The Complexities of Multicultural Competence with LGBT+ Populations: An Evaluation of Current Status and Future Directions

Abstract

This chapter explores existing challenges in describing how one achieves multicultural competence with lesbian, gay, bisexual, transgender (LGBT+), and related populations. What it means to be multiculturally competent with this population has not been precisely defined, is still evolving, and faces several unique challenges. Our intention is to discuss some of those concerns as well as point in a direction that may help the field identify sound aspirations. Three frameworks for understanding LGBT+ issues are presented (diversity, disability, and the sacred), as well as a call for greater humility about what is known and not known regarding LGBT+ issues at present. Recommendations are made for a more nuanced understanding of multicultural competence with LGBT+ and related populations in training and practice.

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Chapter Title The Complexities ofMulticultural Competence withLGBT+ Populations
Copyright Year 2018
Copyright Holder Springer International Publishing AG, part of Springer Nature
Corresponding Author Family Name Yarhouse
Particle
Given Name Mark A.
Sufx
Division
Organization/University Regent University
Address Virginia Beach, VA, USA
Email markyar@regent.edu
Author Family Name Sides
Particle
Given Name Justin
Sufx
Division
Organization/University Regent University
Address Virginia Beach, VA, USA
Email justsid@mail.regent.edu
Author Family Name Page
Particle
Given Name Cassandra
Sufx
Division
Organization/University Regent University
Address Virginia Beach, VA, USA
Email cpage@mail.regent.edu

Abstract This chapter explores existing challenges in describing how one achieves
multicultural competence with lesbian, gay, bisexual, transgender (LGBT+),
and related populations. What it means to be multiculturally competent with
this population has not been precisely dened, is still evolving, and faces
several unique challenges. Our intention is to discuss some of those concerns
as well as point in a direction that may help the eld identify sound aspirations.
Three frameworks for understanding LGBT+ issues are presented (diversity,
disability, and the sacred), as well as a call for greater humility about what is
known and not known regarding LGBT+ issues at present. Recommendations
are made for a more nuanced understanding of multicultural competence with
LGBT+ and related populations in training and practice.
Keywords (separated
by “ - ”)
Cultural competence - LGBT studies - LGBT competencies - Religion and
LGBT issues

575
© Springer International Publishing AG, part of Springer Nature 2018
C. L. Frisby, W. T. O’Donohue (eds.), Cultural Competence in Applied Psychology,
https://doi.org/10.1007/978-3-319-78997-2_23
The Complexities ofMulticultural
Competence withLGBT+
Populations
MarkA.Yarhouse, JustinSides,
andCassandraPage
This chapter focuses on some of the existing
challenges in describing how one achieves multi-
cultural competence with lesbian, gay, bisexual,
transgender (LGBT+), and related populations.
In other words, what it specically means to be
multiculturally competent with this population
has not been precisely dened. The denition of
this level of competence is still evolving and
faces several unique challenges. Our intention is
to discuss some of those concerns as well as point
in a direction that may help the eld identify
sound aspirations.
Multicultural competence has historically
emphasized work with racial and ethnic minori-
ties or persons of color. Many resources exist
today with recommendations for working com-
petently with African-Americans, American
Indians, Asian Americans, Alaska Natives,
Pacic Islanders, Hispanic Americans, Arab
Americans, and persons of multiracial descent,
among others (Sue & Sue, 2013). More recently,
multicultural competence has expanded to
include other populations, including those of
lower socioeconomic status, older adults, persons
with disabilities, persons of immigrant status,
and LGBT+ persons. Discussions of multicul-
tural competence often assume implicitly that the
person providing services belongs to a group that
is different from the client receiving services.
In the context of ethical and professional prac-
tice, a multicultural approach emphasizes under-
standing and appreciating ways in which clients’
unique differences (e.g., age, gender, gender
identity, race, ethnicity, culture, national origin,
religion, sexual orientation, disability, language,
and socioeconomic status) inform clinical con-
siderations, including case conceptualization,
treatment planning, and interpretation of results
from assessment data. The eld of psychology
has also witnessed a corresponding emphasis on
training to achieve multicultural competency for
practitioners; and, more recently, a shift for prac-
titioners to advocate for and participate in social
justice initiatives regarding all marginalized cli-
ents is not typically represented (Arfken & Yen,
2014; Wendt, Gone, & Nagata, 2015).
As many chapters in this handbook can attest,
there are several issues that arise when we turn to
the construct of multicultural competence even
when considering topics that have been under dis-
cussion for much longer than discussions on
LGBT+ concerns. There are numerous concep-
tual, scientic, and applied challenges. For exam-
ple, Sue (2013) recalls that in early stages of
attempting to develop multicultural competence,
well-meaning professors often taught modalities
to well-meaning students that either insults a per-
son’s dignity or mischaracterizes them in one way
or another. Cultural competence is not a construct
M. A. Yarhouse (*) · J. Sides · C. Page
Regent University, Virginia Beach, VA, USA
e-mail: markyar@regent.edu;
justsid@mail.regent.edu; cpage@mail.regent.edu
23
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with conceptual and practical consensus; nor is it
always explicitly grounded in psychological the-
ory or principles. There are various approaches
each discipline is encouraged to take; yet not one
dened pathway to follow toward teaching multi-
cultural competence effectively (Mallinckrodt,
Miles, & Levy, 2014).
As we survey the literature on multicultural
competence and cultural awareness as it pertains
to LGBT+ studies, we see several challenges.
The rst and most prominent challenge is actu-
ally a larger philosophical or worldview consid-
eration. We refer to the different worldviews as
frameworks through which people approach
LGBT+ concerns within psychology’s current
societal context.
Once consideration is given to these different
frameworks, a more nuanced discussion can be
had regarding several other challenges: identify-
ing the parameters of the culture, accuracy and
humility around dissimilarities from prototypical
topics of cultural competency, prejudice and bias
against conventional religious beliefs and values,
and measurement of multicultural competence
for clinical practice. We turn our attention rst to
three contrasting frameworks.
Contrasting Frameworks
In this section we introduce the reader to three
frameworks through which people in US society
view LGBT+ issues: the diversity framework, the
disability framework, and the sacred framework
(Yarhouse, 2015).
The Diversity Framework The rst framework
for discussing LGBT+ issues in the broader soci-
ety is a diversity framework that conceptualizes
“gay” (as an umbrella term) as an identity and
LGBT+ persons as part of an LGBT+ commu-
nity—a unique culture to be recognized, cele-
brated, and honored. This is by far the most
widely recognized framework in our culture
today. Mental health communities, such as the
American Psychological Association, have been
at the forefront of advancing this framework
often in sharp contrast to prior models that have
been informed by conventional religious
perspectives and deemed moral models in the lit-
erature. The reader will recall that homosexual-
ity was removed as a mental disorder from the
Diagnostic and Statistical Manual of Mental
Disorders that reected social trends and advo-
cacy within APA (Bayer, 1981). Indeed, a chap-
ter on cultural competence with LGBT+ persons
is possible as a result of this framework.
The sociocultural context in which we live in
the West has been rapidly moving toward the
direction of celebrating diversity in areas of sexu-
ality and gender identity. Thus, we refer to this as
a diversity framework because it highlights
LGBT+ issues as reecting an identity and a peo-
ple group to be celebrated as a culture. Guidelines
for practice that come from the major mental
health organizations reect this conceptualiza-
tion. Proponents of this framework frequently cite
historical examples in which gender variant
expressions, for example, have been documented
and held in higher esteem, such as the Fa’afane
of Samoan Polynesian culture and the Two-Spirit
people identied in some Native American tribes.1
In discussions of whether and to what extent
sexual identity and gender identity differences
constitute a people group and a culture, it may be
important to recognize that these are discussions
tied primarily to how people make meaning out
of same-sex sexuality and the variations in expe-
riences of gender identity. Put differently, this
meaning-making is at least to some degree
socially constructed and can function as a dis-
tinct narrative intended to inform a vision for
cultural competence worthy of further rening
and reection.
This narrative begins with a discussion of
what comprises a culture. The Ofce of Minority
Health (2013) denes culture as “…integrated
patterns of human behavior that include the lan-
guage, thoughts, communications, actions,
customs, beliefs, values, and institutions of racial,
1
Lynn Conway has a helpful summary that includes
historical and current global perspectives. See http://ai.
eecs.umich.edu/people/conway/TS/TG-TS%20World.
html#Hijra
M. A. Yarhouse et al.
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ethnic, religious, or social groups.” An alternative
denition is offered by Kagawa-Singer, Dressler,
George, and Elwood (2014):
Culture consists of dynamic and ecologically
based inter-related elements that function together
as a living, adapting system. To delineate culture
begins with a perspective that contextualizes
population groups within a multi-level, multi-
dimensional, biopsychosocial, ecological
framework and explicitly recognizes and incorpo-
rates the geographic, historical, social, and politi-
cal realities of diverse communities. All of these
elements constitute the cultural framework its
members use to ‘see’ the world and attribute mean-
ing to their daily lives. (p.12)
Difculties in dening culture have also been iden-
tied insofar as denitions include what is “trans-
mitted across generations.” As O'Donohue and
Benuto (2010) observed, such denitions may pre-
clude the LGBT+ community as a culture to meet
such denitions (p. 35). Baldwin, Faulkner, and
Hecht (2006) begin to identify some of the chal-
lenges associated with dening culture. They offer:
“The denition of culture is a moving target, and
those who choose to dene it should ground their
denitions in a fuller, multidisciplinary and histo-
ricized accounting of the word” (p.24).
For example, in many instances, those who
adhere to the diversity framework support the
deconstruction of norms related to sex and gen-
der. For example, the International Human Rights
Commission represents the diversity framework
in calling for the deconstruction of sex and gender
binaries:
We believe it is indispensable to deconstruct the
binary sex/gender system that shapes the Western
world so absolutely that in most cases it goes unno-
ticed. For ‘other sexualities to be possible’ it is
indispensable and urgent that we stop governing
ourselves by the absurd notion that only two pos-
sible body types exist, male and female, with only
two genders inextricably linked to them, man and
woman. We make trans and intersex issues our pri-
ority because their presence, activism and theoreti-
cal contributions show us the path to a new
paradigm that will allow as many bodies, sexualities
and identities to exist as those living in this world
might wish to have, with each one of them respected,
desired, celebrated. (International Gay and Lesbian
Human Rights Commission [IGLHRC], 2005,
pp.7–8)
Whereas the biological distinction between male
and female had been considered rather immuta-
ble, as we can see, there are those who wish to
recast sex as just as socially constructed as
gender.
This call for the deconstruction of sex/gender
binaries might be thought of as the strong form of
the diversity framework. We do think there is also
a weak form of the diversity framework that sim-
ply places emphasis on LGBT+ identity and
community without the corresponding emphasis
on deconstructing norms associated with sex and
gender (see Yarhouse, 2015).
For our purposes, we are going to focus in on
one facet of a denition of culture offered by
Carpenter-Song, Schwallie, and Longhofer
(2007). Citing Jenkins and Barrett (2004),
Carpenter-Song etal. dene culture in relation to
what is symbolically shared and what is created
by people in the context of their social
relationships.
