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. 2022 Aug 17;78(11):2145–2163. doi: 10.1002/jclp.23434

“You say you're inclusive, but can you show us?” The importance of cultural competence when working with sexual minorities in a mental health setting

Joshua Bishop 1,✉, Dimity A Crisp 1, Janie Busby Grant 1, Brett Scholz 2
PMCID: PMC9804151  PMID: 35975708

Abstract

Objectives

Sexual minorities experience higher rates of psychological distress than heterosexual people, likely due to minority stress. While rates of help‐seeking by sexual minorities are high, sexual minorities report greater dissatisfaction with mental health service providers. This dissatisfaction may result from poor cultural competence practices. Our study sought to determine the importance of service provider cultural competence practices to a community sample of sexual minority people.

Methods

Participants (n = 274) were sexual minority Australians recruited from affirming Facebook groups, organizations, and research‐based organizations. To measure the importance of cultural competence practices, participants completed a modified online version of the Gay Affirming Practices Scale (GAP) and responded to open‐ended questions.

Results

Between 80% and 99% of participants endorsed each item on the GAP, indicating the importance of service providers demonstrating an array of culturally affirming practices. No significant associations were found between overall GAP score and age or sexual orientation, though further analyses revealed individual items on the GAP showed associations with age. A structured tabular thematic analysis, of open‐ended participant responses, found positive attitudes, knowledge, and affirming practices were the three most important characteristics for service providers seeking to demonstrate culturally competent practices, mirroring the tripartite model (attitudes, knowledge, and skills) of cultural competence.

Conclusion

Recommendations for service providers to demonstrate cultural competence include: utilizing affirming practices such as inclusive language, increasing knowledge about sexual minorities, and utilizing education resources such as cultural competence workshops, lived experience stories, and seeking mentorship from service providers with expertise in working with sexual minorities.

Keywords: counselor, mental health, psychologist, service provider, sexual minorities

1. INTRODUCTION

Previous research has suggested that sexual minorities experience higher rates of psychological distress than heterosexual people (Cochran et al., 2003; Plöderl & Tremblay, 2015). 1 The impact of societal inequality and instances of oppressive behaviors toward sexual minority individuals may explain why sexual minorities experience higher rates of psychological distress (Lewis, 2009; Nadal et al., 2011). Being a minority in an unequal society, sexual minorities may experience: heteronormative assumptions, microaggressions, invalidation, or disapproval of sexual orientation (by family, friends, or societal messages), societal endorsement of heteronormative culture, being stereotyped, employment discrimination during the hiring process and during career advancement, shame stemming from internalized homophobia and verbal attacks or physical violence (Gates, 2014; McCann & Sharek, 2014; Nadal et al., 2011).

While sexual minorities may experience higher rates of psychological distress than their heterosexual counterparts, previous research has demonstrated that mental health services are utilized at a similar or higher rate by sexual minorities (Baams et al., 2018; Simeonov et al., 2015). While increased help seeking appears positive, evidence suggests sexual minorities are more likely than heterosexual people to report dissatisfaction or negative experiences with mental health services (Kidd et al., 2016; Simeonov et al., 2015). A scoping review highlighted that 17% of sexual minority individuals reported dissatisfaction with a service they attended, compared to 8% of heterosexual people attending a mental health service (Kidd et al., 2016). Other research demonstrated that sexual minorities who reported unmet treatment needs due to negative experiences related to sexuality or gender identity were more likely to drop out of mental health service use (Simeonov et al., 2015). Differences in service satisfaction may be the result of mental health service providers not demonstrating culturally affirming practices to sexual minorities; this is important for providers to understand as sexual minorities report lower willingness to reattend services that demonstrate poor cultural awareness of sexual minorities (Pereira et al., 2019; Utamsingh et al., 2016).

1.1. Cultural competence

Sexual minorities report valuing mental health services which demonstrate cultural affirming practices in working with sexual minorities, regardless of whether issues related to sexuality are the presenting issue (Bishop et al., 2021; Burckell & Goldfried, 2006). A framework which can be utilized to describe a service provider's ability to provide culturally affirming therapy is tripartite model of “cultural competence” (Crisp, 2006; Sue et al., 1982). Cultural competence describes a provider's: attitudes, beliefs, and biases regarding a cultural group; knowledge of a cultural group and how a cultural background may impact the therapeutic process; and skill to provide culturally affirming service (Crisp, 2006; Sue et al., 1982). The value of service providers demonstrating aspects (attitudes, knowledge, or skills) of culturally competent practices have been well documented in the literature (Anderson & Holliday, 2007; Bishop et al., 2021; Croghan et al., 2015; Foy et al., 2019; Magee & Spangaro, 2017; Mair, 2003). Demonstrating culturally affirming attitudes decreases instances of service provider heterosexism and increases instances of client disclosure of sexual orientation (Anderson & Holliday, 2007; Mair, 2003). Service providers demonstrating knowledge pertaining to sexual minorities are perceived as more trustworthy when discussing issues related to sexuality (Foy et al., 2019). Service providers who create a safe space for sexual minorities through affirming cues throughout the therapeutic process are perceived as more culturally competent by sexual minorities (Croghan et al., 2015; Magee & Spangaro, 2017).

