The Modern Clinician's Guide to Working with LGBTQ+ Clients

The Inclusive Psychotherapist

Margaret Nichols

• Publisher: Routledge
• Year: 2020
• ISBN:
  9780429663697
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The Modern Clinician's Guide to Working with LGBTQ+ Clients is a ground-breaking resource for therapists working with LGBTQ+ clients whose identity expressions span all gender-, sex-, and relationship-diverse groups.

Combining the author's extensive clinical experience with contemporary evidence-based research, the chapters of this book explore the origins and development of sexual minority groups, going beyond lesbian women and gay men to include transgender and gender nonbinary people, kink and polyamory, bisexuality and pansexuality, and those who identify as asexual or aromantic. The text also offers in-depth coverage of clinical work with transgender, gender-nonconforming, and nonbinary clients of all ages. With a wealth of therapeutic strategies and case studies, this resource helps professionals respond to this 'Big Tent' community in an informed and empathetic way.

Spanning sexuality, gender, relationships and age groups, The Modern Clinician's Guide to Working with LGBTQ+ Clients is an invaluable reference for psychotherapists in a broad range of clinical settings.

1

From Bad to Mad to Civil Rights

A History of Deviance and Acceptance of Same-Sex Attracted People

In 2011, biological anthropologists discovered a 5,000-year-old skeleton outside of Prague, a genetic male whose body was arranged in a manner usually reserved for females. News reports were quick to proclaim this figure the ‘gay caveman.’ In fact, reporters were conflating sexual orientation and gender diversity – we have no way of knowing who this person was attracted to, only that they were at least somewhat gender variant. As you will see, this confounding of orientation and gender has been common throughout history; same-sex-oriented people have often been considered to be ‘gender inverts,’ and often were.

The point, though, is that both sex and gender diversity have been part of human culture since before recorded history. In later chapters, I’ll be addressing gender diversity in much more detail; here, I deal primarily with the history of same-sex behavior. As Aldrich writes in Gay Life and Culture: A World History (2006): ‘Since time immemorial and throughout the world, some men and women have felt a desire for emotional and physical intimacy with those of the same sex’ (p. 1) Moreover, same-sex behavior is common among animals (Baghemihl, 1999), having been observed in at least 450 different species. And multiple genders and gender changing are frequently found in Nature as well (Roughgarden, 2013). Those who decry homosexuality as ‘unnatural’ do not know the facts.

Although same-sex attractions and behaviors are historically universal, that does not mean that they appear in the same form as in twenty-first-century Western culture. It may come as a surprise that, in general, ‘sexual variations in behavior are common across human groups, and a high degree of tolerance is accorded to same-gender relationships in the majority of societies’ (Herdt, 1997, p. 10) – unlike in modern Western culture. However, the use of ‘homosexual’ or ‘gay’ as an identity is only about 150 years old. Herdt notes five forms of same-gender relations found across cultures and throughout history. These forms apply primarily to men; in most cultures, female same-sex sexuality was usually ignored. In part, the presumed inferior status of women meant that sex between women wasn’t taken seriously.

The first and arguably the most common of these forms is age-structured homosexuality; sex between older males and young men or boys. Greek and Roman homosexuality was of this type, as is current day homosexual initiation rites among some indigenous tribes of New Guinea. The older male takes an ‘active,’ or ‘insertor’ role, and the younger male, in the passive, or receptive role, is considered to be ‘like a woman.’ In many cultures, these relationships took on a mentor/mentee quality. In New Guinea, for example, all young males must participate in sex with older men in order to become fully masculine adults themselves. A second form of same-sex sexuality is gender-transformed homosexuality, where one person takes on the role of the ‘other’ sex, such as the Native American ‘two spirit’ person, a biological male who often lives as a woman and assumes a female role. Gender-transformed homosexuality can look very much like what we today call being transgender. Some cultures incorporate same-sex-oriented people into niche social roles, such as the so-called ‘Sworn Virgins of Albania,’ female-bodied individuals who live their lives as males in part to satisfy the familial role of sons in families without male children. Both the second and third forms are in part socially proscribed roles, not necessarily freely chosen by the same-sex-oriented individual. A fourth form of homosexual relationships appeared in nineteenth-century Western Europe – the person who is identified by others as a homosexual, as opposed to simply being considered a man engaging in homosexual behavior. Finally, beginning in the second half of the twentieth century, the form of homosexuality with which we are familiar today emerged: individuals who consider themselves intrinsically ‘gay’ and for whom gayness is an important part of their identity, and who seek egalitarian relationships with same-sex peers.