As we have suggested, a larger critique of
these various denitions of culture may be war-
ranted (see [cite chapters in this volume]), but for
now we are simply exploring the idea that what is
shared and created as meaning guides and shapes
people’s thoughts, feelings, and way of experi-
encing the world (Carpenter-Song et al., 2007,
p.1362). This is what Yarhouse (2013) referred to
as a “gay script” and elsewhere as a transgender
script (Yarhouse, 2015). Thus, if a script reects
social expectations for behavior, relationships,
and identity, a gay script is a reection of con-
temporary meaning-making associated with
same-sex sexuality:
• Same-sex attractions reect categorical distinc-
tions between types of people (gay, lesbian,
bisexual, and heterosexual).
• Sexual attractions accurately signal who you
are as a person.
• Sexual attractions reside at the core of your
identity, your sense of self.
• Sexual behavior no longer resides in a cate-
gory of behavior that can be evaluated as right
or wrong in and of itself; rather, it is an expres-
sion of identity insofar as you express and
enjoy who you really are. (Yarhouse, 2013)
23 The Complexities ofMulticultural Competence withLGBT+ Populations
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A gay script also rests on at least two
assumptions:
• You are born gay, lesbian, or bisexual—it is
just a matter of discovering this about
yourself.
• Your attractions are a dening element of
identity in part because they are enduring or
immutable.
This script also leads to a sometimes critical
view of other conclusions people might draw
about one’s identity or behavior:
• If you experience same-sex attractions but do
not identify as gay, lesbian, or bisexual, you
are in denial or not yet ready to be honest with
yourself about who you really are as a person.
• If you experience same-sex attractions but
choose to abstain from sexual expression, you
are either in denial or not yet ready to be hon-
est with yourself about who you really are as a
person. (Yarhouse, 2013, p.70)
Elsewhere, Yarhouse (2015) suggests there is
a comparable meaning-making script or cultural
expectation for meaning associated with being
transgender:
• Gender dysphoria reects a naturally occur-
ring difference among types of people (trans-
gender rather than cisgender).
• Your gender dysphoria as gender incongru-
ence suggests who you are (“who I am”) rather
than how you are (“how I am”).
• Gender dysphoria points to a community of
others who experience a similar phenomenon
(“I am part of the transgender community.”).
• Your gender incongruence points to some-
thing at the core of who you are, something
that is central to your identity (p.132).
We are not particularly critical of any of these
scripts or of the idea that there are commonly
shared ways in which different scripts have
informed meaning and purpose and signicance
in the lives of people navigating sexual and gen-
der identity questions. However, when discussing
cultural competence for a people group, it is
important to recognize the social construction
and assumptions associated with the develop-
ment and claim to a culture, as well as the poten-
tial intended and unintended consequences of
such developments, including any counter-
narrative of exclusion for those for whom the pre-
ferred narrative does not resonate.
For many proponents of the strong form of the
diversity framework, the sex/gender binary is one
more source of authority that needs to be decon-
structed in order to create room for the various
exceptions to the sex/gender binary (Butler,
1990). These exceptions reect a unique cul-
ture—a new vista for the range of ways in which
people experience their sexuality and gender.
Such claims challenge not only gender norms
that have been widely understood to be socially
constructed but also a sex binary as something
xed and stable, tied to an essentialist view with
biological foundations.
• Gay: a contemporary designation of
identity among biological males who
experience predominant or exclusive
same-sex sexual attraction.
• Lesbian: a contemporary designation of
identity among biological females who
experience predominant or exclusive
same-sex sexual attraction.
• Bisexual or bi: a contemporary designa-
tion of identity and sexual orientation
among biological males or females who
experience attraction to both the same
sex and to the opposite sex.
• Biological sex: typically a reference to
the physical, biological, and anatomical
dimensions of being male or female
(including chromosomes, gonads, sex-
ual anatomy, and secondary sex
characteristics).
• Gender identity: how people experi-
ence themselves (or think of themselves)
as male or female, including how
masculine or feminine they feel.
(continued)
M. A. Yarhouse et al.
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A recent article in Nature titled “Sex
Redened” asserted that “the idea of two sexes is
simplistic” (Ainsworth, 2015, p. 288). After an
accurate account of normative male/female
development, the author proceeds to present the
“sex spectrum” by identifying a range of disor-
ders by identifying a range of deviations from
what has been considered to be normative devel-
opment (sometimes referred to as disorders of
sexual development, DSD). This is followed by a
generous prevalence estimate of 1% of the popu-
lation; the more widely recognized estimate is
1 in 4500 people, which the author acknowl-
edges. Some view the recognition of DSD as
challenging the sex/gender binary, while others
view these rare exceptions as conrming the
male/female norm (Yarhouse, 2015).
However, not everyone who adheres to the
diversity framework is actively attempting to
deconstruct norms related to sex and gender.
Others adopt it simply because it offers answers
to questions about identity (“Who am I?”) and
community (“Of which community am I a
part?”). There is a tendency here to discuss diver-
sity not so much as an identity and culture but as
natural variations. Emphasis here is on viewing
differences in sexual attraction, gender identity,
or sexual development as variations that simply
occur in nature. These occurrences would not
necessarily be celebrated as such, but they would
also not be pathologized or viewed from any kind
of moral/ethical framework.
For example, it is not known what causes
transsexualism. One theory proposed by Diamond
(2013) is that transsexuality is “a form of brain
intersex.” In describing his theory—the biased-
interaction theory of psychosexual develop-
ment—Diamond reects the natural variation
lens when he writes:
In general, biological factors starting from XY
chromosomes produce males that develop into
boys and then men with whatever characteristics
are appropriately seen as masculine for society and
females develop into girls and then women with
whatever characteristics are appropriately seen as
feminine for the same society. Differences from
the usual course of development are not seen as
‘things gone wrong’ or errors of development but
as to-be-expected occasional variations due to
chance interactions of all the variables involved.
http://www.hawaii.edu/PCSS/biblio/
articles/2005to2009/2006-biased-interaction.html
Therefore, experiences of differences by
attraction, gender identity, or sexual development
reect nonmoral realities that occur as normal
variations that one would expect to see over time.
While you can hold this view of nonmoral
realities and be a proponent of the diversity
framework, it is also possible that such a view
can inform other frameworks through which peo-
ple see sexual and gender identity concerns.
The limitations to a diversity framework come
to the foreground when proponents overlook or
marginalize other aspects of diversity, or single
out models of care, as the sole expression of cul-
tural competence when working with the LGBT+
community. We turn now to two other frameworks
for consideration to address these concerns.
• Gender dysphoria: the experience of
distress related to having a psychologi-
cal and emotional gender identity that
does not match one’s biological sex.
• Transgender: an umbrella term for the
many ways in which people may experi-
ence or present or express their gender
identity differently than those for whom
gender identity is congruent with their
biological sex.
• Transsexual: a person who believes he
or she was born in the “wrong” body (of
the other sex) and wishes to transition
(or has transitioned) through hormonal
treatment and sex reassignment
surgery.
• Intersex: a term to describe conditions
in which a person is born with sex char-
acteristics or anatomy that does not
allow them to be identied clearly as
male or female. This can be chromo-
somal, gonadal, or genital (e.g., congen-
ital adrenal hyperplasia). Also referred
to as disorders of sex development or
disorders of sex differentiation.
(continued)
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The Disability Framework A second, more
descriptive, way people in contemporary society
think about matters of same-sex sexuality and
gender incongruence has been referred to as a
disability framework (Yarhouse, 2015).
Adherents often use what is referred to as person-
rst language (see Dunn & Andrews, 2015, who
discuss person-rst language with reference to
disability rather than LGBT+ issues). For exam-
ple, rather than reference people as “gay” or
“transgender,” those who adopt this framework
may refer to themselves as “a person who is navi-
gating sexual identity questions” and “a person
who experiences gender identity concerns or who
experiences gender incongruence” (see Yarhouse
& Tan, 2003; Yarhouse, 2013, 2015).
This language allows the person and others
who engage them to reect on the meaning of
one’s same-sex sexuality to oneself and to others.
It is also possible for someone to prefer identity-
rst language over person-rst language but to
also experience their same-sex sexuality as more
like a disability than a culture to be celebrated.
This language parallels the shift in how we
describe individuals diagnosed with mental dis-
orders: We view a person as one with
Schizophrenia rather than “a schizophrenic”
(Keeley, Morton, & Blasheld, 2015). The celi-
bate gay Christian above does adopt identity-rst
language, while others would prefer descriptive
language or person-rst language (e.g., “I am a
woman who experiences same-sex attraction”),
and this is often for personal and religious rea-
sons in which an LGBT+ identity is just not as
helpful to their meaning-making structures
(Yarhouse & Tan, 2003).2 Someone from a
2
The mainstream LGBT+ community did not follow the
Deaf/deaf community in distinguishing between Deaf (as
a culture) and deaf (as a disability). In other words, there
is no formal homosexual/homosexual distinction. Rather,
the LGBT+ community took other pejorative labels, such
as gay and queer, and reclaimed them in the face of what
has been understood to be an oppressive majority that held
out normative claims about sexual identity and behavior
(heterosexual) and a gender identity that corresponds with
one’s biological or birth sex (cisgender). However, there
are members of the LGBT+ community who do experi-
ence their same-sex sexuality and gender incongruence as
more akin to a disability than a mark of diversity as such.
religious faith tradition might view their
same-sex sexuality as a “disability” likely due to
a normative view of sexuality and sexual func-
tioning in which attraction to the opposite sex is
viewed as intended from creation; variations
would be departures from that norm that would
be the result of “fallenness” (of the creation
order) (see Yarhouse & Nowacki, 2007).
For example, a celibate gay Christian who is
also deaf once shared with us why she prefers
identity-rst language (“celibate gay Christian”)
over person-rst language (“A person who expe-
riences same-sex attraction”) (Yarhouse, Morgan,
Anthony & Sadusky, 2015). She indicated that
describing her sexual attractions in isolation
seemed to reduce them to just the desire to be
genitally sexually active; in her experience,
“being gay” was a broader “way of being in the
world” than just identifying to whom she was
sexually attracted.
Additionally, some celibate gay Christians
may be drawn to a disability lens and cite the
example of the deaf/Deaf debates as rationale:
In the world of hearing loss, you have those who
are Deaf and those who are deaf. These two groups
are well-distinguished and identied. Anyone who
uses capital ‘D’ Deaf knows she is referring to
something more than small ‘d’ deaf. People who
are Deaf comprise a culture; they do not see them-
selves as having a disability. Instead they see them-
selves as a people group with their own language
and culture. On the other hand those who are deaf
do not see their hearing loss as an identity; instead,
they see it as a disability or medical condition. This
group is more likely to be ‘oral.’ That is, they often
undergo intensive training to lip-read and use their
voice to communicate instead of using sign lan-
guage. Some might also seek a cochlear implant.
