Out On The Couch
Decolonizing Your Practice with Trans Clients:
Actions Steps and Resources
As a reminder, my goal in writing this two-part series is to reflect on the ways in which TGNB-affirming* clinicians contribute to colonization (Part 1), while also offering, in this article, actionable ways of moving toward decolonization and gender liberation.
You may be familiar with what is now called the Multicultural & Social Justice Counseling Competencies (MSJCC; Ratts et al., 2016). The original elements of knowledge, attitudes and beliefs, and skills originated in 1992 (Sue et al.), and the most recent expansion added the emphasis of taking action.
This model emphasizes that our work needs to transcend the clinical skills and interventions we have been taught. We need to engage in our own self-reflection, navigate the power dynamics that are inherent in every session, and better understand and advocate for change within the very systems that perpetuate the problems our clients are facing.
As mentioned in Part 1, I believe that a clinician’s ability to wholeheartedly and effectively serve the TGNB population requires ongoing critical awareness, examination, and acknowledgment of the following:
- A likely skewed lens of the world
- Your approach to treatment
- How you operate around privilege and oppression (both personally and professionally)
- The history of colonization and enslavement, as well as white supremacy
- The ways in which you have benefited from various systems and/or internalized the intergenerational harmful impact of those systems
If you are unsure of how to transform your clinical work with TGNB people to work toward gender liberation with a lens of decolonization, here are some action steps and values you might find helpful:
“History has its eyes.” Actively educate yourself, acknowledge, raise awareness, and work to change historical systems of oppression related to ability, race, gender, and body diversity. Aim to move beyond affirmation and “multicultural competence” to better understand your own colonized behaviors, as well as each client’s internalized transphobia and racism, and help clients move toward liberation. Antiracism Daily can be a helpful resource in this regard.
OWN YOUR ROLE AND RESPONSIBILITY. SAY THE THING.
We have a responsibility to acknowledge the impact of our racial and gender identities, the actions of our ancestors, our mistakes, our humanness, and our own innate strength and power; I recommend checking out Nora Alwah’s Ted Talk. We also have a responsibility to be authentic and transparent, and to believe what our clients tell us is their lived experience.
Validate client experiences rather than attempting to empathize with an experience of oppression for someone with a marginalized identity you do not hold. Bear in mind that sometimes our clients may not feel able to tell us or ask for what they need, especially if they’re accustomed to making those in positions of power feel more comfortable.
VALUE LIVED EXPERIENCE AS EXPERTISE OF THE SELF.
Decenter your privilege of the expectation of comfort from others. For those of us in positions of power/privilege, we become accustomed to systems and interactions being shaped around our needs, so it creates a dynamic in which those in marginalized bodies spend their lives making us comfortable (e.g., when Black people “code switch” in white spaces). Center your client’s feelings and experiences. Clinically, trust your clients’ awareness and knowledge about what they need and want.
Professionally, seek opportunities to learn from those who have lived experiences with their own BIPOC and/or TGNB identities. Honor their lived experience without questioning their training, education, and competence. And pay them for their time! For example, Sonny Jane talks more about this.
PRACTICE SELF-COMPASSION AND CULTURAL HUMILITY.
Check your shame at the door. We improve with openness to being wrong, trying, failing, and doing better the next time. Following a mistake, shame can lead to inaction and avoidance due to thoughts of being “not enough” and fear of judgment.
On the other hand, guilt allows us to accept responsibility, act to address the hurt our behaviors have caused, and learn from our mistakes for future interactions. You are imperfect, and that’s okay. You can still strive for excellence in TGNB care. Learn more about TGNB self-compassion.
USE A TRAUMA-INFORMED LENS TO HEAL, REST, AND SEEK JOY.
To effectively support TGNB clients, pay attention to both your and your clients’ minds and bodies using a trauma-informed lens. Bodies of all races carry the intergenerational trauma of our ancestors, and it is much more difficult to create a culture of liberation and internalized antiracism without first healing and resting our bodies. I recommend Resmaa Menakem’s book My Grandmother’s Hands; you might also check out The Nap Ministry on Instagram.
Also, part of healing is uncovering moments of joy and pleasure, both for yourself as well as your clients. For example, encourage your clients to be on the lookout for gender euphoria, which entails experiencing a strong sense of comfort and/or joy during an imagined or actual moment of connection and authenticity in one’s gender identity, body, and/or expression. There’s more about this in Laura Kate Dale’s forthcoming book Gender Euphoria. Make sure to celebrate all of the tiny victories in addition to holding space for dysphoria and marginalization. For more information about this, I recommend Adrienne Maree Brown’s Pleasure Activism and Anneliese Singh’s The Queer & Transgender Resilience Workbook.
“UNSCHOOL” AND ANTICIPATE A LACK OF CLOSURE.
We may never achieve some predetermined maximum level of knowledge, awareness, and language expertise. But we can work to expand ourselves beyond the “schoolishness” of doing what we’ve been taught in Western and colonized systems of education and psychology. For example, Akilah Richards’ work examines unschooling as a path to liberation (2020).
BE PATIENT. TRUST AND VULNERABILITY ARE EARNED OVER TIME.
White supremacy, racism, anti-Blackness, transphobia, and colonialism have impacted the world for centuries. It is a naïve privilege to believe that the work of one person alone can break down the barriers. Safety is not universal. Trust has to be earned.
Clinically, we cannot rush connection, courage, trust, affirmation goals, or growth without a cost to ourselves and/or our clients. It is not surprising that our clients distrust us at first; only if and when it starts to feel safer, they may slowly open themselves up to becoming more vulnerable.
CONNECT AND NURTURE YOURSELF.
Connect with other social justice-minded professionals who espouse the values of anti-racism and anti-oppression, such as Inclusive Therapists and Joy and Justice Collaborative. Follow and support the work of healers who actively engage in the work, such as Alisha McCullough, Sonalee Rashatwar, and Haley Jones.
Communities that work together toward these shared goals create a sense of belonging and healing together. We also need to set and maintain boundaries to ensure we are appropriately recharging, checking in about our needs and wants, and creating an environment that best allows us to do effective work.
CHECK YOUR VALUES.
Examine how true racial and gender liberation would serve you, rather than worrying about what it might “take away.” When this work feels hard, do you pull back or move through? Do your words, behavior, commitment, and expenditures stand in line with what you say you value? For example, consider the impact of supporting organizations such as Psychology Today that have problematic histories related to race, gender, and bodies.
You might reimagine your practice policies, fees, structure, and paperwork when reflecting on the ways in which you are reinforcing colonization. For example, please see here and here for a discussion of sliding scales as a tool for economic justice. Also, I highly recommend considering the GALAP Pledge, in which mental health providers commit to offer free or insurance-based access to gender-affirming surgery assessments from an informed consent lens.
Finally, consider whose voices are missing from your education, training, and ongoing work to improve your competence with marginalized populations. Are you centering yourself and/or those in positions of power, or pulling back to make space for marginalized voices?
LEAN INTO DISCOMFORT.
If you’re doing this work, chances are that you will often feel uncomfortable. Discomfort is not bad just because we experience relief when we move away from it. It is not others’ responsibility to make us comfortable, to lead us down the “right” path, etc. View discomfort as an opportunity to get curious (you might check out this radical anger podcast episode)!
Consider that many people experience discomfort when first exploring the sexist and racist history of fatphobia, the harmful impact of diet culture, and the ableism inherent in much of our society. (For more information, see this writer’s related articles here and here; I highly recommend reading The Body is Not An Apology and Fearing the Black Body.) But the joy and grounding that comes from liberating ourselves and our clients from those harmful systems is worth the work!
Though most of my early knowledge and training comes from white Western ideas and people, I have grown the most from queer, fat, TGNB, and BIPOC intersectional mentors, thought leaders, educators, clinicians, and other healers. I am a radically different (and better) version of myself when I am in community with others who hold similar values of anti-racism, body, race, and gender liberation, and restorative/reparative justice. So I can’t emphasize enough how important it is to expand upon this article with the intense heart and body work that comes with decolonization, restorative justice, and liberation.
*Note: For the purpose of this article, TGNB indicates transgender and gender nonbinary populations, though you may come across other “umbrella” acronyms. No acronym will fully represent all experiences of gender diversity, so when referring to individuals, you should always use whatever language feels best for your client. The use of BIPOC sometimes represents Black, Indigenous, and People of Color (i.e., non-white people), and at other times it represents Black and Indigenous people of color primarily (Code Switch episode, Meraji & Escobar, 2020). When discussing BIPOC communities in this article, I am referring to the Black, Indigenous, and other communities of color who experience ongoing marginalization and oppression in relation to the colonized history of the Western world, including the intergenerational impact from their ancestors.
As a reminder, there are approximately two dozen recommendations and resources listed in Part 1 in addition to the ones below. These constitute just a sampling of the vast amount of information available, and my recommendations are based on my personal experience, growth, and perception of their helpfulness. Lean into what resonates, and know that there are alternatives for anything that doesn’t.