It is important to note that the last form of same-sex relationships, between equal partners who identify as gay and see their orientation as baked-in and lifelong, is one of the least common forms, historically and culturally. In fact, exclusive homosexuality was rare: to be accurate, most of the historical/cross-cultural forms of same-sex behavior existed in people – men – who also had heterosexual sex, for example, they had wives and children. Technically, what seems most culturally and historically universal is bisexuality, and later we will see that in the United States today, bisexually identified people outnumber those who embrace a lesbian or gay male identity. Even homosexuality as identity is relatively new; throughout most of human history individuals engaging in same-sex acts were not considered different from others except in their behavior: a man was not ‘homosexual,’ he merely engaged in some sexual acts with other men. It is useful to understand how these two identity-based types of homosexuality came to be dominant in the West.

Greek and Roman societies accepted homosexual behavior, but exclusive homosexuality was rare. Males (female same-sex sexuality was much less common, or at least less noted) were expected to take wives and produce children, but this did not preclude them from having male lovers as well. In both these cultures, the sexual prohibitions that existed had to do with the position the male assumed in sex: being the receptive, or submissive, partner was considered unmanly and thus relegated to younger male partners or slaves. The active partner could penetrate males or females without stigma, and extramarital relations were accepted for men. It was the advent of Christianity that heralded the beginning of disapproval of homosexual acts, and this was in line with the general anti-erotic tone of the Christian ascetic ethos. Sexual pleasure of any kind was frowned upon. Heterosexual intercourse among married partners, with the express purpose of procreation, eventually became the only religiously sanctioned sexual behavior. The anti-homosexual bias of the Church was perhaps most pronounced during the Middle Ages and the Inquisition, but it existed after the Enlightenment as well and, indeed, still exists today. We see this emphasis on procreative sex, not only in religious beliefs about same-sex relations, but even in religious attitudes toward birth control: ‘religious freedom’ was the rationale used by the Trump administration to roll back Obama-era rules mandating that health insurance include coverage for contraceptive devices. Up until the mid-1800s those who committed homosexual acts were considered depraved and immoral – ‘bad.’ Western European, and later American, laws complimented religious disapproval with secular punishment.

Science Weighs In

The latter half of the nineteenth century saw the rise of a more medicalized, ‘scientific’ view of sexuality. The earliest known use of the word ‘homosexual’ is in a letter written in 1868 by Karl Maria Kertbeny to Karl Ulrichs, early sex reformers; both men were active in a movement to oppose Germany’s harsh anti-sodomy statutes. Karl Ulrichs argued the ‘scientific’ perspective that same-sex yearnings were ‘natural’ for some people. He considered homosexuality a form of gender inversion: he thought ‘Urnings,’ his word for men who loved men, to be psychological hermaphrodites, with male bodies and female minds. This conceptualization removed same-sex attraction from the realm of ‘sin’ and placed it within ‘Nature.’ Shortly after this, Richard von Kraft-Ebbing claimed same-sex attraction as a medical problem. His book, Psychopathia Sexualis, published in 1893, attempted to describe and classify sexual deviancy. Although Kraft-Ebbing believed that same-sex attractions were rooted in biology, unlike Ulrichs he did not consider them ‘natural’ or ‘normal.’ Instead he saw them as medical pathologies to be cured, espousing therapeutic methods over legal sanctions. While Kraft-Ebbing thought homosexuality to be the result of both genetic and environmental factors, and others saw it as entirely hereditary, most scientists and doctors of the late nineteenth century agreed that it was an abnormal perversion. Ulrichs, the British physician Havelock Ellis, and later the German proponent of homosexual rights, Magnus Hirschfield, were distinctly in the minority in their belief that homosexuality was a natural, normal biological variation.