When they say ‘I am deaf’ they are not saying ‘I
am Deaf.’ At times there is contention between the
groups because of a conict in how each group
understands its experience of hearing loss. For
example those who are Deaf see cochlear implants
as threatening and an extreme offense. They don't
believe anything needs to be ‘xed.’ They celebrate
their identity as Deaf. (Yarhouse, 2013, p.28)
Additionally, because historically the disabil-
ity lens draws on assumptions about normative
sexual and gender experiences, it offers a story-
line for thinking about sexual identity and gender
identity concerns, too. This storyline is based on
AU1
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a specic understanding of sex and gender norms,
at least insofar as it makes assumptions about
both ability and human ourishing.
There are people who are drawn to a disabil-
ity lens in part because they do not adopt a diver-
sity lens; that is, they do not experience their
gender identity concerns as indicative of an iden-
tity to be celebrated or of a community of which
they tend to identify. Their experiences do not
point them to a culture in the same way it does
for adherents of the diversity framework. Nor are
proponents of a disability perspective necessar-
ily drawn to more religious perspectives, what
we refer to as the sacred framework, which we
will discuss in a moment. Drawn to the disability
lens, they reject both the celebration of identity
from the diversity lens and the rejection of self-
experienced when framed as a moral matter. It is
perhaps easier to see past the disability if a phe-
nomenon in some way reects or is associated
with mental health concerns. Here it may be
more resonant to cite gender dysphoria as an
example, as it is currently in the DSM-5. People
adopt this framework and see the benet in stat-
ing that the person has not chosen to experience
same-sex attractions or gender incongruence,
and the person-rst language (e.g., “I am a per-
son who is navigating sexual identity ques-
tions.”) often associated with this framework
evokes in some a greater sense of compassion
and empathy.
This framework also reects the perspectives
of those who simply do not see their experience
as optimal for human functioning or ourishing
in quite the same way as those who adhere to the
diversity model. A disability framework may be
particularly appealing to those who wish to dis-
tinguish themselves from those who only discuss
sexuality and gender in terms of morality, or of
willful disobedience to standards for behavior or
identity, particularly any claim that same-sex sex-
uality or gender incongruence is chosen as such.
In other words, the disability lens may cultivate
compassion from others who do not know what
an experience is like (e.g., gender incongruence).
Although helpful and perhaps seen as more
compassionate, challenges arise for those drawn
to the disability model. First, supporters will be
viewed by proponents of the sacred model as not
sufciently valuing the sacredness of matters that
drive their own concerns. A critic of the disability
model shared: “Another problem with his
‘Disability’ view is that for the most part people
don’t associate a disability with sinful conduct.
When people think of disabilities they typically
think of such things as physical impairments of
mobility, hearing, or sight; intellectual disability
or other learning impairments; or health impair-
ments like asthma, epilepsy, or attention decit
disorder. Such nonmoral disabilities can be
accommodated in all sorts of ways without vio-
lating any divine standards” (Gagnon, 2015).
Second, for those who adopt a diversity approach,
any deviation from diversity as the lens through
which people are viewed is often experienced as
marginalizing or insulting. In other words, adher-
ents of the disability model are not where propo-
nents of the diversity model will want them to be,
even in cases in which they share many of the
same characteristics (e.g., same-sex sexuality).
The Sacred Framework As we have suggested
already, aspects of the diversity framework can at
times be in conict with conventional religiosity
as practiced by many adherents throughout the
United States and the world (particularly in
Africa, Asia, and South America). Let us consider
what we mean, then, by sacred. Pargament and
Mahoney (2005) observe that “people can per-
ceive virtually any aspect of their lives as having
divine character and signicance” (p. 179). To
treat something as sacred is to sanctify that aspect
of one’s life. That is, it is to set apart a behavior or
an aspect of personhood as having spiritual or
religious signicance. The human capacity to
sanctify has been studied in a few areas, includ-
ing sexuality and sexual behavior (Murray-
Swank, Pargament, & Mahoney, 2005) and the
perception of one’s body (Mahoney etal., 2005).
A related construct, sexual congruence, has also
been studied empirically (e.g., Hook etal., 2015).
Other lines of research on the experiences of
conventionally religious sexual minorities (e.g.,
Yarhouse & Tan, 2003; Yarhouse et al., 2009)
suggest that some individuals draw on similar
23 The Complexities ofMulticultural Competence withLGBT+ Populations
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582
considerations when navigating sexual and
gender identity questions. The human capacity to
imbue with signicance various aspects of per-
sonhood, including one’s sexuality and gender
identity, is what we refer to as the sacred frame-
work. This framework views sex and gender and,
therefore, sexual identity and gender identity
conicts with reference to normative claims
about sex and gender that are informed by reli-
gion or spirituality.
The reason that this framework is under dis-
cussion is that it reects a widely agreed upon
understanding of sex and gender that is held by
many adherents of several major world religions.
Adherents often experience the other lenses as
problematic, as they can at times reect a disre-
spectful or sacrilegious approach to distinctions
that matter to them.
As one conventionally religious theologian
put it, the reference point is “the sacred integrity
of maleness or femaleness stamped on one’s
body” (Gagnon, 2007). This is primarily a reli-
gious and theological argument. Same-sex sexual
behavior and cross-gender identication are con-
cerns to those who adhere to this framework in
large part because such behaviors are thought to
threaten the integrity of male/female distinctions.
Conventionally religious persons of the
Abrahamic faiths, that is, Christians, Jews, and
Muslims, cite passages from their sacred texts
that they view as supporting this sacred integrity,
including references to the importance of compli-
mentary male/female differences from the cre-
ation narrative.
This is in part because of the role religion
plays in informing views of morality in which
homosexual behavior is morally impermissible.
Religious communities essentially joined other
social structures in condemning homosexuality,
whether as pathology or crime. This history
almost certainly makes it difcult for the main-
stream LGBT+ community to protect and safe-
guard the existence of other frameworks,
particularly those informed by religious doc-
trines. This is perhaps one of the greatest
challenges to any discussion of cultural compe-
tence as it has many implications for training,
professional development, and practice.
The religious or theological approach that is at
the foundation of the sacred lens raises similar
concerns about cross-gender identication as are
raised about same-sex sexuality and behavior. In
other words, from this perspective same-sex sex-
ual behavior is a moral concern in part because it
does not “merge or join two persons into an inte-
grated sexual whole...”; the “essential maleness”
and “essential femaleness” are not brought
together as intended. When extended to the dis-
cussion of transsexuality and cross-gender identi-
cation, the theological concerns rest in the
“denial of the integrity of one’s own sex and an
overt attempt at marring the sacred image of
maleness or femaleness formed by God”
(Gagnon, 2007, p.3).
Some recent events highlight these different
frameworks that are present among individuals
and institutions. One example can be seen in the
story of Kelvin Cochran (Riley, 2015), a former
re chief in Atlanta. According to the Wall Street
Journal a, Cochran was a well-respected re chief
who had given 30years of service to the depart-
ment and who had helped improve performance
and service in the department. In 2014, Cochran
was suspended for 30 days without pay for an
investigation into his conduct. At the conclusion
of his suspension, the mayor of Atlanta, Kasim
Reed, terminated him from his position for “pub-
lishing a book in violation of the city’s ethics code
and without permission from the mayor” (Riley,
2015, p.1). Cochran’s book consisted of lesson
plans for a Bible class that he taught to help men
change their lives. In this book, Cochran refers to
homosexual conduct as “perversion.” Though the
original statement indicated that he was not red
for his religious views, later comments made by
the mayor suggested that the beliefs in Cochran’s
book were not in line with the mayor’s personal
beliefs or the city’s. We can readily see distinctive
frameworks at play here. Cochran seems to be
coming from the sacred framework. He views
sexuality and gender from a conventionally reli-
gious perspective and wrote this in a book
intended for the same audience. Mayor Reed and
the city of Atlanta seem to be rooted in the diver-
sity framework and see no place for this perspec-
tive among their employees, despite the fact that it
M. A. Yarhouse et al.
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583
is not something that is directly related to their
work. This example illustrates what was stated
earlier: deviations from diversity as the lens is
experienced as marginalizing or insulting, even if
that is likely not the intention.
Other stories highlight similar disconnects
between those of different frameworks. Dr.
Robert Oscar Lopez, a tenured professor at
California State Northridge University (CSNU),
has been targeted by the Human Rights Campaign
(HRC) and now his university for more conserva-
tive views on family and the rights of children
(Siggins, 2015). Dr. Lopez, a bisexual man, feels
that he has been targeted for believing that chil-
dren have a right to a mother and father and dis-
agreeing with redening marriage. He was not
raised by natural parents, and he, along with oth-
ers raised by same-sex couples, led a brief with
the Supreme Court surrounding these beliefs. Dr.
Lopez sees these issues through a disability lens,
while those at his school utilize a diversity lens.
The HRC and CSNU do not feel that Dr. Lopez’s
beliefs are compatible with what they would
deem acceptable for his current position.
One other example is highlighted in an article
written by Peter Smith (2015). Smith writes
about Wesley Hill, an associate professor and
author who identies as a celibate gay Christian.
Hill believes that gay Christians should be com-
mitted to celibacy while also afrming their sex-
ual orientation. Smith states that this “stance runs
counter to the growing American majority that
supports legalized same-sex marriage among
Americans, including religious progressives…”
(2015, p.1). Additionally, it runs counter to many
Christian conservatives who do not afrm being
gay as an identity. Hill’s stance through a disabil-
ity lens is seen by those in the diversity frame-
work as not fully embracing who the individual is
and by those in the sacred framework as covering
up or avoiding a problem they may have. It is
easy to see how misunderstandings based on dif-
ferent frameworks can cause many difculties in
this discussion.
Yet a challenge for a truly multicultural
framework is recognizing the reality and place of
these religious communities and the persons who
are a part of these communities, even when
adherents of a religion are part of the eld of
psychology or are students in training to become
psychologists. A challenge also arises in recog-
nizing that students in training may also repre-
sent the sacred framework and will need
mentoring in how to navigate their own religious
identity and beliefs and values while developing
as a mental health professional.
Multicultural competence in LGBT+ issues
should also nd ways to navigate education and
training that reects the reality (historically and
globally) of this framework. This involves repre-
senting this perspective accurately and respect-
fully, as well as providing an environment
conducive to students in training who identify as
conventionally religious.
We turn our attention now to several other top-
ics in the cultural competence literature around
which to develop clarication. As was mentioned
previously, these include identifying the parame-
ters of the culture, accuracy and humility around
dissimilarities from prototypical topics of cul-
tural competency, prejudice and bias against con-
ventional religious beliefs and values,
measurement of multicultural competence for
clinical practice, and pinpointing issues for fur-
ther clarication that have to do with identity,
politics, and epistemology.
Identifying theParameters
oftheCulture
When we turn to discussions of multiculturalism
and multicultural competence and their applica-
tions to the LGBT+ community, part of the dif-
culties lay in what the construct of multicultural
competence means in this context. We are refer-
ring to the heterogeneity within the LGBT+ com-
munity, which we have so far been discussing
primarily with reference to lesbian, gay, bisexual,
and transgender. Even if we add to that the rather
modest extension of questioning, queer, and
intersex persons (LGBTQQI), we are already
discussing remarkably different experiences.
Some resources include additional identity labels
such as pansexual, pangender, gender uid, gen-
der queer, asexual, and many more. A person who
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584
seeks care for an intersex condition is having a
very different session from a same-sex couple
having difculties with communication or
nances. Both of these cases are different from
someone who experiences signicant gender
dysphoria.
