Out On The Couch
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.
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!
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. https://doi.org/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://doi.org/10.1016/j.whi.2018.03.002
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.
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://doi.org/10.1071/SH17159
Halkitis, P. N., & Jerome, R. C. (2008). A comparative analysis of methamphetamine use: black gay and bisexual men in relation to men of other races. Addictive behaviors, 33(1), 83–93. https://doi.org/10.1016/j.addbeh.2007.07.015
Harawa, N. T., Williams, J. K., Ramamurthi, H. C., Manago, C., Avina, S., & Jones, M. (2008, October). Sexual behavior, sexual identity, and substance abuse among low-income bisexual and non-gay-identifying African American men who have sex with men. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2574823/.
Lea, T., Kolstee, J., Lambert, S., Ness, R., Hannan, S., & Holt, M. (2017). Methamphetamine treatment outcomes among gay men attending a LGBTI-specific treatment service in Sydney, Australia. PloS one, 12(2), e0172560. https://doi.org/10.1371/journal.pone.0172560
Molitor, F., Truax, S. R., Ruiz, J. D., & Sun, R. K. (1998). Association of methamphetamine use during sex with risky sexual behaviors and HIV infection among non-injection drug users. The Western journal of medicine, 168(2), 93–97.
Nakashian, M. (2019, July 26). Substance Abuse Policy Research Program. Robert Wood Johnson Foundation. https://www.rwjf.org/en/library/research/2012/01/substance-abuse-policy-research-program.html
NIDA. 2019, May 16. Methamphetamine DrugFacts. Retrieved from https://www.drugabuse.gov/publications/drugfacts/methamphetamine on 2020, December 28
NIDA. 2020, September 18. Principles of Effective Treatment. Retrieved from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/principles-effective-treatment on 2020, December 31
Saloner, B., & Lê Cook, B. (2013). Blacks and Hispanics are less likely than whites to complete addiction treatment, largely due to socioeconomic factors. Health affairs (Project Hope), 32(1), 135–145. https://doi.org/10.1377/hlthaff.2011.0983
Wakefield, L., Maurice, E. P., Parsons, V., & Smith, R. (2019, June 26). This is why people drink their own urine after taking drugs. PinkNews. https://www.pinknews.co.uk/2018/04/30/urine-drugs/.
LGBTQIA+ Affirmative Mental Health During the Pandemic
The stress and anxiety wrought by the COVID-19 pandemic may be universal–so many of us face fears of the virus itself, not to mention job loss, illness striking our loved ones, and myriad missed social, professional, and financial opportunities–but all of us experience these differently. Just as everyone’s mental health needs are unique, therapy is not one size fits all. LGBTQIA+ clients in particular need to work with therapists who can understand and validate the unique experiences impacting their emotional wellbeing. Although no one is immune to the detrimental psychosocial effects of the pandemic, LGBTQIA+ clients can face some identity-specific challenges that make affirmative therapy especially crucial at this time.
Affirmative Psychotherapy & Unsupportive Families During the Lockdowns
These include extended time with family of origin and overall decreased social interaction. Pandemic-induced social isolation can hit LGBTQIA+ individuals harder, as many queer and trans people have strained relationships with their families of origin and thus rely heavily on friendships and chosen families for support. Being stuck in toxic family environments due to the pandemic, and enduring sustained lack of contact with friends, can constitute a dangerous combination for any client. LGBTQIA+ people living with family members who don’t respect their gender identity or sexuality may find their mental health negatively affected. This experience can also contribute to dysphoria and has been linked to substance abuse (Newcomb, 2019).
Affirmative Therapy & Lack of Social Connections During COVID-19
Further, lack of social connection is linked to suicidality, for which LGBTQIA+ populations are already at higher risk (Kaniuka, 2019). Prolonged feelings of loneliness can be self-perpetuating; when we feel disconnected, we might start to doubt our ability to connect with others, and we avoid opportunities for socializing out of fear. Happily, ongoing therapy sessions with a therapist who “gets it” and makes us feel seen can serve as a form of connection and help break the cycle of isolation. As we know well, the therapist’s office should be the one place in which clients don’t have to worry about appearing awkward or facing judgment. It can serve as a safer space in which a client can brush up on rusty social skills and build confidence.
