Out On The Couch

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Learn more about working with LGBTQIA+ Clients

References

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

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

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

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

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

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

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

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

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

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

Social isolation due to the pandemic

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

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

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

COVID-19 factors specific to TGNB people

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

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

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

Supporting LGBTQIA+ Clients with boundaries during the pandemic

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

Providing validation for LGBTQIA+ clients

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

Helping LGBTQIA+ Clients Develop Self-compassion

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

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

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

Finding meaning and connection

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

Sign up for our newsletter to stay up to date!

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. 

This is the final installment in a three-part series on boundaries. In the first article, I discussed what boundaries are and why they’re important, and in the second article, I dispelled misconceptions about boundaries. In this last piece, I will name common barriers that femmes may experience in setting boundaries, and will share some tips to help you with this.

If the boundaries discussed here are unsafe for you to set with a partner, please check out resources on intimate partner violence for more appropriate support. 

Common Barriers to Setting Boundaries

• You feel responsible for the other person or are preoccupied with how your boundaries will affect them
• You feel guilty or bad
• You don’t like yourself
• You’re afraid of losing what you have
• You’re afraid of being invisible as a femme without your partner
• You love the other person and setting boundaries feels mean and selfish
• Learning to deal with things yourself is what you’ve always done and all you’ve known how to do up to this point
• In your culture, you don’t set boundaries with your parents or elders
• You don’t feel like you need to set more boundaries because compared to your previous relationships, this one is better
• Thinking about setting boundaries makes you feel confused
• Your immediate circumstances or objective or capacity mean setting boundaries you normally would isn’t in your best interest 
• You’re afraid the person will leave you and that someone else won’t love you

Tips for Boundary Setting

Address Power Dynamics

Particularly in intimate relationships, barriers to your exercise of boundaries may exist if your partner is more masculine than you; is older than you; has more experience sexually, in relationships, or with non-monogamy than you; identifies as straight; has been out longer if they’re queer; or is less marginalized in terms of factors such as size, ability, race, education, class, or profession. If your relationship is long-term, you cohabitate, you’re married, you parent together, and/or you’re part of a polycule, setting boundaries may have significant consequences for you and others. Whether you have a history of trauma separately or together, emotional symptoms can lead to less boundary setting for the sake of shorter-term well-being. Other barriers that may come into play are lack of access to a support system; health care, including  mental health care (and care that is affirming); and income, particularly if you depend on your partner to access these things. 

Name power dynamics early on in a relationship. Having ongoing communication about power dynamics that are inherent, meaning they won’t go away, and addressing how they impact relationship dynamics can help you work with the imbalances they cause.

Take Time & Space

In browsing other articles published on boundaries, I found a definition that stated, “Simply put, boundaries are what set the space between where you end and the other person begins” (Twardowski, 2017). One very simple way in which to achieve a sense of where you end and another person begins is to take time and space. The key is that time and space in themselves differentiate you from others. Take time for self-care and to slow down your mind through journaling, walking, gardening, drawing, and similar activities so that you can clarify what boundaries are right for you. We all process in different ways and at different paces, tolerate different amounts of confrontation, and need to separate our own experiences from the influence of other people’s perspectives.

Acknowledge Your Hurt

Acknowledging the impact of others’ behavior on us helps us set boundaries. Emotions inform our decisions. Often femmes are conditioned to deal with things on our own, say “It’s fine” rather than rock the boat, and not expect things of others. Compassion towards yourself in the form of getting in touch with your feelings like sadness, grief, and anger is foundational. Anger teaches us our boundaries because we get angry when our boundaries are crossed. Once you acknowledge the harm that someone’s behavior is causing you, you can choose to set boundaries on your own behalf. If you’re having a hard time accessing compassion towards yourself, think about what you would want for a friend or what a mentor or role model would do.

Trust Your Gut

Many people say that they know when something doesn’t feel good; they just don’t listen to their gut, or it’s hard to act on that in the moment. We are conditioned to ignore our gut telling us something is wrong, because it benefits others when we are compliant rather than when we set boundaries. Trust your gut–also referred to as your intuition–as a source of information for setting boundaries. You may not be sure why until you’ve had more time to process, and that is okay.