Each of the previously mentioned identiers
point to a specic experience that warrants
thoughtful discussion, but what we are asking is
how does the mental health professional approach
such diversity as though it were a culture around
which to be competent? Is the LGBT+ commu-
nity a culture? If so, what makes it a culture? For
example, in contrast to the African-American
community, which shares a unique cultural his-
tory in the United States, there are dimensions
that are rather dissimilar when we think of the
experience of sexual attraction as compared to
the experience of gender dysphoria or cross-
gender identication or intersex conditions or
asexuality.
In some respects, it is a culture insofar as it
distinguishes itself from those who are hetero-
sexual and cisgender. It is a culture of not being
that. The LGBT+ community as culture origi-
nated from the basis of experiencing a different
pattern of sexual attraction that is conceptualized
as a sexual orientation: homosexual or bisexual
rather than heterosexual. It eventually expanded
to note distinctions between male and female
experiences (gay and lesbian). Today it includes
discussions of pansexuality and asexuality. It
expanded further to include those who are trans-
gender or otherwise gender variant, which has
subsequently expanded to include experiences of
those who are gender queer and gender uid. As
authors who are exploring the challenges associ-
ated with cultural competence in this area, we are
not particularly critical of this development, but
we are asking if there are inherent limitations in
creating a culture of contrasts with existing norms
surrounding sexuality and gender.
Questions also come up within the LGBT+
community around race and socioeconomic
status. According to Petchaur, Yarhouse, and
Gallien, the LGBT+ community relied upon and
was inuenced signicantly in its history by
White, gay identity and its associations with the
middle class. Fukuyama and Ferguson (2000)
offer the following:
Gay identity and the gay liberation movement have
been associated with the White middle class....
[Thus] people of color may resist joining the gay
liberation movement because it is perceived to be
joining with the White oppressor and denying
one’s family ties. In some ways, a gay identity may
be a function of acculturation into American soci-
ety. (p.99)
The emergence of LGBT+ persons as a culture is
further delineated when referencing meaningful
historical events (e.g., Stonewall Inn riots of
1969) and early organizations (e.g., the
Mattachine Society) that hoped to end criminal-
ization of homosexual behavior, as well as his-
torical tragedies (e.g., the execution of an
estimated 50,000 men under the Nazi’s because
they were believed to have a homosexual orienta-
tion). Criminalization of homosexuality also
exists in some countries today (e.g., Iraq, Iran,
Saudi Arabia).
As we mentioned above, one of the strides in
the development in the emergence of the LGBT+
community as a culture was the removal of
homosexuality from the Diagnostic and
Statistical Manual of Mental Disorders (DSM) in
1973. Since that time, subsequent revisions have
recognized that there may be a conict between
one’s sexual orientation and one’s personal
beliefs and values. However, not being classied
as a mental illness does not legitimize the cre-
ation of a culture. But, the removal of homosexu-
ality from the DSM was as important as
de-pathologizing and later decriminalizing same-
sex sexual behavior in fostering a culture group
one could positively ascribe to.
As a result, the LGBT+ community can now
be described as a culture of patterns of sexual
attraction, behavior, and diverse experiences of
gender identity, including in some cases medical
conditions (e.g., Klinefelter syndrome or the
presence of XXY chromosomes rather than XY
or XX). These patterns are argued to be natural,
by which is often meant biological in origin,
which was historically important and contrasted
to the language of sexual preference, which
reected volition on the part of the subject.
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585
Today, what is often pathologized are any
views of homosexuality that are not afrmative,
which is not clearly dened, but had typically
involved (prior to the Supreme Court ruling in
Obergefell v. Hodges in 2015) political endorse-
ment of marriage equality and comparable politi-
cal and ideological positions. Political and moral
positions often show up on measures of compe-
tence, which is a further complication in light of
the various frameworks discussed above.
Presumably, such questions are warranted
because psychologists and other mental health
professionals are urged to examine their beliefs
and values for any “heterosexual and cisgender
privilege” (Sue & Sue, 2013, p.484), which is an
all too often ambiguous declaration that is
becoming canonical in the cultural competence
movement. Readers are often urged to examine
one’s beliefs for any cisgender privilege because
failing to do so may perpetuate the cycle of
microaggressions that can leave an individual
feeling invalidated, misunderstood, and less than
(American Psychological Association [APA],
2009; Hebard & Hebard, 2015). It is unclear,
however, how each of these concepts (e.g., cis-
genderism) is practically conceptualized when
they are articulated from a diversity lens and how
to incorporate other lenses (e.g., sacred, disabil-
ity) that may be held by client and clinicians alike
that view some of these distinctions not as signed
of privilege but as normative claims regarding
personhood with identiable variations which
can be responded to with understanding and
compassion.
As we bring this section to a close, we want to
reiterate the challenges associated with this
remarkably heterogeneous population. Much of
the history of meaning-making and culture devel-
opment has been in reference to a negative—in
regard to what a person is not and often tied to the
deconstruction of social norms regarding sex and
gender. At a practical level, we have to ask
whether true cultural competence will be reected
in reviewing paperwork, policies, and procedures
for privileges associated with gender congruency
(to reect the concerns of those who report gen-
der dysphoria), heterosexuality (for clients who
may be attracted to the same sex or both same
and opposite sex), sexual desire (for those who
may be asexual), gender constancy (for those
who may be gender uid), and nonmedical con-
ditions related to disorders of sexual develop-
ment (for those who may be intersex). Perhaps
more thought can go into what constitutes good
professional practice to those who may present
with any number of clinical concerns and who
may represent the different frameworks or lenses
previously discussed.
Parallels Drawn toSkin Color
Another related difculty has to do with attempts
to pattern the LGBT+ community and corre-
sponding multicultural competence after racial
minority discussions. The questions that arise
are: In what ways is the LGBT+ population a cul-
ture akin to that of an African-American culture
or a Hispanic culture? In what ways are they sim-
ilar? In what ways are they different? Is drawing
a parallel to race or ethnicity an accurate anal-
ogy? If not, why not?
After all, we are not discussing a group of
people who are a community of like-minded peo-
ple. We are not discussing what it means to be a
Republican or a Democrat (as though all within a
political party agreed with one another). This is
not a discussion of being an animal rights advo-
cate. We are talking about presenting the LGBT+
community as a culture by virtue of being differ-
ent wherein the difference is one that occurs in
nature (a natural human kind of difference) and
that is immutable.
Perhaps the most emotionally compelling
analogy that been used in the past 40years has
been to connect patterns of sexual attraction to
race to argue that just like racial minorities, sex-
ual minorities are a people group whose very
existence is tied to an innate and immutable char-
acteristic (i.e., sexual orientation). It has been
widely presented as though sexual orientation
was an immutable characteristic. This argument
is then extended to discussions about etiology
and change, for the assumption is that if sexual
orientation has biological markers in the way
race has biological markers, then the LGBT+
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586
community comprises a similar culture. Along
the same lines, if it can be demonstrated that pat-
terns of sexual attraction or orientation are immu-
table, then perhaps the reference to race is an apt
analogy.
The larger argument has meant connecting
LGBT+ personhood to the civil rights movement
among African-Americans. This has been a com-
pelling analogy that has captured the imagination
of many younger Americans who see LGBT+
equality as the civil rights issue of their genera-
tion. In many ways, the celebration of marriage
equality or gay marriage in the Supreme Court’s
5–4 decision on Obergefell v. Hodges in 2015
reected this connection.
The language of LGBT+ youth reects this
preference for a parallel to race. However, what is
particularly difcult with this analogy as extended
to youth is that a percentage of young people who
report same-sex attraction, orientation, and/or
identity may not continue to experience the same
degree of same-sex sexuality into adulthood. The
Adolescent Health Study data suggested a stable
same-sex sexuality for a smaller percentage of
adolescents and those in emerging adulthood;
however, a higher percentage experienced more
of an ebb and ow of attractions toward the same
sex and the opposite sex, with greater uidity in
same-sex sexuality (e.g., those for whom bisexu-
ality was a preferred designation in adolescence
often reported greater heterosexual attraction in
emerging adulthood; see Savin-Williams, Joyner,
& Rieger, 2012; cf., Li, Katz-Wise, & Calzo,
2014; Savin-Williams & Joyner, 2014).
Jones’s (2012) conclusion seems apt:
So, is sexual orientation like skin color? At birth,
or in the womb for that matter, we know whether
a child is a boy or girl (except in those rare aber-
rant cases where the multivariate phenomenon of
sex goes awry) and we know that the child will
share the racial characteristics, in some creative
mix, of his or her two biological parents. At this
point, we know little with clarity about the etiol-
ogy of homosexual orientation. Given the theo-
retical and empirical possibilities of genes
interacting with environment, the clear evidence
of postnatal, socio-cultural variables having an
inuence upon sexual orientation … and the clear
evidence of the modest contribution of genetic
and other biological factors that has emerged
from studies of similar truly representative
samples, it is safe to conclude that sexual orienta-
tion is disanalogous to skin color, and of mysteri-
ous origins indeed. (p.12)
Etiology In our previous work (Jones &
Yarhouse, 2012), the fundamental validity of the
analogy as to whether sexual orientation is akin
to skin color was discussed. Skin color is biologi-
cal/genetically caused and is essentially immuta-
ble (aside from cosmetic, chemical, or surgical
interventions or disease states, e.g., vitiligo). The
biological hypothesis for the etiology of sexual
orientation has been forcefully advanced since
the early 1990s. Several studies have been pub-
lished on genetic and prenatal hormonal hypoth-
eses with mixed results. Resulting evidence
appears to support biological contributions for a
subset of persons. For example, the original
genetic hypothesis studied by Dean Hamer and
his colleagues (1993; Hu etal., 1995) indicated a
signicant concordance for the Xq28 subtelo-
meric region of the sex chromosome, which
would suggest a genetic basis for male homosex-
uality. These study ndings failed replication by
Rice, Anderson, Risch, and Ebers (1999) and by
Mustanski etal. (2005). A more recent report was
able to replicate these ndings and perhaps sug-
gests a genetic basis for a certain type of homo-
sexuality, that is, select males only (selected for
higher occurrence among maternal relatives).
Twin studies have also been a point of focus
on genetics. Some of the earliest studies (e.g.,
Bailey & Pilard, 1991) suffered from recruitment
bias that contributed to a broader, public percep-
tion genetic causation that has not been able to be
empirically sustained. Subsequent twin studies
(e.g., Bailey, Dunn, & Martin, 2000) that drew
upon a more representative sample signicantly
reduced the genetic factors, as only 3 of 27 iden-
tical twin pairs matched for homosexual orienta-
tion). A study that drew from the Swedish twin
registry also reported a much lower concordance
rate, as only 7 of 71 twin pairs matched on
homosexual behavior (Langstrom, Rahman,
Carlstrom, & Lichtenstein, 2010).
