The Modern Clinician's Guide to Working with LGBTQ+ Clients: The Inclusive Psychotherapist [1 ed.] 2020020046, 2020020047, 9780367077297, 9780367077303, 9780429022395

The Modern Clinician's Guide to Working with LGBTQ+ Clients is a ground-breaking resource for therapists working wi

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The Modern Clinician's Guide to Working with LGBTQ+ Clients: The Inclusive Psychotherapist [1 ed.]
 2020020046, 2020020047, 9780367077297, 9780367077303, 9780429022395

Table of contents :
Half Title
Title Page
Copyright Page
Table of contents
Introduction: Grad School Didn’t Prepare You for This
Who I Am
Some Themes of this Book
Sex and Gender-diverse Affirmative Psychotherapy
A Word about Identity: Fingers Pointing at the Moon
The Rest of This Book
The Case Histories and Vignettes
1 From Bad to Mad to Civil Rights: A History of Deviance and Acceptance of Same-Sex Attracted People
Science Weighs In
Homosexuality is Normalized
The Impact of the De-pathologization of Homosexuality
Case Vignette
The Development of Affirmative Therapy
What Is Gay-affirmative Therapy?
Bisexuality – the Scarlet ‘B’
The Spectrum of Sexual Attraction
2 The Roads Converge Again: How the ‘T’ Got Added to the LGB
Transgender People in US History
Things Change in the Twentieth Century
The Ascendency of Transgender Activism
3 The ‘Big Tent’ and Intersectionality
Who Are We Talking About?
The Birth of New Identities
The Creation of the ‘Big Tent’
4 Exactly What Are We Studying, Anyway, and What Does It Mean?
The Diversity of Nature
The Function of Sex and Gender Diversity
Research on Etiology
What Does This Mean for Clinicians?
5 Who Is Gay?
The Complexity of Sexual Orientation
Even More Complexity
Takeaways for the Clinician
6 The Twentieth-century Gay and Lesbian Client
Case Vignette
When It’s Not Just Homophobia
Assessing the Impact of Growing Up Gay
Helping Clients Heal from Homophobia-related Trauma and Shame
The Takeaways for the Clinician
7 Today’s Gay or Lesbian Client
Twenty-first-century LGB Youth
The Stress of Growing Up Gay
LGB Youth Resiliency
Coming Out
What You Can Do to Help the Parents
Created Families vs. Families of Origin
Takeaways for the Clinician
8 Issues of Gay Men and Boys
Mental Health Issues of Gay Men
The Role of Sex in Gay Male Culture
HIV and Gay Male Sexuality
Clinical Work with Gay Men
Case Vignette: a Harm-reduction Approach with a Barebacking Man
Case Example: A Gay Man with Trauma-induced Alcohol Abuse and Self-defeating Behavior
Takeaways for the Clinician
9 Gay Male Couples
The Research on Same-sex vs. Mixed-sex Couples
Issues Common to Both Gay Male and Lesbian Couples
Working with Male Couples
Case Example: A Gay Couple Considering Parenthood
Case Example: Sex after Seroconversion
Case Example: Nonmonogamy as a Solution to Sexual Script Incompatability
Case Example: Children from a Prior Marriage
A Word on Working with Mixed-orientation Couples
Takeaways for the Clinician
10 Counseling Lesbian Women
History of Lesbianism
Today’s Lesbian Client
Issues of Today’s Lesbian Woman
Case Vignette: Fears of Losing Motherhood Status
Case Vignette: The Slightly Supportive Family
Case Vignette: On the Cutting Edge of Diversity
Takeaways for the Clinician
11 Lesbian Couples
Clinical Issues of Lesbian Couples
Generational Issues
Case Vignette
Case Vignette
Case Vignette
Takeaways for the Clinician
12 Bi Any Other Name: Science Grapples with Multiple Gender Attractions
Bisexuality: Current Attitudes
The Demographics of Bisexuality
Bisexuality and Mental Health
What Therapists Need to Know about Bisexuality
Case Vignette
13 Clinical Issues of Bisexually Identified Clients
Case Vignette
Case Vignette
Case Vignette
Mixed-orientation Couples – When One Couple is Bisexual
Case Vignette
Takeaways for the Clinician Counseling Bisexual Clients
14 ‘Aces and Aros’: Asexuals, Aromantics, and Other Variations on a Theme
What Is Identity?
The Asexual Identity
Attitudes and Beliefs about Asexuality
Working with the Asexual Client
Case Vignette
Takeaways for the Clinician
15 Pansexuals, Mono vs. Multisexuals, and Sexual Fluidity
What Does This Mean for Clients?
Case Vignette
Takeaways for the Clinician
16 From Two Genders to Many
Shunned and Shamed: A History
The Internet as Healer
Parents Support Their Kids
What’s It Like to Feel This Way?
Wait: Gender Isn’t Binary?
The Queer Revolution
The Path of Therapy
General Principles of Working with Transgender Clients
The Shape of Things to Come
A Word about Words
What You Need to Do as a Clinician
17 Working with Adult Transgender Clients
The Job of the Mental Health Professional with Adult Transgender Clients
Medical Transition
Other Issues Facing Adult Transgender People
Working with Partners
Men Who Love Transgender Women
Takeaways for the Clinician
18 Working with the Transgender Adolescent
The Trans Youth Explosion
Co-morbid Conditions in Transgender Adolescents
Case Vignette
Two Paths to a Trans Identity
Trauma and the Transgender Child and Adolescent
Medical Intervention
Is it Gender Dysphoria or a Fad? The Truth about ROGD
Working with Transgender Adolescents
Takeaways for the Clinician
19 The Gender-expansive Child
Recent History of Treatment of Pre-pubescent Gender-expansive Children
The 80% Desistance Myth – ‘Maybe It’s Just a Phase’
Maybe They Are Too Young to Know
Treatment for Transgender and Gender-nonconforming Children
What Therapists Need to Know about Gender-affirmative Treatment
Case Vignette
Controversies Around Puberty Blockers
Takeaways for the Therapist
Working with Parents
20 Nonbinary Identities and Gender Fluidity
Nonbinary vs. Intersex
Health and Mental Health of Nonbinary Clients
Case Vignette
Clinical Issues of Nonbinary People
Takeaways for the Clinician
21 BDSM Comes Out of the Shadows
Myths and Misconceptions
Myth #1: BDSM is Abuse
Myth #2: People Who Like BDSM Were Abused as Children
Myth #3: BDSM is Addictive
Myth #4: BDSM Is All about Pain
Modern History of BDSM
How Many Kinky People Are There?
Characteristics of Kinky People
Stigma and the BDSM Community
Takeaways for the Clinician
22 Working with Kinky Clients
Best Practices/Guidelines for Clinicians Working with Kinky Clients
Countertransference: ‘If It Isn’t Sick, Why Do I Feel Disgust?’
Pathologizing by Looking for ‘Reasons’
‘Coming Out’ – and ‘Cure Me’
But My Wife Will Leave
Case Vignette
Case Vignette
Case Vignette
Working with Partners and Families
But What If It Really Is Abuse?
Case Vignette
People Who Want to Explore BDSM
What Kinky People Can Teach Us All
Communication and Negotiation
Objectivity and Nonjudgmentalism about Sex
Sexual Variety
Planning vs. Spontaneity
Technical Skill
Sex as a Form of Healing
Sex as Spirituality
Takeaways for the Therapist
23 Introduction to Consensual Nonmonogamy
A Brief History of CNM
Marriage Counseling, Anyone?
Another Way
What Does CNM Look Like?
Case Vignette
Case Vignette
What about the Problems?
What about the Children?
Case Vignette
What Does It Mean?
What We – as Therapists and Humans – Can Learn from CNM
24 Working with Clients Who Are Nonmonogamous: And Those Who Want to Be
Who Is Nonmonogamous – and How?
Case Vignette
When CNM Strengthens a Relationship
Case Vignette
Helping Couples Open Up
Jealousy and Compersion
Other Common Issues
Solo Nonmonogamists and Poly-Mono Relationships
Relationship Counseling with More than Two
Case Vignette
Takeaways for the Clinician
Conclusion: The Tangled Path Forward
How Did We Get Here?
What Are Principles of Sex and Gender-Affirmative Treatment About?
Principles of Affirmative Psychotherapy Care for Gender, Sexuality, and Relationship-diverse Clients (GSRD)
Where Are We Going?
Glossary of Terms
Appendix A Sample Letters for Transgender Clients
Appendix B Clinical Practice Guidelines for Working with People with Kink Interests

Citation preview

THE MODERN CLINICIAN’S GUIDE TO WORKING WITH LGBTQ+ CLIENTS 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. Margaret Nichols, PhD, is a licensed psychologist, AASECT-​certified sex therapist, and American Board of Sexology diplomate in sex therapy. She has been a leader in the field of mental health, particularly in New Jersey, for over 20 years. In addition to founding the Institute for Personal Growth/​ IPG Counseling, Nichols helped create the Women’s Center of Monmouth County, NJ, one of the first battered women’s shelters in New Jersey, and founded the Hyacinth Foundation, New Jersey’s primary HIV social service agency. She is an internationally published author and speaker.

‘Margie Nichols has written the most useful book for clinicians to update their skills in providing care to sexual and gender diverse individuals, couples and families. It is extremely timely, well written, practical and useful. This is a must read for every clinician!’  –​ Eli Coleman, PhD, professor, director and academic chair of the Sexual Health Program in Human Sexuality, University of Minnesota Medical School. ‘There are few people in the world as qualified as Margaret Nichols to guide mental health practitioners in working with sexual issues. No one understands the intersection of psychotherapy, non-​traditional sexuality, and American culture better than Margie –​a master in her craft, and a brilliant teacher whose case descriptions and theory are instantly usable by clinicians of every background. Read this book –​it will change the way you see your clients, yourself, and the way you do therapy with everyone.’  –​ Marty Klein, PhD, certified sex therapist, forensic expert, and author of Sexual Intelligence and His Porn, Her Pain. ‘If you are looking for an understanding of how LGBTQ+ people made their journey from sinner to sick to affirmation, Dr. Nichols is the most trusted tour guide. A pioneer way before it was imaginable or even acceptable, Dr. Nichols creates the safe therapeutic, educational, and political space for queer people (including kinksters and polyamorists) to take their psychological, relational, and political seats at the table. Her personal and professional journey contained in these pages is a tour-​de-​force of courage, persistence, and resistance. Filled with moving rich case material interwoven with scientific insight, historical events, and clinical advances, this book is beautifully written and describes how queer folks overcame societal and medical prejudice to become cultural disruptors and change agents. Under Dr. Nichol’s influence in this powerful book, psychology and psychotherapy will no longer be viewed as neutral, apolitical endeavors. As Nichols brazenly reveals the political in the “scientific” and “therapeutic,” we are encouraged, even compelled to ask not what we know about sexualities and gender, but who gets to shape the discourse. This book is a seminal contribution toward an inclusive and ever-​changing understanding of queer psychologies. It should be read and studied by clinicians of all personal and theoretical persuasions.’  –​ Suzanne Iasenza, PhD, author of Transforming Sexual Narratives: A Relational Approach to Sex Therapy. ‘At last, Dr. Margie Nichols, one of our pioneers, has compiled a resource that is required reading for anyone seeking to work with LGBTQ+ persons, those involved in kink, polyamory or anyone with an alternative sexual orientation, gender/​gender identity or relationship/​relating style. The case material along with thorough reviews of the sociohistorical and scholarly landscape make this book a standout among its peers. Written with hearts and smarts as well as humanity and compassion, this volume is destined to become a seminal text.’  –​ Michael C. LaSala, PhD, LCSW, author of Coming Out, Coming Home.


Margaret Nichols

First published 2021 by Routledge 52 Vanderbilt Avenue, New York, NY 10017 and by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2021 Taylor & Francis The right of Margaret Nichols to be identified as author of this work has been asserted by her in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-​in-​Publication Data Names: Nichols, Margaret Elizabeth, 1947– author. Title: The modern clinician’s guide to working with LGBTQ+ clients: the inclusive psychotherapist / Margaret Nichols. Description: New York, NY : Routledge, 2021. | Includes bibliographical references and index. | Identifiers: LCCN 2020020046 (print) | LCCN 2020020047 (ebook) | ISBN 9780367077297 (hardback) | ISBN 9780367077303 (paperback) | ISBN 9780429022395 (ebook) Subjects: LCSH: Sexual minorities–Psychology. | Sexual minorities–Mental health. | Sex (Psychology) | Psychotherapy. Classification: LCC RC451.4.G39 N53 2021 (print) | LCC RC451.4.G39 (ebook) | DDC 616.890086/6–dc23 LC record available at LC ebook record available at ISBN: 978-​0-​367-​07729-​7  (hbk) ISBN: 978-​0-​367-​07730-​3  (pbk) ISBN: 978-​0-​429-​02239-​5  (ebk) Typeset in Minion by Newgen Publishing UK




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

103 116

vi Contents

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 Practice Guidelines for Working with People with Kink Interests Index

