Psychotherapy

© 2024 American Psychological Association 2024, Vol. 61, No. 1, 1–30

ISSN: 0033-3204 https://doi.org/10.1037/pst0000518

Bridging the Multicultural Orientation Framework With Sexual and Gender

Minority Psychotherapy: A Mixed Studies Systematic Review
Olivia Fischer, Daniel W. Cox, Johanna M. Mickelson, and Kelly Lyons
Counselling Psychology Program, University of British Columbia

Sexual and gender minorities (SGM) experience higher rates of psychological distress and seek psychotherapy
at higher rates compared to their heterosexual and cisgender counterparts. However, few therapists are trained
on how to provide effective psychotherapy with SGM clients. The multicultural orientation (MCO)
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

framework, which has been linked to improved therapeutic processes and outcomes, may be a valuable tool for
This document is copyrighted by the American Psychological Association or one of its allied publishers.

working with SGM clients. The primary aim of this systematic review was to link the MCO framework to
existing empirical psychotherapy research with SGM clients. A secondary aim was to examine how MCO
constructs that we identified within the SGM literature have been associated with therapeutic processes and
outcomes with SGM clients. A systematic search of five databases yielded 61 studies that were included in the
review. Framework analysis was used to extract data and identify themes and subthemes related to MCO
constructs from included studies. Results of the review demonstrate how the MCO framework can be used to
conceptualize psychotherapy with SGM clients and—using the MCO framework—highlight potential
beneficial and harmful therapist qualities and actions when working with SGM clients. Implications for future
research and psychotherapy practice with SGM clients are discussed.

Clinical Impact Statement

Question: When working with SGM clients, what are the therapist qualities and actions that are in line with
the multicultural orientation (MCO) framework and how do these qualities and actions benefit (and harm)
SGM clients in psychotherapy? Findings: MCO’s key constructs have been defined and conceptualized
within the context of psychotherapy with SGM clients, and clinically meaningful and practical examples of
how to embody cultural humility, take cultural opportunities, and foster cultural comfort are provided.
Meaning: The MCO framework offers a practical, expansive, and promising way to conceptualize
psychotherapy with SGM clients. Next Steps: Future research should directly test hypotheses consistent
with the MCO framework with SGM clients to better understand how cultural humility, cultural
opportunities, and cultural comfort influence therapeutic processes with this group.

Keywords: sexual and gender minorities, psychotherapy, multicultural orientation framework, systematic
review

Supplemental materials: https://doi.org/10.1037/pst0000518.supp

It is important that psychotherapists cultivate a more comprehen-
sive understanding of therapeutic practices that encompass the diverse
needs and experiences of clients who identify with minoritized sexual
and gender identities (hereinafter referred to as sexual and gender
minorities [SGM]). This group seeks psychotherapy at higher rates
compared to their heterosexual and cisgender counterparts (Bieschke
et al., 2007; Dunbar et al., 2017; Steele et al., 2017) and experiences
higher rates of mental illness, substance misuse, violence, and
discrimination (Hatzenbuehler et al., 2009; M. King et al., 2008;
White Hughto et al., 2015). Given the high rates of psychotherapy
use, distress, and external stressors experienced by SGM people, there
is a pressing need for therapists to become increasingly competent to
work with SGM clients. Professional governing organizations, such
as the American Psychological Association (APA), have responded
to this need by adopting policies and guidelines for working
affirmatively with SGM clients (APA, 2015, 2021). Despite these

This article was published Online First January 11, 2024.
Olivia Fischer https://orcid.org/0000-0002-6387-0586
Daniel W. Cox https://orcid.org/0000-0002-4082-7243
This work was supported in part by a Doctoral Canada Graduate
Scholarship from the Social Sciences and Humanities Research Council of
Canada awarded to Olivia Fischer. The authors have no known conflicts of
interest to disclose. This review was not preregistered.
Olivia Fischer played a lead role in conceptualization, data curation, formal
analysis, funding acquisition, investigation, methodology, writing–original
draft, and writing–review and editing and a supporting role in supervision.
Daniel W. Cox played a lead role in supervision and a supporting role in
conceptualization, writing–original draft, and writing–review and editing.
Johanna M. Mickelson played a supporting role in data curation and formal
analysis. Kelly Lyons played a supporting role in data curation and formal
analysis.
Correspondence concerning this article should be addressed to Olivia
Fischer, Counselling Psychology Program, University of British Columbia, 2125
Main Mall, Vancouver, BC V6T1Z4, Canada. Email: oliviajf@student.ubc.ca

1
 2 FISCHER, COX, MICKELSON, AND LYONS

guidelines, there is evidence that SGM clients regularly experience Existing Systematic Reviews
discriminatory, harmful, and therefore unethical treatment from their
There has been a surge of research focused on psychotherapy with
mental health providers (Liu et al., 2022; McNamara & Wilson,
SGM clients over the past 2 decades. Several researchers have sought
2020; Snow et al., 2022). Unsurprisingly, discrimination and
to systematically consolidate the growing evidence about what
microaggressions from mental health providers are associated with
constitutes effective psychotherapy with SGM clients (Bieschke et al.,
higher psychological distress and lower treatment engagement
2007; Bishop et al., 2022; Compton & Morgan, 2022; A. E. Ellis et
(Cochran et al., 2003; James et al., 2016). Further, despite the
al., 2020; M. B. King et al., 2007; McNamara & Wilson, 2020;
disparities in mental health and counseling uptake, therapists report
O’Shaughnessy & Speir, 2018; Singh & Shelton, 2011). These reviews
little training and competence in psychotherapy with SGM clients
have added to our understanding of what facilitates psychotherapy with
(Dillon et al., 2004; Graham et al., 2012). Given the needs of the
SGM clients including (a) the importance of therapists’ attitudes and
SGM community and the deficits of psychotherapists, there is a need
knowledge about SGM clients in delivering beneficial psychotherapy
for a more comprehensive understanding of practices that constitute
(Bieschke et al., 2007; Bishop et al., 2022; Compton & Morgan, 2022;
effective therapeutic experiences for SGM clients.
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M. B. King et al., 2007; McNamara & Wilson, 2020; O’Shaughnessy