To demonstrate appropriate culturally affirming practices providers may also be need to consider the demographic characteristics of presenting sexual minority clients (Carnaghi et al., 2021; Taylor, 2018). Previous research has demonstrated that a person's age and sexuality may add additional layers of complexity regarding mental health, as these factors may predispose sexual minorities to experience additional stressors (Carnaghi et al., 2021; Taylor, 2018). A recent study which sought to determine how participants categorized people's sexuality based on age (younger vs. older men), found that most participants associated being gay with being young, suggesting older gay men may experience greater identity invisibility (Carnaghi et al., 2021). Age intersectionality may influence how service providers need to provide culturally affirming support; for example, providers should be aware they may be less likely to code older people as sexual minorities and therefore have a greater likelihood of demonstrating heteronormative practices. Furthermore, while the increased risk of poor mental health in gay and lesbian populations can be explained by sociodemographic characteristics and early life psychosocial experiences, similar results are not indicated in the literature examining the mental health outcomes of bisexual clients (Taylor, 2018). Bisexual people experience additional stressors contributing to poorer mental health outcomes, such as community rejection from both the gay and straight communities, and threats to identity legitimacy (Taylor, 2018). This highlights the importance of not treating sexual minorities as homogenous; intersectional factors, therefore, may require providers to attain a higher level of cultural competence (Carnaghi et al., 2021; Taylor, 2018). Currently, very limited literature has examined whether demographic factors, such as age and sexuality, may influence the need for culturally affirming practices when working with sexual minorities.

Much of the research which describes the importance of culturally affirming care in working with sexual minorities reflects service provider perspectives on what constitutes culturally affirming practices (Bermea et al., 2019; Israel et al., 2008; Kilicaslan & Petrakis, 2019; Magee & Spangaro, 2017; Moe & Sparkman, 2015; Rutherford et al., 2012). While it is useful to examine what practices service providers believe constitute culturally competent care when working with sexual minorities, it is those who may use such services that are best placed to provide insight regarding how culturally competent practices affect their communities (Shea et al., 2005). While several studies examining cultural competence have incorporated the perspectives of sexual minorities, many of these studies rely on small sample sizes to interpret what cultural competence means to sexual minorities (Burckell & Goldfried, 2006; Eady et al., 2011; Mair, 2003; Moore et al., 2020; Pennay et al., 2018; Semp & Read, 2015; Willging et al., 2006). Our research seeks to determine what constitutes culturally affirming mental health care from previous exploratory research and explore if these results are consistent across a larger sample of sexual minorities.

1.2. Current study

A scale designed to investigate a mental health provider's level of cultural competence in working with sexual minorities is the Gay Affirming Practice Scale (GAP) (Crisp, 2006). The GAP is a self‐reflective, dual‐domain scale with a beliefs and behaviors domain designed to allow service providers to measure their beliefs and practice in providing culturally affirming services to sexual minorities (Crisp, 2006). The GAP describes an array of service provider practices relevant to providing cultural affirming therapy including learning about diversity within sexual minorities, being knowledgeable about the sexual minorities, use of professional developments to improve cultural competence, develop skills necessary to work with sexual minorities, and assisting clients reduce shame about sexual orientation where applicable. While the GAP is usually a self‐administered scale for service providers to use for reflective practice, we propose using a modified version of the GAP administered to sexual minorities, allowing them to determine the importance of particular cultural competence practices during therapy.

The aim of the present study was to determine the importance of service providers demonstrating culturally competent practices as reported by a sample of sexual minorities. Previous research has demonstrated cultural competence is important to sexual minorities, though to our knowledge, no studies have assessed the importance of particular cultural affirming practices with a community sample of sexual minority people (Moe & Sparkman, 2015). This study used a modified version of the GAP, accompanied by an open‐ended question, to elicit judgments of, and details about, the importance of cultural competence practices in mental health services among a community sexual minority sample. We also sought to determine if sexual minorities who may experience additional minority stress, such as older aged sexual minorities and bisexual people specifically, desire a greater level of cultural competence from their service providers (Carnaghi et al., 2021; Taylor, 2018).

Based on the research validating the use of the tripartite model of cultural competence, we predicted a community sample of sexual minority participants would specifically report indicators of cultural competence, such as demonstrating positive attitudes, knowledge about sexual minorities, and skill in providing culturally affirming practice as important for service providers seeking to provide best practice to sexual minority clients. Second, we predicted older participants and bisexual/pansexual participants would score higher on the GAP due to valuing culturally affirming practices to a greater degree, based on the additional stressors experienced by these populations (Carnaghi et al., 2021; Taylor, 2018). We employed a structured tabular thematic analysis on free text responses to investigate the culturally affirming practices considered to be most important to sexual minorities when accessing a service provider.

In this paper, we acknowledge the intersectionality and shared history, connection, and advocacy between those with a sexual minority identity and those who are gender diverse. While people can hold both a sexual minority identity and gender diverse identity, we propose there are several unique experiences that transgender and gender diverse people may experience, which can include: gender dysphoria repeated misgendering or incorrect use of pronouns, and understanding the impacts of transitioning (Sequeira et al., 2020; Strauss et al., 2020; Vidal‐Ortiz, 2008). Due to these unique stressors, we propose that describing culturally affirming practices will differ when working with sexual minorities and gender‐diverse participants. To ensure our study provides useful results and appropriate recommendations, our paper seeks to understand what cultural competence means to someone identifying as a sexual minority individual. We encourage future researchers to examine what cultural competence means to transgender and gender‐diverse people as we believe this to be important research.

2. METHODS

2.1. Participants

The study comprised 274 sexual minority participants aged 18–73 years old (M = 31 years, SD = 13). Participants met the study criteria if they identified as same‐sex attracted; were 18 years or older, lived in Australia, and were willing to respond to questions regarding the importance of specific cultural competence practices service providers should demonstrate when working with same‐sex attracted people. Most participants identified as lesbian (n = 79) or bisexual (n = 71), Australian (n = 214), and female (n = 138). Complete demographic characteristics are presented in Table 1. Ethnicity, sexual orientation, and gender options were presented to participants as in Table 1. Participants were asked to input their age in a free text box.