302 309 317 324 327



irst and foremost, I  owe a debt of gratitude to the lesbian and gay activists who, back in the 1970s, got homosexuality removed from the American Psychiatric Association’s Diagnostic and Statistical Manual, thereby effecting an overnight ‘cure’ of hundreds of thousands of people. Without this, I quite literally would not have had my career. I was a graduate student in psychology at the time; two years later I ‘came out’ in my department, something that would not have been possible if being gay was still considered a mental illness. And I  certainly would not have been able to devote my career to helping queer people had it not been for their efforts. Second, I am indebted to the brilliant, courageous, and innovative colleagues in those early days who created the new paradigm that was ‘gay-​affirmative therapy.’ Prior to 1973, psychotherapy had focused on ‘curing’ homosexuality. Don Clark, Betty Berzon, Vivenne Cass, John Gonsiorek, Eli Coleman, and many others pioneered concepts like internalized homophobia, stages of coming out, the need to validate external stigma, and the importance of dealing with family members and creating ‘chosen families’ and a supportive community. These concepts evolved into the principles of gay/​lesbian affirmative counseling which in turn are the building blocks of all affirmative therapies for sex and gender-​diverse people. Closer to home, I am grateful to the many people over the years who have encouraged me to write a book –​it took decades, but I finally did it! I owe the most to the many clients I have worked with from 1976 to the present who have taught me –​everything. Throughout the years, many colleagues have educated me, encouraged me, and inspired me. My fellow therapists at the Institute for Personal Growth have consistently and lovingly created an environment that encourages out-​of-​the-​box thinking and the development


viii Acknowledgments

of cutting-​edge clinical interventions. I  am grateful to several IPG and former IPG colleagues who generously contributed case stories and commentary for this book: Cindy Caneja, L.C.S.W., Sherill Cantrell, L.P.C., James Fedor, Ph.D., L.C.S.W., Mike Moran, L.C.S.W., Lori Sequeira, L.P.C., and Kelly Stolberg, L.C.S.W. The late Dr. Sandra Leiblum trained me in sex therapy and was the first to push me to write academic articles. My friend and colleague, the late Michael Shernoff, L.C.S.W., inspired me in ways too numerous to describe. For many years Michael was a primary connection to other LGBTQ+ health care providers who were leaders in the field, and he collaborated with me on numerous training seminars and articles. He is sorely missed for his friendship as well as his professional acumen. Special thanks to Dr. Michael LaSala, who offered invaluable advice upon reading an earlier draft of this manuscript. And this book would have been much less well written were it not for the editing efforts of Nancy Musgrave, my life partner. Nancy has been my biggest booster and the strongest encourager of my writing throughout my career. For her support, editing, and much more, I am eternally grateful. Finally, my children, Cory, Jesse, Alejandra, and Diana, have always provided me with the nurturance and love I need to survive. Apologies to Alejandra and Diana for the many hours during the writing of this book that I have been effectively absent from their lives. They have been patient with me beyond belief. My daughter Jesse passed away years before I began to write this book, but her memory warms me when I am most discouraged and downhearted.

INTRODUCTION Grad School Didn’t Prepare You for This


recent post on one of the therapist listservs I  belong to read:  ‘ISO therapist to work with lesbian couple, one partner transitioning, both partners kinky, wanting to work on adjustment to the transition and possibly opening up the relationship.’ This is not the gay-​affirmative psychotherapy you may have learned about in graduate school. In 2018, Gallup reported that: •​ 4.5% of Americans self-​identify as gay, lesbian, or bisexual, and 11% report some same-​sex attractions; •​ 0.7% are transgender, and 4% identify as nonbinary; •​ 1% identify as asexual; •​ One in five Americans have participated in consensually nonmonogamous relationships, 5% in the last year; •​ More than half are interested in being dominated sexually, and 36% use masks, blindfolds, and/​or bondage tools during sex. In the twenty-​first century, everyone will likely meet, know, or have as a family member someone with unconventional sex or gender behavior or identity. And this means every therapist may have clients who diverge from mainstream expectations of sex or gender. If you are a therapist, this book will prepare you to work in this new world. It will help you deal with the broad group of clients who today might be considered ‘queer’: not just gay and lesbian clients, but transgender, nonbinary, asexual, bisexual, pansexual, ‘mostly heterosexual,’ kinky, swinging, or polyamorous, to name a few. You will understand how the LGBTQ+ community

2 Introduction

has evolved over the last 50 years, why it changed in this particular direction, and where it’s headed. You will become familiar with concepts like gender and sexual orientation fluidity and see how many people are sex and/​or gender diverse without identifying as such. You’ll learn how this big-​tent community has influenced the ‘mainstream,’ and what new mainstream trends you can anticipate. Most importantly, each minority group will be described and explained with information about the most common clinical issues you will encounter and practical therapeutic strategies for helping. Who I Am I am a clinical psychologist and certified sex therapist with nearly four decades of experience working with sex and gender-​diverse clients and training therapists to work with this population. I am myself queer –​I often introduce myself as a ‘bisexual lesbian mother who is kinky and nonmonogamous.’ In 1983 I founded a therapy clinic specializing in work with LGBTQ+ clients, the Institute for Personal Growth (IPG) in New Jersey, and I directed IPG for 35 years. I now have a small private practice of sex-​and gender-​diverse clients. More and more, I find myself working with the ‘+’ in ‘LGBTQ+.’ In the last few months, for example, my clients have included: • A lesbian couple learning to experiment with BDSM (Bondage and Discipline, Dominance and Submission, Sadism and Masochism) to keep the passion alive in their relationship; • A pansexual nonbinary teen who is struggling to get the adults around them to use ‘they/​them/​theirs’ pronouns; • A couple with a 20-​year history in the ‘swingers’ community that is entering into a polyamorous relationship with another couple; • A ‘heteroflexible’ millennial man trying to decide whether to tell a prospective girlfriend that he occasionally hooks up with men. I understand these clients not only because I have lived and worked in the ‘queer’ community for decades –​but also because my personal journey has included lots of twists and turns off the mainstream road of sex and gender. By the end of this book, I promise that you will understand these clients and many more, as well. I am uniquely qualified to take you on this journey. Besides being a licensed clinical psychologist, I am a certified sex therapist, and I have spent my life and career in the LGBTQ+ community. I came out as lesbian in 1975 and in subsequent decades I have acknowledged that I am bisexual, kinky, and nonmonogamous. I saw my first lesbian client in 1975 while still a psychology intern, and almost immediately realized that I wanted to devote my

Introduction  3

professional life to helping other ‘queer’ people. In the 1970s it was difficult to find a therapist who did not consider homosexuality a disease, and so since that time, as soon as gay men and women in New Jersey discovered me, my practice never lacked for clients. Eventually, in 1983, I founded the Institute for Personal Growth, a private practice organization specializing in therapy for, at first, lesbians and gay men, and, eventually, all others who are sex and gender diverse. I completed a postdoctoral program in sex therapy in 1983 as well, and under the guidance of my mentor Dr. Sandra Leiblum began writing papers on queer sexuality for journals and professional books. In 1985 I helped start the Hyacinth Foundation, New Jersey’s largest social service program for people with HIV, and was its first director. Over the years I’ve trained and supervised hundreds of other mental health professionals in LGBTQ+ issues around the country and abroad. Some Themes of this Book Today’s practitioners are light-​years ahead of where we were in the 1970s when I did my graduate work. Few still regard homosexuality as a disease, and most have personal familiarity with gay people. But even as practitioners have kept pace with the times  –​the community has expanded even more rapidly. As a therapist, you may not need me to tell you about how lesbian couples are different from other couples (although I will). But you probably still need help understanding nonbinary people and those in the BDSM community, not to mention men who identify as ‘mostly straight.’ In this book, you’ll learn about it all, from the most basic principles of sex-​and gender-​ diverse affirmative care to the complexities of gender-​expansive children and adolescents. You will see some common themes in this book. In general, I believe that to understand the mental health needs of diverse groups you must understand the social and cultural forces impinging upon them, and how these forces change over time. I  hope to show you the narrowness of the lens through which you were taught to view gender and sexual orientation, and how much diversity exists in Nature, throughout history, and across cultures. You will also come to understand how the expansion of the gay community over the last half century has reflected changes in the culture at large. Two major mainstream social changes that are reflected in LGBTQ+ emergence are: the growth of what is often disparagingly called ‘identity politics’; and the tendency for conditions previously viewed as illnesses to be seen as identities. Andrew Solomon (2012) noted in his book about children who differ dramatically from their parents, Far From the Tree, that since the latter half of the twentieth century, there has been a cultural trend toward viewing what were once considered ‘disabilities’ or ‘diseases,’ as distinctive identities, identities that mark membership in a tribe. This has dovetailed with a more

4 Introduction

general trend, described by Francis Fukuyama in Identity: The Demand for Dignity and the Politics of Resentment (2018). Fukuyama maintains that in developed countries, concerns about economic survival have been replaced by concerns about equal treatment and by what he calls ‘thymos,’ the need to be recognized, seen, and acknowledged as having basic human dignity. At the same time, the breakdown of institutions like religion have left many people feeling a need for stronger social affiliations and seeking them in a variety of different places outside of organized communities of worship. One way that many people who feel marginalized –​unequal –​form social connections is to do so based on the aspects of their identities that leave them feeling socially stigmatized. Some marginalized people share identities with their parents –​most people of color, for ­example –​and their families and neighborhoods may provide them with the connection they need. But some people feel isolated in part because they do NOT ‘fit into’ their families of origin –​for example, most sex-​and gender-​diverse people. These people affiliate on the basis of what Solomon calls ‘horizontal identities,’ as distinct from the ‘vertical identities’ inherited from one’s parents and kin. Those with similar horizontal identities form communities of support, and these communities not only support their members but advocate for social change toward equal rights and recognition. As I will show you, this perfectly describes LGBTQ+ people, whose subgroups follow a common trajectory over time: first, labeled ‘bad’ or ‘immoral,’ then ‘mad’ or psychiatrically ill, then ‘normal’ but ‘separate,’ and finally, at least in theory, integrated within the mainstream culture. As the trajectory of change unfolds, the mental health needs of these subgroups change. For example, gay-​affirmative therapy first developed after homosexuality was removed from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, in 1973. In the early stages after this happened, ‘internalized homophobia’  –​inner shame produced by accepting society’s negative view of gay people –​was the biggest mental health problem gay people faced. My practice in the 1980s was full of clients who, first and foremost, needed validation that their sexuality did not make them evil or sick, and help to understand that it was a bigoted culture that had inculcated these feelings. Now, unless you practice in deeply conservative areas, your gay clients probably feel relatively okay about their orientation, though they may still deal with prejudice from family members, employers, or the larger community in which they live. Internalized homophobia is not as likely to be their biggest problem. Today, you are more likely to be working with gay clients whose problems are not much different from your straight clients, albeit with some twists. Today, a clinician is much more likely to find internalized self-​hatred in transgender people, those whose sexual orientation is kinky, or people who

Introduction  5

practice nonmonogamy, because the culture still holds highly ambivalent and/​or negative views of these people. Sex and Gender-​diverse Affirmative Psychotherapy The example above elucidates one theme that repeats throughout the book: it is impossible to divorce the mental health issues of LGBTQ+ people from politics. This is true on a macro level:  for example, research indicates that the mental health of LGBTQ+ people deteriorates after states pass statutes allowing anti-​gay discrimination (Hatzenbuehler, 2010). And it is true on the individual level as well. For example, without knowing the shameful history of how transgender people were harmed by psychiatry, it is hard to understand the mistrust many trans folk still have of the mental health community. Knowing that BDSM practitioners are still considered ‘paraphiliacs’ by psychiatry helps explain that, in treatment, some kinky clients will still refer to themselves as ‘sick’ and harbor deep shame about their sexuality ‒ and others are afraid to tell their therapists about their kink. The relationship between culture and politics and the mental health of sex and gender-​diverse people informs the practice of what I call sex-​ and gender-​diverse affirmative psychotherapy, the therapy described in this book. While specific issues and techniques vary, there are some principles common to the treatment of all LGBTQ+ people. Here are some of these principles: 1) Sex and gender diversity is normal, not a pathology or illness. Such diversity is found among thousands of animal species, including non-​human primates, and in all cultures throughout history. The idea that this diversity is ‘abnormal’ derives from the belief that the biological function of sex is solely procreation, and that forms of sexuality or gender that do not further the reproductive goal are ‘against Nature.’ But today most contemporary scientists recognize that sex in the animal world is not simply about reproduction; in fact, the majority of sex acts in Nature are non-​procreative. Many biologists believe that sex is more about connection and affiliation than reproduction. If this is true, the major argument against considering sex and gender diversity ‘sick’ or ‘pathological’ is demolished. 2) Sex-​/​gender-​diverse people have grown up in a culture that negates their value, for the most part, often in traumatic ways. This negation is not simply attitudinal, that is, prejudice or bigotry. It is often institutionalized:  sodomy laws were not ruled unconstitutional by the Supreme Court until Lawrence v. Texas in 2003; in many states, it is perfectly legal to fire or deny housing to anyone from the LGBTQ+ community; transgender people are not recognized legally in their affirmed

6 Introduction






gender in many states. Part of an affirmative therapist’s role is to validate and empathize with the traumatizing experiences LGBTQ+ people experience. A primary task of therapy is to affirm and validate the client’s identity and, when present, to help unearth and resolve socially induced feelings of worthlessness. Affirmative therapists do not agree to therapeutic contracts that include efforts to change the client’s identity or orientation-​so-​called ‘reparative’ or ‘conversion’ therapy. Sex-​and gender-​diverse people, like everyone else, need to feel they are living authentically, that is, that their inner experience of themselves is expressed whenever possible in their interactions with others. This may involve ‘coming out’ to others, or it may involve finding safe spaces where they can ‘be themselves.’ Therapy often includes advocacy  –​for example, the therapist must be prepared to interact with a school system that is allowing bullying of LGBTQ+ students; therapists for transgender clients will need to write letters for medical providers to prescribe hormones or surgical procedures. Therapy includes knowing and directing clients to community resources. For many LGBTQ+ clients, a good support group is worth years of treatment. If you work with this population, you must know what is available in your area:  support groups and supportive organizations, medical resources, legal help, political groups. While many LGBTQ+ clients come to treatment for the same reasons as other clients  –​depression, anxiety, relationship problems, stress, parenting issues –​there are some issues more commonly faced by sex-​ and gender-​diverse minorities. For example, at least half of gay male couples are nonmonogamous and may need help negotiating their open relationship; many LGBTQ+ clients are estranged from their family of origin, and the ‘family’ with which they identify is one created from friends and allies. LGBTQ+ affirmative approaches include a great deal of specific knowledge –​which you will gain from this book.

