Who’s Trained in LGBTQ+ Mental Health? Affirmative Counselors, Gender Therapists & More

Mental health professionals aspiring to work with LGBTQ+ populations often wonder where to begin, since few graduate programs provide comprehensive LGBTQ+ mental health training.

To understand how this issue impacts LGBTQ+ youth, GLSEN teamed up with the American Council for School Social Work (ACSSW), the American School Counselor Association (ASCA), and the School Social Work Association of America (SSWAA) to survey 1741 school-based mental health professionals throughout the United States and the District of Columbia. Their 2019 report found that 69.8 percent of school-based mental health professionals had received little to no training on lesbian, gay, or bisexual issues. Of this same sample, 80.5 percent had received little to no training on transgender issues. Yet to make matters even more concerning, 76 percent had received little to no training on how to help LGBTQ+ youth.

In short, three-quarters of the mental health professionals dedicated to helping young people grow in school were not versed on how the bullying and oppression of sexual and gender minorities impact their identity development, self-worth, and academic learning.

Outside of academic settings, mental health professionals in private practice are even less monitored. While there are many counselors who keep their doors open to LGBTQ+ clients, that doesn’t mean they’re actually prepared. Consider how even well-intentioned counselors can overestimate their skill set, operate from a place of biased privilege, or adhere to an outdated theory.

In the field today, there is an observable stratum of allies, yet their dedication to this goal varies a great deal, as does their level of skill, training, and overall experience. For this reason, it’s worth noting the distinct strengths and potential limitations of allied counselors, affirmative counselors, gender specialists, sex therapists, and LGBTQ+ counselors.

Allied Counselors

An allied counselor is a licensed mental health professional dedicated to uplifting and empowering sex, sexual, and gender minorities. Since allies are usually members of the majority, the working assumption is that they’re always heterosexual cisgender people. This is not wholly accurate because of sub majorities and intergroup alliances within the LGBTQ+ community. For example, a gay cisgender man may be an ally for the transgender and nonbinary community by educating himself about gender diversity, and by opposing the oppression and exclusion of gender-diverse people.

In turn, a white transgender person can be an ally to trans people of color by learning how race and ethnicity factor into sex and gender inequality, and by taking a stance against racism and intersectional forms of oppression.

Safe Zone and Ally Training workshops raise awareness, provide basic skills, and are primarily educational. They do not teach therapeutic interventions. Allied counselors, therefore, practice inclusion, offer a safe space, and gather community resources for their clients, but are not necessarily trained in LGBTQ+ mental health issues. Those who are will specify this in their online bio.

Much of the ally training model stems from the four key steps presented in Washington and Evans’ chapter “Becoming an Ally,” published in the 1991 manual Beyond Tolerance: Gays Lesbians and Bisexuals on Campus.

  • During the Awareness stage, allies examine their own bias, privilege, and personal experience, while debunking the myths and stereotypes about sex, sexuality, and gender. For counselors, this may include the myth that internalized homophobia and gender dysphoria are the root of all LGBTQ+ mental health issues.
  • At the Knowledge/Education stage, allies learn about the diversity of LGBTQ+ people and how they’re affected by oppression.
  • Accruing Skills, allies expand their vocabulary, role-play how to correct themselves, and how to intervene when they encounter intolerance.
  • Finally, the Action stage encourages allies to speak up and educate others.

Critics of ally culture observe how allies can be noncommittal or performative in their allyship. Critics of Washington and Evans’ chapter note how their language focused on the hardships and benefits for heterosexuals helping LGBTQ+ people, rather than the LGBTQ+ community itself.

In retrospect, the conversation at that time was how heterosexual allies could convince intolerant people to accept non-heterosexuals. Since then, more and more ally trainings are facilitated by LGBTQ+ people, who have evolved both the tone and overall message.

To be an ally in the 21st century is to be an accomplice in social inclusion efforts, like helping to change policies, defend equality, and create access to affordable LGBTQ+ healthcare.

