CLINICAL QUALITY OF CARE – PRACTICE PARAMETERS 

Office of the Chief Medical Officer 
Clinical Operations 


Sexual and Gender Diversity

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Category: Special Considerations 
Published Date: April 2022
  1. PARAMETER GOAL
    1. To provide guidance and inform practice on administering responsive care to all clients, appreciating the diversity of gender and sexuality, including:
      1. Using appropriate affirming language and terminology
      2. Assessing for clients’ unique needs regarding their gender identity and sexuality
      3. Engaging with clients in conversations around documentation and confidentiality
      4. Referring clients’ to LGBTQ+-friendly service providers
         
  2. TERMINOLOGY
    Limitations of language: Language and terminology related to sexual and gender diversity are consistently evolving as our collective understanding of sexuality of gender continues to expand. The following definitions reflect current and affirming terminology; still, staff is encouraged to exercise thoughtfulness and maintain a client-centered stance when using specific terms.
    1. Asexual: Often called ace for short. A person who experiences little or no sexual attraction to others or interest in sexual activity. They may or may not feel emotional/romantic attraction.
    2. Bisexual: Describes a person who is emotionally, romantically, or sexually attracted to more than one sex, gender, or gender identity, though not necessarily simultaneously, in the same way, or to the same degree.
      1. Bisexual+: Refers to multiple sexual orientations that describe people with attractions to more than one gender (e.g. pansexual, queer)
    3. Bullying: A form of aggressive behavior in which someone intentionally and repeatedly causes another person injury or discomfort. The bullied individual is typically someone perceived as vulnerable.
    4. Cisgender: A term used to describe a person whose gender identity aligns with those typically associated with the sex assigned to them at birth. (Cisgender is the opposite of transgender.)
    5. Coming Out: The process of acknowledging, accepting, appreciating, and/or disclosing one’s sexual orientation or gender identity. Coming out is an ongoing process for many individuals since people often come out multiple times throughout their lives depending on the sociocultural environment, identity development, etc.
    6. Conversion Therapy: A range of dangerous and discredited practices that falsely claim to change a person’s sexual orientation or gender identity or expression; it is sometimes known as Reparative Therapy.
    7. Deadnaming: Occurs when an individual, intentionally or not, refers to the name that a transgender or gender-expansive individual used at a different time in their life. Avoid this practice, as it can cause trauma, stress, embarrassment, and even danger. Some may prefer the terms birth name, given name, or old name.
    8. Differences of Sex Development (DSD): Refers to a variety of conditions characterized by reproductive or sexual anatomy that does not fit typical definitions of male and female. People with differences of sex development are referred to as Intersex.
      1. Sometimes referred to as Disorders of Sex Development; however, this language is seen as overly pathologizing by many.
    9. Gay: A person who is physically and emotionally attracted to someone of the same sex or gender. While it is usually used to describe men attracted to other men,  people of all genders may use it to describe themselves.
    10. Gender: The characteristics and roles of women and men according to social and cultural norms. While sex is described as female, male, and intersex, gender can be described as feminine, masculine, androgynous, and much more.
    11. Gender Affirming Surgery or Gender Confirming Surgery: Many transgender people prefer these terms to the older term, sex reassignment surgery. Gender affirming surgery is only a small part of the transition or expression of gender. Many transgender people do not have surgery for all kinds of reasons. It’s inappropriate to ask a transgender person what surgical or medical procedures they plan or have undergone.
    12. Gender Expression: How a person presents their gender on the outside. This can include how they look, the name they choose, the pronouns they use (e.g., he/him/his, they/them/theirs, ze/zie/zim), and their interpersonal behavior.
    13. Gender-Fluid: Being a person who does not identify with a single fixed gender or has a fluid or unfixed gender identity.
    14. Gender Identity: One’s internal knowledge or sense of one’s own gender. Gender identity is distinct from sex (assigned at birth).
    15. Gender Diverse: Describes the community of people who fall outside of the gender binary structure (e.g., non-binary, genderqueer, gender-fluid).
    16. Gender Diversity: An umbrella term used to describe the diversity in gender expression, beyond the binary (male and female) perspective.
    17. Gender Dysphoria: Discomfort or distress associated with the difference between a person’s gender identity and their sex assigned at birth (or sex-related physical characteristics).
      1. Gender dysphoria is a listed diagnosis in the DSM-5 and is usually required for clients to access gender-affirming medical care. While a diagnosis of gender dysphoria is often conceptualized as synonymous with being transgender, it is important to remember that not all transgender people experience gender dysphoria, and not everyone who experiences gender dysphoria is transgender.
    18. Gender Identity: A person’s inner sense of being a girl/woman/female, boy/man/male, other gender(s), or having no gender.