Know Your Needs

It’s easier to set boundaries if you first recognize your needs. Of course, this isn’t always realistic, and we learn many of our boundaries through our experiences. That being said, if you know that you don’t want children, or you don’t want others to access your email, or you alternate holiday plans year-to-year, or that because of previous traumatic experiences you need someone with a certain demeanor or communication style in order to feel safe, you can prioritize these boundaries with more self-assuredness. 

Reframe Boundaries

This section revisits many of the Common Barriers listed above so that you can work through them:

• Boundaries allow you to have actual intimacy because the relationship is based on your true needs, capacity, and desires.
• Saying no isn’t about not loving the other person. With boundaries you convey, “I love you, and I also love myself” (Viado & Greer, 2019).
• Not setting boundaries with someone is actually doing a disservice to them; you’re not teaching them what’s okay or not, you’re enabling their dependence on you by doing things for them. If they’re also femme, you’re not modeling valuable skills.
• Prioritize accountability over responsibility. Rather than not setting boundaries because of someone’s manipulation, gaslighting, blaming, denial, or guilting, set a boundary in response to it. Consider that these are effective tools for avoiding accountability rather than taking on someone’s struggles or circumstances.
• Saying no doesn’t just mean losing something–it means making room for the people who are out there who will love you, support you, and see you for who you are.
• Boundaries attract people who are able to respect them.
• Becoming single doesn’t make you invisible as a femme; your essence is within you and nothing can take it away from you.
• Boundaries free up space to accept your partner and yourself as you are without trying to change each other (Viado & Greer, 2019).
• If someone isn’t able to meet your needs, it doesn’t mean you’re unlovable; it means that the two of you aren’t compatible at this point in time.
• Rather than creating conflict with loved ones, boundaries give you the opportunity to confront your relationship in a deeper, more meaningful way.
• Boundary setting allows you to truly let go of someone rather than ending the relationship out of spite, resentment, or to rebel (Viado & Greer, 2019).
• Your feelings don’t go away just because you don’t deal with them.
• You don’t need acceptance or validation from another person; it comes from within yourself.
• Setting boundaries with someone from whom you’re seeking approval isn’t what keeps them from supporting you.
• Just because something isn’t common practice around you doesn’t mean it’s not what’s best for you, nor that you’re alone in doing it.
• No one can set your boundaries for you.
• If your relationship is sustained by you not asserting your needs and you tell yourself that you’re being more passive for the other person’s sake, are you really avoiding risking feelings of abandonment?
• Setting boundaries is something you can do for your younger self now that you’re an adult with more autonomy.
• Your boundaries are tributes to all the femmes who have fought so hard for your ability to say no.
• Boundaries are a political act; they’re the basis of movements built by people collectively saying “no more.” 

Boundaries are a practice. Each opportunity to practice boundary setting is a new one. Boundaries represent a chance for you to redefine yourself in the present. I hope that this series helps ground you to say no when you feel the need in your body. Know that you are not alone–you are a part of a long legacy of femmes enacting their worth.

Learn More

References

Desano, A. (n.d.). Intimate Partner / Domestic Violence. Retrieved from https://lalgbtcenter.org/health-services/mental-health/intimate-partner-domestic-violence.

Twardowski, J. (2017, December 7). 6 Steps to Setting Boundaries in Relationships. Retrieved from https://www.huffpost.com/entry/6-steps-to-setting-boundaries-in-relationships_b_6142248.

Viado, L., PhD, & A. G., PhD (Host & Guest). (2019, February 20). 105: Everyday Codependency [Audio blog post]. Retrieved from https://lourdesviado.com/105-everyday-codependency/

In my previous article on boundaries, I talked about definitions and why setting boundaries can be difficult and important for femmes. In this, the second part of a three-part series on the topic, I’ll clarify misconceptions and broach avoiding confusion and shaming when it comes to discussing boundaries.

If the boundaries discussed here are unsafe for you to set with a partner, please check out resources on intimate partner violence for more appropriate support. 

