A key aspect for therapists practicing affirmative psychotherapy is deconstructing heteronormativity. Defined by the American Psychological Association as “the assumption that heterosexuality is the standard for defining normal sexual behavior,” heteronormativity stems from a long-standing, embedded cultural belief that traditional gender roles are unchanging and omnipotent. (2022) Taken a step further, heteronormativity becomes compulsory heterosexuality – the belief that every person must be straight, even if they have attraction to people of the same gender. Angeli Luz writes in the “Lesbian Masterdoc,” “compulsory heterosexuality easily ties in with the misogyny that causes women’s sexualit[y] and…identities to be defined by our relationships with men.” (2021) Sometimes abbreviated as comphet, compulsory heterosexuality pervades even benign interactions between therapists and clients.

As affirmative therapists, our work with LGBTQIA+ clients must break down the immutable belief in compulsory heterosexuality both for their clients and themselves. It impacts every stage of psychotherapy, from engagement to termination. In this article, we will explore the ways in which comphet erodes the therapeutic alliance, the challenges this poses to treatment, and how to begin deconstruction in your therapy practice.

Defining Compulsory Heterosexuality

The concept of compulsory heterosexuality was introduced in 1980 by the lesbian feminist writer Adrienne Rich in her groundbreaking essay, “Compulsory Heterosexuality and Lesbian Existence.” Her article describes compulsory heterosexuality as a “bias,” an automatic assumption that all women are heterosexual, and that “lesbian experience is perceived on a scale from deviant to abhorrent, or simply rendered invisible” (Rich, 1980, p. 1).
Queer theorist Michael Warner expanded on Rich’s work in his 1991 publication “Introduction: Fear of a Queer Planet,” in which the author introduces the concept of heteronormativity. Warner writes, “the task of queer social theory…must be to confront the default heteronormativity of modern culture with its worst nightmare, a queer planet” (1991, p. 17). Theoretically speaking, heteronormativity represents the status quo: a culture where everyone is presumed straight, enacted by compulsory heterosexuality.
In the decades since these words were published, our understanding of gender and sexuality has changed a lot. We can pay homage to the radical nature of Rich and Warner’s work in context while also acknowledging that they are further reaching than originally thought. For example, comphet does not only affect lesbians – bisexual, pansexual, and omnisexual people often experience a combination of erasure and stigmatization. With increasing visibility and representation of queer people in our modern era, we are closer to Warner’s idea of a “queer planet” than ever before, but still with further to go.
Armed with an understanding of the etiology and meaning of compulsory heterosexuality, it is easy to see how this mindset persists in psychotherapy. Although this article will focus on heterosexism, it is important to note that endosexism, cissexism, racism, and other biases also impact treatment. To begin the work of unlearning this unconscious bias, we must first learn to identify it.

How Compulsory Heterosexuality Erodes Psychotherapy

1. The therapist assumes that their clients are straight.

Many therapists might even believe that to suggest a client is LGBTQIA+ is impolite or inappropriate, and avoid addressing the topic in therapy sessions. Others might simply assume that a client is straight because they are themselves, because they don’t “look gay,” or they are unfamiliar or uncomfortable with queer identity. But the root of this issue is just as Rich wrote back in 1980 — that there is something “deviant” about queerness, or that someone would not want to be thought of in this way (p. 1).
Instead of allowing our clients to be “straight until proven otherwise,” therapists can invite conversation about sexuality and identity early in treatment. We become better therapists by treating our clients as the experts on their own experience, and letting them teach us about their sexual identities. It is well-established that a person-centered approach and strong alliance between therapist and client are reliable predictors for positive outcomes in psychotherapy, especially when paired with an affirmative approach for LGBTQIA+ clients (Davis et al, 2021). We can build the therapeutic alliance with our clients by creating a safe space for discussion of sexuality and identity. And overall, we can challenge our assumptions about sexuality and gender presentation through education, consultation, and rigorous self-reflection.

2. The client believes that they “should” be straight.

Similar to how a therapist might assume a client is straight based on their own internalized comphet, a client may have been socialized the same way. Our culture sends strong messages about what sexuality looks and feels like, which can be hard to parse through alone. Clients may have been taught to view their experiences with sexuality and identity through a lens of straightness.
In 2005, the New York Times published a piece by Stephanie Rosenbloom describing the phenomenon of a “girl crush.” Rosenbloom posited that “women, especially young women, have always had…feelings of adoration for each other,” differentiating a girl crush as “romantic but not sexual” (2005). Critics pointed out that many people experience romantic and sexual attraction separately, including those who are queer-identified. Another example would be straight women using the term “girlfriend” to describe their friends and peers – while this refers to the close and intimate nature of their relationship, it also dilutes the meaning of “girlfriend” as a romantic identifier. This is comphet in action: erasing the experiences of queer women by creating a new term to reassure straight women of their heterosexuality. As affirmative therapists, we can reframe this experience with our clients, and encourage them to adopt a more complex view. We can explore the meaning of sexual identity with our clients, and start to construct a new lens through which to view attraction.

