In recent years, both the ethics and efficacy of affirmative mental healthcare have been debated on a national stage. In 2022 alone, Florida state legislators have proposed a “Don’t Say Gay” bill, Alabama passed a law outlawing gender-affirming medical or mental healthcare for teens, and more than a dozen states like Ohio have followed in their wake. Conservative lawmakers feel that things have “gone too far” by allowing transgender and gender nonbinary (TGNB) people access to care that validates their identity, especially youth, and are using their power and influence to limit that access.

While these dog whistles may be daunting, it is important for mental health providers to have all the evidence when making decisions about clinical care. To be clear: the literature of the field strongly reflects that providing gender-affirming care is associated with positive outcomes for TGNB clients. In this article, we will address arguments against providing affirmative care and summarize recent evidentiary support and best practices.

Criticisms of gender-affirming care

A common criticism of gender-affirming care is that children and adolescents are not mature enough to self-identify their gender. Any psychotherapist with an understanding of human development can easily debunk this claim. According to the work of Lawrence Kohlberg, a foundational theorist in the field of psychology, children develop a sense of gender identity as early as preschool (Sravanti & Sagar K, 2019). Many gender-expansive youth opt to socially transition long before entering puberty, though the standard approach in our field is that of “watchful waiting,” in which the child’s medical team closely observe their exploration of gender until puberty (Ehrensaft et al., 2018).  In contrast, a gender-affirmative approach stresses the importance of self-identification by allowing the child to socially transition at any age, access puberty blocking medication if desired, and pursue medical transition after the onset of puberty (Ehrensaft, 2017). Both of these approaches have been heavily researched in recent years, yet the public consensus remains that we don’t (or can’t) know enough to establish gender-affirming care as a best practice.

One reason is that concerns about regret and detransition abound — though there is a paucity of research to support this. One study of adults who identify as transgender in the United Kingdom found that out of 175 individuals, only 12 reported detransitioning in the 16 months after receiving cross-gender hormone treatment (Hall et al., 2021). Out of that already small sample, only two patients reported feeling regret (Hall et al., 2021, p. 7). However, many clinicians actually recommend against further research on detransition or “desistance” rates, stating that it contributes to public mistrust and skepticism without serving youth. Academics have raised concerns about the methodology of desistance studies, as well as the working definition of “gender identity” that is used by other researchers, as lacking consensus may muddy the waters (Brooks, 2018). 

Research in support of gender-affirming care

So how do we reach this consensus? Emerging research strongly indicates that affirmative care improves the mental health of transgender and gender nonbinary clients. A 2021 study of 104 TGNB youth at Seattle Children’s Hospital found that receiving gender-affirming interventions such as puberty blockers or gender-affirming hormones was associated with 60 percent lower odds of moderate to severe depression and 73 percent lower odds of self-harm or suicidal thoughts during their first year of involvement in gender care (Tordoff et al., 2022). A recently published secondary analysis of the 2015 United States Transgender Survey found that out of over 3,500 respondents reporting gender-affirming surgeries in the prior two years, undergoing surgery was associated with lower past-month psychological distress and was not associated with greater lifetime risk of suicidality (Almazan & Keuroghlian, 2021). The authors of this analysis answer earlier concerns about the methodology of “desistance” studies by controlling for baseline mental health status in their work (Almazan & Keuroghlian, 2021). 

Similarly, a 2018 study published in JAMA Pediatrics found that out of 68 trans masculine patients undergoing chest reconstruction (top surgery), only one reported experiencing regret “sometimes” (Olson-Kennedy et al.). This study found no statistically significant differences between participants who underwent top surgery before age 18 and those who had surgery as adults (Olson-Kennedy et al.). The inverse effect can be observed when taking the impact of the COVID-19 pandemic into consideration — an international survey of 964 TGNB people conducted between April and August 2020 found that 55 percent of respondents experienced reduced access to gender-affirming resources, and this was correlated with higher prevalence of depression, anxiety, and suicidal ideation (Jarrett et al., 2020). 

Conclusions

The literature of the field reflects clear conclusions: increasing access to gender-affirming care improves mental health outcomes, and limiting access negatively impacts them. Our profession’s division over best practices for the mental healthcare of TGNB clients has laid the groundwork for public uncertainty, as well as legislative harm. It is crucial that we continue to pursue research into mental health outcomes for TGNB clients and publish these findings in ways that are accessible outside of academia — not hidden behind a paywall or requiring institutional access. For cisgender psychotherapists, we need leverage our privilege and be generous with our labor, sharing this information with friends, family, colleagues, and writing to our elected representatives. It is an issue worth the extra time and effort, and can have life-altering consequences.

Learn more about working with transgender and nonbinary clients

References

Almazan, A. N., and Keroughlian, A. S. (2021, April 28). Association between gender-affirming surgeries and mental health outcomes. JAMA Surgery 156 (7), 611-618.

Brooks, J. (2018, May 23). The controversial research on ‘desistance’ in transgender youth. 

Ehrensaft, D. (2017). Gender nonconforming youth: current perspectives. Adolescent Health, Medicine, and Therapeutics (8)1, 57-67.

Hall, R., Mitchell, L., and Sachdeva, J. (2021, October 1). Access to care and frequency of detransition among a cohort discharged by a UK national adult gender identity clinic: retrospective case-note review. British Journal of Psychiatry 7(6), 1-8. 

Jarrett, B. A., Peitzmeier, S. M., Restar, A., Adamson, T., Howell, S., Baral, S., and Beckham, S. W. (2020, November 4). Gender-affirming care, mental health, and economic stability in the time of COVID-19: a global cross-sectional study of transgender and non-binary people. medRxiv: the preprint server for health sciences (2), 1-32.

Olson-Kennedy, J., Warus, J., Okonta, V., Belzer, M., and Clark, L. F. (2018, May). Chest reconstruction and chest dysphoria in transmasculine minors and young adults: Comparisons of nonsurgical and postsurgical cohorts. JAMA Pediatrics 172(5), 431-436.

Sravanti, L., and Sagar K, J. V. (2019). Gender Identity: Emergence in Preschoolers. Journal of Psychosexual Health I(3-4), 286-287. 

Tordoff, D. M., Wanta, J. W., Collin, A., Stepney, C., Inwards-Breland, D. J., and Ahrens, K. (2022, February 25). Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care. JAMA Pediatrics (5)2, 1-13.

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

Self-Disclosure and Community Building

We know that LGBTQIA+ community members are resourceful and resilient. We also know about startling disparities in the mental health of queer and trans individuals v. that of cisgender and heterosexual ones. As a queer femme clinical social worker who has spoken openly and published about my own lived experience of major depression and trauma–thereby “coming out” many times over the years–I posit that normalizing such experiences through mindful self-disclosure benefits LGBTQIA+ therapists and can make for healthier workplaces. One way in which we can help de-stigmatize lived experience among clinicians, as I will explore in this article, is by building online community via social media. My hope is that, through establishing online outlets for support and authentic discussion with other lived-experience practitioners, LGBTQIA+ psychotherapists living with mental health conditions ourselves can build stronger and genuinely thriving communities of practice.