Multicultural orientation (MCO) differs from the broader field of
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& Speir, 2018); (b) that there is minimal evidence to support the
multicultural competence as MCO is concerned with a therapist’s “way
hypothesis that matching clients and therapists on sexual or gender
of being” with diverse clients rather than a “way of doing” (Owen et al.,
identities improves outcomes (Compton & Morgan, 2022; A. E. Ellis et
2011). There are three pillars that make up the MCO framework: (a)
al., 2020; M. B. King et al., 2007), especially if seeking therapy for
cultural humility, (b) cultural opportunities, and (c) cultural comfort
issues outside of sexual orientation and gender identity (Bishop et al.,
(Owen, 2013). Cultural humility is the overarching and organizing
2022); and (c) that general counseling skills such as clear interventions
virtue of the MCO framework. Cultural humility refers to being open,
and empathy are associated with treatment engagement and outcomes
curious, and nonjudgemental toward the aspects of clients’ cultural
(Bishop et al., 2022; Compton & Morgan, 2022; A. E. Ellis et al., 2020;
identities that are most important to them, involves being oriented
McNamara & Wilson, 2020; O’Shaughnessy & Speir, 2018). While
toward the client, having a clear understanding of the limits of one’s
these reviews contribute to our understanding of psychotherapy with
abilities, and is marked by an absence of arrogance and a genuine
SGM clients, some notable gaps remain. First, within existing reviews,
desire to understand clients’ cultural identities (D. E. Davis et al., 2018;
there has been a paucity of theoretical frameworks guiding the analyses
Hook et al., 2013). The second pillar, cultural opportunities, are
of psychotherapy processes with SGM clients, which limits our
moments in psychotherapy when there is an opening for therapists to
understanding of the underlying mechanisms that drive successful
explore clients’ cultural identities, such as their background and beliefs
therapeutic outcomes and hinders the development of best practice
(D. E. Davis et al., 2018). For instance, consider a gay, cisgender man
guidelines for this specific population. Presently, we applied the MCO
telling his therapist that his colleagues are using homophobic slurs in
framework to the extraction and synthesis of existing research. Second,
the workplace, which is reinforcing his disengagement at work and
there has been a limited focus on the experiences of people belonging
his hopelessness about the future. Instead of solely focusing on his
to gender minority groups, with one exception (Compton & Morgan,
depressive thoughts, the therapist might explore how his gay identity
2022). Gender minority individuals, distinct from sexual minorities,
interacts with his heterosexist workplace culture (Owen et al., 2016).
refer to people whose gender identity or expression differs from the
Moments such as these are cultural opportunities in which clients
societal expectations based on the sex they were assigned at birth. This
and therapists can engage in meaningful therapeutic work about
includes, but is not limited to, individuals who identify as transgender,
clients’ cultural identities. The final pillar of the MCO framework is
nonbinary, or genderqueer. In the present review, we add a specific
cultural comfort, which refers to the therapist’s thoughts and feelings
emphasis on the psychotherapy experiences of individuals with gender
preceding, during, and following a conversation about clients’ cultural
minority identities.
identities (Owen et al., 2017). Marked by feelings of ease, cultural
comfort relates to therapists’ abilities to self-regulate when exploring
clients’ cultural identities (D. E. Davis et al., 2018).
The Present Study
The three MCO constructs are associated with perceived
improvement in psychotherapy and therapeutic processes (D. E. The primary aim of this study was to extend the MCO framework
Davis et al., 2018; Owen et al., 2011). The MCO framework was (Owen, 2013) into the context of psychotherapy with SGM clients.
developed to be widely applicable to culturally diverse groups, More explicitly, to draw from existing empirical psychotherapy
including SGM people (D. E. Davis et al., 2018). However, few research with SGM clients to (a) identify the clinically meaningful
studies have explicitly examined the MCO framework in the context ways that MCO constructs have been found to manifest in work
of sexual minority psychotherapy (Alessi et al., 2019; Kangos & with SGM clients and (b) examine how MCO constructs impacted
Pieterse, 2021). Further, no studies have examined MCO constructs therapeutic processes and outcomes with SGM clients. To do this, we
in the context of gender minority psychotherapy or extended the first identified empirical papers that examined therapeutic processes
MCO framework to psychotherapy with SGM clients in a systematic from SGM clients’ perspectives. Second, we used framework
way. Given the evidence supporting the MCO framework and the analysis, a flexible, deductive, and inductive approach, to extract
importance of examining therapeutic processes with SGM clients, themes and subthemes to conceptualize and operationalize MCO
we drew on the existing empirical work with SGM clients to constructs in the context of psychotherapy with SGM clients. Third,
consider how MCO constructs might be conceptualized, operatio- we examined how the SGM-operationalized MCO constructs have
nalized, and understood in the context of psychotherapy with SGM been found to impact therapeutic processes and outcomes with SGM
clients using a primarily deductive approach. clients.
 BRIDGING THE MULTICULTURAL ORIENTATION FRAMEWORK
Method
Search Strategy
The Preferred Reporting Items for Systematic Reviews and Meta-
Analyses guidelines were used to identify, select, and synthesize
studies (Page et al., 2021; see Figure 1). A systematic search strategy
was implemented across five electronic databases (APA PsycInfo,
Medline, Lesbian, Gay, Bisexual, Trans, Queer (LGBTQ+) Source,
Education Resources Information Center, and Web of Science)
to identify studies related to psychotherapy with SGM clients.
To facilitate our aim of drawing from the existing empirical
psychotherapy research with SGM clients to bridge the MCO
framework into psychotherapy with SGM clients, we developed
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search criteria that sought to capture literature that included (a) SGM
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identity markers (e.g., lesbian, gay, bisexual (LGB*), trans*, queer,
nonbinary) and (b) psychotherapy markers (e.g., psychothera*
process, working alliance). Using free-text terms and each database’s
controlled terms, a customized search strategy was developed for
each database consisting of key terms related to psychotherapy with
SGM clients (see Supplemental Material, for full search strategy).
Two reference librarians reviewed the Boolean indicators, search
term syntax, and spelling, and then we tested and revised the search
process. Additionally, a hand search of the references within the
included studies was conducted, which yielded 12 additional studies
of interest. The final search was conducted on May 26, 2023.
While there has been recent advancement in the field of SGM
psychotherapy, we did not restrict publication dates in our search.
Our goal was to extract findings from the existing psychotherapy
literature into the pillars of the MCO framework, not to extract what
was considered best practice.
Figure 1
Flow Diagram of the Systematic Review and Article Selection Process, Preferred Reporting
Items for Systematic Reviews and Meta-Analyses
Records identified from databases
(n = 2153)
Identification
Records after duplicates removed
(n = 2005)
Records screened
Screening
(n = 2017)
Records assessed for eligibility
(n =133)
Included
Records included
(n = 61)
3
Using the systematic review management software, Covidence,
the abstracts of all unique records retrieved (n = 2,153) were
screened by two independent reviewers using established inclusion
and exclusion criteria (see inclusion/exclusion criteria below and
Figure 1). In instances of disagreement, the first author reviewed
contested articles and made a final decision based on the inclusion
and exclusion criteria. Following the abstract review, full texts of the
studies deemed eligible were further screened (n = 133). Of those
screened, 61 publications were retained in the final sample (refer to
Supplemental Material, for the list of included studies).
Inclusion and Exclusion Criteria
To facilitate our aim of drawing from existing empirical
psychotherapy research with SGM clients to identify the clinically
meaningful ways that MCO constructs have been found to manifest
in work with SGM clients, we developed inclusion and exclusion
criteria to ensure that included studies examined (a) psychotherapy
processes with SGM clients and (b) were congruent with the MCO
framework. To facilitate the inclusion of studies on SGM clients, we
included studies that reported results from the perspective of SGM
individuals, including analogue studies. We excluded studies where
it was not possible to disaggregate the experiences of SGM clients
from non-SGM clients. Studies examining conversion therapy were
excluded as the aims of these studies were inconsistent with the
aims of this systematic review. Studies that were not specific to
psychotherapy were also excluded, such as those in other health care
settings. Further, studies had to be empirical and published in
English; gray literature was not sought.
Records identified from other
sources (n = 12)
Records excluded
(n = 1882)
Records excluded
(n = 72)
 4 FISCHER, COX, MICKELSON, AND LYONS
Studies were considered congruent with the MCO framework if
findings aligned with one or more of the MCO constructs: cultural
humility, cultural opportunities, or cultural comfort. This appraisal
was done deductively, using an a priori codebook (see Supplemental
Material) based on the MCO literature (Hook et al., 2013; Owen
et al., 2016; Pérez-Rojas et al., 2019). The MCO framework
emphasizes cultural dynamics between therapists and clients.
Therefore, the findings of the included studies had to relate to the
interactions between client and therapist, or therapeutic processes.
Consequently, research focusing exclusively on treatment efficacy
was omitted; for instance, randomized controlled trials to gauge
the effectiveness of an SGM-modified psychotherapy (e.g., Austin
et al., 2018; Budge et al., 2021). Studies that focused exclusively
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on client preference for the therapist’s sexual orientation without
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examining psychotherapeutic processes were also excluded.
A key aspect of the MCO framework is that the perspectives and
experiences of clients are privileged over therapists’ (D. E. Davis
et al., 2018). Therefore, only studies that reported the results from
the perspective of SGM individuals were included, such as
qualitative interviews or self-report measures. Studies from the
perspective of therapists were excluded, such as studies concerned
with therapists’ self-ratings of affirmative therapeutic practice
(e.g., Alessi et al., 2015).
Data Extraction and Framework Analysis
We employed a framework analytic approach (Oliver et al., 2008) to
extract and synthesize the studies using the three pillars of the MCO
framework (cultural humility, cultural opportunities, and cultural
comfort). This deductive strategy was coupled with inductive and
reflexive thematic analysis techniques, allowing for a nuanced
exploration of the data. In the first stage of the framework analysis,
we developed an a priori coding scheme anchored in the three pillars of
multicultural orientation (see Supplemental Material). This coding
scheme was guided by the existing measures of the three MCO
constructs (Hook et al., 2013; Owen et al., 2016; Pérez-Rojas et al.,
2019) and tailored specifically for psychotherapy involving SGM
clients. Using the codebook, two independent reviewers analyzed the
full texts of the included studies and extracted the relevant data. To
extract, integrate, and “qualitize” data from all incorporated studies, we
applied a convergent synthesis design (Hong et al., 2017). This method
facilitated the simultaneous analysis of qualitative, quantitative, and
mixed-methods studies using a cohesive synthesis approach, allowing
for a unified presentation of results. Given that a single synthesis
method is applied across all evidence, we categorized or thematized
quantitative data (Hong et al., 2017). The data extracted from each
study included authors’ names, year of publication, title, study location,
sample size, sample characteristics (age, gender, sexual orientation),
method, study design, primary findings, and results relevant to cultural
humility, cultural opportunities, and cultural comfort (as dictated by the
codebook). These results were then compared and reviewed for any
discrepancies by the first author. Each instance of disagreement was
carefully reviewed, and decisions were guided by the previously
established coding scheme.
The second stage involved establishing a thematic framework
based on the findings of the extracted data, relying on an inductive,
reflexive approach (Barnett-Page & Thomas, 2009; Braun & Clarke,
2006). Common themes were identified across studies based on
cultural humility, cultural opportunities, and cultural comfort and
examined for their conceptual similarities and differences. During
this stage, it was evident that to capture clinically relevant nuance,
cultural humility, cultural opportunities, and cultural comfort needed
to be split into two categories—one positively valenced and one
negatively valenced. Therefore, we expanded (a) cultural humility
to include cultural arrogance, (b) cultural opportunities to include
missed cultural opportunities, and (c) cultural comfort to include
cultural discomfort. This decision was further supported by the
two-factor structure (positive and negative expressions) of both the
Cultural Humility Scale (Hook et al., 2013) and the Therapist
Cultural Comfort Scale (Pérez-Rojas et al., 2019).
In the third and fourth stages, the thematic framework was applied
to all included studies, and the sections of the data were indexed
and charted according to each theme. During this stage, the authors
and research assistants completed a card sort. Generated themes and
subthemes were printed individually and categorically sorted under
MCO framework headings (i.e., cultural humility, missed cultural
opportunities, etc.). This process was conducted by five individuals
with graduate degrees in counseling psychology. The first and
second authors then reviewed and discussed the completed card
sorts. They then finalized the themes and subthemes, which were
subsequently incorporated into Tables 1–3. Finally, the fifth stage
involved mapping and interpreting the data, including defining all
MCO framework constructs in the context of SGM psychotherapy as
well as linking themes and subthemes to therapeutic process and
outcomes from the included studies. Given the reflexive and complex
nature of this review’s purpose and method, we acknowledge that
there are likely multiple ways to interpret the existing literature
through the lens of MCO.
Research Paradigm
Our approach to knowledge generation in this systematic
review is rooted in the philosophical framework of pragmatism.
Pragmatism, as a research paradigm, is not committed to any one
system of philosophy and reality, allowing for a flexible approach
that is oriented toward solving practical problems in the research
process (Kaushik & Walsh, 2019). In the context of this review,
pragmatism has guided our use of a convergent synthesis design,
enabling us to integrate diverse studies—qualitative, quantitative, and
mixed methods—into a unified synthesis. This approach aligns
with the pragmatic view that research methods should be selected
based on their ability to answer the research question rather than
adherence to a particular methodological ideology. Furthermore,
our pragmatic stance is reflected in our process of “qualitizing”
data or transforming quantitative data into qualitative data. This
process allowed us to explore complex phenomena that cannot be
fully understood through quantitative or qualitative data alone. This
balance between deductive and inductive reasoning is characteristic
of the pragmatic paradigm and has shaped our analysis and
interpretation of the studies included in this review.
Positionality Statement
To ensure the utmost rigor in this systematic review, we wish
to thoughtfully acknowledge our positionality as researchers and
recognize our potential influence on the review process. All the
authors involved in this study share a common identity as white
individuals working in the field of counseling psychology. The
 BRIDGING THE MULTICULTURAL ORIENTATION FRAMEWORK
Table 1
Cultural Humility and Cultural Arrogance in Psychotherapy Research With SGM Clients
Cultural humility in SGM psychotherapy (themes)
Cultural humility
Unbiased and accepting of sexual orientation
and gender
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Openness and curiosity
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Absence of pathologization of sexual orientation
and gender
Appropriate focus on SGM identity
Microaffirmations
Cultural arrogance in SGM psychotherapy (themes)
Cultural arrogance
Biased and unaccepting of sexual orientation
and gender
Operationalized (subthemes)
• Expressed accepting views of SGM people
• Used inclusive language
• Discussed SGM identities as equally valid
to heterosexual/cisgender identities
• Respected client’s understanding of sexual
orientation and/or gender
• Countered the biased views of other
professionals
• Adopted a curious, flexible stance
• Explorational mindset
• Created atmosphere of openness
• Displayed a willingness to discuss all topics
• Conveyed a respectful attitude
• Transparent about their level of knowledge
of SGM topics
• Used nonpathological language
• Stated that SGM identity is not pathological
• Communicated belief that SGM identity is
natural
• Not focused on diagnosis
• Only discussed SGM identity when relevant
• Holistically integrated SGM identity into
therapy
• Explored SGM identity sufficiently—not
too much and not too little
• Sensitive to intersectional identities and
systematic forces of racism, ableism, and
so forth
• Used correct pronouns and/or name
• Subtlety conveyed that SGM identity
is valid
• Mirrored client’s language
• Distinguished between sexual orientation
and gender
• Acknowledged the differences between
SGM individuals and heterosexual/cisgen-
der individuals
Operationalized (subthemes)
• Communicated explicit homophobic/bi-
phobic/transphobic views (e.g., being gay is
inferior)
• Disrespected SGM identity
• Denied existence of SGM people
• Questioned validity of client’s identity
• Discouraged client from coming out
• Suggested that client renounce self-
identification
• Advised client to “not act on” SGM identity
• Enforced binary understandings of gender
and/or sexual orientation
• Discussed SGM identity as a “choice,”
“phase,” or “lifestyle”
• Instructed SGM client’s to not discuss
sexual orientation/gender in group
counseling
• Refused to say SGM words such as “gay”
or “trans”
5
Impact on psychotherapy processes
and outcomes
• Felt safe, accepted, validated, celebrated,
free, hopeful, and supported
• Experienced therapy as helpful
• Felt more comfortable in therapy to talk
freely
• Countered previous deleterious experiences
with health care providers
• Improved psychological well-being
• Experienced therapists as professional,
encouraging, reassuring, collaborative, and
validating
• Felt more empowered
• Satisfied with therapy
• Therapeutically aligned with their therapist
• Increased sense of self-determination
• Experienced therapy as helpful
• Ameliorated fears of being discriminated
against or judged in therapy
• Felt encouraged, reassured, heard, and
validated
• Integrated sense of self
• Felt welcomed
• Increased satisfaction with therapist
• Therapist seen as having good boundaries
• Strengthened therapeutic relationship
• Felt affirmed, supported, and understood
• Decreased feelings of rejection and shame
Impact on psychotherapy processes and
outcomes
• Felt insulted, misunderstood, judged,
unsafe, confused, frustrated, shamed,
resentful, invalidated, violated, and
uncomfortable
• Experienced therapy as unhelpful
• Disengaged from therapy
• Terminated prematurely
• Ruptured therapeutic alliance
• Experienced further psychological distress
and despair
• Dishonest with their therapist
• Purposefully concealed aspects of
themselves
• Unwilling to seek mental health support in
future
• Negatively impacted SGM identity
development
• Perceived therapist as uncredible, incom-
petent, and untrustworthy
(table continues)
 6 FISCHER, COX, MICKELSON, AND LYONS

Table 1 (continued)

Impact on psychotherapy processes and

Cultural arrogance in SGM psychotherapy (themes)
Assumptions made about sexual orientation and
gender
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Operationalized (subthemes)
• Assumed that SGM identity is the primary
reason for seeking treatment
• Assumed expert position on what gender-
affirming surgeries most appropriate for
client
• Made heteronormative and cisnormative
assumptions about identity (e.g., assuming
clients are heterosexual/cisgender)
• Assumed that there is a universal SGM
experience
• Assumed trans individuals wanted to pursue
outcomes
• Felt unsafe, disrespected, hopeless, or
uncomfortable
• Unlikely to return to therapy
• Disengaged from therapeutic process
• Unwilling to disclose personal information
• Mistrusted therapist
• Suppressed discussion of SGM-related
topics

medical transition
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• Relied on stereotypes to inform interactions

with SGM client
Pathologization of sexual orientation and/or • Expressed view that SGM identity is an
gender identity illness
• Blamed mental health challenges on sexual
orientation/gender
• Uninvited hypotheses about the source of
SGM identity
• Gatekeeping related to gender-affirming
procedures
Overfocus on SGM identity • Asked about SGM identity when irrelevant
and inappropriate
• Overidentified with SGM identity
• Overstated importance of SGM identity
• Overfocused on couple’s SGM identities in
couple’s therapy
• Lacked intersectional sensitivity regarding
client’s other identities
Microaggressions • Communicated implicit homophobic/bi-
phobic/transphobic attitudes
• Used incorrect pronouns and/or name for
client and/or client’s partner
• Conflated gender with sexual orientation
• Subtle denial and/or invalidation of identity
• Only used heterosexual examples
Note. SGM = sexual and gender minorities.
• Experienced serious harm and lack of
agency
• Felt isolated, violated, and unsafe
• Mistrusted therapist
• Felt stifled and stuck in the therapeutic
process
• Created therapeutic disconnection and
misunderstanding
• Perceived therapist as inauthentic
• Prevented deeper therapeutic work
• Felt uncomfortable discussing intersecting
identities
• Felt invisible, disrespected, uncomfortable,
and unsupported
• Damaged therapeutic relationship
• Experienced therapy as a negative
experience
• Withdrew from therapeutic process

first author, who identifies as nonbinary and queer, brings their
perspective as a therapist specializing in working with SGM clients
to this review. Their experiences and insights within this population
likely influenced the identification and interpretation of relevant
studies, as well as the recognition of important themes and consi-
derations within the reviewed literature. The second author is a
professor at a Canadian university and identifies as a cisgender,
heterosexual man. His positionality may have influenced the framing
of research questions and the overall analytical approach. The third
and fourth authors both identify as cisgender, heterosexual women
and were primarily responsible for coding and extracting data. Their
identities may have influenced their understanding and interpretation
of the data.
Throughout the research process, our team engaged in a
collaborative process to cultivate a nuanced and comprehensive
understanding of the subject matter. The first author held recurring
consultations with the second author, focusing on the conceptual
framework and article development. In addition, the first author
organized meetings with the third and fourth authors to reconcile
coding discrepancies, deliberate on emergent themes, and reflect on
the data.
Before embarking on this review, all authors held a basic
understanding of, and interest in, the MCO framework. The review
process, however, deeply enriched our comprehension of the MCO
framework. This evolving insight may have influenced our selection
and analysis of studies, potentially favoring those that resonate with
the MCO perspective as well as how we understood the MCO
constructs. We recognize that our researcher positionality could
introduce unconscious biases or limitations. To counteract this, we
have committed to uphold transparency and rigor. This commit-
ment is reflected in our systematic methods, stringent screening and
data extraction processes, and continuous team discussions aimed
at critically evaluating our interpretations and reducing potential
biases.
Results
Study Characteristics
The extracted study characteristics are included in Table 4.
In summary: 19 studies explicitly examined the experiences of
transgender populations, including gender-diverse and nonbinary
participants; 19 studies focused on sexual-minority clients (lesbian,
 BRIDGING THE MULTICULTURAL ORIENTATION FRAMEWORK 7

Table 2
Cultural Opportunities in Psychotherapy Research With SGM Clients

Impact on psychotherapy processes

Cultural opportunities in SGM context (themes) Operationalized (subthemes) and outcomes

Taken cultural opportunities

Cultural opportunities • Asked about SGM identity
• Initiated conversation about meaning and impact
of SGM identity
• Provided own pronouns
• Asked for client’s and client’s partner’s pronouns
• Explored impact of living in a heteronormative
and cisnormative culture
• Initiated discussion of intersectionality and
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• Felt safe, accepted, empowered, and
supported
• Increased comfort and openness to discuss
SGM identity in therapy
• Perceived therapist as SGM-friendly
• Increased hope about therapist’s ability to
help them
• Increased sense of clarity about life and self
• Facilitated SGM processes (i.e., coming

systems of oppression
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out, transitioning, etc.)