3. The therapist interprets a client’s identity as pathology.

Affirmative psychotherapy firmly centers the belief that LGBTQIA+ identities are valid, and acknowledges their experiences of homophobia and oppression (Hinrichs & Donaldson, 2017). We acknowledge the harmful legacy of our profession’s work with the queer community, and how institutional oppression persists today. The DSM only removed homosexuality from its pages in 1973 – until this point, professionals were trained to believe that LGBTQIA+ identity was a disease state to be treated (Drescher, 2015).
Compulsory heterosexuality frames any experience of sexuality outside of straightness as “deviant,” as Adrienne Rich wrote. While the literature of the field reflects a shift in attitude in the years since this DSM update, there are still practitioners who were trained under this belief. There are may be others, too, who hold a personal bias that queerness is wrong or immoral. According to the Family Equality Council, conversion therapy is still legal in 25 states and 4 territories (2019). Affirmative psychotherapy believes that clients’ mental health symptoms may be due to such stigma and discrimination, but are not caused by their queerness.

4. The client intellectualizes their desire.

Intellectualizing is a defense mechanism in which clients create distance from their emotions through excessive overthinking (Bowins, 2021, p. 1). When clients intellectualize their problems, they are defending against the negative emotion by focusing instead on logical or rational explanations… even when their emotions are telling them otherwise. Some might argue that Rosenbloom’s description of a “girl crush” is intellectualizing by creating new terminology to describe romantic attraction between women (2005). A client who intellectualizes questioning their identity might search for an alternate explanation for their emotions that aligns with the belief that they must be heterosexual.
It is important to remember that we cannot equivocate desire or attraction with identity, and some people may identify as straight while experiencing romantic attraction to the same sex. Psychotherapists should help clients to move towards the belief that identity is far more expansive than simply “straight” or “not” – combating compulsory heterosexuality by encouraging non-judgmental exploration and expression of their sexuality.

Deconstructing Compulsory Heterosexuality in Your Practice

Once you have an understanding of compulsory heterosexuality, it can be overwhelming to think about how to implement a change to your therapy practice. As in much of affirmative psychotherapy, a good place to start is with yourself. Hinrichs and Donaldson define affirmative therapy as “a set of attitudes or approaches rather than specific techniques” (2017, p. 947). Reflect on the ways comphet shows up in your own practice. Do you default to gendered terminology for clients’ partners or dating interests? Are you comfortable sitting in ambiguity with a client who is questioning their sexuality without prematurely applying labels?
While much of the work of unpacking comphet happens at intake, you can deconstruct its influence throughout treatment. Taking an affirmative and client-centered approach, focus on what they see as the problem. Think of yourself as an advocate and collaborator with your client as you identify compulsory heterosexuality and experiences of homophobia or discrimination together. After all, meeting your client where they are at does not stop after the first session – therapists walk alongside our clients throughout the journey.

Learn more about working with LGBTQIA+ Clients

References

American Psychological Association. (n.d.). Compulsory Heterosexuality. American Psychological Association. Retrieved February 16, 2022, from https://dictionary.apa.org/heteronormativity.

Bowins, B. (2021). Psychological defense Mechanisms. In B. Bowins (Ed.), States and Processes for Mental Health: Advancing Psychotherapy Effectiveness (1st ed., Vol. 1, pp. 23–40). essay, Academic Press. Retrieved February 16, 2022, from https://www.sciencedirect.com/science/article/pii/B9780323850490000039?via%3Dihub#!.

Davis, A.W., Lyons, A. & Pepping, C.A. Inclusive Psychotherapy for Sexual Minority Adults: the Role of the Therapeutic Alliance. Sex Res Soc Policy (2021). https://doi.org/10.1007/s13178-021-00654-y

Drescher J. (2015). Out of DSM: Depathologizing Homosexuality. Behavioral sciences (Basel, Switzerland), 5(4), 565–575. https://doi.org/10.3390/bs5040565.

Family Equality Project. (2019, December 18). Conversion therapy laws. Movement Advancement Project. Retrieved February 18, 2022, from https://www.familyequality.org/resources/conversion-therapy-laws/.

Hinrichs, K., & Donaldson, W. (2017). Recommendations for Use of Affirmative Psychotherapy With LGBT Older Adults. Journal of clinical psychology, 73(8), 945–953. https://doi.org/10.1002/jclp.22505.

Luz, A. (2021). Copy of am I A Lesbian_ masterdoc.pdf. Am I A Lesbian_Masterdoc.pdf. Retrieved February 18, 2022, from https://www.docdroid.net/N46Ea3o/copy-of-am-i-a-lesbian-masterdoc-pdf#page=2.

Rich, A. (1980). Compulsory Heterosexuality and Lesbian Existence. Signs, 5(4), 631–660. http://www.jstor.org/stable/3173834.

Rosenbloom, S. (2005, August 11). She’s So Cool, So Smart, So Beautiful: Must Be A Girl Crush. The New York Times. Retrieved February 16, 2022, from https://www.nytimes.com/2005/08/11/fashion/thursdaystyles/shes-so-cool-so-smart-so-beautiful-must-be-a-girl-crush.html.

Warner, M. (1991). Introduction: Fear of a Queer Planet. Social Text, 29, 3–17. http://www.jstor.org/stable/466295

I am Black, gay, and a social worker. I work in a recovery center where I help individuals attain and maintain their sobriety.  I have had experience on both sides of the “social service” table, and my personal and professional experience has given me access to the elusive community of crystal meth users.