Self-Disclosure in Clinician Communities

Therapist self-disclosure (TSD) has been examined and categorized in specific ways in extant literature, and clinicians may be familiar with some terminology surrounding immediate v. non-immediate TSD; deliberate v. unavoidable TSD; and accidental, inappropriate, and client-initiated TSD (Alfi-Yogev et al, 2020, Zur, 2009) to clients. Some literature also explores disclosure to and identification with LGBTQ+ clients, and how this shows up both in queer and TGNB community as well as in relational practice (Hansbury and Bennett, 2014). But the possibilities for positive change when we share about our own lived experience with other practitioners, particularly via social media, have not been explored at length.
In other words, we can easily find commentary and research on the risks and benefits of TSD to clients. But what about the risks and benefits of disclosure within communities of practice, i.e. among therapists in a clinic or group practice setting–or between clinicians and workers such as certified peer specialists, whose lived experience is a requirement of their position because it is seen as a strength (Byrne et al., 2016, Marino & Child, 2015)? King et al. (2020) frame mental health professionals with lived experience as an underutilized resource, one whose presence and authenticity can help lessen stigma and foster healthier mental health service-oriented workplaces overall. At the same time, practitioners such as peer specialists face “the unique challenges of…being professionally isolated, feeling outnumbered and ostracised,” especially when few of them are employed in a given workplace (Moran et al., 2013, as cited in Byrne et al., 2016, p. 11).

Self-Disclosure and Resilience

First, we might consider here the stress induced by identity concealment, and how research has shown that the pressure of hiding our true selves as LGBTQIA+ people results in negative psychological responses associated with PTSD (Alessi & Martin, 2017). Support from online communities can potentially help mitigate these stressors for those of us who are both queer and living with mental health conditions, allowing for therapists with lived experience to be seen and valued for the unique gifts we bring to the workplace.

While self-help models have long been grounded in the principles of discussing lived and shared experiences, and peer models can indeed be enhanced by self-disclosure (Psychopathology Committee of the Group for the Advancement of Psychiatry, 2001), it seems that few conversations are happening about how TSD among practitioners–LGBTQIA+ ones in particular–can benefit us. Yet I have found that my own self-disclosure has led to my sense of increased authenticity and even self-efficacy. This is especially salient considering that lived experience is a form of expertise, albeit one that is frequently undervalued in mental health care professions, unto itself.

Mindful Self-Disclosure

In exploring the idea of online TSD, we may consider that some transparency is simply unavoidable, as it would be if we were living in a small town; in fact, Zur (2015) conceptualizes the Internet as a “global village.” This is particularly relevant to social media use–in addition to shared physical social spaces–among LGBTQIA+ community, which tends to be surprisingly small and deeply interconnected even in major metropolitan areas such as my hometown of New York City.

Both Zur (2015) and Longley (2021) caution that therapists may not be aware of the information clients have uncovered about them online, thus leaving them unable to appropriately address unintentional disclosures in session. Clinicians considering issues of disclosure around lived experience will want to bear this in mind. If we operate from the assumption that our clients as well as our colleagues have read any- and everything we have written for publication, online or off, we will be better prepared for the possibility of our authentic selves to show up in the therapy room as well as the conference room–or the Zoom rooms! Further conversations about self-disclosure from different intersections have been explored in previous articles published by The Affirmative Couch by Mandy Simmons and Jerry St. Louis. 

Online Communities for Therapists

We might look to Facebook and Twitter for an idea of what intentional social media-based disclosures within communities of practice can look like. Both are homes to LGBTQIA+ mental health discussions in the forms of groups and chats, but it can be difficult to find dedicated space to share support around being a queer therapist with lived experience. Frustrated with the lack of such spaces, I started a small, private Facebook group in early 2020, inviting a few clinicians I knew who had openly shared their status as peers. The intention was to create a safer space in which we could discuss our work and lives. Some themes that have emerged include professionally navigating dual identities as clinicians and peers; potential over-identification with clients with similar lived experiences; and how much disclosure, and to whom, feels safe. With fewer than 20 members at present, the group is low-traffic, but an available and hopefully growing resource for LGBTQIA+ therapists with lived experience.

Risks and Benefits of Online TSD

The risks and benefits of TSD in terms of client impact is familiar terrain in the literature. Risks include violating boundaries and burdening the client with extraneous personal information that detracts from focus on the client, while benefits include potentially enhancing trust and strengthening the therapeutic alliance (Alfi-Yogev et al., 2020; Johnsen & Ding, 2021; Lehavot, 2010; Longley, 2021; Moody et al, 2021; Psychopathology Committee of the Group for the Advancement of Psychiatry, 2001; Zur, 2009). Some psychotherapeutic modalities, including dialectical behavior therapy (DBT) and relational therapy, may better lend themselves to TSD than others, such as traditional psychoanalytic models (Hansbury and Bennett, 2014; Psychopathology Committee of the Group for the Advancement of Psychiatry, 2001).
Worth noting, per Lehavot et al. (2010), is the tension of the generational divide between therapists born into an Internet-savvy world v. those born prior to the Internet’s omnipresence, and how this can factor into differing attitudes about online TSD. Generational and cultural differences persist, and different schools of thought on privacy-related values may clash. Traditional psychotherapeutic views on self-disclosure, online or off, may certainly err on the side of conservatism and eschew clinician authenticity; after all, in classical psychoanalysis, “self-disclosure was thought to result in gratification of patients’ wishes rather than analysis of them” (Psychopathology Committee of the Group for Advancement of Psychiatry, 2001, p. 1489).

Meantime, more modern viewpoints support that some self-disclosure can provide role modeling and confirm what is already publicly available online, thereby deepening trust with clients (Johnsen & Ding, 2021). Therapists who choose to disclose should be mindful about their rationale and have thoughtful responses at the ready, considering that revealing a diagnosis can elicit bias from clients, colleagues, and employers. This is why I encourage us all to reflect on the validity of lived experience as a form of expertise, and consider sharing pertinent literature–such as some of the articles in the below reference list–as tools for further learning.

Further Recommendations 

Further education can help those who harbor bias and stigmatize individuals with lived experience unlearn harmful attitudes, and perhaps even their own internalized oppression. It is difficult to locate any data regarding the risks and benefits of LGBTQIA+ therapists themselves disclosing to each other, whether online or in person. What we do know is that LGBTQIA+ community members frequently use social media to discuss their mental health concerns and care. Interestingly, researchers have found social media usage to be both a risk factor for and a protective factor against depression for LGB people. Per Escobar-Viera et al. (2018), who draw on the Meyer minority stress model, social media can be conducive to the formation of social support and connection among queer folks, thereby encouraging stress reduction and forming protective factors against depression. At the same time, social media use can also foster social comparison and yield experiences of cyberbullying and stigmatization, leading to such negative outcomes as lowered self-esteem and symptoms of depression (Escobar-Viera et al., 2018).

Perhaps we can extrapolate some ideas from existing literature about the general benefits of sharing in alleviating self-stigma. Normalizing disclosure among not only “lived experience practitioners,” such as certified peer specialists, but also licensed mental health clinicians can provide both personal and community-wide benefits, eliminating feelings of isolation, being outnumbered and stigmatized in the workplace, and easing distress around identity concealment (Byrne et al., 2019; King et al., 2020). When we, as LGBTQIA+ clinicians, share about our lived experience and provide support to each other online, discussing our experiences of workplace challenges, we can make it more feasible for ourselves and each other to disclose to colleagues in our clinics, agencies, and organizations. This kind of effort can lead to further understanding of diverse experiences, identities, and states of mind, which ultimately benefits everyone.

Conclusions

Research on this topic moving forward should focus on the outcomes and benefits of disclosure in online communities formed specifically for this purpose–to provide support for queer and trans clinicians with lived experience. Worth noting is my own positionality in writing this article as a white cis femme for whom being doubly “out” as queer and having mental health-related diagnoses is, in some ways, relatively safe. Risks may be more significant for community members facing multiple forms of marginalizations; it is crucial to take an intersectional lens to the impact of self-disclosure and social media use on, for instance, LGBTQIA+ Black, Indigenous, and people of color communities (BIPoC) (Marino & Child, 2015). Future directions in research should address this when also examining how disclosure and authenticity in the workplace–i.e. outpatient clinics, group practices, and agency-based settings–benefits LGBTQIA+ clinicians with lived experience.