A third line of research implicating biological
contributions to sexual orientation is referred to
M. A. Yarhouse et al.
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587
as the fraternal birth order research. This line of
research examines the inuence of having an
older brother on male sexual orientation, and it
draws upon the “maternal immune hypothesis”
as the primary rationale for the relationship
between older brothers and increased rates of
homosexual orientation. This hypothesis states
that the mother’s body develops anti-male anti-
bodies in response to subsequent male fetuses,
which prevent the full masculinization of the
fetus’s brain. The greater the number of older
brothers, the greater the chance of subsequent
males developing a homosexual orientation
(Jones & Yarhouse, 2012).
There does appear to be a relationship between
the number of brothers in a family and homosex-
uality. What is unclear from the data so far is the
strength of that relationship and the causal path-
way as well as other possible, often overlooked
variables. However, even if the older brother
hypothesis were conrmed across several
research labs, it is estimated to only account for
about 15% of male homosexuals. That leaves
multiple other potential pathways for male homo-
sexuality, not to mention female homosexuality.
A more accurate way to conceptualize homo-
sexuality might be to think of their being multiple
homosexualities and multiple pathways to the
same endpoint (the principle of equinality).
Moreover, the endpoint of homosexuality is quite
broad, as there appear to be signicant differ-
ences between male experiences of homosexual-
ity and female experiences of homosexuality, as
well as differences among male experiences and
female experiences.
Instability Evidence of sexual identity instabil-
ity has been documented among sexual minority
male and female adolescents and emerging adults
(Kinnish, Strassberg, & Turner, 2005; Ott,
Corliss, Wypij, Rosario, & Austin, 2011). That
same-sex sexuality is uid was unthinkable not
too many years ago. It was a view challenged
notably by a line of research by Diamond (2008)
but perhaps thought of as a unique difference in
uidity among female sexual minorities.
However, as more evidence is collected on male
and female sexual minorities, from adolescence
through emerging adulthood and into adulthood,
it is unclear how the prior narrative of immutabil-
ity upon which so much policy has been written
will fare.
When we turn to the question of gender iden-
tity, most young people who are diagnosed with
gender dysphoria do not meet criteria in adult-
hood. The DSM-5 estimates that about 75% of
cases resolve on their own before a child enters
late adolescence or adulthood. These children are
referred to as desisters (rather than persisters).
Here, the parallel to race breaks down, and the
analogy does not inform competent practice as it
was perhaps intended.
Among those whose gender dysphoria per-
sists, the person now faces several pathways: liv-
ing and forming a gender identity congruent
with one’s biological/birth sex, engaging in
cross- gender behavior/presentation intermit-
tently, or forming a cross-gender identity through
various measures that may or may not include
hormonal treatment and sex reassignment sur-
gery (Carroll, 2007; Yarhouse, 2015). Again, as
with lesbian, gay, and bisexual identity and value
congruence, perhaps creating supportive avenues
for a range of resolutions would be helpful in
achieving a more nuanced cultural competence
when managing gender dysphoria and identify-
ing person- specic pathways for achieving
congruence.
In addition to potential changes in attraction
and gender dysphoria, we also note that just at the
level of identity and behavior, many people
choose not to identify themselves as LGB nor to
engage in same-sex sexual behavior for personal,
cultural, or religious reasons. In an effort to pro-
tect the LGBT community as a culture, this could
be dismissed as a reection of internalized
homophobia or sexual self-stigma; however,
while internalized negative messages may play a
role for some people, any such declarations fail to
grapple sufciently with the full range of reasons
why a person might choose to dis-identify with
the gay community or might choose to refrain
from sexual behavior. We have seen this in
surveys of sexual minorities at religiously
afliated colleges and universities, for example
23 The Complexities ofMulticultural Competence withLGBT+ Populations
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588
(Stratton etal., 2013; Yarhouse etal., 2009), as well
as community samples (Yarhouse & Tan, 2003).
The more narrow the focus, the more likely
we are to nd similarities. For example, if we
were to only discuss gay males, we might have
more of a sense for gay males being like other
groups that so often comprise discussions of mul-
ticultural competence. For example, there is more
research suggesting biological contributions to
homosexual orientation among males. There is a
less a sense of choice in gay males who have
been surveyed about such matters. In a recent
survey, for example, gay, lesbian, and bisexual
persons were asked the question, how much
choice do you feel you had about being [lesbian/
gay/bisexual/queer/homosexual; depending on
the respondent’s preferred term] (Herek, Norton,
Allen, & Sims, 2010, p.186)? While about 42%
of bisexual men and women indicated having a
fair amount or a great deal of choice and 16.4%
of lesbian respondents reported having a fair
amount or a great deal of choice in the matter,
only 5.2% of gay men reported having a fair
amount or a great amount of choice in being gay.
This may t with other lines of research that
suggest greater sexual uidity among female sex-
ual minorities (women who identify as lesbian or
bisexual, for instance) than male sexual minori-
ties (e.g., Diamond, 2008).
Perhaps a more helpful question for multicul-
tural competence has to do with identifying the
developmental pathways toward an LGBT iden-
tity as well as developmental pathways among
those for whom an LGBT identity is not sought
or realized (Yarhouse, 2001). Current research on
identity models or pathways toward an LGBT
identity (Worthington, Savoy, Dillon, &
Vernagalia, 2002) follows a similar template to
those of racial/ethnic identity development: one
from self-hating to one that is self-accepting, in
the attempt to capture this experience of grap-
pling with and understanding one’s own sexuality
(Morgan, 2012).
We think the challenge for multicultural dis-
cussions is to consistently extend the discussion
beyond those declarations that draw upon male
experiences to the exclusion of other experiences.
Further, the interpretation of such ndings can at
times occur with reference to political utility and
a single lens (i.e., diversity) rather than humility,
scientic accuracy, and a recognition of multiple
lenses adopted by clients, clinicians, and
researches alike.
Mutability Insofar as members of the LGBT+
community are said to be a culture analogous to
racial groups distinguished by skin color, the
question arises whether sexual orientation is an
immutable characteristic. However, as we turn
our attention from etiology to the question of
mutability, we face similar complexities. At a
time when sexual orientation was being discussed
as absolutely immutable, we (Jones & Yarhouse,
2007) set out to conduct a longitudinal and pro-
spective study to test that hypothesis. We studied
the experiences of 98 adults who sought to
change their sexual orientation through involve-
ment in religious ministries. These participants
were followed for a total of between 6 and 7years
(Jones & Yarhouse, 2011).
Here is a helpful summary of the ndings at
the conclusion of the study:
Of the original 98 participants in the study (72
men, 26 women), 61 subjects completed the key
measures of sexual orientation and psychological
distress at the conclusion of the study, and were
successfully categorized for general outcome. Of
these 61 subjects, 53% were categorized as suc-
cessful outcomes by the standards of Exodus
Ministries. Specically, 23% of the subjects
reported success in the form of ‘conversion’ to het-
erosexual orientation and functioning, while an
additional 30% reported stable behavioral chastity
with substantive dis-identication with homosex-
ual orientation. On the other hand, 20% of the sub-
jects reported giving up on the change process and
fully embracing gay identity. On the measures of
sexual orientation, statistically signicant changes
on average were reported across the entire sample
for decreases in homosexual orientation; some sta-
tistically signicant change, but of smaller magni-
tude, was reported in increase of heterosexual
attraction. These changes were less substantial and
generally statistically non-signicant for the aver-
age changes of those subjects assessed earliest in
the change process, though some of these subjects
still gured as ‘Success: Conversion’ cases. (Jones,
2012, p.15)
M. A. Yarhouse et al.
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589
In this study, “conversion” referred to a change in
strength of attraction toward the same sex and a
corresponding increase in attraction toward the
opposite sex; “behavioral chastity” referred to the
ability to refrain from same-sex behavior, which
was made possible because of a sufcient
decrease in the strength of same-sex attraction;
and gay identity referred to a decision to discon-
tinue all change efforts and to integrate same-sex
attractions into a gay identity and view same-sex
behavior as morally permissible (see Jones &
Yarhouse, 2007, 2011).
We also measured psychological distress and
reported that there was not an average increase in
psychological distress associated with the attempt
to change orientation through these religious
ministries; if anything, there were, on average,
slight improvements in reported psychological
distress over time.
These ndings should not be taken to mean
that categorical changes from gay to straight are
likely, but we did see meaningful shifts along a
continuum for some people and not for others. It
is unclear whether those shifts were due to
involvement in a religious ministry; they may
have also reected a natural uidity and may
reect to some extent a combination of changes
in orientation and also behavior and identity as
we discussed in our peer-reviewed journal publi-
cation (Jones & Yarhouse, 2011).
The question of natural uidity is a more
recent one. Recall that our study was launched at
a time when it was the prevailing view that sexual
orientation is immutable, which is the nod to skin
color analogy. However, today there are increas-
ing numbers of researchers who have docu-
mented shifts in sexuality over time—these shifts
are sometimes referred to as a reection of natu-
ral uidity. One of the more well-known lines of
research is by Diamond (2008) who reported
shifts in self-reported sexual behavior, identity,
and attractions among sexual minority women,
including self-identied lesbians (in addition to
bisexual women and women who eschewed a
sexual identity label as such).
Perhaps we are seeing multiple homosexuali-
ties rather than any one phenomenon. With greater
humility and honesty, perhaps it can be concluded
for the time being that sexual orientation is in
some cases mutable. As Jones (2012) states it,
“‘Homosexuality’ is a multifaceted phenomenon;
there are likely many homosexualities, with some
perhaps more malleable than others” (p. 15).
Such an observation, if increasingly demonstrated
to be the case, further suggests we reconsider
analogies to skin color and reect greater humil-
ity about what we do and do not know.
Identity, Politics, and Epistemology As we bring
our discussion of etiology, instability, and muta-
bility to a close, we want to reiterate that the sci-
entic work and associated debates occurred in
the sociocultural context of what has been
referred to as identity politics (Heyes, 2012).
Much of the ground that has been gained in dis-
cussions centering on homosexuality has been
due to an essentialist view of sexual orientation
as something immutable and essential to who
someone is (their identity) as a person.
Nowhere have conceptual struggles over identity
been more pronounced than in the lesbian and gay
liberation movement. The notion that sexual object
choice can dene who a person is has been pro-
foundly challenged by the advent of queer politics.
Visible early lesbian and gay activists emphasized
the immutable and essential natures of their sexual
identities. For some, they were a distinctively dif-
ferent natural kind of person, with the same rights
as heterosexuals (another natural kind) to nd ful-
llment in marriage, property ownership, and so
on. This strand of gay organizing (perhaps associ-
ated more closely with white, middle-class gay
men, at least until the radicalizing effects of the
AIDS pandemic) with its complex simultaneous
appeals to difference and to sameness has a geneal-
ogy going back to pre-Stonewall homophilic activ-
ism … (Heyes, 2012)
Discussions centering on people who experi-
ence gender dysphoria have moved in a similar
direction. Adherents of the diversity framework
often draw on (as their primary paradigm) an
essentialism that distinguishes types of persons:
transgender from cisgender. The biological
essentialism that has been associated with sexual
orientation (with an emphasis on neurobiological
brain differences, markers on the X chromo-
some, twin studies, etc.) is being discussed
with reference to a corresponding essentialism
23 The Complexities ofMulticultural Competence withLGBT+ Populations
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590
associated with gender identity, particularly as it
is conceptualized in the brain-sex theory men-
tioned above (see Yarhouse, 2015).