Let’s focus for a moment on the first principle: that sex and gender diversity is normal  –​that is, a naturally occurring, non-​pathological phenomenon. Increasingly, we have scientific data supporting this. A  full discussion of this is beyond the scope of this book, but interested readers are directed, for example, to Bruce Baghamihl’s book Biological Exuberance (1999) which enumerates many of the thousands of animal species that regularly exhibit not only homosexual sexual activity, but unusual non-​procreative sexual behaviors. Readers can gain insight as well from Joan Roughgarden’s work in Evolution’s Rainbow (2013) and The Genial Gene (2009), in which she catalogs the extraordinary range of gender expression in animals and posits the use

Introduction  7

of sex among animals as a mechanism to promote affiliation and cooperation. Ann Fausto-​Sterling has documented the gender ambiguities inherent in the human body in her acclaimed book, Sexing the Body (2000). And a 2019 article in the American Psychologist (Hyde et al.) listed evidence from five sources –​neuroscience, behavioral neuroendocrinology, psychological findings on similarities between men and women, psychological research on transgender and nonbinary individuals, and developmental research –​that contradict the notion of a gender binary. In brief, the more we learn both about the diverse range of animal behavior and the complexity of gender determination, the more science supports the non-​pathological viewpoint. In future chapters of this book, I will discuss some of the cross-​cultural, historical evidence for this point of view in humans. A Word about Identity: Fingers Pointing at the Moon According to Francis Fukuyama, the concept of identity is only a few hundred years old (2018). The foundations of identity were laid with the perception of a disjunction between one’s inside and one’s outside. Individuals come to believe that they have a true or authentic identity hiding within themselves that is somehow at odds with the role they are assigned by their surrounding society. The modern concept of identity places supreme value on authenticity, on the validation of that inner being that is not being allowed to express itself. (p. 25) So the concept of identity is rooted in internal, lived experience, not external roles or behaviors. It is important to understand how this impacts LGBTQ+ identities  –​and why it makes research on sex-​and gender-​ diverse minorities difficult. Let us take the example of sexual orientation. There are, in general, three different measures of sexual orientation used by scientists: attraction to same-​sex vs. opposite sex people; same vs. opposite sex sexual behavior; and identity. Most commonly, social science research uses identity –​a person’s self-​labeling. The problem is, identity is not a ‘stand-​ in’ for the others. Two self-​identified lesbians may share the same identity, but one may have a long history of bisexual behavior and attractions, and one may have only experienced same-​sex attractions and relationships. But we often behave as if identity reflected a real, material ‘thing.’ It is useful to remember the Buddhist saying about words and spiritual teachings: they are like fingers pointing at the moon, they are not the moon itself. Sex and gender variations are real, but the identities people use to describe them are merely rough analogies. Moreover, these identities vary by time period and

8 Introduction

culture. Indian hijiras, Native American two spirits, and Thai ‘ladyboys’ are all identities that express gender variance, but the realities they represent, while similar, are not exactly the same, and efforts to make simple one-​to-​ one comparisons will be inaccurate. And while sex and gender diversity are universal, because different cultures define the parameters for expression, the identity labels are different. People must assume the identity that is available for them within their culture. No one identified as ‘genderqueer’ a hundred years ago; no one identifies as an ‘Uranian’ –​Karl Ulrichs’ term for a homosexual in the 1800s –​ today. Moreover, identity is a different level of experience from feelings and behavior. To the extent that an identity is stigmatized, one can expect fewer people to choose that identity than are theoretically eligible. For example, surveys of people’s same-​sex attractions, behavior, and self-​identification always show the highest number of respondents acknowledge attraction, followed by same-​sex experience, and finally, the lowest number choose a gay or lesbian identity. In later chapters I will discuss the process that individuals follow that transforms feelings into identities. But any culture that stigmatizes variant gender and sexuality incentivizes its members to hide their diversity. Therefore, research that uses identity labels as measures of variant behavior will underrepresent the number of people that actually exhibit that behavior or those attractions. The Rest of This Book The first section of this book is about the history of the LGBTQ+ community, and the second is on the science –​what we know, and don’t know ‒ about what it means to be sex and/​or gender diverse, who fits in these categories, and the origins of sex and gender variation. You can skip these chapters if you want and go straight to the clinical stuff. But I recommend that you read them first, in the order intended. This is because I believe that to understand how to be a queer-​affirmative therapist, you need to have this background. Chapters 1, 2, and 3 focus on history, including the history of how sex-​ and gender-​diverse people were viewed by psychiatry. We are taught that mental health and therapy are apolitical, ‘scientific,’ and free from bias. Nothing could be further from the truth. Psychiatry has a shameful history of oppressing women, non-​white people, and sex-​and gender-​diverse minorities. In the mid-​nineteenth century, slaves who tried to run away were said to be suffering from ‘drapetomania,’ a disease caused by masters who were too ‘familiar’ with their slaves and treated them like equals. The cure was ‘whipping the Devil’ out of them or cutting off both big toes to prevent running. Women were considered constitutionally prone to ‘hysteria,’ and thousands of Victorian women were locked in asylums for daring to rebel against their subordinate, submissive roles. As you will see in the following

Introduction  9

chapters, during the twentieth century and to an extent today, psychiatry labeled homosexuals, transgender people, and those with unusual sexual interests as ‘mad,’ and treatments ranged from institutional confinement to lobotomies to electric shock. As psychiatrist Thomas Szasz argued decades ago, the mental health field replaced religion as the enforcer of traditional social norms, labeling as ‘mad’ those who had previously been considered ‘bad.’ Understanding the history of our field’s maltreatment of sex and gender minorities helps us comprehend why ‘reparative therapy’ still exists and why so much of our work today focuses on correcting the damage done by mental health labeling. Just as negative biases dominated the mental health field, the scientific study of sex and gender diversity has been warped by prejudice as well. Chapters 4 and 5 present some of the newer research on animals and humans that describes and explains in non-​pathologizing ways how diversity operates in the natural world. If you read these chapters, you will forever more be skeptical of both the pronouncements of evolutionary psychologists about how homosexuality has no evolutionary value, and of articles about the ‘gay gene.’ Chapters  6 through 24 will teach you what you need to know as a mental health practitioner about working with sex-​and gender-​diverse clients, from gay men and lesbians to those who are polyamorous, kinky, and/​or asexual. They will prepare you to conduct effective therapy sessions with anyone who walks into your office with an unconventional identity or lifestyle. You will learn how to make sex-​and gender-​diverse people feel safe and comfortable in therapy with you, and you will know about the most common issues these clients may face. Finally, the last chapter presents some ideas on where we are going  –​will assimilation rule, or will we travel toward an ever-​increasing proliferation of new identities and ways of being? Will there be a time when being sex and/​or gender diverse is not the defining characteristic of one’s sense of self? How will bodies of the future look if gender-​diverse people continue to push the boundaries of conventionality? It is my hope that this book will help your clinical practice today as well as prepare you for the future. There are some omissions from this book. I have not written about therapy with intersex people because, frankly, I am inexperienced with this population. Moreover, I  have omitted some groups that have caught the public’s eye: I don’t write about ‘furries,’ because it is not a primarily sexual phenomenon. I haven’t talked about ‘findoms’ (BDSM play that involves submissives giving dominants money) because it strikes me as just one of many less common kinky activities, even if it is currently enjoying 15 minutes of fame. I’m sure there are other omissions I don’t realize now. They will have to wait for a future edition of this book.

10 Introduction

The Case Histories and Vignettes Throughout the book I  have illustrated my points using case vignettes and histories. All of these are composites; that is, they are examples typical of more than one client, and the ‘clients’ are imaginary people exhibiting the characteristics and problems of a number of actual people. Thus the identities are disguised not only by changing details, but by merging details from several different clients. References Bagemihl, B. (1999). Biological Exuberance: Animal Homosexuality and Natural Diversity. Macmillan. Fausto-​Sterling, A. (2000). Sexing the Body:  Gender Politics and the Construction of Sexuality. Basic Books. Fukuyama, F. (2018). Identity:  The Demand for Dignity and the Politics of Resentment. Farrar, Straus and Giroux. Hatzenbuehler, M. L. (2010). Social factors as determinants of mental health disparities in LGB populations:  Implications for public policy. Social Issues and Policy Review, 4(1),  31–​62. Hyde, J. S., Bigler, R. S., Joel, D., Tate, C. C., and van Anders, S. M. (2019). The future of sex and gender in psychology:  Five challenges to the gender binary. American Psychologist, 74(2), 171. Roughgarden, J. (2009). The Genial Gene:  Deconstructing Darwinian Selfishness. University of California Press. Roughgarden, J. (2013). Evolution’s Rainbow: Diversity, Gender, and Sexuality in Nature and People. University of California Press. Solomon, A. (2012). Far from the Tree: Parents, Children and the Search forIdentity. Simon & Schuster.

1 FROM BAD TO MAD TO CIVIL RIGHTS A History of Deviance and Acceptance of Same-​Sex Attracted People


n 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,

12  From Bad to Mad to Civil Rights

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,’

From Bad to Mad to Civil Rights  13

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

14  From Bad to Mad to Civil Rights

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

From Bad to Mad to Civil Rights  15

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,

16  From Bad to Mad to Civil Rights

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 homosexuality was of relatively minor importance. When homosexuals did speak out publicly it was to urge the repeal of criminal sanctions for consensual homosexual activity. Since the threat of criminal prosecution was the immediate danger, it is not surprising that homosexuals did not attack the standard psychiatric view of sexual deviation. (Bayer, p. 68)

From Bad to Mad to Civil Rights  17

This was particularly true because the mental health field also urged decriminalization. Although psychiatrists saw homosexuals as mentally ill, they also saw mental illness as distinctly different from criminality. The latter needed to be punished, but the former could be cured, and so psychoanalysts in particular argued that treatment should replace incarceration. This inclined gay people toward seeing psychiatrists as allies, but not only because they favored decriminalization. A  considerable number of gay people agreed with the premise that their homosexuality represented mental illness, and at the time psychiatry promised a cure. Many early homophile groups wanted acceptance  –​but acceptance for their ‘disability,’ which they considered inborn and not chosen. In the 1950s, issues of the Mattachine Review, the official publication of the Mattachine Society, were notable for their articles debating whether homosexuality was a mental disorder. The concept that ‘gay is good’ did not emerge until after Stonewall. By the 1960s, the tide was beginning to turn. Frank Kameny, one of the more prominent pre-​Stonewall activists, was convinced that the ‘mental illness’ designation stigmatized homosexuals and stood in the way of obtaining full civil rights. In 1965 the Washington, DC chapter of Mattachine, headed by Kameny, declared that ‘homosexuality is not an illness, disturbance, or other pathology in any sense but is merely a preference, orientation, or propensity on a par with, and not different in kind from, heterosexuality’ (Bayer, 1987, p. 88). The New York chapter of Mattachine soon joined the opposition to the psychiatric classification. The year 1969 is generally marked as the beginning of the modern gay activist movement, with the June 1969  ‘Stonewall Rebellion’ emblematic of the sea change in the attitudes of gay men and women. Political change was no longer focused on pleading for the acceptance of gay people as a disabled minority, but rather on demanding recognition of gay people as the equals of heterosexuals. By 1970 gay activist leaders were focused upon the removal of the ‘mental illness’ designation as a goal. Beginning in 1970 gay activists disrupted meetings of the American Psychiatric Association and related psychotherapy organizations in order to agitate for their position. In 1973 the APA removed homosexuality from the Diagnostic and Statistical Manual, first by vote of the Nomenclature Committee, and then, in an unprecedented action forced by APA members like Socarides and Bieber, by a full vote of the membership. The removal was supported by the membership but not by a large majority: the final vote was 58% in favor of removal and 37% opposed. The entire process was criticized by many psychiatrists as motivated by politics and not science. In truth, they were right: the research findings disseminated in the 1950s by Hooker and others served as the rationale for the decision, but it was clearly driven by political considerations, chief among them the desire to end the disruptions of their own professional meetings.