Learn more about working with LGBTQIA+ Clients

References

Alfi-Yogev, T., Hasson-Ohayon, I., Lazarus, G., Ziv-Beiman, S., & Atzil-Slonim, D. (2020). When to disclose and to whom? Examining within-and between-client moderators of therapist self disclosure-outcome associations in psychodynamic psychotherapy. Psychotherapy Research, 1–11.

Alessi, E. J., & Martin, J. I. (2017). Intersection of trauma and identity. In K. L. Eckstrand & J. Potter (Eds.), Trauma, resilience, and health promotion in LGBT patients (pp. 3–14). Springer. DOI 10.1007/978-3-319-54509-7_1

Byrne, L., Roennfeldt, H., Davidson, L., Miller, R., & Bellamy, C. (2021). To disclose or not to disclose? Peer workers impact on a culture of safe disclosure for mental health professionals with lived experience. Psychological Services. https://doi.org/10/gj7w6r

Escobar-Viera, C. G., Whitfield, D. L., Wessel, C. B., Shensa, A., Sidani, J. E., Brown, A. L., Chandler, C. J., Hoffman, B. L., Marshal, M. P., & Primack, B. A. (2018). For better or for worse? A systematic review of the evidence on social media use and depression among lesbian, gay, and bisexual minorities. JMIR Mental Health, 5(3), e10496. https://doi.org/10.2196/10496

Hansbury, G., & Bennett, J. L. (2014). Working relationally with LGBT clients in clinical practice: Client and clinician in context. In Relational social work practice with diverse populations (pp. 197–214). Springer.

Johnsen, C., & Ding, H. T. (2021). Therapist self-disclosure: Let’s tackle the elephant in the room. Clinical Child Psychology and Psychiatry, 26(2), 443–450. https://doi.org/10/gmvf8w

King, A. J., Brophy, L. M., Fortune, T. L., & Byrne, L. (2020). Factors affecting mental health professionals’ sharing of their lived experience in the workplace: A scoping review. Psychiatric Services, 71(10), 1047–1064. https://doi.org/10/gk87w8

Lehavot, K., Barnett, J., & Powers, D. (2010). Psychotherapy, professional relationships, and ethical considerations in the MySpace generation. Professional Psychology: Research and Practice, 41, 160–166. https://doi.org/10/btg4mw

Longley, H. (2021). A psychotherapist’s experience of self-disclosure, when practising in the digital era: A heuristic self-study [PhD Thesis]. Auckland University of Technology.

Marino, C. “Khaki,” Child, B., & Campbell Krasinski, V. (2016). Sharing Experience Learned Firsthand (SELF): Self-disclosure of lived experience in mental health services and supports. Psychiatric Rehabilitation Journal, 39(2), 154–160. https://doi.org/10/f8rkjh

Moody, K. J., Pomerantz, A. M., Ro, E., & Segrist, D. J. (2021). “Me too, a long time ago”: Therapist self-disclosure of past or present psychological problems similar to those of the client. Practice Innovations. https://doi.org/10/gmvf8x

Moran, G. S., Russinova, Z., Gidugu, V., & Gagne, C. (2013). Challenges experienced by paid peer providers in mental health recovery: a qualitative study. Community Mental Health Journal, 49(3), 281-291.
Psychopathology Committee of the Group for the Advancement of Psychiatry. (2001). Reexamination of therapist self-disclosure. Psychiatric Services, 52(11), 1489–1493. https://doi.org/10/bnhpwc

Zur, O., Williams, M. H., Lehavot, K., & Knapp, S. (2009). Psychotherapist self-disclosure and transparency in the Internet age. Professional Psychology: Research and Practice, 40(1), 22. https://doi.org/10/bss28g

Zur, O. (2015). The Google factor: Psychotherapists’ intentional and unwitting self-disclosure on the net. Zur Institute. http://www.zurinstitute.com/onlinedisclosure.htm

Before getting into this article, I would like to locate myself. I am a white, bisexual, able-bodied, ambiamorous, cisgender woman with anxiety and a chronic illness who has been in both monogamous and polyamorous relationships. As someone who identifies as bisexual, has navigated both polyamorous and monogamous relationships, and specializes in working with these communities, I believe that it is important for clinicians to understand the unique experiences of bisexual polyamorous individuals.

As an affirmative therapist throughout the COVID-19 pandemic, I have worked with clients with marginalized identities who have been experiencing higher-than-baseline levels of anxiety and depression due to the pandemic. This has filtered into much of our work, even if their primary presenting problem was originally to navigate their sexual orientation or relationship orientation, or to navigate concerns within their relationships. COVID-19 has highlighted the fact that, as clinicians, it is important to recognize that our clients’ identities do not exist in a vacuum – just as our own identities do not exist in a vacuum. Therefore, it is always important to take into account the impact of both internal and external factors in clients’ lives while working with them – as well as how our own experiences may or may not come into the therapy room. 

Potential Benefits of Polyamory for Bisexual Clients

Bisexuality has been defined as “the potential to be attracted – romantically and/or sexually – to people of more than one gender, not necessarily at the same time, not necessarily in the same way, and not necessarily to the same degree” (Ochs, n.d.). Studies show that bisexual people prefer polyamorous or open relationships in greater frequency than people of other sexual orientations (Weinberg, Williams, & Pryor, 1994). One benefit of polyamory for bisexual people is: “polyamory and bisexuality propose a plurality of loves, both in the number of partners and genders thereof” (Anderlini-D’Onofrio, 2004). Polyamory can be a beautiful thing for many bisexual individuals who want to add diversity to their sexual and romantic lives with people of more than one gender. 

However, they don’t always have a “preference” in their partner’s gender; it is more about the people they are dating and how polyamory enhances their lives. In fact, 70% of bisexual polyamorous participants in one study did not care whether their partners were of the same or different genders at any one time (Weitzman, 2006). Their preference for polyamory, therefore, may come from the fact that more bi-identified men and women tend to believe that monogamy in relationships is less enhancing and more sacrificing than gay-identified or straight-identified individuals (Mark, Rosenkrantz, & Kerner, 2014). 

Bisexual Erasure and Strategic Identities

Polyamory offers an exceptional way to provide a buffer against bi erasure or invisibility and challenges the risk of falling into heteronormativity (Robinson, 2013). In fact, non-monogamy has been identified as a “strategic identity” to maintain bisexual visibility in the world (Klesse, 2011; Moss, 2012; Robinson, 2013; Weitzman, 2006). A strategic identity is an identity that serves a political, social, or interpersonal function. In this case, the function of polyamory could be visibility and support of bisexuality as an authentic identity. When bisexual individuals can express their identity more fully and be visibly bisexual, especially in the context of a polyamorous relationship, they also tend to have more: 

• Freedom to have partner choices of all genders, 
• Freedom to speak openly about the full range of their attractions and fantasies,
• Opportunities for group sex, and 
• Sexual and romantic enjoyment of different genders. 

Therefore, if bisexual individuals engage in polyamorous relationships, they can express their sexuality more freely – both for themselves and within the larger world. 

Potential Disadvantages of Polyamory for Bisexual Clients

There are also unique disadvantages to being both bisexual and polyamorous. These individuals may be doubly stigmatized as “confused” or “promiscuous” (McLean, 2011; Weitzman, 2006). They may experience prejudice and discrimination from both the gay and straight communities (e.g., prejudice from gay partners about other-gender partners; prejudice from straight partners about same-gender partners). This internalized stigma and biphobia from partners (either monosexual or bisexual partners) can also lead to potential increased rates of intimate partner violence. Turell, Brown, and Herrmann (2017) found that bi-negativity and the oversexualization of bisexual individuals was a risk factor for higher rates of jealousy and IPV. This risk was highlighted by bisexual participants who are also polyamorous. 