Impact on psychotherapy processes

Missed cultural opportunities in SGM context Operationalized (subthemes) and outcomes

Missed cultural opportunities

Missed opportunities
Note. SGM = sexual and gender minorities.
• Did not ask about pronouns or SGM identity
• Ignored SGM identity disclosure
• Overlooked impacts of societal discrimination
• Dismissed SGM identity
• Felt invalidated, stuck, shameful, confused,
and discouraged
• Experienced therapy as harmful and
unhelpful
• Viewed therapist as ignorant and lacking
empathy
• Unlikely to seek therapy in the future
• Decreased self-worth
• Terminated prematurely
• Felt burdened by responsibility to bring up
discussions about intersectionality

gay, bisexual, queer); eight studies included both sexual and gender
minority clients (LGBTQ); five studies focused specifically on
bisexual adults; five on lesbians; and five on gay men. Most of the
included studies were conducted in the United States (n = 38),
followed by the United Kingdom (n = 7), multinational (n = 4),
Canada (n = 3), China (n = 3), New Zealand (n = 2), South Africa
(n = 1), Australia (n = 1), the Netherlands (n = 1), and Italy (n = 1).
The total sample size of SGM clients was 9,933, with study samples
ranging from 6 to 2007 (M = 162.84, SD = 342.16). Of the 61
included studies, 33 reported the mean participant age. Across
these 33 studies, the weighted mean age of participants was 30.45
years old. Regarding race and ethnicity, most studies predomin-
antly included white participants, with a few notable exceptions
(i.e., Brooks et al., 2010; Liu et al., 2022, 2023; McCullough et al.,
2017; Wang et al., 2021). The majority of included studies used a
qualitative methodology (n = 41), followed by a quantitative
method (n = 16), and then a mixed methodology (n = 4).
Multicultural Orientation Framework
Conceptualization and Operationalization of
Multicultural Orientation Constructs in Psychotherapy
With SGM Clients
Below, we drew from the existing MCO literature (Hook et al.,
2013; Owen et al., 2016, 2017) to conceptualize cultural humility,
cultural arrogance, cultural opportunities, missed cultural opportu-
nities, cultural comfort, and cultural discomfort in the context of
psychotherapy with SGM clients. Following each conceptualization,
we have described how each construct was operationalized based on
the existing empirical literature. Tables 1–3 include the themes and
subthemes that comprised the operationalization of the MCO
constructs in psychotherapy with SGM clients. While our narrative
emphasizes therapist characteristics and behaviors, these are based on
the perceptions and reported experiences of SGM individuals. By
structuring our findings this way, we hope to provide a clear and
practical account for psychotherapists while remaining faithful to
participants’ perspectives.
Cultural Humility. Cultural humility has been broadly defined
as the ability to be other-oriented, marked by a respectful openness
and a lack of superiority toward clients’ cultural backgrounds
(Hook et al., 2013; Owen et al., 2016). In the context of
psychotherapy with SGM clients, we conceptualized cultural humility
as therapists’ attitudes that convey openness toward sexual orientation
and gender identity, prioritizing clients’ experiences, understanding,
and perspective of their SGM identities over therapists’. Markers of
cultural humility included acceptance, respect, and sensitivity toward
SGM clients’ identities.
Across the included studies, therapists working with SGM clients
demonstrated cultural humility when they took an unbiased and
accepting stance toward clients’ SGM identities (see Table 1). These
therapists prioritized clients’ perspectives by expressing supportive
views and were respectful of clients’ SGM identities both within and
outside of sessions (e.g., Israel et al., 2008). Cultural humility was also
evident when therapists adopted a curious or flexible stance toward
clients’ SGM identities. Therapists who were culturally humble created
 8 FISCHER, COX, MICKELSON, AND LYONS

Table 3
Cultural Comfort and Cultural Discomfort in Psychotherapy Research With SGM Clients

Impact on psychotherapy processes and

Cultural comfort in SGM context Operationalized (subthemes) outcomes

Cultural comfort
Comfortable, relaxed, and confident
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• Ease in which therapist engaged in SGM • Enhanced psychological well-being
conversations • Improved working alliance
• Demonstrated comfort and confidence in discussing • Therapist seen as affirming, competent,
SGM topics and safe
• Appeared comfortable discussing sexuality • More forthcoming in therapy
• Confidence to ask about SGM identity • Felt empowered
• Relaxed in manner
• Therapist seen as comfortable with their own

sexuality/gender
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Impact on psychotherapy processes and

Cultural discomfort in SGM context Operationalized (subthemes) outcomes

Cultural discomfort
Uncomfortable, uneasy, nervous, and
awkward
Note. SGM = sexual and gender minorities.
• Perceived therapist as uncomfortable
• Displayed visual discomfort through body language
and facial expressions
• Overcompensated through being overly positive and
polite about SGM identity
• Appeared shy around SGM topics
• Discomfort discussing identity differences
• Avoided SGM topics
• Avoided sexual topics
• Blocked deeper therapeutic work
• Assumed therapist had a negative attitude
toward SGM identity
• Limited therapeutic disclosure
• Perceived therapist as incompetent
• Therapy seen as waste of time
• Decreased sense of safety
• Attempted to protect therapist from sexual
topics
• Ruptured therapeutic relationship

an atmosphere of openness within the therapeutic space (e.g., Buser
et al., 2011; Goodrich et al., 2016), asked questions about clients’
experiences rather than making assumptions (e.g., Duffy et al., 2016),
and were honest and open about the boundaries of their knowledge
about SGM topics. Culturally humble therapists sought out information
when it was relevant to their therapeutic work rather than assuming that
they were knowledgeable or expecting their clients to educate them
(e.g., McCullough et al., 2017; Nedela et al., 2022).
Specific to SGM clients, an absence of pathologization contri-
buted to a culturally humble stance within psychotherapy. Given
the history of pathologization of SGM communities and the past
and present inclusion of SGM experiences in the Diagnostic and
Statistical Manual of Mental Disorders, 5th Edition: Text Revision
(DSM-5-TR; APA, 2022), this is a crucial component of cultural
humility with SGM clients. Therapists who took a nonpathologizing
stance used nonpathological language (i.e., gay vs. homosexual) and
communicated their belief that SGM identities are normal. An absence
of pathologization was understood as cultural humility because it
signaled to clients that therapists were not arriving at psychotherapy
with a preconceived idea that their SGM identity was the source of
their challenges or that it needed to be cured (e.g., Elder, 2016).
When therapists focused appropriately on clients’ SGM identity
(rather than ignoring or overfocusing), they were seen as embodying
cultural humility. These instances were evident when therapists only
engaged in conversations about sexuality and gender when it was
appropriate (e.g., Liddle, 1996) and holistically integrated sexuality
and gender into psychotherapy (e.g., Pixton, 2003).
The final marker of cultural humility in included studies was
when therapists displayed microaffirmations, the subtle intentional
or unintentional gestures that validate SGM identities (Galupo et al.,
2019). Microaffirmations included therapists using correct names
and pronouns for their clients, mirroring clients’ language, and
acknowledging the unique aspects of SGM life experiences (e.g.,
Anzani et al., 2019).
Cultural Arrogance. In the context of SGM psychotherapy,
we conceptualized cultural arrogance as therapists’ attitudes that
convey superiority regarding sexual orientation or gender identity,
prioritizing therapists’ experiences, understanding, and perspectives
over clients’. Markers of cultural arrogance included disdain,
disrespect, and a lack of sensitivity toward SGM clients’ identities.
Across the included studies, the most common marker of cultural
arrogance was therapists expressing biased or unaccepting views
about sexual orientation or gender identity (see Table 1). In these
instances, therapists believed that they held a superior understanding
of SGM experiences and looked down upon their clients. For
example, some therapists communicated a belief that SGM identities
are amoral (e.g., Victor & Nel, 2016). For some transgender clients,
therapists would refuse to conduct psychotherapy with them based
on their gender (e.g., Elder, 2016) or would overtly question them
about the validity of their transgender identity (e.g., Morris et al.,
2020). Some therapists went as far as to discourage clients’ from
adopting a SGM identity, including advising them to not act on their
sexuality or gender identity (e.g., Elder, 2016). These therapists took
on an expert stance to warn SGM clients about the dangers of an
SGM lifestyle (e.g., Shelton & Delgado-Romero, 2011).
Therapists who exhibited cultural arrogance were also prone to
making assumptions about clients’ sexual orientation and gender
identities. Most often, this included heteronormative and cisnormative
assumptions about clients’ identities and assuming that they were
heterosexual or cisgender (e.g., B. Hunt et al., 2006; Welch et al., 2000).
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Table 4
Study Characteristics

Qualitative/
quantitative/
mixed Study Age Age Age
Study Sample methods location (M) (SD) (range) Gender Sexual orientation Race and ethnicity Aims Primary results

Alessi et al. N = 184 LGBQ Quantitative United States 27.57 8.5 18–64 Woman: 65.8%, man: Not reported White: 77.2%, Asian/Pacific To examine associations between Practicing affirmative techniques was
(2019) individuals 21.2%, not Islander: 7.1%, Latino/ affirmative practice, the therapeutic linked to a stronger therapeutic
cisgender: 13.0% Hispanic (White): 6.5%, relationship, and psychological relationship, leading to higher
biracial: 5.4%, African well-being among LGBQ clients psychological well-being for LGBQ
American/Black: 2.2%, clients
American Indian or
Alaskan Native: 1.1%,
Latino/Hispanic (Black):
0.5%
Anzani et al. N = 64 transgender Qualitative Multinational 30.73 12.1 18–65 Agender: 4.7%, Not reported White: 79.7%, biracial/ To investigate the experiences of Four main microaffirmations were
(2019) individuals bigender: 4.7%, multiracial: 7.8%, Asian/ transgender individuals seeking identified: (a) absence of
gender Asian American: 4.7%, mental health support and identify microaggressions, (b) recognition of
nonconforming: Black/African American: microaffirmations within the cisnormativity, (c) challenging
1.6%, Genderqueer/ 3.1%, Hispanic/Latino: therapeutic relationship cisnormativity, and (d) authentic
fluid: 10.9%, man 3.1%, Native American/ gender acknowledgment
with a transgender Alaska Native: 1.6%,
history 6.3%, other: 1.3%
transfeminine/trans
woman: 35.9%,
transmasculine/trans
man: 28.1%, Two-
spirit 1.6%, woman
with a transgender
history: 7.8%
Applegarth N = 6 transgender Qualitative United Not Not 30–49 Female: 83.3%, Not reported Not reported To explore the personal experiences of Four overarching themes were
and individuals Kingdom reported reported bigendered: 16.7% transgender individuals undergoing identified: “a fearful time,”
Nuttall talk therapies developing comfort with personal
(2016) gender identity, the importance of
the client–practitioner relationship,
and progress beyond therapy
Arora et al. N = 12 QTBIPOC Qualitative United States 22.33 Not 19–26 Transgender/nonbinary: Queer: 58%, asexual: Black: 25%, multiracial: To explore how QTBIPOC individuals Optimal therapy experience for
(2022) individuals reported 50%; cisgender: 50% 25%, bisexual: 25%, Chinese: 17%, experience therapy and based on QTBIPOC individuals relies on
BRIDGING THE MULTICULTURAL ORIENTATION FRAMEWORK

17% Indigenous; 17%, Middle their experiences, if they have actively dismantling systemic
Eastern: 8%, Korean recommendations for improving oppression in therapy
American: 8% practice
Benson N = 7 transgender Qualitative United States 39.85 14.62 24–57 FTM: 42.9%, MTF: Not reported European Americans: 85.7%, To provide a critical analysis of Four themes emerged: reasons why
(2013) individuals 42.9%, MTF Latino(a): 14.3% historical perspectives of transgender clients sought therapy,
crossdresser: 14.3% transgender clients and underscore challenges faced in practice,
their experiences in therapy therapist reputation, and the
effectiveness of transgender
affirmative therapy
Berke et al. N = 13 LGBTQ Qualitative United States Not Not Not Male-identified: 61.5%, Gay: 46.2%, queer: Not reported To examine situational and individual Interpersonal connection and genuine
(2016) individuals reported reported reported female-identified: 23.1%, asexual/ factors impacting LGBTQ therapy affirmation impact clients’ mental
15.4%, trans man: demisexual: 7.7%, experiences health and well-being. Various
15.4%, trans woman: pansexual: 7.7% intersecting aspects of identity
7.7% shaped participants’ experiences of
psychotherapy
9

(table continues)
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Table 4 (continued) 10
Qualitative/
quantitative/
mixed Study Age Age Age
Study Sample methods location (M) (SD) (range) Gender Sexual orientation Race and ethnicity Aims Primary results