The challenge in discussions about multicul-
tural competence, however, comes with how peo-
ple may wish to use research in the context of
broader political interests (of, say, liberation or
civil rights or identity politics) while also demon-
strating self-control and humility about the limi-
tations of science and what can be known from
science. What do we know about causation at this
point from the research that has been conducted
so far? What do we know about the mutability of
sexual orientation or resolutions of gender iden-
tity conicts?
Of course, the LGBT+ community may still
be a culture, and discussions of what constitutes
cultural competence will continue to be salient.
However, the difference in discussions of and
training toward cultural competence is that they
would not use the prevailing analogy to skin
color to advance that perspective. Such
discussions and training may also be enhanced
through the inclusion of multiple lenses through
which people conduct and interpret such
research, as well as how clients make meaning
out of their own experiences of sexual and gen-
der identity.
Humility RegardingWhat Is
Known/Not Known withRespect
toLGBT+ Families
Another area where there is some contention and
confusion is the research on LGBT+ families. It
seems that there is conicting research on
LGBT+ relationships, LGBT+ parenting, and
the outcomes for children growing up with
LGBT+ parents between the mainstream LGBT+
community and those on the other side of the
debate. Both sides are asking the same ques-
tions, but there seems to be a lack of consensus
on the denitions of key terms and the method-
ologies used. The current political realities only
make it that much more difcult to identify
points of consensus for serving those who iden-
tify as LGBT+.
Some of the arguments against LGBT+
families have been that LGBT+ relationships do
not last as long as heterosexual ones because of
higher frequencies of sex outside of the current
relationship, indicating lower levels of commit-
ment. For example, the National Lesbian Family
Study (NLFS) conducted by Gartrell and col-
leagues (2011) found that 40 out of 73 lesbian-
mother relationships dissolved by the time their
child was 17years old. Other research (Goldberg
& Garcia, 2015) has shown that relationship dis-
solution of lesbian or gay couples is about as fre-
quent as it is for heterosexual couples. Both
studies have relatively small sample sizes, and
each give their own reasoning for why the num-
ber is not higher or lower, depending on their
point of view.
These assumptions have led individuals who
likely view the topic through different lenses to
research the effects of LGBT+ parents on the
children that they raise. Part of the difculty here
is that each side is looking to prove a point or
obtain certain ndings, which may affect their
ability to objectively perform research. The
Witherspoon Institute put out a book entitled No
Differences? How Children in Same-Sex
Households Fare: Studies from Social Sciences
(Samuel, 2014) which aims to give evidence that
children who are raised by same-sex parents have
signicant differences from those raised by het-
erosexual parents. This book was a direct chal-
lenge to the APA’s 2005 document that stated that
there were no studies of children of LGBT indi-
viduals that showed any negative effect.
Therefore, this line of research was conducted to
directly prove this statement wrong, drawing into
question whether or not it has been done
objectively.
In this text, Marks (2012) argues that previous
research that shows no effect is centered on small
convenience samples and should be called into
question. Regnerus’s (2012) study that indicates
signicant differences on 25 out of 40 outcome
measures for a large group of children is also
highlighted. He found that children of same-sex
parents scored suboptimally on measures of
receiving welfare, needing therapy, STIs, sexual
victimization, and lower educational attainment,
M. A. Yarhouse et al.
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591
to name a few. Altogether, the text paints a
picture that “…in a cross-section of children
raised by parents in same-sex relationships, life
outcomes tend to resemble those of children
raised by single and divorced parents”
(Londregan, 2014, p.14).
On the other hand, those from the mainstream
LGBT+ community have multiple problems with
the research presented by the Witherspoon
Institute. Cheng and Powell (2015) reexamined
Regnerus’s (2012) study based on the belief it
was poor methodology and all too convenient for
the researcher. They state that there was not a
valid or reliable measure of family type, which
may conate some of the ndings. Additionally,
they state Regnerus may have overestimated the
number of children with gay or lesbian parents,
as his denition of a LGBT+ family was some-
what confusing. After reanalyzing the data, they
believe that, had all the respondents been prop-
erly categorized, there would be no signicant
difference between those raised by same-sex par-
ents and those raised by heterosexual parents.
Other research done by those in the main-
stream LGBT community consistently nd that
children of same-sex parents have outcomes sim-
ilar to or sometimes better than those raised by
heterosexual parents. Some suggest that these
children are better off because they must create
new identities, examine what they believe, and
think critically due to their different situation
(Sasnett, 2015). Others suggest that the psycho-
logical well-being of children with same-gender
parents is better than those of heterosexual par-
ents (Fedewa, Black, & Ahn, 2015).
As clearly indicated, there is essentially no
agreement between the two sides, and there
seems to be no middle ground, suggesting that
each side may be serving their own bias. Because
of this, there are multiple things that we do not
know. We do not know if having same-sex par-
ents will increase the likelihood of an individual
exploring same-sex sexuality or identifying as
lesbian, gay, or bisexual (and on one “side” of the
cultural debate, the very question is itself not a
concern). We also do not know whether or not
having same-sex parents has a universal effect on
the psychological well-being of children or their
development. Additionally, we do not know any
mediating factors that may be inuencing nd-
ings. In sum, what is uncertain is: If there are dif-
ferences, are they a direct result of the parents
themselves or other factors in the environment,
such as relational strains with extended family,
societal views, etc.? These are ample avenues to
pursue in future research.
Despite the disagreements and the questions
surrounding the research, there are a few things
that we do know. We know that there will be an
increase in LGBT+ families and that there are
different views which may affect how the fami-
lies operate and how they experience themselves.
We also know that LGBT+ parents often times
face more discrimination and more obstacles in
parenting, specically when adopting (Farr &
Patterson, 2013). Furthermore, we know that
there is no consensus on LGBT+ families and
their effect on children and society as a whole.
This can make it difcult when discussing mea-
suring competence in working with this popula-
tion as it is difcult to know of which research to
base our work. Perhaps collaboration between
the opposing sides would aide in a consensus
being reached that is helpful and valuable to the
discussion.
Cultural Competence inTraining
andPractice
As we consider the practical dimensions of
obtaining cultural competence in work involving
LGBT+ persons, we note two areas of primary
concern: training and practice. As we enter into a
discussion of these two areas for review, we
invite the reader to consider whether the present
way of understanding LGBT+ issues has become
the preferred way of understanding to the poten-
tial exclusion of other perspectives, including
other important expressions of diversity. If so,
such a view may risk taking a narrow slice of
recent history, speak of a LGBT+ rights move-
ment following signicant events and people that
shape the contours of the LGBT+ movement as a
whole, and establish a standard by which other
worldviews and perspectives are rejected.
23 The Complexities ofMulticultural Competence withLGBT+ Populations
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One of the interesting developments in
training has been efforts to measure LGBT+
competence. At present, the empirical base for
providing evidence-based training in LGBT+ cul-
tural competence is “a relatively underdeveloped
literature” (Pantalone, 2015, p.147). As Pantalone
and others have suggested, there is a need to iden-
tify core themes that constitute cultural compe-
tence in LGBT+ studies and to empirically test
those core themes. Several suggestions have been
offered as a potential line of research toward the
end of establishing greater evidence-based train-
ing. These include whether the core themes that
are being identied in the mainstream of LGBT+
studies (e.g., Matza, Sloan, Kauth, & DeBakey,
2015) are “the most important, impactful ones”;
whether one “can train nonexperts to some stan-
dard of delity” for LGBT+ competence; and
whether those training to be culturally competent
providers can “achieve clinical outcomes similar
to experts” (Pantalone, 2015, pp.148–149).
Measuring LGBT+ Cultural Competence We
see the mainstream approach toward LGBT+ per-
sons in the multicultural movement as organized
around attitudes, knowledge, and skills. We have
not thoroughly critiqued whether competence is
rightly established and measured by paying atten-
tion to these three areas. However, we are con-
cerned by some of what is included under each
heading, especially attitudes and knowledge.
Attitudes (and measures associated with coun-
selor competence) are afrming in ways that pre-
clude a psychologist from holding views or
reaching conclusions about sexual ethics/moral-
ity or marriage that are rational and historically
signicant. What counts as knowledge can
include inated prevalence estimates and limited
theories about causation (e.g., the biological
hypothesis that has been forcefully advanced
since the early 1990s). Interest in other life tra-
jectories (e.g., celibacy, chastity, or even attempts
to change strength of attractions) is either not dis-
cussed or treated as akin to bleaching the skin of
an African-American client who requests it. In
any case, any non-afrming position is reduced
to homophobia and internalized homophobia—
both poorly dened constructs.
One scale for measuring attitudes toward the
LGBT community is the attitudes toward lesbi-
ans and gay men scale (ATLG-R; Herek, 1998).
Several problems have been noted, however, with
bias toward conventionally religious persons
(Rosik, 2007), such that a Christian, for example,
could score high in homophobia by simply
endorsing items that reect historical doctrinal
positions of Christianity vis-à-vis sexual morality
(e.g., “Female homosexuality is a sin” and “Sex
between two men is just plain wrong”; Rodriguez-
Seijas, 2014). Other items ask about legal matters
(e.g., marriage) where we might expect to see
great variability in a diverse and pluralistic cul-
ture and democracy. Indeed, there is not even
consensus among those in the LGBT+ commu-
nity with respect to marriage equality.
Other measures of attitudes similarly include
items that preclude the possibility of competence
by students or clinicians who hold a conservative
or more traditional sexual ethic. For example, in
the eld of counseling, Bidell’s (2005) Sexual
Orientation Counselor Competency Scale distin-
guishes attitudes, knowledge, and skills with no
empirical support offered for the assumption that
attitudes are a critical piece of competence. As
mentioned elsewhere (Yarhouse, 2009), at least
three scale items are problematic in this regard:
“The lifestyle of a LGB client is unnatural or
immoral”; “Personally, I think homosexuality is
a mental disorder or a sin and can be treated
through counseling or spiritual help.”; and
“When it comes to homosexuality, I agree with
the statement: ‘You should love the sinner but
hate the sin’” (p.273).
These three items are problematic for many
reasons. The rst item conates “unnatural” and
“immoral,” which are two different topics. A per-
son who adheres to a traditional view of sexuality
and sexual behavior might recognize that homo-
sexual behavior occurs in nature but might take
issue with whether such behavior among humans
is moral or immoral. The second item fuses psy-
chopathology and sin. It compounds this concern
by adding the question of clinical intervention
and spiritual care. The third item reects a state-
ment many conventionally religious people use
to organize their own thinking about morality and
M. A. Yarhouse et al.
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593
respect for those who have reached different
conclusions about sexual behavior. Its inclusion
here, however, is as a measure of competence that
simply begs the question: Are conventionally
religious people less competent to provide men-
tal health services to LGBT+ clients?
