Clinical application in sexual orientation

When we talk about sexual orientation the first think that come into our mind is on the individual’s sexual identity in relation to the gender. But, we should know that sexual orientation and sexual identity are different. Sexual orientation is also generally defined in terms of several groups, such as heterosexuals, where there is psychological, romantic or sexual attraction towards the opposite sex, homosexuals like gay or lesbian with a psychological, social or sexual preference towards the same sex. This paper is one of the assignments in the Multicultural Counseling's subject, which discusses several cases that discuss about client's sexual orientation, then the causes and impacts of the social environment on their sexual orientation. As we know, this problem is a thing that not consider in majority of environment. Also, we convey how future counselors should respond and behave when dealing with sexual orientation clients.


Introduction
Based on this subject ECG 21303 Multicultural Counselling. The student required to summaries the case and complete the reflection and discussion questions. This task is base on group work project where we as group member have decide to choose a topic on the Clinical Application in Sexual Orientation of case study which we found out that this topic were quite interesting and one of the type of cases that we as future counselor has to face. Hence, we take this opportunity to learn and explore on what and how does a therapist should handle this kind of cases.
Meanwhile, when we talk about sexual orientation the first think that come into our mind is on the individual's sexual identity in relation to the gender to which they are attracted such as being heterosexual, homosexual, bisexual. Research also has shown that sexual preference varies from exclusive attraction to another sex to exclusive attraction to the same sex over many decades. Sexual orientation is also generally defined in terms of several groups, such as heterosexuals, where there is psychological, romantic or sexual attraction towards the opposite sex, homosexuals like gay or lesbian with a psychological, social or sexual preference towards the same sex. In various cultures and nations all over the world, this scope of behaviors and attractions is allowed. Many societies use identification labels to identify the attractions.
The main attractions for adult sexual orientation usually occur between middle childhood and early adolescence, according to existing theoretical and professional perceptions. These social, romantic, and sexual attractiveness patterns can be developed without any past sex. They can be allowed to marry and still have sex with their partner like gay, homosexual, bisexual or heterosexual.Various gay and bisexuals had quite different sexual orientation perspectives. Some people know that they've been lesbian, gay, or bisexual for a long time before they actually engage in relationships with others. Some people engage in sexual activity with the same-sex or other-sex partners before assigning a clear label to their sexual orientation.
Prejudice and discrimination make it difficult for many people to come to terms with their sexual orientation identities, so claiming a lesbian, gay or bisexual identity can become a slow process in our cultures. If we could see most of this individuals have a higher rate of mental health concerns than their heterosexual, homosexual or bisexual counterparts (Psychological Bulletin, 129(5),674-697).The major reason for these increased concerns regarding mental health may be that they are still stigmatized and rejected by society, thus increasing mental health problems and preventing mental health care services. Such people are aware of these stress as they come out and may be prone to mental health issues. While, in order to build stability against these stress of mental health, individuals need coping, social support, and interpersonal energy which make them seek counselor for their support system.

Reflection and Discussion Question ( The Story of Tony ) Case Description
Tony is 23 years old African-American gay man. He has presented to a psychotherapy with many issues that has been affecting him with his professional and personal life. Tony had experience of facing racism in the gay community and homophobia by the community of color. He was raised by his mother in small town of Southern city. Tony was criticized and bullied by his peers and also his family members due to his skin tone and lack of interest in sports. He also being labelled as a "sissy boy" by the community and family. Results from that, he skipped school often. However, Tony managed to get a scholarship for music college in Northeast and he have moved there as soon as he finished high school. This has made Tony to have a little connection with his family. Tony has a low motivation on his future and don't want to think too much on what he wants to do professionally.
As a result, from that experience, Tony reported to feels depressed. This makes him to involves in self-destructive behaviors which are smoking marijuana and also substance abuse. He doesn't have many friends that inhibit with his social world. Most of them will be heterosexual women. He does socialize with other gay man especially when he goes to the bar. But then, Tony often feels marginalized as an African American man especially in White gay culture. Because of the racism that he received among gay community; Tony always feels like he is "invisible" among others in that community.
Suddenly, Tony has been up to a relationship with a tall gay man, White model for a local retailer. He feels more motivated when he received acknowledgement of his reality from this White gay man. Results from that, he able to completed his bachelor's degree, get a corporate position on a company which he thinks it is interesting and he purchased a house to starts a proactive social life. Tony started to created his own "family of choice" with his boyfriend.