Bess and N = 7 transgender Qualitative United States 46.29 14.29 19–64 FTM: 28.6%, MTF: Not reported White: 100% To investigate the perceptions of both Participants did not encounter many of
Stabb individuals 71.4% transgender and transsexual the heterosexist, sexist, and
(2009) individuals regarding psychotherapy pathologizing biases documented in
and the existing roles and training previous studies (some had negative
of mental health experts who might experiences). Instead, they reported
assist such clients having supportive and affirming
relationships with their therapists
Bettergarcia N = 409 individuals Quantitative United States 29.5 10.3 18–74 Genderqueer: 39%, Pansexual: 24%, European American/White: To investigate how a therapist’s The video condition lacking affirmation
and Israel who self-identified transgender man: bisexual: 23%, 78%, African, American/ reaction to transgender identity significantly impacted participants’
(2018) as being on the 20%, transgender lesbian: 13%, Black: 8%, Latino(a)/ exploration influences participants’ perceptions of the therapist and the
transgender woman: 17%, heterosexual: Hispanic: 7%, Asian views of the therapist and the quality of the therapeutic
spectrum woman: 6%, man: 12%, gay: 10%, American: 5%, American therapeutic relationship relationship. No significant
4%, “something and/or “other:” Indian/Alaska Native: 5%, differences were observed between
else:” 13%, intersex: 24% Middle Eastern: 2%), the transition-affirming and non-
1% Native Hawaiian or binary-affirming conditions
Pacific Islander: 1%, or
“other:” 5%
Brooks et al. N = 14 ethnic- Qualitative United States 30 Not 25–53 Woman: 100% Bisexual: 100% Asian: 36%, Black: 29%, Identify counseling considerations for Important counseling considerations
(2010) minority bisexual reported Biracial: 14%, Multiracial: ethnic-minority bisexual women include counselors’ knowledge of
women 7%, Native American: based on their personal experiences the bisexual experiences of ethnic-
7%, unsure: 7% minority individuals, addressing
client concerns about counseling,
specific therapeutic tasks,
counselors’ awareness of biases, and
client preferences for counselor
characteristics
H. M. Brown N = 15 transgender Qualitative United States 32.33 13.27 19–53 Female-affirmed: 46.7%, Queer: 26.7%, White: 60.0%, multiracial: To explore the impact of the referral Thematic analysis identified two core
et al. and gender male-affirmed: 40%, lesbian: 26.7%, 20.0%, African American: letter requirement on TGNC themes: (a) the challenges
(2020) nonconforming nonbinary: 13.33% heterosexual: 13.3%, Black: 6.7% individuals’ therapy experiences and participants faced due to the referral
FISCHER, COX, MICKELSON, AND LYONS

individuals 20%, bisexual: overall transition processes. letter requirement and (b) the
13.3%, pansexual: positive experiences that TGNC
6.7%, none: 6.7% individuals had because of this
requirement. Participants expressed
better therapy experiences when
their therapists actively affirmed
their gender and choices related to
transition, supported their transition
process, provided knowledge and
resources, and collaborated to
determine therapy focus
Burckell and N = 42 Quantitative United States 20.86 Not 18–29 Female: 62%, male: Gay man or lesbian: White: 74%, ethnic minority: To identify therapist attributes that Participants valued therapists who
Goldfried nonheterosexual reported 38% 42.9%, bisexual: 26% sexual-minority individuals prefer possessed knowledge about the
(2006) adults 40.5%, and to determine how the presenting LGB community and had general
questioning or issue impacts the selection of a therapeutic skills while expressing a
queer 9.5%, no therapist desire to avoid therapists with
label: 7.1% heterocentric views

(table continues)
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Table 4 (continued)

Qualitative/
quantitative/
mixed Study Age Age Age
Study Sample methods location (M ) (SD) (range) Gender Sexual orientation Race and ethnicity Aims Primary results

Buser et al. N = 7 LGBT Qualitative United States Not Not Not Female: 57.1%, male: Gay: 42.9%, lesbian: White: 100% To understand the perceptions of The identified themes include (a)
(2011) individuals reported reported reported 28.6, transgender: 28.6%, bisexual: LGBT clients regarding counseling negative counseling experiences, (b)
14.3% 14.3%, asexual: experiences that involve religious client perseverance in seeking
14.3% and spiritual issues additional counseling, (c) positive
counseling experiences, and (d)
reframing counselor responsibility
Conlin et al. N = 14 nonbinary and Qualitative United States 24 Not Not Genderqueer/nonbinary: Pansexual: 28.5%, White: 85.7%, African To qualitatively explore nonbinary The analysis revealed five primary
(2019) genderqueer reported reported 100% bisexual: 21.4%, American: 7.1%, Middle identities from a counseling themes: (a) identity development,
participants pansexual with a Eastern: 7.1% perspective (b) diverse identities, (c) the divide
slight preference between identity expression, (d)
for women: 57.1% invisibility and stressors, and (e)
resilience and support
Daley (2012) N = 18 lesbian women Qualitative Canada Not Not 20–58 Cisgender: 94.4%, Lesbian: 100% White: 83.3%, Native: 5.6%, To describe how lesbians choose to Three self-disclosure strategies were
reported reported transgender: 5.6% Chinese: 5.6%, Israeli: disclose their sexual orientation identified: (a) voluntary and explicit
5.6% during extended interactions with self-disclosure, (b) prompted and
mental health service professionals explicit self-disclosure, and (c)
subtle and tentative self-disclosure
A. W. Davis N = 464 LGBQ Quantitative Australia 32.7 13.6 18–75 Cisgender woman: 60%, Gay: 31.7%, lesbian: Not reported To explore if higher inclusivity of Higher levels of client-reported
et al. individuals cisgender man: 40% 29.3%. bisexual: sexual minorities in therapy, as psychotherapy inclusiveness were
(2022) 27.8%, other: perceived by the client, was linked associated with increased client
11.2% to client satisfaction and perceived satisfaction and perceived outcome,
results, and whether elements of the mediated by the task component of
therapeutic alliance mediated any the therapeutic alliance.
such association Inclusiveness also influenced client
satisfaction through the bond
component of the therapeutic
alliance
DeLucia and N = 274 bisexual Quantitative United States 24.4 5.12 18–49 Woman: 55.8%, trans/ Bisexual: 46.6%, Bi+ White: 83.6%, Latinx: 7.7%, To determine whether the positive and Increased openness with mental health
Smith adults nonbinary: 38.0%, (bisexual plus one Asian: 5.8%, other: 3.3%, negative experiences of bisexual providers predicted more positive
(2021) man: 4.4%, missing: other identity): Black: 1.8%, Native individuals with mental health experiences of microaffirmations
1.8% 29.2%, pansexual: American/Indigenous: providers in relation to their sexual from those providers. Negative
8.8.%, queer: 1.8%, Hawaiian/Pacific: identity influence the connection experiences of biphobia had a
5.5%, Pan+ 0.4% between openness about sexual significant negative impact on the
(pansexual plus identity and intentions to seek intention to seek mental health
BRIDGING THE MULTICULTURAL ORIENTATION FRAMEWORK

one other psychological help treatment

identity): 4.7%,
other: 5.5%
Dorland and N = 126 lesbian, gay, Quantitative United States 40.8 10.3 19–85 Men: 35.7%, women: Exclusively White: 93%, African To analyze the responses of GLB Participants in the bias-free group
Fischer bisexual 62.7%, unspecified: homosexual: 76%, American: 2%, Hispanic/ participants to heterosexist and perceived and rated the counselor
(2001) participants 1.6% mostly Latina/Latino: 2%, nonheterosexist language within a more positively, expressed a higher
homosexual: 16%, multiracial: 2%, other: 2% simulated counseling session. likelihood of returning for future
mostly sessions, exhibited greater
heterosexual: 4%, willingness to disclose personal
bisexual: 4% information, and felt more
comfortable disclosing sexual
orientation compared to the group
exposed to heterosexist bias

(table continues)
11
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Table 4 (continued) 12
Qualitative/
quantitative/
mixed Study Age Age Age
Study Sample methods location (M) (SD) (range) Gender Sexual orientation Race and ethnicity Aims Primary results

Duffy et al. N = 84 transgender Qualitative Multinational 22.3 3.91 18–33 Women: 7%, men: 36%, Lesbian: 50%, gay: White: 79.8%, mixed To investigate the unique treatment Thematic analysis revealed three
(2016) and gender-diverse nonbinary: 57% 33.3%, bisexual: ethnicities: 11.9%, Black: experiences of transgender themes: (a) the role of the body in
participants 16.6% 3.6%, Hispanic or Latino: individuals diagnosed with eating treatment, (b) negative experiences
3.6%, Asian: 1.2% disorders with clinicians, and (c)
recommendations for treatment
centers and providers. Participants
reported deficiencies in clinicians’
understanding of gender, leading to
beliefs that eating disorder treatment
was ineffective and, at times,
harmful
Eady et al. N = 55 bisexual Qualitative Canada Not Not 16–69 Female: 54.5%, male: Bisexual: 74.5%, White: 69%, people of color: To understand the experiences of Negative experiences included
(2011) people reported reported 45.5%, transgender: queer: 16.3%, 31% bisexual clients, their perceptions of judgment, dismissal of bisexuality,
20% pansexual: 3.6%, providers’ attitudes toward pathologization of bisexuality, and
omnisexual: 1.8% bisexuality, and whether they felt intrusive or excessive questioning.
that the mental health care system Positive experiences involved
adequately met their overall needs seeking education, asking open-
ended questions, and maintaining
positive or neutral reactions to
disclosure
Earley et al. N = 12 formerly Qualitative Multinational 42 Not 25–68 Not reported Gay: 91.7%, White: 91.7%, Hispanic: To explore the counseling experiences Participants desired therapists to not
(2020) heterosexually reported bisexual: 8.3% 8.3% of gay fathers who were previously assume a predetermined outcome
partnered gay in heterosexual relationships and regarding their sexual orientation.
fathers raised with raised in religious environments and Instead, they wanted therapists to
religion provide recommendations for respect and support their exploration
mental health professionals in their of their own individual sense-
work with this group making around their identities,
rejecting fixed notions from both
ex-gay and gay affirmative therapy
FISCHER, COX, MICKELSON, AND LYONS

regarding what it means to be a

“well-adjusted” gay father
Elder (2016) N = 10 TGNC Qualitative United States Not Not 60–83 Female: 40%, male: Heterosexual: 30%, White: 80%, Black: 10%, To present viewpoints of TGNC Following thematic analysis, the results
individuals reported reported 30%, trans man: Bisexual: 20%, Chinese: 10% individuals and to enhance the revealed 10 themes grouped into
10%, MTF and back: Lesbian: 20%, quality of psychotherapeutic care three categories: (a) therapy
10%, trans woman: Gay: 10%, for people with diverse gender experiences, including healing,
10% Asexual: 10%, identities painful moments, and
Attracted to men: improvements; (b) life experiences,
10% including gender and transitioning,
older TGNC issues, family,
discrimination, resilience, and
activism; and (c) recommendations
for TGNC clients and mental health
providers
S. J. Ellis et N = 621 trans people Mixed United Not Not 18–78 Woman: 40%, man: Bisexual: 27%, queer: White: 93%, other ethnic To enhance understanding of the Untreated gender dysphoria, intrusive
al. (2015) methods Kingdom reported reported 25%, nonbinary: 24%, straight/ groups: 7% experiences of transgender questioning/tests, prejudicial
23%, unsure: 6%, heterosexual: individuals and to assess mental attitudes from service providers, and
20%, pansexual: restrictive treatment pathways

(table continues)
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Table 4 (continued)

Qualitative/
quantitative/
mixed Study Age Age Age
Study Sample methods location (M ) (SD) (range) Gender Sexual orientation Race and ethnicity Aims Primary results

other: 3%, no gender 15%, lesbian: health and gender identity services contribute to minority stress,
identity: 3% 13%, not sure/ for trans clients negatively impacting the mental
questioning: 12%, health and well-being of trans
other: 11%, do not individuals
define: 10%, gay:
10%,
polyamorous: 9%,
asexual: 8%
Gerritse et al. N = 10 transgender Qualitative Netherlands Not Not 20–70 Trans woman: 40%, Not reported Not reported To examine the ethical dilemmas and Three main themes related to ethical
(2023) and gender-diverse reported reported trans man: 40%, standards that transgender and challenges and norms in gender-
(TGD) individuals nonbinary: 20% gender nonconforming (TGD) affirming medical care: (a) client
clients encounter while making autonomy, (b) preventing harm, and
decisions about gender-affirming (c) individualized decision making
medical treatment
Glyde (2023) N = 12 LGBTQ+ Qualitative Multinational Not Not 46–62 Cisgender: 25%, Queer: 50%, Not reported To explore the experiences of queer While some participants had positive
identified reported reported nonbinary: 25%, pansexual: 25%, individuals going through experiences, practitioners often
participants transmasculine: asexual: 8.3%, menopause and their perceptions of failed to meet the needs of queer
16.7%, agender: bisexual: 8.3%, therapy and the broader health care menopausal clients, lacking
8.3%, genderfluid: lesbian: 8.3% system knowledge about menopause and
8.3%, genderqueer: understanding of queer identities.
8.3%, transfeminine: Participants recommended that
8.3% therapists: listen without
assumptions, acknowledge previous
negative health care experiences,
recognize information gaps about
menopause, acknowledge positive
experiences, and receive further
training on identities, menopause,
and hormones
Goodrich et N = 12 LGBTQQI Qualitative United States Not Not 18–58 Female: 66.7%, male Lesbian: 50.0%, gay: White: 100% To explore the therapeutic experiences Four themes emerged from participant
al. (2016) clients reported reported 33.3% 33.3%, bisexual: of individuals identifying as interviews: (a) self-acceptance, (b)
16.6% LGBTQQI and the extent to which counseling goals, (c) identification
counseling addressed their sexual with the counselor, and (d)
and religious/spiritual identities counseling environment and
BRIDGING THE MULTICULTURAL ORIENTATION FRAMEWORK

relationship
Grove and N = 9 people in same- Qualitative United 39.7 7.6 29–54 Female: 66.7%, male Not reported White: 100% To explore client’s experiences with the Four themes were identified: the
Blasby sex relationships Kingdom 33.3% counselor and therapy in same-sex counselor’s comfort and discomfort,
(2009) couple therapy overcompensation based on sexual
orientation, the need to protect the
counselor, and uncertainty and lack
of knowledge about the counselor
Hall (1994) N = 35 lesbians Qualitative United States 37 Not 24–54 Women: 100% Lesbians: 100% Euro-American: 68%, To describe the experiences of lesbians Lesbian clients expressed mistrust
reported African American: 17%, in alcohol recovery and pinpoint toward culturally ignorant providers
Latina: 9%, Asian/Pacific: barriers to seeking help and who inappropriately reversed
3%, Native American: 3% recovery from their perspective therapeutic roles. Incongruence
between providers and clients
regarding alcohol problems
hindered recovery
13

(table continues)
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Table 4 (continued) 14
Qualitative/
quantitative/
mixed Study Age Age Age
Study Sample methods location (M ) (SD) (range) Gender Sexual orientation Race and ethnicity Aims Primary results