Freud is responsible for the twentieth-century view of homosexuality as a psychiatric condition representing the failure to develop ‘normal’ heterosexuality. Freud believed that human infants were born bisexual and as a result of predictable phases of sexual development ‘progressed’ to a heterosexual orientation. Thus homosexuality was an ‘immature’ form of sexuality, an infantile fixation that was the result of a combination of genetic and environmental factors. Freud’s views were comparatively benign and accepting, and he was pessimistic about the possibility of cure. Freud’s perspective dominated the young field of psychiatry until the 1940s and the advent of Sandor Rado. Rado was a Hungarian-born American analyst who founded the adaptational school of psychoanalysis. Rado rejected Freud’s views of inborn bisexuality. He conceptualized homosexuality as a phobic response to the opposite sex, and considered it treatable through analysis. Rado’s work paved the way for American analysts like Irving Bieber, who in 1962 published an influential study of 106 homosexual and 100 heterosexual psychoanalytic patients. Bieber’s work was an attempt to explore the etiology of homosexuality. He presented findings suggesting that the homosexual patients were more likely to have distant or absent fathers and overly intimate relationships with their mothers. Bieber’s study also concluded that as a result of psychoanalytic treatment, 27% of the homosexual patients had ‘converted’ to a heterosexual orientation. Bieber’s study was accepted as accurate despite a methodology that would today be ridiculed: findings about the family were based on the therapists’ reports, rather than clients’ or parents’ narratives. But because the study was well regarded, the mainstream psychiatric view of homosexuality came to be that it was a condition created by disturbed family dynamics and changeable with dedication, hard work, and psychotherapy. Bieber, and shortly thereafter Charles Socarides, another psychiatrist, came to be the leading proponents of the view that homosexuals needed psychotherapy, not acceptance, and that they could be ‘converted’ back to heterosexuality. Socarides persisted in that view long after psychiatry had declared homosexuality to be non-pathological. In 1992, along with Joseph Nicolosi, Socarides founded NARTH, the National Association for Research and Therapy of Homosexuality. NARTH has become associated with religious conservatives, who are often sponsors of so-called ‘reparative therapy,’ attempts to change those with a same-sex orientation.

The pathology view of same-sex attractions prevailed throughout most of the twentieth century, and when the American Psychiatry Association issued its first compendium of mental disorders in 1952, the Diagnostic and Statistical Manual, Mental Disorders (DSM I) included homosexuality as a ‘sociopathic personality disturbance.’ Moreover, the assumption of the pathology of homosexuality outlasted the pervasiveness of psychoanalysis. ‘When the dominance of psychoanalytic theory in American psychiatry began to wane in the 1960’s, other schools of thought incorporated, without much difficulty, the view that homosexuality was an abnormality’ (Bayer, 1987, p. 38).

Challenges to this view came first from the scientific community. In 1949 Alfred Kinsey published his research volume on the sexual behavior of the American male. The public was shocked by his findings, among which was the revelation that 37% of his white male subjects had experienced at least one homosexual sexual experience during adulthood. Kinsey believed the prevalence of homosexual behavior was evidence of its normality. Soon after, the anthropologists Cleland Ford and Frank Beach published a cross-cultural study of 76 cultures (1951). They found that in 49 of these societies, homosexual behavior was not only accepted but socially sanctioned for some members. And in the 1950s the psychologist Evelyn Hooker published research on non-clinical samples of homosexual men showing that they exhibited no more psychopathology and/or functional impairment than heterosexual controls (1957). Hooker argued that if the only evidence of psychopathology in homosexuals was their behavior and desires, homosexuality could not be considered a mental disorder. Meanwhile, theoretical challenges to the psychiatric view came from psychiatrists like Thomas Szasz, who in The Myth of Mental Illness argued that psychiatry’s treatment of homosexuals was evidence that the field of psychiatry had taken on social control functions previously the domain of religion.

Homosexuality is Normalized

These scientific inquiries did little to change mainstream views of homosexuality, however. Until the latter decades of the twentieth century much of the public saw homosexuals as depraved, psychiatrically ill degenerates who preyed upon young people. And the mental health community disregarded non-psychiatric studies such as the work of Kinsey and Ford and Beach. It was activism that turned the tide.

