Chapter 1. Lesbian: The L in LGBTQ²IAPA

Although it is generally no longer true that gay bars are the main place where queer people meet, queer people, both men and women, have higher rates of alcohol and drug use disorders than the general population. The higher risk is likely due to minority stress—a concept that will be explained multiple times in this text—which generally refers to the stress individuals encounter from being different from the larger population around them. Histories of sexual and physical trauma, which affect all women, may further increase queer women’s risk of addictions. Queer women may benefit from recovery services that address their complete identities and offer support from other queer women.

Although children, youth, and adult-age lesbians and queer women may experience bullying, gender-nonconforming individuals are at highest risk to become the targets of bullying in elementary, middle, and high school years or by school-age peers. Girls and female youth who dress or present as more masculine, whether or not they later identify as gay, are often targets of bullying. Without a strong support system and healthy self-esteem, these young people or children are vulnerable to verbal and physical violence. Butch lesbians, studs, or bois may be confronted with physical assaults, which may lead them to consider or carry out self-harming or suicidal behavior. Efforts to reduce bullying or threat of violence will provide a more validating environment for women to express their identities.

Coming out as a gay woman or lesbian may be a lengthy and complicated process if the youth or woman fears identifying as gay because of stigma. Lesbians and queer youth have been thrown from their homes because of family rejection, and the world continues to be an unsafe place for queer people regardless of where they live. Other young lesbians have experienced support and acceptance, allowing them the opportunity to move through developmental sexual milestones, although the process is rarely a linear one. There is still outside influence from the community, religious organizations, and the media, which can have an effect on a person’s identity journey. Furthermore, it is possible for people to come out as gay or lesbian and decide later on that they no longer identify that way—remember that sexual orientation for some can be fluid (Magee and Miller 1997).

It is important to create a safe space for individuals to explore their sexual identity issues and to ask awkward and uncomfortable questions. It is critical that clinicians leave judgment out of the room. Allow people to determine their own sexual orientation and social presentation at their own pace. It is important for people who are coming out to have social supports to help them maintain their emotional health and personal safety. If an individual is worried she will be kicked out of her family and home, listen to her and honor her fears until it is clear that she is in a safe place at home or elsewhere. Too many LGBTQ+ young people are disowned by their families and become homeless overnight.

Clinicians should be mindful that people who appear to be knowledgeable about the LGBTQ+ community might also need help with the coming out process. Even lesbian or queer-identified moms might need help with their children in the coming out process. Some parents in their supportive enthusiasm have outed their children on social media, leaving children and young people in an awkward and vulnerable position. Children and youth should talk with their supportive parents and family members about the different ways to come out. Communication is key. There are pros and cons in every situation, and children and youth need time to reflect on these issues rather than impulsively coming out to their larger communities.

The experience of coming out as a lesbian in countries outside of the United States lies on a spectrum of acceptance through imprisonment and risk of death by death penalty. Even in the United States, LGBTQ+ people do not have equal civil rights to their straight counterparts. Individual liberties can differ greatly depending on geographic location. Queer people can lose their jobs, homes, access to medical care, or parental rights despite recent civil rights progress. Be mindful of people from other countries who have fled their homelands out of fear of persecution. Some patients may need help with asylum because returning to their countries of birth could mean imprisonment or death.

End-of-life issues for lesbian and queer women may be simple or more complicated depending on the level of pre-preparation that has been done legally. Some lesbians choose to legally outline their rights and specifications for medical treatment as well as for what they own. Death-related concerns can become more complicated depending on the degree of family support and acceptance, as well as the strength of friendships and other social supports involved in the process. Lesbians with strong community and family supports who lose their lesbian spouse or intimate partner may live more satisfying or positive lives versus spending their lives in isolation. Those with fewer supports are at an increased risk for suicide. Bereavement counseling and support groups are important resources for survivors. When working with patients who are either dying or have lost a loved one, be mindful of their social network and supports.

Lesbians have built families with varying degrees of biological family members versus chosen family members. Queer women have been having children as long as there have been people. Whether or not they have been out about their identities during this process is another story. We know that gay and lesbian parents have children who are no different from the children of heterosexual parents.

Lesbians or queer women bring children to their relationships in a variety of ways. Some women have children together using sperm from chosen donors. Some women come out later in life after having had children from heterosexual relationships. Other women choose to have children by becoming foster parents or through adoption. Laws around parental rights may differ from state to state. Patients should be encouraged to be aware of the legal aspects regarding their children. It is also important for queer parents to be aware that their struggles with their children are typically not due to the parent’s queer identities. Some queer mothers who have troubled children might blame their queer identity as the cause; however, all parents have some difficulties with their children, and queer parents should be reminded that this is true for them, just as for any other parent. It is important for clinicians to be aware how the many different facets of a person’s identity can affect an already complicated parent-child relationship.