On an individual level, bisexual people may experience guilt about reinforcing the stereotype that “bisexual people aren’t/can’t be monogamous.” And, they may also experience their own or others’ misperceptions that same-gender relationships are somehow less important than other-gender relationships (Weitsman, 2006). 

As clinicians, it is our duty to challenge these cognitions if we have any of them; by reinforcing these stereotypes, we would be harming our bisexual clients as well. We can challenge our own thoughts and feelings through: 

• Being curious about clients’ lived experiences
• Identifying and being curious about our own reactions and expectations for our clients’ lives
• Reading, following, and engaging with media created by bisexual polyamorous folx 
• Educating ourselves about the reality of bisexuality and polyamory
• Seeking supervision or consultation with another polyamory-affirmative clinician

Clinical Work with Bisexual Polyamorous Clients

Having explored the potential advantages and disadvantages of polyamory for bisexual individuals, clinicians will hopefully be better positioned to provide a safe space for their bisexual polyamorous clients. Helping bisexual polyamorous clients with their relationships may include talking about safer sex practices with many genders, assessing for biphobia, assessing and creating safety plans for IPV, as well as addressing any other clinical issues.

Clinical work may include an exploration of how competition shows up in their relationships (if it does at all). Some partners of bisexual individuals may take comfort in knowing that they are currently the only person of a particular gender that the person is dating; therefore, they may feel as though there is less of a risk of their bisexual partner leaving them. For others, they may be acutely aware that their body is different from that of their metamours’; therefore, they may be concerned about never being able to fulfill a particular role or sexual desire for their partner (Armstrong & Reissing, 2014).

In doing this work, affirmative clinicians should also be on the lookout for any potential biphobia or IPV within a relationship. Couples’ therapy or multi-partner relationship therapy is not recommended in cases where IPV is prevalent. 

Unique Stressor: A “Choice” 

Bisexual polyamorous people also often are asked to make a choice between a partner and their relationship orientation. This is because potential other-sex partners of bisexual individuals tend to have expectations of monogamy (Armstrong & Reissing, 2014). This decision is a frequent reason couples end up in my office: one person craves non-monogamy, while the other can only envision a monogamous relationship for themselves. This is not always related to one person having a bisexual identity, but it can be one aspect of mono-poly relationship experiences. When faced with a monogamous-minded partner, some bisexual individuals do end up feeling like they have to make a choice, and may explore their options in our office. Some questions a bisexual client may be struggling with are:  

• Do I stay in a monogamous relationship, or do I go? 
• What does this say about my identity? 
• Am I being true to myself?
• What will my community think?
• Will I be rejected from bisexual spaces or polyamorous spaces? 
• Would I be a “sell-out” for choosing a partner of one gender or choosing a monogamous relationship? 

Bisexual erasure happens to bisexual folx all the time; it is a weight we often feel, even if we aren’t expressing it. Therefore, an affirmative clinician should try to be aware of both the explicit and implicit choices that a client may be making when they are exploring the pros and cons of their relationship structures and how they are designing their relationships. While polyamory may help some bisexual folx combat bi erasure and be more visible, it also brings other difficulties with it. There is no one “correct” way to structure relationships, but exploring the various options, benefits, and disadvantages with bisexual individuals may help clients find the best choice for themselves and live more authentically in their life. 

References 

Anderlini-D’Onofrio, S. (2004). Plural loves: Bi and poly utopias for a new millennium. Journal of Bisexuality, 4, 1-6, doi:10.1300/J159v04n03_01

Armstrong, H. L. & Reissing, E. D. (2014). Attitudes toward casual sex, dating, and committed relationship with bisexual partners. Journal of Bisexuality, 14, 236-264. doi:10.1080/15299716.2014.902784

Klesse, C. (2011). Shady characters, untrustworthy partners, and promiscuous sluts: Creating bisexual intimacies in the face of heteronormativity and biphobia. Journal of Bisexuality, 11, 227-244. doi:10.1080/15299716.2011.571987

Mark, K., Rosenkrantz, D., and Kerner, I. (2014). “Bi”ing into monogamy: Attitudes toward monogamy in a sample of bisexual-identified adults. Psychology of Sexual Orientation and Gender Diversity, 1(3), 263-269. doi:10.1037/sgd0000051

McLean, K. (2011). Bisexuality and nonmonogamy: A reflection. Journal of Bisexuality, 11, 513-517. doi:10.1080/15299716.2011.620857

Moss, A. R. (2012). Alternative families, alternative lives: Married women doing bisexuality. Journal of GLBT Family Studies, 8(5), 405-427. doi:10.1080/1550428X.2012.729946

Ochs, R. (n.d.). Bisexual: A few quotes from Robyn Ochs. Retrieved from https://robynochs.com/bisexual/

Robinson, M. (2013). Polyamory and monogamy as strategic identities. Journal of Bisexuality, 13(1), 21-38. doi:10.1080/15299716.2013.755731

Turell, S. C., Brown, M., & Hermann, M. (2017). Disproportionately high: An exploration of intimate partner violence prevalence rates for bisexual people. Sexual and Relationship Therapy, 33, 113-131. doi:10.1080/14681994.2017.1347614

Weinberg, M., Williams, C., & Pryor, D. (1994). Dual attraction: Understanding bisexuality. New York, NY: Oxford Press. 

Weitsman, G. (2006). Therapy with clients who are bisexual and polyamorous. Journal of Bisexuality, 6, 137-164. doi:10.1300/J159v06n01_08

Check Out Stephanie’s CE Courses on working with polyamorous clients

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

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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 

Crystal Meth & the Gay Community

Crystal meth has had a devastating effect on the gay community. Over the last 20 years, meth has grown into a catastrophic force, contributing to about 15% of all drug death overdoses (NIDA, 2019). Gay and bisexual men use methamphetamines at a higher rate than heterosexual men (Lea et al., 2017). As a result, it is safe to assume that a high percentage of crystal meth overdoses come from within the LGBTQIA+ community.

Crystal Meth & HIV

Further, crystal meth has played an instrumental role in the increase of HIV infection rates. “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). During use, the neurotransmitter dopamine floods parts of the mesolimbic dopaminergic pathway in the brain, which regulates feelings of pleasure (CSAT, 2009). 

Considered a club or party drug, crystal meth is often used by young adults and teenagers to stay awake (Dowshen, 2018). In addition, a common effect shared by gay and bisexual men during crystal meth use is an insatiable sexual appetite. 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. In other words, crystal meth can produce feelings of confidence, power, and invulnerability on a psychological level. Subsequently, the aforementioned increased sexual desire can overpower necessary activities of daily living like bathing and going to work. 

Crystal Meth & Chemsex

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. Since the use of crystal meth lowers one’s inhibitions, meth 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-metabolized 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, 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., 2008). 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). For example, Black men reported a higher rate of usage of methamphetamines than white men and less enrollment in treatment (Saloner & Le Cook, 2013). 

Moreover, 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

Meanwhile, there are not enough affirmative treatment facilities for substance use treatment of Black Gay men. For example, of the eight crystal meth treatment facilities in New York designed for gay and bisexual male patients, seven of them are located in Manhattan. Therefore, this imposes severe geographical demographic limitations. Substance abuse is significantly more prevalent among those living in poverty, as are most of the risk factors for drug abuse (Nakashian, 2019). For instance, 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). As a result, this forces those who are seeking help to search outside of their neighborhoods for treatment and services. Furthermore, traveling outside of one’s neighborhood can be intimidating and present a culture shock. Certainly, culture can play a dynamic role in patient and provider engagement.  

