Growing up female as a first-generation Mexican American in a family where the women thought he was too masculine, Zander Keig — who began transitioning in 2005 — says it was a seventh-grade teacher and a social worker at a group home where he lived at 16 who enabled him to gain a healthy attachment to well-meaning people. Those experiences also inspired him to go into social work.
Today, Keig, LCSW, MSW, former chair and current member of NASW’s National Committee on Lesbian, Gay, Bisexual and Transgender Issues, works primarily with veterans — including veterans who identify as LGBT — using trauma-informed strategies in Jacksonville, Fla. But even early on in college in Denver in the mid-1990s, when he was a lesbian, Keig counseled people coming to the center where he worked to consider the consequences of decisions relating to their sexual orientation or gender identity status.
Students might say they were planning to come out to their families at Thanksgiving and Keig would ask certain questions: “Are your parents paying for your education? Would they have a negative reaction and withhold your tuition? Which is more important? Can you afford to pay for college on your own? Think it through. Let’s talk it through.” To this day, he takes a prevention/intervention approach with patients and clients “because I don’t want people to end up homeless, jobless, being physically or mentally or otherwise assaulted.”
Keig acknowledges how far U.S. society has come in terms of awareness and openness regarding people who identify as LGBT. But their minority status — and lack of federal protection — still leaves them open to stigmatization, discrimination and poorer health.
The continuation of stigma and discrimination offers an opportunity for social workers to be active across the LGBT spectrum, in micro, mezzo and macro practice. More resources than ever are available and social workers should familiarize themselves with these to make the most of their support for clients, patients and their families as well as to advocate on behalf of LGBT people.
Sexual and Gender Minority (SGM) Children and Youth
Jeremy Goldbach, PhD, LMSW, directs the Center for LGBT Health Equity at the University of Southern California, where he is associate professor of social work in the Suzanne Dworak-Peck School of Social Work.
He co-authored a 2015 paper, “The Grand Challenge of Promoting Social Equality by Addressing Social Stigma” for the American Academy of Social Work and Social Welfare. The paper is part of the 12 Grand Challenges for Social Work initiative.
Stigma, Goldbach says, leads to stress, which can lead to poor health outcomes if the stressors go unaddressed. He is currently working on a longitudinal study with LGBT youth to determine psychometric measurements and to try to discern when and how to intervene to minimize stigma and stress.
Goldbach emphasizes the importance of connection, whether for social workers themselves or for family and friends of LGBT people. Though most people may identify as cisgender and heteronormative, he says they can still find times in their lives when they have felt maligned because of some fundamental difference and someone deciding they should be left out. Tapping into that feeling opens their empathy and informs potential actions they may take with sexual or gender minorities.
Recognition of the influence of stigma also can inform language. “LGBT” itself doesn’t necessarily encompass the broad scope of descriptors with which SGM people may identify themselves, Goldbach said. They could be “gender nonbinary” or “gender queer.” “Gender,” assigned at birth based on the genital makeup of a newborn, could shift as early as two, three or four years old. That’s the age when children start to be pushed to express themselves in a certain way, yet feel different from what external aspects suggest they are.
“Gender is how we feel inside and how we express ourselves, and how we feel comfortable,” Goldbach said. Sexual identity tends to begin later, around puberty and into the teens when young people start dating. Then, people who identify as a sexual minority may begin to feel a level of difference that leads to stress, anxiety, internalization of shame, and negative outcomes, he said. Having support then is crucial.
“There’s a lot of evidence that shows that really just having at least one supportive adult is pretty important for SGM youth growing up — not necessarily a parent, but great if it is,” Goldbach said.
Social workers who work with schools may have an opportunity to encourage teachers and administrators to display a safe space sticker or other inclusive materials in their offices or classrooms to identify them as someone kids can open up to, suggests Goldbach.
It’s important for on-site social workers to create an atmosphere in which teens can find solutions for themselves. Also, social workers in private practice and everyone via their websites can indicate inclusiveness for LGBT youth and adults. It also can be helpful if the school has a Gay-Straight Alliance (gsanetwork.org).
“When a person comes out to the first person,” Goldbach said, “that person represents 100 percent of how that person [coming out] understands what it means to come out. They take that into the next experience they have.... If I’m 15 or 16 and seeing the school therapist or counselor and I’ve had one or two experiences and it was bad, I won’t come in assuming I can trust you.”
