Informed Consent: Ethical Considerations for Working With LGBTQ+ Clients
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There’s a lot to cover before a prospective client can consent to treatment.
Following the guidelines in the 2014 ACA Code of Ethics (Section: A.2.b.), a therapist must clearly convey their qualifications as a mental health practitioner; the purpose and goal of therapy; the techniques and procedures implemented, including their potential limitations, risks, and benefits; as well as the client’s legal rights, and the role of technology in session.
Verbal consent is always necessary, yet written documentation is best to clarify information, memorialize the occasion, and officially record the client’s consent for legal purposes. To make sure the client adequately comprehends their rights, it’s vital to adapt the discussion for the client’s benefit, and use easy to understand language.
Yet informed consent can be far more than just an intro to therapy covering all professional matters in one fell swoop. It can be an ongoing process, returning safety and agency to the client by continually updating them about any and all ethical, legal, practical, or relevant issues that may arise during the therapeutic alliance. For more on this, please review the ACA and APA ethical practices, and Lidz, Appelbaum and Meisel’s (1988) article “Two Models of Implementing Informed Consent.”
As always, clients should be encouraged to ask questions, yet due to the long history of discrimination, LGBTQ+ individuals may have some unique concerns pertaining to their privacy, emotional safety, and legal rights. Relational trust begins with the informed consent process, and for prospective LGBTQ+ clients, it can assuage some deep concerns.
Indeed, reviewing informed consent during intake, as well as returning to it throughout the course of therapy, can reinforce trust and rapport by highlighting inclusivity, confidentiality, the duty of care, the goodness of fit, and social boundaries.
Inclusivity
Inclusivity isn’t just an open-minded perspective—it’s an action paradigm that invites diversity and makes room for the client’s personal experience, dynamic identity, and unique voice.
The language used during informed consent demonstrates how expansive, aware, and mindful (or narrow, neglectful, and clumsy) a therapist is when it comes to sex, sexuality, and gender diversity.
During intake:
- Does the therapist introduce their own pronouns?
- Do they deliberately or accidentally misgender the client?
- Do the informed consent documents confuse sex and gender, or ask nonbinary clients to tick one of two boxes?
- Is there a space to write in pronouns?
- At the bottom of the page, are transgender people forced to sign their deadname because that’s what’s on their insurance card, or is there room for their actual name?
- When writing down an emergency contact, is there ample time to explore that person’s role, honoring the client’s family of choice?
- When talking about a significant other, does the therapist use heteronormative language, presuming men have girlfriends and women have boyfriends, or do they use cisnormative language, presuming the client or their partner even use gendered terms?
- Do they use monogamous language, presuming there is only one partner needing to be contacted in case of emergency?
These questions directly relate to informed consent, as negligence on the therapist’s part may insult the client’s dignity, undermine trust, compromise emotional safety, and impact their willingness to consent to treatment.
Confidentiality
Confidentiality is both a legal ethos and an emotional bond validating the client’s need for privacy and security. It’s also worth emphasizing as sessions progress in order to illuminate the therapeutic container as a safe space. Since doubt and shame are pervasive obstacles for sexual and gender minorities, it’s important to honor confidentiality at each tier of personal disclosure.
Revisiting confidentiality may also generate some unique opportunities and bridge some very delicate conversations. For example, therapists can help clients who are actively experimenting with names and pronouns by providing a judgement-free testing ground. Therapists can also help clients not yet ready to disclose their identity by providing a safe space for their authenticity.
In both cases, this means using the client’s chosen name and personal pronouns in session, while recognizing that they may present a different identity outside of a session. This level of confidentiality matters a great deal if a client is not yet “out of the closet,” and there’s a chance of engaging in family therapy or couples counseling.
A well-prepared document, reviewed and understood from the start, helps clarify the therapist’s legal obligations. This includes a delineation between necessary forms of professional consultation and unnecessary breaches of confidentially, as well as a client’s legal rights to privacy. In the USA, this includes informing the client about the Health Insurance Portability and Accountability Act (HIPAA), as well as state privacy laws.
