Lesbians: Practice Interventions
Abstract and Keywords
This entry will provide an overview of psychosocial issues and social work intervention relevant to working with lesbians. Practice issues related to the impact of heterosexism, coming out, lesbian identity development, and lesbian couple and family formation will be discussed. Assessment and intervention methods appropriate for social work practice with lesbians will be addressed.
Lesbians are women whose intimate attractions are to other women. Lesbians compose ∼4–12% of the U.S. population (Gates & Ost 2004; Green, 1994; Patterson, 1995). Some are single, some are in partnered relationships, and many are also parents. Lesbians are impacted daily by the pervasive social stigma assigned to sexual minority people. This stigma is made manifest through homophobia, the fear and hatred of gay and lesbian people, and heterosexism, the belief in the superiority of a heterosexual orientation over lesbian and gay orientations (Morrow, 1996a). The effects of these forms of oppression permeate virtually all facets of lesbian and gay lives. Yet, many social workers have limited preparation for serving lesbian clients, even though such preparation is called for in social work education standards (Council on Social Work Education, 2004).
Lesbian Identity Development
Recognizing and coming to terms with one's identity as lesbian is a lengthy process. Heterosexism confers legal, political, and social privilege on those who identify as heterosexual and concomitant negation of those who identify as lesbian or gay. Therefore, to develop a positive lesbian identity, lesbians must engage in the process of critically examining the effects of heterosexism on their lives. They must work to dismantle the negative stereotypes and untruths perpetrated against them and seek to affirm and validate their own existence as lesbian women.
Numerous models of lesbian identity development have been proposed (Chapman & Brannock 1987; McCarn & Fassinger 1996; Ponse, 1978; Raphael, 1974; Sophie, 1986), the most recent of which is by McCarn and Fassinger (1996). Their model proposes four phases of identity development, or progression, for lesbians. Phase one, awareness, relates to a person's increasing awareness of being different from the dominant heterosexual culture. One's prior assumptions of heterosexuality are called into question. There is a growing awareness that heterosexuality is not universal—that there are other forms of sexual orientation other than heterosexuality.
Phase two, exploration, involves continued critical examination of a lesbian identity in relation to presumptive heterosexuality. Women in this phase may demonstrate strong feelings for other women. They may actively pursue knowledge about lesbian and gay people, and they may nurture their interest in the possibility of developing group membership with other lesbians.
In phase three, deepening or commitment, there is a growing sense of individual identity characterized by further clarity and self-understanding as lesbian. Critical examination of the effects of heterocentric culture and the related social oppression of those who identify as lesbian also occurs. In further describing this phase of development, McCarn and Fassinger (1996) state, “The emerging lesbian is likely to recognize her desire for other women as within herself and, with deepening self-awareness, will develop sexual clarity and commitment to her self-fulfillment as a sexual being” (p. 523).
Phase four is known as internalization or synthesis. This phase involves a deepening self-acceptance of one's personal identity as lesbian. A woman in phase four has clarity and focus about who she is as a lesbian. Her internal and external expressions of identity are integrated and she exhibits a synthesis of her sexual identity with the external world.
Assisting lesbians with moving through the processes of identity development can be an essential feature of social work intervention with this population. A strengths-based perspective is an appropriate intervention framework, given the oppressive impact of heterosexism. Facilitating client understanding that coming to terms with a lesbian self-identity is a normative and progressive process can be empowering. Assisting clients in critically examining the forces of heterosexism in their own lives is an important step toward beginning to dismantle its power.
Coming out, or disclosure, is a common issue for many lesbians seeking social work intervention. Disclosure may be defined as the acknowledgment of a lesbian (or gay or bisexual) identity to oneself and then to others. Disclosure is often positively correlated with progression through the stages, or phases, of identity development (Cass, 1979; Kahn, 1991; Morrow, 1996b). That is, the farther along a person is in accepting herself as lesbian, the more likely she is to disclose that identity to others.
Social workers may observe there is a great variability in the degree of “outness” among lesbians. Appropriate intervention is individually driven, as each individual has a right to self-determine her personal degree of outness. Workers can assist clients with examining the consequences of disclosure for given contexts—for example, outness at work or with one's family of origin. Berzon (2001) suggests there are two principal reasons for disclosure. The first is the personal growth that can accompany being honest about oneself, and the second is the political power in being part of a visible lesbian or gay community. Berzon states, “The changes that are needed in social policies and in laws in order to improve the quality of life for gay people have come only when there was a political and economic gay and lesbian constituency that was visible and identifiable” (2001, p. 28). Other motivating factors for disclosure include the desire to preserve a sense of integrity and honesty within oneself and when interacting with others (Harry, 1993), an interest in maintaining openness and closeness in communicating with others (Ben-Ari, 1995a; Cramer & Roach 1998), an interest in increasing one's self-confidence and in developing an improved self-image (Rhoads, 1995), and a desire to avoid the social and psychological effects of secrecy and falsehood (Ben-Ari, 1995a; Cain, 1991; Harry, 1993).