Working with Young People and Families
Social workers walk a fine line. They don’t need to understand every nuance, Goldbach says, but they should not expect clients or patients — whether minors or adults — to educate them. If a young person they’re working with wants to come out to their family and the parents are extremely homophobic or transphobic — to the point where the teen probably will be kicked out — a social worker can acknowledge that while coming out is a generally positive step for mental health, it’s not always safe or good and, like Keig suggests, walk through the scenarios.
On the other hand, Goldbach cautions that clients or patients won’t necessarily open up to therapists or counselors about their sexual or gender status, and social workers should not pathologize problems relating to SGM status. Maybe that 14-year-old just broke up with her girlfriend and is experiencing the usual heartache related to that—not because she identifies as lesbian.
Likewise, social workers should not assume that parents are unsupportive. Some may be, but others want to be supportive and don’t know how, Goldbach says. It can be easy to align with young clients — especially if they are the client and, like many young people, find their parents annoying. Parents, too, may have their own anxiety and feel loss, sadness and grief. What looks like anger could be a natural reaction to learning that the child they love and want to protect has an identity that will make the child’s life more difficult, he said.
Ellen Kahn, LCSW, senior director for Programs and Partnerships at the Human Rights Campaign in Washington, D.C., sees great strides having been made in terms of public acceptance of LGBT people in the last couple of decades, as more people who identify as LGBT have gone public, succeed and thrive. The Internet has made it easier for people, especially young people, to connect without having to check a book out of a library, for example. People can come out at younger ages now, but the risk factors associated with lack of acceptance at those ages are higher, she says.
For families navigating such critical times in the lives of their children, Kahn suggests the American Academy of Pediatrics’ Healthy Children website, which also has information in Spanish. Searching for LGBT brings up information for families with children who are coming out as well as those who are trans and those who are fostering LGBT children. She also suggests help for families through PFLAG, with chapters throughout the United States.
Finding the right provider is extremely important, Kahn says. A trans child, even at a preverbal stage, may begin to push back. This could come in the form of the type of clothing they will or won’t wear or their interests. The right help can spark a 180-degree turn in the child’s mental well-being, she says.
That said, there are plenty of LGBT youth who end up in foster care, where they may be further traumatized because of the lack of training and inclusiveness. HRC’s All Children – All Families (hrc.org/campaigns/all-children-all-families) seeks to shift the foster care dynamic by providing agency self-assessments and training. Agencies and organizations that have completed the program are listed on HRC’s website and can serve LGBT people who are interested in adoption or fostering LGBT children.
Keig likes to remind people “how far we’ve come” in the last 40 years. Young people who identify as LGBT may not know or appreciate those who walked the path decades ago, who were even killed trying to make things better. He finds it helpful to universalize needs, including access to education and educators knowledgeable and competent about LGBT people and their issues; health care providers who are trained and competent; and employers who provide insurance that covers medical treatment, whatever the specific needs may be. These are things all people desire and need, regardless of sexual orientation or gender identity.
Social workers can — and should — gain insight through continuing education and training. An underlying question should be how to improve clients’ experiences, and that could come down to complementary therapies, such as cognitive behavioral, somatic, and more, Keig says.
Social workers in agencies may see crossover among the groups of people they work with — from children who have issues relating to their sexual or gender status to adults identifying as LGBT with substance-use disorders. Training on those issues may not be required, but social workers should seek it out and stay up to date on what resources are available for their clients.
For example, Keig says, there are now some 80 gender clinics in the United States that are specifically geared toward children and adolescents. They may have a nurse practitioner or registered nurse and maybe a social worker who does a diagnostic assessment for gender dysphoria, but who does not serve as a case manager. So, the endocrinologist may prescribe hormones and give information about how they’ll affect the young person’s physiology, but not ask some of the other core questions: What will be the other kinds of effects? How will you handle it when these effects begin? And, Keig adds, it would go a long way if such clinics and other programs that serve transgender or transitioning people would hire transgender or transitioning employees, because who better to understand?
Social workers should feel comfortable referring out, if needed. It’s one thing if a client or patient is seeking general help for anxiety or depression. It may be another if they are seeking help for a long-standing addiction that ties directly to their sexual orientation or gender identity.
To help effectively, social workers need to understand the environmental context of LGBT clients and patients. Under an executive order, upheld by the Supreme Court, trans people now can enter the armed forces only as their natal sex and have to stay that way the whole time they’re enlisted, says Keig. Only if they were in the military and started to transition from July 2016 to April 11, 2019 — and have command office approval—can they proceed. Those kinds of details are important, and social workers need to understand the culture and attitudes of clients’ or patients’ workplaces as well as the employer’s policies.
