Understanding LGBTQ-Affirmative Psychotherapy
What are L, G, B, T, and Q?
We live in a heteronormative society. In other words, heterosexual relationships are the cultural norm, and anything different is, well, different. Yes it is true that things are changing rapidly in parts of the Western world and elsewhere – evolving societal attitudes about cultural diversity, softening religious dogma, the repeal of DOMA and the military’s “don’t ask, don’t tell” policy, growing intolerance of pejorative terms like “faggot,” “homo,” and “dyke,” legalized gay marriage, and more – but this doesn’t mean that people whose sexual orientation and/or gender identity falls outside the norm suddenly have an easy time of it. In fact, these individuals typically experience, at best, confusion (not just from others but within themselves) about who/what they are why/how they are different. In fact, sometimes even psychotherapists are unsure about what it means to be LGBTQ, and even the clinicians who do possess a basic understanding typically bring a lifetime of cultural bias to the therapy room.
Happily, the Internet has gone a long way toward alleviating much of this confusion and bias, providing therapists and laypersons alike with both deeper and more readily accessible insight. Furthermore, young people now receive active education in schools and elsewhere about the evils of bullying and bigotry, and the benefits of diversity and acceptance. And grown-ups are getting the message too. For one recent example check out this incredible story on Honey Maid graham crackers. Be sure to watch the video at the bottom of the link. (When I watched it, I cried.) Nevertheless, despite the efforts of educators and sensitive corporations like Nabisco (the parent company of Honey Maid), there is still a great deal of ignorance, misunderstanding, and rigidity (and sometimes even downright hatred) when it comes to LGBTQ issues. If there wasn’t, then Honey Maid would never have needed to craft such a beautiful and loving response.
I think the key words in the preceding paragraph are “ignorance” and “misunderstanding.” Simply put, people who’ve not been educated about LGBTQ issues are much more likely to view the heteronormative model of living as “right” and anything else as “wrong,” and to respond accordingly. Recognizing this widespread lack of basic knowledge, even among some in the psychotherapy field, it seems that some rudimentary LGBTQ definitions may be useful.
- Lesbian (L): Lesbians are women who have a personally significant and meaningful romantic and/or sexual attraction to other women.
- Gay (G): Gays are men who have a personally significant and meaningful romantic and/or sexual attraction to other men.
- Bisexual (B): Bisexuals are people who have a personally significant and meaningful romantic and/or sexual attraction to both men and women. Those who self-identify as bisexual need not be equally attracted to both genders.
- Transgender (T): Transgender people (also called transsexuals) feel as if they were born into a wrong-gender body (a woman trapped in a man’s body, or a man trapped in a woman’s body). They may be pre-operative (still in the wrong body) or post-operative (finally in the right body, thanks to modern medicine).
- Queer (Q): Queer used to be synonymous with gay, but now it is a catch-all term used by anyone who feels outside the sex/gender norm. Lesbians, gays, bisexuals, and transgender people can all self-identify as queer, as can individuals with gender dysphoria issues that don’t reach the level of transgenderism (cross-dressers, for instance). People with fetishes, a desire for polyamory, or other non-normative sex and gender related thoughts and feelings may also choose to self-identify as queer.
- Closeted: Closeted LGBTQ people are those who are not comfortable with their sexual orientation and/or gender identity and choose to conceal it from others. In other words, they keep it hidden away “in the closet.”
Without question, these definitions are both broad and limiting. Many very reasonable and intelligent people may prefer alternative wording (or even no definitions at all). Plus, there’s a huge array of non-heteronormative behaviors that are not easily categorized. For instance, I frequently treat heterosexual men who fetishize the wearing of women’s clothing. Similarly, I’ve met numerous heterosexual women who enjoy the traditionally male role in sex, wearing strap-on sex toys for penetration purposes. I’ve also treated heterosexual sex addicts of both genders who will have sex with anyone in the vicinity, regardless of the other person’s gender. And all of these individuals, despite the behaviors described above, are highly unlikely to self-identify as gay, lesbian, bisexual, transgender, or even queer. So at the end of the day, when facing a client troubled by sexual orientation or gender identity issues, the best we can do is provide basic education and direction, encouraging these individuals to self-identify with whatever label feels most comfortable – even if that label is “none of the above” or changes over time.