Reasons that people give for avoiding coming out include fear of rejection (Elliott, 1996; Harry, 1993), fear of being physically harmed (Elliott, 1996), fear of discrimination and harassment (Rhoads, 1995), and a desire to protect loved ones from the stress that disclosure may bring (Ben-Ari, 1995b; Boon & Miller 1999). A particularly stressful coming out event for lesbian and gay people is disclosure to parents (Boon & Miller 1999). Social workers are prudent to keep in mind that the greatest predictor of outness among lesbians is their perception of other people's acceptance of lesbian and gay people in general (Franke & Leary 1991). Workers can help clients assess the potential climate of acceptance or rejection of disclosure to others. They can also help clients develop and rehearse disclosure statements, as well as help them formulate responses to potential rejecting statements. Additionally, they can assist lesbian clients considering disclosure and make connections with affirming community resources, such as PFLAG (parents, family, and friends, of lesbians and gays) and to the Human Rights Campaign National Coming Out Project (Morrow, 2006a).
In transitioning from childhood to adulthood, adolescents engage in the task of identity development (Erikson, 1950, 1963). For lesbian adolescents, the process carries added challenges in that their developing sense of lesbian identity is imbued with stigma. Thus, a principal task for lesbian adolescents is to adjust to the social stigma assigned to being lesbian (Hetrick & Martin 1987). Their sense of self as lesbians is developed in the midst of intense social pressure to be heterosexual. Lesbian adolescents have few adult role models and few social resources to assist them in developing a positive identity.
Many lesbian youth go through a questioning period before arriving at an internal understanding of who they are as lesbians. Because of the overwhelming social pressure to be heterosexual, lesbian youth often present a history of attempts at other-sex relationships prior to identifying as lesbian (Coleman & Remafedi 1989). They may fear that being same-sex identified is pathological, and they may fear the social repercussions of being “found out” as lesbian by others. Some may cope by engaging in risky behaviors such as sexual promiscuity, substance abuse, running away, or suicide (Gonsiorek, 1988; Morrow, 2006b; Proctor & Groze 1994; Savin-Williams, 1994).
A particular challenge, and risk, for lesbian adolescents is coming out to family. Those who disclose to families hope for greater honesty, closeness, and support. Yet, they are also at-risk for rejection and violence by family members (Teague, 1992). The risk of rejection can be especially high in minority families where being gay may carry a particularly intense stigma (Newman & Muzzonigro 1993). There is some evidence that lesbian and gay youth who have a close relationship with their families may be more reluctant to disclose their sexual orientation because of fear of disappointing their loved ones (Waldner & Magruder 1999). Such youth may experience more internal pressure to try and meet the heterosexual expectations held by family.
D'Augelli, Hershberger, and Pilkington (1998) found that, of those lesbian and gay youth who disclose to families, they are more likely to come out to mothers than to fathers. In a sample of over 100 lesbian and gay youth who had disclosed to families, only half the mothers and siblings were accepting of the news, and that less than 25% of fathers were accepting. Youth who disclosed their sexual orientation were at greater risk of violence from family members. Thus, social workers are prudent to recognize the potential risks for lesbian youth in coming out to families. D'Augelli (2008) found that gay youth, who had disclosed their sexual orientation to parents, experienced reduced family support.
Social work intervention with lesbian adolescents includes helping them explore their emerging sexual identity in a safe and affirming environment. Psychosocial education related to lesbian identity development, coming out, and healthy relationship development can be valuable. The Family Acceptance Project (Ryan, 2010) identifies family behaviors that reduce risk and promote well-being among LGBT youth including: family discussions with youth about theiri LGBT identity; requiring that members of the family respect LGBT members; and, connecting the LGBT youth to adult role models. Helping lesbian youth recognize, understand, and cope with the effects of heterosexism can also be beneficial. Because of the social stress that accompanies being lesbian in a heterocentric social culture, assessment of lesbian youth should include screening for depression, suicide, and substance abuse. In addition, assessment with lesbian adolescents should include exploring family supports, as well as assessing for a history of violence or abuse based on the adolescent's sexual orientation (Morrow, 2006b).