Gay women and lesbians, just like any person, can act in violent ways—emotionally, verbally, physically, and sexually. Whether they are more feminine, more masculine, or somewhere in between, women can be both the victim or perpetrator of violence in intimate relationships. Similar to straight peers who batter, gay women are brought up in families where domestic abuse occurs, and individuals may experience the violence directly or by witnessing it. Be aware of your own assumptions around women in relationships and understand that there are many ways in which violence can manifest.

The U.S. Supreme Court guaranteed same-sex couples the fundamental right to marry in Obergefell v. Hodges in 2015, but, despite the new freedoms, many queer couples who have openly married have suffered consequences due to their expressions of love. Some have found themselves legally unemployed through job termination, homeless after being kicked out of their housing by homophobic landlords, or faced with finding new health providers because their doctors don’t feel they are morally obligated to treat queer people. Political climates can vary greatly, and queer women unfortunately have to consider potential consequences they might face due to their sexual identity. Because of confidentiality, a mental health provider’s office might be the only place a queer woman feels safe expressing herself and asking questions about her health.

Ilan Meyer, Ph.D., developed a model of stress and illness in minority populations that demonstrates that discrimination and prejudice have an additive effect on minority individuals at the intersection of their sexual orientation, race, ethnicity, and gender identities (Meyer 2003). Dr. Meyer’s research has also demonstrated that sexual minority individuals with multiple minority identities have poorer health and mental health outcomes due to these additive effects. Research using the minority stress model has been effective in demonstrating the impact of social stressors on increasing risk for addiction, homelessness, unemployment, isolation, sexual violence, interpersonal violence, suicide, and homicide. In the past, some people might have blamed a person’s identity as the cause of their increased stressors. This turned out to be true, but not in the way imagined. Having a minority status in a larger homogenous community is likely the cause. If minority people were surrounded by people who were like them, they likely would not face these medical and mental health disparities.

Despite a sordid history of religious nonacceptance, queer people are finding many more supportive religious groups today. Even so, many gay and lesbian women who value their religious life and community continue to experience loss of church and other religious communities because of their identities. This loss may be a particularly devastating experience for some individuals and families who have grown up within a tight-knit religious community. Finding themselves rejected by their community may be as or more harmful than losing family. When meeting with an individual who is working through these loss issues, you must first understand the seriousness of this loss in the person’s mind and then support them through their grief process. Some religious groups are more judgmental or harsh than others. Levels of prejudice can vary widely within religions that have otherwise homogenous ideologies. Some religions have been guilty of outright abusive behavior toward queer women. Religion can often be thought of as another support network that may need attention to ensure a person’s safety. Gaychurch.org is a website helpful to those in need of finding a religious home.

Same-sex parents are visible today in schools in larger numbers than ever before. Same-sex parents deserve the same respect from teachers and administrators given to their heterosexual counterparts. It is important for schools to have safe spaces for parents and children and be mindful that a parent’s sexual identity may create unique situations depending on the overall acceptance level of the community.

Queer parents will often deal with their own set of challenges. As their child ages, they will likely need to come out all over again to a new set of people—teachers, day care providers, pediatricians. Helping parents find groups of same-sex parents and their allies may be the most effective way to support parents and their children. Connecting parents to support such as COLAGE (www.colage.org) and Family Equality (www.familyequality.org), as well as other resources, may be helpful.

Rates of suicide and suicidal behavior have long been identified as being significantly higher in queer people than straight peers. LGB youth ages 10–24 years have suicidal ideation about three times as often as heterosexual peers (Centers for Disease Control and Prevention 2016). This is largely believed to be likely due to minority stress, as mentioned previously. Suicidal behavior is increased in gay female youth, and clinicians should be mindful of this when doing suicide assessments or working with patients in crisis (Haas et al. 2011).

Everything previously said about risk factors and minority stress needs to take into account that queer women of color will experience increased doses of stigma and harm or even more, depending on their intersecting identities (National Center for Health Statistics 2012). The data on black women being at increased risk for pregnancy complications and loss, regardless of their socioeconomic status and access to health care, show that minority stress is expressed in a variety of ways. Queer ethnic minority women face increased stigma, discrimination, and stress burden. They may also have a harder time building a support network. Women of color may have a more difficult time finding community within lesbian social circles and organizations, which will likely be majority white and may feel unwelcoming to women of color. When working with queer women of color, consider how a woman’s race may affect her current life stressors and be open to conversations about race.