A look at transgender issues amongst African and Asian-Amercians.

1. Gender-Variant People of Color in the United States: Individuals of Asian and/or African Descent Alliant International University Emi Komaki Naomi Jackson KannonNalls

2. Intersectionality The manner in which multiple social locations and identities influence one another Identities cannot be viewed completely independently of one another This is a very important consideration for members of multiple minority groups, who must often develop ways of negotiating their identities outside of those utilized by mainstream minorities Collins, 2000; Phillips & Stewart, 2008; Wynn & West-Olatunji

3. Issues Concerning Gender-Variant People of Color “Dual minority” = members of two minority groups (e.g. transgendered and Asian-American)(Israel & Tarver, 1997, p. 125) Might be a member of more than two minority groups Compounded effects of racism, transphobia, homophobia, etc. Often marginalized – distant from both the dominant, majority culture as well as from the culture of origin Disproportionately higher rates of victimization, unemployment, substance abuse, HIV infection, prostitution, homelessness, and other difficulties If lower SES, may go for many years without adequate medical/mental healthcare May be forced to seek dangerous illegitimate transition-related treatments Israel & Tarver, 1997

4. Problems in Research With Racial and Gender/Sexual Minorities Research acknowledging their distinct issues is limited Racial and sexual identity development models helpful in understanding some aspects of their experience – limited because they portray development as linear or bound by well-defined categories Racial identity development models often fail to acknowledge the influence of sexual/gender identity formation Sexual identity development models often fail to acknowledge the influence of race/racism Wynn & West-Olatunji, 2008

5. Guidelines for Clinical Work with Gender-Variant People of Color Examine personal biases before beginning therapy; maintain awareness of biases throughout treatment Do not make assumptions, even if familiar with the ethnic culture Make specific requests for information about client’s “cultural experiences, perceptions, and emotional responses” (Israel & Tarver, 1997, p. 126) Be aware of personal level of acculturation and how it differs from that of the client Do not pathologize a client’s reluctance or lack of trust – racial/ethnic minorities are commonly guarded with people from the dominant culture Israel & Tarver, 1997

6. Guidelines for Clinical Work with Gender-Variant People of Color (Cont’d) Remember that depending on culture, clients may have difficulty with the following: Discussions about sex, sexual practices, and intimate feelings Discussions about negative family dynamics Physical contact (e.g. touching, hugging) Ask clear questions about and respect client’s preferences Israel & Tarver, 1997

7. Transgenderism and Gender-Variance within Eastern Asians and Pacific Islanders in the U.S.By Emi Komaki

8. Where is Eastern Asia and Pacific Islands? Eastern Asia include People’s Republic of China, Hong Kong, Taiwan, Japan, Macau, Mongolia, North Korea, and South Korea Pacific Islands consist of up to 30,000 islands in the Pacific Ocean, which are normally grouped into Melanesia, Micronesia, & Polynesia

9. Population of Asian and Pacific Islanders in the U.S. Asian and Pacific Islander population is rapidly increasing (National Center for Health Statistics, 2011). 15 million in the year of 2008

10. Comparison to the U.S. total population and to other racial groups

11. Cultural aspects – traditional role Males In East Asian cultures, the family is highly valued and there are strict cultural expectations and role assigned to each member of the family (Liu & Chan, 1996) Males are more valued and wanted than females, especially in East Asian cultures, and are expected to be the leader of the family to produce male offspring (Shon & Ja, 1982) East Asian females are expected to obey their parents and then to husbands, and to be a caretaker at home (Shon & Ja, 1982)

12. Transgender people in Eastern Asia and Pacific Islands Mythological storytelling involving transgender figures across Asian and Pacific Islander cultures (Park & Manzon-Santos, 2000) Adverse impacts of Western colonization changed the dynamics of traditional Asian and Pacific Islander cultures, including the perspective and attitude toward transgender people (Park & Manzon-Santos, 2000)

13. Transgender Eastern Asians and Pacific Islanders in the U.S. Very limited number of studies on transgender Eastern Asians and Pacific Islanders in the U.S. The number of transgender Asian Americans and Pacific Islanders in the U.S. is difficult to grasp An estimate number of 2,500, or 40 % of the local transgender population, in San Francisco are Asian Americans and Pacific Islanders (Park & Manzon-Santos, 2000) Transgender people are among the “most invisible and marginalized” of all Asian Americans and Pacific Islanders (Park & Manzon-Santos, 2000)