Table 1.

Demographic characteristics

n %
Age
18–29 174 63.5
30–49 69 25.2
50+ 31 11.3
Gender
Male 46 16.8
Female 148 50.4
Transgender 11 4.0
Nonbinary 52 19.0
Agender 7 2.6
Other 20 7.2
Ethnicity
Australian 214 78.1
Aboriginal and Torres Strait Islander 14 5.1
New Zealander 4 1.5
Asian 1 0.4
Indian 2 0.7
Middle eastern 1 0.4
European 21 7.7
North American 1 0.4
South American 1 0.4
Some other race, ethnicity, or origin 11 4.0
Prefer not to answer 4 1.5
Sexuality
Gay 45 16.4
Lesbian 79 28.8
Bisexual 71 25.9
Pansexual 38 13.9
Other 40 14.6
Did not disclose 1 0.4
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2.2. Measures

2.2.1. Culturally Affirming Practices Scale

The study employed a modified version of the GAP to investigate the importance of various culturally affirming practices in mental health service provision to a community sample of sexual minority participants (Crisp, 2006). The modified version utilized the 15 items of the beliefs domain of the GAP as used by Crisp (2006). The scale includes items relating to practices such as the importance of service provider attitudes in providing effective service to sexual minorities, the importance of service provider knowledge about sexual minorities, and actions service providers should undertake when providing service to sexual minorities. Two additional questions were added to capture information relating to the importance of affirming on‐site cues and provider's highlighting expertise in providing service to sexual minorities. These questions were developed in line with literature highlighting the importance of services providers advertising a willingness to work with sexual minorities and a willingness to create a safe space for sexual minorities (Hinrichs & Donaldson, 2017). With the additional two questions included, 17 items were administered as part of the modified GAP scale.

The wording of original GAP items was modified to be suitable for distribution to sexual minorities; specifically, references to “gay/lesbian clients” were changed to “same‐sex attracted clients” and the term “practitioner” modified to “service provider.” Gay/lesbian was changed to same‐sex attracted to reflect a desire to capture anyone who identified as a sexual orientation other than heterosexual. After consideration and feedback from participants, we have opted to use sexual minority in the place of same‐sex attracted in this article, as some participants indicated the term “same‐sex attracted” has been used negatively against sexual minorities. Items were responded to on a 5‐point scale from 1 (strongly disagree) to 5 (strongly agree).

Participants then responded to a single item using a 5‐point scale from 1 (strongly disagree) to 5 (strongly agree) included after the modified 17‐item GAP scale, to determine whether service use would increase if services appeared culturally competent. To assess the most important elements of cultural affirming practices, an open‐ended question was included which asked participants: “What are the three most important things service providers can do to provide culturally competent services to same‐sex attracted clients?”

2.3. Procedure

Participants completed the measures via an anonymous online survey administered using Qualtrics survey software. Participants were recruited using paid Facebook advertising and via distribution through the following networks: Facebook groups containing Australian sexual minorities, primary health networks, organizations advocating for sexual minorities, and other research‐based organizations.

2.4. Data analysis

Data were analyzed using IBM SPSS statistics version 27 predictive analytic software. Descriptive statistics were utilized to determine which, if any, service providers cultural competence practices are valued among a larger population of sexual minorities. The bivariate association between age and overall GAP score was examined using a Pearson's r correlation analysis, and the bivariate association between sexual orientation (gay/lesbian vs. bisexual/pansexual) and overall GAP score was assessed using a point‐biserial correlation to address the hypotheses. For the point biserial correlation, gay and lesbian participants were collapsed into one group for comparison with bisexual and pansexual participants (collapsed into a second group) to investigate whether bisexual/pansexual participants desired a greater level of cultural competence due to experiencing additional minority stressors such as bierasure (Taylor, 2018). Bivariate associations between age/sexual orientation and individual GAP items were also assessed using a Pearson's r test/point biserial correlation. An inductive structured tabular thematic analysis was conducted to develop and determine the frequency of themes from the open‐ended question examining the most important things service providers can do to provide culturally competent services to sexual minorities (Robinson, 2021). Participants' responses to the open‐ended question were coded and tabulated by the lead author, who holds PhD level experience in qualitative research methods. Codes were then discussed with the research team to confirm agreement of the codes developed. All three authors were involved in discussing code development. Discussion of codes occurred until a consensus was reached. The research team agreed to resolve disagreements by majority vote, though this was not needed during data analysis. Codes were grouped by similarities and higher‐order themes developed by the research team.

3. RESULTS

3.1. Support for culturally competent practices

To determine the support for different culturally affirming practices, a frequency analysis of the GAP was conducted (see Table 2). Participants positively endorsed the importance of service providers demonstrating all culturally competent practices in our analysis, with greater than 80% of participants indicating agree or strongly agree for each item of the GAP. The only exception was for item 17 (service providers should indicate on their website if they will accept same‐sex attracted clients), which scored 79.9%. Most items scored above 90% except for four items: Service providers should indicate on their website if they will accept same‐sex attracted clients (79.9%), service providers should encourage same‐sex attracted clients to create networks that support them as same‐sex attracted individuals (82.9%), service providers should put affirming cues toward same‐sex attracted clients in the waiting room (83.5%), and service providers should verbalize respect for same‐sex attracted clients (83.6%). When participants were asked if they were more likely to attend a service that was culturally competent, 91.9% indicated agree or strongly agree.

Table 2.

Participant's responses to culturally affirming practices.

