The LGBT abbreviation first came into use in the 1980s, and since then, criticism abounds that both the B (bisexual) and T (transgender) perspectives have been widely silenced. Although some general patterns connected to health care, mental health, and addiction recovery needs are ubiquitous throughout the larger LGBT+ community, the people represented by each individual "letter" have their own unique needs and perspectives that should be considered. In newer usage of the term, the plus (+) symbol has been added to include even more sexual or gender identity minorities who are seeking to find community and recognition in a heteronormative world. Intersex (formerly called androgynous or hermaphroditism), questioning, queer, and asexual individuals can all now be included under the growing scope of the LGBT+ community.

The American Institute for Bisexuality, formerly called the Klein Institute, was founded by Dr. Fritz Klein, a pioneer of bisexual visibility, in 1998. The Institute's mission is to educate the public, including human service professionals, about the needs of those who identify as bisexual. The Institute also seeks to promote and fund research on bisexuality and to engage in public discourse on bisexuality and issues of sexual identity. In his book, The Bisexual Option, Dr. Klein offers a set of concepts to describe bisexual identity and the bisexual experience [3]. In essence, a bisexual person has the capacity for romantic and/or sexual attraction to more than one gender. For most people, this means they can be attracted to both men and women. If one honestly feels he or she meets this criterion, then he or she is bisexual.

Bisexual and other non-binary sexual identity advocates have long embraced the Klein definition for its inclusivity and lack of emphasis on labels, categories, or boxes. The well-known Kinsey Scale was a step in the right direction, offering a continuum (on a scale of 0 to 6) as a measure for describing sexual identity (0 being exclusively heterosexual and 6 being exclusively homosexual, with various degrees expressed in between). However, Klein found the Kinsey scale too limiting and developed his own alternative—the Klein Sexuality Orientation Grid (KSOG), a more nuanced measure of the fluidity and complexity of sexual orientation (Table 1). The KSOG takes seven key variables into account—sexual attraction, sexual behavior, sexual fantasies, emotional preferences, social preferences, heterosexual/homosexual lifestyle, and self-identification (which can include sexual identity and political identity)—and recognizes that a person's preferences may change over time. According to Klein, recognizing that sexual orientation is an ongoing dynamic process is necessary in order to understand a person's orientation properly in its entirety [3]. After completion of the KSOG, a point score is issued that gives some insight into where an individual falls on the continuum (21 being exclusively heterosexual and 147 being exclusively homosexual), with more specific findings than the Kinsey Scale.

The American Institute for Bisexuality also explains that newer terms such as pansexual, polysexual, omnisexual, and ambisexual are now preferred by individuals who may have traditionally identified as bisexual. They offer this very succinct explanation [8]:

By replacing the prefix bi- (two, both) with pan- (all), poly- (many), omni- (all), ambi- (both, and implying ambiguity in this case), people who adopt these self-identities seek to clearly express the fact that gender does not factor into their own sexuality, or that they are specifically attracted to trans, genderqueer, and other people who may or may not fit into the mainstream gender categories of male and female. This does not mean, however, that people who identify as bisexual are fixated on traditional notions of gender.

Scholarship and advocacy around trans issues have brought an additional term—non-binary—into wider use. As it relates to gender, non-binary (often stylized as ENBY) is a gender identity and experience that embraces the full universe of expressions and ways of being that resonate for an individual. It may be an active resistance to binary gender expectations and/or an intentional creation of new unbounded ideas of self within the world. For some people who identify as non-binary, there may be overlap with other concepts and identities, like gender expansive and gender non-conforming [10]. While discussions around the fluidity of gender have shaped the terminology around experiences traditionally described as bisexual by ushering in the new terminology (e.g., pansexual, polysexual, omnisexual, ambisexual), many bisexual and sexually fluid individuals are choosing to adopt the term non-binary to describe their sexual identities as well. Non-monosexual is another option being utilized, a contrast to monosexual, or having sexual attractions/feelings to only one gender.