- GALAP Pledge (A group of mental health providers in the US who have committed to offering free or insurance-based accessible referral letters for gender affirming surgery). https://thegalap.org/
- Inclusive Therapists (A mental health professional directory, community, & justice movement). [@inclusivetherapists]. https://www.inclusivetherapists.com/
- Joy & Justice Collaborative (A healing and mental health professional community, education events, & justice movement). [@joyandjusticecollab]. https://www.joyandjusticecollab.org/
- The Blacker the Brain (Thea Monyee´ of MarleyAyo LLC is building a community of multidisciplinary practitioners & creatives to decolonize mental health/healing/wellness work). [@TheBlackerTheBrain]. https://marleyayo.com/unlearning
Media & Web Resources:
- Alwah, N. (clinician, she/her). (n.d.). Nora Alwah. [@noraalwah]. [Website, Instagram profile]. www.noraalwah.com
- Breland-Noble, A. (clinician/vlogger, she/her). (n.d.). Couched in Color with Dr. Alfiee. [@dralfiee]. [Instagram profile, YouTube channel]. https://www.youtube.com/c/CouchedinColorwithDrAlfiee
- Cardoza, N. (editor). (2020 – present). Anti-Racism Daily. [@antiracismdaily]. [Online newsletter, Instagram profile]. https://www.antiracismdaily.com/
- Feder, S, & Scholder, A. (Director & Producers). (2020). Disclosure: Trans Lives on Screen [Documentary]. Field of Vision.
- Finch, S.D. (coach & writer, he/they). (n.d.). Sam Dylan Finch. [@SamDylanFinch] [Website, Instagram profile]. www.samdylanfinch.com
- Hersey, T. (founder/blogger/coach). (n.d.). The nap ministry. [@thenapministry]. [Instagram profile; Blog]. https://thenapministry.wordpress.com/
- Jane, S. (peer support/lived experience counselor, they/them). (n.d.). Lived Experience Studio[@LivedExperienceCounsellor]. [Website, Instagram profile]. www.livedexperiencestudio.com
- Jones, H. (LPC-intern & content creator, they/them). (n.d.). [@the_queer_counselor]. [Instagram profile]. https://www.instagram.com/the_queer_counselor/
- McCullough, A. (clinician, she/her). (n.d.). Black and Embodied. [@blackandembodied]. [Instagram profile, Website]. www.blackandembodied.com
- McNeil, Toliver, M., Grinnell, M., & Wiltey, J. (Hosts). (2019 – Present). The melanated social work podcast. [Audio podcast]. Producer unknown. https://melanatedsocialwork.buzzsprout.com/
- Melanated Social Work (clinicians/podcasters). (n.d.). [@MelanatedSocialWork]. [Instagram profile, Website]. https://melanatedsocialwork.buzzsprout.com/
- Menakem, R. (clinician/author, he/him). (n.d.). Resmaa Menakem. [@ResmaaMenakem] [Website, Instagram profile]. www.resmaa.com
- Mullan, J. (clinician/author, she/her). (n.d.). Jennifer Mullan – Decolonizing Therapy. [@decolonizingtherapy] [Instagram profile, Website]. https://www.drjennifermullan.com/
- Rashatwar, S. (clinician/lecturer/organizer, she/they). (n.d.). Sonalee Rashatwar. [@TheFatSexTherapist]. [Website, Instagram profile]. www.sonaleer.com
- Richards, A. (writer/coach/podcaster, she/her). (n.d.). Raising Free People. [@fareofthefreechild]. [Instagram profile, Website]. https://raisingfreepeople.com/
- Taylor, S.R. (writer/poet/thought leader, she/they). (n.d.). The Body is not an Apology. [@SonyaReneeTaylor, @TheBodyIsNotAnApology]. [Website, Instagram profile]. https://thebodyisnotanapology.com/
- Toler, M. (Host). (2020 – Present). Hearing our own voice. [Audio podcast]. Producer unknown. https://www.melissatoler.com/podcast
Alwah, Nora. (2020, October 26). Reclaiming our power: Making ourselves seen [Video]. TEDxCU. https://www.youtube.com/watch?v=mYi42ydUe7Q&feature=emb_logo
binaohan, b (2014). decolonizing trans/gender 101. biyuti publishing.
Brown, A. M. (2019). Pleasure activism: The politics of feeling good. AK Press.
Cunningfolk, A. (2015, Aug. 11). The sliding scale: A tool of economic justice. Worts + Cunning Apothecary. http://www.wortsandcunning.com/blog/sliding-scale?rq=sliding%20scale
Cunningfolk, A. (2018, Apr. 23). How to make the sliding scale better for you & your clients. Worts + Cunning Apothecary. http://www.wortsandcunning.com/blog/a-better-sliding-scale
Dale, L. K. (anticipated, 2021). Gender euphoria: Stories of joy from trans, non binary and intersex writers. [Book preparing for print]. Unbound: United Authors Publishing Ltd.
Gender euphoria. (n.d.). In Gender Wikia. https://gender.wikia.org/wiki/Gender_Euphoria
Guenther, J. (2018, October 21). Psychology Today magazine loves white people: Especially beautiful and thin white women. Therapy Den. https://www.therapyden.com/blog/psychology-today-magazine-loves-beautiful-thin-white-women
Hemphill, P. (Host). (2020 – Present). Finding our way. [Audio podcast]. Producer unknown. https://prentishemphill.com/new-page-4
jackson, k. & Shanks, M. (2017). Decolonizing gender: A curriculum. [Zine] https://www.decolonizinggender.com/
Menakem, R. (2017). My grandmother’s hands. Racialized trauma and the pathways to mending our hearts and bodies. Central Recovery Press.
Meraji, S.M. & Escobar, N. (Hosts). (2020, September 30). Is it time to say R.I.P. to POC? [Audio podcast episode]. In Code Switch. NPR. https://www.npr.org/2020/09/29/918418825/is-it-time-to-say-r-i-p-to-p-o-c
Ratts, M. J., Singh, A. A., Nassar-McMillan, S. N., Butler, S. K., & Rafferty McCullough, J. (2016). Multicultural and social justice counseling competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44(1), 28-48. https://doi.org/10.1002/jmcd.12035
Richards, A. (2020, Oct. 20). Raising free people: Unschooling our way to intergenerational healing. In Joy & Justice Collab: Empowered Learning Summit. [Presentation].
Singh, A. S. (2018). The queer & transgender resilience workbook: Skills for navigating sexual orientation & gender expression. New Harbinger Publications, Inc.
Strings, S. (2019). Fearing the Black body: The racial origins of fat phobia. New York University Press.
Sue, D. W., Arrendondo, P., & McDavis, R. J. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Multicultural Counseling & Development, 20, 64-88. https://doi.org/10.1002/j.2161-1912.1992.tb00563.x
Taylor, S. R. (2021). The body is not an apology: The power of radical self-love. (2nd ed.). Berrett-Koehler Publishers.
Tucker, M. (2019, June 19). At the intersection of fat and trans. The Affirmative Couch. https://affirmativecouch.com/at-the-intersection-of-fat-trans/
The Allied Minds Collective (2020, July 31). Psychologist’s stance on the “vilification of Karens” exposes the inequities embedded within mental health care. Medium. https://email@example.com/psychiatrists-stance-on-the-vilification-of-karens-exposes-the-inequities-embedded-within-c76a35622aee
Tucker, M. (2019, November 22). Helping TGNB young adults build self-compassion. [Webinar Training]. The Affirmative Couch. https://affirmativecouch.com/product/helping-transgender-and-gender-nonbinary-young-adults-develop-self-compassion/
Tucker, M. (2019, November 27). Helping queer and trans clients navigate fatphobia during the holidays. The Affirmative Couch. https://affirmativecouch.com/helping-queer-and-trans-clients-navigate-fatphobia-during-the-holidays/
Tucker, M. (2020, Aug 4). Deactivating psychology today and moving forward. https://www.wholeheartedpsych.com/post/deactivating-psychology-today-moving-forward
Learn more about transgender and gender nonbinary affirmative therapy
Crystal Meth & the Gay Community
Crystal meth has had a devastating effect on the gay community. Over the last 20 years, the drug–also known by its street name, Tina–has grown into a catastrophic force, contributing to about 15% of all drug death overdoses (NIDA, 2019). Because gay and bisexual men use methamphetamines at a higher rate than heterosexual men (Lea et al., 2017), it is safe to assume that a high percentage of crystal meth overdoses come from within the LGBTQIA+ community.
Further, crystal meth has played an instrumental role in the increase of HIV infection rates. According to a joint report by The National Alliance of State and Territorial AIDS Directors (NASTAD) and the National Coalition of STD Directors (NCSD), “crystal methamphetamine use is a large contributing factor to a substantial increase in risky sex behaviors and higher rates of HIV infection among MSM” (Molitor et al., 1998 p. 3).