Lesbian Relationships and Families
Heterosexual culture supplies a bounty of legal, social, and religious sanctioned rituals to demarcate relationship and family development (Human Rights Campaign, 2003; Johnson, 2000; Parks, 1998; Slater & Mencher 1991). Many of those rituals, such as legal marriage and two-parent legal guardianship of children, are not available to lesbian relationships and families in most states. This lack of social recognition is noteworthy in that how people view themselves is influenced, in part, by how they are viewed by the larger social context in which they exist. To a great extent, lesbian relationships and families are rendered socially invisible. Lesbians must learn to build their relationships and families within a culture that denies their very existence. Partnered relationships are dismissed as friendships and lesbian parents are questioned in terms of who is the “real” mother of a child.
The term, fusion, has been proposed to describe the nature of some lesbian relationships. Fusion relates to a deep connection between the members of the couple, whereby healthy individual boundaries may become compromised by an overemphasis on the coupled identity, and individual identity becomes overshadowed (Burch, 1985; Krestan & Bepko 1980; Lowenstein, 1980). A critical examination of the concept of fusion in more recent years, however, has supported the premise that fusion is a functional adaptation by lesbian couples for coping with a negating social environment (Laird, 1993; Mencher, 1990; Slater & Mencher 1991). When threatened by external forces such as religious and legal sanctions, a “circling of the wagons” to protect the integrity of the coupled relationship is a reasonable adaptation. Whenever the outer world is threatening, greater energy is directed toward the more validating inner world of the couple relationship.
Nonetheless, such adaptation may still be stressful for couples. Social work intervention with couples can include helping them establish connections with validating external supports, such as lesbian-affirming social groups, friendship networks, and faith communities, so that couples can nurture healthy individual boundaries as well as preserve the integrity of the coupled relationship. Evidence also supports that affirmation of lesbian couples by friends and family helps to reduce characteristics of fusion and enhance couple satisfaction (Caron & Ulin 1997; Eldridge & Gilbert 1990; Parks & Humphreys 2006).
Researchers have found that lesbians as parents tend to value the equitable distribution of parenting and household responsibilities (Patterson, 1995; Sullivan, 1996). This finding contrasts with traditional heterosexual relationship patterns in which women are expected to have greater involvement than men in both parenting and household responsibilities. Patterson (1995) found this more equitable distribution of responsibilities was beneficial to the family adjustment of both parents and children.
Children of lesbian parents tend to fair as well as children of heterosexual parents in terms of normative development. In studies of children reared by lesbian parents compared with children reared by heterosexual parents, no significant differences were found with regard to gender identity (Patterson, 1992), intellectual development (Flaks, Ficher, Masterpasqua, & Joseph 1995; Green, Mandel, Hotvedt, Gray, & Smith 1986), behavioral problems (Flaks et al., 1995; Lewis, 1980), and overall psychological adjustment (American Psychological Association, 2004).
Social work intervention with lesbian families includes, above all, validation of the family experience. Similar to any couple, regardless of sexual orientation, lesbian couples may seek support for coping with the stress of family life and parenting. In addition, intervention with lesbian families must recognize the impact of heterosexism on the family. Workers may be called on to advocate for equitable legal treatment of lesbian women involved in child custody battles—especially when the status of their sexual orientation per se is under attack.
Social work advocacy on behalf of legal recognition of lesbian relationships and lesbian families is critical to preserving the security and continuity of lesbian families and their children.
Older lesbians are an especially isolated and closeted population. They came of age in an era when being gay was presumed to be mental illness. Institutional settings, such as assisted living centers and nursing homes, are decidedly heterosexist in nature. There is little place for the recognition of lesbian couples and families, including the option for lesbian couples to share a room together. Social work intervention in these and related medical settings often centers on validation of a lesbian presence and advocacy for the inclusive and equitable treatment of lesbians and their families.
Encountering heterosexism and homophobia on a virtually daily basis can have an impact on lesbian health and well-being. The internalization of social shame related to being lesbian can be a risk factor for the occurrence of substance abuse (Bobbe, 2002; Garofalo, Wolf, Kessel, Palfrey, & DuRant 1998), depression (Ryan & Gruskin 2006), and suicide (Hershberger & D'Augelli, 1995; Remafedi, Farrow, & Deisher 1991). Therefore, social work assessment and intervention with lesbian women should address these areas of concern.