Need for more accessible mental health care

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). Above all, providers who understand the cultural intricacies and experiences of Black men who use crystal meth can be instrumental in their recovery.

Being client centered 

In order to keep treatment for crystal meth and other substance use client-focused, affirmative therapists can draw on Rogers’ approach to treatment. Therapists must allow clients to use the therapeutic relationship in their own way (Client-centered therapy, 2006). Certainly, 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. In short, crystal meth addiction is a disease that shows no cultural biases. As a result, mental health providers must ensure that our services reflect that.

Learn More

References 

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/

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://www.publish.csiro.au/sh/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://linkinghub.elsevier.com/retrieve/pii/S0306460307002122

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://dx.plos.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. http://www.healthaffairs.org/doi/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/. 

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.

Learn more about working with LGBTQIA+ Clients

References

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. http://doi.apa.org/getdoi.cfm?doi=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

“Grant me the serenity to accept the things I cannot change, the courage to change the things that I can, and the wisdom to know the difference.”

In 12-step treatment settings, the Serenity Prayer often makes an appearance at the beginning or end of a group session in substance abuse treatment. Drawn from the Christian tradition, reciting this prayer is intended to unite group members, reminding them to make the small choices every day that will help them maintain their sobriety from substance use. Some things, like developing healthy coping skills, are within the client’s control. With access to resources, a supportive sober community, and for many, clinical treatment, recovery from substance abuse can and does happen. 

But what about those things that are outside of our clients’ control? For many LGBTQIA+ people, factors like homophobia, transphobia, family rejection, and discrimination complicate the recovery process. These systemic forces weigh on our clients along with the pressures of finding a support network, managing basic needs like shelter and food, and learning new coping skills for cravings and mental health symptoms. While recent years have seen an increase in resources allocated for people in recovery, navigating this system can be challenging. It can also be isolating as an LGBTQIA+ person to successfully start treatment for substance abuse, only to arrive on day one and be the only queer and/or trans person in the room. How can a client find sober support when they feel singled out? And how can they mitigate the overtly Christian themes of 12-step and other sober communities as a queer and/or trans person?

Affirmative Substance Abuse Treatment

As treatment providers, it is important for us to practice cultural humility and establish competence in LGBTQIA+-affirming therapy in our substance use treatment. The 2018 National Survey on Drug Use and Health revealed that in sexual minority adults–those who described themselves as lesbian, gay, or bisexual–37.6% reported marijuana use in the past year, compared with 16.2%  in the general population (Drugabuse.gov). This suggests that it is likely that many of your clients identify as part of the LGBTQIA+ community, and will be looking to you to cultivate an environment that is both affirming of their identities and informed about how substance abuse may impact their community differently. While this process of learning and unlearning is a lifelong commitment to growing your clinical practice, starting to research and reflect is a great place to start.

Barriers to Accessing Affirmative Treatment

Using a barriers model to accessing treatment, there are several elements that may deter LGBTQIA+ clients from seeking services. First, to reiterate, substance abuse treatment is often heavily rooted in Christianity. While many in recovery find comfort in finding a higher power and drawing strength from their faith community, for others, the church has historically been a place of harm and rejection. The idea alone of going to an Alcoholics Anonymous meeting in the basement of a church might feel like walking into the lion’s den. AA and other 12-step groups also often use literature like the Big Book and daily devotionals that have been criticized for their gendered language and heteronormative themes. This may lead LGBTQIA+ clients to feel as though they do not fit into the recovery community.

Similarly, many treatment programs themselves are gendered. From settings such as sober housing to residential treatment, as well as within intensive outpatient programs (IOPs) and partial hospitalization programs (PHPs), many groups are gender segregated. Veteran treatment providers may remember the original logic for this decision as preventing group members from starting romantic relationships while in treatment, or perhaps to give clients a “safe place away from the opposite sex.” We know now that this line of thinking is flawed: it erases the existence of same-sex relationships. 

While many treatment programs do recommend that clients refrain from starting new relationships while they are in the vulnerable period of early recovery, it is naïve to think that two members of a women’s discussion group could not start dating. Additionally, that “safe place” we are trying to establish for our clients must also take into account gender-expansive identities. How can we properly serve our transgender and non-binary clients if we only offer women’s and men’s treatment programs? If you are at the level of executive leadership in your agency, asking these questions is a good place to start in establishing accessible and equitable treatment provision.

LGBTQIA+ Communities & Substance Abuse Treatment

It is also important for clinicians to understand how substance abuse can impact different populations within the LGBTQIA+ community. Since the 1970s, for example, the vasodilator inhalant “poppers” has been a club drug popular among gay men, as it can produce a euphoric effect and relax smooth muscle in the body, making sex more pleasurable (Hall et al., 2014). Other club drugs, like methamphetamines and cocaine, have been commonly used among gay and bisexual men as well (Hazelden Betty Ford, 2016). Similarly, when considering substance use in social settings, research indicates that lesbians and gay men are less likely to abstain from alcohol use than their straight counterparts, with lesbian and bisexual women reporting more frequent heavy drinking (Green & Feinstein, 2013).

Further, it is worth noting that for LGBTQIA+ clients, seeking substance abuse services is an issue of access to healthcare. According to Faces and Voices of Recovery, a 2017 survey by the National Institute on Drug Abuse (NIDA) found that 77% of respondents identifying as gay, lesbian, or bisexual, and only 57% of those identifying as transgender, have access to affordable healthcare (Pennelle, 2019). While many substance abuse treatment agencies are funded by state programs like Medicaid, and do not require that clients have health insurance, others do require coverage. Still more are private-pay only, and can get quite expensive. For someone who is contemplating starting treatment, finding out that they are not able to afford it or that a state-funded program has a long wait list can be enough to push them back to a state of precontemplation.

As we know that substance abuse affects the LGBTQIA+ community at higher rates, and that it can impact various LGBTQIA+ populations differently, service provision may seem like a daunting task. Whether your role is as a case manager, a therapist, or a program director, there are a number of resources that you can offer to your clients as they start their recovery journey. While the best place to start is by making changes within your own agency, you may also want to review community resources. One place to start is calling 211, a nationwide service provided by the United Way. Whether you call or go online for information, a trained resource navigator can help you to identify LGBTQIA+ specific resources like sober support group meetings, sober housing, and more. Keeping in mind that many queer clients may not feel comfortable going to traditional 12-step meetings, an alternative to consider is SMART Recovery. This program uses a non-denominational approach to promote sobriety using science- and evidence-based interventions, and may appeal to clients seeking a peer support group without religious overtones. Another option may be looking into support groups or other resources through your local LGBTQIA+ center, or services on campus at your local college or university.

Changing the Things We Can As Therapists

Revisiting the idea of the Serenity Prayer, we as clinicians do not have to accept the things we cannot change in the substance abuse treatment community. There are real, tangible actions we can take to make services more equitable and accessible for our LGBTQIA+ clients. Whether you are part of executive leadership or a newly hired clinical staff member, you can and should educate yourself about how substance abuse impacts your queer clients. Remember: recovery can and does happen. It is up to us to help identify and remove institutional barriers, and help our clients get what they need to do it.

Affirmative Organizational Development Consulting for Substance Abuse Treatment Centers

The Affirmative Couch offers affirmative organizational development consulting for substance use treatment centers 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 ways in you can become more affirmative in your services for LGBTQIA+ community members. We provide a needs assessment and a community narration evaluation to begin exploring the gaps in service delivery to these communities and how this lines up (or doesn’t) with the mission and values of your organization. Our technical report will review our findings from these tools, offer next steps, and provide the foundation for your ongoing training with The Affirmative Couch. 