Scholarship and advocacy around trans issues have brought an additional term—non-binary—into wider use. As it relates to gender, non-binary (often stylized as ENBY) is a gender identity and experience that embraces the full universe of expressions and ways of being that resonate for an individual. It may be an active resistance to binary gender expectations and/or an intentional creation of new unbounded ideas of self within the world. For some people who identify as non-binary, there may be overlap with other concepts and identities, like gender expansive and gender non-conforming [10]. While discussions around the fluidity of gender have shaped the terminology around experiences traditionally described as bisexual by ushering in the new terminology (e.g., pansexual, polysexual, omnisexual, ambisexual), many bisexual and sexually fluid individuals are choosing to adopt the term non-binary to describe their sexual identities as well. Non-monosexual is another option being utilized, a contrast to monosexual, or having sexual attractions/feelings to only one gender.

A significant barrier for many bisexual individuals presenting for health care or clinical care is the fear of being truthful when asked certain questions. There can be a significant fear of being judged or further marginalized, especially when questions are asked about sexual history. Many individuals withhold truthful information that, in an ideal world in which the spectrum of sexuality is largely understood, may help professionals to better serve them. Biphobia (i.e., others' fear of bisexuality and misunderstanding about bisexuals) pushes many bisexuals further into the closet. This self-imposed isolation is generally to avoid ridicule and rejection, affecting well-being and sense of identity.

The findings of this article likely come as no surprise to those who have been researching bisexual mental health and social conditions for years. Research has consistently found poorer health outcomes, mental health outcomes, and poverty levels/income inequality among bisexuals when compared with monosexual peers [16,17,18,19,20].

Any minority group, especially those traditionally discriminated against by family members, the community, faith organizations, and society at large, is extremely vulnerable to being traumatized or wounded. In some cases, these traumatic experiences are public and large, such as in the case of hate crimes, physical violence, or pointed vandalism. For each of these public experiences, there are hundreds more that have remained uncovered. Moreover, much of the wounding faced by LGBT+ persons is experienced in the form of bullying, snide comments, and spiritually abusive messages by religious leaders or parents. For members of the LGBT+ community, dismissals and invalidation of personal identity and selfhood make up a large part of their trauma histories. Many individuals who identify as LGBT+ have also been forced into "reparative therapy," or variations thereof. These damaging religious programs are used to try to force change upon the individuals and how they love and express themselves in the world. It is essential that clinicians validate these subtler, yet equally insidious, experiences as traumatic.

Complex trauma, first coined by Dr. Judith Hermann in 1992, refers to conditions of prolonged trauma or trauma that occurs at developmentally vulnerable times for an individual. Courtis and Ford describe complex traumas as having the following characteristics [22]:

Levis and Siniego first published the concept of oppressive cognitions in 2016. This term emerged from Levis' work as a trauma specialist/EMDR therapist and as a specialist in multicultural issues and providing culturally attuned psychotherapy. In EMDR therapy, the construct of negative cognitions, or the maladaptive messages that people receive about themselves or how they are in the world because of traumatic experiences, is critical. Levis took this a step further to suggest that when these negative cognitions or messages are received due to oppression, cultural trauma, or bias, they can crystallize more insidiously. Oppressive cognitions may be relevant to both the individual and to the specific minority group [26]. Furthermore, oppressive cognitions are sociopolitically influenced and culturally reinforced in an ongoing and insidious manner by the dominant majority and the media.

Levis and Siniego contend that treatment of oppressive cognitions requires a broadening of therapeutic focus [26]. Successful resolution depends on an acknowledgment of the impact that historic and ongoing social oppression have upon the presenting problem. For clinicians working with bisexual clients, recognizing the damaging messages that have traditionally been received by individuals identifying as part of the bisexual umbrella is paramount. While all of the messages reported from the HRC survey could apply, in this course, four specific messages are isolated for further exploration as oppressive cognitions:

The assumption that bisexual people are inherently confused or are simply on some path of discovery is prevalent in popular and clinical culture. While some people's sexual behavior, especially during points of developmental transition, may be described as experimental or bi-curious, it is very important that clinicians never shame individuals who are seeking to find their sexual voice or identity. While it is true that some people transition into and out of bisexual attractions and behaviors, it is vital not to assume that it is a phase for everyone who identifies as bisexual.