Agree Strongly agree Total
n % n % %
Indicate acceptance of sexual minority clients on website 62 22.6 157 57.3 79.9
Assist client to develop supportive networks 84 30.7 143 52.2 82.9
Affirming cues in the waiting room 73 26.2 157 57.3 83.5
Verbalize respect 81 29.6 148 54.0 83.6
More likely to attend culturally competent services 50 18.2 202 73.7 91.9
Challenge misinformation 59 21.5 194 70.8 92.3
Find professional development opportunities 53 19.3 200 73.0 92.3
Support diverse families 42 15.3 216 78.8 94.1
Help clients develop positive identities 51 18.8 205 75.4 94.2
Develop skills 58 21.3 201 73.9 95.2
Learn about diversity 39 14.2 223 81.4 95.6
Acquire knowledge 56 20.4 206 75.7 96.1
Knowledge about issues affecting sexual minority couples 67 24.5 196 71.8 96.3
Address discrimination in treatment 52 19.0 212 77.4 96.4
Affirming attitudes 53 19.3 212 77.4 96.7
Assist clients in reducing shame 32 11.7 234 85.4 97.1
Self‐education 38 13.9 230 83.9 97.8
Knowledgeable about support resources 46 17.0 220 81.5 98.5
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3.2. Examining the association between age/sexuality and GAP items

A Pearson's r correlation was conducted to determine if age was associated with higher endorsement of culturally affirming practices. No significant relationship was found between age and overall GAP score, r(272) = 0.054, p = 0.370. A point‐biserial correlation was run between sexuality (gay/lesbian vs. bisexual/pansexual) and no significant relationship was found between sexuality (gay/lesbian vs. bisexual/pansexual) and overall GAP score, r(231) = 0.009, p = 0.885.

To examine if age or sexuality was associated with service provider practices captured by GAP items, Pearson's r correlations were conducted between age and individual GAP items. Service providers verbalizing respect for sexual minorities was positively correlated with age, r(272) = 0.138, p = 0.023 such that older participants rated verbal respect as more important than younger participants. Service providers learning about diversity (r(272) = −0.132, p = 0.029), assisting clients in reducing shame (r(272) = −0.183, p = 0.002), service providers addressing discrimination in treatment (r(272) = −0.141, p = 0.020), and participants being more likely to attend culturally competent services (r(272) = −0.124, p = 0.040.) were all negatively correlated with age. The results indicate younger participants valued providers learning about diversity, assisting clients in reducing shame, addressing discrimination in treatment, and were more likely to attend culturally competent services than older participants. No other GAP items were significantly correlated with age. A point‐biserial correlation was run between sexuality (gay/lesbian vs. bisexual/pansexual) and GAP items, with no significant associations found. The results indicate most culturally affirming practices were important to participants irrespective of age or sexuality, though small effects were found for some culturally affirming practices for differing age groups.

3.3. The most important cultural competence practices to sexual minorities

To further understand the importance of various culturally affirming practices to a community sample of sexual minority people, participants were asked to highlight the most important things service providers can do to provide culturally competent service to sexual minorities. Eleven themes were developed from participants' responses and the frequency of codes relating to these themes is reported (see Table 3.) Table 3 presents a summary of all themes identified. The four most frequently cited themes were positive attitudes (n = 137, 50%), affirming practice (n = 137, 50%), knowledge (n = 134, 49%), and education (n = 85, 31%). The themes of positive attitudes, affirming practices, and knowledge are discussed below due to their relationship to the tripartite model of cultural competence. Education is also discussed as this theme provides insight into how service providers can increase cultural competence.

Table 3.

Themes regarding what service providers can do to demonstrate cultural competence

Category Description Freq.
Positive attitudes Participants valued open‐minded, respectful, and inclusive service providers. Participants discussed how judgmental or biased service providers negatively impact rapport. 137
Affirming practice Participants valued service provider who demonstrated affirming practices. Practices may include ascertaining and using pronouns appropriately, demonstrating support toward sexual minority clients, avoiding discrimination, and avoiding pathologizing sexuality. 137
Knowledge Participants valued providers who had knowledge pertaining to the experiences of being a sexual minority. Knowledge regarded: intersectionality, shame, minority stress, gender diversity, asexuality, and differences within sexual minorities of diverse orientations. 134
Education Participants valued providers who demonstrated education in culturally affirming practices through training, mentoring, or provider‐sourced education. Some participants highlighted the importance of providers being proactive in acquiring knowledge. Participants discussed education as ongoing due to the evolving nature of sexual minorities and the issues impacting them. 85
Safe space Most participants valued a service which created a visually affirming safe space. Visually affirming stimuli include rainbow flags, affirming pamphlets, affirming policy, ally imagery, and pronouns on staff placards. A small portion of participants stated that visual cues of affirmation were unnecessary or highlighting the “otherness” of sexual minorities. These participants preferred providers to treat sexual minority clients like all other clients. 75
Understand client's needs Participants wanted providers to ensure they were meeting the needs of the client. In this way, participants highlighted that providers should seek to understand to what degree, if any, a client's sexual orientation is relevant to treatment. If relevant, participants valued a service where they could openly discuss issues related to their sexuality. 60
Sexual minority‐friendly services Participants valued services which had some degree of outwardly allyship of sexual minorities. This may involve: being a specific service for sexual minorities, employing sexual minority staff members, connecting a client to affirming services if relevant and disciplining staff who make services unfriendly. Client‐provider sexual orientation matching may be useful if sexuality is related to the presenting issue. 29
Advertising Many participants valued services which advertise as affirming toward sexual minorities as this increased the perception of a service as a safe space. 21
Community engagement Some participants discussed valuing a service provider who was connected to the communities which valued sexual minorities (such as the LGBTIQA + community), for example, being involved in advocacy or pride events, engaging with sexual minorities as stakeholders and being knowledgeable about local resources, services, and groups for sexual minorities. 20
Service traits Some participants valued services which were not religious and services which had increase accessibility options. 11
Provider qualities Some provider qualities participants value included: good therapeutic skills, maintaining confidentiality, and challenging homophobia during sessions. 11
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3.4. Theme one—The importance of positive attitudes