Common Confusing Language in Intimate Relationships

These terms are all related but differ slightly from each other:

• Expectations can inform boundaries, but they don’t act as boundaries. For instance, if you expect your partner to celebrate your body and honor your bodily autonomy, you may set a boundary such as stopping sex if your body is touched or commented on in a way that doesn’t bring you pleasure.
• Standards are the criteria you use to judge a partner. Standards may include educational background, annual income, physical characteristics, etc. Like expectations, standards differ from boundaries. They can inform boundaries  but are a different entity. Your standards may determine your make-or-breaks.
• Make-or-breaks are boundaries, but not all boundaries are make-or-breaks, which definitively make or break a relationship for you. You may break up with a partner (or not enter into a relationship with someone at all) if you want an open relationship and they want a monogamous one, for instance.
• Ultimatums and boundaries can entail similar or identical phrasing. However, unlike boundaries that are based on you doing what is in your control in response to your partner, ultimatums consist of you telling your partner to do something. For instance, saying “If you don’t stop lying to me about your drinking, then I’m done” is an ultimatum. Ultimatums are more like threats, because you can’t actually control what another person does, even though they may comply (Matlack, Winston, & Lindgren, 2018). Additionally, ultimatums may be made based on your make-or-breaks.
• Lastly, rules and agreements tend to differ from boundaries because partners establish them together. They can also have less clear consequences when they’re not followed (Matlack, Winston, & Lindgren, 2018). Again, your boundaries and your partner’s boundaries are your own, respectively.

Beyond Boundary Binaries

Boundaries are considered an important part of healthy relationships, but you’ll notice that I’m not talking about boundaries in terms of healthy and unhealthy or good and bad here. That’s because I wouldn’t even know how. It’s not for me or anyone else to judge what is healthy or good for you. You may also be used to the boundary binary of strong and weak. This oversimplification can shame people who struggle with sticking to boundaries or want to set more of them. It puts blame on femmes without contextualizing our challenges within cultural systems designed to exploit our bodies, intellects, emotional labor, and other skills. Additionally, I often see boundaries talked about in all-or-nothing terms. There’s no such thing as having “no” boundaries. Boundaries are always at play. Even the simple act of turning off notifications on your phone can be considered a boundary.

Boundaries aren’t fixed, nor is their development linear. Boundaries are personal and individual; it’s for you to decide what boundaries you need at any given time in relation to any given person. Consider, too, that boundaries are set among varying factors. Who you’re with, who’s around, where you are, what kind of day you’re having, what stakes are involved, timing, previous experiences with the person, having to compartmentalize an aspect of your identity in order to reach an objective of your given interaction or for your safety, not being offended by something that on a different day would bother you or vice versa, are all factors that are quickly being assessed and play into the fluidity of boundaries.

By addressing misconceptions, I hope to have clarified many practical elements about boundaries. In the last article, I’ll name common barriers that femmes may experience in setting boundaries. I’ll also share tips that can help you with your boundaries, including reframing them in order to work through those barriers.

Learn More

References

Desano, A. (n.d.). Intimate Partner / Domestic Violence. Retrieved from https://lalgbtcenter.org/health-services/mental-health/intimate-partner-domestic-violence.

Matlack, E., Winston, D., & Lindgren, J (Hosts). (2018, July 3). 178 – The Basics of Boundaries [Audio blog post]. Retrieved from https://www.multiamory.com/podcast/178-basics-boundaries

It’s your right to tell someone that you love them and you want to have a relationship with them. That they get to say, do, and believe whatever they want because that’s their business. But not with you. It’s your right to tell them the harm that their actions are causing you, the way that it’s interfering with you having a relationship with them the way you want, and that until they can support you as you are, they’re not welcome in your life.

This is what I told my client whose internalized biphobia was blocking her from recognizing the hurt that her mom’s biphobia is causing her. She knows that the relationship is strained and she’s beginning to see that she needs to set boundaries, but she doesn’t know how.

When I verbalized the above boundary to her in session, I meant it seriously, but I was also doing an exercise with her. I wanted to point out the influence of internalized biphobia on her understanding of her choices in how to interact with her mom. I wanted to say it out loud as an unashamed counterpoint because it didn’t seem like she had entertained the idea that she wasn’t responsible for her mom’s anxiety.

Ultimately, establishing this boundary didn’t feel right for her, at least not now, and we moved on to talk about her calling her mom less. And while my vision is of a femme revolution in which we lead our beautiful, queertastic lives without wasting energy on unnecessary emotional labor, the reality is that life consists of many more gray areas, that our beauty is in our ability to grapple with its complexities, and that there is revolution in the small, everyday boundaries we set.