18  From Bad to Mad to Civil Rights

An interesting side note to this process is something revealed many years later by psychologist Charles Silverstein, one of the activists involved in lobbying the APA (2009). In a letter to the Archives of Sexual Behavior, the preeminent journal in the field of sexology, Silverstein writes of the mindset that he and other activists had at the time: I argued that psychiatric diagnosis was the child of morality and that Judeo-​Christian values controlled psychiatric practice … Besides homosexuality, the DSM also listed sadism, masochism, exhibitionism, voyeurism, pedophilia, and fetishes as mental disorders. If there was no objective, independent evidence that a homosexual orientation is in itself abnormal, then what justification was there for including any of the other sexual behaviors in DSM? (p. 162) Although neither Silverstein nor his colleagues argued this position to the APA committee at the time, it was a perspective shared by many sex-​and gender-​diverse people. As we shall see, in later years, both transgender activists and activists in the BDSM community used this rationale to argue, respectively, for the removal of the diagnosis of gender identity disorder and the removal of all ‘paraphilias’ from the DSM. The social impact of the de-​classification of homosexuality was enormous. Most historians believe that, without this, the substantial civil rights gains made by gay and lesbian people since the 1970s would not have been possible. It served, first, as a successful basis for challenging sodomy laws. During the 1970s, most states removed their sodomy laws. In 2003, the Supreme Court ruling in Lawrence v. Texas invalidated the sodomy laws of the 14 states that still had them on the books. But the effects of the removal went beyond decriminalization. Psychiatrist Jack Drescher sums up the long-​ term impact of the decision (2015): The result, in many countries, eventually led, among other things, to (1) the repeal of sodomy laws that criminalized homosexuality; (2) the enactment of laws protecting the human rights of lesbian, gay, bisexual and transgender (LGBT) people in society and the workplace; (3) the ability of LGBT personnel to serve openly in the military; (4) marriage equality and civil unions in an ever growing number of countries; (5) the facilitation of gay parents’ adoption rights; (6) the easing of gay spouses’ rights of inheritance; and (7)  an ever increasing number of religious denominations that would allow openly gay people to serve as clergy. (p. 572)

From Bad to Mad to Civil Rights  19

The Impact of the De-​pathologization of Homosexuality Why should therapists care about this history? First, I  hope it serves as a lesson about psychiatric diagnoses, at least regarding sex-​and gender-​diverse people. I will be referring to this history later in this book when I write about transgender concerns, and about other sexual variations such as BDSM and consensual nonmonogamy. Mental health professionals need a healthy dose of skepticism when evaluating claims that socially nonnormative behaviors and feelings are evidence of psychiatric illness. Second, knowing this history informs a generational view of the issues faced by gay people. When I first saw lesbian women and gay men as a psychology intern in the 1970s, a few short years after the APA decision, most of them considered themselves to be mentally ill and some asked to be cured. During the late 1970s and throughout the 1980s, many of the clients who came for therapy to the Institute for Personal Growth had come of age when it was dangerous to reveal your homosexuality to anyone, including family. Case Vignette Lucille, a lesbian woman in her late 40s, was typical of the clients we saw back then. As a teen in the 1950s, Lucille’s family had found her with another young girl and surmised her gayness. They promptly had her committed to a psychiatric institution, where she remained for many months, subjected to heavy mind-​altering medication and, finally, electro-​shock therapy. Later, in her 20s, Lucille was stopped by police outside a clandestine gay bar. In those days, gay bars frequently changed locations and kept their location unpublicized because of laws against serving alcohol to homosexuals, and against same-​sex dancing, and because law enforcement officers frequently were hostile to those suspected of same-​sex desires. The officers who stopped Lucille searched the bag she was carrying (often called a ‘butch bag’) and discovered men’s clothing. On the pretense that she was breaking a law forbidding people to dress in the clothing of the opposite sex, the police threatened to arrest her but ultimately instead settled for beating her and leaving her injured, lying in a gutter. It goes without saying that those experiences left Lucille traumatized and fearful. She sought out therapy in 1979 because she was aware that her history had left her unable to sustain a long-​term relationship. At first, treatment consisted of simply letting Lucille tell her story, repeatedly and in detail, and validating that her experiences were unjust. She found it difficult to believe that the profession that had victimized her as a teen could help her now, but on the other hand she found it affirming that I, a ‘legitimate’ mental health professional, asserted that her treatment had been cruel, brutal, and unfair. Lucille

20  From Bad to Mad to Civil Rights

also needed to grieve the loss of the family that had rejected her and the wasted years when she lived alone and afraid, consumed with self-​hatred for her sexual orientation. The Development of Affirmative Therapy Back in the early days of the Institute for Personal Growth, clients like Lucille were common. The primary issues we handled were severe trauma, loss and grief, and intense self-​hatred, called ‘internalized homophobia.’ For many clients, simply reframing their problems as an internalization of unjust social stigma was enlightening and the first step to recovery. Today, most gay people are much less self-​hating, and the intensive work to help uncover the internalization of cultural condemnation is less necessary. The concept of ‘internalized homophobia’ was one of many concepts that were developed by gay and lesbian mental health practitioners post-​ 1973. Once homosexuality was removed from the DSM, gay psychiatrists, psychologists, and social workers began to feel they could safely ‘come out,’ that is, reveal their sexual orientation. Before 1973, being gay could be grounds for dismissal from a graduate school or training program. John Fryer, the gay psychiatrist who testified at hearings held in 1972 during the American Psychiatric Association’s deliberations, appeared wearing a mask and using the name ‘Dr. Henry Anonymous’ because he could have lost his license to practice were his true identity known. But after 1973, gay therapists began to ‘come out’ in large numbers, often eager to change the field. I  myself ‘came out’ professionally in 1975 while still a graduate student, and like many others, quickly decided to devote my career to the mental health needs of lesbians and gay men. This meant not only challenging the status quo of my profession –​it meant developing a whole ‘psychology of sexual orientation.’ A  field devoted to ‘curing’ homosexuals had neither theory nor methodology to help gay people who wanted to accept their gayness and thrive while living a gay life. By the mid-​1970s, some gay mental health professionals began publishing work that focused on healing techniques:  Don Clark’s Loving Someone Gay (1977) and Betty Berzon’s Positively Gay (1979) were among the first of these books. By the early 1980s, this approach –​that of validating a client’s sexual orientation and helping them overcome the effects of years of social oppression –​had been labeled ‘gay-​affirmative therapy.’ The principles of ‘gay-​affirmative therapy’ have, over the years, been extended to work with other sex and gender minorities. This book is a product of this movement, 40 years or more of work, by primarily sex-​and gender-​diverse professionals, to develop therapeutic approaches for stigmatized LGBTQ+ minorities.

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What Is Gay-​affirmative Therapy? Gay-​affirmative therapy is an approach that is informed not only by psychological theory, but also by political and historical realities. Therefore, it concerns itself with issues specific to people with a same-​sex orientation, such as: • Social oppression, including bullying and harassment, and resultant trauma and internalized self-​hatred; • The stage of development of a gay identity; • Special problems of ‘coming out’ –​to family, friends, the community-​ including the pros and cons of coming out, when to do it, how to do it, etc.; • Problems resulting from discrimination and exclusion, e.g., employment and housing discrimination; • Issues particular to same-​sex couples; • Problems of parenting as a same-​sex couple. And, as we will see, gay-​affirmative therapy established the template for gender-​affirmative therapy and for the approach we espouse here for working with clients with all forms of sex and gender diversity. Bisexuality –​the Scarlet ‘B’ Mainstream America probably sees the LGBTQ+ community as a monolith  –​one big happy family. The truth is a bit less idealistic. The early ‘homophile’ groups were segregated by gender  –​for example, Mattachine Society was for gay men and the Daughters of Bilitis for lesbian women. The first post-​Stonewall activist groups tended to be called ‘gay’ –​Gay Activist Alliance, Gay Liberation Front, and so on ‒ and they were dominated by gay men, often to the exclusion of women. In the 1970s, gay women, who felt invisible in these groups, lobbied to have the ‘L’ added, and organizations gradually complied: the oldest national LGBT organization was founded in 1973 entirely by gay men and called the National Gay Task Force until 1985, when it became the ‘Gay and Lesbian’ task force (the current name, National LGBTQ Task force, wasn’t adopted until 2014). Bisexual people, and, as we shall see later, transgender people, had a harder time finding acceptance under the queer umbrella. It’s not because the concept of bisexuality was exactly new. Before the twentieth century the term ‘bisexual’ often meant ‘bigender,’ or ‘hermaphrodite,’ but that had changed by the time Freud promulgated his theory that all humans were born bisexual –​with the capacity to be attracted to both sexes –​and only later ‘matured’ into heterosexuality. But it was Alfred Kinsey, the

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great sex researcher of the first half of the twentieth century, who brought bisexuality to national attention. Kinsey recognized that same and opposite sex attractions were not mutually exclusive. When conducting his thousands of field interviews with ordinary Americans, he devised a 7-​point rating system known thereafter as the ‘Kinsey Scale.’ Study participants rated themselves on a gradient, with ‘0’ representing exclusive heterosexuality, and ‘6’ representing exclusive homosexuality. Kinsey’s results shocked the nation: 37% of his male sample, and 13% of his female respondents had at least one overt homosexual sexual experience in adulthood, although only 4% of men and 1–​3% of women were exclusively homosexual (2019 Kinsey Institute). Kinsey’s research is flawed by today’s standards. His sample was by no means representative of the United States population as a whole, and was overly weighted with prison inmates, college students, and people recruited through ads in homophile organizations. Unsurprisingly, other surveys since then have found percentages of same-​sex behavior and attractions that vary significantly from Kinsey’s findings. However, all have found that the number of people reporting bisexual attractions and/​or experience is greater than the number reporting exclusively same-​ sex orientation, and that more people identify themselves as bisexual than identify as gay or lesbian. And yet within queer organizations, bisexuals are often all but invisible, and highly stigmatized. A  2011 report by the San Francisco Human Rights Commission found that self-​identified bisexuals make up the largest single population within the LGBT community in the United States, yet the bisexual community was one of the least represented groups within LGBT organizations (Burleson, 2016). A  2016 survey with a nationally representative probability sample found that while, in general, Americans held positive attitudes toward lesbians and gay men, they had neutral or negative beliefs about bisexuals, with heterosexual men expressing the most negative attitudes but with lesbian and gay respondents holding negative or neutral beliefs as well (Dodge et al., 2016). Bisexual organizations began to form in the 1970s –​Fritz Klein’s Bisexual Forum, in New York City was the first bisexual support group, founded in 1974 –​but the letter ‘B’ was not included in most queer organizations names until the 1990s. Although openly bisexual men and women participated in the first national March on Washington for Gay and Lesbian Rights in 1987, March organizers did not include ‘Bisexual’ in the name of the march until 1993. Interestingly, bisexual women have been at the forefront of bisexual activism, beginning in the 1980s, and many of these were women who had identified as ‘lesbian’ before coming out as bisexual. In fact, I was one of these women; I ‘came out’ as lesbian in 1975 but then ‘came out’ again in the 1980s as bisexual. In 1989, I attended a bisexual conference in Boston organized by a group of women who called themselves ‘the Hasbians.’

From Bad to Mad to Civil Rights  23

What is the cause for the at best tenuous and ambivalent acceptance of bisexuals into the lesbian and gay ‘family’? In the queer community, bisexuals are often seen as potential ‘traitors’ who will hide behind heterosexual privilege and, in difficult times, revert to heterosexuality. Bisexuality is often seen as a temporary identity, one that a lesbian or gay individual might choose because it is perceived as more acceptable than being gay. And in the 1980s, many lesbians feared that bisexual women were vectors for HIV transmission, despite the total lack of evidence for this view. Although these attitudes still persist, by the 1990s most queer organizations included a ‘B’ in their titles. The Spectrum of Sexual Attraction As the history I  have described here makes evident, within the span of a few decades people who exhibited same-​sex attractions and behavior went from being considered deviant, to mentally ill, and then to ‘normal,’ at least from the point of view of mental health. The activism that made this possible sprang from a community that at first was centered on gay men, then grew to include lesbian women, and finally expanded to acknowledge people who had both same and opposite sex attractions. In the next chapter, we will see how this community –​and activist movement –​broadened beyond same-​ sex attraction to encompass issues of nontraditional gender and other sexual desires. References Aldrich, R. (ed.). (2006). Gay Life and Culture: A World History. Thames & Hudson, p. 120. Bagemihl, B. (1999). Biological Exuberance: Animal Homosexuality and Natural Diversity. Macmillan. Bayer, R. (1987). Homosexuality and American Psychiatry:  The Politics of Diagnosis. Princeton University Press. Berzon, B. and Leighton, R. (1979). Positively Gay. Celestial Arts, pp. 1–​14. Bieber, I. and Dain, H. J. (1962). Homosexuality: A Psychoanalytical Study. Basic Books. Burleson, W. E. (2016). Bisexuality: An invisible community among LGBT elders. In D. Harley and P. Teaster (2016), Handbook of LGBT Elders. Springer, pp. 309–​321. Clark, D. and Clark, D. H. (1977). Loving Someone Gay. Lethe Press. Dodge, B, Herbenick, D, Friedman, M. R., Schick, V., Fu, T-​C., Bostwick, W., Bartlett, E., Munoz-​Laboy, M., Pletta, D., Reece, M., and Sandfort, T. (2016). Attitudes toward bisexual men and women among a nationally representative probability sample of adults in the United States. PLoS One, 11(10), e0164430. Drescher, J. (2015). Out of DSM:  Depathologizing homosexuality. Behavioral Sciences, 5(4), 565–​575. Ford, C. S. and Beach, F. A. (1951). Patterns of Sexual Behavior. Harper and Brothers. Herdt, G. H. (1997). Same Sex, Different Cultures:  Gays and Lesbians Across Cultures. Westview Press.

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Hooker, E. (1957). The adjustment of the male overt homosexual. Journal of Projective Techniques, 21(1),  18–​31. Kinsey, A. C., Pomeroy, W. B., and Martin, C. E. (1949). Sexual behavior in the human male. The Journal of Nervous and Mental Disease, 109(3), 283. Kinsey Institute (2019) (retrieved 9/​ 2019) https://​​research/​ publications/​historical-​report-​diversity-​of-​sexual-​orientation.php) Krafft-​Ebing, R. and Chaddock, C. G. (1893). Psychopathia Sexualis:  With Especial Reference to Contrary Sexual Instinct: A Medico-​legal Study. FA Davis. Roughgarden, J. (2013). Evolution’s Rainbow: Diversity, Gender, and Sexuality in Nature and People. University of California Press. Silverstein, C. (2009). The implications of removing homosexuality from the DSM as a mental disorder. Archives of Sexual Behavior, 38(2), 161–​163. Szasz, T. S. (1960). The myth of mental illness. American Psychologist, 15(2), 113.