Considered a club or party drug, crystal meth is often used by young adults and teenagers to stay awake (Dowshen, 2018). During use, the neurotransmitter dopamine floods parts of the mesolimbic dopaminergic pathway in the brain, which regulates feelings of pleasure (CSAT, 1999). A common effect shared by gay and bisexual men during crystal meth use is an insatiable sexual appetite, and drug use can result in feeling sexually adventurous and experiencing a heightened sense of pleasure, stamina, and endurance that can last for days even without the user taking proper rest. On a psychological level, crystal meth can produce feelings of confidence, power, and invulnerability. The aforementioned increased sexual desire can overpower necessary activities of daily living like bathing and going to work.
While in this state, men who have sex with men (MSM) may engage in chemsex–taking any combination of drugs including crystal meth, mephedrone, and/or GHB/GBL while engaging in sex. The use of crystal meth lowers one’s inhibitions and is often associated with multiple partners, who may contact each other via hookup apps.
Crystal meth users may also engage in what is called “tinkle tweaking,” in which they store their own urine and try to recover un-metabolised methamphetamine from it to fuel another high (Wakefield et al., 2019). Another version of this is called a “booty bump.” One way to receive a booty bump is to dissolve a shard of crystal in water and put it into a syringe without the needle, then “bump” this solution of crystal into one’s anus. A version of this may be practiced during chemsex as well, but what users may not realize is that booty bumps can result in hepatitis, parasites, and other diseases (Frankis et al., 2018).
Crystal Meth & Black Men
In the gay world, crystal meth has been known as a rural white men’s drug; however, per most recent reports, Black men’s use of crystal meth has increased significantly. A study conducted by MSM in New York demonstrated that Black men reported use of methamphetamines at a higher rate than white men (Halkitis et al., in press). Filter, a New York City magazine, shared that Black men experienced more hospitalizations for amphetamine poisoning, dependence, and “nondependent abuse” in the city’s public hospitals than did all white people (Blanchard, 2019). Although Black men reported a higher rate of usage of methamphetamines than white men, they reported less enrollment in treatment (Saloner & Le Cook, 2013).
Research shows that those who enroll in treatment programs for substance misuse demonstrate a higher success rate in their journey of sobriety; obviously, treatment provides access to necessary behavioral supports such as counseling, and is linked to improvement in social and psychological functioning (NIDA, 2020). Statistically, if Black men are not seeking or receiving treatment, then they are at higher risk of long-term use or succumbing to addiction. Positive responses to treatment outcomes are, of course, dependent upon the appropriateness of the intervention, as both affirmative care and client involvement are essential.
Affirmative Treatment Facilities for Gay Black Men
Of the eight crystal meth treatment facilities in New York designed for gay and bisexual male patients, seven of them are located in Manhattan, imposing severe geographical demographic limitations. It bears noting that substance abuse is significantly more prevalent among those living in poverty, as are most of the risk factors for drug abuse (Nakashian, 2019). Residents of Black neighborhoods are 7.3 times more likely to live in high poverty with limited to no access to mental health services, according to the CDC (Denton & Anderson, 2005). This forces those who are seeking help to search outside of their neighborhoods for treatment and services. Traveling outside of one’s neighborhood can be intimidating and present a culture shock. Culture can play a dynamic role in patient and provider engagement.
There is a great need for knowledgeable and accessible mental health care and substance abuse service providers who can treat Black gay and bi men using crystal meth. Culturally cognizant psychotherapists can help to increase awareness of use of illicit drugs amongst African American communities, and can also provide culturally appropriate services targeted to consumers’ needs (Harawa, 2008). Providers who understand the cultural intricacies and experiences of Black men who use crystal meth can be instrumental in their recovery.
In order to keep treatment for crystal meth and other substance use client-focused, drawing on Rogers’ approach to treatment, therapists must allow clients to use the therapeutic relationship in their own way (Client-centered therapy, 2006). This means taking into consideration the client’s cultural background and personal experiences in creating an effective treatment plan for them. Crystal meth addiction clearly transcends racial and ethnic lines, making evident the need for further outreach and support to Black gay and bisexual men who are using. Further, specific assessment and risk reduction measures to address crystal meth use and sexual behaviors and roles among these community members are warranted. Crystal meth addiction is a disease that shows no cultural biases; as mental health providers, we must ensure that our services reflect that.
Blanchard, S. K. (2019, August 8). Black New Yorkers Hospitalized for Amphetamines at Alarming Rates. Filter. https://filtermag.org/black-new-york-amphetamines-hospital/
Center for Substance Abuse Treatment (CSAT). Substance Abuse Treatment: Addressing the Specific Needs of Women. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2009. (Treatment Improvement Protocol (TIP) Series, No. 51.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK83252/
Center for Substance Abuse Treatment (CSAT). Treatment for Stimulant Use Disorders. Rockville (MD) Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 33.) Chapter 2—How Stimulants Affect the Brain and Behavior. Available from: https://www.ncbi.nlm.nih.gov/books/NBK64328/
Client-centered therapy. (January 2006). Harvard Health Publishing. Retrieved December 28, 2020, from https://www.health.harvard.edu/newsletter_article/Client-centered_therapy
Denton, N. A., & Anderson, B. J. (2005). Poverty and Race Research Action Council analysis of U.S. Census Bureau data. The Opportunity Agenda. Retrieved from http://www.opportunityagenda.org.
Dowshen, S. (Ed.). (2018, May). Methamphetamine (Meth) (for Teens) – Nemours KidsHealth. https://kidshealth.org/en/teens/meth.html.
Frankis, J., Flowers, P., McDaid, L., & Bourne, A. (2018). Low levels of chemsex among men who have sex with men, but high levels of risk among men who engage in chemsex: analysis of a cross-sectional online survey across four countries. Sexual health, 15(2), 144–150. https://doi.org/10.1071/SH17159
Halkitis, P. N., & Jerome, R. C. (2008). A comparative analysis of methamphetamine use: black gay and bisexual men in relation to men of other races. Addictive behaviors, 33(1), 83–93. https://doi.org/10.1016/j.addbeh.2007.07.015
Harawa, N. T., Williams, J. K., Ramamurthi, H. C., Manago, C., Avina, S., & Jones, M. (2008, October). Sexual behavior, sexual identity, and substance abuse among low-income bisexual and non-gay-identifying African American men who have sex with men. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2574823/.
Lea, T., Kolstee, J., Lambert, S., Ness, R., Hannan, S., & Holt, M. (2017). Methamphetamine treatment outcomes among gay men attending a LGBTI-specific treatment service in Sydney, Australia. PloS one, 12(2), e0172560. https://doi.org/10.1371/journal.pone.0172560
Molitor, F., Truax, S. R., Ruiz, J. D., & Sun, R. K. (1998). Association of methamphetamine use during sex with risky sexual behaviors and HIV infection among non-injection drug users. The Western journal of medicine, 168(2), 93–97.
Nakashian, M. (2019, July 26). Substance Abuse Policy Research Program. Robert Wood Johnson Foundation. https://www.rwjf.org/en/library/research/2012/01/substance-abuse-policy-research-program.html
NIDA. 2019, May 16. Methamphetamine DrugFacts. Retrieved from https://www.drugabuse.gov/publications/drugfacts/methamphetamine on 2020, December 28
NIDA. 2020, September 18. Principles of Effective Treatment. Retrieved from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/principles-effective-treatment on 2020, December 31
Saloner, B., & Lê Cook, B. (2013). Blacks and Hispanics are less likely than whites to complete addiction treatment, largely due to socioeconomic factors. Health affairs (Project Hope), 32(1), 135–145. https://doi.org/10.1377/hlthaff.2011.0983
Wakefield, L., Maurice, E. P., Parsons, V., & Smith, R. (2019, June 26). This is why people drink their own urine after taking drugs. PinkNews. https://www.pinknews.co.uk/2018/04/30/urine-drugs/.
Moving Towards Trans and Nonbinary-Affirmative Therapy Practice
As psychotherapists, we know that transphobia’s pervasive social impact affects our clients and our own internal worlds. This results in transgender and gender nonbinary (TGNB) folx internalizing society’s gender-normative attitudes and lays the groundwork for them to develop negative attitudes about themselves and their communities, which can ultimately lead to poor mental health outcomes (Babine et al., 2019).
I reviewed these resources for clinicians to help them address internalized transphobia; this term is used, for the purposes of this article, to mean phobia toward and discrimination against trans binary and non-binary individuals. In doing so, I encourage all of us to use our positions of power to educate community members including educators, employers, health care providers, and other support service staff who work with TGNB folx. It is incumbent upon us to help ensure that our clients are offered LGBTQIA+ affirmative care in every aspect of their lives (Babine et al., 2019). The resources listed in this article are a call to action to all providers offering care to the TGNB community; my hope is that we can consider these readings to create a more inclusive and gender-just world in which TGNB folx can live fully.