Heiden- N = 84 LGBQ young Qualitative United States 22.09 2.28 18–25 Cisman: 25.0%, Bi+ (bisexual, White: 79% To explore the experiences of LGBQ The survey results identified two
Rootes et adults from ciswoman: 64.3%, pansexual, queer, young adults from religious superordinate themes: (a) “Being
al. (2021) religious nonbinary: 10.7% etc.): 50%, backgrounds in psychotherapy free in the relationship with the
backgrounds lesbian: 29.8%, therapist” and (b) “Rejection in the
gay: 20.2% therapy room.” The interview
results yielded two themes: (a)
openly struggling with the “right
questions” and missed
opportunities, and (b) strong
negative feelings about therapy and
the therapist
J. Hunt N = 74 transgender Mixed United Not Not 16–70 Female: 36%, Not reported White: 95% To examine the experiences of Participants sought help for common
(2014) people methods Kingdom reported reported transgender: 31%, transgender individuals in seeking psychological concerns, as well as
male: 23%, and obtaining counseling or gender identity and coming out
transwoman: 54%, psychotherapy outside of U.K. issues. Barriers included fear of
transman: 38%, other gender identity clinics discrimination and exploring gender
14% for the first time. Participants
reported mixed experiences with
counseling but valued a therapeutic
relationship where they felt
affirmed, listened to, and understood
B. Hunt et al. N = 25 lesbians with Qualitative United States 40 Not 24–57 Women: 100% Lesbians: 100% White: 100% To investigate the experiences of Five themes emerged regarding
(2006) physical disabilities reported lesbians with physical disabilities in participants’ perceptions of their
relation to counseling professionals counselors: general satisfaction or
dissatisfaction, counselors’
effectiveness, counselors’ awareness
and education regarding sexual
orientation and/or disability,
discrimination and bias, and
FISCHER, COX, MICKELSON, AND LYONS

counselor identity
Israel et al. N = 42 LGBT Qualitative United States 36 Not 20–56 Women: 35.7%, men: Bisexual: 28.6%, European American/White: To identify wide array of variables that The results indicated that basic
(2008) individuals who reported 42.9%, MTF: 7.1%, lesbian: 21.4%, 54.8%, African American/ characterize the beneficial and counseling skills and the therapeutic
have been in FTM: 7.1%, gay: 28.6%, other: Black: 14.3%, Asian unbeneficial therapy experiences of relationship were crucial factors in
therapy genderqueer: 7.1% 7.1% American/Pacific Islander: lesbian, gay, bisexual, and the quality of therapy experiences
11.9%, Hispanic/Latino/a: transgender (LGBT) individuals. for LGBT clients. Therapist
7.1%, multiracial: 11.1%, variables (e.g., professional
other: 2.4% background, attitudes toward sexual
orientation/gender identity), client
variables (e.g., identity development
stage, health status, social support),
and environmental factors (e.g.,
confidentiality) also influenced the
helpfulness of the therapy
experience
Kangos and N = 158 LGB Quantitative United States 30.49 12.93 18–73 Not reported Lesbian: 26.6%, gay: White: 70.9%, Black/African To analyze lesbian, gay, and bisexual The participants’ perceptions of their
Pieterse Christians 24.1%, bisexual: American: 5.1%, East (LGB) Christian clients’ religious therapists’ cultural humility
(2021) 40.5% Asian/Pacific Islander: commitment and their perceptions positively predicted therapeutic

(table continues)
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Table 4 (continued)

Qualitative/
quantitative/
mixed Study Age Age Age
Study Sample methods location (M) (SD) (range) Gender Sexual orientation Race and ethnicity Aims Primary results

4.4%, multiracial: 4.4%, of their therapists’ cultural humility outcomes, and the working alliance
Latinx: 7% concerning the working alliance and partially mediated the relationship
therapeutic outcomes between cultural humility and
therapeutic outcomes. Contrary to
predictions, religious commitment
did not moderate the relation
between cultural humility and the
working alliance
Keating et al. N = 161 LGBTQ+ Quantitative Canada Not Not 18–72 Nonbinary: 34.8%, trans Bisexual: 54.7%, White: 73.8%, South Asian: To identify the frequency of barriers Participants identified multiple barriers
(2021) people reported reported man: 9.9%, trans lesbian: 28.6%, 7.1%, Indigenous/First that prevent LGBTQ+ individuals to accessing and receiving
woman: 6.2% gay man: 10.6% Nations/Metis/Inuit: 6.5%, from receiving trauma intervention intervention for psychological
African: 4.8%, Chinese: and to understand how to make trauma, including lack of inclusive
4.2%, Caribbean: 2.4%, trauma intervention more language and previous anti-LGBTQ
Latin American: 2.4%, welcoming for them + comments by service providers.
Arab: 1.2%, Southeast They also endorsed several provider
Asian: 1.2%, West Asian: behaviors that would make
0.6%, other: 13.1% interventions more welcoming, such
as displaying a commitment to
nondiscriminatory care and asking
clients about their pronouns
Kelley N = 116 lesbian and Mixed United States 39 11.9 19–69 Not reported Lesbian: 65.5%, gay: European American/White: To understand lesbian and gay male The real relationship between the
(2015) gay clients methods 34.5% 83.6%, Hispanic/Latino/ clients’ perceptions of their current therapist and client predicted
Latina: 5.2%, African therapists’ practices, therapy positive feelings about the therapist,
American/Black: 3.4%, relationship, and how these factors even when considering therapy
Native American/ affect their feelings about their duration, practices, and the working
American Indian/Alaska therapists alliance. However, therapy practices
Native: 0.9%, Asian/ did not significantly predict feelings
Asian American/Pacific about the therapist beyond the
Islander: 0.9%, South working alliance and the real
Asian/Asian Indian: 0.9%, relationship. Some reported that
biracial/multiracial: 2.6%, their therapist lacked knowledge
ethnicity/race not about LGBTQ+ issues or was
included: 2.6% dismissive of their sexual
BRIDGING THE MULTICULTURAL ORIENTATION FRAMEWORK

orientation
Lebolt (1999) N = 9 gay males Qualitative United States Not Not Not Male: 100% Gay: 100% Not reported To explore the experiences of gay male Heterosexual therapists can be
reported reported reported clients undergoing gay affirmative affirmative with sensitivity,
therapy imagination, and experience, while
gay therapists may serve as role
models
Liddle (1996) N = 392 lesbian and Quantitative United States Not Not 22–71 Women: 56%, men: Lesbian: 56%, gay: European American: 94%, To examine the impact of sexual Gay, lesbian, and bisexual therapists of
gay participants reported reported 44% 44% African American: 1%, orientation match on client reports both genders, as well as
Asian American: 1%, of therapist approaches and heterosexual female therapists, were
Latin American: 2%, practices with gay and lesbian rated as more helpful than
multiracial: 2% clients heterosexual male therapists.
Negative practices were associated
with clients designating a therapist
as unhelpful or terminating therapy
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15
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Table 4 (continued) 16
Qualitative/
quantitative/
mixed Study Age Age Age
Study Sample methods location (M ) (SD) (range) Gender Sexual orientation Race and ethnicity Aims Primary results

after one session, while positive

practices were inversely associated
with unhelpful ratings and early
termination. Therapist practices had
a greater impact on ratings of
helpfulness than therapist
demographic characteristics
Liddle (2000) N = 336 gay and Quantitative United States Not Not 22–71 Women: 58%, men: Lesbian: 58%, gay: White: 94%, African To understand how different Psychiatrists were rated as less helpful
lesbian participants reported reported 42% 42% American: 1%, Hispanic: professional psychotherapeutic compared to other mental health
2%, Asian American: 1%, designations have served their professionals, with a significantly
multiracial: 2% lesbian and gay clients higher likelihood of discounting,
arguing against, or pressuring clients
to renounce their self-identification
as a lesbian or gay man
Liu et al. N = 128 LGBQ clients Quantitative China 25.26 5.46 Not Cisgender men: 50%, Gay or Lesbian: Chinese: 100% To investigate whether LGBQ LGBQ affirmative practice was
(2022) reported cisgender women: 71.9%, Queer/ affirmative practice is associated positively associated with
38.3%, nonbinary/ Questioning: with improved psychological well- psychological well-being among
genderqueer: 11.7% 14.8%, Bisexual: being and whether factors like LGBQ clients, even after controlling
13.3% internalized homophobia and filial for pretherapy distress and
piety moderate this relationship therapists’ credibility. The
association was stronger for LGBQ
clients with higher levels of
internalized homophobia and
affirmative family support, while the
effect did not vary with religious
family pressure
Liu et al. N = 12 Chinese Qualitative China 26.1 4.32 20–35 Cisgender women: Gay: 42%, lesbian: Chinese: 100% To explore Chinese LGBQ clients’ The findings suggest that counselors
(2023) LGBQ individuals 58.3%, cisgender 33%, bisexual: perceptions of LGBQ affirmative working with Chinese LGBQ clients
men: 41.7% 16.7%, and nonaffirmative practice should demonstrate calm assurance
FISCHER, COX, MICKELSON, AND LYONS

questioning: 8.3% in their affirming attitude, expand

their LGBQ-related knowledge,
improve their capacity to provide
guidance, and flexibly utilize LGBQ
affirmative skills based on clients’
sexual identity development and
presenting issues
Mair (2003) N = 14 gay men Qualitative United Not Not 22–51 Man: 100% Gay: 100% Not reported To understand the experiences of gay Internalized homophobia impacted both
Kingdom reported reported men who have undergone gay men and the therapeutic
counseling relationship
Malley and N = 637 gay and Qualitative United Not Not 20–60 Men: 52.7%, women: Not reported White: 92% To investigate the perceived Issues related to sexual identity, along
Tasker lesbian participants Kingdom reported reported 45.7%, transgender: helpfulness or unhelpfulness of with generic qualities of the
(2007) 15.7% psychotherapy as experienced by therapeutic relationship, were
lesbians and gay men important in psychotherapy
McCullough N = 13 transgender Qualitative United States 35 Not 21–54 Transgender and gender Queer: 53.8%, gay: Black/African American: To understand the counseling Four main themes were identified: (a)
et al. and gender reported nonconforming: 15.4%, bisexual: 30.8%, White: 30.8%, experiences of TGNC individuals the process of selecting a mental
(2017) nonconforming 100% 15.4%, multiethnic or multiracial: health professional, (b) a
heterosexual: 30.8%, Latino: 7.7% transaffirmative approach, (c) a
7.7%, pansexual: transnegative approach, and (d)
7.7% support systems beyond counseling
(table continues)
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Table 4 (continued)

Qualitative/
quantitative/
mixed Study Age Age Age
Study Sample methods location (M ) (SD) (range) Gender Sexual orientation Race and ethnicity Aims Primary results

Mizock and N = 45 participants Qualitative United States 46 16.5 21–71 Trans women: 46.7%, Not reported White: 75.6%, biracial To identify specific issues that arise Thematic analysis revealed several
Lundquist who self-identified Trans men: 37.8%, participants: 15.6%, during the psychotherapy process themes including education
(2016) as TGNC. genderqueer/ African American: 2.2%, for TGNC individuals burdening, gender inflation, gender
genderfluid: 15.6% Asian American: 2.2%, narrowing, gender avoidance,
Latino American: 2.2%, gender generalizing, gender
Native American: 2.2% repairing, gender pathologizing, and
gatekeeping
Morris et al. N = 91 transgender or Qualitative United States 27.99 9.83 18–62 Transfeminine/trans Gay/lesbian: 25.3%, White: 71.4%, other: 14.3%, To investigate descriptions of Thematic analysis identified four
(2020) gender diverse woman: 35.2%, queer: 20.9%, Mixed: 9.9%, Latinx: microaggressions perpetrated by therapy-salient themes: (a) lack of
transmasculine/trans bisexual: 19.8%, 2.2%, East Asian: 1.1%, mental health care providers toward respect for client identity, (b) lack
man: 23.1%, gender pansexual: 18.7%, Middle Eastern: 1.1% their transgender clients of competency, (c) saliency of
queer/fluid: 16.5%, heterosexual: identity, and (d) gatekeeping
man with a 5.5%, asexual:
transgender history: 5.5%, questioning:
8.8%, woman with a 4.4%
transgender history:
5.5%, agender: 5.5%,
gender
nonconforming:
4.4%, bigender:
1.1%
Nedela et al. N = 8 female, same- Qualitative United States 24.2 Not 19–34 Cisgender female: 94%, Bisexual: 56.3%, White: 69%, Hispanic: 19%, To provide therapists with insights into Thematic analysis revealed three salient
(2022) gender couples, in reported transgender woman: lesbian: 31.3%, multiracial: 6%, working with female bisexual themes: (a) bisexual couples are
which at least one 6% bisexual and Indigenous to Australia: couples similar to any other couple, (b)
partner identified as pansexual: 6%, 6% bisexual couples face internal
bisexual, 16 unknown: 6% stigma, and (c) therapists hold
participants bisexual stigma
Page (2004) N = 217 bisexual men Mixed United States Not Not Not Women: 71%, men: Bisexual: 100% European American: 84%, To explore the specific experiences and Bisexual individuals seek help for
and women methods reported reported reported 29% other: 16% needs of bisexual clients in mental sexual orientation issues less
health treatment frequently and rate their services as
less helpful compared to gay and
lesbian participants in similar
research. Participants who disclosed
BRIDGING THE MULTICULTURAL ORIENTATION FRAMEWORK

their sexual orientation often or

always to mental health providers
generally experienced acceptance.
However, those with more serious
clinical issues disclosed their
bisexuality less frequently,
experienced less acceptance upon
disclosure, and encountered biased
clinical interventions. Participants
emphasized the need for providers
to validate bisexuality, be informed
about bisexual issues, and
proactively support bisexual clients

(table continues)
17
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Table 4 (continued) 18
Qualitative/
quantitative/
mixed Study Age Age Age
Study Sample methods location (M) (SD) (range) Gender Sexual orientation Race and ethnicity Aims Primary results