A friend of mine who experienced addiction once asked me to accompany him to a Crystal Meth Anonymous (CMA) meeting. Upon our arrival, the room buzzing with conversation, I noticed that my friend and I were two of only three people of color in the space of about 25 people. When the meeting opened up the floor to share, the only other person of color present shared about a tough time he was going through and broke into tears. He was raw in the moment, and as much as I wanted to walk over and console him, I froze. No one approached him. 

I didn’t know what to do at that moment. So I waited until after the meeting and then I pulled him aside. He shared that this wasn’t the first time he had a breakdown or breakthrough in a CMA meeting, and that he didn’t expect comfort because no one had ever comforted him before. He went on to say that even in a room filled with people who share the same pain, he still felt alone. 

Racism: the elephant in the room

This is not unusual: within the larger gay community, I often hear stories of cultural difference–that in these spaces of “inclusion,” there is an elephant in the room that many refuse to acknowledge or address. Many of the white men in this room were on dating and hookup sites advertising their attraction to men of color; they plastered their desire for “BBC” (big black cocks) all over these apps, accompanied by the capital letter T as a silent signal to meth users. Why is it so difficult for these same individuals to console someone in an emotional state of need? Is it because they don’t see our value outside of the bedrooms? Wealthy white men’s fetishizing and desire of Black men‘s bodies while using is not uncommon, and they dangle crystal meth like a carrot hoping for a treat from their trick.

I remember being in these rooms and feeling afraid, embarrassed and mostly alone. These dark emotions fueled my desire to use so that I could lower my inhibitions and allow myself to engage in these humiliating experiences.  All for Tina. These sex rooms were eerily similar to that CMA meeting room, but here, the white men couldn’t keep their hands off me, nor anyone who looked like me.  When I finally crossed paths with those who shared my same hue and were also users, I discovered that we shared that same experience. That’s when I decided to look for help, which wasn’t easy.

Addiction as a disease of isolation for Black gay men

It can be difficult as a Black gay man who has suffered from addiction, whether current or in the past, to find community support. Black crystal meth users have a harder time because it is widely seen as a “white man’s drug.” The Black gay men with whom I have worked often express their fears of sharing about their struggle with addiction even with their friends. With the fear and shame of their addiction, most of these men succumb to one of the most dangerous symptoms of crystal meth addiction: isolation. 

Connection is a pillar in the Black community. Connection informs how we give and receive love,  how we communicate, and also how we feel valued. Connection bonds the value and friendships that we create with our chosen families. Chosen families are an essential part of the LGBTQIA+ community; they enable us to find the support and love that our biological families might not provide. Crystal meth addiction can be detrimental to these connections, forcing the men who use it to suffer in silence. They may not share about their addiction because of how they will be viewed, or for fear of becoming the subject of the latest gossip.

Unfortunately, that fear became my reality. I had reached out for help from someone I thought was part of my circle of support, only to end up being grist for the rumor mill. These experiences severed my trust in people, scaring me from looking for help. I was afraid of sharing more with old friends, for fear that they would repeat the same behavior. I also struggled with making new connections, afraid that they would somehow find out about my addiction and want nothing to do with me.

On being both client and service provider

It took some time, but I was able to connect myself with services; I credit my professional experience with helping me locate resources. My background in linking consumers to community supports like Medicaid and substance abuse programs became my reality. I was on the other side of the table, having been in the position of both client and provider. 

I am confident that many out there can maneuver beyond their addiction and locate the necessary support to begin their own journeys to sobriety. However, there are so many others who are unable or are too discouraged by the daunting process. 

Applying for Medicaid and enrolling in substance abuse treatment programs can be tasks within themselves. Fortunately, organizations like the D.C.-based Us Helping Us and Whitman-Walker Clinic offer streamlined services for MSM with crystal meth addiction, help with applying for health benefits, and much more.  In New York, there is the Ike & Tina meeting, which centers the experiences of Black queer and trans folx seeking recovery. 

But there is a tremendous need for culturally sensitive program models offered on a national level, along with greater accessibility of culturally cognizant therapists. Affirmative therapy provides safer spaces in which to unpack one’s life experiences, which is essential for anyone in or seeking recovery. My love for my profession plays an instrumental role in my search for the best way to support those with addiction. However, beyond this passion for the work that I do, my reach as an individual is limited. 

It is time to tailor, on a larger scale, recovery services to our clients’ cultural experiences and needs. Community and mental health providers must seek training specifically designed to address the intersections of addiction and culture. Continuing education is vital for any and all of us providing services to clients whose multiplicity of identities and experiences we recognize and respect. In addition to pursuing ongoing training to create a workforce rich in cultural humility, providers should engage in advocacy efforts to ensure the creation and funding for recovery programs that will meet our clients where they are and propel them forward. There is much work ahead for affirmative providers! 

In my third and final article in this series, I will explore the resources available to help practicing clinicians address the intersections of culture and addiction. 