14. Major Issues among transgender Eastern Asians and Pacific Islanders in the U.S. Cultural and Legal Issues: 86 % of MTF Asian and Pacific Islanders (APIs) born outside of the U.S. (Operario & Nemoto, 2005) A group of MTF Asian sex workers (e.g. Chinese, Thai, and Filipina) in one study in New York City were exclusively immigrant, often undocumented (Hwahng & Nuttbrock, 2007) Language and cultural barriers (Park & Manzon-Santos, 2000) Limited access to legal, medical, mental health, and other social services Distrust in the medical and health care systems due to fear of deportation and language barrier (Hwahng & Nuttbrock, 2007)

15. Major Issues among transgender Eastern Asians and Pacific Islanders in the U.S. Cont’d Interpersonal Issues: Feeling isolated from family and community due to a conflict with transgender identity (Tran, 1998) Transphobia and racism experienced within the “dual minorities” (Israel & Tarver, 1997, p. 125)

16. Major Issues among transgender Eastern Asians and Pacific Islanders in the U.S. Cont’d Health and Mental Health Issues: 13 % of MTF APIs reported being HIV-positive (Operario & Nemoto, 2005)  Low prevalence when compared to African-American (41 %) and Hispanic groups (21 %) A group of MTF Asian sex workers in New York City reported having a moderate HIV risk work for survival (Hwahng & Nuttbrock, 2007) MTF transgender APIs reported the lowest needs for medical and social services among transgender persons of color (Nemoto, Operario, & Keatley, 2005) 1 in 4 MTF transgender APIs reported being clinically depressed (Operario & Nemoto, 2005)

18. Major Issues among transgender Eastern Asians and Pacific Islanders in the U.S. Cont’d 46 % of MTF transgender APIs reported having sex while under the influence of substances, with amphetamines used the most (40%) (Operario & Nemoto, 2005) Transgender API sex workers reported high rate of use of injected and non-injected methamphetamine (Park & Manzon-Santos, 2000)

19. A qualitative study involving 12 FTM Asian and Pacific Islanders (Mar, 2010) Findings: Most participants were not talking hormones or did not have any gender-related surgeries Most participants were out in their 20swhen they met other transgender persons and learned about them 1 in 2 participants were officially out to their family, but most of them received some type of support from family More mothers struggled accepting the gender identity of their sons than fathers 1 in 2 participants reported feeling isolated from API community due to different reasons (e.g. religion, mixed racial background, gender identity)

20. A qualitative study involving 12 FTM Asian and Pacific Islanders (Mar, 2010) cont’d 3 participants, who fit a role of a traditional oldest son, were asked by their parents to discuss financial obligations for the family after they were out 1 in 2 participants viewed the transgender community is dominated by White people Most participants have observed and/or experienced racial discrimination and stereotyping within the transgender community

22. Be educated of clients’ cultural, ethnic, and familial backgrounds and how these factors may interact with their gender issues

23. Provide informed consent and relevant information in the language clients feel comfortable the most

24. Normalize the stigma associated with gender and racial minority as they are members of “duel minorities”

26. Transgenderism and Gender-Variance in Southern and Southeastern Asians in the U.S.By KannonNalls

27. What is “Southern Asia?” South Asia is often referred to as the “Indian Subcontinent.” Countries apart of South Asia include: India Pakistan Bangladesh Bhutan Nepal Maldives Afghanistan Iran Sri Lanka

28. Cultural facts about Southern Asian Americans South Asian Americans occupy the third largest Asian group in America and follow various religions such asChristianity, Islam, Hinduism, Jainism, Sikhism, etc.(Choudhury, et al., 2009).

29. Cultural facts about Southern Asian Americans (Cont’d) “Five Asian groups number 1 million or more people: Chinese, Filipino, Asian Indian, Vietnamese and Korean. Together these five groups made up about 80% of the Asian population.” (http://www.ameredia.com)

30. South Asian Transgender Culture-The Hijira (Lev, 2004) In Indian culture, the “Hijira” occupy a third gender where physiological males engage in feminine gender expressions and gender roles. “Gender is an illusion…maleness and femaleness are simply mirror images of each other…” (p. 61). The Hijira lifestyle is based around the emasculation of male identity via voluntary castration, being impotent, or being born hermaphroditic (p. 62). Due to the increasing westernization of India, the social status of the Hijira is decreasing, leaving many to rely on prostitution/entertainment to make a living (Penrose, 2005).