Related to questions about counselor compe-
tence scales, we also see measures of homopho-
bia and sexual prejudice. The construct of
homophobia is problematic in many ways. The
term homophobia suggests a phobic reaction to
anxiety-provoking stimuli. It is unclear that any
evidence exists that supports this narrow use of
the term. Yet the connotation is much broader
than that, as the term is often used in response to
any discussion or response to same-sex sexuality
or behavior that is not fully afrming or
advocacy- based. It just may not be the most
accurate word to use in discussions of cultural
competence. Further, to cite it as a measure of
practice is also a concern. It is unclear whether
any concern a client has about his or her sexual
attractions, orientation, or behavior is deemed
internalized homophobia and pathologized.
Such measures seem to often overlook sincerely
held personal beliefs and values regarding sexu-
ality that may in some cases be tied to religious
and/or spiritual beliefs, doctrinal positions
regarding theological anthropology, sexual
morality, and so on.
Similarly, the Sexual Prejudice Scale
(Chonody, 2013) was designed to measure the
construct of sexual prejudice. The researchers
who developed the scale take as evidence of prej-
udice differing views of morality: “It’s wrong for
men to have sex with men.” A prejudice is a pre-
judgment (by denition) and is irrational.
However, a rational conclusion may be that one
holds that specic actions are morally impermis-
sible. That rational conclusion is not, by deni-
tion, a prejudice.
Other items get at political concerns, such as
views on gay marriage, health care and retire-
ment benets for partners, and so on. It is unclear
how differing views on these political matters
constitutes evidence of prejudice. Such views
could be held by a person who is prejudiced
against LGBT+ persons; but to indicate that these
items are foregone conclusions and evidence of
prejudice moves beyond what we know and is
poorly conceptualized. It is unclear how these
scales are used in practice or in training, but inso-
far as they could be used to identify undesirable
or potentially dangerous clinicians is problematic
on many fronts.
One of the chief questions we are asking is
this: Is there a relationship between afrmative
practice or LGBT+ competence as measured by
these scales and actual clinical practice out-
comes? In an interesting study of afrmative
training, Rock et al. (2010) ask the question
“Does afrmative training matter?” and answer
the question by collecting data about perceived
self-competence from students in training.
However, that is not a study that answers the
question of treatment outcomes.
Perhaps more to the point for training,
Hathaway (2014) asks the important question,
“Are conservative religious convictions profes-
sional counter-indicators?” (p.99). A few recent
legal cases have been the impetus to this ques-
tion. In one case (Ward v. Wilbanks, 2010) a
graduate student, Julea Ward, brought a concern
to her supervisor that had to do with whether
she should refer a client as she was unable, for
religious reasons, to afrm his same-sex behav-
ior. The supervisor supported the referral
option, but this led to an informal hearing that
then followed with the decision to force Ward to
either withdraw from the program or go through
a formal review. Ward did not withdraw from
the program, and the formal review was held.
The decision was reached that Ward had vio-
lated the code of ethics of their professional
association. Ward subsequently led a suit
against her program. Although a federal judge
initially ruled in favor of the program, the
appeals court determined that the claim should
go to a jury and questions were raised regarding
the programs’ referral policy and the manner in
which Ward’s religious beliefs were addressed
(Wise etal., 2015).
To return to Hathaway’s (2014) question
about whether conservative religious conviction
can be properly identied as a counter-indicator
to clinical practice, he offers the following:
23 The Complexities ofMulticultural Competence withLGBT+ Populations
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594
Psychologists and other mental health profession-
als with conservative religious views have worked
with people form mixed faith marriages, couples
cohabiting outside of marriage, atheists, those
adhering to other faiths, secularists, couples going
through divorces, and countless other areas of dif-
ference that might represent counternormative
forms of life within those varieties of religious
convictions. We simply do not have at present a
scientic basis to warrant treating students (or
applicants) with conventional religious convictions
on these matters as ipso facto impaired in their
potential to work with clients across value divides.
(Hathaway, 2014, p.99)
There has been an interesting line of research
(e.g., Bassett etal., 2005) suggesting that those
who are high on intrinsic religiosity demonstrate
a regard for LGBT+ persons but may not support
sexual behavior. This has been studied more
recently by Rodriguez-Seijas (2014). It may be
an interesting line of research to consider whether
clinicians with a genuine and deeply help reli-
gious faith may be more likely to respect the
human dignity of, and have heartfelt empathy for,
all clients regardless of their presentation.
To return to the question of training, a poten-
tially signicant concern in training and mentor-
ing of conventionally religious students is the
need to recruit and retain conventionally religious
faculty in training settings: It has been argued
that “pedagogical foreclosure” (Hathaway, 2014,
p. 99) may have contributed to Ward’s posture
and the subsequent polarization. Interestingly,
the case was ultimately settled out of court after
the 6th Circuit court ordered the district court to
rehear it.
There have also been numerous opinion pieces
published in response to this and other legal cases
that could be read as rather dismissive of the
place of sincerely held religious beliefs and val-
ues among students in training or professionals in
general. For example, the language of “if you
can’t take the heat, stay out of the kitchen”
(Plante, 2015, p.96) is unlikely to be as produc-
tive in the discussions surrounding cultural com-
petence, training, and inculcating professional
identity among all students, including those for
whom religious and spiritual considerations
inform moral reasoning in ways that appear
contrary to the current form of the diversity
framework as it is being presented. We turn our
attention now to challenges in achieving cultural
competence in training and practice.
Cultural Competence in Training and Practice It
was mentioned above that one potential chal-
lenge facing the mainstream LGBT+ multicul-
tural movement is that it can function out of the
strong form of the diversity framework without
demonstrating sufcient regard for the other
frameworks and the beliefs and values of the
adherents of those frameworks. We can apply this
to both clinical practice and training.
Culture is often multidimensional; we might
discuss a female client who also self-identies as
African-American and Baptist. The current lan-
guage for this is intersectionality. However, very
little work has been done on the kinds of inter-
sections that are most difcult to navigate, such
as when a person is gay and intrinsically reli-
gious (Yarhouse & Tan, 2003). What if the client
above was a devout Baptist whose faith informed
her moral reasoning regarding sexuality and sex-
ual behavior? What if the client identied as les-
bian or bisexual? What do clinicians need to
know to be either sensitive to or competent with
such a client?
Most of the discussions of culture, compe-
tence, and cultural competence with reference to
LGBT+ issues extend the discussion and deni-
tions used in the broader racial minority literature
and apply it to the LGBT+ community:
Cultural competence with LGBT people therefore
involves the sensitivity and understanding of indi-
viduals in the profession, from trainees to practic-
ing clinicians, about the relevant issues that
specically and uniquely affect members of sexual
and gender minority communities, and those psy-
chological concerns that, while more universally
applicable, differentially inuence those within
these communities. (Boroughs, Bedoya,
O’Cleirigh, & Safren, 2015, pp.152–153)
For others, cultural competence includes hon-
oring members of the LGBT+ community: “As
professionals invested in multicultural compe-
tence, we also hope to train students to honor
those who are different, rather than merely
accepting differences or looking beyond differ-
ences” (Cochran & Robohm, 2015, p.120). It is
M. A. Yarhouse et al.
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595
unclear what “honoring” means in training and
practice, although the statement was made in the
context of a larger discussion of religious and
spiritual beliefs and values which may be held by
students in training. It also follows statements
suggesting a biological basis for sexual orienta-
tion and the claim that efforts to change either
sexual orientation or gender identity are “invali-
dating at best and iatrogenic at worst” (p.120).
Many proponents introduce training and prac-
tice by referencing Sue and Sue’s (2013) model
emphasizing knowledge, attitudes, and skills and
then applying that directly to the topic and inter-
ests of the LGBT+ community—frequently with-
out dening other terms, such as the LGBT+
community as a culture per se and how the diver-
sity within the LGBT+ community, including the
existence of conventionally religious members,
shapes the discussion of culture, and cultural
competence, as well as how one experience of
diversity intersects with other important expres-
sions of diversity, specically religion and spiri-
tualty. These discussions become increasingly
problematic in direct proportion to political con-
siderations. For example, Hope and Chappell
(2015) extend the discussion of knowledge, atti-
tudes, and skills to include a fourth area of com-
petence: advocacy. We do not disagree with the
value of learning advocacy in psychology; how-
ever, the charge for mental health professionals to
see themselves as advocates and social justice
practitioners for those who are LGBT+ rarely
reects the nuances needed to demonstrate
respect for multiple stakeholders in a discussion
about LGBT+ concerns. In this context, it is
unclear how to best dene “social justice” in
LGBT+ contexts and how to address the many
divergent perspective represented.
It is one thing to lobby for access to mental
health services or to advocate for safety in a local
school system. It is another thing to advocate for
legislation for/against a student trainee’s right to
abide by sincerely held religious beliefs regarding
client services. Consider the recent discussions
centering on training in which conventionally
religious students experience a conict with
working with specic client presentations, such
as a same-sex relationship. For some embroiled in
the political debates, these are policies and
debates about “convictions of conscience”; for
the vast majority who have written about these
matters in our eld, however, these are clearly
legislative efforts focused on “refusal of services.”
With few exceptions, this is the way the matter is
framed with an almost “everybody knows” qual-
ity about which is the correct side in the debate.
So are these conicts in training a matter of
religious liberty or of prejudice and bigotry? Our
position is that neither of these two dichotomies
captures the nuance needed to adequately respond
to the complexities inherent in balancing the inter-
ests of multiple stakeholders in areas of overlap-
ping competence and diversity. Yet much of the
mainstream LGBT+ discussion—often anchored
in a vision of cultural competence—discusses
these cases with the foregone conclusion that the
proper frame is “refusal of services” steeped in a
kind of religious prejudice and bigotry anathema
to professional training and ethics.
One of the better and more tempered state-
ments came from the APA Board of Education
Affairs, which approved a statement developed by
the Education Directorate’s Working Group on
Restrictions Affecting Diversity Training in
Graduate Education. Part of that statement states:
Training environments foster the ability of trainees
to provide competent care to the general public,
and trainees’ competencies in professional practice
are evaluated regularly. Some trainees possess
worldviews, values, or religious beliefs that con-
ict with serving specic subgroups within the
public. For example, they may experience strong
negative reactions toward clients/patients who are
of a particular sexual orientation, religious tradi-
tion, age, or disability status. Trainers take a devel-
opmental approach to trainee skill and competency
acquisition, and support individual trainees in the
process of developing competencies to work with
diverse populations. Trainers respect the right of
trainees to maintain their personal belief systems
while acquiring such professional competencies.
Trainers also model the process of personal intro-
spection; the exploration of personal beliefs, atti-
tudes, and values; and the development of cognitive
exibility required to serve a wide diversity of cli-
ents/patients. Training to work with diverse clients/
patients is integral to the curriculum, and consists
of both didactic coursework and practical training.
http://www.apa.org/pi/lgbt/resources/policy/diver-
sity-preparation.aspx
23 The Complexities ofMulticultural Competence withLGBT+ Populations
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The emphasis in the document is on core compe-
tencies to practice psychology and the “pedagog-
ical support and time” needed to train students:
Training programs, trainers, and trainees cannot
be selective about the core competencies needed
for the practice of psychology because these com-
petencies are determined by the profession for the
benet of the public. Further, training programs
are accountable for ensuring that trainees exhibit
the ability to work effectively with clients/patients
whose group membership, demographic charac-
teristics, or worldviews create conict with their
own. Trainers respectfully work with trainees to
benecially navigate value- or belief- related ten-
sions. At times, training programs may wish to
consider client/patient re-assignment so trainees
have time to work to develop their competence to
work with client/patients who challenge trainees’
sincerely held beliefs. Trainers utilize profes-
sional judgment in determining when client/
patient re-assignment may be indicated in this
situation as in all other possible situations in
which client/patient re- assignment may be con-
sidered. The overriding consideration in such
cases must always be the welfare of the client/
patient. In such cases, trainers focus on the train-
ees’ development, recognizing that tensions aris-
ing from sincerely held beliefs or values require
pedagogical support and time to understand and
integrate with standards for professional conduct.