Affirmative Counselors

An affirmative counselor is a mental health professional trained in affirmative therapy—an inclusive modality that validates the lived experience of LGBTQ+ people. Since affirmative therapy is not technique-driven, it’s frequently integrated into other modalities, such as Cognitive Behavior Therapy (CBT), Dialectical Behavior Therapy (DBT), Acceptance and Commitment Therapy (ACT), Narrative Therapy (NT), and Person-Centered Therapy (PCT).

Because of this, the kind of experience a client may have with affirmative therapy is not uniform. For example, an affirmative CBT approach will be more directive and skills-based than an affirmative PCT approach, though both seek to empower the dignity and self-worth of the client.

To appreciate the advent of affirmative therapy, one must consider the historical and ongoing advocacy needed to depathologize sexual and gender diversity. The cumulative works of Magnus Hirschfield, Alfred Kinsey, Evelyn Hooker, Clellan Ford, Frank Beach, and Harry Benjamin gave new light to sexuality, sexual behavior, and gender identity.

Simultaneously, the Mattachine Society’s fight to remove homosexuality from the DSM, alongside the various Pride movements following the Stonewall Riot, progressively changed the public’s overall discourse by challenging “ego-dystonic homosexuality.”

Subsequently, a new, humanistic approach was needed to help gay and lesbian clients value their lived experience, trust their internal wisdom, and empower their unique voice.

The term “affirmative therapy” was first coined by Alan K. Malyon in 1982, yet its foundations are clearly evident in Don Clark’s (1977) Loving Someone Gay, Mitch Walker’s (1977), Men Loving Men: A Sex Guide and Consciousness Book, and Betty Berzon’s (1979) Positively Gay, to name a few.

Initially regarded as “gay affirmative therapy,” the model has progressed to include all sexual and gender identities. While there were certainly trans-positive and gender-affirming therapists in practice, especially with the rise of Poststructural-Feminism and Queer Theory, they were trailblazers ahead of the curve. Arguably, transgender affirmative therapy didn’t expand until the late 90s, after Milton Diamond and H. Keith Sigmundson challenged the tabula rasa theory of gender upheld by John Money.

Critics have accused affirmative therapy of being loose and unstructured, leading proponents like Proujansky & Pachankis (2014) to assert five key principles:

  1. Normalize the mental health impact of minority stress
  2. Facilitate emotional awareness, regulation, and acceptance
  3. Decrease avoidance strategies
  4. Restructure minority stress cognitions
  5. Empower through assertive communication

Today, affirmative therapy is a standard modality for professionals working with LGBTQ+ clients. As such, various organizations have created post-graduate certifications for licensed mental health professionals, adhering to the most up-to-date standards of care presented by the APA, ACA, and the Society for Sexual, Affectional, Intersex, and Gender Expansive Identities (SAIGE).

Gender Specialists

Gender specialists are licensed mental health counselors whose graduate, post-graduate, or doctorate level training specializes in gender dysphoria, gender identity development, and gender self-actualization. There is an overlap between gender specialists and affirmative therapists, though they’re not synonymous, since not all affirmative therapists are trained in gender-based healthcare, and not all gender specialists are trained in affirmative therapy.

As a focus, gender specialists are more likely to be versed in both the lived experience of transgender and nonbinary people, as well as practical information pertaining to transition, hormone regimens, gender confirmation surgery, and the letters required to procure them.

There are many criticisms of the gatekeeping medical model, both from clients and counselors alike, which means even gender specialists are not uniform in their professional and ethical perspectives. Some may align with the client’s need for autonomous self-actualization, whereas others may be more critical and by-the-book.

The APA and ACA lean heavily on the Standards of Care established by the World Professional Association for Transgender Health (WPATH), which states that in order to procure hormones or chest surgery, one letter of recommendation is required from a mental health counselor. The counselor in question does not have to be a gender specialist, per se, they just have to be licensed.