In the case of adolescents, these rights must be understood by their legal guardian who, according to HIPAA, typically maintain the right to access medical records pertaining to their child’s diagnosis and treatment. This makes controversial diagnoses like gender dysphoria (DSM-V) and gender incongruence (ICD-11) problematic if the child isn’t prepared for their guardian to know.
If there’s a risk to the minor, by way of abuse, neglect, or endangerment, a therapist can withhold said records, and may even need to call child services. But what if there isn’t a direct threat, and the guardian is just a concerned parental figure clashing against their child’s need for privacy?
First and foremost, transgender and nonbinary individuals are not defined by gender dysphoria, and a client should not be slapped with a diagnosis just because of their gender identity, or because they’re exploring their gender identity.
Indeed, many mental health practitioners, as well as transgender and nonbinary individuals, deem gender dysphoria/incongruence to be stigmatizing. By assessing LGBTQ+ youth on the basis of their mental health needs, rather than their identity, it becomes possible to proceed with a more apropos diagnosis, allowing the client to disclose their gender to their guardian when they’re ready.
If, however, the therapist finds gender dysphoria/incongruence to be the best diagnostic fit and the guardian has a legal right to know the child’s diagnosis, then the therapist should seek immediate consultation, as it can be psychologically damaging to “out” a client, even to family members by way of documentation.
Fortunately, HIPAA’s Privacy Rule shields psychotherapy notes, where a therapist is more likely to record details about a client’s sexuality or gender identity for their own private review. The Privacy Rule leaves access to psychotherapy notes up to the therapist’s discretion, yet therapists are encouraged to seek outside clinical and legal advice before providing access to them.
Duty of Care
The limits of confidentiality bump up against a therapist’s duty of care and, given the ethical and legal obligation to protect individuals from harm, their duty to warn.
Some clients may compassionately nod along, agreeing that it’s important to keep other people safe, only to pause when self-harm is mentioned. Consider that, of the 40,000 respondents to the Trevor Project’s 2020 National Survey on LGBTQ Youth Mental Health, 48 percent had engaged in self-harm and 40 percent had considered suicide in the prior year.
A client’s resistance to sharing their history of self-harm or suicidal ideation can stem from many things, including defensive compartmentalization, a fear of losing control, or of having their agency superseded.
LGBTQ+ youth in particular often experience their autonomy being overwritten by parents, teachers, religious mentors, and even mental health professionals, attempting to “protect them from themselves.” This can leave an expectation of being misunderstood and a fear of knee-jerk reactions. Such clients, even as adults, may assume a therapist will blow their unhealthy behavior out of proportion; misdiagnose minority stress as a mood disorder; commit them if they share any suicidal thoughts; or mistake a BDSM lifestyle for clinical self-harm.
Yet, discussing duty of care can actually strengthen trust in the therapeutic alliance, provided the therapist presents and maintains an allied power dynamic. A client can garner a lot from the language and cadence of both the informed consent documents and the therapist talking about them. A calm, conscientious, and humanizing delivery can help clients recognize a therapist’s duty of care for what it is: caring. By normalizing the ubiquity of suffering, the therapeutic container is framed as a safe place to process sadness, pain, anger, hostility, and even suicidal ideation.
Duty of care, and even duty to warn, may need to be revisited if a client’s hostility, self-harm, or suicidality worsens. The client may need to sign a safety contract, collaborate with their therapist about treatment options, and be frontloaded about ethically mandated responses if there’s a heightened risk to themselves or others.
Goodness of Fit
From the get-go, informed consent prepares a client for eventual termination, the possibility of premature termination, how treatment will proceed if the therapist is incapacitated in some way, and the benefit of referral. The topic of referral segues nicely into the goodness of fit and the goal of providing the client the best possible course of treatment.
Therapists often share their educational background and therapeutic approach via a brief explanation or handout so the client can decide if their modality is right for them. Yet, a goodness of fit is also relational, meaning clients often look for clues about their therapist’s personality. Are their family photos in their office? A rainbow flag? Are their queer books on the shelf?