What might the therapist consider in addressing Tony's sexual health?
Based on Tony's sexual health, the therapist can consider on addressing his selfdestructive and his negative self-concept. Why do we said so? This is because, in our opinion we can see that from the article has highlight on the highest risk group for new HIV infections involve young gay colored men, according to the Centers for Disease Control and Prevention. The reasons for this are not defined, but it is speculated that men in this group feel victimized and are putting their health at risk in order to have sexual or romantic connections with other men. Based on Tony case, the therapist has addressed on his negative self-concept where he have develop sexual and romantic connection with another men which led him into unprotected sex on several occasion. Moreover, if we could see more details of Tony's case maybe the therapist can address on his negative behaviour that taking drugs (marijuana) and alcohol which can relate it to unprotected sex that he had made for a several times that also might leads high risk to have HIV or AIDS infection if we are aware on it.
As an evidences that we can provide to support the above statement, where in United States entering into the second decade of the AIDS epidemic, it has become evident that prevention of activities contributing to HIV transmission is the main protection against the spread of this disease. Recent psychological studies have reflected on discovery of factors that could be controllable and lead to behavior. The use of alcohol or drugs with sex (Leigh 1990,a;Stall 1988) is one of the current factors contributing to sexual risk-taking. Because alcohol and drugs are thought to interfere with judgment and decision-making, it has been suggested that their use in conjunction with sexual activity may increase the chances of risky behavior (e.g., Howard et al., 1988;USDHHS, 1991). In recent years, there have been a number of reports indicating that a person is more likely to be at higher risk for HIV infection in connection with alcohol or drug use and sexual behaviour, such as unprotected sex relationships. To guide Tony's issue, the therapist can use Psychoeducation therapy where process of providing education or information to those seeking or receiving mental health services. By using this tool, the therapist can provide information to guide Tony to prevent or create awareness and reduce the risks of HIV, and sexually transmitted infections for him and others clients with and without chronic health condition. How can therapy influence Tony's seeming lack of motivation in addressing professional and personal issues?
In order to influence Tony to make him feel more motivated on dealing with his professional and personal issues, the therapeutic process should be more on encouraging process. This is because from his past experience that he received which are racism in gay community and homophobia in his community of colour that has made him to feel demotivated and discouraged to do what he wanted to do professionally. In the process of encouraging Tony, therapist can first educate Tony on the importance of maintaining individual's wellbeing which it will results in high motivation and improve in mood. This will encourage Tony to start to have a healthy life styles with starts to applying an exercise program. The exercise programs which promote good health behavior includes reasonable diet, sleep regulation and exercise is the best influence in therapy to address his self-destructive behavior.
Another encouraging method that can be a big influence for Tony after he gets a good and healthy life styles, which indirectly his mood and motivation has been improved, therapeutic process will need to start to focus on encourage Tony to starts socialize. The goal for this therapy is to make Tony to have a self-awareness on the strength that he has. For example, he needs to embrace his strength as a fit and attractive young man. With a more positive thinking about himself and not mind what others think about him which is the community, it will somehow boost his self-esteem and confidence to starts to socialize. With socializing, Tony will start to feel motivated again when he receives acknowledgement for his existence by others which is gay community.

What strategies might be most useful in empowering Tony to move from a victim mentality to that of a survivor?
The best strategies that can help to empowering Tony's victim's mentality is to challenge or dispute the negative thinking that can be discover from his internalize feeling of inadequacy. The inadequacy are the results from the experience that he gets from his homo-negative family and his peer group. In order to do this strategy, the therapist can use Cognitive Behavioral Therapy (CBT) as a guide. Therapist can use reframing or restructuring as a technique to help Tony dispute his negative thinking to a positive one (Cognitive Behavioral Therapy (CBT), Aaron T. Beck, 1960s).
First, Tony will need a help to make his aware of his negative pattern of thinking for example, feeling invisible when with others gay community, undesirable man, reluctant to socialize and the feeling of less than others. Once Tony able to realize of this negative pattern o f thinking, he then will be able to reframe the negativity to a more positive and productive thinking. As for example, his advantage of his masculinity that makes him desirable, the difference that Tony have from the others makes him special and also, he can socialize despite what the others think of him.
As a result, from this strategy, Tony will start to have a new positive pattern of thinking where will make him to go out from his victim's mentality. This reframing technique will make Tony to have his own regulations on how to be a man. Indirectly, Tony will become a self-made man and that will make him not to be affected anymore from what are the cultural environment perspective which has gave a big impact to his life negatively.

Reflection and Discussion Question ( The Story of Beth ) Mission Impossible: The Story of Beth
This case highlights the particular vulnerability of persons in homo-negative religious and familial environments who have a history of abuse.

Case Description
Beth, age 42, has been married for 20 years. Beth reports that her marriage has been very unsatisfactory, having been physically and sexually abused by her alcoholic husband for much of their time together. However, when consulting her pastor about leaving her husband, Beth has consistently been advised to obey her husband. She states that she has always experienced same-sex desires but never acted on them. Beth met a woman. This woman, an out lesbian, developed a romantic relationship with Beth, and the two fell in love. Beth did not disclose the relationship to her husband but did discuss it with her pastor. Her pastor responded with outrage, telling her that she was a "homosexual adulterers".
In an effort to be compliant, Beth attempted to cut off the relationship with her lover (Ellen). Beth's guilt compelled her to seek consultation with her pastor to "cure" her of her homosexual desires. The ritual became more bizarre, some of the participants flogged her with straw and consumed carbonated beverages in order to belch on her, w hich was said to be an effort to exorcise her evil lesbian demons. This ritual was the turning point for Beth, who decided once and for all that the religious environment in which she had been living was both wrong and dangerous.
She left her husband and her church and moved in with Ellen. Beth reports being very happy with the relationship. She presents for therapy struggling with residual guilt as well as post traumatic reactions following her treatment at the hands of her former pastor. Beth also seeks to redefine herself at age 42: Does the fact that she is in a same-sex relationship mean that she is a lesbian? What, if anything, will she do to replace her former church home? How does she adapt to a brand-new social network? These are some of the questions on Beth's agenda as she begins psychotherapy to heal some of the trauma of a sexist socioreligious world as well as the reverberations of failed reparative therapy.

