Queer Affirming Mental Health Therapy
Author’s note: This blog post does not discuss gender affirming medical care. Here is a post that does, if that is what you are looking for, dear reader.
Finding a therapist can be an anxiety-inducing chore. At a time when you feel your most vulnerable, you reach out to a stranger and cross your fingers hoping that they will be the right person to help. Will our personalities mesh well? Do they have the knowledge and skills needed to help me? Will I be able to let down my guard and open up to this person?
Those who identify as LGBTQIA+ (a.k.a. queer) also have to ask themselves if a therapist will be a safe person to talk to. What overt or covert judgements and stigma might the therapist have? Will they treat me differently? Will they respect my identity? Will they see my gender or sexual orientation as a mental health problem? Is it safe for me to go to their office?
Why it makes sense to be distrustful of mental health practitioners
It makes a lot of sense for queer consumers to be suspicious of the mental health industry. The sad truth is that the mental health professions have done and continue to do queer folks a lot of harm. From pathologizing queerness in past versions of the Diagnostic and Statistical Manual (DSM) to inflicting trauma through harmful therapies like conversion therapy, the mental health care profession is not innocent of institutional violence against queer folks. “Institutional violence” is a term that describes how oppression can be built into the foundational structures and fabrics of our society. Describing homosexuality as a personality disorder in the DSM I and DSM II, is one example of institutional violence against queer folks. Another is the Hetero/White/Euro-American ethno-centric development of psychological theory and research which led to those who don’t fit into these categories being labelled as abnormal or ill. In other words, homophobia, sexism and racism are values baked into the foundations of the mental health sciences.
Due to the tireless work and advocacy of queer and BIPOC leaders, researchers and mental health professionals, the mental health industry is slowly correcting course. Research in the 1980s and 1990s highlighted the need for greater understanding and better therapeutic services for diverse populations. The latest version of the Diagnostic and Statistical Manual (DSM V, 2013) recognizes that diversity in sexuality and gender is normal. The only remaining gender-related diagnosis, gender dysphoria, describes the suffering one experiences as a result of internalized stigma and stigma in society.
The American Psychological Association (APA) defines “stigma” as “the negative social attitude attached to a characteristic of an individual that may be regarded as a mental, physical, or social deficiency. A stigma implies social disapproval and can lead unfairly to discrimination against and exclusion of the individual.”
In 2017, The APA also adopted new guidelines requiring psychologists to practice with multicultural competency, which includes discussion of concepts such as fluidity of identity and the relationships between power, privilege, and oppression. (“Multicultural competency” is an umbrella term that describes the therapist's ability to effectively provide services to diverse populations.) Accreditation organizations that certify higher education programs for therapists now require coursework in multicultural competency. Modern licensure exams include questions to assess a therapist's understanding of multicultural competency. Chances are, if your therapist earned their counseling degree after 1990, they have received some level of education on the importance of multicultural competency.
What makes a therapist “Queer Affirming”?
This subtitle is a bit misleading because “queer/LGBTQIA+ affirming” is not something that you are, it’s something that you do. Practicing queer affirming mental health care requires a continuous process of analysis, awareness and growth. Queer affirming therapist engage in the following practices (Sue & Sue, 2013):
Explore our values, beliefs, and biases - This means taking a brutally honest inventory of the way we think about queerness so that we can understand how these attitudes might affect our work. We bear the responsibility for doing the necessary work of debunking and challenging those beliefs and biases that don’t align with our values.
For example: Challenging the assumption that trans folks should “pass” could help you focus on building confidence and celebrating differences with your trans clients instead of guiding them to conform more strictly to gender stereotypes about appearance.
Educate ourselves - Professionals must educate themselves so that we do not burden our clients with this task. Imagine going to see a dentist and having to explain to them what a cavity is - that wouldn’t inspire much trust in their ability to help relieve your pain. Therapists simply cannot wait for a queer client to walk through the door to decide to learn about queer identity.
For example: A client experiencing low sex drive comes to therapy for help. After careful assessment and history-taking, you learn that the client has never been interested in sex and would be happy if they never had sex again. Because of your knowledge of queer identity and sexuality, you’re able to have a discussion with your client about asexuality, demi-sexuality and the normal spectrum of sexual attraction and drive.
Learn and use relevant skills to meet our clients’ needs - A queer affirming therapist understands the Minority Stress Theory and Intersectionality and approaches diagnosis and treatment with these perspectives in mind.They are able to recognize and help clients unpack internalized stigma. Queer affirming therapists seek to amplify their clients’ joy and celebrate their strengths and resiliency. At other times, being queer affirming means learning which therapeutic skills NOT to use.
For example, a common technique used in Cognitive Behavioral Therapy and Dialectical Behavioral Therapy, is to generate alternative thoughts about events that are less catastrophic to change the way we feel about the event (i.e. Devon wasn’t ignoring me, they just couldn’t hear me because they were wearing headphones). What if we used this cognitive modification strategy in response to a client’s distress after being consistently misgendered by a coworker (i.e. It’s difficult to learn new pronouns for Reiley because he’s from an older generation)? In this case, a therapist could be inflicting more harm than good using cognitive modification. This rethinking exercise minimizes the distress experienced by the client and could unintentionally reinforce the harmful belief that the client is a burden for asking others to use their pronouns.
The aforementioned practices are meant to be exercised continuously throughout a therapist's career. They are elements of a practitioner's overall approach to providing therapy and can be incorporated into any form of therapeutic practice. Ideally, every therapist would adopt this framework - which is not exclusively used to develop competency working with queer clients, but with all clients. It requires humility, honesty, self-awareness, and sometimes bravery - all things that we ask of our clients.
A few more thoughts on queer affirming care in mental health
We must acknowledge the ongoing atmosphere of uncertainty and danger queer folks - and trans individuals in particular - are facing in the United States today. Trans lives and human rights are in danger. There is no shortage of hateful rhetoric demonizing trans folks; a robust contingent of transphobic, pseudo-scientists spread harmful and false narratives about trans folks in the media which further fuels hateful and violent attacks on the queer community. This affects our clients, and we need to be ready to discuss current events with them in session.
Identifying as a queer therapist doesn’t automatically translate into queer-affirming care. It may give a therapist a unique perspective and help their clients feel more comfortable. It does not exempt a therapist from engaging in conscientious self-exploration, education and skill building.
Queer affirming therapists need to be vocal about it! Make it known! Don’t force clients to pick apart your website or therapist-finder profile looking for clues that your LGBTQIA+ competent. Make a statement, write about your values, make a short video, or provide resources for queer clients. Queer folks have been forced to live in secrecy and communicate with coded language, clothing, and images for decades. Please don’t make us have to read between the lines. Visibility matters.
References:
Brooker AS, Loshak H. Gender Affirming Therapy for Gender Dysphoria: A Rapid Qualitative Review [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2020 Jun 8. Available from: https://www.ncbi.nlm.nih.gov/books/NBK564233/
Donahue, R. (March 28, 2019). Why I Needed to See a Queer Therapist (And How You Can Find One, Too). Them.us. Retrieved from: https://www.them.us/story/how-to-find-a-queer-therapist
Farook, M. W. (2018). The state of multicultural counseling competencies research. Psychotherapy Bulletin, 53(4), 48-58. Retrieved from: https://societyforpsychotherapy.org/the-state-of-multicultural-counseling-competencies-research/
Sue, D. W. & Sue, D. (2013). Counseling the Culturally Diverse: Theory and Practice. (6th edition). Hoboken, New Jersey: John Wiley & Sons.
Resources:
National Alliance on Mental Illness (NAMI)
National Queer and Trans Therapist of Color Network