The post-World War II era in the United States saw the emergence of homosexual political activism in the form of ‘homophile’ groups. The most important of these was the Mattachine Society for men, founded in 1950, and the Daughters of Bilitis for women, founded in 1955. It was Mattachine, for example, that convinced Evelyn Hooker to do her ground-breaking research. These groups, however, tended to see psychiatrists as allies rather than enemies. To understand this, it is important to realize the conditions of the time and how World War II changed the sensibilities of many same-sex-oriented people. Thousands of gay men and lesbians joined the military after Pearl Harbor, and the need for recruits meant that few efforts were made to weed out those with ‘homosexual tendencies.’ For many gay soldiers and lesbian WAACS (Women’s Auxiliary Army Corps), the military provided a space to meet and become involved with others like them. Once the war ended, some of these soldiers were reluctant to give up the sexual/romantic freedom that they had found during their enlistment. Many flocked to urban centers where small ‘gayborhoods’ were forming, and these centers were fertile ground for the development of activist groups.

But American society was not only deeply homophobic, it was severely punitive toward those gay people whose activities became known. Every state had sodomy laws; 45 US cities had laws against cross-dressing. It was illegal to serve alcohol to a homosexual, illegal for homosexuals to dance together in public, and perfectly legal to deny someone housing, employment, or social services because of their homosexuality. Bars where gay people congregated were regularly raided by the police, with patrons arrested and their names published in the newspaper. Parents – and spouses – could have their children or partners committed to psychiatric institutions if they were found to be gay. I recently watched the movie Before Stonewall, a documentary made in 1984. The documentarians interviewed many gay men and lesbians born in the first part of the twentieth century, who lived their adult lives in the 1930s, 1940s, 1950s, and 1960s. It is shocking today to hear their stories: of lives lived surreptitiously in the shadows for fear of exposure; of families who nearly universally disowned a gay child; of people committed for extended periods of time to mental institutions for just the whisper that they might be gay; of McCarthy-inspired witch hunts conducted in the military and government that ousted and disgraced thousands of hard-working, patriotic Americans. I came out in 1975, and that era seems oppressive by today’s standards, but it was a walk in the park to be gay in the 1970s compared to what it had been a mere 20 years earlier.

Given the impact of the criminalization of homosexuality, the psychiatric classification of homosexu...

Table of contents

• Cover
• Half Title
• Endorsements
• Title Page
• Copyright Page
• Contents
• Acknowledgments
• Introduction: Grad School Didn’t Prepare You for This
• 1 From Bad to Mad to Civil Rights: A History of Deviance and Acceptance of Same-sex Attracted People
• 2 The Roads Converge Again: How the ‘T’ Got Added to the LGB
• 3 The ‘Big Tent’ and Intersectionality
• 4 Exactly What Are We Studying, Anyway, and What Does It Mean?
• 5 Who Is Gay?
• 6 The Twentieth-century Gay and Lesbian Client
• 7 Today’s Gay or Lesbian Client
• 8 Issues of Gay Men and Boys
• 9 Gay Male Couples
• 10 Counseling Lesbian Women
• 11 Lesbian Couples
• 12 Bi Any Other Name: Science Grapples with Multiple Gender Attractions
• 13 Clinical Issues of Bisexually Identified Clients
• 14 ‘Aces and Aros’: Asexuals, Aromantics, and Other Variations on a Theme
• 15 Pansexuals, Mono vs. Multisexuals, and Sexual Fluidity
• 16 From Two Genders to Many
• 17 Working with Adult Transgender Clients
• 18 Working with the Transgender Adolescent
• 19 The Gender-expansive Child
• 20 Nonbinary Identities and Gender Fluidity
• 21 BDSM Comes Out of the Shadows
• 22 Working with Kinky Clients
• 23 Introduction to Consensual Nonmonogamy
• 24 Working with Clients Who Are Nonmonogamous –: And Those Who Want to Be
• Conclusion: The Tangled Path Forward
• Glossary of Terms
• Appendix A: Sample Letters for Transgender Clients
• Appendix B: Clinical Guidelines for Working with People with Kink Interests
• Index