Finally, more free time and solitude can make space for greater self-reflection, which may in turn bring up complex emotions in clients just discovering their sexuality and/or gender identity. It’s important for therapists to welcome discussions of these realizations with curiosity and validating support, whether we fully understand them or not. Other difficult topics that can emerge during extended periods of solitude and self-reflection–the trauma related to minority stress that so many LGBTQIA+ people face, for instance–may be challenging to navigate on one’s own but can provide rich fodder for the virtual therapy room as well.
Training in Affirmative Therapy
Simply put, now more than ever, LGBTQIA+ clients need therapists who can treat them without bias. They may be coming into sessions with a lot of self-doubt about their gender identity and/or sexuality. They may have wanted support before now, but perhaps did not feel confident approaching a provider due to the double stigma of being LGBTQIA+ and having a mental health condition. If you are an affirmative provider who is welcoming a client like this into your practice, congratulations on ensuring a safer space. Taking the time to get training in best practices for working with LGBTQIA+ communities makes you an invaluable resource for clients and a genuine lifeline during this unbelievably challenging time.
Alessi, E. J., Dillon, F. R., & Van Der Horn, R. (2019). The therapeutic relationship mediates the association between affirmative practice and psychological well-being among lesbian, gay, bisexual, and queer clients. Psychotherapy (Chicago, Ill.), 56(2), 229–240. https://doi.org/10.1037/pst0000210
Feder, S., Isserlin, L., Hammond, N. Norris, M., & Seale, E. (2017). Exploring the association between eating disorders and gender dysphoria in youth, Eating Disorders, The Journal of Treatment and Prevention, 25:4, 310-317, DOI: 10.1080/10640266.2017.1297112
Johnson, K., Vilceanu, M. O., & Pontes, M. C. (2017). Use of Online Dating Websites and Dating Apps: Findings and Implications for LGB Populations. Journal of Marketing Development and Competitiveness, 11(3). Retrieved from https://articlegateway.com/index.php/JMDC/article/view/1623
Kaniuka, A., Pugh, K. C., Jordan, M., Brooks, B., Dodd, J., Mann, A. K., … & Hirsch, J. K. (2019). Stigma and suicide risk among the LGBTQ population: Are anxiety and depression to blame and can connectedness to the LGBTQ community help? Journal of Gay & Lesbian Mental Health, 23(2), 205-220.
Newcomb, M.E., LaSala, M.C., Bouris, A.,Mustanski, B., Prado, G., Schrager, S.M., & Huebner, D.M. (2019). The Influence of Families on LGBTQ Youth Health: A Call to Action for Innovation in Research and Intervention Development. LGBT Health, 6:4, 139-145. DOI: http://doi.org/10.1089/lgbt.2018.0157
“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!
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
Keywords: queer, LGBTQ, LGBTQIA, impostor syndrome, impostor, cognitive behavioral therapy, CBT, core beliefs
I thought I identified one way, but now I’m not sure. What if this really was just a phase?
I’m afraid I won’t like all of the changes medical transition will cause to my body. What if I’m not really trans?
Can I still be bisexual if I’ve never dated someone of the same gender?
Our clients seek therapy for a variety of reasons, but commonly, they are struggling to mitigate their own core beliefs with external influences. These may include family, friends, partners, or society at large–for LGBTQIA+-identified folks, how we see ourselves can often conflict with how the world interprets us. This type of invalidation can lead to self-doubt for many people, even making them question whether they are frauds or impostors. As therapists, our goal is to help clients identify and challenge their negative core beliefs, to challenge these external influences and find internal validation.