Participants discussed the importance of service providers demonstrating open‐minded, respectful, and inclusive attitudes. Participants highlighted a willingness to reattend and engage with services which demonstrated positive attitudes toward sexual minorities. Conversely, participants highlighted some services which advertised as affirming of sexual minorities demonstrated judgment toward sexual minorities due to service providers having negative attitudes toward sexual minorities; this was seen as detrimental to continued help seeking and service engagement to sexual minorities. One participant stated, “Have professionals be critical and aware of their responses in these situations, it's all good to say an organization is safe and to have symbols around saying it's safe but that works the opposite when a patient speaks up and is then judged or treated weirdly, or fetishized, or looked at with a big stigma etc. Keep it casual and genuinely accepting.” This participant highlights the importance of professionals being “critical” and “aware” of their response to ensure inclusive practices are maintained by service providers seeking to create safe spaces for sexual minorities. Demonstrating positive attitudes toward sexual minority clients may require some nuance and cultural understanding to ensure service providers are not prone toward heteronormative biases, judgments, or fetishizations of sexual minority clients.

3.5. Theme two—Being knowledgeable

Participants discussed feeling more comfortable discussing experiences related to their sexuality if their service provider demonstrated knowledge relating to sexual minorities. One participant discussed wating service providers to, “be knowledgeable and supportive of [sexual minority] identities, oppressions, and experiences.” Knowledge may help service providers demonstrate a supportive space and an ability to understand the experiences of sexual minorities. Two specific sexual minority experiences came through commonly: providers understanding the “impact of discrimination” and providers understanding “different or non‐traditional family structures” that may exist for sexual minorities. Sexual minorities who had not experienced acceptance from their biological family, friends, or peers may seek out a chosen family, those who are accepting of their sexuality. Providers who understood the general issues that may impact sexual minorities were reported to be more trustworthy and less likely to pathologize sexuality.

Sexual minorities also highlighted the importance of providers understanding the intersectionality between sexuality and other minority identities. The most prevalent intersections were between sexuality and gender or culturally diverse participants. For example, participants discussed the importance of providers being aware of how cultural expectations, norms, and practices may create conflict between sexuality and cultural identity, especially if participants came from cultures less accepting of sexual minorities. Further to this, participants discussed the importance of providers understanding the diversity within sexual minority clients such that providers, as one participant stated, “recognise that not all LGBTQIA + people have the same lived experience.” Participants highlighted that even though sexual minorities do not have the same lived experience, there is still value in providers being able to understand and connect to the diverse experiences of sexual minorities.

3.6. Theme three—Demonstrating affirming practice

Participants discussed valuing service providers who skillfully demonstrated affirming practices when working with sexual minorities. Correctly using inclusive language, such as pronouns, and avoiding heteronormative assumptions, such as assuming the partner's sexuality or partner's gender, were the most reported skills providers can display to demonstrate affirming practice, as highlighted by one participant where they write, “If [clients] prefer to use pronouns ask them when you first meet them how they would like to be addressed, seriously considered what questions you ask before you do as they can come off invasive.” As discussed by this participant, to demonstrate affirming practice, providers must first be aware of the assumptions they hold regarding presenting clients and “consider” ways to ensure their language and practice are culturally affirming.

Participants also highlighted the importance of providers demonstrating affirming practice. Many participants reported using services which advertise as friendly toward sexual minorities or had visual cues of affirmation where the provider failed to demonstrate culturally affirming care during sessions. The disconnect between service perception and service delivery was found to negatively impact the user's experience, as stated by one participant: “It's not enough to say you're LGTBIQ + friendly, plenty of straight folk do and are unintentionally damaging. I need you to show me with actions.” Demonstrating allyship creates a sense of trust and expectation that a service will be affirming of sexual minorities; service providers who are unable to deliver culturally affirming services may cause damage to clients and erode their trust in services.

3.7. Theme four—The importance of education

Participants highlighted a need for providers to be educated in cultural competence to enhance their ability to work with sexual minorities. Many participants highlighted that the responsibility to acquire education about cultural competence should be sourced by service providers as this reflects part of their service delivery. Some participants discussed the frustrations of losing valuable session times due to clients, “having to educate workers about LGBTIQ + issues and basic terms/understandings.” Participants highlighted that provider education can be sourced from cultural competence training, people with lived experience, online training, local sexual minority affirming organizations, and mentoring from providers with expertise in working with sexual minorities. Participants also highlighted the benefits of the entire service being trained in understanding the issues that impact sexual minorities, as highlighted by one participant who writes, “it is especially important that the infrastructures [service providers] work within, the administration team, the corporate culture they work within—that these spaces are LGBTQIA friendly and active in allyship and education.” Having entire mental health services which are affirming of sexual minorities and active in allyship may reduce barriers and increase the confidence of sexual minority clients utilizing services.

4. DISCUSSION

Previous research has explored the importance of mental health service providers demonstrating cultural competence in working with sexual minorities (McNamara & Wilson, 2020; Pereira et al., 2019). Our study sought to expand on this research, to investigate the importance of various culturally affirming practices to a community sample of sexual minorities when accessing mental health care. Aligned with our hypothesis, most participants agreed that service providers should demonstrate cultural competence across several indicators. Contrary to our hypothesis, identifying as bisexual or pansexual did not impact participant's desire for culturally affirming services. While no association was found between age and overall GAP score, some significant correlations were found between age and individual GAP items. There was strong agreement among participants regarding the most important aspects of culturally affirming care. The results will assist service providers in understanding the role of cultural competence in providing best practice to sexual minority clients.