31. A Community Study Examining LGBT Issues in South Asians Americans in Southern California (Choudhury, et al., 2009) Findings All respondents aged 17 to 25 years old reported the experienced homophobia, transphobia, or biphobia from their own South Asian community. 56% reported to have experience racism and exoticism in the LGBTIQ community

32. A Community Study Examining LGBT Issues in South Asians in Southern California (Choudhury, et al., 2009)-Cont’d 9 out of every 10 respondents admitted to have some mental health issue (45% experienced suicidal thoughts and 29% admitted to problems with alcohol, tobacco, or other drugs. Despite medical services being available to 79% of the sample, only 30% had utilized these public services within the past year. Significance? Because of the stigma and shame that surround overt sexuality and mental illness in South Asian-American culture, this group is less likely to take advantage of these services. Due to this lack of public discourse on sexual issues, HIV prevalence remains high and related issues are often ignored.

33. A Community Study Examining LGBT Issues in South Asians in Southern California (Choudhury, et al., 2009)-Cont’d As a “dual minority,” South Asian Americans may be rejected by the LGBT community due to their race and also rejected by “mainstream” South Asian culture due to their gender variance.

34. What is “Southeastern Asia” Countries of Southeast Asia: Cambodia Laos Burma (Myanmar) Thailand Vietnam Peninsular Malaysia East Malaysia Brunei Indonesia Philippines Singapore East Timor

35. Cultural Aspects-Intersection of transgenderism and Asian-American family values Shame and Dishonor Traditionally, the respect and status of the family’s reputation in the community is the most important cultural value (Ohnishi, Ibrahim, and Grzegorek, 2006). Members who do not conform to expected roles and behaviors are subject to shame and guilt, essential components in the socialization of Asian children (Wong, Chng, Ross, Mayer,1998). Having an identity outside of that of the family, can dishonor the family name, thus violating the ultimate cultural norm (Wong, Chng, Ross, Mayer,1998).

36. Cultural Aspects-Intersection of transgenderism and Asian-American family values (Cont’d) Consequently, members are at risk for family rejection, emotional problems and self-destructive behaviors (Ohnishi, Ibrahim, and Grzegorek, 2006). Due to this risk of being ostracized, LGBT Asian Americans are less likely to come out They are more likely to disclose their status to friends and non-parent family members (Wong, Chng, Ross, Mayer,1998).

37. Transgender People of Color and Sex Work (Nemoto, Keatly, Operario, & Villegas, 2004) Interviewed 48 MTF transgendered sex workers (including 15 API’s) about the context of their sexual practices and HIV risks in an American city Participants say they were more likely to have unprotected (without a condom) when having sex with their intimate partner because “…unprotected sex was a way to increase of intimacy and connection…” (p. 730). A majority of the sample stated they always used condoms during “sex work” (unless more money was offered to forego the condom).

38. Transgender People of Color and Sex Work (Nemoto, Keatly, Operario, & Villegas, 2004)-Cont’d Needs for Gender Validation and Risky Sexual Behavior Some participants said they desired the attention and validation of being a woman (i.e. being courted, flirted with, doing the sexual acts themselves) and would make sacrifices to maintain these feelings. As such, many of them would compromise their values and “put up with” unfaithful , abusive, and drug addicted intimate partners(p. 733). This desire may also have rendered them psychologically vulnerable and more likely to engage in unsafe sex practices and drug use, two factors which elevate the chances of contracting HIV.

39. Transgenderism information in 2 Southeast Asian countries-A Supplement Indonesia (Prabawanti, et. al., 2011) A study measured the prevalence of HIV at 24.4% for the MTF transsexual population (“Waria”). The seroprevalence for syphilis in the waria was 26.8%. Low condom use, ignorance of safe sex and other risky sexual behaviors are implicated in these elevated rates.

40. Transgenderism information in 2 Southeast Asian countries-A Supplement (Cont’d) Sri Lanka (Nichols, 2010) Study highlights the unique physical and harassing abuses performed by clients (and police) unto the “nachchi,” sex workers who are physiological males with feminine gender expression. Because of the stigma of gender variance coupled with being sexually active with men and women, the nachchi are subject to higher levels of violence, legal prosecution, and extortion, even by police. Compared to that experienced by traditional male (homosexual) and female (heterosexual) sex workers.