2 THE ROADS CONVERGE AGAIN How the ‘T’ Got Added to the LGB


ne spring day in 1979, when I  had just started doing peer counseling for gay and lesbian people, I was taken aback when I saw a prospective client walking toward my door wearing a dress and heels –​and sporting a full beard. I marveled at his courage walking around in Central New Jersey like this, knowing that the reaction he would get from the average person would be, to say the least, negative. In my office, Reggie told me he had seen the notice I had posted about offering nonjudgmental peer counseling to gay people and hoped he could be included. ‘I’m not gay,’ he said, But I like to wear women’s clothes sometimes, and I even have a name for my female self: Regina. I don’t know if you can accept me or help me, but I feel very alone. Gay people don’t understand me, but straight people treat me like I’m a freak, and if a cop stopped me dressed like this, I’m afraid I’d get arrested. Reggie was my first introduction to transgender people, and he was right. Back then, there was no place for him. Today, he might identify as a cross-​ dresser or nonbinary, and he would have a community to support him. How did things change so much in four decades? If bisexuals have found an uneasy acceptance within the queer community, transgender and gender-​nonconforming people still often face outright hostility. This is in some ways ironic, because throughout most of recorded history, homosexuality has been seen as inextricably linked to gender variance. Moreover, the early radicals in the gay activist movement were often transgender. Two of the leaders of the rebellion at the Stonewall Inn in

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Greenwich Village, the event often considered the beginning of the modern movement, were transgender women of color:  Sylvia Rivera and Marsha P.  Johnson. So why were trans people not included in the lesbian and gay community right from the beginning? In Chapter 1, I discussed the fact that same-​sex attractions and behavior are universal in humans and most other animal species, and they have existed throughout time and across cultures. The same is true of transgenderism, and in fact, the two are often conflated and frequently related. A map published by PBS in 2015 showed hundreds of cultures on every continent who have recognized three, four, five, or more different genders. The ‘gay caveman’ referenced in Chapter  1 was most likely a gender-​variant biological male. A study of graves from a 3,000-​year-​old Persian Civilization (David, 2018) found evidence that this civilization either recognized a third gender or saw gender as more of a spectrum than a rigid dichotomy. As of 2019, eight countries worldwide legally recognized more than two genders, and a number of US states and jurisdictions, including Oregon, Minnesota, and California, allow a third gender option on official documents. But in general, Western societies have been slower to recognize nonbinary genders, and the United States has been slower than Europe. The earliest white settlers in the colonies looked down upon Native American tribes who incorporated third gender and ‘two spirit’ individuals into the fabric of their communities. Europeans have historically been a bit more open-​minded. For example, by the early 1900s, Germany became a haven and advocate for both homosexual and transgender people, largely due to the influence of Magnus Hirschfeld. Hirschfeld, a physician and sexologist, believed that every human being represented a unique configuration of both male and female characteristics, including biological traits, erotic desires, and psychological attributes. Hirschfeld, like other sexual scientists of his time, grouped transgender people, same-​sex attracted, and bisexually oriented people together as ‘sexual variants.’ He formed the first advocacy organization for these minority populations, and his Institute for Sexual Science was founded to study ‘sexual intermediaries’ or ‘variants.’ Hirschfeld believed in a biological basis for all sex/​gender variance, and campaigned against criminalization of gay and transgender individuals. Some of the first hormone treatments and surgeries for transgender people were done at his institute. The most famous of these was Lili Elbe, whose story became the basis for the book and movie The Danish Girl. Hirschfeld’s work was tragically cut short when the Nazis came into power in Germany. His institute was destroyed by the Nazis in 1933 and Hirschfeld himself died in exile in 1935. Transgender People in US History The United States has a history of punitive views of cross-​dressing as well as of homosexuality. Beginning in Columbus Ohio in 1848, most jurisdictions

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in the US had laws against ‘impersonating the opposite sex.’ Most of these laws were finally struck down in the 1970s, but as recently as 2014 a cross-​ dressing law was on the books (and successfully challenged) in Haddon Township, New Jersey. Of course, transgender people existed in the United States despite the laws that made it difficult for them to be public in any way. It is difficult to get a sense of their numbers, in part because of the need for secrecy and in part because until mid-​twentieth century no distinction was made between different kinds of ‘sexual variants,’ and even transgender people did not make these distinctions. The rise of large urban centers in the middle of the nineteenth century provided a way for men to leave rural life and encounter large numbers of other men. In these cities, the rudiments of a subculture of variant men formed, and cross-​dressers and transgender people could begin to meet and associate with each other as well as with drag queens and gay men in a community that made few distinctions between these types of variance (see the Glossary for definitions of these terms). In fact, an entire ‘drag ball’ culture flourished in this time period. Originating in Harlem in 1869, these were large parties where men could come dressed as women and which afforded public space for gender-​variant and gay people. In general, women had no such outlets, although some performed in the theater as male impersonators. Some of those who were brave enough to express their experienced male gender became part of a phenomenon known as ‘passing women.’ Because few of them left written records, we cannot know whether they lived this way simply to escape the constricted life to which women were confined, because they were attracted to other women, whether they had what we would now consider a transgender identity, or whether they were motivated by a combination of the above reasons. Some were eventually discovered, often only when they died and were prepared for burial. US history is replete with examples of these individuals: Loreta Janeta Velazquez passed as Confederate soldier Harry Buford during the Civil War; Mary Anderson lived as the New York City Tammany Hall politician Murray Hall; Charlotte Parkhurst lived as the stagecoach driver Charlie Parkhurst in the 1800s; and in the twentieth century, Dorothy Lucille Tipton lived as the jazz musician Billy Lee Tipton. Most of these people were not revealed to be biological women until death; Tipton was married three times and allegedly none of his wives knew his identity. Things Change in the Twentieth Century In the early twentieth century, American scientists and researchers became interested in gender-​variant people. Some, like the sex researcher Alfred Kinsey and later the endocrinologist Harry Benjamin, viewed such variation as a normal expression of biological diversity. But as the new fields of psychiatry and psychology emerged, a different perspective developed.

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‘As their authority escalated, psychiatrists and psychologists turned increasingly to environmental explanations of mental conditions’ (Meyerowitz, 2009, p. 105). This began a turf war that persists to this day and eventually made it much more difficult for transgender people to obtain the medical help  –​hormones and surgery  –​that had been available in Germany as early as the 1920s. If ‘transsexualism,’ the term for being transgender until the 1990s, was a mental disorder, the cure was psychotherapy, not medical intervention. Medical treatment was made even less accessible by a California 1949 legal opinion that genital surgery would constitute ‘mayhem’  –​the willful destruction of healthy tissue  –​and would subject any doctor doing such surgery to criminal prosecution. These procedures were known for decades; for example, Dorchen Richter, a male to female transgender person, had undergone castration in 1922 and vaginoplasty to construct a vagina in 1931 at Hirschfeld’s clinic in Germany. Nevertheless, they were used rarely in the United States and only under conditions of great secrecy. In the 1950s, Louise Lawrence, who had been born male but who had been living full time as a woman since 1942, came into contact with Karl Bowman, the head of the Langley Porter Psychiatric Clinic in San Francisco, a center for the study of variant sexuality and gender. Lawrence had developed an extensive correspondence with other transgender people throughout the US through placing personal ads; her connection with Bowman provided an important interface between this tiny trans community and the medical establishment, including Harry Benjamin, the endocrinologist who became a major proponent of medical intervention for transsexuals. In fact, it is through Lawrence that Benjamin had his first contact with transsexual patients. Lawrence might be considered one of the pioneers of transgender activism in the US Another was Virginia Prince. Prince, born male, came into contact with Lawrence in 1942, while still living as a furtively cross-​dressing man, and through Lawrence, Prince also became integrated into the growing medical community interested in sex and gender variance. Prince was a heterosexual transvestite (a term for cross-​dressers) and made a bright line distinction first, between transvestitism and homosexuality, and later on, between transvestitism and transsexualism. Prince would eventually found the first enduring organizations in the United States devoted to transgender concerns. In spite of her open disdain for homosexuals, her frequently expressed negative opinions of transsexual surgeries … (she) has to be considered a central figure in the early history of the contemporary transgender political movement. (Stryker, 2008, p. 46)

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Prince founded the magazine Transvestia in 1960 and in 1962 convened the first meeting of the cross-​dressers association later known as Tri-​Ess, the Society for the Second Self, which eventually had chapters across the United States and still exists today. Other early pioneers include Lou Sullivan, one of the first female to male activists, and, most importantly, Reed Erickson. Erickson was another female-​to-​male transgender person and a millionaire who founded the Erickson Educational Foundation and two other philanthropic bodies that funded research on gender variance at major universities. Erickson supplied the funding for Harry Benjamin to write his influential book, The Transsexual Phenomenon. But the person who was perhaps most influential, certainly the best known, for promoting the cause of medical treatment for transgender people was Christine Jorgensen. Jorgensen, born male to Danish American parents, traveled to Copenhagen for hormones and surgical treatment and returned to the United States in December of 1952. By then, these procedures had been performed numerous times in Denmark, but Jorgensen was the first person from the United States to receive a great deal of media attention, probably because after her transition she was a conventionally pretty woman and because she was an ‘ex-​GI.’ As transgender historian Susan Stryker points out, ‘Jorgensen’s fame was a watershed event in transgender history. It brought an unprecedented level of public awareness to transgender issues, and it helped define the terms that would structure identity politics in the decades ahead.’ Virginia Prince was quick to distinguish Jorgensen from transvestites, who (according to Prince) did not desire to change gender. It was also clear that Jorgensen was neither homosexual nor intersex (born with both male and female biological characteristics); after Jorgensen’s emergence, Harry Benjamin started promoting the use of the word ‘transsexual’ to distinguish people like her from these other three categories. These four categories –​transvestites, transsexuals, homosexuals, and intersex people –​ remained in use until recently, and designated different communities of people who rarely had anything to do with one another, and in some cases looked down on each other. By the mid-​ 1960s, interest in transsexualism in the United States peaked: Harry Benjamin’s book The Transsexual Phenomenon was published in 1966, and the first university-​based gender clinic that performed surgeries was established by John Money at Johns Hopkins in the same year, with the help of funding from Reed Erikson. Soon such clinics proliferated in the US Within ten years of the establishment of the Hopkins clinic there were more than 40 university-​affiliated gender clinics. With the advent of these centers, an avenue opened for transgender people in the United States to obtain medical treatment without going to Europe. Unfortunately, the clinics adopted an extremely restrictive model of what

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constituted a ‘true’ transsexual. Transgender men –​those born female who wished to transition to a male body and identity  –​were rarely considered for medical intervention, and transsexual women –​born male, transitioning to female  –​were tightly screened. Applicants had to maintain that their dysphoria was present from an early age, that they had a history of playing with dolls as children, and that they were exclusively attracted to males. It was at this time that the narrative of ‘a woman trapped in a man’s body’ became the dominant story told by trans women, even though this idea originated with Karl Ulrich in the nineteenth century –​‘a female soul trapped in a male body’  –​as an explanation for homosexuality. In addition to these criteria, trans women desiring hormones and surgery had to be deemed by their doctor to be able to ‘pass’ successfully as women. Few could overcome these barriers. Unable to meet these narrow and biased criteria, the vast majority of transsexual people were turned away from the gender identity clinics. In its first two and a half years, John Hopkins received almost 2,000 requests for gender-​affirming surgery, but performed operations on only 24 individuals. (Beemyn, 2014, p. 51) Medical doctors were ‘gatekeepers’ for medical intervention, and the gates were locked very tightly indeed. Not only was the likelihood of ‘passing’ as a woman an important criteria for gaining access to medical care, physicians counseled and sometimes required their patients to avoid socializing with other transsexual individuals. They were encouraged to cut ties with old acquaintances and begin a new life with a manufactured history, a process Renée Richards labeled ‘woodworking’ (Richards and Ames, 1983). These requirements mitigated against the formation of support or advocacy organizations, and for many years the only such groups were found in the ‘ballroom culture’ of mostly poor, mostly black and Latinx drag queens in urban areas. Ball culture in the twentieth century, like its nineteenth-​century predecessor, included ‘drag’ events in which members of different groups, called ‘Houses,’ competed on dancing skills, the quality of their drag couture, and the ability to walk on the runway. Houses served as families for many of their members, and the culture itself became somewhat visible to the mainstream through the 1990 documentary ‘Paris Is Burning’ and Madonna’s song ‘Vogue,’ based on the performance style of ballroom events. The university-​based gender clinics’ restrictive criteria posed a huge barrier to transgender people seeking medical care in the late 1960s and 1970s. What made matters even worse was in 1979, the director of the Hopkins clinic, Jon Meyer, published a study, later criticized widely for its methodology

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and bias, that purported to show that surgery did not improve the lives of transsexuals (Meyer and Reter, 1979). Ultimately, it was revealed that the study was seriously flawed and that the ending of surgery was orchestrated by the Hopkins psychiatrist Paul McHugh, who believed that surgery was not an appropriate treatment for transsexualism, which he deemed a mental disorder. But before this came to light, every university-​based clinic in the United States shut down, making medical treatment even less available than before. These events marked the victory of the psychiatric view of gender diversity –​the idea that gender variance is a mental illness caused by poor parenting and correctible through psychotherapy  –​over the biological paradigm –​a view that persists to this day. In 1980 the Illness model of gender variance was codified into the American Psychiatric Association ‘Bible’ of mental illness, the Diagnostic and Statistical Manual of Mental Disorders. It was not until the fifth edition of the DSM was published in 2013 that this was modified, largely as a result of transgender activism. As mentioned in the beginning of this chapter, Sylvia Rivera, a Puerto Rican transgender woman, and Marsha P.  Johnson, an African American self-​identified drag queen, were leaders in the uprising at the Stonewall Inn. Despite the importance of gender-​variant people in early queer activism, they soon found themselves outsiders among both gay male activist and lesbian feminist groups. The Gay Activist Alliance of New York, which became a dominant political group among gay men, explicitly excluded transgender people. The lesbian feminist groups which formed in the early 1970s often viewed drag queens as ‘mocking’ women, and in 1973 Robin Morgan, a prominent lesbian feminist leader, denounced transgender women as ‘men attempting to infiltrate lesbian spaces.’ Finally, in 1979 the lesbian feminist Janice Raymond published a virulent attack on transgender women in the book The Transsexual Empire. Raymond’s views remain even in the twenty-​ first century among a small group of feminists sometimes called ‘TERF’s’ –​ Trans Exclusionary Radical Feminists. The 1970s and 1980s were especially dark times for transgender people in the United States, and their plight was made worse by the disappearance of university-​based gender clinics. The Ascendency of Transgender Activism The 1990s became a turning point in transgender activism and the beginnings, finally, of the merger of the transgender community with lesbian, gay, and bisexual groups. Some of this came from gender-​variant people within lesbian and gay communities. Writer and activist Leslie Feinberg, who first identified as a ‘butch lesbian’ but later as transgender, was one of the first to promote the term ‘transgender’ and the concept that all gender-​ variant people should unite, in their 1992 pamphlet ‘Transgender Liberation: A Movement Whose Time Has Come’ (1997). When transsexual women