Through this empowered approach, you will have everything you need to make systemic change in all areas of your treatment center from your paperwork to administrative procedures and from staff training and transforming organizational culture. We are here to answer questions to enhance your learning on your journey to becoming an affirmative treatment center.

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

Learn More About Addiction and LGBTQ Clients

References

Butler Center for Research. (2016, January 1). Substance Abuse Factors Among LGBTQ Individuals. Retrieved October 11, 2020, from https://www.hazeldenbettyford.org/education/bcr/addiction-research/lgbtq-substance-abuse-ru-116. 

Green, K. E., & Feinstein, B. A. (2012). Substance use in lesbian, gay, and bisexual populations: an update on empirical research and implications for treatment. Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors, 26(2), 265–278. https://doi.org/10.1037/a0025424. 

Hall, T. M., Shoptaw, S., & Reback, C. J. (2015). Sometimes Poppers Are Not Poppers: Huffing as an Emergent Health Concern Among MSM Substance Users. Journal of Gay & Lesbian Mental Health,19(1), 118-121. doi:10.1080/19359705.2014.973180

National Institute on Drug Abuse. (2020, August 25). Substance Use and SUDs in LGBTQ* Populations. Retrieved October 11, 2020, from https://www.drugabuse.gov/drug-topics/substance-use-suds-in-lgbtq-populations. 

Pennelle, O. (2019, August 16). LGBTQ+ Recovery Resources. Retrieved October 11, 2020, from https://facesandvoicesofrecovery.org/blog/2019/08/16/lgbtq-recovery-resources/. 

Rapp, R. C., Xu, J., Carr, C. A., Lane, D. T., Wang, J., & Carlson, R. (2006). Treatment barriers identified by substance abusers assessed at a centralized intake unit. Journal of substance abuse treatment, 30(3), 227–235. https://doi.org/10.1016/j.jsat.2006.01.002

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)

Alison Picard, MA, AMFT

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.

Learn more about working with LGBTQIA+ Clients

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Blum, S. (2020, Mar 7). How Coronavirus Is Affecting the LGBTQ+ Community, From Drag Queens to the HIV+. Them.

Burns, K. (2020, Mar 18). Campuses shutter for coronavirus, leaving some LGBTQ students with nowhere to go. Vox. 

Green, A.E., Price-Feeney, M. & Dorison, S.H. (2020). Implications of COVID-19 for LGBTQ Youth Mental Health and Suicide Prevention. New York, New York: The Trevor Project.

Kuhr, E. (2020, April 5). Coronavirus pandemic a perfect storm for LGBTQ homeless youth. NBC News.

Lang, N. (2020, Mar 26). Coronavirus Is Exposing How the Health Care System Neglects LGBTQ People. Vice.

Loffman, M. (2020, April 7). Asian Americans describe ‘gut punch’ of racist attacks during coronavirus pandemic. PBS News Hour.

Loggins, K. (2020, Mar 19). As Hospitals Prepare for COVID-19, Life-Saving Trans Surgeries Are Delayed. Vice.

Taub, A. (2020, April 6). A New Covid-19 Crisis: Domestic Abuse Rises Worldwide. NYTimes.

Wynne, G. (2020, April 7). How To Safely Chest Bind Amid Coronavirus Concerns. Bustle. 

As we approach winter and prepare for “hibernation,” diet culture and fatphobia often kicks into high gear.  Family meals, holiday parties, and New Year’s resolutions surround us, regardless of whether we celebrate, and become fertile ground for fat shaming. The “holiday season” is already hard enough for many LGBTQIA+ folx*. It can also be an exceptionally dangerous time of year for fat folx, as well as those who experience disordered eating. (Note: See my previous article, At The Intersection of Fat & Trans, for further descriptions of fatphobia and weight stigma).

*Folx is an alternative spelling of folks, meant to represent inclusivity in a way similar to terms such as womxn and latinx.

Did she just say fat? 

Yes, you read that correctly. “Fat” is not a bad word, though it’s often wrapped in a framework of shame. How often do those with larger bodies get unsolicited weight management or weight loss advice? When a person says, “Ugh, I’m so fat,” how quickly do we jump in to dismiss their experience and try to make them feel “better”? Our response to a friend who has lost a significant amount of weight (e.g., “wow, you look great!”) differs  significantly from the response to a friend who has gained weight (e.g., “I’m concerned about your health”). The messages we get from diet culture, the media, and most other humans is that fat=lazy, bad, ugly, and unhealthy, versus thin=fit, good, desirable/attractive, and healthy. 

But surely queer and trans communities are less fatphobic?

Unfortunately, members of LGBTQIA+ communities have not quite embraced fat liberation yet. Many activists and theorists have spoken to fatness as a queer and feminist issue, as well as discussing fatphobia in the queer and trans community (e.g., Mollow, 2013). For example, consider trans and nonbinary folx who feel pressure to shrink their bodies to avoid being misgendered, gay men who indicate “no fats, no femmes” on their dating profiles (Conte, 2018), and queer women who are called fat bitches or fat dykes when they turn down someone’s advances.

As in most intersectional social justice work, the impact is often worse for people of color (Strings, 2019). For further reading, please see Fearing the Black Body by Sabrina Strings (2019).  Mollow writes, “Anti-racist, feminist, and queer activists must make fat liberation central to our work; we need to explicitly and unequivocally reject the notion that body size is a ‘lifestyle choice’ that can or should be changed” (for further reading, please see The Bizarre and Racist History of the BMI; Your Fat Friend, 2019).

What should I keep in mind for my clinical work? 

During the holidays, people are bombarded with messages on how to avoid weight gain, ways to “eat smart” during holiday meals, and what workouts are most effective to keep one’s body at its “best” (read: smallest). If all else fails, resolution season arrives with plenty of reduced-fee gym memberships, exercise programs, and diet plans. Many gatherings with family and friends are centered around food. Unfortunately, those in our immediate circles often believe our food intake and how our bodies have changed since they last saw us are fair game for dinner conversation. This behavior is almost always a wolf in sheep’s clothing–fat shaming and food policing thinly veiled by “I care about your health.” It also often connects to the commenter’s insecurity and their own internalized fatphobia or beliefs about what their body should look like, what they should be eating, etc.

While these experiences happen to people of all shapes and sizes, this kind of commentary is more frequent and insidious for fat folx, as most people are conditioned to believe that we are less worthy if we are fat or at risk of becoming fat. LGBTQIA+ people, who already approach the holidays feeling worried about various family dynamics, lack of acceptance, and/or outright homophobia/transphobia, might need support to develop a game plan. (Note: Please also check out earlier pieces written about this topic by Chastain, 2014a; 2014b; Mollow, 2013; Murphy, unknown; Raven, 2018; and Rutledge & Hunani, 2018.)

Here are some possible topics to address fatphobia with your clients:

 1) Make a choice about attending, if optional

With my LGBTQIA+ clients, we first consider whether going to visit certain family members and/or attending various holiday events is physically and emotionally safe. If not, could they spend the holiday with chosen family? If there is no ideal alternative or the person is sure they want to go, I empower their decision and encourage them to approach the situation with a grounded sense of self, giving themselves permission to step back and engage in self-care as needed; see #6 below.