“Not everything that is faced can be changed; but nothing can be changed until it is faced.” –  James Baldwin

Reference

Lee, C., Oliffe, J. L., Kelly, M. T., & Ferlatte, O. (2017). Depression and suicidality in gay men: Implications for health care providers. American Journal of Men’s Health, 11(4), 910–919. https://doi.org/10.1177/1557988316685492

Learn More

With the global COVID-19 pandemic continuing into its second year, the conversation around access to healthcare has never been more relevant. For many people, going to a doctor for an annual physical was not feasible before the pandemic, whether due to lack of insurance coverage, financial cost, taking time off from work, transportation issues, or anxiety around healthcare-related trauma. On top of this, the added stress of COVID-19 exposure risk has led many to postpone necessary care. LGBTQIA+ people often face an additional barrier: whether the provider they see will be affirming, supportive–or even safe.

Primary Care as a “Medical Home”

Primary care is founded on a “medical home” model, meaning that patients will return periodically to the same practice, developing a relationship with their provider or medical team to ensure high-quality, comprehensive healthcare (Rosenthal, 2008). This can include physicians, nurses, social workers, and non-medical staff in the office. In an article for the Journal of American Board of Family Medicine, physician Thomas Rosenthal writes that “When people get sick, they use stories to describe their experience,” and goes on to say that “patient-oriented care is bound up in a physician’s ability to accurately perceive the essence of a patient’s story” (2008, p. 428). 

This is a fundamental principle of the medical home model, and it speaks to the importance of primary care providers demonstrating expertise in LGBTQIA+-affirmative care. By gaining an understanding of how LGBTQIA+ people live and experience the world, providers build an essential framework for interpreting their stories and addressing their concerns. In this way, LGBTQIA+-affirmative primary care becomes a partnership, with patients and providers allying together to promote good health.

Social Determinants of Health in Primary Care

Furthermore, there has been a push in recent years for primary care practices to focus on the impact of social determinants of health–the factors that impact a patient’s well-being outside of their physical traits. Emerging from the Center for Disease Control and Prevention’s Healthy People 2020 campaign, social determinants of health include elements like poverty, depression, alcohol or drug use, social isolation, and exposure to violence in one’s home or neighborhood (CDC, 2020). To incorporate this into the flow of the office visit, patients may answer a paper or digital questionnaire about their experiences, or may be interviewed by a medical professional. In their medical homes, patients would ideally feel comfortable answering questions about such sensitive topics, as they have a relationship with their team. 

LGBTQIA+-Affirmative Healthcare

However, without expertise in LGBTQIA+-affirming care, this is not always the case. Additionally, there is evidence to suggest that LGBTQIA+ people are more likely to be impacted by one or more of these elements due to the social stigma of being out in their communities (Knight et al., 2014). In a 2014 study of LGBTQIA+ youth in primary care, researchers examined the impact of “a set of social conditions that influence [the] health-related outcomes [of LGBTQIA+ people], including heteronormative and cisnormative assumptons, stigma, and social exclusion” (Knight et al., p. 662). In addition, queer and trans people comprise a large percentage of the gig economy and part-time workforce. As such, they are less likely to have employer-sponsored health insurance coverage, and are less likely to be able to afford out-of-pocket insurance costs (National LGBTQ Workers Center, 2018). This means that members of the LGBTQIA+ population may not make it to the doctor’s office at all when they are sick. As our understanding of health changes, primary care must be responsive to it. 

With so many barriers to accessing healthcare, skipping appointments or going long times in between them is a reality for many LGBTQIA+ patients. Particularly during a global pandemic, this has become commonplace, and even necessary, for many people. But foregoing essential healthcare can have significant and long-lasting impacts on patients’ physical and mental health. A 2019 study in BMC Medicine concluded that missed appointments comprise a significant risk factor for increased comorbidities and overall mortality (McQueenie et al.). This means that patients who skip necessary appointments are likely to only get sicker. LGBTQIA+ people are at unique risk for various health problems as well, including higher rates of depression and substance abuse, as opposed to the general population (Ng & McNamara, 2016). 

The need for affirmative care surfaces in the long-term treatment of HIV, for which LGBTQIA+ people–particularly gay men and transgender women of color–face a disproportionate risk (Feldman et al., 2014). HIV is a chronic illness that is often managed by a patient’s primary care provider. With daily medication and regular follow-up, patients can live healthy lives. However, this depends greatly on a patient’s retention in care, i.e. their ability to stay connected to their provider and maintain adherence to their medication regimen. When we factor in the influences previously mentioned, this becomes an increasingly challenging task.

Trans-Affirming Medical and Mental Healthcare 

As the patients’ medical homes, primary care providers serve as liaisons to other specialties (Rosenthal, 2008). We know about the negative impact of postponing necessary health maintenance, but to make matters worse, LGBTQIA+ people without primary care providers are cut off from necessary specialist care. For transgender and gender non-conforming people, medical transition may be inaccessible without documentation of treatment by a primary care provider. While some clinics have adopted an informed-consent model for cross-gender hormone therapy, the majority of gender-affirming surgeons require that patients have a working relationship with not only a primary care provider, but a mental healthcare provider as well. 