Penn et al. N = 10 LGBTQ Qualitative United States Not Not 22–51 Males: 50.0%, females: Lesbian: 20.0%, gay: White: 50.0%, Hispanic: To examine the unique barriers, needs, Revealing and integrating one’s sexual
(2013) individuals reported reported 40.0%, trans woman: 30.0%, bisexual: 20.0%, Native American: and experiences of LGBTQ identity in the therapeutic
10.0% 20.0%, 20.0%, Black: 10.0% individuals diagnosed with both environment was identified as
transgender: substance abuse and a mental health important. Participants endorsed a
10.0%, lesbian/ disorder more holistic and integrative
bisexual: 10.0%, approach
gay/bisexual:
10.0%
Pixton (2003) N = 17 LGB Qualitative United Not Not 17–56 Men: 41.2%, women: Not reported White: 100% To understand what lesbian, gay, and The identified themes include
participants Kingdom reported reported 58.8% bisexual clients found affirming in communicating a nonpathologizing
their therapy, and whether these perspective on homosexuality, the
aspects were unique to gay counseling relationship, the
affirmative therapy counseling space, what the
counselor brings to the relationship,
humanity, and the counselor
adopting a holistic approach. Some
affirming elements are unique to
gay affirmative therapy and cannot
be attributed to other factors
Puckett et al. N = 158 transgender Mixed United States 33.06 12.88 19–70 Nonbinary: 25.3%, trans Queer: 52.5%, White: 69%, multiracial/ To examine self-reported mental health Participants reported greater satisfaction
(2023) and gender-diverse Methods man: 23.4%, trans pansexual: 38.0%, multiethnic: 16.5%, Black diagnoses among TGD people and with providers who specialized in
adults woman: 20.3%, bisexual: 27.8%, or African American: demographic differences among working with TGD clients and those
genderqueer: 10.1%, gay: 14.6%, 5.1%, Asian: 3.8%, those in therapy and not in therapy who listed professional
woman: 5.7%, man: lesbian: 12.7%, Latinx: 3.8%, American memberships
3.8%, agender: 1.9%, asexual: 10.1%, Indian or Alaskan Native:
genderfluid: 1.3%, heterosexual: 1.3%, not listed: 0.6%
bigender: 1.3%, 5.1%, not listed:
androgyne: 0.6% 5.1%
Quiñones et N = 77 sexual- Qualitative United States 38.3 14 18–75 Male: 41.6%, female: Gay/lesbian/queer/ White: 83.1%, African To explore sexual-minority clients’ Participants reported appreciating
FISCHER, COX, MICKELSON, AND LYONS

al. (2017) minority 54.5%, genderqueer: homosexual: American/Black: 2.6%, perceptions of what was helpful and general person-centered
individuals in 3.9% 79.2%, bisexual: Latino: 7.8%, Asian unhelpful in therapy experiences psychotherapy competencies, such
psychotherapy 7.8%, other American: 2.6%, biracial: with respect to their sexual identity as active listening, validation, and
(nonquestioning): 3.9% Socratic questioning. They also
13% emphasized the relevance of various
aspects of sexual orientation, such
as therapist sexual identity and
knowledge about sexual-minority
populations, which should be
directly addressed by therapists
Rachlin N = 93 transgender Quantitative United States Not Not 17–57 FTM: 68.5%, MTF: Not reported White: 85%, African To understand the experiences of Individuals commonly see a
(2002) individuals reported reported 21.5% American: 8%, Mixed transgender and transsexual psychotherapist for general personal
Heritage: 3%, Native individuals in psychotherapy across growth before seeking a therapist
American: 2%, Hispanic: various treatment settings with experience in transgender work
1% to focus on gender issues. Provider
experience in gender-related work
was associated with positive
changes, higher patient satisfaction

(table continues)
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Table 4 (continued)

Qualitative/
quantitative/
mixed Study Age Age Age
Study Sample methods location (M ) (SD) (range) Gender Sexual orientation Race and ethnicity Aims Primary results

in both personal growth and gender-

related issues. Flexible treatment
approaches and respect for the
patient’s gender identity were
appreciated by individuals
Rosati et al. N = 25 nonbinary Qualitative Italy 27.44 4.31 19–35 Nonbinary: 100% Bisexual: 32%, White and Italian: 100% To explore the experiences of Using codebook thematic analysis,
(2022) people unlabeled: 20%, nonbinary individuals in three main themes were identified:
lesbian: 16%, psychotherapy and identify (a) the self of the psychotherapist
queer: 16%, emergent themes in their narratives (including personal and professional
pansexual: 12%, characteristics), (b) the practice of
gay: 4% the psychotherapist (affirmative or
negative approaches toward
nonbinary identities), and (c) the
therapeutic relationship (including
the alliance, rupture, and reparation
based on openness toward
nonbinary identities)
Schuller and N = 177 LGBTQ+ Quantitative United States Not Not 18–34 Trans woman: 62.2%, Bisexual: 17.8%, White: 86% To determine which aspects of the Clients who felt less trust for their
Crawford clients reported reported transman: 18.1%, lesbian:16.9%, client–provider relationship affected providers perceived inadequate time
(2022) nonbinary: 12.2%, pansexual: 12.8%, satisfaction with the quality of spent in therapy and believed their
ciswoman: 5.2%, heterosexual: mental health care received providers looked down on or judged
cisman: 2.4% 8.6%, queer: them reported lower satisfaction
5.4%, gay: 5.0%, with the quality of mental health
demisexual 3.6%, care received. Additionally, less
questioning: 2.3%, satisfaction with the quality of care
self-identified: was associated with reduced
27.7% confidence in receiving future
adequate mental health care among
LGBTQ clients
Semp and N = 13 same-sex- Qualitative New Zealand Not Not Not Man: 100% Not reported Not reported To understand whether clients feel able Staff in Primary Mental Health
Read attracted male reported reported reported to disclose issues regarding sexual Services rarely ask clients about
(2015) clients and 12 LGB orientation to psychiatric services sexual orientation, resulting in
staff and how such services enable or difficulties for clients in disclosing
BRIDGING THE MULTICULTURAL ORIENTATION FRAMEWORK

hinder this process their sexual orientation even when

relevant to their mental health issues
Shelton and N = 16 self-identified Qualitative United States 26.25 Not 20–47 Female: 56.3%, male: Gay: 37.5%, queer: White: 81.3%, Hispanic/ To expand the concept of Microaggression themes include
Delgado- LGBQ individuals reported 43.8% 25.0%, bisexual: Latino: 12.5%, Black: microaggressions to sexual assumptions about sexual
Romero 18.8%, lesbian: 6.3% orientation and explore the themes, orientation as the cause of
(2011) 6.3%, bisexual/ experiences, and impacts of such presenting issues, avoidance and
queer: 6.3%, microaggressions in psychotherapy minimizing of sexual orientation,
lesbian/queer: overidentification with LGBQ
6.3% clients, stereotypical assumptions,
expressions of heteronormative bias,
assumption of psychotherapeutic
need, and warnings about the
dangers of identifying as LGBQ

(table continues)
19
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Table 4 (continued) 20
Qualitative/
quantitative/
mixed Study Age Age Age
Study Sample methods location (M ) (SD) (range) Gender Sexual orientation Race and ethnicity Aims Primary results

Sherman et N = 58 LGBT Qualitative United States Not Not 20–61 Female: 55%, male: Heterosexual/straight: White: 84%, Black or To explore the experiences, beliefs, and Approximately two thirds of veterans
al. (2014) veterans reported reported 33%, transgender: 0%, homosexual/ African American: 12%, preferences of LGBT veterans when reported that none of their VA
12% gay or lesbian: American Indian/Alaska communicating with health care providers asked about their sexual
81%, bisexual: Native: 19%, other: 2% providers orientation, and a significant portion
12%, questioning: did not disclose their orientation to
2%, missing: 5% any VA provider. Veterans
expressed fears about disclosure and
varied opinions about routine
assessment of minority status. Only
28% of LGBT veterans perceived
the VA as welcoming
Smetana and N = 10 lesbian Qualitative United States 38.6 9.3 21–48 Woman: 100% Lesbians: 100% White: 100% To qualitatively assess the therapeutic Lesbian couples who accepted their
Bigner couples, 20 satisfaction of lesbian couples who sexual orientation reported higher
(2005) participants have received couples therapy levels of satisfaction in therapy and
an improved sense of self. Positive
therapeutic experiences were
associated with therapists who
portrayed positive acceptance of
homosexuality, low levels of
heterosexism, and knowledge of
lesbian community issues
Snow et al. N = 1,576 trans and Qualitative United States Not Not Not Nonbinary: 38.2%, Bisexual/pansexual: White: 64.2%, multiracial: To analyze the experiences of Affirming providers are not always
(2022) gender diverse reported reported reported feminine 37.2%, gay: 32.6%, Hispanic/Latinx: transgender and gender-diverse adept. Some providers inflate their
adults expressions: 30.4%, 25.5%, other: 2.0%, African American/ individuals with mental health expertise, conflate transgender and
masculine 19.6%, ace Black: 1.4%, Asian professionals who identify as gender-diverse experiences with
expressions: 24.6%, umbrella: 11.7%, Pacific Islander: 1.4%, inclusive sexual-minority experiences, and
other: 6.5% straight: 6.1% Indigenous: 0.5% manipulate their clients Competent
providers are identified by their
helpfulness, trustworthiness, and
FISCHER, COX, MICKELSON, AND LYONS

understanding of transgender and

gender-diverse issues
Victor and N = 15 LGB Qualitative South Africa Not Not Not Not reported Not reported Not reported To explore the experiences of South Positive experiences in counseling and
Nel individuals reported reported reported African LGBTI people with psychotherapy included receiving
(2016) psychotherapy and counseling, with unconditional positive regard,
the goal of informing guidelines’ acceptance, and nonjudgment from
structure and content therapists, affirming participants’
sexual orientation as normal, and
acknowledging it as one aspect of
their identity. Negative experiences
were attributed to therapists’
disaffirming attitudes toward clients’
sexual orientation
Wang et al. N = 2007 sexual- Quantitative China Not Not Not Transgender: 17.1% Lesbian: 12.8%, gay Chinese: 100% To investigate prevalence and factors Among participants who had used
(2021) minority clients reported reported reported man: 52.4%, associated with counseling and counseling and psychotherapy
bisexual: 17.7% psychotherapy service use among services, many perceived
Chinese sexual-minority populations discrimination, some reported being
refused treatment or experiencing

(table continues)
 BRIDGING THE MULTICULTURAL ORIENTATION FRAMEWORK 21

verbal harassment, and a portion felt

A significant percentage of respondents

Note. LGBQ = lesbian, gay, bisexual, queer; QTBIPOC = queer, trans, Black, Indigenous, people of color; FTM = female-to-male; MTF = male-to-female; LGBTQ = lesbian, gay, bisexual, trans, queer; LGBT = lesbian, gay, bisexual, trans; TGNC = transgender,
psychotherapists lacked knowledge

had received “lesbian-unfriendly”

Specific to gender minority clients, culturally arrogant therapists

and experience in treating sexual

sometimes assumed that transgender clients wanted to pursue

providers in the past 5 years

discrimination from service
that their counselors and/or

treatment and experienced

Primary results
medical transition (e.g., Bettergarcia & Israel, 2018), that there was a
universal transgender experience (e.g., Mizock & Lundquist, 2016),
and that issues related to gender were the reason they were seeking
psychotherapy (e.g., J. Hunt, 2014).

gender nonconforming; LGB = lesbian, gay, bisexual; GLB = gay, lesbian, bisexual; LGBTQQI = lesbian, gay, bisexual, trans, queer, questioning, intersex; VA = Veterans Affairs; LGBTI = lesbian, gay, bisexual, transgender, and intersex.
minorities In contrast to the absence of pathologization in cultural humility,
cultural arrogance was observed when therapists expressed patholo-
gizing views of sexual orientation or gender, such as expressing a
their experiences with mental health
lesbians in New Zealand, as well as

view that SGM identities are an illness (e.g., Earley et al., 2020) or
To describe the mental health of

focusing on clients’ SGM identities as the source of their mental

health challenges (e.g., Kelley, 2015; Liddle, 1996). For example, one
participant remarked,
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Aims
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My sexuality isn’t actually something I’m here for. This is not a problem
for me. It’s not an issue; this is not the reason I’m here. This is not what’s
services

causing the problems in my life, and that’s not something that I want on
the agenda. (Eady et al., 2011, p. 384)

Some transgender and gender nonconforming participants commented

Australian: 1.6%, Pacific
European: 87.5%, Maori:
Race and ethnicity

7.1%, British: 2.4%,

explicitly on the inclusion of gender dysphoria within the DSM-5 and

the use of diagnosis within psychotherapy (e.g., Bess & Stabb, 2009).
Islander: <1%

One participant reflected, “We changed it from disorder to dysphoria …

well, the fact that it’s in the DSM and the fact that it’s a dysfunction
or a dysphoria, it says, ‘There’s something wrong with you.’” (Elder,
2016, p. 183).
Gatekeeping was evident within several of the included studies
Sexual orientation

nonidentifying:
Lesbian: 95.2%,

focused on gender minorities (H. M. Brown et al., 2020; Elder, 2016;

bisexual or

Glyde, 2023; Mizock & Lundquist, 2016; Morris et al., 2020; Rachlin,
4.8%

2002). Gatekeeping refers to mental health professionals serving as

arbiters who control or restrict access to medical interventions such as
hormone replacement therapy or gender-affirming surgeries (H. M.
Brown et al., 2020). Inherently, this process may foster cultural
Gender

arrogance as it assumes that therapists are the experts who hold the
Woman: 100%

power to decide if the client is gender dysphoric enough to qualify for

gender-affirming care.
Therapists who overfocused on SGM identity in psychotherapy
(range)

were also understood as culturally arrogant due to therapists over-

19–66
Age

shadowing clients’ therapeutic goals to prioritize what they thought

was important. For example, some therapists asked clients about
reported reported
(SD)
Age

Not

gender-affirming surgery when it was unrelated to the topic at hand

(e.g., Duffy et al., 2016).
The final marker of cultural arrogance in the reviewed studies was
Age
(M )