2) Define boundaries and potential consequences

This part is crucial. Boundaries are as simple as what is okay and what is not okay. Help your client identify their boundaries and the potential consequences if those boundaries are crossed. Make sure they feel comfortable following through with these (e.g., don’t threaten to leave if it’s not a feasible option). For example, “What I’m eating is fine. Please stop commenting on my food choices. If it happens again, I’m going to excuse myself from the table.” Encourage them to practice the boundary setting in advance, preparing for best versus worst case scenario with particularly difficult individuals. Finding the humor, even if they’re the only one in on the joke, can sometimes help. You might check out Oh, Boundaries (Oh, Christmas Tree) Song Adaptation (Chastain, 2016).

3) Pregame conversations

Once the client knows what their boundaries are, they might consider reaching out to trusted family, friends, or the event host in advance. For example, they could send a text or blind copy email that says, “Hi family, just a reminder that I am working on loving my body at all sizes and practicing intuitive eating. My body has also changed slightly since I started taking hormones, so please do not make any comments about my food choices, my body, or my weight when I am home next week. Appreciate your understanding – see you soon!” This gives those individuals an opportunity to prepare and learn more rather than responding defensively in the moment. If this approach may not be well received by everyone in attendance, could the client identify one or two trusted folx who will have their back if the conversation turns to weight and body talk? 

4) Address internalized fatphobia

One of the toughest parts of resisting fatphobia and diet culture is our cultural internalized stigma and belief that fat is bad. Help your clients see the roots of fatphobia in racism, misogyny, and oppression (that is, while remaining attentive and attuned to their experiences of internalized body shame). Firstly, remind your clients that no one has the right to comment on their body or food choices. If they struggle to comfort and care for themselves, you might ask them to imagine those external comments and internal shame narratives impacting a close friend or a young sibling.

Above all, food is not good or bad. That is to say, being fat is not bad, and body size is not a determinant of health, worth, or desirability. We can feel uncomfortable with certain parts and features of our body (hello, dysphoria) without harming or hating the parts of our body that help us to survive. Bodies experience natural fluctuations in weight throughout the year. People can make whatever choices they want about their bodies and food. That includes making decisions for themselves about whether to engage in diet behavior or body modification, as well as whether to embrace fat liberation, health at every size, and intuitive eating philosophies. It also might include examining their social media consumption to critically examine which accounts activate internalized self-judgment and shame while shifting toward those that engage in transformational and affirming conversations about bodies, fashion, and food.

5) Prepare ways to respond

Helping our clients advocate for themselves is an important component of recovering from diet culture and internalized fatphobia. LGBTQIA+ people have often been expected to perform in certain placating ways when interacting with hurtful others. “Too often we get the message that as [LGBTQIA+ people], it’s our responsibility to always be ‘on’–to always advocate for the cause, or to behave ‘properly,’ or to keep the peace. We’re told that it’s our job to endure demonizing sermons and degrading misgendering in the name of ‘dialogue’ or whatever. But we don’t have to.” (Murphy, unknown).

 Therefore, when responding to fatphobic comments and questions such as, “Should you really have a second serving?” each person needs to think about what might work best for them depending on whether they’d like to shut the conversation down or potentially open it up for further dialogue.

Here are some examples of responses: 

•        Short & sweet, then continue to eat (e.g., “Yes, I should.”)
•       Humor & sarcasm (e.g., “If I want to talk to the food police, I’ll call Pie-1-1”; Chastain, 2014)
•       Firm boundaries (e.g., “I get to make my own food choices – it’s not okay for you to comment on them. Please stop, or I will leave the table.”) 
•       Authentic curiosity (e.g., “What made you decide to comment on what I eat?”)
•       Reflect on diet culture (e.g., “Isn’t it interesting how shaming it is when we comment on others’ bodies and food choices?”)
•       Self-reflection (e.g., “Those types of comments are really hurtful, and I know there are times I’ve commented on your food choices as well–I’d like us to stop doing that.”) 
•       Reframe and shift (e.g., “I wonder if you think those types of comments come from a place of caring. They actually make me feel shame and the desire to pull away from you. Let’s focus on catching up and enjoying our time together.”)
•       Ignore and move through discomfort – It is always an option to decide not to respond, not to speak up, and to instead move through and take care of yourself in other ways. Sometimes this is the safest option emotionally and/or physically.
•       A potential dilemma – It can be hard to meet family and friends where they are, especially when the conversations are painful. Making the decision to educate someone is always optional, as the other person should take responsibility for educating themselves (and this goes for various other social justice matters, such as racism). At some point, many of us have made value judgments and comments about others’ food choices or body size based on our internalized shame around diet culture and fatphobia. It can take some time and energy to adjust those patterns of thinking. Bottom line: there is a difference between healthy, respectful, and curious discourse versus harmful and fatphobic comments, questions, and behaviors. Hence, the need for boundaries.

6) Have an exit strategy (i.e. self-care plan)

In many cases, setting a firm boundary and following through with the consequence should be quite effective. However, sometimes these responses may do little or nothing to stop others from perpetrating harmful microaggressions and fatphobic judgments. In those cases, it is good for your client to have a plan for self-care, considering the following:

•       Permission giving – If things don’t feel good, can they give themselves permission to be prepared to leave if necessary?
•       Take space – go for a walk, play with the kids or pets, watch a movie, listen to music, etc.
•       Get support – Does the client have a friend who “gets it” and can be available to call or text? Or can the client log onto social media and check out some of the dietitians, bloggers, clinicians, and influencers who focus on fat liberation and intuitive eating (see resource list at the end of this article)? 
•       Practice validation & self-compassion:
•       Duality: It’s okay to care about someone while also being disappointed or hurt by their behaviors and comments. 
•       Remember: Setting boundaries is a healthy way to show our expectations of love and respect for people who matter. 
•       Forgive themselves: It makes sense that they are tempted to go along with the comments–it is hard to speak up against diet culture and fatphobia.
•       Validation: Many LGBTQIA+ people struggle around this time of year with difficult family interactions; they are not alone. 
•       Self-nurturance: Clients can use affirmations such as, “I am worthy. I am enough. My body is worthy at all sizes. I deserve to be treated with respect and common human dignity. It’s okay to protect myself from fatphobic comments.” 

How can I continue to learn about fat liberation and radical self-love to support my clients? 

•       Practice radical body love and fat acceptance–for yourself and others! It doesn’t mean you will successfully love all parts of your body all the time, but it sure will help. 
•       Consider anti-diet and intuitive eating practices all year round–they can be life changing. 
•       Actively reduce and aim to eliminate diet talk, which often serves to shame people and essentially teaches us to avoid at all costs becoming a “bad fat person.” 
•       Rather than praising bodies that have thin privilege or seem to have lost weight, consider finding other ways to let people know we appreciate them. 
•       Instead of using descriptors that are pathologizing (“overweight” suggests there is a lower weight that is normal/better/good), stick with actual descriptors that help us to understand (such as “fat”). When possible, check in with others about the descriptors that work for them and what words they prefer.
•       Surround yourself with social media and images of fat people of all races and abilities, appreciating the beauty and diversity of the human body. 
•       “If previously you have ruled out fat people as potential sexual partners, rule them back in, and rule out ‘fatphobes’ instead” (Mollow, 2013).
•       Make choices for your body that feel good for you, and only you. Give your body size permission to vary with time, hormones, and many other factors. 
•       Be mindful of where your clients are in terms of their readiness for discussions related to diet culture and internalized fatphobia; as with any other intervention, gauge helpfulness as well as observing their body language as you move through.

A final note for those of you who are already anti-diet and practicing fat acceptance: It takes so much courage to move through these conversations with our clients, friends, and family members who don’t quite understand (yet!). Keep doing this work, because it matters. You matter. Thank you for persisting. 