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were banned from the National Lesbian conference in 1991 and later that year from the Michigan Womyn’s Music Festival, some lesbian women came to their defense. The murder of the female to male transgender person Brandon Teena, later depicted in the movie Boys Don’t Cry, prompted the new group the ‘Transsexual Menace’ to successfully stage a highly visible national demonstration and drew more media attention than had ever been given to transgender concerns. The proliferation of the Internet brought previously isolated transgender people into contact with each other and promoted the formation of transgender gatherings like Southern Comfort and political groups such as GenderPac and the National Transgender Advocacy Coalition. Transgender activists in these groups fought to affiliate with existing lesbian, gay, and bisexual groups. PFLAG  –​Parents and Friends of Lesbians and Gays –​was the first group to have an explicitly trans welcoming policy, in 1998, but since then nearly all LGB groups have added the ‘T’ to their name and their missions. This does not mean that there is no prejudice within the LGB community toward transgender people, but it is disappearing. One factor facilitating the diminishment of anti-​trans bias is the breakdown of the gender binary and sexual categories, particularly among younger people, who often identify as ‘queer.’ More about that in later chapters. Since the dawn of the twenty-​first century, activists have secured substantial civil rights gains for transgender people. As of 2019, 20 states, the District of Columbia, Guam, and Puerto Rico have anti-​discrimination statutes that include gender identity as well as sexual orientation; three more states prohibit such discrimination based on executive orders or case law. During the Obama administration, federal guidelines were issued to protect the rights of transgender students, but the Trump administration has been working to roll back those protections, and several states have considered (but as of this writing, not enacted) so-​called ‘bathroom bills’ that limit the use of bathrooms to people whose birth-​assigned gender matches the gender label of the bathroom. Moreover, the Obama-​era policy allowing transgender people in the military is being rescinded by President Trump, as is the policy protecting transgender federal employees from discrimination. Just as early gay activists recognized the importance of removing homosexuality from the American Psychiatric Association DSM and thus removing the label of psychiatric illness, transgender activists have recognized the importance of removing ‘gender identity disorder’ from the DSM. It took some time, however, for trans advocacy groups to agree on a strategy because of a complicating factor: the need for insurance coverage for medical care. Insurance companies pay for procedures necessary to alleviate or cure ‘disease,’ and without a psychiatric diagnosis, advocates feared that coverage for medical procedures like hormones and surgeries would be denied. Thus trans rights groups were seeking three things: more self-​determination for transgender people, that is, taking decisions about hormones and surgeries out

The Roads Converge Again  33

of the tight control of doctors; the recognition of gender diversity as normal and not pathological; and a mechanism for insurance coverage for medical care for transgender people. All three of these goals have been at least partially accomplished. First, as a result of activism by transgender people and their health and mental health allies, the fifth edition of the DSM changed the category ‘gender identity disorder’ to ‘gender dysphoria’ and specified that gender variance is not in and of itself a mental illness. However, ‘transvestic disorder’ is still considered a fetish and listed as a disease in the DSM, and many activists and allies still maintain this should be removed. Second, the worldwide standards for medical care have changed. Since 1979, the medical standards for prescribing treatment to transgender people have been set by an international group of professionals in an organization called the Harry Benjamin Society. In 2007, the organization changed its name to WPATH –​the World Professional Association for Transgender Health –​and elected its first transgender president, Stephen Whittle. In an even more radical move, the 7th Standards of Care (SOC), published by WPATH in 2011, not only affirmed that gender diversity is a normal, natural phenomenon, it also changed the role of mental health practitioners substantially, taking them largely out of their previous positions as gatekeepers of medical care (Coleman et al., 2012). For example, psychotherapy is no longer a requirement for either hormone or surgical treatment. Most significantly, hormone treatment for adults is permissible under the standard of ‘informed consent,’ meaning no mental health professionals need be involved in this decision whatsoever. Prior to this, transgender people needed a year or more of psychotherapy and a letter from a licensed mental health professional to obtain hormone treatment, and two such letters for surgery. However, it is important to remember that the SOC are guidelines, not laws, and not all professionals follow them. Third, in a final move to de-​pathologize being transgender while at the same time providing a vehicle for health insurance reimbursement, the World Health Organization has changed its catalogue of illness, the International Classification of Diseases, or ICD. ICD 11, which will become fully operational in 2022, uses the term ‘gender incongruence’ instead of ‘gender identity disorder’ or ‘gender dysphoria.’ In the new ICD 11, gender incongruence will be located in a section called ‘conditions related to sexual health,’ and completely removed from the chapter on mental and behavioral disorders. It should be noted that not all mental health professionals agree with these changes, particularly in the United States and Canada. The DSM 5 changes were contentious, and there are heated battles among professionals, particularly about the new standard of ‘informed consent’ and about the treatment of children and adolescents, which will be discussed in more detail in Chapters 16–​20. I hope that knowing some of the history I have described,

34  The Roads Converge Again

however, will make readers more understanding of the suspiciousness that mental health providers sometimes encounter from transgender clients, particularly those with a political/​activist bent. Unfortunately, as a mental health professional, you are automatically associated with a tradition of denying life-​ saving medical interventions to transgender men and women. This is changing as more psychotherapists are informed and trained in gender diversity, and as more transgender professionals enter the fields of mental health and medicine. Today, in large urban areas in the United States, transgender clients often have the choice to use trans-​identified therapists, endocrinologists, and surgeons. Increasingly, transgender people are able to obtain competent care, and the hostility toward mental health practitioners is decreasing. As a reader of this book, you are on your way yourself to becoming a trans-​ affirming professional. References Beemyn, G. (2014). US history, in L. Erickson-​Schroth (ed.). (2014), Trans Bodies, Trans Selves:  A Resource for the Transgender Community. Oxford University Press, pp. 501–​537. Benjamin, H., Lal, G. B., Green, R., and Masters, R. E. (1966). The Transsexual Phenomenon (Vol. 966). Julian Press. Coleman, E., Bockting, W., Botzer, M., Cohen-​Kettenis, P., DeCuypere, G., Feldman, J., … and Monstrey, S. (2012). Standards of care for the health of transsexual, transgender, and gender-​nonconforming people, version 7. International Journal of Transgenderism, 13(4), 165–​232. David, Ariel (12/​ 20/​ 2018). Ancient civilization in Iran recognized transgender people 3000  years ago, study suggests.​archaeology/​.premium. MAGAZINE-​ancient-​civilization-​in-​iran-​recognized-​transgender-​p eople-​study-​ suggests-​1.6790205 Feinberg, L. (1997). Trans liberation: A movement whose time has come. In R. Hennessy and C. Ingraham (eds.) (1997), Materialist Feminism: A Reader in Class, Difference, and Women’s Lives. Psychology Press, pp. 227–​235. Meyer, J. K. and Reter, D. J. (1979). Sex reassignment:  Follow-​up. Archives of General Psychiatry, 36(9), 1010–​1015. Meyerowitz, J. J. (2009). How Sex Changed. Harvard University Press. Raymond, J. G. and Neville, J. (1979). The Transsexual Empire:  The Making of the She-​ male. Beacon Press, p. 264. Richards, R. and Ames, J. (1983). Second Serve: The Renee Richards Story. Stein & Day Pub. Stryker, S. (2008). Transgender History. Seal Press.



  n 2015, the Open House on Wesleyan University’s campus advertised itself as ‘a safe space for Lesbian, Gay, Bisexual, Transgender, Transsexual, Queer, Questioning, Flexual, Asexual, Genderfuck, Polyamorous, Bondage/​Disciple, Dominance/​Submission, Sadism/​Masochism (LGBTTQQFAGPBDSM) communities and for people of sexually or gender dissident communities.’ Some college groups now just use the acronym GLOW  –​Gay, Lesbian or Whatever You have probably seen acronyms like LGBTQ (lesbian, gay, bisexual, transgender, queer) or LGBTQQ (lesbian, gay, bisexual, transgender, queer, questioning) and other variations containing I  for intersex, A  for ally or asexual, and so on. As silly as some of these acronyms may appear, they are an attempt to acknowledge a serious phenomenon. In the last 20 years, the community that began as gay and lesbian has expanded to include all forms of sex and gender diversity imaginable. Some of the acronym letters simply stand for people who have always been there but may be assuming a new identity label: ‘queer’ is a label that many appropriate for political reasons, or to designate that they are members of more than one sex-​and gender-​ diverse subgroup. Others ‒ like A for asexual –​stand for distinct and rather new identities. What is happening is a growing sense that all forms of sex and gender diversity have some things in common. In Chapter 4, I will show that there is actually some biological evidence for this commonality. Here I deal with social/​cultural similarities and other issues. I  will focus on three groups of people now considered to be part of the sex and gender diversity ‘Big Tent’: kinky people, polyamorous people, and asexuals.

36  The ‘Big Tent’ and Intersectionality

Who Are We Talking About? Let me start with definitions. By ‘kink’ I am referring to people who practice BDSM (Bondage and Discipline, Dominance and Submission, Sadism and Masochism) and who often consider this an important part of their identity. ‘Polyamory’ –​literally ‘many loves’ –​is a type of consensual nonmonogamy, having more than one sexual/​romantic relationship at the same time, with all parties consenting to the arrangement. There are many types of consensual nonmonogamy, but polyamorous people (as opposed, for example, to ‘swingers’) more frequently consider their nonmonogamy to be essential to who they are, and more often align with the LGBT community. At any given Pride Day celebration you are likely to see some marching under a polyamory banner. Asexuals experience little or no sexual attraction to any gender (although they may have romantic feelings). They are one of the most recent additions to the queer Big Tent; the first usage of the term as an identity label appears in the late 1990s. Kink affiliation groups were first formed in the United States in the 1970s. The Eulenspiegel Society (usually abbreviated and now known as TES) began in 1971 in New  York City, followed by San Francisco’s Society of Janus in 1974. These organizations were largely for heterosexual and bisexual kink practitioners. BDSM  –​known as ‘Leather’  –​had already been an unofficial part of gay male subculture, since the 1950s. Starting in the 1970s, gay ‘Leather men’ congregated in certain bars such as the Mineshaft in New York, which opened in 1976, and at large gatherings like International Mr. Leather (IML), started in 1979 and continuing to this day. Gay male leather groups like GMSMA (Gay Male S/​M Activists) formed in the early 1980s. And lesbians formed their own S/​M groups, beginning with Samois, formed in San Francisco in 1979. When these groups originated, they served particular sexual orientations: groups like Samois and the NYC Lesbian Sex Mafia were for lesbian and bisexual women, TES for bi and heterosexual BDSM aficionados, and leather bars and organizations like GMSMA for gay men. But over time they came to see their commonalities and even if membership did not overlap much, the organizations themselves began to participate in common activities. For example, in New York, Leather Pride Night, established in 1982 and running until 2015, was an event that raised money, first, for the Pride Parade, and then later for a variety of causes including the National Coalition for Sexual Freedom, the activist organization for all kinky people. By the 1990s, Leather Pride was run by a coalition of groups working together that included TES and LSM. The AIDS crisis and anti-​pornography laws that targeted kink served as issues that helped coalesce and bring together ‘kinksters’ of all sexual orientations. In 2019, TES considers itself to be a ‘pansexual’ organization and Pride Parades usually have BDSM contingents of all sexual orientations.