Basic Issues in LGBTQ Therapy
LGBTQ people enter therapy for the same reasons everyone else enters therapy. They are depressed, or they’re severely anxious, or they’re compulsively abusing substances, or they’ve endured a recent breakup, or their mother just died, or whatever. Regardless of LGBTQ status, the challenges that bring people into therapy and the diagnoses they are given – major depression, PTSD, substance use disorder, and the like – are most often manifestations of early-life trauma and shame. In other words, these are not LGBTQ issues, they are human issues. Unfortunately, many LGBTQ people arrive in therapy with an extra layer of trauma and shame related to their sexual orientation or gender identity and the ways in which that orientation/identity has been responded to by their families and/or society. Let’s not forget that a mere 40 years ago homosexuality was both illegal and deemed a mental illness, and that the anti-LGBTQ prejudices most people over 40 grew up with have been passed (and are still being passed) to younger generations.
The simple truth is that for the most part men are still expected to fall in love with women, women are still expected to fall in love with men, and together they are still expected to marry, reproduce, and inculcate their children with similar beliefs and expectations. And whenever a person feels or desires something outside that cultural norm, life becomes more difficult. Even when people who are different are raised in tolerant homes, surrounded by supportive others, the overarching expectations of society are readily apparent from birth onward. As such, these individuals know, deep in their hearts and usually rather early in life, that who they are and/or what they want in a partner is regarded by many as abnormal and/or unacceptable. Hence: the extra layers of trauma and shame that many LGBTQ people carry. Is it any wonder that LGBTQ individuals have higher than normal rates of both substance abuse and suicidal ideation and behavior?
Making matters worse is the fact that even the most loving and well-meaning of families, friends, and therapists can place value judgments on a “different” person’s sexual orientation or gender identity. Sometimes these family, friends, and clinicians try to help the “afflicted” person by suggesting that he or she either cover-up or ignore his or her differentness. This is an instance where the timeworn adage, “The road to hell is paved with good intentions,” really has meaning. Even more vexing is when misguided families and clinicians attempt to “cure” a person’s sexual orientation or gender dysphoria with things like aversion therapy (now illegal to practice in California) or by labeling the individual as a sex addict as a way to explain his or her “abnormal” thoughts, feelings, and behaviors. Needless to say, these tactics are harmful and counterproductive, usually creating more layers of trauma and shame.
You can’t change a person’s sexual orientation or gender identity (no matter how ego-dystonic it may be). Simply put – and I find it sad that I even have to write this – a gay man is attracted to other men whether he likes it or not, and a lesbian woman is attracted to other women whether she likes it or not, and bisexuals are attracted to both genders whether they like it or not, and a transgender man or woman is exactly that, no more, no less. No amount of therapy is going to change these situations. Yes, there are moralist and religious therapists, clergy, and families out there who are convinced they can “pray away the gay.” However, more than two decades of LGBTQ-affirmative clinical experience and a gigantic heap of scientific research say otherwise, as do an ever-increasing number of state licensing boards.
So in therapy “the problem” is not the client’s sexual orientation or gender identity. Instead, it’s that person’s relationship to and feelings about his or her fixed and immutable orientation/identity. As such, the proper role for any therapist, clergy member, or family member when dealing with a person who is struggling with sexual orientation or gender identity is to help that person understand and accept what he or she is thinking, feeling, and desiring as a natural part of who he or she is. In LGBTQ-affirmative therapy (and LGBTQ-affirmative families) acceptance and integration are the keys to healing. This means helping LGBTQ individuals to feel more comfortable with who they are and what they truly desire, thereby evolving healthier, more hopeful, and more holistic human beings. Anything less is not nearly enough.
