly
agree)
Learn About .067 .040 .104 .027 .045 .034 .020 .051 .024
Total
SLGHRS Total .018 .007 .347** .038 .007 .603*** .044 .008 .639***
∗p<.05; ∗∗ p<.01; ∗∗∗ p<.001.
165
166 M. S. Green et al.
(R2=.46, F =19.45, p<.001). Unlike other client configurations, support
for gay and lesbian human rights was the only significant predictor of comfort
level working with gay families in therapy (β=.64, p<.001). See Table 2
for hierarchical regression models for comfort level working with gay male
individuals, couples, and families.
In addition to individual comfort scores, a total comfort score was cre-
ated by summing the six individual comfort scores. The overall relationship
between variables was significant (R2=.53, F =25.02, p<.001). Similar to
the individual comfort levels, support for gay and lesbian human rights was
a significant predictor of overall comfort level working with gay and lesbian
individuals, couples, and families (β=.56, p<.001). In addition, sex of
the therapist was a predictor of overall comfort level working with gay and
lesbian individuals, couples, and families (β=.12, p<.05).
DISCUSSION
In this sample of AAMFT Clinical Members, females were more likely to
report that they were politically liberal, supportive of civil unions, and sup-
portive of gay and lesbian human rights. This became clearer as sex was
shown to be a predictor of comfort level working with lesbian individuals,
couples, and families. However, sex did not play a role in predicting com-
fort level working with gay individuals, couples, and families. It may be that
there is a gender-difference in creating working alliances, with females be-
ing able to create a high quality working relationship with lesbians because
they are of the same gender. This provides support for previous reports that
professionals and people in general are less comfortable with the reality of
gay males than they are of lesbian females (Herek, 1999).
The majority of the participants in this study (73.5 percent) were sup-
portive of legal recognition of civil unions for gay and lesbian couples.
Support for civil unions was a predictor of comfort level in working with
gay and lesbian individuals; however, it was not a predictor of comfort level
working with gay or lesbian couples or families. It could be that therapists
may feel supportive of civil unions, but have not had the opportunity to work
with gay couples or gay and lesbian families. Additionally, support for gay
and lesbian human rights was a strong predictor of comfort level working
with all gay and lesbian client configurations. Finally, most therapists in our
sample expressed comfort working with gay and lesbian clients.
In this sample, over 95 percent of participants report that they learned
about gay and lesbian individuals through clinical experience. Only 65 per-
cent report learning about sexual orientation issues during graduate training
and 46 percent reported learning during clinical supervision. The lack of
therapists’ learning about gay/lesbian clients in graduate courses or in su-
pervision is cause for concern. However, it is important to note that the
Marriage And Family Therapists’ Comfort 167
average age of participants in our study was 55, with the majority of sub-
jects falling within a range of ages 45–64, meaning that contextually and
historically, it is not surprising that many participants did not receive formal
education on sexual minority issues during their graduate training. Much of
this kind of training has only been added in schooling in more recent years
and in some instances has yet to still be included in graduate training.
Therapists have a professional responsibility to be aware of the biases
and prejudices they bring to the therapy room. Therapists are not immune to
the dominant homophobic and heterosexist assumptions in our society (Long
& Serovich, 2003). Therefore, graduate training programs and clinical super-
vision could serve as an opportunity for self-exploration and self-awareness
in regard to a variety of diversity issues, including sexual orientation. It is pos-
sible that more training in regard to diversity would increase self-awareness,
which could increase comfort working with gay/lesbian clients. Indeed, more
training on special populations like sexual minorities would not only have
the potential to increase self-awareness, which may increase comfort levels
in working with this population, but may also help mental health clinicians
feel more prepared in working with sexual minority clients (Twist, Murphy,
Green, & Palmanteer, 2006).
Based on the results of our study, we suggest that therapists-in-training
primarily focus on increasing their support for gay/lesbian human rights.
In general, the sample for this study was fairly comfortable working with
gay and lesbian clients and the majority (89 percent) reported that they had
learned about gay and lesbian individuals through personal experience. This
personal experience may have increased their level of support for gay and
lesbian human rights. Becoming involved in organizations that are supportive
of gay and lesbian human rights can assist professionals in gaining more
personal and professional experience with sexual minorities and in turn may
increase support for gay and lesbian human rights. On the other hand, we
suggest that therapists who do not support gay/lesbian human rights refrain
from working with gay/lesbian clients. Additionally, if a therapist is unsure
of whether or not he/she supports gay and lesbian human rights, he/she
should be very careful working with sexual minority clients because of the
potential of engaging in unintentional antigay behaviors (Green & Twist,
2005).
This study aimed to explore predictors of AAMFT Clinical Member’s
comfort level in working with gay and lesbian populations. The findings
have significant professional and personal implications. Professionally, there
is the potential to influence MFT education, training, supervision, as well as
organizational practices and policies. Personally, an opportunity is created for
therapists and therapists-in-training to reflect on their biases regarding sexual
minority clients, including level of self-awareness, and encouragement of
participation, action, and interaction in gay and lesbian communities outside
of the therapeutic context.
168 M. S. Green et al.
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