41. Clinical Implications for South/Southeastern Asian-Americans Understand the importance of the family culture and how a transgender identity will affect this dynamic. Western ideals of independence and “self-discovery” may not be as important, if not insignificant, in Asian-American households. Interventions must be administered accordingly as clients balance the demands of American and Asian culture (Individualism vs. Conformity). Issues of sexuality and sexual expression may not be as freely expressed in Asian culture-Be sensitive and tactful when approaching these areas. On average, mental illness and/or mental health issues may be more stigmatized in Asian culture. Because transgender Asian-Americans are a dual minority, a clinician must be mindful of the intersection of race and gender identity and subsequent experiences of discrimination.

42. Support Groups for the South/Southeast Asian LGBT Community http://www.trikone.org/index.shtml South Asian Lesbian and Gay Association-New York City (SALGA-NYC) South Asian Network (SAN) Asian Pacific Islander Queer Women & Transgender Coalition (APIQWTC) APIQWTC Gay Asian & Pacific Islander Men of New York (GAPIMNY) The mission of the Gay Vietnamese Alliance (GVA) National Queer API Alliance (NQAPIA) Queer Asian Pacific Alliance (QAPA) South Bay Queer and Asian (SBQA)

43. Transgenderism and Gender-Variance within African-Americansby Naomi Jackson

44. Traditional Views of Mainstream African-American Community Lack of distinction between issues of gender identity and issues of sexual orientation – social judgments based on natal sex (e.g. MTF with biological male partner is considered gay) Prevalent homophobia – often manifests in violence against misunderstood LGBTQQI African-Americans “Coming out” is taboo; “silence is rewarded with tacit acceptance” (Phillips & Stewart, 2008, p. 386) Phillips & Stewart, 2008

45. Traditional Views of Mainstream African-American Community (Cont’d) Hierarchy of gender/sexual expression: Masculine heterosexual men Feminine heterosexual women Men/women who maintain traditional gender presentation, but have sex/romantic relationships with partners of the same sex AND race either secretly or monogamously Transgender, transsexual, androgynous, gender-bending/blending individuals of any sexual orientation Intersexuality is invisible and unacknowledged Phillips & Stewart, 2008

46. Marginalization of Gender-Variant African-Americans Frequently excluded from mainstream LGBTQQI culture -> increased risk of: Isolation Estrangement Psychological vulnerability Loss of crucial communal support -> negative impact on well-being and identity development Wynn & West-Olatunji, 2008

47. Marginalization of Gender-Variant African-Americans (Cont’d) “Coming out” viewed as counterproductive to the success of African-American culture Often ignored or denigrated by churches and religious groups – spirituality is a fundamental part of African-American culture Spiritual emptiness Fewer coping skills Smaller support network Wynn & West-Olatunji, 2008

48. Still, There’s a Rich History of Gender Variance among African-Americans From Left to Right: Bessie Smith (female masculinity); Sylvester (Black “diva” tradition; Willie Mae “Big Mama” Thornton (female masculinity); Unidentified female impersonators (Black “diva” tradition) Willi Ninja (Black “diva” tradition); Gertrude “Ma” Rainey (female masculinity); Andre “RuPaul” Charles (Black “diva” tradition); Dennis Rodman (gender bending) Phillips & Stewart, 2008; transgriot.blogspot.com

49. Clinical Concerns for Gender-Variant African-Americans High incidence of: Depression Anxiety Suicidal Ideation Substance Abuse HIV infection Prostitution/sex work for survival Clinicians MUST assess the impact of the following factors upon mental health: Family dynamics Religion Racism Transphobia (and homophobia) Internalized oppression Wynn & West-Olatunji, 2008

50. Clinical Concerns for Gender-Variant African-Americans (Cont’d) Nemoto et al. (2000) conducted 7 focus groups with 48 MTF transgendered individuals, 16 of which were African-American, and found the following for the African-American group: 37% reported depression 41% reported suicide attempt(s) 39% reported physical assault 40% reported sexual assault(s) as a minor 35% reported sexual assault(s) as an adult