    19. Gender Non-Conforming: A broad term referring to those who do not behave in a way that conforms to the traditional expectations of their gender, or whose gender expression does not fit neatly into a category.
    20. Gender Role: A set of societal norms dictating what types of behaviors are considered acceptable, appropriate, or desirable for a person based on their actual or perceived gender. These roles change with time, culture, context, and interpersonal relationships.
    21. Genderqueer: Describes a person whose gender identity is not entirely man or woman (see also Non-Binary).
    22. Gender Transition: The time period during which a person begins to live according to their gender identity rather than the gender they were assigned at birth.
    23. Heteronormative Language: Language that assumes everyone is heterosexual and cisgender (i.e., using the terms boyfriend or girlfriend instead of partner, or using mother and father instead of parent).
    24. Homophobia/Biphobia/Transphobia: Fear or hatred of people who are gay, bisexual, or transgender. Often shown through prejudice, discrimination, intimidation, or acts of violence.
    25. Inclusive Language: Language that is not gender-specific (i.e., partner instead of boyfriend or girlfriend; parent instead of mom or dad; the pronoun they instead of he or she).
    26. Intersectionality: Refers to the overlap of social categorizations or identities such as race and ethnicity, sexuality, gender, disability, geography, and class in an individual or group of people that can contribute to discrimination or disadvantage.
    27. Intersex: Describes a variety of naturally occurring variations in reproductive or sexual anatomy that does not fit the typical definitions of male and female.
    28. Lesbian: A woman who is emotionally, romantically, or sexually attracted to other women.
    29. LGBTQ2S+/LGBTQ*/LGBTQ+/GLBT/LGBTQ2/LGBTTQQIA: Acronyms that refer to the collection of sexual and gender identities including lesbian, gay, bisexual, transgender, two-spirit, queer, questioning, intersex, and asexual. These acronyms mean the same as sexual and gender minorities. The asterisk (*) or plus sign (+) show that there are other identities included that were not referenced in the acronym.
    30. Non-binary: Describes a person whose gender identity exists outside of the gender (man/woman) binary (see also Genderqueer).
    31. Outing: Involuntary or unwanted disclosure of another person’s sexual orientation or gender identity.
    32. Pansexual: Describes someone who has the potential for emotional, romantic, or sexual attraction to people of any gender though not necessarily simultaneously, in the same way, or to the same degree. Sometimes included under the umbrella of bisexual+ sexual orientations.
    33. Pronouns: The words used to refer to a person other than their name. Common pronouns are they/them, he/him, and she/her. For those who use pronouns (and not all people do) they are not preferred, they are essential.
      1. Neopronouns: Pronouns created to be specifically gender-neutral, including xe/xem, ze/zir, and fae/faer. Pronouns are sometimes called Personal Gender Pronouns (PGPs).
    34. Pushout: Refers to practices, including unwelcoming, uncaring, and unsupportive school environments, that contribute to students being sent to substandard schools and/or academic programs, or dropping out of school altogether.
    35. Queer: An umbrella term describing people who think of their sexual orientation or gender identity as not exclusively heterosexual and/or cisgender; may also be used by individuals who see their sexuality and/or gender outside of societal norms. Some people view the term queer as more fluid and inclusive than traditional categories for sexual orientation and gender identity. Although queer was historically used as a slur, it has been reclaimed by many as a term of empowerment. Nonetheless, some still find the term offensive.
    36. Questioning: Describes a person who is unsure about, or is exploring their sexual orientation and/or gender identity.
    37. Same-Gender Loving: A term used to express attraction to and love of people of the same gender. Men Loving Men (MLM) refers to gay, bisexual, pansexual, or otherwise same-gender-loving men and is used most within the Black and African Heritage communities. Preferred by some instead of lesbian, gay, or bisexual due to their European descent.
    38. Sex: See Sex Assigned at Birth.
    39. Sex Assigned at Birth: The sex (male, female, or intersex) assigned to an infant, most often based on the infant’s anatomical and other biological characteristics. Sometimes referred to as birth sex, natal sex, biological sex, or sex; however, sex assigned at birth is the recommended term.
    40. Sexual Orientation: A person’s sexual identity, referring if or to whom one is attracted.
    41. SOGIE: An acronym that stands for Sexual Orientation, Gender Identity, and (Gender) Expression.
    42. Transfeminine: A person who is transgender and whose gender identity is that of being a femme/feminine person.
    43. Transgender: Describes a person whose gender identity is different from the gender they were thought to be at birth.
    44. Transition: A process of change in which a person begins to live according to their gender identity when their gender identity is different from their sex assigned at birth.  This may include physical, legal, and social changes.
    45. Transmasculine: A person who is transgender and whose gender identity is that of being a masc/masculine person.
    46. They/Them: A gender-inclusive, singular, or plural personal pronoun.
    47. Two-Spirit: Describes a person who embodies both a masculine and a feminine spirit. This is a culture-specific term used among some Native American, American Indian, and First Nations people. This may include concepts of spirituality, sexual orientation, and gender identity.
       