Depression and anxiety are 1.5 times higher in lesbian, bisexual, and gay adults than in the general population (Ng & McNamara, 2016). In a 2017 study of over 400 transgender adults in primary care, foregoing or postponing medical care due to fear of discrimination was associated with poor mental health, including increased incidence of depression and suicide attempts (Seelman et al). This suggests that the impression of discriminatory or stigmatizing healthcare practices is out there, and is acting as a barrier to care for many transgender patients before they even get in the door. When trans people are denied medical transition care, whether due to lack of access to healthcare services or to medical gatekeeping, the impact on their mental health can be devastating. In a population already at disproportionate risk of poor mental health and increased substance abuse, this is not a risk we can afford to take.

By developing a continuous relationship with their patients, primary care providers can foster trust with them to address health inequities. Many patients feel uncomfortable discussing their sexual and reproductive health with providers, and providers who are not trained in LGBTQIA+-affirming care may fumble or avoid these conversations altogether. Assumptions around patients’ sexual behaviors can lead to missed opportunities for STI screening and reproductive health counseling. For example, providers may believe that women who identify as lesbian or bisexual do not need the HPV vaccine or routine Pap smears, and may forego inquiring further about sexual behavior or partners. A 2018 qualitative study included interviews with 39 assigned-female-at-birth patients about their experiences with reproductive healthcare, revealing discrepancies in treatment but indicating similar needs between cisgender, heterosexual patients and LGBTQIA+ patients (Wingo et al.). This suggests that reproductive healthcare providers must be both well-versed in LGBTQIA+-affirming practices and also practice from what Ng & McNamara (2016) refer to as an anatomical inventory, or “screen what you have” model. 

The authors suggest that providers “screening for breast, cervical, and prostate cancer…should consider an individual patient’s surgical history and hormonal status” (2016, p. 535). This means that, for example, transgender men or gender non-conforming people who have had a mastectomy may not need breast cancer screening. By “screening what you have,” physicians can individualize care to the needs of a specific patient, and further avoid making gendered assumptions or using exclusionary language like “women’s health screenings.”

The Imperative of Becoming an Affirmative Healthcare Provider

Bearing this in mind, there are a number of practices that primary care offices can adopt to create LGBTQIA+-affirming environments and retain their patients in care. For employees at every level, this can include practical or administrative changes, like changing documentation and medical records to reflect a patient’s sexual orientation or gender identity, or designating gender-neutral restrooms in an office setting (Ng & McNamara, 2016). For medical providers, adopting screening for mental health and substance use disorders is critical when working with LGBTQIA+ patients, as well as shifting cis- and heteronormative assumptions around patients’ responses (Ng & McNamara, 2016; Knight et al., 2014). Increasing education of all staff around LGBTQIA+-affirming care, social determinants of health, and their intersections can improve patients’ experiences in primary care and prevent negative health outcomes.

One final note to consider is that in many studies, recommendations are made for improving primary care practices for providers who are “interested” in LGBTQIA+ populations. This view is outdated and simply no longer reflects the reality of the patients coming into our offices. According to the Williams Institute at UCLA Law School, an estimated 4.5 percent of all Americans identify as LGBTQ+ (2019). These data are several years old, and do not include the responses of adults in Generation Z, who are predicted to identify as LGBTQ+ at higher rates. The message here is clear: whether or not providers have a special “interest” in working with LGBTQIA+ patients, those patients are here in our practices. To serve these community members and promote better health overall, our care must reflect an understanding of their unique needs and experiences, and affirm their LGBTQIA+ identities.

Affirmative Organizational Development Consulting

The Affirmative Couch offers affirmative organizational development consulting for mental and medical healthcare clinics who want to create a safe, welcoming environment for all patients who walk through their doors. 

Our consulting team joins your clinic and gathers information to identify all the ways in which you can improve your services for LGBTQIA+ community members. We utilize the community narration approach to begin exploring the mission and values of your organization, and the gaps in service delivery to these communities. Our tailored needs assessment will review our findings from these interactions, offer next steps, and provide the foundation for your ongoing training with The Affirmative Couch. 

Through this empowered approach, you will have all the information and support you need to make systemic change in your paperwork, administrative procedures, staff training, and organizational culture. We are here to answer every question in a non-judgmental, non-shaming way to help you become a more affirmative provider. 

If you want to learn more, schedule a call with us to discuss your needs!

Learn more from our continuing education courses

References

Centers for Disease Control and Prevention (2020, August 19). About Social Determinants of Health (SDOH). https://www.cdc.gov/socialdeterminants/about.html 

Feldman, J., Romine, R. S., & Bockting, W. O. (2014). HIV risk behaviors in the U.S. transgender population: prevalence and predictors in a large internet sample. Journal of homosexuality, 61(11), 1558–1588. http://www.tandfonline.com/doi/abs/10.1080/00918369.2014.944048 

Knight, R. E., Shoveller, J. A., Carson, A. M., & Contreras-Whitney, J. G. (2014). Examining clinicians’ experiences providing sexual health services for LGBTQ youth: considering social and structural determinants of health in clinical practice. Health Education Research, 29(4), 662-670.

Movement Advancement Project & The National LGBTQ Workers Center. (2018). LGBT People in the workplace: Demographics, Experiences and pathways to equity.  [Infographic]. lgbtmap.org. https://www.lgbtmap.org/file/LGBT-Workers-3-Pager-FINAL.pdf 

Ng & McNamara (2016). Best practices in LGBT care: a guide for primary care physicians. Cleveland Clinic journal of medicine, 83(7), 531.