Suggested Resources

Online & Social Media (Note: @ = Instagram handle):

@ragenchastain & https://danceswithfat.org/blog; @chr1styharrison & Food Psych podcast; @yrfatfriend; @recipesforselflove & book; @bodyposipanda; @mynameisjessamyn; @jazzmynejay; @livinginthisqueerbody; @mermaidqueenjude; @ihartericka; @thefatsextherapist; @decolonizingtherapy

 NOLOSE – Originally the National Organization for Lesbians of Size – later expanded to include all genders. Has a queer fat-positive ideology. http://nolose.org  

 Strings, S. (2019). Fearing the black body: The racial origins of fat phobia. New York University Press. New York, NY.

 Taylor, S. R. (2018). The Body is Not an Apology: The Power of Radical Self-Love. Berrett-Koehler Publishers, Inc: Oakland, CA.

Your Fat Friend. (2019). The bizarre and racist history of the BMI. Medium – Elemental. Retrieved from: https://elemental.medium.com/the-bizarre-and-racist-history-of-the-bmi-7d8dc2aa33bb

Learn more from addyson tucker‘s continuing education courses

References

 Baker, Jes. (2015). How to stay body positive during the holidays: Master list. The Militant Baker. Retrieved from:http://www.themilitantbaker.com/2015/12/the-how-to-stay-body-positive-during.html 

 Conte, M. T. (2018). More fats, more femmes: A critical examination of fatphobia and femmephobia on Grindr. Feral Feminisms: Queer Feminine Affinities, 7.https://feralfeminisms.com/wp-content/uploads/2019/04/3-Matthew-Conte.pdf 

 Chastain, R. Blog – Dances with fat: Life, liberty, and the pursuit of happiness are for all sizes. 

•       Combating holiday weight shame. (2014a).https://danceswithfat.org/2014/11/20/combating-holiday-weight-shame/
•       Dealing with family and friends food police. (2014b)https://danceswithfat.org/2014/11/24/dealing-with-family-and-friends-food-police/
•       Setting holiday boundaries – in song! (2016).https://danceswithfat.org/2016/12/14/setting-holiday-boundaries-in-song/
•       Dealing with diet season. (2018a).https://danceswithfat.org/2018/01/05/dealing-with-diet-season/
•       Resources for surviving fatphobia at the holidays. (2018b).https://danceswithfat.org/2018/12/24/resources-for-surviving-fatphobia-at-the-holidays/

 McKelle, E. (2014). Cutting fatphobic language out of your life. Everyday Feminism. Retrieved from:https://everydayfeminism.com/2014/04/cutting-fatphobic-language/ 

 Mollow, A. (2013). Why fat is a queer and feminist issue. Bitch Media. Retrieved from:https://www.bitchmedia.org/article/sized-up-fat-feminist-queer-disability 

 Murphy, B. (unknown). 8 queer tips to get through the holidays. Queer Theology. Retrieved from: https://www.queertheology.com/queer-holiday-tips/ 

 Raven, R. (2018). 6 ways to deal with fat-shaming during the holidays, from someone who knows what it’s like. Hello Giggles. Retrieved from:https://hellogiggles.com/lifestyle/health-fitness/6-ways-to-deal-fat-shaming-during-holidays/ 

 Rutledge, L., & Hunani, N. (2018). Take it from dietitians: Holiday diet advice shouldn’t be fatphobic. Huffington Post. Retrieved from: https://www.huffingtonpost.ca/lisa-rutledge/holiday-diet-advice-weight-loss_a_23621979/ 

 Tucker, M. (2019). At the intersection of fat and trans. The Affirmative Couch Out on the Couch. https://affirmativecouch.com/at-the-intersection-of-fat-trans/  

LGBTQ+ caregivers of older adults (generally people age 60+) are a special population in need of support and affirmative care. These family members and friends provide unpaid physical and/or emotional assistance to spouses and partners, parents, friends–some of whom were former partners–siblings, and neighbors. While temporary caregiving for others, when one is recovering from surgery, injury, or illness, can take place at any stage of life and is challenging in many ways, caregiving for older adults can last for many years. This article will explore the issues that some LGBTQ+ caregivers experience in the course of caring for elders.

My own experiences with working with caregivers

I have had the privilege, during my years of practice in the field of aging, of facilitating support groups for caregivers seeking out assistance. The members of my groups have openly shared their innermost thoughts and feelings about giving care with me and with each other. They have expressed feeling that there is no end in sight as more and more of their time and energy becomes consumed with caring for a loved one who will never get better–only worse. Some members have participated in these groups for years on end as they witness the gradual decline of their care recipients due to dementia, medical frailty, cancer, or Parkinson’s disease.

All of these caregivers find that their friends and acquaintances just don’t understand what they are going through and the toll that giving care takes on them. They have relied on each other, and on a trained social worker who holds space in the group setting, to help them navigate the increasingly challenging situations they encounter. When providers become more well-versed in understanding experiences of unpaid caregiving in LGBTQ+ communities, people like these can get better care and more support outside of a group setting. So here are a few things to bear in mind about these generous, caring, and often severely stressed-out individuals.

Unique considerations with LGBTQ+ caregivers

First, it is common for queer and trans people who are not related by blood or marriage to care for each other. In fact, former romantic partners will sometimes become caregivers. Mainstream service providers may not be accustomed to this, and community members have reported encountering a lack of understanding about why an ex-partner would remain closely connected. But the formation of familial relationships among our loving LGBTQ+ communities is commonplace; a number of my LGBT older adult clients have considered their exes to be family members. It is important that providers include anyone an older adult has designated as a caregiver in health care decision making processes–and also that providers recognize the significant strain such caregivers may experience.

That strain can manifest in a number of different ways and lead to negative social and health outcomes. Providing physical, emotional, and financial support for a loved one while putting one’s own needs on the back burner time and again leads to exhaustion and isolation. And LGBTQ+ caregivers face risk factors beyond those commonly experienced by non-LGBTQ+ caregivers. For instance, LGBTQ+ adults who are childless are often expected to take on all of the responsibility of caring for aging cisgender and heterosexual parents. But they may also have faced a historic lack of acceptance, potentially entailing verbal and/or physical abuse, from those parents. And same-sex partners and spouses may still face significant discrimination in the medical, senior services, and institutional settings in which their loved ones receive care.

Supporting LGBTQ+ caregivers

Without adequate support and without anyone to help share the care, caregivers risk burning out. While LGBTQ+-specific groups can be difficult to find outside of SAGE: Advocacy and Services for LGBT Elders’ NYC headquarters, caregiver support programs are available in every state. The National Family Caregiver Support Program (NFCSP), a federal initiative, provides grants to fund not only support groups but case management and some respite and supplemental services. This means that local resources–from assistance with information, benefits and entitlements, and referrals to limited financial help paying for home care and medical supplies–are available to all unpaid caregivers.

Further, an important piece of legislation affecting caregivers has been enacted in roughly 40 states so far. The CARE (Caregiver Advice, Record, and Enable) Act, known by a different name in some states, requires hospitals to ask patients, at the time of their admission, if they would like to designate someone as their caregiver. Whatever the relationship of the caregiver to the patient, the hospital must then record the caregiver’s name in the medical record, notify the caregiver of patient discharge, and provide training for performing medical tasks once the patient is home. This is an important legal consideration for LGBTQ+ caregivers without a formal or documented relationship to their care recipients.

For further reading on this topic, check out the selection of caregivers’ resources at the National Resource Center on LGBT Aging.

Learn more from Teresa Theophano, LCSW

References

Stewart, D. B., & Kent, A. (2017). Caregiving in the LGBT Community: A Guide to Engaging and Supporting LGBT Caregivers through Programming. Retrieved September 29, 2019, from https://www.lgbtagingcenter.org/resources/resource.cfm?r=883.