At this point you may be wondering what I mean by LGBTQ-affirmative therapy, and whether it differs from LGBTQ-friendly therapy. (It does.) Consider trauma treatment, where there are two basic levels. First is trauma-informed care (TIC), an approach that recognizes most individuals entering therapy have a history of trauma that relates to their present-day distress either directly or indirectly. Of course, some clients need an approach that recognizes and addresses trauma as a defining and organizing experience in their life. This higher level of care is known as trauma-focused treatment (TFT). It is my strong belief that all therapy should be trauma-informed, with TFT implemented as needed in response to a client’s particular history and needs. In many respects, LGBTQ-friendly therapy corresponds to TIC, recognizing that any LGBTQ person will have certain issues that feed their present-day distress. Meanwhile, LGBTQ-affirmative therapy corresponds to TFT, implemented when issues related to sexual orientation and/or gender identity are overarching for a particular client.
Any therapist can be LGBTQ-friendly (and every therapist should be). LGBTQ-affirmative therapy, however, is a bit more difficult. Most often, LGBTQ-affirmative therapists are either LGBTQ themselves or they have loved ones who are LGBTQ. They are neither externally nor internally homophobic, seeing no real difference between LGB people and straight people. They are similarly accepting of gender dysphoria and all sorts of other “queer” issues. Furthermore, LGBTQ-affirmative therapists are fully cognizant of the discrimination, ridicule, and shame that their LGBTQ clients may have experienced, and they understand how these hurtful external messages can become internalized. Finally, whenever appropriate, LGBTQ-affirmative therapists actively build this understanding into the therapeutic process.
Below are a few useful LGBTQ-affirmative measures you may wish to implement:
- During intake and assessment, asking specifically about sexual orientation, gender identity and dysphoria, preferred pronoun use, and what the client calls his/her significant other if there is one (husband/wife, partner, mate, etc.)
- As part of therapy, educating LGBTQ clients about heterosexism, homophobia, bi-phobia, trans-phobia, and the ways in which these biases can manifest in both the external world and the client’s internal self-evaluation
- As part of therapy, educating LGBTQ clients about the ways in which shame forms, festers, and prevents them from living fully and happily
- As part of therapy, exploring the self-discovery and “coming out” processes, including both positive and negative reactions (not only external, but internal)
- Recognizing the ways in which the media, religion, and popular culture both affirm and denigrate LGBTQ existence, and being willing to discuss this in therapy
- As part of therapy, educating about other forms of bigotry (racism, religious abuse, sexism, class-ism, etc.)
It is important for therapists to fully understand, first and foremost, their own issues with homophobia, bi-phobia, trans-phobia, and the like. We all have them! (I can’t tell you how long it took me to use the word “husband” when referring to the man I have loved and lived with for 14 years.) Finally, as is always the case, therapists must remember to do no harm. If you have a client who is unhappy with his or her sexual orientation and/or gender identity, it is your job to inform that client of your beliefs and your knowledge of both science and the law. The client can then, based on that disclosure, decide if he or she wishes to continue in therapy with you. Furthermore, if you find that you are not comfortable providing LGBTQ-affirmative therapy for any reason, you should refer a client who needs it to a clinician who is.
If you wish to learn more about LGBTQ-affirmative therapy, the California branch of the American Association for Marriage and Family Therapy offers a certification program (which can be completed online if you can’t travel to an in-person training). Several other organizations around the country offer similar certification programs. If there is nothing “official” in your state regarding LGBTQ-affirmative therapy, you may still find programs like the one in California useful.
Robert Weiss LCSW, CSAT-S is Senior Vice President of Clinical Development with Elements Behavioral Health. He has developed clinical programs for Right Step near Dallas/Fort Worth, The Ranch outside Nashville, Tennessee, Promises Treatment Centers in Malibu, and The Sexual Recovery Institute in Los Angeles. An author and subject expert on the relationship between digital technology and human sexuality, he has served as a media specialist for CNN, The Oprah Winfrey Network, the New York Times, the Los Angeles Times, and the Today Show, among others. He has also provided clinical multi-addiction training and behavioral health program development for the US military and treatment centers throughout the United States, Europe, and Asia. For more information you can visit his website, www.robertweissmsw.com.
Weiss LCSW, R. (2014). Understanding LGBTQ-Affirmative Psychotherapy. Psych Central. Retrieved on January 19, 2017, from http://blogs.psychcentral.com/sex/2014/04/understanding-lgbtq-affirmative-psychotherapy/