Not

instances of microaggressions, subtle expressions of discrimination that

New Zealand

are communicated verbally and nonverbally and are often unconscious

location
Study

(Nadal et al., 2012). Microaggressions within the included studies

encompassed conflating gender with sexual orientation (e.g., Morris et
quantitative/

al., 2020), suggesting clients were confused about their identity (e.g.,
Quantitative
Qualitative/

methods
mixed

Penn et al., 2013), and misgendering (using the wrong pronouns) or

deadnaming (using the wrong name) gender minority clients (e.g.,
Conlin et al., 2019).
Cultural Opportunities. Cultural opportunities are moments
N = 561 lesbians
Sample
Table 4 (continued)

that occur in psychotherapy where there is an opening to directly

attend to clients’ cultural beliefs, values, or other aspects of their
cultural identity (D. E. Davis et al., 2018; Owen et al., 2016). Within
the context of psychotherapy with SGM clients, we conceptualized
cultural opportunities as the moments in psychotherapy when
Welch et al.
(2000)
Study

therapists took or created an appropriate opportunity to explore

clients’ SGM identities, backgrounds, or experiences.
 22 FISCHER, COX, MICKELSON, AND LYONS
Cultural opportunities were evident within the included studies
when therapists took opportunities to explore clients’ SGM identity,
provided their own pronouns and asked for clients’ pronouns, or
initiated conversations about the meaning and impact of SGM
identities on clients’ lives and presenting concerns (e.g., Semp &
Read, 2015; see Table 2). Therapists who took cultural opportunities
not only explored clients’ SGM identities but explored all of their
salient cultural identities (e.g., Brooks et al., 2010; Goodrich et al.,
2016). A further example of cultural opportunities included instances
when therapists acknowledged systemic forces and explored the
impact of living in a heteronormative and cisnormative culture (e.g.,
Earley et al., 2020).
Missed Cultural Opportunities. Missed cultural opportunities
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refer to moments when therapists miss the chance to have deeper
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conversations about clients’ salient cultural identities. Within the
context of psychotherapy with SGM clients, we conceptualized
missed cultural opportunities as the moments in psychotherapy
when therapists missed or ignored an opportunity to explore clients’
SGM identities, backgrounds, or experiences.
Missed cultural opportunities were evident within the included
studies when therapists ignored SGM clients’ disclosure about their
sexual orientation or gender (e.g., Hall, 1994), failed to integrate
clients’ SGM identity into the content of psychotherapy (e.g., Welch
et al., 2000), or dismissed the importance of clients’ SGM identity
(e.g., McCullough et al., 2017; see Table 2). Therapists missed
important cultural opportunities when they only engaged in superficial
conversations about SGM topics, failed to recognize the significance
of clients’ romantic partner (e.g., Shelton & Delgado-Romero, 2011),
or discounted the impacts of societal discrimination (e.g., Welch et al.,
2000). For example, in one included study (Arora et al., 2022, p. 504),
a queer black woman noted how her therapist could have better
attended to her identities and multiple axes of oppression by, “taking
that next step, seeing how [my] identities played a role.”
Cultural Comfort. Cultural comfort refers to how at ease a
therapist feels before, during, and after a conversation about
culturally focused topics (Owen et al., 2017). In psychotherapy with
SGM clients, cultural comfort refers to therapists conveying comfort
when discussing topics relevant to clients’ sexual orientation or
gender identity. Cultural comfort is characterized by feelings of ease
and confidence when engaging in SGM conversations.
Therapists who were culturally comfortable appeared relaxed
(e.g., Burckell & Goldfried, 2006), were able to confidently ask
about SGM identities and experiences (e.g., Malley & Tasker, 2007),
and appeared comfortable with their own sexuality and gender (e.g.,
Victor & Nel, 2016; see Table 3). One participant who was seeking
couples therapy, commented on their therapist’s cultural comfort,
“[The couples counselor] was smiling and relaxed in her manner, she
seemed confident, she used language that validated the relationship”
(Grove & Blasby, 2009, p. 260).
Cultural Discomfort. Cultural discomfort is therapists con-
veying discomfort when discussing topics relevant to clients’ sexual
orientation or gender identity. Cultural discomfort is characterized
by feelings of unease, nervousness, uncertainty, and awkwardness
when engaging in conversations about SGM topics.
Therapists who displayed cultural discomfort did so through their
body language, facial expressions, or avoidance of SGM topics (e.g.,
McCullough et al., 2017; see Table 3). Sometimes this discomfort was
noticeable during conversations surrounding sexuality (e.g., Burckell &
Goldfried, 2006) or during discussions of identity differences between
clients and therapists (e.g., Penn et al., 2013). Other times, therapists
overcompensated for their discomfort by being overly positive and
polite about clients’ SGM identity (e.g., Grove & Blasby, 2009).
Impacts of Cultural Humility, Cultural Opportunities, and
Cultural Comfort on Psychotherapeutic Processes
and Outcomes
When psychotherapy was undertaken with cultural humility, it
played a “pivotal and supportive role” in the lives of SGM clients
(Conlin et al., 2019, p. 127). Therapists who approached psycho-
therapy with a genuine openness to explore clients’ SGM experiences
and perspectives often led to more effective and ethical psychotherapy
(e.g., Morris et al., 2020; see Table 1). Among samples of sexual
minorities, cultural humility positively predicted therapeutic out-
comes, led to stronger therapeutic relationships, and increased
psychological well-being (e.g., Alessi et al., 2019; Kangos & Pieterse,
2021; Liu et al., 2023; see Supplemental Table S5). Within included
studies, markers of cultural humility such as therapists being flexible
in their therapeutic approach, respecting sexual orientation or gender,
avoiding heteronormative language, focusing appropriately on SGM
topics, and addressing the historical pathologization of SGM commu-
nities generally led to SGM clients’ appreciating psychotherapy (e.g.,
A. W. Davis et al., 2022; Rachlin, 2002). Moreover, SGM clients with
culturally humble therapists experienced their therapists as trustwor-
thy, professional, and having good boundaries (e.g., Victor & Nel,
2016). They also reported a greater willingness to disclose personal
information and a greater likelihood of returning to the counselor
(e.g., Dorland & Fischer, 2001). Collectively, these promising
outcomes of therapist cultural humility with SGM clients highlight the
impact of therapist qualities of openness and respect.
Therapists who took cultural opportunities often helped SGM
clients feel safe, accepted, empowered, and supported (e.g., Pixton,
2003; see Table 2). For example, therapists who provided their own
pronouns and asked clients about their and their partner’s pronouns
increased SGM clients’ sense of feeling welcomed and increased
the perceived usefulness of psychotherapy (e.g., Keating et al., 2021;
Puckett et al., 2023). Exploring SGM clients’ identities and
experiences typically helped increase SGM clients’ sense of clarity,
facilitating self-awareness and their coming out and transitioning
processes, both critical life transitions for SGM people (e.g., Anzani et
al., 2019). The therapists who took cultural opportunities were viewed
by their clients as being capable to work with SGM populations and
having a greater understanding of the diversity of SGM identities and
experiences (e.g., Lebolt, 1999). One participant, a biracial transgender
person remarked at the potential benefit of therapists initiating cultural
opportunities,
I feel like, maybe talking more about how those identities intersect and
like how they can create really unique mental health challenges for
individuals. … I feel like it’d be really helpful if like, you know,
counseling services, were able to more openly talk about that, rather
than waiting for the client to bring it up on their own. (Arora et al.,
2022, p. 504)
Similarly, clients of therapists who appeared culturally comfort-
able when discussing SGM topics experienced more beneficial
therapeutic outcomes (e.g., Pixton, 2003; see Table 3). Further,
SGM clients who experienced their therapist as at ease when
discussing SGM topics felt more freedom to explore and disclose
 BRIDGING THE MULTICULTURAL ORIENTATION FRAMEWORK
their identities (e.g., Buser et al., 2011) and a greater sense of
empowerment (e.g., Grove & Blasby, 2009).
Taken together, cultural humility, cultural opportunities, and
cultural comfort increased SGM clients’ satisfaction with psycho-
therapy, helped clients feel empowered in their SGM identities, and
generally felt supported and understood by their therapist.
Impacts of Cultural Arrogance, Missed Cultural
Opportunities, and Cultural Discomfort on
Psychotherapeutic Processes and Outcomes
Unsurprisingly, therapists’ cultural arrogance was detrimental to the
therapeutic process with SGM clients (see Table 1). Therapists who
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displayed qualities in line with cultural arrogance generally weakened
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the therapeutic relationship and discredited the therapist in clients’ eyes
(e.g., Bettergarcia & Israel, 2018). Cultural arrogance often created
barriers for SGM clients accessing and receiving psychological care
(e.g., Keating et al., 2021), increased the likelihood of premature
termination (e.g., Liddle, 1996), and decreased psychotherapy atten-
dance and satisfaction (e.g., Schuller & Crawford, 2022). Further,
therapists who overfocused on SGM identity were more likely to be
perceived as inauthentic and seen as preventing deeper therapeutic
work (e.g., Grove & Blasby, 2009). For example, one client who
identified as a lesbian, cisgender woman commented on the impact of
her therapist’s heteronormative assumptions and later, her inappropri-
ate focus on her sexual orientation:
The most negative experience I had, it took over a month for the
therapist to clarify that “girlfriend” was a romantic relationship, despite
being able to see my sexual orientation on the intake form. When she did
realize it was romantic, she changed the subject to ask about my coming
out experience. This was a problem as I was suicidal at the time and that
should have taken priority over my coming out story. (Heiden-Rootes et
al., 2021, p. 158)
Cultural arrogance led some SGM clients to disengage from the
therapeutic process (e.g., Hall, 1994); perceiving their therapists as
untrustworthy, uncredible, and incompetent (e.g., Applegarth &
Nuttall, 2016); and feeling insulted, misunderstood, and dissatisfied
(e.g., Brooks et al., 2010; Buser et al., 2011; McCullough et al., 2017;
Penn et al., 2013; Rachlin, 2002). SGM clients typically avoided
therapists who expressed bias (e.g., DeLucia & Smith, 2021);
however, when exposed to biased therapists, transgender clients
experienced greater minority stress (e.g., S. J. Ellis et al., 2015). For
example, one participant seeking eating disorder treatment remarked,
In spite of my identification, “professionals” tend to fall back on
essentialist notions: “you are a man.” I am simply not interested in
educating professionals about my gender or identity; it’s the one space
where I do not have the energy left to do so. (Duffy et al., 2016, p. 143)
This quotation underscores the fatigue that can accompany routinely
confronting therapist cissexism. Collectively, these impacts of
therapist cultural arrogance with SGM clients highlight the delete-
rious effects of therapist qualities of superiority and disrespect.
When therapists missed cultural opportunities, it often left SGM
clients feeling invalidated, shameful, confused, resentful, and
discouraged (see Table 2). Like cultural arrogance, missed cultural
opportunities resulted in SGM clients experiencing psychotherapy
as harmful and unhelpful, and they expressed a reticence to pursue
psychotherapy in the future (e.g., Quiñones et al., 2017). When
23
moments to explore clients’ SGM backgrounds were ignored,
therapists were seen as lacking empathy and being ignorant to the
challenges that can accompany SGM identities (e.g., Glyde, 2023).
Further, some clients reported feeling stuck and stifled in psycho-
therapy when their therapists failed to explore their sexuality or
gender (e.g., Mair, 2003).
Therapist cultural discomfort often limited SGM clients’
therapeutic disclosures, and clients experienced discomfort as
indicating that therapists held negative views about SGM people,
decreasing their sense of safety (see Table 3). Cultural discomfort
typically interfered with therapists’ ability to maintain a therapeutic
alliance with their transgender clients (e.g., McCullough et al.,
2017). Further, clients would screen their therapists for signs of
discomfort prior to electing to work with them (e.g., J. Hunt, 2014).
For example, one participant in Daley’s (2012, p. 220) study
remarked, “[My sexual orientation] is one of the first things I tell
[therapists] because if there’s any discomfort, it ain’t going to work.
It’s very much a part of who I am plus it’s also relatively new.”
Taken together, cultural arrogance, missed cultural opportunities,
and cultural discomfort decreased SGM clients’ satisfaction with
psychotherapy and contributed to clients feeling unsafe, unsup-
ported, and misunderstood.
Discussion
In this systematic review, we drew from existing empirical
psychotherapy research with SGM clients to bridge the MCO
framework into psychotherapy with SGM clients. We identified 61
studies that we used to conceptualize and operationalize cultural
humility, cultural arrogance, cultural opportunities, missed cultural
opportunities, cultural comfort, and cultural discomfort in the context
of psychotherapy with SGM clients. Additionally, we drew from these
studies to examine how MCO constructs impacted therapeutic
processes and outcomes. Our findings suggest that the MCO frame-
work can be a useful framework for conceptualizing therapeutic work
with SGM clients. Cultural humility, cultural opportunities, and
cultural comfort generally improve SGM therapeutic processes and
outcomes. Conversely, cultural arrogance, missed cultural opportu-
nities, and cultural discomfort led to deleterious effects on SGM
therapeutic processes and outcomes.
Expanding Multicultural Orientation Constructs
An implication of this review is that it is important to consider both
the good (i.e., cultural humility, cultural opportunities, and cultural
comfort) and bad (i.e., cultural arrogance, missed cultural opportu-
nities, and cultural discomfort) of MCO constructs. In extracting data
relevant to cultural humility, cultural opportunities, and cultural
comfort, we found that it was also necessary to conceptualize their
inverse—cultural arrogance, missed cultural opportunities, and
cultural discomfort—to capture the negative therapeutic experiences
evident within the findings of reviewed studies. For example, cultural
arrogance is not equivalent to a lack of cultural humility. Therapists
explicitly disrespecting client’s SGM identities is more than a mere
absence of openness to their cultural background. Without including
cultural arrogance, important information—which has notable clinical
implications—would be missed. By expanding the three constructs of
MCO to include their opposite, we hope to advance the field by
refining our understanding of what it means to be culturally humble,
 24 FISCHER, COX, MICKELSON, AND LYONS
engage with cultural opportunities, and exude cultural comfort.
Clinically, this allows for a clearer application of what therapists
should embody and avoid with SGM clients. Empirically, we gain
greater measurement precision by explicitly defining the two factors
evident within the Cultural Humility Scale (Hook et al., 2013) and the
Cultural Comfort Scale (Pérez-Rojas et al., 2019).
This expansion to include cultural arrogance, missed cultural
opportunities, and cultural discomfort illustrates the complexity
within MCO framework categories. We acknowledge that labeling
certain harmful therapist behaviors—such as expressing disdain for
a client’s SGM identity—as cultural arrogance may not fully capture
the severity or harm of these attitudes and behaviors. These actions
denote therapists’ assertion of their professional knowledge and
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perspectives over the lived experiences of their clients, thereby
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creating a harmful hierarchy. Using incorrect pronouns, for example,
communicates therapists’ disregard for clients’ self-proclaimed
identity, leading to detrimental impacts on the therapeutic process
and clients’ well-being. Therefore, while the MCO framework
provides a valuable lens for analyzing these harmful attitudes and
behaviors, it is essential to consider the broader impacts of such
behaviors grouped under cultural arrogance, such as a reinforcement
of oppression and manifestations of intolerance.