This client is like many femmes in expressing that they don’t know how to set boundaries in relationships. When I hear this, I hear the need to break down the practical elements of what boundaries are and what, in practice, they look like. Perhaps even more importantly, I also hear the need to address the emotional blocks to establishing boundaries. 

This three-part series does both. In this first article, I will provide my own definition of boundaries and contextualize what makes boundary setting both particularly hard and important for femmes. I will then break down boundary setting and provide an example from queer pop culture. 

While these articles are written for femmes (you can check out my previous article, “Are You Femme? What Femme Isn’t and What it is” for reference on femme identity) setting boundaries in their intimate relationships, the information here can also be relevant to people who don’t identify as femme (particularly anyone who’s been considered feminine at some point). It can apply to members of non-intimate relationships, including parents and other family of origin, members of polycules, friends, housemates, and co-workers, too.

If the boundaries discussed here are unsafe for you to set with a partner, please check out resources on intimate partner violence for more appropriate support.

Boundaries Defined & Contextualized

Boundaries are acts of self-love that define your needs, capacity, and desires.

Let’s collectively pause for a moment and breathe this in. Boundaries are about self-love. Within our patriarchal, femmephobic, homophobic, biphobic, fatphobic, transphobic, xenophobic, racist, classist, ageist, and ableist culture, people believe that feminized people’s very existence is for the benefit of others, and fear emerges when we take up space of our own. This compounds our need to set boundaries and challenge the pushback we get when we do. Femmes navigate relationships within this paradigm, and we often do this while working through our own internalized “-isms.”

Therefore, when we set boundaries, they are radical acts. And because boundaries are about you, they’re about saying no, and they’re about exercising your power based on your needs, they are radical acts of self love.

Boundaries: The Breakdown

• Rather than adapting yourself for the sake of a relationship, you set boundaries so that a relationship best meets your needs.
• For boundaries to be effective, they have to be within your control, and what’s in your control is you, not the other person. Trying to control another person is toxic. Boundaries are about what you communicate and the actions you take.
• The clearest and most obvious boundary entails disengaging and removing yourself altogether, either in the moment by walking away, or ongoing by breaking up or cutting off contact with the other person.
• When you communicate a boundary, it’s up to your partner, friend, or family member to decide if your boundary works for them or not, and to proceed accordingly. Boundaries have a cause and effect that goes both ways. If the other person sets a boundary, it’s up to you to decide if their boundary works for you or not, and to proceed accordingly. You have the right to set a boundary and you have the right to decide that another person’s boundary doesn’t work for you. If your boundary doesn’t work for them, that doesn’t mean the boundary changes. It means that how you relate to each other does.
• Boundaries are not conditional on how someone else responds to them. It’s not a boundary if you’re asking someone or waiting for someone to change in order for your need to be met, because they may change–but they may not.
• You’re not responsible for anyone else’s feelings or behavior. We are each responsible only for our own.
• Boundaries are about creating your own options rather than acting according to what the other person wants. If you only act according to what the other person wants, they have all the power.
• If you find that you keep having to set the same boundary, you may need to address this as a larger issue by taking more space or evaluating the relationship overall. It is a form of gaslighting when someone denies an ongoing issue, thereby making you question your own perceptions, and responds to you by saying things like “What are you talking about?” or “No, we haven’t talked about this before.” 
• If a person’s behavior escalates when you set a boundary, it doesn’t mean the boundary is wrong. It may be from fear of change or because they don’t want things to change.
• The key is setting boundaries to which you’re able to stick. If you don’t stick to them, then they’re not actually boundaries. They’re dependent on the other person’s behavior not requiring that you stick to them. They function more as requests if they’re not enforced. Situations like this teach others that they don’t have to take your boundaries seriously.
• If you find that you’re setting boundaries in order to get a certain response from your partner (like a sign of commitment or intimacy), friend (like attention or acceptance), or family member (like approval or permission) rather than with the intention of sticking to them, these are not actual boundaries. You’re coercing a desired outcome that’s not in your control and some honest reflection may be helpful. 