4.1. An indication of the importance of cultural competence to sexual minorities

Almost all participants (91.7%) indicated they would be more likely to attend a service that demonstrates culturally affirming practices. Furthermore, approximately 80%–99% of participants agreed or strongly agreed that all cultural competence practices on the GAP should be demonstrated by service providers when providing service to sexual minorities. With 91.7% of participants indicating they are more likely to attend a service which demonstrates cultural competence, and previous research highlighting the role of affirming practices improving meeting the treatments needs of sexual minorities, service providers who are unable to demonstrate cultural competence risk failing to meet the treatments needs of sexual minority clients (McCann & Sharek, 2014). The strong, positive response to the GAP and the development of the themes of positive attitudes, knowledge, and affirming practice align with the tripartite model of cultural competence (attitudes, knowledge, and skill) and can be used as an effective tool to help service providers determine what areas of education and development they need to work effectively with sexual minorities (Crisp, 2006; Sue et al., 1982).

4.2. Cultural competence practices and recommendations for providers

4.2.1. Positive attitudes, knowledge, affirmation attitudes, and education

96.7% of participants endorsed the importance of service providers having positive attitudes. Participants consistently described in the free text responses that service providers with positive attitudes were open‐minded, respectful, and inclusive. These words highlight an inclusive intention; an awareness and acknowledgment of sexual minorities. Based on existing literature, we posit that sexual minorities are often subject to invisibility due to living in a heteronormative society; service providers who have inclusive intentions can deconstruct heteronormative practices and validate sexual minority identities (Kilicaslan & Petrakis, 2019). Service providers with positive attitudes toward sexual minorities are also less likely to incorrectly attribute mental distress to sexuality, are less judgmental toward sexual minorities, and are less likely to rely on stereotypes when interacting with sexual minorities (Mohr et al., 2001). Conversely, previous research has demonstrated that attitudes impact behavior through reflective and impulsive systems; providers should be aware that ambivalent or negative attitudes held by providers may emerge in their behavior inadvertently (Strack & Deutsch, 2004). Based on our results, we suggest service providers who hold negative attitudes toward sexual minorities should undertake development opportunities such as cultural competence training or mentoring from affirming providers to cultivate positive attitudes. If service providers feel their values may impact the therapeutic process with a sexual minority client, it is recommended they refer the client to someone affirming.

96.1% of participants responding to the GAP also highlighted the importance of service providers learning and acquiring knowledge about sexual minorities. Participants responding to the GAP indicated service provider having specific knowledge may be important to working effectively with sexual minority clients, including knowledge regarding the impact of discrimination (96.4%), understanding same‐sex couples (96.3%), and the impact of internalized homophobia (97.1%). In particular, previous research has demonstrated the impact of discrimination and perceived discrimination as a factor contributing to the higher instances of distress seen in sexual minority populations as compared with heterosexual populations (Douglass et al., 2017). Two reasons can explain why sexual minorities experience discrimination: Laws and legislations which impact the rights of sexual minorities, and social homophobia, where norms and acceptable behavior are influenced by moral, religious, and cultural beliefs (Lamontagne et al., 2018). While discrimination can affect sexual minorities individually, discrimination has been shown to also negatively impact same‐sex couples, such as increasing feelings of shame or otherness felt by same‐sex couples and distress from the rejection of same‐sex couple by family and friends (Douglass et al., 2017; Frost et al., 2016). Understanding the power structures that contribute to minority stress and discrimination can assist providers in understanding how minority stress may increase distress for sexual minority clients.

Due to the impact of homophobia, participants highlighted in the free text response that service providers should also be aware of the differences in social support networks utilized by sexual minorities. Some participants discussed the importance of their chosen family (friendships or like‐minded peer networks) as distinct from their family of origin, feeling more comfortable asking their chosen family for support. Some evidence suggests sexual minorities, particularly gay and bisexual men, are more likely to utilize chosen family networks when seeking minor or major support than families of origin (Frost et al., 2016). Gay and bisexual men may be more likely to develop chosen families due to an increased chance of rejection by their family of origin than lesbian and bisexual women (Frost et al., 2016). Our findings suggest service providers seeking to connect sexual minorities with appropriate support people should be aware that for some presenting sexual minority clients, their strongest support network may be their chosen family.

Sexual minority participants (95.2%) highlighted the importance of providers demonstrating affirming practices. In the free text, response participants highlighted that service provider correctly using pronouns, avoiding pathologization of sexuality and avoiding using heteronormative language increased confidence in services. This is supported by previous research, which demonstrated using correct pronouns and avoiding pathologizing or heteronormative language in a clinical setting increases client comfort and indicates provider acceptance of a client's sexuality (Anderson & Holliday, 2007; Brown et al., 2020). While we acknowledge incorrect use of pronouns is typically viewed as encompassing a transgender and gender diverse issue, the acknowledgment and respect of pronouns usage reflect an affirming service to sexual minorities. For sexual minority individuals, failure to use inclusive language reinforces the heteronormative, cisnormative bias present in society and may demonstrate a devaluation of sexual minority communities (Pullen Sansfaçon et al., 2020). We recommend providers seek to understand how their language may advertently or inadvertently reinforce heteronormativity, through reflective practice, supervision, or external mentorship. During sessions, providers should repeatedly practice and reflect on their language use to improve their ability to use inclusive language.