The theory of Impostor Syndrome originates from a 1978 paper from Georgia State University that examined the phenomenon in more than 150 “high-achieving women” (Clance & Imes). The authors found that in their psychotherapy practices, women often presented with “scholastic honors, high achievement on standardized tests, praise and professional recognition from colleagues and respected authorities,” yet did not report “an internal feeling of success” (Clance & Imes, 1978). Rather, these clients felt like “impostors,” as though they were given undue praise or accolades they did not deserve.
In recent years, Impostor Syndrome has entered the lexicon as a common experience among millennials. A 2013 article by Weir at the American Psychological Association examined the experiences of graduate students and suggested that for many, there is “‘confusion between approval and love and worthiness. Self-worth becomes contingent on achieving.” This attitude is compounded by factors like gender, sexuality, disability, class, and race, with impostor feelings being a strong predictor of future mental health problems among college students of color (Cokley et al., 2013).
Similarly, impostor feelings often pop up in psychotherapy with millennial clients, particularly those with one or more marginalized identities. In our culture, certain roles or industries are often referred to as a “boys’ club”–as these spaces were built by and designed for white, heterosexual, cisgender men, anyone who varies from this norm can feel like they don’t belong. Higher education is just one example of a much more global dynamic.
For LGBTQIA+-identified people, impostor feelings are often less about achievement and more about community. Many people find comfort in the use of labels or identity words–such as gay, lesbian, bisexual, transgender, genderqueer, gender non-binary, and more–to describe themselves and their sexuality and gender. For someone who is just starting to explore their identity, finding a community of people who have been where they are can be healing and fulfilling. But what if none of the labels fit quite right? Or what if your experience differs from that of your friend, or even of your partner?
Though it is often said that “comparison is the thief of joy,” human beings are prone to noticing the similarities and differences between themselves and others. It can feel isolating to know that how you identify differs greatly from someone else. But this is where we as therapists can employ cognitive behavioral therapy to help our clients change their thinking and develop their senses of internal validation.
One example might be a therapist working with a client who identifies as a cisgender woman and a lesbian. At the first appointment, the client shares, “I’ve only dated women since coming out in college. Lately I’ve noticed myself looking at men differently than before, and it’s confusing. If I’m attracted to guys, am I still a lesbian?”
From what this client is saying, she sees the problem as confusion about her identity. It is worth exploring with the client what being a lesbian means to her, and furthermore, what it would mean if she were to identify differently. Often, this is where impostor feelings start to surface: if I’m not this, then what? I must have been faking. I don’t really belong here.
Using the framework of cognitive behavioral therapy, clarifying the client’s core beliefs about herself can be helpful. These are deeply held feelings that are central to our being, and that influence how we see and interact with the world. Core beliefs can be positive or negative, such as “I am worthy” or “I am unworthy,” “I am safe” or “I am unsafe,” “I am good enough” or “I am not good enough.” For this client, the core belief underlying her impostor feelings may be related to belonging, or feeling like she does not belong in her community of friends–or safety, from feeling like she is on the outside.
After isolating a client’s core beliefs, one CBT intervention that can be utilized would be fact-finding, asking the client to provide as many pieces of evidence as they can why their belief is true or untrue. Using our same example, if this client’s impostor feelings trigger the core belief that she does not belong in her community because she is questioning her identity, the therapist and client can list a number of examples of evidence to the contrary.
“Well, my friends will still be my friends no matter what. They have always supported me. That wouldn’t change,” the client offers. “And even if I did have a boyfriend someday, that wouldn’t make me straight. I wouldn’t think that about somebody else in my position.” By talking through this fact-finding process, the client is starting to challenge and reconstruct her core belief of belongingness. It may also be helpful to have a client write down thoughts, beliefs, and evidence in a journal between sessions. This can be a helpful reflective exercise and also encourage clients to use their coping skills outside of therapy.