51. Elevated HIV Risk For Gender-Variant African-Americans Men who have sex with men (MSM), especially those of color, are the single highest group at risk for HIV/AIDS Currently, the Centers for Disease Control and Prevention (CDC) do not separate MTF individuals from MSMs, and do not include any statistics specific to FTM individuals (cdc.gov; gender.org) One study found that over 35% of MTFs surveyed were HIV+, and nearly two thirds of that group were African-American (Transgender Community Health Project) Rose et al. (2002; meta-analysis) findings: African-American MTFs have a greater than 50% HIV prevalence 42 of 71 (60%) African-American MTFs surveyed locally were HIV+

52. Factors Which Increase HIV Risk Among Gender-Variant African-Americans Sex work: HIV status often not discussed with partners Pressure from partners to engage in unprotected sex Other health and social needs often outweigh considerations of HIV prevention Substance abuse (often for coping): Impaired judgment Sharing of syringes Injection Silicone Use (ISU) Not administered/monitored by medical professionals Syringes often shared Rose et al., 2002; gender.org

53. Recommendations for Clinical Work With Gender-Variant African-Americans Utilize a culturally-centered approach (must be trained/prepared to do so) Use culturally-appropriate terminology (e.g. “same-gender-loving” rather than “gay”) Help the client to: Deal with the stress of managing multiple identities Reduce anxiety from conflicting cultural expectations Clarify the social forces that contribute to their dilemma Develop effective support networks (may include nontraditional family structures) Be prepared with referrals to other culturally-sensitive professionals/organizations Wynn & West-Olatunji, 2008

54. A Final Note on Resiliency African-Americans have fought against racism, discrimination, and oppression for hundreds of years. Gender-variant African Americans are no exception. It’s important for professionals and clinicians to remember that even in the most dire circumstances, many clients have the capacity to be resilient, and even thrive. Isis King: First transgendered contestant on America’s Next Top Model Tona Brown: Successful violinist, vocalist, and music instructor

55. Resources for African-American Gender/Sexual Minorities Books Boykin, K. (2005). Beyond the down low: Sex, lies and denial in Black America. New York: Carroll & Graf. Ettner, R. (1999). Gender loving care: A guide to counseling gender-variant clients. New York: W.W. Norton & Company. Griffin, H. L. (2006). Their own receive them not: African American lesbians and gays in Black churches. Cleveland, OH: The Pilgrim Press. Films Riggs, M. T. (Producer). (1994). Black is Black Ain’t [Documentary]. Independent Television Service. Organizations Black Gay and Lesbian Leadership Forum The Brothers Network in San Francisco Educational Transvestite Chapter (ETVC) National Task Force on Aids Prevention Israel & Tarver, 1997; Wynn & West-Olatunji, 2008

56. References Ameredia.com Centers for Disease Control and Prevention.: http://www.cdc.gov/hiv/topics/msm/index.htm Choudhury, P.P., Badhan, N.S., Chand, J., Chhugni, S., Choksey, R., Husainy, S., Lui, C., Wat, E.C. (2009). Community alienation and its impact on help-seeking behavior among LGBTIQ South Asians in Southern California, Journal of Gay & Lesbian Social Services, 21, 247–266. Collins, P. H. (2000). Black feminist thought: Knowledge, consciousness, and the politics of empowerment. New York: Routledge. Dang, A., & Hu, M. (2004). Asian Pacific American Lesbian, Gay, Bisexual and Transgender people: A community portrait, a report from New York’s queer Asian Pacific legacy conference, 2004. National Gay and Lesbian Task Force Policy Institute. Retrieved from mhttp://www.thetaskforce.org / downloads/ reports/ reports/ APACommunityPortrait.pdf Gender.org – Medical Advisory Bulletin. http://www.gender.org/resources/dge/gea02004.pdf Hwahng, S.J. & Nuttbrock, L. (2007). Sex workers, fem queens, and cross-dressers: Differential marginalizations and HIV vulnerabilities among three ethnocultural male-to-female transgender communities in New York City. Sexuality Research & Social Policy, Journal of NSRC, Vol. 4, No. 4. Israel, G.E., & Tarver, D.E. (1997). Transgender care: Recommended guidelines, practical information & personal accounts. Temple University Press, Philadelphia. Lev, A.I (2004). Transgender Emergence: Therapeutic Guidelines for Working with gender-variant people and their families. The Haworth Press, Inc.: New York. Liu, P. & Chan, C.S. (1996). Lesbian, gay and bisexual Asian Americans and their families. In J. Laird & R. J. Green (Eds.), Lesbians and gays in couples and families: A handbook for therapists (pp. 137-152). San Francisco: Jossey-Bass.