Many bisexuals describe feeling excluded from the gay and lesbian communities. Various reasons can exist for this exclusion, including fear of dating bisexuals because of perceptions that they are sexually greedy/more likely to cheat and the belief that bisexuals are really "closeted" gays/lesbians who are practicing internalized homophobia by identifying as bisexual. Bisexuals and others under the bisexual umbrella are often accused of wanting to present as sexually progressive and maybe even reaping the benefits of the fashionable aspects of gay culture without fully participating in the daily trials and social struggles of being out. These messages can internalize as oppressive cognitions (e.g., "I am defective/sexually deviant," "I am an attention monger," "I am a poser/inauthentic") and may be a part of many clients' experiences. The message that can create the biggest sting is the accusation that because bisexuals have passing privilege, they are not fully part of the LGBT+ community.

Three aspects have been identified as a minimum of affirmative practice with LGBT+ clients [28]:

The concept of coming out is more widely recognized as a phrase and a concept in modern society. However, it is rarely simple to define. Coming out is typically described as the process of revealing one's non-heteronormative sexual or gender identity to others. While coming out is often portrayed as a rite of passage or a dramatic event in the lives of LGBT+ people, the reality is that people who identify as LGBT+ are "coming out" their entire life in a society that is still largely heteronormative: to new friends, in new relationships, and in new work settings. When an individual decides to come out, it is generally a multi-layered process that usually begins with "coming out" to one's self first. People may then choose to come out to those closest to them, such as family, or may need to first come out to people they feel are safer than family, such as friends/a peer group, a school counselor, a clinical professional, or another ally. An ally is generally described in the LGBT+ community as someone who is affirmative, supporting, and accepting of diversity in sexuality and gender identity and does not attempt to change or steer the individual away from being who they are. Some people are outed without their consent or permission due to others in the community making assumptions about them or their behaviors. Such forced coming-out experiences generally qualify as traumatic or wounding for the individuals affected by this invasion of personal privacy.

For bisexuals across the gender spectrum, coming out to friends and their community as bisexual after initially coming out as gay or lesbian can be difficult. Consider the case of Client A, who initially came out as bisexual and was told by her family, "There is no such thing as bisexuality." Affected by this judgment, Client A chose to come out as a lesbian and ultimately to marry a woman. After her marriage ended, in exploring her relational dynamics in her own therapeutic process, Client A reclaimed her bisexual identity. Coming out as bisexual proved challenging, as she was still met with comments about "picking a side" and "switching teams." Yet, describing her sexuality authentically as a bisexual woman ushered in a new era of growth for her. Mental health professionals can help guide clients on this journey instead of keeping them stuck in those patterns of shame by practicing from a place of bias, assumption, or misinformation.

The Substance Abuse and Mental Health Services Administration (SAMHSA) provides guidelines on trauma-informed care in their Treatment Improvement Protocol. The trauma-informed movement can be characterized as embracing the paradigm shift of asking what happened to clients as opposed to what is wrong with clients. The SAMHSA defines a trauma-informed approach to the delivery of behavioral health services as including an understanding of trauma and an awareness of the impact it can have across settings, services, and populations. It involves viewing trauma through an ecologic and cultural lens and recognizing that context plays a significant role in how individuals perceive and process traumatic events, whether acute or chronic [31]. For providers working with bisexual clients, recognizing the inherently traumatic nature of being bisexual/part of the bisexual umbrella in a heteronormative mainstream is part of viewing clients through an ecologic and culturally informed lens.