Remember, the client is consenting to work with the individual practitioner, as much as they’re consenting to the course of treatment. It can be tricky to gauge a good match, especially if a therapist chooses to minimize their own identity in the therapeutic relationship. Each therapist must come to terms with personal disclosure in their own practice, recognizing when a personal anecdote can normalize a client’s experience, and when over-sharing may invalidate or decenter the client.
Therapists would also do well to assess if their skillset, experience-level, or even style of communication is beneficial to the client, necessitating both self-awareness and professional humility. No single therapist is suited for every client, making it important to accept one’s professional strengths, limits, and growth points, not to mention bias and privilege.
It is unethical to reject a client on the basis of their sex, sexuality, or gender identity, yet it’s also unethical to proceed if there’s a clear political, religious, or moral impasse. Mental health practitioners naturally want to help people, but for LGBTQ+ clients struggling with issues of safety, trust, and identity suppression, goodness of fit is vital to their process.
While the risk of psychological harm resulting from bias, judgment, or professional incompetence cannot be understated, heteronormative and cisnormative privilege isn’t always apparent. For example, a client may actively appreciate their therapist, yet withhold what they share in session if said therapist is too straight, cisgender, or vanilla to understand.
In some instances, clients in transition may see a gender specialist as well as their weekly therapist, though not everyone can afford the luxury of two mental health practitioners. Taking limited resources into account, sometimes the best thing a therapist can do is connect a client to a better fit. This may include matching them to a specialized therapist, an affirmative therapist, an LGBTQ+ identified therapist, or just a therapist with a different therapeutic modality, communication style, or personality.
Boundaries
On the whole, counselors are advised to keep their personal and professional lives separate in order to maintain clear and respectful boundaries. However, therapists who are active allies, who live in small rural communities, or who are LGBTQ+ themselves, may have to be very mindful about their degrees of separation.
The LGBTQ+ community is, after all, a collection of diverse micro-groups and pride-based support networks, which can result in social overlap. This makes it important to discuss what happens when the client and clinician see each other in public. So as not to make a client feel uncomfortable or ignored, it’s important to place the proverbial ball in their court, so they can decide whether or not to acknowledge, approach, or engage.
Considering reputation, it’s important for therapists to be aware of their community standing. On the plus side, respected therapists receive a lot of LGBTQ+ referrals by word of mouth. On the negative side, some clients—especially those struggling with stigma or internalized shame—may want to publically distance themselves from someone associated with therapy, or the LGBTQ+ community. This brings the client’s comfort and personal boundaries to the forefront of the conversation.
It may also be important to identify shared associations, like when the therapist and their client orbit the same social scene; or dual roles, like when a therapist and their client both volunteer with the same Pride organization.
While it’s always inadvisable to provide therapy to one’s friends, what happens when a client is a friend-of-a-friend? At all times, the therapist must be conscious of such weighted power dynamics, the likelihood of encounter outside of session, their client’s confidentiality and emotional safety, and the need for objectivity in the therapeutic relationship.
Sexual interactions are never appropriate and sexual misconduct directly harms the client’s well-being. That said, sexual and affectional attractions do occur, especially when sessions actively explore themes of authenticity, intimacy, sexuality, and love. Therapists struggling with such feelings may need to refer out and should seek professional consultation and therapeutic counseling for themselves so as not to burden their client.
Affection originating from the client must also be addressed with great care, as clients struggling with loneliness, alienation, or attachment issues can sometimes project onto the caring professional holding space for them. Once again, boundaries must be crystallized in a healthy, mutual context in order to maintain honest communication, process the client’s feelings, or refer out if necessary. Given the delicacy of these matters, and their tendency to cloud objectivity, therapists are always encouraged to seek outside consultation.
Some clients may wish to continue a platonic friendship or working relationship concluding therapy. In response, some therapists maintain a strict “once a client, always a client” policy, whereas others may permit personal interactions after two years without contact. However, for therapists working in a small LGBTQ+ community, total separation may not be realistic, making it crucial to role model healthy boundaries that are both compassionate and ethically congruent.
Alex Stitt, LMHC
Writer & Contributing ExpertAlex 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.