Rosenthal, T. C. (2008). The medical home: growing evidence to support a new approach to primary care. The Journal of the American Board of Family Medicine, 21(5), 427-440.

Seelman, K. L., Colón-Diaz, M. J., LeCroix, R. H., Xavier-Brier, M., & Kattari, L. (2017). Transgender noninclusive healthcare and delaying care because of fear: connections to general health and mental health among transgender adults. Transgender health, 2(1), 17-28.

The Williams Institute, UCLA School of Law. (January 2019). LGBT Demographic Data Interactive. https://williamsinstitute.law.ucla.edu/visualization/lgbt-stats/?topic=LGBT#density

Wingo, E., Ingraham, N., & Roberts, S. (2018). Reproductive Health Care Priorities and Barriers to Effective Care for LGBTQ People Assigned Female at Birth: A Qualitative Study. Women’s health issues : official publication of the Jacobs Institute of Women’s Health, 28(4), 350–357. https://linkinghub.elsevier.com/retrieve/pii/S1049386717305996 

Keywords: queer, LGBTQ, LGBTQIA, impostor syndrome, impostor, cognitive behavioral therapy, CBT, core beliefs

I thought I identified one way, but now I’m not sure. What if this really was just a phase?

I’m afraid I won’t like all of the changes medical transition will cause to my body. What if I’m not really trans?

Can I still be bisexual if I’ve never dated someone of the same gender?

Our clients seek therapy for a variety of reasons, but commonly, they are struggling to mitigate their own core beliefs with external influences. These may include family, friends, partners, or society at large–for LGBTQIA+-identified folks, how we see ourselves can often conflict with how the world interprets us. This type of invalidation can lead to self-doubt for many people, even making them question whether they are frauds or impostors. As therapists, our goal is to help clients identify and challenge their negative core beliefs, to challenge these external influences and find internal validation.

The theory of Impostor Syndrome originates from a 1978 paper from Georgia State University that examined the phenomenon in more than 150 “high-achieving women” (Clance & Imes). The authors found that in their psychotherapy practices, women often presented with “scholastic honors, high achievement on standardized tests, praise and professional recognition from colleagues and respected authorities,” yet did not report “an internal feeling of success” (Clance & Imes, 1978). Rather, these clients felt like “impostors,” as though they were given undue praise or accolades they did not deserve.

In recent years, Impostor Syndrome has entered the lexicon as a common experience among millennials. A 2013 article by Weir at the American Psychological Association examined the experiences of graduate students and suggested that for many, there is “‘confusion between approval and love and worthiness. Self-worth becomes contingent on achieving.” This attitude is compounded by factors like gender, sexuality, disability, class, and race, with impostor feelings being a strong predictor of future mental health problems among college students of color (Cokley et al., 2013). 

Similarly, impostor feelings often pop up in psychotherapy with millennial clients, particularly those with one or more marginalized identities. In our culture, certain roles or industries are often referred to as a “boys’ club”–as these spaces were built by and designed for white, heterosexual, cisgender men, anyone who varies from this norm can feel like they don’t belong. Higher education is just one example of a much more global dynamic.

For LGBTQIA+-identified people, impostor feelings are often less about achievement and more about community. Many people find comfort in the use of labels or identity words–such as gay, lesbian, bisexual, transgender, genderqueer, gender non-binary, and more–to describe themselves and their sexuality and gender. For someone who is just starting to explore their identity, finding a community of people who have been where they are can be healing and fulfilling. But what if none of the labels fit quite right? Or what if your experience differs from that of your friend, or even of your partner? 

Though it is often said that “comparison is the thief of joy,” human beings are prone to noticing the similarities and differences between themselves and others. It can feel isolating to know that how you identify differs greatly from someone else. But this is where we as therapists can employ cognitive behavioral therapy to help our clients change their thinking and develop their senses of internal validation.

One example might be a therapist working with a client who identifies as a cisgender woman and a lesbian. At the first appointment, the client shares, “I’ve only dated women since coming out in college. Lately I’ve noticed myself looking at men differently than before, and it’s confusing. If I’m attracted to guys, am I still a lesbian?” 

From what this client is saying, she sees the problem as confusion about her identity. It is worth exploring with the client what being a lesbian means to her, and furthermore, what it would mean if she were to identify differently. Often, this is where impostor feelings start to surface: if I’m not this, then what? I must have been faking. I don’t really belong here. 

Using the framework of cognitive behavioral therapy, clarifying the client’s core beliefs about herself can be helpful. These are deeply held feelings that are central to our being, and that influence how we see and interact with the world. Core beliefs can be positive or negative, such as “I am worthy” or “I am unworthy,” “I am safe” or “I am unsafe,” “I am good enough” or “I am not good enough.” For this client, the core belief underlying her impostor feelings may be related to belonging, or feeling like she does not belong in her community of friends–or safety, from feeling like she is on the outside.

After isolating a client’s core beliefs, one CBT intervention that can be utilized would be fact-finding, asking the client to provide as many pieces of evidence as they can why their belief is true or untrue. Using our same example, if this client’s impostor feelings trigger the core belief that she does not belong in her community because she is questioning her identity, the therapist and client can list a number of examples of evidence to the contrary. 