A male plumber or electrician who wants to transition to female may have more to contend with in those occupations, for example. Once social workers understand the person’s context, they can role-play the scenarios, says Keig. “God didn’t make you to be like this” might be something the person would encounter, he said.
Keig suggests encouraging clients to avoid hostility, value the relationships, and act and speak accordingly. “I don’t want to be written off,” he said, “so I don’t do that to other people.”
Programs and Advocacy
Stigma and discrimination impact LGBT-identified individuals across their lifespan and can result in many hardships in daily living.
Homelessness is a risk. At Project PLASE (People Lacking Ample Shelter and Employment) in Baltimore, co-founder and Executive Director Mary Slicher, LCSW-C, says the organization’s emergency shelter welcomes 1,500 people, 18 years old and older, in any given year. An estimated 2 percent to 3 percent of them are transgender people, while 5 percent to 10 percent identify as lesbian, gay or bisexual.
As a population, they may have had a harder time than cisgender people with the same kinds of issues that everyone confronts—getting to know who they are, which is especially challenging for trans people, and choosing the kind of person they may want to spend their life with. Difficulties with these and the accompanying trauma may make LGBT people more susceptible to mental health issues and substance abuse.
If homeless, they may feel scared to go to a shelter because they aren’t sure they’ll be accepted and may exchange sex for a warm place to stay—which puts them at risk of sexually transmitted diseases. They may be poorer because of discrimination that leads to unemployment or underemployment, and the corresponding holes in their resumes may create more holes, Slicher says.
Project PLASE conducts trainings with staff every 18 months and residents also receive some of this training, which includes addressing conflict. It helps for residents to better understand LGBT issues. The training can relate to how people self-identify and what they would like to be called. Where things may grow more complex is in room placements, where one person may not feel comfortable sharing a room with another. In those kinds of situations, it may be difficult to choose which one needs to switch residences. Too often it falls to the SGM person to move and it should not, Slicher says.
As Project PLASE raises money for renovation of an existing building for permanent housing, the organization is planning to include single bathrooms to accommodate trans people, who often choose not to use bathrooms because of the stress.
There is no question that the political climate has shifted when it comes to LGBT issues, and there are lots of opportunities for macro social work. Of 24 state legislatures back in session in mid-January, 12 had proposals that would limit access to care for transgender people, says Kahn.
Bills had also been proposed that would allow faith-based, child-placement organizations and agencies that receive federal funds to exclude LGBT people, divorced people or people in religious minorities. On the positive side, Utah was moving to criminalize conversion therapy for minors, she says. NASW and its chapters also have been active in opposing conversion therapy. In 2015, NASW released a position statement on Sexual Orientation Change Efforts and Conversion Therapy with Lesbians, Gay Men, Bisexuals and Transgender Persons.
No one can deny the patchwork nature of such laws. That’s why NASW and many other organizations, like HRC, support the federal Equality Act, which the House passed last year. The legislation would amend the Civil Rights Act of 1964 to protect LGBT people from discrimination in housing, employment, credit and public accommodations.
Currently, 26 states allow discrimination based on sexual identity and 29 allow it based on gender identity, says Kahn. Given the makeup of the current administration and Senate, she said advocates plan to reintroduce the legislation after 2020, when there is likely to be a better path for it in the Senate.
Preventing Adverse Childhood Experiences (ACEs): Leveraging the Best Available Evidence
This CDC report is a resource to help states and communities leverage the best available evidence to prevent ACEs from happening in the first place as well as lessen harms when ACEs do occur. It features six strategies drawn from the CDC Technical Packages to Prevent Violence.
NASW's National Committee on Lesbian, Gay, Bisexual and Transgender Issues
American Academy of Pediatrics LGBT Resources
American Academy of Pediatrics Healthy Children website
Human Right Campaign: "All Children-All Families"
Improving Equity: Working with Rural LGBT Individuals
Understanding Evaluation Assessments for Gender Affirming Treatments
The Human Rights Campaign’s annual Time to Thrive conference offers helpful workshops and includes CEs.
World Professional Association for Transgender Health (WPATH) has an annual conference and helpful resources.
For social workers involved with children and families, the Family Acceptance Project® offers training as well as information that can be shared with families.
For social workers in schools who may be tapped for their expertise in sex ed, SIECUS offers information specific to LGBT youth.