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More controversial is the inclusion of polyamorous people in the Big Tent. The term itself was first used in 1990 in an article written by Morning Glory Zell Ravenheart, a polyamorous woman. But polyamorous communities existed in the United States as far back as the 1800s. One of the more well-​ known and long-​lasting was the Oneida community, in Oneida, New York. Led by the preacher John Humphrey Noyes, Oneida practiced what was called ‘complex marriage.’ Noyes believed that monogamy was sinful, and that God required group love, which meant a continual change of sexual partners. Oneida’s group love experiment lasted some three decades, until Noyes fled to Canada under threat of prosecution from local clergy (Klaw, 1993). Many polyamorous people believe that their predisposition to need multiple romantic/​sexual relationships is ‘hard-​wired,’ for which there is some evidence. In other words, poly people see their way of life as an ‘orientation’ and thus see themselves as legitimately affiliated with other sexual orientations. In addition, a huge number of poly families or combinations include at least one bisexual or gay member. Many LGBT+ people remain skeptical, but the polyamory Pride flag, designed in 1995 with stripes of blue, red, and black, is evident during most LGBTQ+ Pride events. The concept of asexuality as an orientation is even newer. While there have always been some people who are asexual, the community did not begin until the Internet made it possible. In 1997 a Yahoo group called ‘Haven for the Human Amoeba’ started, and in 2001 David Jay erected a web page called ‘AVEN’  –​ Asexual Visibility and Education Network, still the largest group and meeting place for those who consider themselves as asexual. Self-​defined asexuals consider their lack of sexual attraction a distinct and separate orientation. However, some asexuals experience non-​sexual romantic attractions, and these people may also define themselves by the gender of those to whom they feel romantically inclined –​for example, heterosexual, gay, bi, or pansexual. The Birth of New Identities What is happening here and why is it happening now? In the Introduction I mentioned two current trends that began in the latter part of the twentieth century in developed Western countries. The first has to do with ‘identity politics.’ In 1943 Abraham Maslow theorized that there was a hierarchy of human needs, and that the lowest rungs of this hierarchy had to do with basic survival needs  –​shelter, protection and safety, food and water. For most of recorded history, and even today in many countries with emerging economies, humans have been preoccupied with these needs. Up until fairly recently, success in life meant not dying from hunger, predators, or the elements, and reproducing yourself, and these goals required all of one’s time and energy. Today, however, for many people in countries like the United States, survival is not an all-​consuming enterprise. Maslow hypothesized that once

38  The ‘Big Tent’ and Intersectionality

basic needs were met, humans aspired to higher needs like love and belonging, esteem, and self-​actualization. The political economist Francis Fukuyama has applied a Maslow-​type theory to societies, and he has conceptualized these higher needs in a slightly different way (2018). Fukuyama recalls Socrates’ idea of thymos, the ‘third part of the soul,’ which is the craving for dignity. All humans, he believed, are motivated by the need to be seen as just as good as everyone else. When sheer survival is no longer an issue, thymos ascends in importance. According to Fukuyama, the latter half of the twentieth century was dominated by this striving for the recognition of equality, what he calls isothymia. The first manifestation of this was on behalf of African Americans in the form of the civil rights movement. From there, similar movements attempted to reprise the experience of civil rights activism on behalf of women, gay and lesbian people, Native Americans, the disabled, and transgender people. But these admirable struggles took a particular turn which Fukuyama decries as problematic. Instead of focusing on achieving equality and recognition by integrating these disparate groups in the mainstream, these movements fostered a multiculturalism that was notable for emphasizing differences. Whether you believe this emphasis on difference is good or bad, it is evident that it predominates, especially on the political Left. Why has this happened? It may have to do with another need that Maslow recognized: the need to belong to a community or tribe. In earlier times, this desire to belong was satisfied by extended family, religion, and/​or smaller cohesive physical communities –​towns and villages. But religion is no longer as important as it was, families no longer necessarily live near each other, and many people live in geographically dispersed suburban settings or in large cities. In the current age, this need is fulfilled for many people by membership in a smaller group with its own subculture and its own unique identifying characteristics that distinguish its members from everyone else. The old melting pot ideal was the image of people from heterogenous backgrounds eventually blending into a more homogenous whole. The melting pot has been replaced by the multicultural ideal of a mosaic, a society where different groups have equal status and rights but retain customs and beliefs that set the group apart from the mainstream. In other words, in our current ‘mosaic’ culture, subgroups of people each retain a distinct identity  –​and the members retain a loyalty to others with the same identity, sometimes to the detriment of other subgroups. This cultural development is often decried as ‘identity politics,’ which the Merriam-​Webster dictionary defines in the following way: politics in which groups of people having a particular racial, religious, ethnic, social, or cultural identity tend to promote their own specific interests or concerns without regard to the interests or concerns of any

The ‘Big Tent’ and Intersectionality  39

larger political group. Identity politics took its modern form during the second half of the last century. It emerged as an emancipatory mode of political action and thinking based on the shared experience of injustice by particular groups ‒ notably blacks, women, gays, Latinos and American Indians. No matter what one thinks of ‘identity politics,’ the phenomenon of individuals affiliating with others on the basis of a shared oppression, and claiming the basis of oppression as an identity, has clearly impacted sex-​and gender-​ diverse people. The result is the LGBTQ+ community. Another historic shift that has contributed to the development of the larger LGBTQ+ community is the sexual liberation movement that began in the 1960s. I am old enough to remember when Elvis Presley appeared on the Ed Sullivan show and the camera cut off above his hips –​the movements of his pelvis were considered too sexual to be shown on TV. But in 1960 the birth control pill became available, at first only to married couples. A 1972 Supreme Court decision made ‘the pill’ available to all women, and in 1973 abortion was legalized. This effective de-​coupling of sex from pregnancy and childbirth gave women more sexual freedom than ever before. This, in conjunction with the emergence of second-​wave feminism, and the general anti-​establishment attitude of the young people of this era, gave birth to the so-​called ‘sexual revolution.’ Beginning in the 1960s, behavior that was previously considered socially undesirable, like premarital sex or living together without marriage, became commonplace among young people. In this new atmosphere of openness and acceptance of sex, it was only a matter of time before same-​sex relationships were liberated. Andrew Solomon, in his book Far From the Tree (2012), describes another cultural shift that started in the late twentieth century:  the inclination to view human conditions previously regarded as disabilities as identities. This movement has affected people with conditions such as deafness, dwarfism, and autism, but it also has impacted sex and gender minorities. It is a trend that confers human dignity, equality, and respect upon people previously shunned, marginalized, or pitied. The removal of homosexuality from the DSM is an obvious example of the transformation of a condition previously diagnosed as a mental illness into an identity. A more nuanced instance of this is the movement of ‘asexuality’ out of the realm of sexual dysfunction. Solomon describes yet another social phenomenon that contributed to the formation of LGBT+ community: the emergence of the importance of horizontal identities. Vertical identities are ones inherited from one’s parents, like race or ethnicity. Horizontal identities, however, are aspects of self that set the child apart from the parent, things like being sex and/​or gender variant. Some vertical identities are certainly stigmatized in our culture: non-​white races, non-​Christian religions, for example. But people with stigmatized

40  The ‘Big Tent’ and Intersectionality

vertical identities are generally born into families and communities with the same stigmatizing characteristic. As bad as their oppression may be, they have a readily available support system of people who can help them navigate a hostile larger society, who can perhaps act as a buffer to protect them from the mainstream culture, and who can offer help when needed. But those with horizontal identities have no such built-​in support system. Having a horizontal identity means that if one wants to affiliate with others like oneself, to have a ‘community’ or ‘tribe,’ one needs to break from the family of origin and that family’s support system. In earlier generations, children who were sex and gender-​variant often attempted to hide their difference when possible, even from their families, or else tried to live their lives in the background. Although this is still somewhat true, today many sex and gender diverse have communities of support available outside their families and communities of origin. I had an uncle who everyone in the family suspected was gay, who lived his entire life as a ‘bachelor’ without, as far as we knew, any contact with other gay men. In this way, Uncle Joe remained part of a large Catholic Italian-​American extended family that might have rejected him had his homosexuality been overt. He sacrificed his authenticity and the ability to have a full-​time partner as a result, but he continued to belong to a supportive community. Later generations were not willing to make the sacrifices Uncle Joe made in order to retain family of origin acceptance. Beginning in the 1960s, as young people tended more and more to move away from the places where they were raised and where their parents lived, and as the desire to be ‘authentic’ gained more and more cultural dominance, sex and gender-​ variant young people were more likely to seek out others like them. Although small gay enclaves existed before this in large urban areas, the trends of the 1960s and later resulted in the emergence of large LGBTQ+ communities in smaller cities and towns as well as big metropolitan centers. Since the advent of the Internet, these communities have been formed in virtual as well as physical space. Finally, as other elements of identity have receded in importance, sex and gender variance has become more important. My mother was first generation Italian. Most of her family lived near each other in the Italian section of Newark, New Jersey, and their ethnicity and their Catholic religion were enormously important. My mother married a non-​Italian and moved away from Newark. My Italian heritage was mostly a matter of food taste for me, and my Catholicism stopped being important by the time I was 16. Most of my cousins dispersed all over the country and, while they may feel pride in their heritage, they don’t live in Italian communities and their children are even more removed from their ethnic identity. Other aspects of self have become more important in terms of identity –​and in terms of affiliation. I am a member of the Baby Boomer generation. In adolescence I was confused

The ‘Big Tent’ and Intersectionality  41

about my sexual orientation, and saw no role models to help me sort out my feelings, but in the 1970s I joined a chapter of the National Organization for Women that had a large contingent of ‘out’ lesbian members. In this atmosphere my confusion dissipated, I declared myself gay, and from that time on have lived and worked in the queer community: it is my ‘tribe’ in a way that Italians never could be. It is hard to describe the relief I felt finding others like me and the comfort provided by having a group with which I  could identify. The Creation of the ‘Big Tent’ But if our society has tended to split itself into small subcultures that seek to differentiate themselves from one another rather than melt into a homogenous larger group, why has the gay and lesbian community become more inclusive of disparate identities? In the early gay rights movement and the homophile movement that preceded it, not only were, for example, transgender or bisexual people not included, even lesbian and gay organizations tended to be separate from each other. There was sometimes outright animosity between gay men and women. My partner Nancy, whose best friend in the 1970s was a gay man, remembers being unwelcome in gay men’s bars, and recalls Gregory facing hostility if the two tried to enter a lesbian bar together. Why did that change? How did the Big Tent become created? There are several reasons that this has happened. First, the AIDS epidemic of the 1980s brought lesbians and gay men together in a significant way. Under the Reagan Administration, AIDS was ignored for the first decade after it emerged in the US AIDS victims were vilified and isolated, even by medical professionals, and care of people with AIDS fell to the gay community. Gay men formed AIDS service organizations that provided help to sufferers, but these organizations were overwhelmed with requests for help, which far outstripped resources. In response, lesbian and bisexual women put aside whatever hostility they may have had toward gay men, and stepped up in large numbers to volunteer in organizations like Gay Men’s Health Crisis in New York and AIDS Project Los Angeles in California. Gay men were enormously grateful, and much of the antagonism between gay men and women dissipated as they joined in a common life and death struggle. I have direct experience with that. In 1984 in New Jersey I spearheaded a coalition of service providers and community organizers to form the Hyacinth Foundation, New Jersey’s first, and still most prominent, HIV social service agency. My therapy practice, the Institute for Personal Growth, became the first ‘home’ for Hyacinth. We donated office space and many hours of our time  –​for a couple of years there was a Hyacinth branch office in my home in Jersey City  –​to ensure that Hyacinth became viable and functional. For many lesbians and gay men, the AIDS crisis was the first time they had substantial

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contact with one another, and these partnerships created enduring bonds and a sense of a common enemy and a common purpose. Another factor that has facilitated the expansion of the queer community is that many of these other sex-​and gender-​diverse people were members of the lesbian and gay community already, or had counterparts in that community. What this means is that the community did not ‘expand’ as much as recognize identities that already existed. For example, gay men and lesbians formed BDSM organizations as far back as the 1970s. It was not a huge leap to incorporate other ‘kinky’ people into the fold. Bisexual organizers first came from the lesbian and gay community. Some had previously identified as gay, in fact:  the Boston bisexual women’s group that called themselves the Hasbians did so because so many members had been lesbian-​identified before coming out as bisexual. Transgender people were not mystifying to gays and lesbians the way they often are for heterosexuals, because many gay people are gender nonconforming themselves, and cross-​dressing in the form of ‘drag’ is a gay tradition. Consensual nonmonogamy was the norm for gay male couples pre-​HIV, and in the twenty-​first century it is again a staple of relationship life for about half of male couples. Lesbian feminists of the 1970s promoted nonmonogamy and it is still somewhat more common among lesbian couples than mixed gender couples. Therefore, polyamorous people, who often are bisexual, easily blend into the larger queer community. The existence of kinky, bisexual, gender-​variant, and nonmonogamous gays and lesbians paved the way for the inclusion of their non-​gay kinky, gender-​ variant, and nonmonogamous brothers and sisters. As should be obvious from the examples above, there is a great deal of intersectionality in the LGBT+ community. The sociological term was first used in 1990 by Kimberlé Crenshaw, a civil rights activist and legal scholar, to refer to individuals who were members of two or more marginalized groups, for example, black women (1990). The Merriam-​Webster dictionary defines intersectionality as: the complex, cumulative way in which the effects of multiple forms of discrimination (such as racism, sexism, and classism) combine, overlap, or intersect especially in the experiences of marginalized individuals or groups. The LGBT+ community is rife with intersectionality, not just of race, gender, and social class, but of forms of sex and gender variance. For example, according to the 2011 National Transgender Discrimination Survey, only 23% of transgender individuals identified their sexual orientation as straight or heterosexual (Grant, Motter, and Tanis, 2011). Surveys of kinky people and polyamorous people find higher numbers of lesbian, gay, bisexual, and