“Well, my friends will still be my friends no matter what. They have always supported me. That wouldn’t change,” the client offers. “And even if I did have a boyfriend someday, that wouldn’t make me straight. I wouldn’t think that about somebody else in my position.” By talking through this fact-finding process, the client is starting to challenge and reconstruct her core belief of belongingness. It may also be helpful to have a client write down thoughts, beliefs, and evidence in a journal between sessions. This can be a helpful reflective exercise and also encourage clients to use their coping skills outside of therapy.

Core belief work is not always easy, nor is it a quick fix for impostor feelings. Therapy sometimes makes things worse before they get better, and clients can sometimes unearth deep-seated issues in therapy that take time, effort, and dedication to work through. That does not make their effort any less valuable, however, and small changes in the client’s self-perception should be noticed and praised. There may be certain situations or stages of life in which a client feels old impostor feelings starting to emerge again. When they do, it is important for the client  to remember that they have control over their own thoughts and feelings, and that they can reconnect with their positive core beliefs.

Learn more about working with LGBTQIA+ Clients

References

Clance, P. R., & Imes, S. A. (1978). The Impostor Phenomenon in High Achieving Women: Dynamics and Therapeutic Intervention. Psychotherapy: Theory, Research and Practice, 15(3), 241-247.

Cokley, K., Mcclain, S., Enciso, A., & Martinez, M. (2013). An Examination of the Impact of Minority Status Stress and Impostor Feelings on the Mental Health of Diverse Ethnic Minority College Students. Journal of Multicultural Counseling and Development,41(2), 82-95. doi:10.1002/j.2161-1912.2013.00029.x

Weir, K. (2013). Feel like a fraud? GradPSYCH, 11, 24. doi: https://doi.org/10.1037/e636522013-001

By now, we are all experiencing the impact of the ubiquitous trauma and stress surrounding COVID-19 in some way. What might have started with a distal awareness of the problem quickly snapped to a reality that the world will forever be changed by this virus. You might have also noticed the varying “stages of grief” through which our clients and we ourselves are shifting, the unfortunate stage of denial being the one that has caused the most irrevocable damage to the world.

On the one hand, many may find the universality of this experience comforting–it is rare that everyone on the planet understands the same thing to some degree. The current situation presents a valuable opportunity for emotional validation and a sense of common humanity (i.e., increased self-compassion due to awareness of the common human experience of suffering). It often takes personal experience and connection to a situation to increase empathy and compassion, and we are seeing a lot of that right now. 

On the other hand, I wish there was this strong of an empathic connection and worldwide response to problems like climate change, the murder of black and brown bodies, and the impact of capitalism on class disparities. Interestingly, each of these intersects with the effects of COVID-19, especially the disparity of the impact on (and deaths of) black folks in our country.

No matter how we process and move through this situation, many feel its impact as a trauma. While we work to validate our clients’ experiences and help them make sense of something entirely unprecedented, it is also important to remember that this situation impacts different people very differently. The disparities affecting various marginalized populations are amplified during this time. It is crucial to acknowledge the potentially devastating impact on the LGBTQIA+ community, especially on transgender and gender nonbinary (TGNB) individuals, many of whom are no strangers to trauma and grief. More background on this can be found in The Affirmative Couch’s course Gender Minority Stress and Resilience in Transgender and Gender Nonbinary Clients. 

How our LGBTQIA+ clients might experience a compounded impact of grief and/or trauma related to COVID-19:

Physical distancing in unsafe and/or unaffirming living situations due to quarantine 

• College students who were suddenly asked to leave campus
• Those in domestic violence or other abusive home environments
• People who have not disclosed or come out to their families/housemates

Social isolation due to the pandemic

• Being physically distant from one’s chosen family or an affirming environment (e.g., at a university)
• Being unable to explore communities or experiences that might be affirming, such as closed, limited, or postponed LGBTQIA+ centers and Pride month activities

Lack of resources to access safe space and online support for LGBTQIA+ Clients

• Limited resources to pay for stronger Internet connection, or lack of multiple devices
• Lack of privacy or safe space to seek online support or therapeutic help
• Food, housing, or job insecurity during this time

COVID-19 factors specific to TGNB people

• Canceled or postponed lifesaving gender-affirming surgeries
• Barriers to beginning gender-affirming hormones, monitoring bloodwork, and receiving preventative affirming healthcare
• Risk of misgendering via phone/video and distress/dysphoria of seeing one’s face via video conference
• Inability to affirm one’s gender expression due to lack of support and/or awareness of other household members
• Limited or no access to gender-affirming haircuts (i.e., hair can make or break someone’s experience of dysphoria on a given day)
• Increased body insecurity and disordered eating in response to the fatphobia strengthened by this crisis; you can read more about this in my article At the Intersection of Fat & Trans

How therapists can help our LGBTQIA+ clients during the coronavirus crisis: 

The impact of each of these concerns is amplified for those with intersecting marginalized identities related to, for instance, race, class, ability, and mental/physical health status. To make matters worse, many of our clients experience anticipatory grief for the continued losses ahead as well as for the uncertainty of when things will “return to normal.” Here are some ways in which we might help our LGBTQIA+ clients, especially members of the TGNB community, to navigate this situation and find ways to practice self-compassion, gratitude, and hope. 