57. References (Cont’d) Mar, K. (2010). Female-to-male transgender spectrum people of Asian and Pacific Islander descent (Doctoral dissertation). Alliant International University, San Francisco, CA. National Center for Health Statistics. (2011). Health, United States, 2010: With special feature on death and dying. U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. National Center for Health Statistics. Nemoto, T., Keatly, J., Operario, D., & Villegas, D. (2004). Social context of HIV risk behaviours among male-to-female transgenders of colour..AIDS CARE, 16,(6), 724-735. Nemoto, T., Keatley, J., Operario, D., & Soma, T. (2000). Psychosocial factors affecting HIV risk behaviors among male-to-female transgenders (MTF TGs) in San Francisco. Center for AIDS Prevention Studies, University of California, San Francisco. Funded by the National Institutes on Drug Abuse. Nemoto, T., Operario, D., & Keatley, J. (2005). Health and social services for male-to-female transgender persons of color in San Francisco. The Haworth Press, Inc. Nichols, A. (2010). Dance ponnaya, dance! Police abuses against transgender sex workers in Sri Lanka. Feminist Criminology, 5(2), 195-222. Operario, D., & Nemoto, T. (2005). Sexual risk behavior and substance use among a sample of Asian Pacific Islander transgender women. AIDS Education & Prevention, Vol. 17, Issue 5, p. 430-443. Ohnishi, H., Ibrahim, F.A., Grzegorek, J.L. (2006). Intersections of identities: Counseling lesbian, gay, bisexual, and transgender Asian Americans. Journal of LGBT Issues in Counseling, 1, 77-94. Park, P., & Manzon-Santos, J. (2000). Issues of transgendered Asian Americans and Pacific Islanders. Asian & Pacific Islander Wellness Center. Retrieved from http://www.apiwellness.org/article_tg_issues.html Penrose, W.D. (2005). India. GLBTQ Social Sciences, 1-5. Phillips, L., & Stewart, M. (2008). I am just so glad you are alive: New perspectives on non-traditional, non-conforming, and transgressive expressions of gender, sexuality, and race among African-Americans. Journal of African-American Studies,12, 378–400. DOI 10.1007/s12111-008-9053-6. Prabawanti, C., Bollen, L., Palupy, R., Morineau, G., Girault, P., Mustikawati, D.E., Majid, N., Nurhayat, Aditya, E.R., Anartati, A.S., & Magnani, R. (2011). HIV, Sexually Transmitted Infections, and Sexual Risk Behavior Among Transgenders in Indonesia. AIDS Behavior, 15, 663-673.

58. References (Cont’d) Rose, V., Scheer, S., Balls, J., Page-Schafer, K., & McFarland, W. (2002). San Francisco Department of Public Health, San Francisco, CA; Center for AIDS Prevention Studies, University of California, San Francisco, CA. Shon, S., & Ja, D. (1982). Asian families. In M. McGoldrick, J.K Pearce & J. Giordano (Eds.), Ethnicity and Family Therapy (pp. 208-228). New York: Guilford Press. Tran, D.K. (1998). Transgender/transsexual roundtable (D. K.Tran Trans.). In D. L. Eng & A. Y. Horn (Eds.), Q & A: Queer in Asian America (227-243). Temple University Press, Philadelphia. Transgender Community Health Project : http://hivinsite.ucsf.edu/InSite?page=cftg-02-02#S4X Transgriot: http://transgriot.blogspot.com/2009/01/african-american-transgender-history.html U.S. Census Bureau (2010). State and County QuickFacts. U.S. Census Bureau. Retrieved from http://quickfacts.census.gov/qfd/states/00000.html Wong, F.Y., Chng, C.L., Ross, M.W., Mayer, K.H. (1998). Sexualities as social roles among Asian- and Pacific Islander American gay, lesbian, bisexual, and transgender Individuals: Implications for community-based health and prevention. Journal of the Gay and Lesbian Medical Association, 2, 157-166. Wynn, R., & West-Olatunji, C. (2008). Culture-centered case conceptualization using NTU psychotherapy with an African-American gay male client. Journal of LGBT Issues in Counseling, 2(4), 308-25. Haworth Press. DOI: 10.1080/15538600802501995