Participants (97.8%) highlighted the importance of service providers attaining cultural competence education and that this education should be self‐sourced. Education is a foundation for service providers to acquire the tools to reflect on their attitudes, to learn about minority stress and the experiences of sexual minorities, and to develop culturally affirming skills to provide inclusive service to sexual minorities (Crisp, 2006; Graham et al., 2012; Moe & Sparkman, 2015). Free text responses from our participants highlight the importance of service providers continuing to develop their cultural competence. It is important to recognize cultural competence is never fully attained, providers must recognize that biases and experiences will inform how they respond to sexual minorities (Mosher et al., 2017). To recognize the ongoing nature of cultural competence, researchers have developed a cultural humility framework which can assist therapists to: engage in self‐reflection, build a therapeutic alliance, repair any ruptures caused by a lack of cultural awareness, and navigate differences when therapists and clients hold different values (Mosher et al., 2017).

Many professional developments, online tools, self‐reflection inventories, and lived experience stories are accessible tools for service providers to increase their cultural competence (Bishop et al., 2021; Crisp, 2006; Moe & Sparkman, 2015). Participants discussed an expectation that culturally affirming practices should be included as part of service delivery, putting the expectation onto providers to source this education. Studies compiled into a systematic review examining the experience of sexual minorities in a mental health setting indicated that service providers lacking knowledge or demonstrating an inability to understand issues relevant to sexuality was a negative experience to sexual minority service users (McNamara & Wilson, 2020). Sexual minority individuals reported feeling frustrated when misunderstood or being pumped for information about their sexuality (McNamara & Wilson, 2020). Service providers should therefore be proactive in their acquisition of culturally competent practices to assist in meeting the treatment needs of sexual minorities. Previously, researchers have demonstrated that skills workshops (not simply passive lectures) are sufficient to increase self‐perceived levels of cultural competence and as such, service providers who are time poor or who are uncertain what steps will improve cultural competence, can be assured that increasing cultural competence does not necessarily require intense training or resourcing (Graham et al., 2012).

Acquiring knowledge about sexual minorities can be done through cultural competence training which can be sourced from leading organizations who work with sexual minorities. Providers should seek to identify these organizations within their community. One such example in Australia is the Aids Council of New South Wales (ACON) who are expert in community health, inclusion, and HIV awareness. Identifying such organizations can assist service providers in accessing validated cultural competence training. Approaching service providers with expertise in understanding issues which impact sexual minorities or people who have lived experience may help service providers to learn more about the issues impacting sexual minorities.

4.2.2. Safe spaces, provider traits, service qualities, and community engagement

While positive attitudes, knowledge, affirming practice, and education were the most frequently reported themes in the structured tabular thematic analysis, themes regarding the importance of safe spaces, clients' needs, community engagement, and service traits/provider qualities were developed (see Table 3). While these themes were less frequently reported by participants as important to effective cultural competence, providers should still consider how these themes may enhance service delivery to sexual minorities.

Some participants highlighted a desire to attend services which were advertised as a safe space for sexual minorities. Attending a mental health service requires people to be open and vulnerable to an unknown professional, for sexual minorities, this may carry an additional fear of rejection based on sexuality (Hinrichs & Donaldson, 2017). Participants highlighted that a safe space can be created through advertising as friendly toward sexual minorities, visible cues of affirmation such as rainbow, bisexual and transgender flags, staff wearing rainbow lanyards, inclusive sexuality questions on the intake form, and receiving accreditation from human services organizations, such as receiving the “rainbow tick” (Bishop et al., 2021; Carman et al., 2020). Interestingly, participants also reported that although many services advertised as affirming toward sexual minorities, some services demonstrated a lack of cultural competence. To our knowledge, no research has examined the negative impact of service providers advertising as culturally compentent in working with sexual minorities though in their practice failing to demonstrate cultural competence. Service providers may risk causing distrust in sexual minority clients attending mental health services if they cannot deliver their advertised culturally affirming practices. Participants indicated that while some staff within services may have an adequate level of cultural competence, other staff in the service may lack this level of cultural competence. We recommend that services which advertise as affirming or allies to sexual minorities should be mindful of ensuring all staff, including administration staff, have received proper cultural education training and that staff can provide a consistent standard of service to sexual minorities.

In the free text responses, participants highlighted several qualities that can enhance cultural competence. Service providers should aim to understand the client's needs to determine whether a discussion of sexuality is relevant to treatment. Previous research has highlighted some service providers may lack confidence discussing sexuality with clients, due to a lack of knowledge or lack of confidence in using inclusive language (McNamara & Wilson, 2020). Lack of confidence has been demonstrated to impact trust in services by sexual minorities (McNamara & Wilson, 2020). Service providers confidence in discussing sexuality can be increased through roleplays during supervision with knowledgeable supervisors or peers, exposure to sexual minority clients, and through attending cultural competence workshops (Graham et al., 2012).

Several themes developed from the free text response indicated that service providers could demonstrate cultural competence by being areligious, having increased accessibility options, and engaging with sexual minority communities. Previous research supports that sexual minorities are more likely to experience apprehension accessing religious organization and sexual minority people may experience additional accessibility barriers to accessing care (Cronin et al., 2021; Schuck & Liddle, 2001). Service providers aligned with religious organizations or who demonstrate religious affirming cues, may consider the importance of also demonstrating clear allyship to sexual minorities. Similarly, we recommend service provider consider policies or options for sexual minority participants who have limited service accessibility options. Service providers can also increase accessibility options through advocacy and engagement with sexual minority communities.