Boundaries mean saying: no, I won’t just stand here while you yell at me; no, I won’t stay silent while you misgender me; no, I won’t answer my phone right now; no, I won’t remind you to do the dishes; no, I won’t spend time with you if you’re guilting me; no, I won’t stay in a relationship in which my partner continually gaslights me; no, I won’t have sex with you if you fetishize me; no, I don’t have time for you to vent to me right now; no, I won’t pay for things you’re able to afford; no, I won’t cancel my plans to come over; no, I won’t wear what you want me to instead of what I want to wear, and; no, I won’t smile and laugh when you say something that offends me.

Boundary Setting Within Queer Pop Culture

If you want an amazing example of queer boundary setting, look no further than the most recent season of Are You the One? The MTV dating show features 16 participants meant to find their predetermined “perfect match” among each other in order to win money. In its eighth season, and the first season to have an all-bisexual, -pansexual, and -sexually fluid house, the show portrays the toxic relationship between Jenna, a cis, femme-presenting woman, and Kai, a nonbinary transmasculine person, as one of the primary character arcs. Jenna and Kai continue to be drawn to each other despite Kai’s manipulative behavior (like crying, pleading, and making grand statements that contradict his actions) and despite confirming through the show’s Truth Booth that they’re not a perfect match.

The turning point several episodes in that left many queers cheering from their couches was when Jenna saw Kai’s toxic behavior play out with another femme-presenting person. When, in desperation, Kai goes back to Jenna again and tells her, “I’m madly in love with you,” Jenna responds, “But I don’t want this, because this isn’t healthy. I need to put me first. I need to love myself first right now.”

So many femmes fear that if they set a boundary with another queer, that person will be worse off and isolated. However, you can keep watching and see that after Jenna set her own boundary, the house stepped up to collectively and empathically call in Kai on his behavior. This is described in the article “How On Earth Did Are You The One Get Queer Love So Right?” by Jeanna Kadlec, which reads, “There is a rich and real no person left behind mentality, which is so distinctive to the queer community. Even as the femmes rally around each other, the entire cast is unwilling to let bad behavior go unchecked.” Kadlec goes on, “The drama affirms how much intentional work there is to be done when it comes to building relationships and examining attraction—but also how much joy and especially self-love can be found along the way” (2019).

Now you have a better sense of what boundaries are and how they work. In the next article in this series, I’ll dispel misconceptions to address confusing and shaming ways in which boundaries are commonly discussed.

Learn More

References

Desano, A. (n.d.). Intimate Partner / Domestic Violence. Retrieved from https://lalgbtcenter.org/health-services/mental-health/intimate-partner-domestic-violence.

Kadlec, J. (2019, August 30). How on Earth Did ‘Are You The One’ Get Queer Love So Right? Retrieved from https://www.elle.com/culture/a28857415/are-you-the-one-jenna-kai-queer-toxic-relationships/.

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/  

It’s a given that finding affordable, accessible, LGBTQ-affirming mental health care can pose a serious challenge, especially if you live outside of a major metropolitan area. Even in New York City, where I live, many community members find that their care needs are not easily met. As queer and trans people living with mental health conditions, what can we do to ensure meaningful connections among each other? What are the most effective ways for us to share support and guidance with others who really “get it”? How can we best move forward to help each other cope and perhaps complement the mental health care we may receive from providers?

Advantages of peer support

Peer support can be invaluable in this regard. This entails people with lived experience of mental health conditions, also known as peers, showing up for one another in a formalized way. Peer support services have been lauded as “an established, maturing area of development and study, with great promise for the future of services to promote recovery” (Farkas & Boevink, 2018). Literature on peer services reflects that activities such as education and advocacy programs “promote hope, socialization, recovery, self-advocacy, development of natural supports, and maintenance of community living skills” (Chinman et al, 2014). All of these factors are essential for our well-being as people with multiple marginalized identities.

Creating your own peer support group

Forming a peer-led support group is one idea for taking a DIY approach to your own mental health. I put this idea into action myself back in the summer of 2014, and it was a meaningful experience. When an online group called Queer Mental Health sprang up on Facebook, I ended up joining forces with its administrator, another Brooklyn resident, to form the NYC Queer Mental Health Initiative (QMHI). Intended solely for peers, QMHI was an all-volunteer initiative that I hoped to model, to some extent, after Brooklyn Queer Support (BQS), an ad-hoc support group with which I was briefly involved in years prior. BQS had begun as a way for LGBTQ+ people in Brooklyn to show up for each other after the suicide of a community member. I attended the groups as a participant, then as a volunteer facilitator, and found them inestimable. People created a safer space where one had not previously existed, and the sense that we had one another’s backs was, for me, life-affirming.