What happens in sexual orientation change efforts (SOCE) that could be traumatizing?
Sexual orientation change efforts (SOCE) is an efforts have been made to switch a person's sexual orientation towards heterosexuality by counseling or other therapies (The Royal Australian and New Zealand College of Psychiatrists, 2019). What happened is the SOCE is that some of the process could create trauma, this efforts like some of other therapy if done in an extreme way can cause a bad outcomes from the subject. As found by research studies, that various attempts to alter sexual identity may have negative consequences on the subject. This would include stress, depression, or even suicidal thoughts (Nugraha, 2017). Some of the example of therapy are: actually applying electrical shock to the hands and/or genitals or to medications that cause nausea.
In this case, the traumatizing happened when her religious belief system does not value and sees her misery as a problem. She has been abused by her husband but the system, mainly the pastor asked her to obey the abuser husband. Then again it happened when the pastor using the religious belief system wrongly or dangerously when it comes to same sex relationship. Despite it is not acceptable in this religion, the pastor used his power to abuse a vulnerable and confused believer to the extend he did some bizarre ritual to Beth that cause her to traumatized.

How do we distinguish the related concepts of sexual orientation and sexual identity?
The concept of sexual orientation and sexual identity are definitely different and have their own meaning, despite being related to each other that causes some confusion. Sexual orientation is define as a person emotional and sexual attraction to another person (Lumen Learning, n.d.). The concepts commonly included for several categories which are sexual attraction to members of one's own sex (gay, lesbians or homosexuals), sexual attraction to members of the other sex called heterosexuals and attraction to members of both sexes (bisexuals). While these categories seem to be prominently used, studies has shown that sexual identity does not necessarily exist in these describable categories, however it exists on its own spectrum (American Psychological Association., 2012).
While sexual identity is specifically refers to "individual's sense of being male, female, or transgender"(American Psychological Association., 2012). In Beth's case, her sexual identity are definitely born as a female as stated in the case description and based on her relationship history, her sexual orientation might started as heterosexuals as she has been married to her husband and her relationship with Ellen might change her sexual orientation to homosexuals and it might not. As it does not clearly stated in the case what Beth wants it to be. Beth has decided to separate herself from her husband and her former religious tradition but expresses guilt at leaving her children and the loss of her former church. What are the implications for treatment ? The answer does not answered the question.
The implications is in the future, Beth might have a deep trauma. Either she will be scared every time she sees straw because she was ever beaten with it. Or she will also be frightened if she just sees a place that is similar to her place of worship, even at worst she most likely no longer wants to believe or enter a religion. Other implications are chronic depression and sometimes thought of suicide, intimate relationship problems, poor self-esteem, and feelings of inadequacy as a woman or mother, because guilty feeling have left children and her religion will continue to haunt. She also will tend to be difficult to trust others and view the world as a cruel place. It is difficult to build relationships and closeness with others and feel isolated from society. Physically, she will often feel chronic pain, dizziness, abdominal pain, diarrhea, tightness in the chest, muscle cramps, or back pain. If allowed to continue, it will fail to function either at work, or in the social environment. Even worse, she could be taking drugs or alcohol as an escape.

Conclusion
From these two cases, it can be seen that the social and religious environment has a big influence in causing mental well-being for individuals. Especially in this case we discuss something dominant to be rejected by the environment, same-sex sexual orientation. From the first case, Tony, even though his environment is also of the same sex there are still other things that make him marginalized, namely about skin color. Whereas in the second case, Beth's religious environment is indeed against the desires of the same sex.
Then talk about sexual orientation and sexual identity, of course different. As mentioned above sexual orientation is define as a person emotional and sexual attraction to another person (Lumen Learning, n.d.). While sexual identity is specifically refers to "individual's sense of being male, female, or transgender"(American Psychological Association., 2012). And from the case above, sexual orientation can actually occur due to environmental factors. In this case it is clearly seen in the case of Beth, at first she was married and related to the opposite sex but then she had a desire for the same sex that could be triggered by an unsatisfactory relationship with the opposite sex and instead tortured her.
As overall what we can conclude is that by asking clients how they self-identify is a good idea in our opinion after we go through on this project, because this allows us as future counselors to learn and use the same language that clients use to describe themselves. "We are prone to want to fit people into a box or category that makes sense to us, and we have been socialized to see men and women as behaving, dressing, speaking, etc., in a certain way. As counselors whom working with sexual orientation clients we believed they must be prepared to challenge some of their own preconceived notions about sex, gender and relationships and understand the client from their unique perspective."