Core belief work is not always easy, nor is it a quick fix for impostor feelings. Therapy sometimes makes things worse before they get better, and clients can sometimes unearth deep-seated issues in therapy that take time, effort, and dedication to work through. That does not make their effort any less valuable, however, and small changes in the client’s self-perception should be noticed and praised. There may be certain situations or stages of life in which a client feels old impostor feelings starting to emerge again. When they do, it is important for the client to remember that they have control over their own thoughts and feelings, and that they can reconnect with their positive core beliefs.
Clance, P. R., & Imes, S. A. (1978). The Impostor Phenomenon in High Achieving Women: Dynamics and Therapeutic Intervention. Psychotherapy: Theory, Research and Practice, 15(3), 241-247.
Cokley, K., Mcclain, S., Enciso, A., & Martinez, M. (2013). An Examination of the Impact of Minority Status Stress and Impostor Feelings on the Mental Health of Diverse Ethnic Minority College Students. Journal of Multicultural Counseling and Development,41(2), 82-95. doi:10.1002/j.2161-1912.2013.00029.x
Weir, K. (2013). Feel like a fraud? GradPSYCH, 11, 24. doi: https://doi.org/10.1037/e636522013-001
By now, we are all experiencing the impact of the ubiquitous trauma and stress surrounding COVID-19 in some way. What might have started with a distal awareness of the problem quickly snapped to a reality that the world will forever be changed by this virus. You might have also noticed the varying “stages of grief” through which our clients and we ourselves are shifting, the unfortunate stage of denial being the one that has caused the most irrevocable damage to the world.
On the one hand, many may find the universality of this experience comforting–it is rare that everyone on the planet understands the same thing to some degree. The current situation presents a valuable opportunity for emotional validation and a sense of common humanity (i.e., increased self-compassion due to awareness of the common human experience of suffering). It often takes personal experience and connection to a situation to increase empathy and compassion, and we are seeing a lot of that right now.
On the other hand, I wish there was this strong of an empathic connection and worldwide response to problems like climate change, the murder of black and brown bodies, and the impact of capitalism on class disparities. Interestingly, each of these intersects with the effects of COVID-19, especially the disparity of the impact on (and deaths of) black folks in our country.
No matter how we process and move through this situation, many feel its impact as a trauma. While we work to validate our clients’ experiences and help them make sense of something entirely unprecedented, it is also important to remember that this situation impacts different people very differently. The disparities affecting various marginalized populations are amplified during this time. It is crucial to acknowledge the potentially devastating impact on the LGBTQIA+ community, especially on transgender and gender nonbinary (TGNB) individuals, many of whom are no strangers to trauma and grief. More background on this can be found in The Affirmative Couch’s course Gender Minority Stress and Resilience in Transgender and Gender Nonbinary Clients.
How our LGBTQIA+ clients might experience a compounded impact of grief and/or trauma related to COVID-19:
Physical distancing in unsafe and/or unaffirming living situations due to quarantine
- College students who were suddenly asked to leave campus
- Those in domestic violence or other abusive home environments
- People who have not disclosed or come out to their families/housemates
Social isolation due to the pandemic
- Being physically distant from one’s chosen family or an affirming environment (e.g., at a university)
- Being unable to explore communities or experiences that might be affirming, such as closed, limited, or postponed LGBTQIA+ centers and Pride month activities
Lack of resources to access safe space and online support for LGBTQIA+ Clients
- Limited resources to pay for stronger Internet connection, or lack of multiple devices
- Lack of privacy or safe space to seek online support or therapeutic help
- Food, housing, or job insecurity during this time
COVID-19 factors specific to TGNB people
- Canceled or postponed lifesaving gender-affirming surgeries
- Barriers to beginning gender-affirming hormones, monitoring bloodwork, and receiving preventative affirming healthcare
- Risk of misgendering via phone/video and distress/dysphoria of seeing one’s face via video conference
- Inability to affirm one’s gender expression due to lack of support and/or awareness of other household members
- Limited or no access to gender-affirming haircuts (i.e., hair can make or break someone’s experience of dysphoria on a given day)
- Increased body insecurity and disordered eating in response to the fatphobia strengthened by this crisis; you can read more about this in my article At the Intersection of Fat & Trans
How therapists can help our LGBTQIA+ clients during the coronavirus crisis:
The impact of each of these concerns is amplified for those with intersecting marginalized identities related to, for instance, race, class, ability, and mental/physical health status. To make matters worse, many of our clients experience anticipatory grief for the continued losses ahead as well as for the uncertainty of when things will “return to normal.” Here are some ways in which we might help our LGBTQIA+ clients, especially members of the TGNB community, to navigate this situation and find ways to practice self-compassion, gratitude, and hope.