In bridging the MCO framework with existing SGM psychother-
apy research, we had to make decisions around the categorization
of specific constructs. Two decisions that were particularly chall-
enging were categorizing microaffirmations and microaggressions.
Microaffirmations—subtle gestures that validate SGM identities—
could be conceptualized as cultural opportunities, as they can
represent moments where therapists can delve deeper into clients’
SGM identities or experiences. However, because microaffirmations
prioritize openness and acceptance of clients’ SGM identities,
placing clients—rather than therapists—as the experts, we catego-
rized microaffirmations within cultural humility. Regarding micro-
aggressions, they encompass a wide range of subtly discriminatory
behaviors (Nadal et al., 2012). For this review, we made a distinction
between microaggressions that fail to engage with identity, which
we categorized as missed cultural opportunities, and microaggres-
sions that detrimentally engage with identity, which we categorized
as cultural arrogance. We acknowledge that there are other
reasonable ways to categorize these constructs. We hope that this
review encourages further research that scrutinizes and refines these
categorizations for a more nuanced understanding of the therapeutic
process.
Consistent with existing MCO research and theory, our findings
support the significance of cultural humility (and cultural arrogance)
when engaging in psychotherapy with SGM clients (D. E. Davis et al.,
2018). While cultural opportunities have been found to contribute to
therapeutic outcomes within the wider MCO literature (Owen et al.,
2016), cultural humility has been found to explain more variance in
therapeutic outcomes than cultural opportunities (K. M. King et al.,
2020; Owen et al., 2016). In our review, the subthemes of cultural
humility and cultural arrogance were frequently observed in the
included studies. When these instances occurred in psycho-
therapy, they appeared to carry a significant impact on SGM clients.
This observed prevalence and potential importance may have been
influenced by how we conceptualized and operationalized the MCO
constructs, classifying statements associated with affirmation as
cultural humility and pathologization as cultural arrogance. Previous
work within SGM psychotherapy has mirrored these findings. SGM
clients’ perceptions of therapist attitudes have been previously
associated with the perceived helpfulness of psychotherapy (M. B.
King et al., 2007) and found to be a predictor of therapist engagement
in affirmative practice (Alessi et al., 2015). Collectively, these
findings underscore the importance of therapists’ attitudes and add
credence to the argument that cultivating cultural humility is a
worthwhile pursuit for therapists working with SGM clients.
Intersecting Identities
Within the included studies that emphasized intersecting
identities (e.g., lesbians with disabilities, religious lesbian, gay,
bisexual, trans clients), an ability to focus on and explore all salient
identities was noted by participants as an important feature of
effective psychotherapy (Buser et al., 2011; Goodrich et al., 2016;
B. Hunt et al., 2006). The flexibility to focus on multiple intersecting
identities within psychotherapy is one of the primary advantages of
the MCO framework. The therapeutic application of the MCO
framework facilitates responsiveness to clients’ unique experiences
and encourages therapists to dispose of preconceived ideas and
assumptions about clients’ cultural backgrounds. Budge et al.
(2016) similarly acknowledged the importance of multiple identities
in their study exploring how intersecting identities impact mental
health outcomes among gender minorities. They found that socio-
economic, racial, and educational privilege were important identity
markers for which levels of anxiety differed among transgender
people. Attending to intersecting identities is important as it draws
attention to the multiplicity of identity configurations within gender
minority populations, as nontransgender identities are often over-
shadowed by transgender identities in both research and clinical
practice.
A strong intersectional approach extends beyond focusing on
multiple identities to emphasizing how systems of oppression
distinctly impact individuals who hold membership to multiple
groups (Adames et al., 2018). In practicing cultural humility and
engaging with cultural opportunities, therapists can understand and
explore experiences shaped by systemic oppression such as racism,
heterosexism, and cissexism. When working with SGM clients and
engaging with strong intersectionality, therapists should not only
recognize clients’ multiple identities but also explore how various
systems of oppression might influence clients’ experiences.
While we have presented cultural humility as a desirable and
attainable characteristic for all therapists, some have argued that
therapists’ personal identities and own experiences with discrimina-
tion may influence their ability to express cultural humility (Moon &
Sandage, 2019). They have argued that there can be challenges tied to
embodying cultural humility, especially for therapists who are part of
marginalized groups. The cumulative impact of systemic discrimi-
nation, frequent microaggressions, intergenerational trauma, and
pressures to conform to dominant cultural norms may hinder their
cultural humility efforts. Consequently, there is likely nuance to
practicing cultural humility for therapists who do not belong to
dominant groups, including therapists who themselves are SGM.
This presents a valuable avenue for future research.
Gender Minorities and Cultural Arrogance
Our findings indicate that clients in gender minority groups
experienced more explicit and severe forms of cultural arrogance
 BRIDGING THE MULTICULTURAL ORIENTATION FRAMEWORK
than sexual minorities. For example, therapists outright denied
transgender clients’ identities (Morris et al., 2020); declined to
provide treatment based on their gender identity (Elder, 2016); and
refused to give referral letters for gender-affirming care, leading to
unnecessary delays in their transition process (H. M. Brown et al.,
2020). These findings are consistent with nonpsychotherapeutic
research in which attitudes toward gender minorities have been
found to be more negative than attitudes toward sexual minorities
(Norton & Herek, 2013), and it is well demonstrated that these
attitudes contribute to minority stress and negative mental health
outcomes among gender minorities (Hendricks & Testa, 2012;
White Hughto et al., 2015). Given that gender minorities experience
disproportionate cultural arrogance in psychotherapy, as a profes-
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sion, it is prudent that we emphasize cultural humility in practice,
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training, and policy. To mitigate the impact of cultural arrogance in
psychotherapy with SGM clients, training programs should
prioritize elevating critical consciousness. Specifically, this involves
cultivating an awareness of social inequities and power dynamics, as
well as promoting reflective practices that allow therapists to
understand how these elements manifest in the therapeutic setting
(A. L. Brown & Perry, 2011).
Pathologization and Gatekeeping
Relative to many other marginalized groups, pathologization is a
unique feature of SGM clients’ experiences with psychotherapy.
Clients with gender minority identities within the reviewed studies
experienced more pervasive pathologization (theme of cultural
arrogance) relative to sexual-minority clients. While homosexuality
was removed from the second edition of the DSM in 1973, gender
dysphoria persists in the current DSM-V-TR (American Psychiatric
Association, 2022). Despite the diagnostic criteria being updated to
be more culturally sensitive, the mere inclusion of gender dysphoria
in the DSM has been equated to pathologization and has been a
source of great controversy between transgender communities,
activists, and psychological and medical communities (Davy &
Toze, 2018). One of the main arguments for keeping gender
dysphoria within the DSM is that diagnosis hypothetically increases
access to medical gender-affirming procedures (Kumar et al., 2022).
However, this process has created a system of gatekeeping, requiring
transgender people to provide evidence of gender transition readiness
from their mental and health care providers in most jurisdictions
(Davy & Toze, 2018).
It is important to note that regardless of previous experience with
gender minorities or possessing an affirmative stance, all therapists
are at risk of being culturally arrogant if they are not responsive to
clients’ needs. For example, in a study looking at missteps that
psychotherapists make when working with gender minorities, one
transgender client was told by their therapist, “We’ll just do the
eleven appointments you need, and I’ll give you the piece of paper”
(Mizock & Lundquist, 2016, p. 152). For this client, the clinician
treating the gatekeeping process as obligatory was seen as a missed
opportunity to engage in a helpful psychotherapy process. However,
for another client, this may have been a validating experience. There
is some evidence that the process of engaging in psychotherapy for
the purpose of obtaining a letter of readiness for gender transition
can lead to improved client outcomes (Budge, 2015). While
gatekeeping has the potential to positively contribute to therapeutic
processes, it is also at risk of exasperating existing power
25
imbalances, leaving gender minorities fearful of being honest about
their mental health challenges in fear of their challenges being used
to block or interfere with their access to gender-affirming care (H.
M. Brown et al., 2020). Based on the results of the present review,
therapist attention to cultural humility and cultural arrogance is
essential for supporting gender minorities as they navigate gender
transition, especially if playing a gatekeeping role.
Inconsistent Findings
While many of the findings in this review were consistent across
studies, some were not. For example, while several studies indicated a
negative association between making assumptions, such as assuming
that all transgender people wish to transition, and desired client
outcomes (e.g., Duffy et al., 2016), an analogue study comparing
therapist affirmation video conditions found no significant difference
between the condition that assumed that all transgender clients desire
to transition and another that did not make such an assumption
(Bettergarcia & Israel, 2018). Additionally, while several studies
supported a negative association between therapists being biased and
unaccepting of sexual orientation and gender and affirming behaviors
(e.g., Liddle, 1996), a study examining bisexual individuals’
experiences with mental health providers indicated that experiences
of antibisexual bias with therapists were not significantly correlated
with microaffirmations (DeLucia & Smith, 2021). These examples
indicate that there is additional nuance to be gleaned regarding
therapists’ behaviors and their therapeutic impacts when working
with SGM clients.
Clinical Implications
MCO differs from the broader field of multicultural competence as
MCO emphasizes a therapist’s “way of being” with diverse clients
rather than a “way of doing” (Owen et al., 2011). In this way, the
MCO framework offers a promising scaffold to engage with diverse
clients, regardless of therapists’ previous experience and knowledge
about specific groups. There are several ways that therapists can use
the MCO framework to implement and conceptualize psychotherapy
with SGM clients (refer to Tables 2 and 3). By positioning SGM
clients as experts in their own experiences and identities, therapists
can positively facilitate therapeutic processes and outcomes. For
instance, if a transgender client is discussing their experiences with
gender dysphoria, the therapist should avoid making assumptions or
drawing conclusions based on their own knowledge or experiences
with other clients. Instead, they should encourage the client to share
their unique feelings, thoughts, and experiences and treat these
narratives as the primary source of information about the client’s
experience. In this scenario, a therapist embodying cultural humility
might say something like, “I can provide information and resources
about the experiences of other transgender individuals if you’d like,
but I understand that everyone’s journey is different. Can you tell me
more about your own experiences of being transgender?” (Budge,
2015). Given that gender minorities have disproportionate experi-
ences with cultural arrogance, it is particularly important to cultivate
cultural humility when working with these clients.
By avoiding cultural arrogance and avoiding assumptions about
clients’ experiences and identities, therapists can increase clients’
sense of safety and engagement in therapy. This includes therapists’
being cautious about overstating the importance of the client’s SGM
 26 FISCHER, COX, MICKELSON, AND LYONS
identity, recognizing that while it is a significant aspect of their
selfhood, it does not define them entirely. For instance, a therapist
might ensure they address other salient issues in clients’ lives, such
as their relationships, careers, or mental health concerns, rather than
focusing exclusively on their sexual and gender identity. In this way,
working with SGM clients is not wholly different from working with
other clinical groups. However, special attention should be given to
avoiding pathologizing SGM identities.
Being responsive to what clients bring to sessions, following their
lead, and looking for cultural opportunities improves psychotherapy
processes and outcomes with SGM clients. Critically, therapists
should not pursue cultural topics if they are not important to clients.
For example, if an SGM client mentions that they grew up in the
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Muslim faith, it would be prudent for the therapist to ask about these
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early experiences and how they have interacted with their SGM
identities. However, if the client is disinterested in the conversation,
there is potential harm in continuing to assume that their Muslim faith
is relevant to their present concerns. When unsure, therapists always
have the option of asking clients directly about the importance of
their identities and their desire to discuss them in sessions.
Limitations of Review and Future Directions
There are several important limitations of the present review worth
considering. First, the focus was on peer-reviewed, empirical articles
available in English, and therefore, these findings may not reflect the
perspectives of either non-peer-reviewed gray literature or research
published in languages other than English. Additionally, based on the
available research, we elected to include studies that combined
sexual and gender minorities. This combination of distinct groups
should be kept in mind when interpreting the results. Given the
unique experiences of gender minorities and the present underrepre-
sentation within the literature, future research should explicitly focus
on this population. Further, most of our included studies were
conducted in the United States with predominately young, white
participants, potentially limiting the generalizability of our findings
to other countries and racial, ethnic, and age groups. Future research
should emphasize more diverse populations, as there is evidence that
racial and ethnic minorities experience psychotherapy differently
than white clients (Morales et al., 2018; Ward, 2007). A limitation of
this review lies in the limited diversity, specifically racial and ethnic
diversity, among the contributing authors. This lack of diverse
perspectives could potentially restrict our capacity to fully grasp and
articulate the complexities inherent in intersectional identities.
Another potential limitation of our study was the exclusive
focus on SGM client perspectives. Our goal was to link the
MCO framework to existing empirical psychotherapy research with
SGM clients, focusing on their unique experiences and viewpoints.
However, this approach may limit the range of perspectives
considered. Future research could extend this work by incorporating
the perspectives of therapists or third-party observers. Finally, our
analysis primarily relied on a deductive approach to categorize
existing SGM psychotherapy research into the pillars of the MCO
framework, thereby limiting our ability to capture the entirety of the
findings of included studies. This limitation may have led to missing
findings that fell outside of MCO constructs. A negative case analysis
could be conducted in future research to address this limitation and
allow for a better understanding of the applicability and limitations of
the MCO framework within SGM psychotherapy research.
Conclusion
In summary, the MCO framework offers a useful, expansive, and
promising way to conceptualize psychotherapy with SGM clients.
This systematic review linked the MCO framework with psycho-
therapy research with SGM clients and provided therapists with an
explicit framework for conceptualizing their work with SGM clients.
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