This review comes from my perspective as a white, able-bodied, licensed clinical therapist and nonbinary art therapist. I encountered some difficulties in reading through these books because they hit close to home for me and in relation to the everyday trauma my TGNB clients face. I recommend that other TGNB therapists and clients working through these books take breaks and engage in self-care practices when needed. Fortunately, Hoffman-Fox has included a Self-Care Checklist on page xxxi in their workbook, reviewed in this article.
Interactively Challenging Internalized Transphobia Through Workbooks
Transphobia is deeply rooted in a cis-hetero, capitalist, western settler-colonial political system, and it will take a much more organized response to address than filling out a workbook. But we can start by addressing internalized transphobia in ourselves, thus moving towards challenging it on a larger scale.
Exploring my Identity(ies): Interactive by Van Ethan Levy, LMFT
Written by a queer, non-binary, trans, AFAB (assigned female at birth), NBPOC (Not Black Person of Color) who uses the pronouns Van/they, Exploring my Identity(ies): Interactive asks clinicians to address their privileges, power, biases, and the stereotypes they have absorbed, and how these are intrinsically linked to internalized transphobia. Van engages the reader immediately by asking the reader “Who am I?” as a starting point to encourage vulnerability. This helps readers reduce shame and examine all the ways in which they have internalized negative messages about the TGNB community.
The workbook offers clinicians actionable steps to confront and address their internalized transphobia by breaking down language in an interactive format. This allows them to deepen their understanding of the ways in which internalized transphobia impacts us and our clients on both individual and systemic levels (Soto & Garman, 2018). The book names how internalized transphobia takes hold of us via unconscious bias by absorbing messages from our cis-focused society that shames, criticizes, and dehumanizes TGNB people. These messages, some overt and some subtle, serve to exclude trans people from full participation in life and are especially harmful to TGNB people trying to live freely in our world (Lighthouse Inc., 2020).
Levy (2020) closes the book by offering clinicians ways to be better allies. They challenge how our inflated academic egos are informed by the experiences of mostly white cis-hetero folx, rather than through the lens of the many marginalized TGNB folx fighting for their lives. The author recognizes that this is a lifelong practice for clinicians, and recommends approaching social issues with an intersectional lens.
You and Your Gender Identity: A Guide to Discovery by Dara Hoffman-Fox, LPC
Written by a white, queer, nonbinary mental health counselor who uses the pronouns Dara/they/them, You and Your Gender Identity: A Guide to Discovery offers affirmation to readers in a person-centered way, wherever they are in their own gender journeys. Hoffman-Fox breaks down the journey into three accessible stages: 1) Preparation, 2) Reflection, and 3) Exploration. In stage one, Hoffman-Fox (2017) speaks directly to removing the stigma of putting labels or diagnoses on ourselves, which one may find a healing experience due to the historical precedent of the DSM labeling TGNB folx with a “mental illness.”
Using this workbook, I felt as if I was creating my gender memoir, inspired by what Hoffman-Fox would consider “hands-off mentors”; this type of mentor is someone with whom you won’t be interacting on an individual or personal basis (Hoffman-Fox, 2017). I was excited to learn about this concept, as my own experience with hands-off mentors has led me to discover TGNB folx to whom I look up and relate. These mentors have assisted me in understanding my own nonbinary identity as well as my TGNB clients’ experiences.
Stage two speaks directly to how internalized transphobia manifests in our internal world beginning in childhood, when the adults around us began to censor and police our genders. The section breaks down such experiences by ages including childhood (ages 3 to 11) and adolescence (ages 12-17), with a reflection piece describing how some TGNB people experienced their gender at each age. Hoffman-Fox touches on the impact puberty has on young TGNB folx, and how this feeds into gender dysphoria and affects both their development and mental health. For cis-hetero clinicians who may not have questioned their gender and who, unlike many TGNB young folx, experienced puberty simply as a rite of passage, this section of the workbook may be very eye-opening.
In stage three, Hoffman-Fox encourages readers to reflect on how they feel about their gender in the present; the reader may take on an explorer role to deepen their understanding of their gender and gain agency in defining their gender identity through various questions. Hoffman-Fox notes the many barriers one may face in their gender exploration in terms of financial stability, relationships, resources, and health care, noting that no exploration process is right or better than another. It’s about tapping into the reader’s unique strengths and abilities (Hoffman-Fox, 2017). In this section, Hoffman-Fox offers the reader actionable ways to combat internalized transphobia by journaling and recognizing when one engages in internalized transphobia, reframing it to positive self-talk about one’s gender. At times I struggle with the idea that, by the end of this chapter, readers will unearth, gather, and digest enough information about themselves to gain a deeper understanding of how to define their gender identity (Hoffman-Fox, 2017). The author’s recognition of how one’s experience with their gender as a life-long multifaceted and complex exploration resonates more deeply with me.
The Queer & Trans Resilience Workbook: Skills for Navigating Sexual Orientation & Gender Expression by Anneliese Singh, Ph.D., LPC
The third workbook I reviewed is The Queer & Trans Resilience Workbook: Skills for Navigating Sexual Orientation & Gender Expression by Anneliese Singh, Ph.D., LPC, a South Asian multiracial Sikh queer and genderqueer femme clinician who uses she/they pronouns. Singh’s workbook speaks to the crucial skills TGNB folx need to build resiliency skills to thrive in a trans- and queerphobic world that demands conformity (Singh, 2018). Singh’s workbook centers intersectionality with TGNB folx and speaks to myriad LGBTQIA+ identities such as same-gender-loving, asexual, omnisexual, monosexual, polysexual, and pansexual, many of which may get overlooked by clinicians as well as by the general population. Further, Singh discusses the importance of developing a sense of body positivity, which the other workbooks do not address. Singh describes actively valuing one’s body and with whom one decides to share their body (Singh, 2018).
Singh’s workbook describes ten resilience skills for LGBTQIA+ folx to develop. A few of these skills include You Are More Than Your Gender and Sexual Orientation, Knowing Your Self Worth, Affirming and Enjoying Your Body, and Building Relationships and Creating Community. Each section offers a resilience exercise to encourage the reader to practice these skills, and many of the practices borrow from cognitive behavioral therapy with an added queer lens. One example is how to use positive self-talk to affirm one’s gender, and as a way to reframe negative thoughts about it.
Too often we focus on the ideas of self-care with TGNB clients to heal and manage pain inflicted on them via micro- and macroaggressions from our heterosexist and transnegative society. But we may fail to offer actionable ways to build up resiliency, like assertiveness skills, to empower our clients to survive and thrive. When discussing self-care with our TGNB clients, we must talk about cultivating resilience and how to develop skills to build up their confidence, communication, and self-esteem to navigate life in the face of discrimination and adversity (Singh, 2018). This workbook speaks to gender liberation to celebrate, respect, affirm, love, and recognize the value TGNB folx across the lifespan bring to our society, along with the power of enacting mutual aid efforts, as a way to develop resilience and create stronger communities.
Final Thoughts about Workbooks Addressing Internalized Transphobia in Clinicians
I found these workbooks to be engaging and useful, and I appreciate that they were created by clinicians who are themselves a part of our TGNB community. They share their own pain from having to navigate a cis-heteronormative society and the joy of experiencing gender liberation. Too often, books about LGBTQIA+ clients are authored by cis and/or heterosexual folx who are white/white-passing, of middle to higher socioeconomic status, neurotypical, and able-bodied. They come up with their own biased conclusions about our TGNB community members.
At the same time, I do reflect critically on who creates these books. I recognize how the language used in these workbooks about affirming queer experiences comes from queer folx in positions of power. They may, at times, use too much vocabulary from academic circles, a stark contrast to the reality of trans, nonbinary, and gender non-conforming folx who are fighting to survive (Levy, 2020). I wonder who gets to engage in these books, and who even knows they exist. Too often, TGNB folx–especially TGNB folx of color–are in constant survival mode, facing housing and food insecurity, compared to cis and hetero folx. Black trans womxn are being murdered at alarming rates each year. Are clinicians expecting TGNB folx to use workbooks in therapy, homeless shelters, or community mental health settings amid a deadly pandemic, one disportionately impacting BIPOC?
I note how my own position of privilege has exposed has me to the wonders of queer theory; I can see the benefits of these works in clinical practice with clients exploring their gender and internalized transphobia, which too often holds our TGNB clients back from embracing all the ways of being in our world. Each workbook speaks to the role that shame and guilt play in shaping one’s experience with internalized transphobia. Hoffman-Fox takes it one step further to break down shame and guilt and explore how each negatively impacts TGNB folx’ existence. Furthermore, shame and guilt together form a powerful force that perpetuates gender trauma in our society and leads our TGNB clients to isolation, censorship, and submission into a binary. Clinicians must work through shame and guilt with their clients across the gender spectrum because of the relentless grip this combined force can have on one’s gender identity.