Supporting LGBTQIA+ Clients with boundaries during the pandemic

 This is not an “opportunity” for people to do the things for which they don’t usually have time. “Productivity porn” is shame-inducing for many who are experiencing this situation as a trauma. It is okay to limit time spent on consuming the news and social media. To paraphrase an important sentiment, this is not just remote work. You are at home during a pandemic crisis and attempting to work.

Providing validation for LGBTQIA+ clients

Acknowledge to your clients that employing all self-care strategies possible still may not help beyond simply keeping them afloat during this time. Surviving a traumatic experience takes an extreme emotional and physical toll, and it’s okay if clients’ eating habits and bodies change, if they sleep more than usual, and if they struggle to get work done. 

Helping LGBTQIA+ Clients Develop Self-compassion

I can’t emphasize enough how important it is for our clients to be mindful and self-compassionate. Whatever thoughts, feelings, and behaviors emerge during this time make sense given the impact of collective traumas. Even if someone acts in a way that is inconsistent with their values, they are still worthy of self-nurturance and connection. You can learn more about these concepts through The Affirmative Couch’s course Helping Transgender and Gender Nonbinary Young Adults Develop Self-Compassion. 

Finding and Celebrating little moments of joy and gratitude with LGBTQIA+ clients

• Ask clients to reflect on a vulnerable moment where they were able to nurture themselves or others
• What was one show/movie/podcast/song that made them smile or laugh? 
• What is one thing they’re looking forward to in the upcoming week? 
• What are three things about the past week for which they felt most grateful?
• Direct them to some of the many inspirational, hopeful, and positive ways in which people have been expressing themselves and creating via social media. 

Finding meaning and connection

• Can clients volunteer virtually? Reach out to someone who is more isolated? Offer to drop off groceries for an elderly neighbor?
• What creative talents might be employed to help others? 
• Engage clients in storytelling and/or writing–expressive writing exercises like these can be particularly useful–to help work through their feelings
• If they have financial resources, what organizations might benefit from their support?
• Connect virtually with supportive others, especially in spaces that are queer- and trans-affirming. Balance their socializing with meaningful conversation and moments of fun
• Help your clients explore whether local or statewide LGBTQIA+ organizations are running online groups and support spaces, and/or offering other forms of connection

Looking for Hope for the future (i.e., not focused on a specific time when things return to “normal”)

• Who is the first person a client can’t wait to hug again?
• What restaurant are they excited to go to first?
• For students, how will it feel to step back onto campus again?
• What is the first event/trip/appointment they’re looking forward to rescheduling?

A final note: These points are important for clinicians to keep in mind as well. We need these reminders now more than ever. Most of us are not at our best right now, and it is foolish to pretend to our clients that we are. This is a time for us to hold that we are all human, and that authenticity models for our clients why it is important to be less hard on themselves for struggling. At the very least, consider reading this “Dear Therapists” blog post. 

References

Berinato, S. (2020, Mar 23). That discomfort you’re feeling is grief. Harvard Business Review. Retrieved from https://hbr.org/2020/03/that-discomfort-youre-feeling-is-grief 

Thebault, R., Tran, A.B., & Williams, V. (2020, Apr 7). The coronavirus is infecting and killing black Americans at an alarmingly high rate. The Washington Post. Retrieved from: https://www.washingtonpost.com/nation/2020/04/07/coronavirus-is-infecting-killing-black-americans-an-alarmingly-high-rate-post-analysis-shows/?arc404=true  

Patton, S. (2020, Apr 11). The pathology of American racism is making the pathology of the coronavirus worse. The Washington Post. Retrieved from: https://www.washingtonpost.com/outlook/2020/04/11/coronavirus-black-america-racism/

Tucker, M. (2019). Gender minority stress & resilience in TGNB clients. Retrieved from: https://affirmativecouch.com/product/gender-minority-stress-and-resilience-in-transgender-and-gender-nonbinary-clients/

Tucker, M. (2019) At the intersection of fat & trans. The Affirmative Couch. Retrieved from: https://affirmativecouch.com/at-the-intersection-of-fat-trans/

Ahmad, A. (2020, Mar 27). Why you should ignore coronavirus-inspired productivity pressure. The Chronicle of Higher Education. Retrieved from: https://www.chronicle.com/article/Why-You-Should-Ignore-All-That/248366

Tucker, M. (2019) Helping TGNB young adults develop self-compassion. The Affirmative Couch. Retrieved from: https://affirmativecouch.com/product/helping-transgender-and-gender-nonbinary-young-adults-develop-self-compassion/

Pennebaker, J.W., Blackburn, K., Ashokkumar, A., Vergani, L., & Seraj, S. (2020). Feeling overwhelmed by the pandemic: Expressive writing can help. The Pandemic Project. Retrieved from: http://exw.utpsyc.org/#tests

Katy (2020, Mar 21). Dear therapists. Navigating Uncertainty Blog. Retrieved from: https://navigatinguncertaintyblog.wordpress.com/2020/03/21/dear-therapists/

Learn more about affirmative therapy with addyson tucker, PsyD (they/them)