4.3. Associations between culturally competent practices and age/sexuality

Despite evidence that bisexual/pansexual people or older sexual minorities experience particular stressors such as identity invisibility or greater marginalization, no correlation was found between overall GAP scores and sexuality/age (Carnaghi et al., 2021; Taylor, 2018). No correlation was found between single items on the GAP and sexuality, though given the strong, positive response from most participants to the GAP, the results suggest that regardless of sexual orientation, culturally affirming practices are important when working with sexual minorities. Despite no correlation between GAP and sexual orientation, a recent literature review determined many unique stressors that bisexual/pansexual people face that are not experienced as frequently by lesbian and gay people when accessing mental health services (Taylor, 2018). Bisexual/pansexual people reported less willingness to disclose their sexuality to service providers and reported mixed acceptance from service providers (Taylor, 2018). The mixed acceptance from service provided often occurred due to service providers demonstrating negative beliefs about bisexual/pansexual, such as inappropriate comments regarding romantic relationships and biphobic attitudes (Taylor, 2018). Service providers should ensure their attitudes remain inclusive and validating of bisexual/pansexual identities.

While no correlation was found between overall GAP scores and age, positive and negative associations were found between some GAP items and age. Older participants rated verbal respect as more important than younger participants. Verbalizing respect may be more important to sexual minorities who are older due to the additional stressors and disrespect sexual minorities who are older may have experienced across the lifespan; stigmatization of same‐sex behaviors, high rates of discrimination, and targeted violence (Fredriksen‐Goldsen et al., 2017). The negative association between age and attending culturally competent services, learning about diversity, addressing discrimination during treatment, and assisting in reducing client shame may reflect the vulnerability of younger people as they explore their sexual orientation (Rice et al., 2019). Sexual minorities who are younger have been shown to be more at risk of depressive episodes and anxiety episodes, likely attributed to the vulnerability experienced during the coming out period and the peer victimization that can occur during schooling (Rice et al., 2019). Service providers working with younger populations may need a higher level of cultural competence as younger people may be more likely to present at services for reasons related to their sexuality (D'augelli, 2002).

4.4. Limitations and future research

While this study provides needed support for the importance of culturally affirming practices among mental health service providers, there are several limitations to the research. First, no information was gathered regarding whether participants had experienced cultural competence in services they had attended as this was outside the study scope. Future research should determine if participants' experience of utilizing mental health services reflects culturally competent practices. Second, while participants reported the three most important things service providers can do to provide culturally competent services to sexual minority clients in response to a single open‐ended question, there was not scope in this study to obtain detailed, descriptive data to interpret these themes. Future studies may wish to use qualitative methods to further investigate how service provider attitudes, knowledge, and skills impact therapeutic outcomes. Third, research should seek to expand the importance of cultural competence to gender diverse, intersex, and asexual people. Previous research has demonstrated they have unique cultural needs that would benefit service providers in their delivery to these populations (Vidal‐Ortiz, 2008). Fourth, the nature of the data collected in the gender demographics collected did not allow for distinction between transgender men and transgender women. For this reason, we did not examine the association between gender diversity, sexuality, and cultural competence. Future studies should seek to explore if an association between gender‐diverse people, sexuality, and cultural competence exists, as research suggests affirming practices may differ for sexual minority gender diverse individuals (Cheshire, 2013). Finally, while efforts were made to recruit a large cross‐section of the sexual minority individuals, the final sample obtained did not allow for comparison to be made based on the intersecting experiences of other identities, such as culturally diverse people, rural people, or people with a disability. Future studies should seek to understand the interaction between cultural competence, sexuality, and these intersecting identities as these populations may experience additional minority stress based on identity intersectionality. Service providers seeking to provide culturally affirming support to people with many intersecting identities may require a more nuanced understanding of culturally affirming practice (Babbitt, 2013; Carnaghi et al., 2021; Cheshire, 2013; Fraley et al., 2007; Kwok & Wu, 2015; Willging et al., 2006).

5. CONCLUSION

The present study sought to determine the importance of mental health service providers demonstrating culturally competent practices when working with sexual minority clients. Based on previous research, we predicted sexual minority participants would endorse the importance of service providers demonstrating culturally competent practices, and this was supported across several practice measures. No significant associations were found in the current cohort between overall GAP score and age/sexuality, although some individual practices showed associations with age. The three most important aspects of cultural competence cited by sexual minorities were service providers having a positive attitude, being knowledgeable, and demonstrating affirming practices. These findings align with the tripartite model of cultural competence, reinforcing the importance of service providers upskilling in each element of culturally competent care. With most participants indicating they would prefer to seek a service which demonstrates cultural competence, providers should seek to access appropriate resources to upskill in culturally affirming practices. This will ensure they are able to meet the treatment needs of sexual minorities and increase the likelihood that sexual minorities will continue to access mental health services.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

PEER REVIEW

The peer review history for this article is available at https://publons.com/publon/10.1002/jclp.23434

Supporting information

Supplementary information.

Click here for additional data file. (17.1KB, docx)

ACKNOWLEDGMENTS

The research team would like to thank Doctor Lara Bishop and Mr Benjamin Leming for reading drafts of the final manuscript. The study was approved by the University of Canberra Human Research Ethics Committee (project number 20216892). Open access publishing facilitated by University of Canberra, as part of the Wiley ‐ University of Canberra agreement via the Council of Australian University Librarians.

Bishop, J. , Crisp, D. A. , Grant, J. B. , & Scholz, B. (2022). “You say you're inclusive, but can you show us?” The importance of cultural competence when working with sexual minorities in a mental health setting. Journal of Clinical Psychology, 78, 2145–2163. 10.1002/jclp.23434

ENDNOTE

1

For this paper, the term sexual minorities refers to all people who identify with a sexual orientation which includes a component of experiencing same‐sex attraction (including pansexual and queer identities.)

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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