At the core of these workbooks is their commitment to combat transphobia and their demand for others to recognize transphobia–even if unaware of their engagement in it–which will get us closer to ending it (Levy, 2020). This means no more dead TGNB folx as a result of inequitable access to basic human rights created by a transphobic society. The workbooks can serve as a set of armor for our TGNB clients to learn how to experience positive self-growth (Singh, 2018) that helps them thrive and affirms their identity.
To fully grasp and address internalized transphobia, mental health professionals need continuing education that includes listening to the stories created by TGNB community members outside of the academic sphere of clinical practice. This will help providers continue to develop more TGNB-affirmative therapy practices. In my next article, I will review memoirs from TGNB artists who speak to their lived experience of navigating a cis-normative society and recount the ways in which they have developed resilience strategies to address both socially imposed and internalized transphobia. Additionally, I will offer takeaways, resources, and further recommendations to address internalized transphobia.
A Therapist’s Guide to Navigating & Overcoming Internalized Transphobia. Lighthouse. (2018). https://blog.lighthouse.lgbt/overcoming-internalized-transphobia/
American Psychological Association. (2015). Guidelines for Psychological Practice with Transgender and Gender Nonconforming People. American Psychologist, 70 (9), 832-864. DOI: 10.1037/a0039906
Babine, A., Torho, S. S., Fizpatrick, O., Kolodkin, S. R., & Daly, L. (March 2019). Dismantling Stigma in the Transgender and Gender Non-Conforming Community. The New York Transgender Advocacy Group.
Hoffman-Fox, D. (2017). You and your gender identity: A guide to discovery. Skyhorse Publishing.
Levy, V. (2020). Exploring my Identity(ies): Interactive. Self Published.
Singh, A. (2018). The Queer and Transgender Resilience Workbook Skills for Navigating Sexual Orientation and Gender Expression. New Harbinger Publications.
Garman, S. & Soto, M. (Hosts.) (2018-present) Transform: Beyond the transition. [Audio Podcast]. Stitcher. https://www.stitcher.com/show/transform-beyond-the-transition
Check out our Continuing Education Courses on Transgender Affirmative Therapy
13 Signs You Need to Decolonize Your Practice with Trans Clients:
Paying Attention to Your Colonization-Connected Behaviors
This two-part series is intended to first reflect on the ways in which transgender and gender nonbinary (TGNB)-affirming clinicians perpetuate harm connected to colonization, then to present actionable ways of moving toward decolonization and gender liberation. I am a queer, white, able-bodied, and “cis-ish” person (i.e., I do not feel discomfort in my body or with she/her pronouns, though I struggle with the construct of “womanhood”). I am an uninvited guest occupying the land of the Narragansett & Wampanoag people in what is now called Rhode Island in North America (note: I strongly recommend learning more about Indigenous culture, e.g. the All My Relations podcast).
While social justice movements tend to focus on addressing the oppression of marginalized communities, decolonization involves a discrete and critical understanding of settler colonization and the movement toward reparation of land and resources (Tuck & Yang, 2012). I cannot discuss decolonization without acknowledging that I benefit from stolen land and resources as well as oppressive systems that are violent toward Indigenous and Black communities, including that of mental health care. MarleyAyo LLC (2020) defines decolonization as the “intentional repairing and reclaiming of ancestry, traditions, and values lost or violently disrupted by colonization and the transatlantic slave trade.”
“…colonization was a direct attack to our physical AND spiritual beings…they cut off a line to that ancestral knowledge and almost guaranteed that history would be lost.” – Decolonizing Gender (jackson & Shanks, 2020)
The history of settler colonization has deep roots connected to white supremacy and racism, anti-blackness, transphobia, fatphobia, and essentially any system, community, or person that vilifies, criminalizes, punishes, rejects, and erases those who at first glance seem “different” (Morgensen, 2012). For additional context, you can learn more about the 4 I’s of oppression in this Healing While Black podcast episode. Also, consider learning about the characteristics of white supremacy culture, which can show up in any group or organization as a reflection of the attitudes and behaviors of all people (regardless of race)–for example, believing there is only one right way to do something.
The construct of gender liberation expanded on the work of Ignacio Martín-Baró, a social psychologist who lost his life because of his revolutionary work; see Helping Queer Clients Become Their Own Liberators (Spector, 2020) for more details. Gender liberation involves shifting our focus from basic gender affirmation with the TGNB community toward liberation by addressing power dynamics, advocating for systemic and social change, and freeing ourselves and our clients from the systems of gender oppression (Singh, 2016; note: Anneliese Singh is a phenomenal speaker, writer, and researcher in this area–see also her TedX talk). This includes an awareness that the concept of “transness” itself is a historically white construct, meaning that gender fluidity and diversity existed and were accepted for centuries prior to settler colonization (e.g. A Map of Gender-Diverse Cultures; see also The Platypus Poem by J Mase III).
I have chosen not to explore these constructs more deeply because a) individuals who have experienced that history and live it every day do not need an explanation, b) it’s not my place to tell their stories, and c) there are many other appropriate sources that do so (e.g. Adrienne Maree Brown, Rachel Cargle, & Alok V Menon). It is my responsibility to listen, learn, and do better to honor the voices, bodies, and land that have been telling the story for years and continue to do so.
“Cisheteropatriarchy holds its roots in colonialism, and dismantling and unlearning these Western agendas forced upon us is a necessary action in the liberation of all oppressed peoples. If we are to obliterate white supremacy, a key component of that necessary project is recognizing and dismantling transphobia as an ongoing destructive phenomenon directly rooted in colonialism.” (Paramo, 2018)
Some clinicians may be completely new to these concepts and what this work looks like. Other clinicians may already be doing this work more intentionally. Still other clinicians may have no choice but to do this work because of their own personal experiences of marginalization, oppression, and intergenerational trauma.
13 common forms of colonization-connected behaviors in your clinical work with TGNB people
To be clear, it would be toxic allyship to consider completing a ‘checklist’ as the way to do this work, given the need for decolonization to be a long-term commitment. Decolonization work is ongoing with the intention of returning land, resources, and opportunities to the populations from which they were taken, as well as supporting Indigenous and Black communities as they continue to navigate intergenerational and present-day trauma.
Regardless, it may be helpful to reflect on possible warning signs of colonization-connected behaviors in your clinical work with TGNB people, including the following:
1. Limited historical knowledge
(e.g. relying on mostly white and/or cisgender people and systems to teach you what you need to know about settler colonization, antiracism and gender; understanding a lot about trans identities but less about working with BIPOC clients; having little understanding of how colonization, white supremacy, and fatphobia intersect with gender)
2. Exploitation of BIPOC and/or TGNB people
(e.g. expecting BIPOC and/or TGNB experts to train/consult with you for free; asking TGNB and/or BIPOC clients to explain things to us; using before-and-after photos of TGNB bodies without considering the potential felt objectification and dehumanization)
3. Relying on diagnosis and “the written word”
(e.g. doubting someone’s knowledge of their gender because of their developmental stage or another diagnosis like autism; noticing yourself getting bogged down by what is written in the DSM, WPATH manual, or trans guidelines; focusing on whether or not someone meets the criteria for gender dysphoria to accept their TGNB identity)
4. Performative/toxic allyship
(e.g, telling yourself that you are anti-racist while rarely engaging in action steps that help you to learn, grow, and change in movement toward anti-racism; privileged ‘allies” jumping to judge others who make a mistake when talking about race/gender without inviting them into a conversation; expressing how important this work is but not being willing to pay for consultation/supervision/training to improve competence).
Deborah Plummer’s work talks more about how to take anti-racist allyship to the next level.