  3. MEASURES
    1. Asking clients in conversation (in order) their: 
      1. Authentic/Chosen Name
      2. Pronouns
      3. Gender Identity
      4. Sexual Orientation
        1. Note: Authentic/Chosen Name, Gender Identity, and Pronouns are essential from the initial interaction since they pertain to how we will address/refer to other people. Sexual Orientation is important information for us to gain holistic knowledge of a person’s lived experience, but it isn’t 100% necessary at every first contact.
    2. Asking clients if they have any concerns around gender identity or sexuality:
      1. Identity development/journey and associated emotional responses
        1. Clients may experience layered and complex emotions related to their identity journey; these emotions may be pleasant/wanted and unpleasant/unwanted.
        2. There is no inherently normative or pathological emotional response(s) in this context; all emotions are valid and normal, including conflicting emotions.
      2. Treatment preferences
        1. Preference of clinician (gender, sexuality, etc.)
      3. Disclosure/coming out
        1. With whom has the service recipient discussed/disclosed their sexual and/or gender identity? How have these individuals responded? 
        2. Does the service recipient have any concerns about disclosing their identities, being outed, etc.?
      4. Referrals/linkages (e.g., LGBTQ+ affirming housing, gender affirming medical care)
      5. Familial and/or community supports
      6. Safety within their multiple environments (e.g., family, school, work, friends)
      7. Multiple intersecting identities
      8. Preferred language or terminology around gender and sexuality
        1. What language do they want the provider to use in reference to them?
        2. Note: Some clients prefer that their provider use the same language/terminology that they use, and others prefer that their provider uses different wording than what they use for themselves.
    3. Charting
      1. Checking that the health record is accurate 
      2. Correcting the client’s name, pronouns, and/or gender markers
      3. Ensuring the use of the correct name, gender, pronouns when writing progress notes
         