Health care delivery systems have generally been perceived as unreceptive to lesbians (Ryan & Gruskin 2006). Medical forms often exclude the recognition of lesbian relationships and families. Health care providers presume heterosexuality among women patients. Lesbians may refrain from disclosing their sexual orientation to healthcare providers for fear of being ostracized and viewed as deviant. Antigay bias has been found in both physician (Schatz & O'Hanlan, 1994) and nurse (Eliason, 1998) attitudes toward lesbian and gay patients. Lesbians seeking options for parenting have reported discrimination from reproductive healthcare providers (Ryan & Gruskin 2006). Social workers in healthcare settings can provide diversity training for staff on sexual orientation topics, and workers can also advocate for creating more inclusive health care environments (for example, inclusive medical forms, recognition of partnered relationships).
Some concerns have been raised regarding a potential higher risk for breast cancer among lesbians in comparison to heterosexual women. However, research to date has not supported a higher incidence (Ryan & Gruskin 2006). Findings, however, have concluded that lesbians are less likely to receive preventive healthcare such as mammograms and gynecological examinations that can lead to early detection of cancer (Cochran, et al., 2001).
An important health issue for lesbians is the use of conversion (also known as reparative) therapy for the purpose of changing a person's sexual orientation from lesbian or gay to heterosexual. Conversion therapies often occur within the context of socially conservative religious traditions. Techniques used to try and change sexual orientation include religious-based shaming, prayer, exorcism, and punishment-oriented forms of behavior modification (Ritter & O'Neill, 1989; Tozer & McClanahan, 1999; White, 1995). Conversion therapy is considered an unethical form of practice by a number of national professional associations, including the National Association of Social Workers, the American Counseling Association, the American Psychological Association, and the American Medical Association (Haldeman, 1994; Jenkins & Johnston 2004; Tozer & McClanahan, 1999). Intervention with lesbian clients seeking to change their sexual orientation to heterosexual is better focused by helping them explore and respond to the internal and external homophobia and heterosexism that creates shame and guilt surrounding their sexual orientation.
Religion and Spirituality
Intervention with lesbian clients must recognize the personal and cultural impact of religion and spirituality. Most Americans are reared with some sort of connection to religious or spiritual ties. As a social institution, religion has long been a tool of heterosexism and oppression against lesbians and gay men (Davidson, 2000; Hilton, 1992; McNeill, 1993; Spong, 1991, 1998). Indeed, the term, “family values,” is for many people a code-phrase representing anti-gay and lesbian social and political perspectives. Many lesbians struggle with their sexual minority status in relation to their faith community teachings on homosexuality. This struggle can create a significant amount of distress when lesbians perceive they have to choose between their sexual orientation and their religious tradition.
Especially in larger urban settings, lesbian-affirmative worship services are available. For those who wish to maintain ties to lifelong religious denominations while also challenging the heterosexism within these institutions, social workers can assist them with accessing affirmative groups such as Dignity (Catholic), Integrity (Episcopalian), More Light (Presbyterian), Affirmation (Mormon, also United Methodist), Friends for Lesbian and Gay Concerns (Quaker), Seventh Day Adventist Kinship International (Seventh Day Adventist), the Work Congress of Gay and Lesbian Jewish Organizations for Jews (Jewish), and Evangelicals Concerned (Evangelicals).
While some lesbians may nurture their spirituality through more traditional forms of religion, others seek avenues such as Native American spirituality that historically honors both the feminine and masculine in all (TaFoya, 1997; Wilson, 1996). In addition, feminist forms of spirituality are important to many lesbians. Themes of finding one's personal spiritual voice and of liberating oneself from patriarchal and heterosexist forces are common in feminist spirituality (Johnson, 2000).
Social workers must be prepared to recognize and honor the personal and social influence of religion on the well-being of lesbian clients. Workers can assist lesbian clients who wish to explore the impact of religion as a tool of social injustice. They can also support lesbian clients by validating their personal religious narratives and by providing reference lists of affirming faith communities and of affirming clergy as sources for pastoral care.
Multicultural and Diversity Considerations
Diversity in the form of sexual orientation is also accompanied by diversity across other dimensions of human expression, including race, ethnicity, gender expression, socioeconomic class, political perspective, physical ability, and religion. Lesbians represent a range of gradations across these representations of diversity. In addition to navigating a dominant heterocentric culture that denies their sexuality, lesbians must also cope with the institutional sexism that comes with their status as women. Lesbians of color carry the added challenge of racism. They often encounter racism within predominately Caucasian lesbian communities and homophobia within predominately heterosexual communities of color. It is neither fair nor healthy to have to choose between minority statuses in order to gain social validation and support.