“Achieving a healthy white-identity resolution and feeling racially secure enough not to exhibit racial superiority does more for eradicating racism than just being an enlightened ally.” ~Plummer, 2020
5. Shame and shutting down
(e.g. feeling frustrated about how hard it is to to “keep up” with the movements and language; defensiveness and/or shame reaction when you make a mistake; dismissing or challenging a perspective shared by a BIPOC and/or TGNB colleague or client about their experience; feeling offended/hurt by a client’s decision to see a “lived experience” clinician)
6. Treatment barriers
(e.g. limited treatment access; high cost of full fee; not taking insurance or having an inaccessible sliding scale range; and/or requiring multiple sessions for a surgery assessment without transparency and collaboration)
7. Saviorism and lack of humility
(e.g. believing that if you don’t do this work, no one will; not seeking training/consultation/supervision when you have a growth edge, i.e. room for improvement; frequent signaling to your TGNB and BIPOC clients, colleagues, and friends the extent of your allyship)
8. Poor boundaries
(e.g. taking on additional clients for extra money; not saying no to people because we feel guilty; not prioritizing our own self-care and work-life balance)
“…it should not be forgotten that one of the privileges of whiteness is having a gender that is defacto more legitimate and more coherent because of the binary framework in which it necessarily exists.” -binaohan, 2014
9. Colonized gender norms
(e.g. making an assumption about a client’s desired gender destination; encouraging forms of social/physical expression that someone hasn’t asked for; using any language/identifiers for gender/body part/surgery etc. that the client hasn’t already expressed or without checking that the language feels okay for them)
10. Colonized race-related norms
(e.g. failing to acknowledge the impact of colonization; assuming that all clients desire and feel safe coming out in all spaces; being unaware of resources that are specific to BIPOC TGNB people; using research and clinical interventions that have not been normed on BIPOC people)
11. Colonized body and ability norms
(e.g. reinforcing the racist history of fatphobia and diet culture by encouraging a client’s attempts at weight loss via dieting; focusing on client weight as a potential barrier to surgery rather than framing from the perspective of medical fatphobia and helping to advocate for client needs; making an assumption about a client’s health status based on their weight and/or eating habits; using ableist language, making assumptions about someone’s capacity to do something, or limiting communication and processing methods). Please see Fearing the Black Body (Strings, 2019).
12. Time and outcome expectations
(e.g. using language that suggests a “full transition” or “complete surgery”; assuming that trans men want to be masculine; finding yourself thinking that clients are moving too slowly and pushing someone to come out to their family and friends)
13. Insisting on comfort
(e.g. having a shame reaction and apologizing excessively when you make a mistake or client provides feedback; mentioning how hard it is to keep up with the language; not bringing up racism or anti-Blackness unless the client mentions they are struggling with the sociopolitical climate; addressing your privilege in the room the first time and then not bringing it up again)
Decolonizing Mental Health is Hard: Take a Moment of Reflection
Notice what comes up in your body and how it feels as you reflect on the above examples. Did you notice any feelings of shame? Embarrassment? Discomfort? Denial? Guilt? Relief? Irritation? Uncertainty?
After checking in with your body, consider how these examples are connected to your clinical training and approach to treatment, your knowledge of history or lack thereof, and your worldview.
I believe that a clinician’s ability to wholeheartedly and effectively serve the TGNB population requires ongoing critical awareness, examination, and acknowledgment of the following:
- A likely skewed lens of the world: past, present, and future
- Your approach to treatment: personally, professionally, and systemically
- How you operate around privilege and oppression inside and outside of the therapy room
- The history of settler colonization, enslavement, and genocide; white Western education, research, training; and lingering medical and mental health care trauma
- The ways in which you continue to benefit from and engage in the perpetuation of those systems that have caused harm or, for those who belong to historically marginalized communities, the ways in which you have internalized the impact of those systems
As you continue to move through this work, you will uncover the countless ways in which colonization is woven into the fabric of our personal and professional lives, which has a direct and ongoing impact on the oppression of marginalized communities. Those in power may seem to benefit in terms of resources and capitalism. But the psychological, emotional, and intergenerational impact of colonization affects everyone, not just TGNB, BIPOC, and other marginalized communities. We all will benefit by working toward racial, gender, and body liberation, as well as striving for decolonization through supporting Black and Indigenous communities to reclaim their ancestry, values, land, and rights.
“If Black women were free, it would mean that everyone else would have to be free since our freedom would necessitate the destruction of all the systems of oppression.” – Taylor, 2017 (in How We Get Free: Black Feminism and the Combahee River Collective)
In the next and final installment of this series, I will further discuss actionable ways to begin transforming your work with TGNB clients. I want to reiterate that this work is multifaceted and is not meant to focus on completing a list of “to-dos.” Rather, it is an opportunity to reflect on your practice and the ways in which you can continue to do better and to help heal the harm caused by our ancestors and our modern-day systems.
Please see below for an extensive list of resources created by TGNB folx and/or BIPOC* who expand on these topics. Another resource list will be provided at the conclusion of my next article as well.
*Note: For the purpose of this article, TGNB indicates transgender and gender nonbinary populations. The use of BIPOC sometimes represents Black, Indigenous, and People of Color (i.e., non-white people), and at other times it represents Black and Indigenous people of color primarily (Code Switch episode, Meraji & Escobar, 2020). When discussing BIPOC communities in this article, I am referring to the Black, Indigenous, and other communities of color who experience ongoing marginalization and oppression in relation to the colonized history of the Western world, including the intergenerational impact from their ancestors.
Resources for decolonizing your clinical work
- binaohan, b (2014). decolonizing trans/gender 101. biyuti publishing.
- Strings, S. (2019). Fearing the Black body: The racial origins of fat phobia. New York University Press.
- Taylor, K-Y. (2017). How we get free: Black feminism and the Combahee River Collective. Haymarket Books.
- Monyee´, T. (Host). (2020 – Present). Shaping the shift. [Audio podcast]. Producer unknown. https://shapingtheshift.com/podcast
- Quiana & Misty. (Hosts). (2020 – Present). Healing while Black podcast. [Audio podcast]. Producer unknown. http://healingwhileblackpodcast.podbean.com/
- Wilbur, M. & Keene, A. (Hosts). (2019 – Present). All my relations. [Audio podcast]. Producer unknown. https://www.allmyrelationspodcast.com/
Electronic print & audiovisual resources:
- Colorado Funders for Inclusiveness and Equity (COFIE). (2010). The four I’s of oppression. Adapted for use by the Chinook Fund. http://www.coloradoinclusivefunders.org/uploads/1/1/5/0/11506731/the_four_is_of_oppression.pdf
- jackson, k. & Shanks, M. (2017). Decolonizing gender: A curriculum. [Zine] https://www.decolonizinggender.com/
- Mase III, J. (2018, Aug 15). Platypus poem: Zone of rarity [Video]. YouTube. https://youtu.be/mnNguCYwx1U
- Meraji, S.M. & Escobar, N. (Hosts). (2020, September 30). Is it time to say R.I.P. to POC? [Audio podcast episode]. In Code Switch. NPR. https://www.npr.org/2020/09/29/918418825/is-it-time-to-say-r-i-p-to-p-o-c
- Okun, T. (n.d.). White supremacy culture. Dismantling Racism. https://www.dismantlingracism.org/uploads/4/3/5/7/43579015/okun_-_white_sup_culture.pdf
- PBS. (2015). A map of gender-diverse cultures. https://www.pbs.org/independentlens/content/two-spirits_map-html/
- Plummer, D.L. (2020, June 5). Not a racist? Then let’s be better antiracist. https://www.dlplummer.com/blog/not-a-racist-then-lets-be-better-antiracist
- Spector, M. (2020, Sept. 9). Helping Queer Clients Become Their Own Liberators. The Affirmative Couch. https://affirmativecouch.com/helping-queer-clients-become-their-own-liberators-liberation-psychologys-critical-contribution/
- Tedx Talks. (2015, June 30). Tedx Georgia State – Anneliese Singh – Trans liberation is for everyone. [Video]. YouTube. https://www.youtube.com/watch?v=-onhIoDRMdM
- The Martín-Baró Initiative for Human Rights. (n.d.). About Ignacio Martín-Baró. The Martín-Baró Initiative for Human Rights. http://martinbarofund.org/about/ignacio/
General Websites & Social Media Accounts:
- Brown, A.M. (writer/thought leader/podcaster, she/they) (n.d.). Adrienne Maree Brown. [@adriennemareebrown]. [Instagram profile, Website]. http://adriennemareebrown.net/
- Cargle, R. (public academic & writer, she/her). (n.d.). Rachel Cargle. [@TheGreatUnlearn, @TheLovelandFoundation, @Rachel.Cargle]. [Website, Instagram profile]. www.rachelcargle.com
- Mase III, J. (poet & educator, he/him). (n.d.). J Mase III. [@jmaseiii]. [Instagram profile, Website]. www.jmaseiii.com
- Menon, A.V. (author/speaker/performer, they/them). (n.d.). Alok V Menon. [@alokvmenon]. [Instagram profile, Website]. www.alokvmenon.com
Decolonization. (2020). By MarleyAyo, LLC. [Definition]. In Thea Monyee´ presents: The Blacker the brain – Free to heal – Decolonizing our practices. www.marleyayo.com
Morgensen, S. L. (2012). Theorising gender, sexuality and settler colonialism: An introduction. Settler Colonial Studies, 2(2), 2-22. https://doi.org/10.1080/2201473X.2012.10648839
Peramo, M. (2018, July 17). Transphobia is a white supremacist legacy of colonialism. Medium. https://medium.com/@Michael_Paramo/transphobia-is-a-white-supremacist-legacy-of-colonialism-e50f57240650
Singh, A. (2016). Moving from affirmation to liberation as psychological practice with transgender and gender nonconforming clients. American Psychologist, 71(8), 755-762. https://doi.org/10.1037/amp0000106
Tuck, E. & Yang, K.W. (2012). Decolonization is not a metaphor. Decolonization: Indigeneity, Education, & Society, 1(1), 1-40. https://www.researchgate.net/publication/277992187_Decolonization_Is_Not_a_Metaphor
Learn more about transgender and gender nonbinary affirmative therapy
with Megan Tucker, PsyD
Please note that this article contains content related to sexual trauma.