With my fellow QMHI co-founder, I drew on and fleshed out BQS’ support group facilitation guidelines to help structure our new initiative, and soon a few people started to meet bi-weekly at the Brooklyn Community Pride Center for support group sessions. Initially I co-facilitated most of the sessions, drawing on my social work background that has helped me gain experience leading groups in other settings. Expanding on a list of therapists that had been compiled by BQS, my co-founder and I launched an online NYC-specific queer and trans mental health resource guide. It features information on not only psychotherapists and mental health programs, but also affordable medical care, local holistic practitioners, and several LGBTQ-affirmative psychiatrists. We supplemented our support group meetings with a free peer-led training on Wellness Recovery Action Plans to help our members make their wishes about their own mental health care known in writing.

Another community member recognized the need for support groups and meditation sessions geared specifically toward LGBTQ people of color, and soon launched QTPoC Mental Health. In 2015, QMHI and QTPoCMH joined together to produce a support group facilitation training for our volunteers, led by an experienced social worker affiliated with the social justice-oriented peer support network and educational resource the Icarus Project. In order to rent a space for the training, provide refreshments to attendees, and pay our trainer an honorarium, QMHI launched a small online fundraiser and promoted it tirelessly via social media, among friends and family, and simply via word of mouth; we were fortunate enough to meet our goal within a week.

Challenges of running a peer support group

One of the biggest challenges QMHI faced was staying afloat without a substantial volunteer base. At any given time we had just a few active volunteers taking on tasks, and ideally at least a dozen would have been on board. It was a time-consuming endeavor that required organizers and facilitators to have the “spoons” (or ability to complete tasks in light of chronic illness) to be able to take on tasks from arranging two facilitators to co-lead each meeting to creating and distributing event invitations to mediating effectively when microaggressions arose. Had I stayed part of QMHI, I would have worked on procuring more training and support for volunteers around these issues, especially the latter one. But I needed to take a step back within a year of launching QMHI to focus on another major project I’d had in the works.

My hope was that QMHI would sustain itself, attracting a rotating roster of volunteers. It’s true that a few people did put in a tremendous amount of work and keep the meetings running for about three years. As with BQS, gradually QMHI’s in-person groups ceased as the tasks became too much for just two or three committed volunteers to handle. But the feedback we got from group participants indicated that our work made a major difference in the wellbeing of our community. The fact that we figured out how to provide this service to each other and our community on a volunteer basis for as long as we did is tremendously encouraging. We continue to help the community through the online resource guide, which I continue to maintain and the Queer Mental Health Facebook group, which my QMHI co-founder still administers–and we can share the knowledge that our little crew of volunteers gained about how to go about forming peer support networks. I hope some of us will be able to operationalize an in-person group again soon! I think that partnering more closely with an established institution like one of the city’s LGBT community centers and receiving ongoing support, training, and perhaps supervision from one of their staff members would be helpful. We could also recruit more people who, like me, are providers or community organizers with lived experience of mental illness to volunteer. People with social work and organizing backgrounds can bring skills to a peer support group that will help sustain it. So can people with excellent administrative skill sets. In my next article, Six Tips for Starting an LGBTQ+ Peer Support Group in Your Community, I will list some concrete suggestions for starting a peer support network in your own community.

Learn more from Teresa Theophano, LCSW

References

Chinman, M., PhD, George, P., PhD, Dougherty, R. H., PhD, Daniels, A. S., Ed.D., Ghose, S. S., Ph.D., Swift, A., MSW, & Delphin-Rittmon, M. E., PhD. (2014, April 1). Peer Support Services for Individuals With Serious Mental Illnesses: Assessing the Evidence. Retrieved April 19, 2019, from https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201300244

Farkas, M., & Boevink, W. (2018). Peer delivered services in mental health care in 2018: infancy or adolescence?. World Psychiatry : Official Journal of the World Psychiatric Association (WPA), 17(2), 222–224. doi:10.1002/wps.20530

Miserandino, C. (2013, April 26). The Spoon Theory written by Christine Miserandino. Retrieved May 26, 2019, from https://butyoudontlooksick.com/articles/written-by-christine/the-spoon-theory/