Thus trainees entering professional psychology
training programs should have no reasonable
expectation of being exempted from having any
particular category of potential clients/patients
assigned to them for the duration of training.
http://www.apa.org/pi/lgbt/resources/policy/
diversity-preparation.aspx
The APA (2011) has offered more detail on con-
tent areas for clinicians to be aware of when look-
ing at competence, and we see these as promising.
They are more descriptive and allow for nuance
in discussing a range of stakeholders and inter-
secting identities, beliefs, and values:
Key areas for psychologists to be familiar with
include, but are not limited to, an understanding of:
(1) human sexuality across the lifespan; (2) the
impact of social stigma on sexual orientation and
identity development; (3) the ‘coming out’ process
and how such variables as age, gender, ethnicity,
race, disability, religion, and socioeconomic status
may inuence this process; (4) same-sex relation-
ship dynamics; (5) family-of-origin relationships;
(6) the struggles with spirituality and religious
group membership; (7) career issues and work-
place discrimination; and (8) the coping strategies
for successful functioning. (APA, 2011)
We see these as promising insofar as they describe
basic lines of research with which a clinician can
become aware. At the same time, we encourage
familiarity with how these content areas may be
discussed with reference to the different frame-
works mentioned throughout this chapter: diver-
sity, disability, and sacred. We are not suggesting
these are equally weighted; however, insofar as
such content areas set the parameters for training
and clinical practice out of a diversity lens to the
exclusion of the other frameworks, we want to at
least raise the concern that current training and
practice approaches may be incomplete.
As we bring this chapter to a close, we want to
return to some of the observations made by
O'Donohue and Benuto (2010) on what needs to
be claried in the cultural sensitivity/competence
movement. We have adapted their suggestions and
added language relevant to the three frameworks
we have presented in this chapter and applied
them to LGBT+ studies with the intention of
developing a more integrated, multicultural
framework for professional training and practice.
• Identify the framework or lens through which
persons see themselves and their experiences
of sexual identity or gender identity-related
matters.
• Identify the cultures to which an individual
LGBT+ client belongs and the broader
regional and contemporary social and cultural
context in which the person resides, including
the person’s religious and/or spiritual identity,
beliefs, and values as relevant.
• Recognize when lenses or frameworks associ-
ated with LGBT+ issues and cultural experi-
ences and convergences across cultural
experiences are salient to the professional ser-
vices being offered.
• Navigate salient frameworks or lenses relevant
to LGBT+ issues and the cultural experiences
and potential points of conict in a profes-
sional and ethical manner, recognizing that the
mental health professions cannot adjudicate
religious doctrinal positions, including ques-
tions of morality.
• Provide interventions in a way that is compe-
tent and sensitive to the identied frameworks
or lenses through which the client views
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LGBT+ issues and the cultures and potential
points of convergence and conict therein.
• Recognize the many variations among
relevant lenses or frameworks through which
people view LGBT+ concerns and the cultures
that may be present in any clinical scenario.
• Understand how the clinician’s own preferred
framework or lens through which he or she
views LGBT+ issues, including how his or her
culture, values, and beliefs interact with the
salient issues presented by the client’s culture.
Each of these points is worthy of further empir-
ical study. While it may be helpful to distinguish
between cultural competence practiced at the level
of the individual and at the level of the institution
(see Carpenter-Song etal., 2007), it is even more
foundational to recognize the frameworks people
use to “see” LGBT+ issues and how underlying
assumptions may inform the present cultural com-
petence movement in LGBT+ studies.3
3
Cultural competence is understood by Carpenter-Song
etal. (2007) to be practiced at the level of the individual
“in the application of specic techniques and skills in the
context of clinical encounters” and at the level of the insti-
tution “in the promotion of organizational practices to
meet the needs of diverse populations” (p.1363).
Along these lines, when we look at institutional consider-
ations, we want to recognize areas for potential improve-
ment in serving different groups. However, there is a
long-standing practice in which one division in the
American Psychological Association regularly reviews
reaccreditation of religiously afliated doctoral programs
in clinical psychology and provides public comment on
these programs and expresses concerns for whether and
how religiously afliated programs provide for the train-
ing and care for LGBT+ students, faculty, and staff, as
well as how they conduct education and training in regard
to LGBT+ client services. It is not so much that such
actions are inappropriate; however, there is no docu-
mented attempt by this division to contact the psycholo-
gists in those programs directly about their professional
and/or ethical concerns as directed by the APA ethics
code, nor is there a sense of self-awareness for how those
raising concerns address cultural competence insofar as it
intersects with conventional religiosity in the lives of stu-
dents training at their own institutions and practice set-
tings. The assumption that potential bias is only in one
direction is remarkable given prior evidence suggesting
bias against conventionally religious applicants to psy-
chology programs (e.g., Gartner 1986). Such practices are
unlikely to produce the kind of professional discourse
necessary to improve training and competence in multiple
areas of diversity across varying training sites.
What does cultural adaptation of services mean
for treatment of LGBT+ persons? This question
primarily discussed under the umbrella of gay
afrmative therapy. However, gay afrmative
therapy functions more like a lens through which
professionals see people rather than a protocol for
treatment. In that sense, adapting services func-
tions more like choosing feminist therapy rather
than cognitive behavioral therapy. Therein lies a
pragmatic applicability of cultural competence.
That is, it is quite unclear how to operationalize
in-session behaviors associated with multicultural
competence with LGBT+ clients.
We saw a promising development in the APA
Task Force Report on Appropriate Therapeutic
Responses to Sexual Orientation (APA, 2009) in
which the task force recognized the distinction
between types of congruence. That is, the task
force distinguished between organismic congru-
ence, in which a person resolves sexual identity
concerns in keeping with their impulses and sen-
sate self, and telic congruence, in which a person
pursues congruence in keeping with a view of
their ideal self and transcendent interests. These
are philosophical differences in which organis-
mic congruence is often associated with what we
refer to as a diversity framework and telic con-
gruence is likely associated with a sacred frame-
work. What we appreciated about the report was
an awareness that either type of congruence could
be viable in the life of the person seeking clinical
services in light of a conict between their sexual
identity and religious identity. From the report:
This difference in worldviews can impact psycho-
therapy. For instance, individuals who have strong
religious beliefs can experience tensions and con-
icts between their ideal self and beliefs and their
sexual and affectional needs and desires
(Beckstead & Morrow, 2004; D.F. Morrow, 2003).
The different worldviews would approach psycho-
therapy for these individuals from dissimilar per-
spectives: The telic strategy would prioritize
values (Rosik, 2003; Yarhouse & Burkett, 2002),
whereas the organismic approach would give
priority to the development of self-awareness and
identity (Beckstead & Israel, 2007; Gonsiorek,
2004; Haldeman, 2004). It is important to note that
the organismic worldview can be congruent with
and respectful of religion (Beckstead & Israel,
2007; Glassgold, 2008; Gonsiorek, 2004;
Haldeman, 2004; Mark, 2008), and the telic
worldview can be aware of sexual stigma and
respectful of sexual orientation (Throckmorton &
23 The Complexities ofMulticultural Competence withLGBT+ Populations
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598
Yarhouse, 2006; Tan, 2008; Yarhouse, 2008).
Understanding this philosophical difference may
improve the dialogue between these two perspec-
tives represented in the literature, as it refocuses
the debate not on one group’s perceived rejection
of homosexuals or the other group’s perceived
minimization of religious viewpoints but on philo-
sophical differences that extend beyond this par-
ticular subject matter. However, some of the
differences between these philosophical assump-
tions may be difcult to bridge. (p.18)
The task force then identied a few published
accounts of approaches to clinical services with
conventionally religious persons that seem prom-
ising insofar as they reect an awareness of these
different worldviews and philosophical differ-
ences (e.g., Throckmorton & Yarhouse, 2006;
Yarhouse, 2008).
In addition to this specic and promising
account, it may be helpful to identity additional
suggestions. As O'Donohue and Benuto (2010)
observe, suggestions include identifying the cul-
tures to which an individual client belongs, recog-
nizing when cultural experiences and convergences
across cultural experiences is salient to the profes-
sional services being offered, navigating salient
cultural experiences and potential points of conict
in a professional and ethical manner, obtaining
knowledge for how to provide interventions in a
way that is competent and sensitive to the identied
cultures and potential points of convergence and
conict therein, developing an expanded apprecia-
tion for the many variations in among relevant cul-
tures that may be present in any clinical scenario,
and having an understanding of how the clinician’s
own culture, values, and beliefs interact with the
salient issues presented by the client’s culture. A
concern has also been raised as to whether cultural
sensitivity and cultural competency as a movement
are more of a political consideration than a scien-
tic consideration (O'Donohue & Benuto, 2010).
As the authors observe, there are entire groups and
cultures (e.g., Italian-Americans) omitted from the
discussion of cultural sensitivity and competence;
this may be because “these are the
traditional political categories used in a certain
political narrative and…these standard political
categories have been imported into these scientic
questions” (p.37).
To the extent that cultural competence as a
movement may be more political than scientic,
is it possible that such a movement is in some
ways a reection of a more homogenous liberal/
progressive sociopolitical orientation of those
drawn to both academia and the eld of clinical
psychology? In the language we have used in this
chapter, are those who are shaping the contours
of the eld committed to a diversity lens with
little awareness of other lenses through which
their colleagues and their clients experience these
phenomena? Does a true cultural competence by
denition require a broader view of the landscape
and a shared humility around various ways in
which people navigate these experiences? If so,
such trends warrant further study so we are
increasingly aware of our own biases that may
inadvertently shape training and service provi-
sion in the years to come.
Conclusion
What we have suggested throughout this chapter is
that there are different frameworks in use by prac-
titioners, clients, students, and other stakeholders
when approaching LGBT+ populations, clients,
and concerns in a culturally competent manner.
These frameworks represent a range of diverse
ways to understand sexual and gender identity
concerns. However, the prevailing or dominant
narrative of diversity that currently informs train-
ing and practice in LGBT+ concerns is weighted
toward one framework that can at times exclude a
more robust engagement of those who adhere to or
draw upon other frameworks. By shedding light
on other existing frameworks, we aim to enhance
the reader’s culturally competent approach to
working with the LGBT+ community.
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Author Queries
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Queries Details Required Author’s Response
AU1 Yarhouse and Tan (2003) are cited in text but not in reference list. Please provide
reference detail.
AU2 Reference “Petchauer et al. (2007)” are not cited anywhere in the text. Please provide
in text citation or delete the reference from the reference list.