In this article, the first in a three-part series about kink-aware therapy, I will lay the groundwork for practitioners to gain an understanding of BDSM and key concepts such as consent and negotiation. Many may believe that BDSM represents bondage, dominance, and sadomasochism practiced during sex–yet these encompass only a small portion of the practices present in the BDSM and kink communities. After emerging in the late 80s and early 90s, the term BDSM itself has gone through a transformation as of the early 2000s (Taormino, 2012) to become more inclusive.
With the passage of time and availability of content on the Internet, the use of BDSM as an umbrella term has expanded to reflect the history of kink vocabulary and the wide variety of practices it encompasses. These include bondage and discipline, domination and submission, and sadism and masochism. While the differences among them may not be immediately clear, these terms are neither mutually inclusive nor exclusive, and kink activity is not limited to sexual experiences.
BDSM has traditionally been pathologized through psychiatric diagnostic manuals such as the DSM (Reiersøl & Skeid, 2006), the effects of which are evidenced by report data. For instance, Kolmes, Stock and Moser (2006) report a concern among consensual BDSM participants that they will receive biased care from mental health professionals. This information was gleaned from a survey administered to both BDSM-involved individuals who have received psychological services and to mental health professionals themselves.
There are a number of reasons why a client might not disclose their participation in kink and BDSM to a provider. Regardless of the context, remaining affirming and empowering combats the classical psychoanalytic and medical traditions of pathologizing BDSM and kink. Because of this, along with evidence suggesting that kinky clients may fear that providers will focus on their “unconventional” sexual desires instead of their concerns, it’s essential that providers become familiar with some basics of kink-affirming therapy.
Moser and Kleinplatz (2004) propose that when therapists accept their clients’ sexuality, clients are empowered to focus on their own concerns rather than defend themselves. The client’s BDSM practices are not “curable,” and any connected distress and dysfunction needs to be understood in the context of discrimination and stigma.
Creating safety in therapy allows clinicians to dispel harmful myths surrounding kink and trauma, and where necessary, to facilitate healing through the basic tenets of kink: consent, empowerment, autonomy, advocacy, and fun. There are two common but contradictory myths, neither more damaging than the other, that prevent many clients from talking about kink with their therapists. Learning about these myths is a way to challenge provider bias, and constitutes a great step toward developing kink awareness. The first is that trauma inherently causes kink, and the other is that you cannot engage in kink if you have a trauma history.
In consideration to the first myth, I refer to a lesson from my undergraduate psychology course regarding a twin sibling study. The study stated that a set of identical twins were separated at birth and both were obsessively clean. When asked why they thought they had this trait, one sibling reported that they had learned it from their adoptive parents. The other stated that their adoptive parents were so dirty that they vowed to never be this way. Perpetuating the connection of experience to meaning not only reinforces shame, but creates a space in which therapists may potentially pathologize a person’s existence. It can be a function of human nature to look back over our lives to find meaning and significance, yet the narratives we choose are not always rooted in a truth of cause and effect. Truthfully, we do not know why individuals develop the fetishes or kinks that they do.
The second myth regarding trauma histories proposes that engaging in kink will cause further harm and will be addressed at length in my next article.
Navigating Kink: The Basics for Kink-Affirmative Therapists
It is important that clients who are first realizing their interest in kink educate themselves before taking action. This is the only safe way to engage in kink. Similarly, therapists require education regarding kink dynamics in order to provide kink-aware therapy and provide a safer space for clients. Consensual kink upholds partner/personal consent, limit setting, and full disclosure of the risks that exist in a kink dynamic, as well as other important considerations that help keep each participant safe.
Let’s explore the extensive communication surrounding consent, limits, safewords, aftercare, and risk awareness that create a foundation for a healthy sexual dynamic.
Here is a terrific guideline to consent that is as easy as FRIESS* from Planned Parenthood (2020). I’ve added an extra S for an important factor you may encourage your clients to take into consideration.
*Sober (C. Cathers, personal communication, November 22, 2020)
Consent is freely given when it does not entail any degree of coercion, threat, or intimidation and it is reversible. This means that consent can be retracted at any time; consenting parties have the right to change their minds. Consent can only be considered informed and specific when every participant is aware of and agrees upon what is going to happen, what would be okay if it happened, what cannot and will not happen, and where, when, and how events are to take place. Think of kink-informed consent like a contract that outlines the expectations and understandings clearly for everyone.
Sober has been added as a reminder that if any participant is under the influence of mind-altering substances, consent cannot be freely given (C. Cathers, personal communication, November 22, 2020).
Within BDSM communities, practices are always understood to be Risk-Aware and Consensual. You may see activities commonly referred to as RACK:
For example, if a client wants to engage in impact play or any other kink activity such as spanking, caning, flogging, etc., that is great! First, it is important to learn some basic human anatomy so they know where it is safe to give and receive impact before they attempt impact play. Education first upholds awareness so that each participant knows how to create an interaction that is safe while still understanding the risks that are involved in any type of BDSM and kink activity.
There are wonderful educational books and Internet-based resources out there. Two of my personal favorites for fun education are SM 101: A Realistic Introduction by Jay Wiseman and videos by Evie Lupine, which you can find on YouTube. Please keep in mind these are not substitutes for completing accredited CE courses or learning from kink educators, but they are a great start. Remember that risk-aware kink practices are meant to keep everyone safe and enjoying themselves.
Negotiation, if done properly, is a collaboration towards a common goal: each partner’s pleasure. Negotiation always comes before a kinky interaction and includes factors like participants’ wants, needs, and soft and hard limits. Soft limits look like activities one is willing to try under the right circumstances, but that must be discussed and agreed upon before trying. Meantime, hard limits are the ones to which a participant says, “No, I am not interested in trying this at all under any circumstances.”
To unpack this a little further, negotiation is multifaceted and will include information such as the logistics of who will be involved, in what capacity, and in which roles. Everyone’s responsibilities must be considered further through the negotiation agreement. A thorough negotiation will also include safety information, including any injuries or illnesses, triggers, psychological limitations, and safewords. If you have further interest in learning about limits or encouraging a client to discover theirs, there are wonderful tools available; my personal favorite is the The Yes, No, Maybe Workbook by Princess Kali.
Discussing and utilizing safewords is another essential aspect of kink safety. Use of a safeword communicates to all participants that a change or complete stoppage of play is needed. A few recommendations include making sure that the word is something easy to remember, but also something that you would not normally utter during kink or sexual activity. Deciding upon a nonverbal gesture is another important consideration, as some activities render a person unable to speak. Gestures can range from a hand signal to a double tap on one’s partner. Working with safewords can be a great exercise in helping clients learn boundary setting and communicating needs.
When kinky play ends, aftercare allows all participants to feel safe, connected, and cared for. This can facilitate a sense of being grounded, an important factor considering the mental and physical “drop” that is described after the rush of endorphins experienced during play. No matter a participant’s role, drop can be experienced and may include aches and pains, feelings of guilt, and sadness or fatigue. This experience is normal and a routine of aftercare can help restore balance. Aftercare looks different for everyone in the same way that drop does, but often includes cuddling, reassurance, praise, a drink of water, or even a warm bath. It can be helpful to elucidate in the therapy room that asking partners what they need after play lays a foundation for stability and connectedness.
While this article does not comprise a definitive list of all things kink, or even all of the basics, I hope it will serve as a starting point as to why kink is healthy and why we should be talking about it in therapy. In the second part of this series I will explore further how having a kink-aware practice reduces stigma, and how we can increase our comfort in working with kinky clients whose past experiences have included trauma.
A Few General Resources for Kink-Affirmative Therapists:
American Sex Podcast with Sunny Megatron
Kolmes, K., Stock, W., & Moser, C. (2006). Investigating Bias in Psychotherapy with BDSM Clients. Journal of Homosexuality, 50(2/3), 301–324. https://doi.org/10.1300/J082v50n02_15
Kleinplatz, P., & Moser, C. (2004). Toward Clinical Guidelines for Working with BDSM Clients. Contemporary Sexuality, 38(6), 1–4.
Reiersøl, O., & Skeid, S. (2006). The ICD diagnoses of fetishism and sadomasochism. In P.J. Kleinplatz & C. Moser (Eds.), Sadomasochism: Powerful pleasures (pp. 243262). Harrington Park Press.