African American and Latino communities—both of which are dominated by relatively conservative religious traditions—are often less accepting of a lesbian orientation in comparison to Anglo communities (Smith, 1997; Snider, 1996). Asian cultures also view lesbianism as rejection of the important role of parenthood (Chan, 1993). Lesbian youth in ethnic minority cultures can be especially vulnerable and invisible (Morrow, 2006b).
Social workers must be mindful of the cumulative nature of multiple oppressions when serving lesbians. Garnets and Kimmel (1993) propose a number of themes from the literature relative to assessment and intervention with diverse lesbian and gay client groups, including recognizing the importance of religion within respective cultures and its relevance for personal beliefs about sexuality; understanding the nature and influence of family structure across diverse communities; and reconciling the fit for individuals across personal ethnicity, gender, and sexual orientation.
Social Work Practice Interventions
There are a range of general social work practice methodologies that tend to fit well with assessment and intervention with lesbians. Cognitive behavioral approaches (Balsam, Martell, & Safren 2006; Weersing & Brent 2006), motivational interviewing (Harper & Hardy 2000; Knight, McGowan, & Dickens 2006), and psychoeducation (deGroot, Lloyd, & King 2003; Goldberg, Fristad, & Gavazzi 1999; Guajardo & Anderson 2007) have all been identified as effective evidence-based practice methods across a variety of populations and problems. Each of these modalities can likely be utilized with lesbian populations, although further research is needed to substantiate or refute their efficacy with lesbians in particular. In addition, feminist theoretical perspectives (Hyde, 2003; Orme, 2002; Saulnier, 2000) may be useful for helping lesbians critically examine and respond to the impact of sexism in combination with heterosexism and other forces such as racism and ableism. For example, Mercier and Harold (2003) propose a feminist approach for exploring the intersection of lesbian mothers and social systems.
An ecological systems perspective (Lum, 2005; Siporin, 1980; Zastrow & Kirst-Ashman, 2007) can be useful to assist lesbians in responding to the multisystemic influences of heterosexism in their lives. And finally, a strengths perspective (Davis, 1993; Greene & Ephross 1991; Maton, Schellenback, Leadbetter & Solarz 2004) can be useful for engendering personal power and efficacy in lesbians who, too often, are systematically disempowered by the impact of internal and external heterosexism.
Determining the best evidence-based practices for working with lesbians, however, is still in the beginning stages. By definition, evidence-based practices rely on empirical investigations to determine which modalities work best with specified populations and problems (Gilgun, 2005). To date, little such research has been conducted on best-practice methodologies among lesbian populations. Thus, there is a clear need for research that will more accurately determine which practice interventions work best with lesbian clients addressing specific life challenges.
A hallmark of social work practice is advocacy for the rights of socially marginalized groups. In honoring this professional value of social justice, social work intervention must address the personal and systemic impact of homophobia and heterosexism on the lives of lesbians. Social workers should seek to validate lesbian individuals, couples, and families and also to provide them services that are equitable to services that are rendered to presumed heterosexual clients. Institutional and political advocacy must address ways to make laws and social institutions more equitable for lesbians and other sexual minority groups. And research on empirical-based intervention methodologies must be more inclusive of lesbian samples in order to better determine which intervention methods best serve this population.
Current Challenges and Controversies
The lack of legal recognition of same-sex relationships remains a significant challenge impacting lesbians. At the time of this writing, Massachusetts is the only state in the United States where marriage between same-sex couples is legal. Civil unions are recognized in Vermont, Connecticut, Hew Hampshire, and New Jersey; and domestic partnerships are recognized in California and Oregon (Human Rights Campaign, 2007). Yet, numerous other states have enacted constitutional amendments or state laws that solidify their resolve to withhold legal recognition of same-sex relationships. The lack of legal sanctioning for same-sex relationships further impacts related family issues such as joint adoption, second-parent adoption, inheritance rights, and domestic partner insurance benefits.
The absence of federal legislation to prohibit discrimination on the basis of sexual orientation is also a human rights concern for lesbians. For instance, lesbians and gay men continue to be terminated from military service in the United States solely because of their sexual orientation. Because of this lack of federal protection, efforts to prevent discrimination on the basis of sexual orientation have been piecemeal and inconsistent across most states and local municipalities. Thus, advocacy for federal protection against discrimination on the basis of sexual orientation remains a major challenge.
Even in the midst of such legal challenges, however, the future is encouraging. Many major businesses in the United States have chosen to offer domestic partner benefits—despite the present lack of a federal mandate for equal inclusion. The Employment Nondiscrimination Act to prevent employment-based discrimination because of sexual orientation is moving through Congress. Lesbians are increasingly visible in the media and in the political arena. And, advocacy for equal rights for all people, including lesbians, grows ever stronger.
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