Supporting LGBTQIA+ Clients with boundaries during the pandemic
This is not an “opportunity” for people to do the things for which they don’t usually have time. “Productivity porn” is shame-inducing for many who are experiencing this situation as a trauma. It is okay to limit time spent on consuming the news and social media. To paraphrase an important sentiment, this is not just remote work. You are at home during a pandemic crisis and attempting to work.
Providing validation for LGBTQIA+ clients
Acknowledge to your clients that employing all self-care strategies possible still may not help beyond simply keeping them afloat during this time. Surviving a traumatic experience takes an extreme emotional and physical toll, and it’s okay if clients’ eating habits and bodies change, if they sleep more than usual, and if they struggle to get work done.
Helping LGBTQIA+ Clients Develop Self-compassion
I can’t emphasize enough how important it is for our clients to be mindful and self-compassionate. Whatever thoughts, feelings, and behaviors emerge during this time make sense given the impact of collective traumas. Even if someone acts in a way that is inconsistent with their values, they are still worthy of self-nurturance and connection. You can learn more about these concepts through The Affirmative Couch’s course Helping Transgender and Gender Nonbinary Young Adults Develop Self-Compassion.
Finding and Celebrating little moments of joy and gratitude with LGBTQIA+ clients
- Ask clients to reflect on a vulnerable moment where they were able to nurture themselves or others
- What was one show/movie/podcast/song that made them smile or laugh?
- What is one thing they’re looking forward to in the upcoming week?
- What are three things about the past week for which they felt most grateful?
- Direct them to some of the many inspirational, hopeful, and positive ways in which people have been expressing themselves and creating via social media.
Finding meaning and connection
- Can clients volunteer virtually? Reach out to someone who is more isolated? Offer to drop off groceries for an elderly neighbor?
- What creative talents might be employed to help others?
- Engage clients in storytelling and/or writing–expressive writing exercises like these can be particularly useful–to help work through their feelings
- If they have financial resources, what organizations might benefit from their support?
- Connect virtually with supportive others, especially in spaces that are queer- and trans-affirming. Balance their socializing with meaningful conversation and moments of fun
- Help your clients explore whether local or statewide LGBTQIA+ organizations are running online groups and support spaces, and/or offering other forms of connection
Looking for Hope for the future (i.e., not focused on a specific time when things return to “normal”)
- Who is the first person a client can’t wait to hug again?
- What restaurant are they excited to go to first?
- For students, how will it feel to step back onto campus again?
- What is the first event/trip/appointment they’re looking forward to rescheduling?
A final note: These points are important for clinicians to keep in mind as well. We need these reminders now more than ever. Most of us are not at our best right now, and it is foolish to pretend to our clients that we are. This is a time for us to hold that we are all human, and that authenticity models for our clients why it is important to be less hard on themselves for struggling. At the very least, consider reading this “Dear Therapists” blog post.
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 affirmative therapy from M. Tucker, PsyD
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.
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As we approach winter and prepare for “hibernation,” diet culture 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 more accepting?
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 bring up 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). 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. Food is not good or bad. 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. You are worthy. You are enough. Thank you for persisting.
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
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/