In order to procure genital surgery, however, WPATH stipulates that two letters should be written following a twelve-month real-life experience (RLE), living continuously “in the gender role that is congruent with their gender identity.” One of these letters can be from the client’s primary counselor, but the other must be from an evaluating mental health professional, which is one of the many reasons a client may seek out a licensed gender specialist.

Sex Therapists

A sexologist is a mental health professional with a doctorate in clinical sexology. Their expertise includes many issues relating to sex, intimacy, and mental health including, but not limited to, sexual dysfunctions, gender dysphoria, and sexual abuse as it pertains to both victims and offenders. Because of their extensive years of study, clinical sexologists may hone their focus. Some areas of specialty include transgender care, kink and alternative lifestyles, sex addiction, or trauma therapy for victims of sex trafficking.

Yet clinical sexologists are not the only professionals under the sex therapy banner. For example, a Certified Sex Therapist (CST) is a licensed mental health professional who is certified by the American Association of Sexuality Educators, Counselors, and Therapists (AASECT) to address issues related to sex, sexuality, and sexual behavior.

A Certified Sex Counselor (CSC), by contrast, only requires a bachelor’s in psychology with three years of counseling experience, or a master’s or doctorate with two years of counseling experience, to complete ASSECT’s requirements. This means that, while a CSC is proficiently trained to address sex, intimacy, sexual health, and LGBTQ+ sexual diversity, they may not be a licensed mental health counselor.

To make matters even more complicated, according to the Modern Sex Therapy Institute, only the state of Florida requires certification for someone to call themselves a “sex therapist.” For this reason, it’s important to find a professional with the appropriate credentials, which should be listed on their website and also posted in their office.

LGBTQ+ Counselors

LGBTQ+ counselors, queer therapists, and queer counselors are mental health professionals who are also members of the LGBTQ+ community. These are self-referential terms used to increase visibility and are not a credentialed title.

Ethically, all mental health counselors must examine their personal and professional boundaries, which is why some counselors are very personable, and others are very private. That said, it is not uncommon for LGBTQ+ counselors to integrate aspects of their identity with their practice in order to provide guidance and mentorship as visible members of their community. While this kind of role modeling is not required in any capacity, there are many passionate LGBTQ+ counselors in the field today who take it upon themselves to provide ally trainings, support groups, and LGBTQ+ youth programs.

It’s important, however, to challenge the stereotype that LGBTQ+ mental health professionals are inherently specialists in sex, sexuality, or gender-related issues. While said counselors certainly have an informed perspective from their life experience, they may choose to focus their training on a different aspect of psychology.

It’s also worth noting that a counselor is not automatically an ally to everyone, just because they’re also a sexual or gender minority. Some may favor a binary view of sex and sexuality, excluding bisexuals, pansexuals, asexuals, as well as trans, nonbinary, and queer people. Additionally, an LGBTQ+ counselor may or may not be familiar with polyamorous or alternative relationship dynamics.

Those who are inclusive or trained to work with diverse sex, sexual, and gender populations, will no doubt put this in their bio by using inclusive acronyms like LGBTQ+, or LGBTQIA, or GLBTQ. The internet has also made it easier for LGBTQ+ counselors to advertise their presence and collaborate with each other in order to make appropriate referrals. Naturally, LGBTQ+ counselors are in high demand.

While further research is required to examine the therapeutic benefit of LGBTQ+ clients being served by LGBTQ+ counselors, the ability for clients to connect with out-and-proud professionals is a huge testament to social progress.

Alex Stitt, LMHC

Alex Stitt, LMHC

Writer & Contributing Expert

Alex Stitt is a nonbinary author, queer theorist, and licensed mental health counselor living in Hawaii. As a proud Queer Counselor, they work to educate professionals in the mental health field interested in working with LGBTQ+ populations. Their textbook, ACT for Gender Identity: The Comprehensive Guide, demonstrates how to apply Acceptance and Commitment Therapy to gender self-actualization.