  4. TREATMENT STRATEGY
    1. Collaborate with the client to maximize safety in:
      1. Physical environments
      2. Social environments
      3. Inner subjective experience (e.g., does the client have the necessary skills to keep physically and/or psychologically safe?)
    2. Work with the client to integrate sustainable and effective strategies to navigate intrapersonal and interpersonal domains, including:
      1. Grounding, distress tolerance, self-soothing, and/or mindfulness skills
      2. Communication, assertiveness, and/or relational skills
        1. Work with youth and families/caregivers to decrease rejecting behaviors and increase supportive behaviors, even if family members/caregivers are having difficulty accepting the youth’s sexuality and/or gender.
    3. Start introductions with pronouns and a validating environment
    4. Engage the client with a gender and sexuality affirmative model of care
      1. Recognize therapist biases and limitations
      2. Acknowledge and affirm client presentation and identification
      3. Explore the language which the client wishes to use
    5. Collaborate with the client treatment goals/plan
    6. Educate the client about evidence-based treatments available:
      1. Cognitive Behavioral Therapy (CBT)
        1. Trauma-focused
        2. Anxiety
        3. Depression
      2. Dialectical Behavioral Therapy (DBT)
      3. Group therapies
      4. Seeking Safety
      5. Peers-Run services
      6. Additional emerging and accepted treatment strategies
    7. Contraindication:
      1. Sometimes known as conversion therapy or reparative therapy, counseling aimed at changing a person’s sexual orientation, gender identity, or gender expression, has been shown to be ineffective and can be extremely harmful. The practice has been banned for minors in a growing number of states, including California.
      2. The belief that clients' sexual or gender identities can be changed through therapy runs counter to the overwhelming consensus in the medical and mental health community.
         
  5. PROVISION OF SERVICES
    1. Environment
      1. Restroom access
      2. Messaging (bulletin boards, etc.)
    2. Cultural Perceptions regarding Mental Health
      1. Internalized stigma
    3. When working with youth, discuss their preferences around privacy and confidentiality related to documentation of gender identity and sexuality
    4. Diversity (age, race, etc.)
    5. Explicitly affirm clients in their authentic self
      1. A client’s authentic self is defined by the client and never by anyone else.
      2. Validate that a client’s identity development/clarity is a non-linear and highly individual process 
    6. Address internalized homophobia, biphobia, transphobia
    7. Service-Specific Guidance
      1. Case Management: Ensure referrals are appropriate, affirming, and have safety protocols in place for sexual and gender diverse individuals.
         
  6. OUTCOMES AND MONITORING
    1. Multi-disciplinary case consultations
       
  7. STAFF TRAINING
    1. Specialized training to develop the skills necessary to serve sexual and gender diversity identified clients.
      1. All therapists should have:
        1. Basic training and working knowledge on serving clients of sexual and gender diverse clients
        2. Use of appropriate terminology
      2. Trained and experienced staff should be available for consultation
         
  8. SUPERVISION AND CONSULTATION
    1. Supervisors should provide opportunities for Los Angeles County Department of Mental Health (DMH) staff to examine their ability to provide services to sexual and gender diverse clients:
      1.   Explore values, attitudes, and biases
      2. Assess and develop competency
      3. Recognize limits
    2. Supervisors should engage in frequent self-reflection and examination of cultural and generational factors and attend to their own biases and assumptions.
    3. In order to foster relational safety with supervisees, supervisors should assess how their own biases and assumptions may be influencing communication dynamics and responsivity:
      1. Between supervisor and supervisee
      2. Among multidisciplinary team members
      3. Between DMH staff and clients
    4. Supervisors should practice strengths-based and reflective approaches to working with supervisees.
      1. Supervisors should model and promote balance, boundaries, and self-care, with the recognition that these may be influenced by the supervisor's or supervisee's cultural identities and experiences.
    5. Supervisors should continue to seek out opportunities through training, workshops, consultation, and direct engagement to further their understanding of anti-racism, diversity, and inclusion with the goal of modeling such inquisitive and supportive behaviors in others.
    6. DMH staff should provide services in the client’s best interest and seek supervision when:
      1. Differences between a clinician and client pose an obstacle in the therapeutic process, the clinician should initiate a consultation with appropriate individuals.
      2. Differences preclude useful treatment despite all attempts to resolve the differences, the client should be timely transitioned to a more appropriate clinician with complete documentation of reasons for the transfer.
         
  9. RESOURCES