Do ask open-ended questions. Questions that start with the words "what" and "how" generally allow clients to provide as much or as little detail as they are ready to give. Questions such as, "What are you willing to share today about your sexual orientation or sexual identity?," or "How has coming out as bisexual impacted your life?" are examples of how to avoid limiting clients to yes/no answers.

Do consider the role of shame in bisexual clients presenting for treatment of addiction, trauma, and/or grief. Most clients identifying as LGBT+ carry some type of internalized shame about who they are and/or what they may have done to deal with the pressure of being who they are in a heterosexist society (e.g., substance use, acting out, hurting others while closeted). Recognizing this reality is an important competency for professionals who are in positions of power to further shame clients by making assumptions and judgments about being bisexual. Instead, professionals should help clients to see new, healthier truths about themselves and their capacity to love.

Do have closure strategies ready. Allow at least 10 minutes to close down and consider teaching a brief coping skill at the end of a first intake session. For all clients, it is important not to run any session to the last minute with questioning and content, especially about sexuality. If a client does have a big reveal that may have even taken them by surprise during an initial intake session, be sure to check in about how they are feeling for disclosing such information about their sexuality or sexual behavior before they leave and develop a plan for self-care between sessions. One can also preview for the client how treatment will help them and address any goals they may have around sexuality. The essential lesson here is to avoid ending the session immediately after the client has unloaded. The term "vulnerability hangover" has been coined to describe the feelings of shame and remorse that people may feel after a big reveal [32]. If clients are ill-equipped to handle the feelings that may come up, they may resort to default coping mechanisms that are self-destructive (e.g., substance use, acting out).

Do have closure strategies ready. Allow at least 10 minutes to close down and consider teaching a brief coping skill at the end of a first intake session. For all clients, it is important not to run any session to the last minute with questioning and content, especially about sexuality. If a client does have a big reveal that may have even taken them by surprise during an initial intake session, be sure to check in about how they are feeling for disclosing such information about their sexuality or sexual behavior before they leave and develop a plan for self-care between sessions. One can also preview for the client how treatment will help them and address any goals they may have around sexuality. The essential lesson here is to avoid ending the session immediately after the client has unloaded. The term "vulnerability hangover" has been coined to describe the feelings of shame and remorse that people may feel after a big reveal [32]. If clients are ill-equipped to handle the feelings that may come up, they may resort to default coping mechanisms that are self-destructive (e.g., substance use, acting out).

Trauma-informed care recognizes the role that unhealed trauma plays in human behavior, provides a template for minimizing harm in the delivery of human services, and offers an education framework for human services systems [33]. In contrast, trauma-focused care assumes that unhealed trauma plays a major role in presenting issues, denotes greater action in the delivery of treatment services, and promotes proactive treatment planning to heal the legacy of trauma [33].

The aim of this section is not to make a case that any one approach works best for bisexual clients. There has not been enough research done specific to bisexual populations to begin making a case for any one modality as the best. In addition, a culturally responsive approach to treatment dictates that clinicians should never force a preferred mode of intervention on a client. Rather, clinicians should blend their expertise and knowledge of effective practices with the cultural needs and preferences of the client. A culturally competent and proficient clinician is "aware of the importance of integrating services that are congruent with diverse populations and capable of meeting their needs. Diversity is valued. There is a willingness to be more transparent in evaluating current services and practices and in developing policies and practices that meet the diverse needs of the treatment population and community at large" [5]. This is in contrast to a culturally destructive clinician or organization that imposes attitudes from mainstream culture, including inflexible beliefs about "what works" for a client.