Sexual Consent. (2020). Planned Parenthood. Retrieved November 23, 2020 from https://www.plannedparenthood.org/learn/relationships/sexual-consent
Taormino, T (2012). The Ultimate Guide to Kink: BDSM, Role Play and other Erotic Edge. Cleis Press Inc.
LGBTQIA+ Affirmative Mental Health During the Pandemic
The stress and anxiety wrought by the COVID-19 pandemic may be universal–so many of us face fears of the virus itself, not to mention job loss, illness striking our loved ones, and myriad missed social, professional, and financial opportunities–but all of us experience these differently. Just as everyone’s mental health needs are unique, therapy is not one size fits all. LGBTQIA+ clients in particular need to work with therapists who can understand and validate the unique experiences impacting their emotional wellbeing. Although no one is immune to the detrimental psychosocial effects of the pandemic, LGBTQIA+ clients can face some identity-specific challenges that make affirmative therapy especially crucial at this time.
Affirmative Psychotherapy & Unsupportive Families During the Lockdowns
These include extended time with family of origin and overall decreased social interaction. Pandemic-induced social isolation can hit LGBTQIA+ individuals harder, as many queer and trans people have strained relationships with their families of origin and thus rely heavily on friendships and chosen families for support. Being stuck in toxic family environments due to the pandemic, and enduring sustained lack of contact with friends, can constitute a dangerous combination for any client. LGBTQIA+ people living with family members who don’t respect their gender identity or sexuality may find their mental health negatively affected. This experience can also contribute to dysphoria and has been linked to substance abuse (Newcomb, 2019).
Affirmative Therapy & Lack of Social Connections During COVID-19
Further, lack of social connection is linked to suicidality, for which LGBTQIA+ populations are already at higher risk (Kaniuka, 2019). Prolonged feelings of loneliness can be self-perpetuating; when we feel disconnected, we might start to doubt our ability to connect with others, and we avoid opportunities for socializing out of fear. Happily, ongoing therapy sessions with a therapist who “gets it” and makes us feel seen can serve as a form of connection and help break the cycle of isolation. As we know well, the therapist’s office should be the one place in which clients don’t have to worry about appearing awkward or facing judgment. It can serve as a safer space in which a client can brush up on rusty social skills and build confidence.
Finally, more free time and solitude can make space for greater self-reflection, which may in turn bring up complex emotions in clients just discovering their sexuality and/or gender identity. It’s important for therapists to welcome discussions of these realizations with curiosity and validating support, whether we fully understand them or not. Other difficult topics that can emerge during extended periods of solitude and self-reflection–the trauma related to minority stress that so many LGBTQIA+ people face, for instance–may be challenging to navigate on one’s own but can provide rich fodder for the virtual therapy room as well.
Training in Affirmative Therapy
Simply put, now more than ever, LGBTQIA+ clients need therapists who can treat them without bias. They may be coming into sessions with a lot of self-doubt about their gender identity and/or sexuality. They may have wanted support before now, but perhaps did not feel confident approaching a provider due to the double stigma of being LGBTQIA+ and having a mental health condition. If you are an affirmative provider who is welcoming a client like this into your practice, congratulations on ensuring a safer space. Taking the time to get training in best practices for working with LGBTQIA+ communities makes you an invaluable resource for clients and a genuine lifeline during this unbelievably challenging time.
Alessi, E. J., Dillon, F. R., & Van Der Horn, R. (2019). The therapeutic relationship mediates the association between affirmative practice and psychological well-being among lesbian, gay, bisexual, and queer clients. Psychotherapy (Chicago, Ill.), 56(2), 229–240. https://doi.org/10.1037/pst0000210
Feder, S., Isserlin, L., Hammond, N. Norris, M., & Seale, E. (2017). Exploring the association between eating disorders and gender dysphoria in youth, Eating Disorders, The Journal of Treatment and Prevention, 25:4, 310-317, DOI: 10.1080/10640266.2017.1297112
Johnson, K., Vilceanu, M. O., & Pontes, M. C. (2017). Use of Online Dating Websites and Dating Apps: Findings and Implications for LGB Populations. Journal of Marketing Development and Competitiveness, 11(3). Retrieved from https://articlegateway.com/index.php/JMDC/article/view/1623
Kaniuka, A., Pugh, K. C., Jordan, M., Brooks, B., Dodd, J., Mann, A. K., … & Hirsch, J. K. (2019). Stigma and suicide risk among the LGBTQ population: Are anxiety and depression to blame and can connectedness to the LGBTQ community help? Journal of Gay & Lesbian Mental Health, 23(2), 205-220.
Newcomb, M.E., LaSala, M.C., Bouris, A.,Mustanski, B., Prado, G., Schrager, S.M., & Huebner, D.M. (2019). The Influence of Families on LGBTQ Youth Health: A Call to Action for Innovation in Research and Intervention Development. LGBT Health, 6:4, 139-145. DOI: http://doi.org/10.1089/lgbt.2018.0157
All corners of our society are affected by the current global health crisis caused by COVID-19. Beyond the obvious risks of severe illness and mortality, many of our clients are managing the myriad mental health effects of financial insecurity, social isolation or co-quarantine, and general societal uncertainty. LGBTQIA+ communities face unique challenges during this pandemic. By understanding what some of these challenges are, clinicians can be better positioned to treat and empower their LGBTQIA+ clients. These challenges fall into several domains: social and emotional, economic, and physical. Additional training to help mental health professionals understand minority stressors can be helpful, especially in these unprecedented times.
How Psychotherapists Can Help With Social and Emotional Health
Some of the social challenges that may disproportionately affect LGBTQIA+ clients are the loss of perceived social connection due to the closure of many community spaces (Green, Price-Feeney, & Dorison, 2020; Burns, 2020), the necessity to shelter in place in an un-affirming or potentially violent space whether due to familial violence or intimate partner violence (Taub, 2020), and for Asian-American and other BIPOC, the increased likelihood of experiencing racist or xenophobic harassment (Loffman, 2020).
Therapists can support clients through these social and psychological challenges by:
Maintaining continuity of treatment via telehealth, thereby ensuring that the therapeutic relationship can remain consistent through a period of uncertainty and change
Nurturing an awareness of the challenges unique to LGBTQIA+ communities (by seeking out online training and understanding the reasons behind the statistics)
Containing the client’s feelings of despair, frustration, and fear
Brainstorming with clients to identify available venues for social connection and/or connecting clients to additional resources*
*Although telehealth and video conferencing offer ways to stay connected to work, friends, and family, clinicians should be aware that transgender and gender nonbinary clients may experience an increase in gender dysphoria as a result of being on screen so frequently. Having the client hide their own view may work for some clients, but for others it may still be intolerable. Phone therapy may be a better option. Talking to your client about the best way to obtain therapeutic support will help.
How Psychotherapy Can Support Clients with Economic Challenges
As the economic impact of the COVID-19 pandemic unfolds over the coming months and year, LGBTQIA+ communities will be among the most vulnerable populations. LGBTQIA+ clients may be cut off from family financial support, may not qualify for financial assistance due to the nature of their work (as in the case of sex workers or undocumented workers), and may not have emergency savings or cushions due to the barriers to high-paying employment as a result of homo-, bi-, and transphobic discrimination (Green, Price-Feeney, & Dorison, 2020; Kuhr, 2020).
Therapists can support clients through these economic challenges by:
Where possible, negotiating financial arrangements with clients as needed, thus ensuring that clients have the option to continue treatment despite temporary financial hardship or uncertainty
Containing difficult feelings that arise in the face of financial insecurity (fear, anger, and shame)
Strategizing with them to advocate for benefits (if applicable), particularly since some clients may feel too ashamed or unworthy to advocate for their own needs
How Therapy Can Improve Physical Health
When it comes to physical health and its effects on mental health, the COVID-19 crisis has already begun to affect the LGBTQIA+ communities in the form of delayed gender-confirming surgeries and delayed appointments required to access hormones or blockers (Loggins, 2020). LGBTQIA+ clients experiencing symptoms of COVID-19 may be hesitant to seek out testing or medical care due to past negative experiences with the medical system (such as misgendering, use of dead name, discrimination, or lack of access to healthcare) (Blum, 2020; Lang, 2020).
Therapists can help clients manage the physical health challenges clients face by:
Working to minimize the psychological toll that delayed procedures can take
Containing frustration, anger, and despair as normal reactions, which is important to help clients from decompensating
Offering psychoeducation on how to bind safely (Wynne, 2020), while keeping respiratory health in mind
Exploring harm reduction options to help clients reduce stress without contributing to physical vulnerability (via smoking or vaping)
Therapists are navigating this unprecedented and stressful time simultaneously with our clients. One of the most effective things we can do is maintain an authentic, caring, and consistent therapeutic relationship when disconnection and fear are abundant.
The Affirmative Couch will be rolling out several courses that address some specific challenges that the COVID-19 pandemic creates for the LGBTQIA+, consensually non-monogamous, and kinky communities over the next few weeks.