Janet's original stages were [34]:

Trauma, grief, and how wounds manifest are not linear, especially for bisexual umbrella clients whose state of being can be qualified as traumatic experience. One concern with models for clinical intervention is that the more "steps," "numbers," or "components" they contain, the more likely clinicians are to be confused about how to deal with unpredictability. No model can capture the truly messy nature of unresolved trauma or grief, let alone offer the perfect solution for healing it. A simpler model allows for flexibility and the ebb and flow that characterizes human healing. As such, the consensus model is a framework. It is common sense to stabilize first—to make sure a person can deal with what may come up in the stage of deeper identification or exploration [36]. Affirmative practices and teaching basic skills for managing affect, feelings, and unpredictability (especially if a coming-out process happens during treatment) are imperative in stage 1 work with bisexual umbrella clients. However, if the exploration stage begins and it is evident that the client is not adequately prepared to engage in deeper work around oppressive cognitions or other traumatic causes of presenting symptoms, the treatment can steer back to a stabilization focus at any time. Even when actively working with clients doing stage 2 processing with any appropriate modality, it is wise to use skills acquired during stabilization (stage 1) to close sessions safely or to remind the client how to use these skills to stay as safe and as regulated as possible between sessions.

Psychoeducation is a critical part of stage 1 work with all clients. Trauma-focused clinicians can do this by finding out if clients are lacking information in a certain area or if they may be operating on misinformation and assumptions given by others. Many clients who grew up in religious institutions that discriminated against LGBT+ persons are still seriously affected by this shame-based messaging. While clinicians are not expected to practice pastoral counseling if this is outside their scope of practice or comfort, pointing the client in the direction of LGBT+-accepting spiritual resources may be necessary. It can be helpful to identify which churches, spiritual communities, or other places of worship are LGBT+ affirming; many socially progressive churches promote this on their websites and in their literature. If a client is comfortable speaking with a leader at such a church, supportive religious teachings can supplement the therapy process.

Another aspect of psychoeducation for bisexual umbrella clients can involve sharing information on healthy sexuality and lifestyle. This can include the basics, like education on safer sex and STI screening for clients who are sexually active. Working with clients to determine what feels like healthy sexuality for them and developing a plan to achieve it is crucial. For bisexual clients, this generally involves connecting with and/or reading about how other bisexuals have managed to thrive and live healthy lives that honor the full expression of their sexuality. This task may include addressing the misconception that to fully claim bisexual identity, one must become polyamorous. Polyamory, literally "many loves" and sometimes referred to as ethical non-monogamy, is a lifestyle path in which multiple relationships or sexual connections are made, with the full knowledge and consent of all parties involved. Some bisexual umbrella clients find polyamory appealing, and others do not.

Be mindful that there are a variety of grief issues that may arise for bisexual clients as they begin fully unpacking and exploring their experiences, especially experiences with oppressive cognitions. Many clients find themselves grieving the lives that they could have had and often feel the heavy emotions and sensations connected to deep regret had they come out at earlier points in their lives. Another reality for many LGBT+ clients who come out later in life is the gap in time that exists between the time they "knew" or identified the nature of their feelings and attractions and the age when they actually came out. If a client suspected at 11 years of age that she was bisexual but does not come out until 36 years of age, there is a 25-year gap in psychosexual development that should be explored to feel fully present in her identity and in herself. A variety of therapeutic approaches designed to help clients work through grief and loss can be beneficial in this process. Additionally, many bisexual umbrella clients are grieving the loss of family connections, spouses/past relationships, their faith community, or other connections that they lost because of coming out or coming out more fully. It should not be assumed that the coming-out process will immediately make bisexual clients feel better because they have chosen to live a more authentic life. A great deal of loss is part of many individuals' coming-out journeys, and therapy should provide a safe place for clients to grieve these losses.

Several qualities have been used to describe a bisexually aware professional:

Seeking supervision or consultation around issues that are clear blind spots in working with LGBT+ clients, specifically with bisexual clients, should be considered. Such supervision may be a necessary requirement if one is blocked from effectively working with a bisexual umbrella or other LGBT+ client because of one's personal beliefs. The ethical guidelines of the major clinical organizations that guide practice in the United States assert that professionals cannot discriminate against clients based on sexual orientation or gender identity [39,40,41]. If referral is not available, the duty falls on the professional to work with the client in as ethical a manner as possible.