The ‘Big Tent’ and Intersectionality  43

transgender people than in the general population. And asexual people who have romantic attractions (despite a lack of sexual attraction) may identify as, for example, a lesbian asexual, panromantic asexual, and so on. Another factor that binds together various subgroups of the LGBT+ community is that they all encounter many similar issues on the path to actualization. Most recognize their ‘differentness’ in childhood or adolescence; most struggle for a time to hide their variance from others, internalize shame about themselves, and go through predictable stages in identity formation and coming out; and have similar issues with family and friends. These commonalities promote connection with others who have suffered similar, if not identical, struggles. Finally, part of the glue that binds together all these disparate groups is a shared sense of marginalization, and a sense that sex and gender-​variant people all have an underlying similarity. Historically, they have often been lumped together, and there may even be an underlying biological basis for this. From a political point of view, there is strength in numbers, and many of the subgroups that have become part of the queer community in the last couple of decades recognize that. Take, for example, the evolution in the United States of the Employment Non-​Discrimination Act, federal legislation aimed at protecting sex and gender minorities that has been introduced in every Congress since 1994. For many years, the legislation only addressed discrimination against individuals based on sexual orientation. Transgender rights groups lobbied strenuously for gender identity to be added, recognizing that it would be much easier for an LGBT act to be passed than one that addressed gender identity alone. Initially, some lesbian and gay groups balked at this inclusion, an action that became very divisive, but in 2009 transgender activists were successful in having gender identity added. Increasingly, activists have tended to agitate for rights for all members of the Big Tent, not simply lesbians and gay men. For all these reasons, what started as affiliations between gay men for supportive and protective purposes has become a Big Tent of sex and gender diversity. Who will be next? On the website https://​girlfags-​guydykes.bine. net/​en/​welcome/​ you can read about girlfags and guydykes. Girlfags are women or feminine spectrum nonbinary people who feel they are ‘gay men trapped in a woman’s body,’ who are attracted to gay men as a gay man. Guydykes are the mirror image:  men or masculine spectrum nonbinary people attracted to lesbians because they feel they are lesbians. Similarly, some people identify as ‘sapiosexual’ because they are attracted to intelligent people independent of their gender. Are these identities fads that will recede into insignificance  –​or do they represent significant minorities of people within the LGBTQ+ community? I will consider these questions again in the conclusion of this book. But therapists working with sex-​and gender-​diverse

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people should expect change. Fifteen years ago I had never talked to anyone who identified as asexual or nonbinary. Fifteen years from today we will undoubtedly be working with clients we cannot imagine today. References Crenshaw, K. (1990). Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Review, 43, 1241. Fukuyama, F. (2018). Identity:  The Demand for Dignity and the Politics of Resentment. Farrar, Straus and Giroux. Grant, J. M., Motter, L. A., and Tanis, J. (2011). Injustice at every turn: A report of the national LGBTQ Task Force.​injustice-​every-​turn-​report-​ national-​transgender-​discrimination-​survey/​#:~:text=Injustice%20at%20Every%20 Turn:%20A,and%20jails,%20and%20ID%20documents Klaw, S. (1993). Without Sin: The Life and Death of the Oneida Community. Allen Lane. Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370. Solomon, A. (2012). Far from the Tree: Parents, Children and the Search for Identity. Simon & Schuster. Zell-​Ravenheart, M. G. (1990). A bouquet of lovers. Strategies for responsible open relationships. Green Egg: The Journal of CAW, 89.


The Diversity of Nature In Chapter 1 you were introduced to the so-​called ‘gay caveman,’ a reminder that sex and gender diversity has been around since the dawn of human civilization. But humans are far from the only animals to exhibit sex and gender diversity. We don’t know as much as we should about this because for many years even the biological sciences were subject to bias in reporting. Indeed, as Joan Roughgarden, the evolutionary biologist, writes in Evolution’s Rainbow, ‘I came to see the book’s main message as an indictment of academia for suppressing and denying diversity’ (2013, p.  3). Fortunately, the record is being corrected by contemporary biologists who are cataloguing and analyzing sex and gender variations instead of discounting them as anomalies and aberrations. When we look at animal studies we find a dazzling array of behaviors and genders: •

An estimated one-​fifth to one-​quarter of all black swan pairings are of two male birds, and the chicks raised by these pairs (obtained by stealing nests or temporarily involving a third, female swan) have a higher survival rate than those raised by mixed-​sex swan pairs. • A sunfish in New Jersey has one female and two male genders; the eggs fertilized by a combination of the two males have a higher hatch and survival rate. • Male giraffes drink the urine of female giraffes before they mate; it is believed they do this in order to determine which females are in estrus. Males engage in sexual behavior with other males more frequently than with females. In one study, male-​male mountings accounted for 94% of

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sexual activity. They sometimes gather in groups of four or five males to engage in sex. • Male bonobo chimps engage in ‘penis fencing’ –​they hang suspended by their arms while they rub their erect penises together to the point of orgasm. • Spinner dolphins participate in ‘wuzzles,’ group sessions of mutual caressing and sexual activity with same or opposite sex dolphins. • Female spotted hyenas live in matriarchal societies, and have enormous elongated clitorises through which they copulate, urinate, and give birth. • Male dolphins have sex with other males by inserting their penises into the blowholes of other males; female dolphins insert their fins or tails into other females’ genital slits. • Male seahorses gestate, give birth to, and care for the young of the species. • Monogamy is the exception, not the norm, among animals. • The majority of sexual acts between animals observed in their natural habitat are non-​procreative. In short, there is no shortage of sex and gender diversity in Nature. Same-​sex sexual behavior has been observed in over 450 species of animals, including most primates, our closest relatives. Hundreds more animal species have three or more genders, including intersex individuals and those who can change gender. Unusual sexual practices abound, and ‘traditional’ gender roles are not universal. The animal world –​right now, here on earth –​is brimming with countless gender variations and shimmering sexual possibilities … In their quest for postmodern patterns of gender and sexuality, human beings are simply catching up with the species that have preceded us in evolving sexual and gender diversity. (Bagemihl, 1999, pp. 260–​261) As I will show later in chapters relating to specific sexual practices, this diversity has also existed in human cultures as far back as we know. A Russian female figure in rope bondage has been discovered that dates back to 23,000 B.C. Homosexuality has been amply documented in Ancient Greece. The Etruscan Tomb of the Whipping, dating to approximately 490 B.C., is named after a fresco showing a ‘three-​way’ sexual encounter between two men and a woman who is being whipped while being penetrated by one man and who may be performing fellatio on the other. The Kama Sutra contains written instructions on four different kinds of hitting during lovemaking, as well as pinching and biting. There is some evidence that pre-​agricultural human

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societies were nonmonogamous. These archeological and historical findings firmly root non-​standard sexual practices in ancient history. The Function of Sex and Gender Diversity What does this diversity mean? First, it is clear that arguments that being gay or transgender or engaging in non-​reproductive sex acts is ‘against nature’ are sadly uninformed. Indeed, Bruce Bagemihl’s work documenting homosexuality in animals was cited in arguments in Lawrence v. Texas, the Supreme Court ruling that struck down sodomy laws. Second, it suggests that sex and gender variance may be useful and functional, that is, serve a purpose in perpetuating the species. Scientists have perpetuated the dominant cultural view that the obvious function of sex is reproduction, and the binary gender system is part of/​necessary for this procreative goal. From this perspective, which permeates our thinking so deeply that we don’t think to question it, any sex or gender variation that does not further or facilitate reproduction is ‘abnormal.’ Science has accepted this view wholeheartedly until recently, leading Roughgarden to write an ‘indictment of academia’ for ignoring diversity. But more recently, biologists have looked at diversity in animal species through the lens of determining how variations are useful. For some species, we now know the answer to that question. For example, the offspring of the New Jersey sunfish with two male genders described in the beginning of this chapter survive better than the offspring of one male and one female. One type of male is large and one small and similar to a female in appearance. This allows the smaller male to ‘slip in’ undetected when a large male is inseminating the eggs of a female, and inseminate some eggs with his sperm. However, since in this species the male guards the eggs from predators until they hatch, the eggs being guarded by a large male and a small male survive more frequently than those guarded by only one male (Roughgarden, 2013). In other animal species, such as bonobo monkeys, sexual contact determines affiliations between animals and groups of animals and serves as a way to gain cooperation and support (Roughgarden, 2009). Similarly, some anthropologists have used this perspective to study sex and gender variations in humans to find what functions diversity serves. For example, male homosexual relations in many cultures served as mentoring/​initiation practices for younger men and boys. Gil Herdt (1997) has chronicled the Sambia of Papua New Guinea, where until recently all males, during boyhood and early adolescence, went through an initiation period of engaging extensively in homosexual sexual acts before becoming heterosexual men. This ritual seemed to bond the boys strongly, an advantage in a warrior culture frequently engaged in tribal conflicts. While our understanding of sex and gender diversity in animals and among human

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cultures is still very limited, what we know suggests that such variations are useful. The third takeaway from what we know about sex and gender diversity is that there is no one ‘reason’ for this diversity, and therefore in all probability no one cause. The Sambia engaged in homosexuality to bond warriors. In another culture, same-​sex behavior might facilitate cooperation between families. Just as it was simplistic to believe that the only function of sexuality was procreation and therefore the only ‘normal’ genders were the male and female binary, it would be reductionistic to look for one function of diverse sexuality and multiple genders. So what can we learn from our observations of diversity in Nature and from the study of human variations? Some things seem clear. It seems obvious that the pathology model has no foundation in the natural world; it is a human construction. If anything, the pathology model has gotten in the way of seeing sex and gender objectively. In addition, there are many types of sex and gender diversity, and there seem to be many ways in which diversity impacts different animal species and human cultures. For example, the Sworn Virgins of Albania are women who take an oath of celibacy and live as males, with all the rights of men in a rigidly patriarchal society. They may not have much in common with twenty-​first-​century Western transgender men, although superficially they appear to be similar. Because there are many ways to be gender variant or to have a nontraditional sexual orientation, there are probably many ‘causes’ of sex and gender diversity. Therefore, it is unlikely there will be one ‘etiology’ for homosexuality or being kinky or being transgender, but rather multiple forces that combine in different ways in different people, just as sex and gender diversity manifest in a variety of ways across cultures and individuals. Research on Etiology Let us examine some of the research on the etiology of sex and gender diversity. The vast majority of this research is on sexual orientation, with a much smaller number of studies investigating the origins of being transgender, and essentially no research on other sex and gender variations. What I discuss here is research on same-​sex desires. There is some consistency in what is observed cross-​culturally about same-​sex orientation:  in most cultures, people with predominantly same-​sex orientation comprise 5% or less of the adult population; there seem to be some differences between male and female same-​sex orientation, primarily that women are more bisexual and possibly more fluid in their orientation; and male and female non-​heterosexuality is frequently preceded by childhood gender nonconformity. The fundamental question addressed by causality/​ etiology research is: how much is sexual orientation determined by innate, inborn factors, and

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how much by learned, environmental factors? In other words, how much is nature, how much is nurture? The question itself is fraught with significance, because people who see sexual orientation as fixed tend to have different political views than those who see it as chosen (Bailey et al., 2016). Religious groups that promote so-​called ‘reparative therapy’ programs tend to believe that homosexuality is a choice influenced by poor parental upbringing. Defenders of gay rights generally support the ‘born that way’ trope. So far, although research is far from finding a ‘gay gene’ (as was once promoted in the 1990s, e.g., Hamer, 1994), there is no data that confirms that environmental factors such as child-​rearing styles, family dynamics, sex role socialization, or peer influence play any role in determining orientation. ‘Nurture’ in the way we think of it doesn’t seem to play a role. The two hypotheses that have garnered the most support from scientists are both ‘Nature’ models that involve hormones and genetics. The first of these, the ‘organizational hypothesis,’ flows from the fact that the development of most physical sex differences in humans are caused by hormonal influences during various stages of fetal development; in other words, these influences of hormones are organizational. Fetuses start out as ‘female’ and masculinize after testosterone and other androgens influence them prenatally. Studies of circulating hormone levels in adults have not yielded many differences between heterosexually and non-​heterosexually oriented individuals. But the organization hypothesis holds that during an early, prenatal period, the brains of same-​sex-​oriented people are affected atypically by sex hormones; specifically, it is hypothesized that homosexual men’s brains are under-​androgenized. As in most research, women are ignored, although studies of intersex humans provide some hints of a reverse process for females, as I will explain below. Two types of research have given at least partial support to this hypothesis (Hines, 2011). First, in studies of mice, rats, and ferrets, experimentally depriving males of testosterone or exposing female to male-​typical levels of testosterone while in utero dramatically alters their adult sexual behavior. Males will exhibit female-​typical behavior, and females will show some forms of male typical behavior. This most commonly means mounting behavior or lordosis, the position taken when an animal is receptive to being mounted. Ordinarily, males of a species will mount and females will exhibit lordosis; when in utero hormones are altered, this reverses. In addition, in some well-​ studied mammalian species, brain regions –​most specifically, an area called the sexually dimorphic nucleus of the preoptic area (SDN-​POA) –​vary in size as a direct result of perinatal exposure to testosterone. This region appears to play an important role in sexual behavior of male mammals. This has been most studied in sheep, because approximately 7% of male rams exclusively mount other males. In these ‘gay rams,’ the SDN-​POA is half the size in male-​ mounting rams as in female-​mounting rams.

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The second type of evidence in favor of the ‘organizational hypothesis’ comes from studies of humans who are exposed to atypical levels of prenatal hormones, most often because they have unusual genetic syndromes. For example, the condition called congenital adrenal hyperplasia (CAH) results when human female fetuses are exposed to high levels of testosterone in utero. After birth, they receive medication to reduce testosterone, but they show differences from non-​CAH females nevertheless, undoubtedly because of the organizational effects of testosterone during fetal development. As children, CAH girls tend more to be tomboys, and as adults, women with CAH report same-​sex attractions at higher rates than non-​CAH women (Meyer-​Bahlburg et al., 2008). But it is still true that most CAH women are heterosexual, so clearly this factor, while influential, is not totally deterministic of sexual orientation. Other evidence that points to the impact of fetal hormone exposure is the difference in finger length ratios. In humans, the ratio of index finger to ring finger length varies by sex, with women having larger ratios than men. However, this is reversed for same-​sex attracted men and women, again suggesting a fetal hormone effect (Grimbos et al., 2010). In addition, in 1991 Simon LeVay published findings that the brains of homosexual men, autopsied after death, differed from the brains of heterosexual men, in parts of the SDN-​POA region mentioned earlier. Homosexual men’s brains in this region were smaller, much like the brains of male-​ mounting rams compared to female-​ mounting rams. There are many limitations of this research testing the organizational hypothesis, but it seems very possibly that prenatal hormone exposure may play at least a partial role in determining adult sexual orientation. The second hypothesis, that sexual orientation is determined by genes, also has partial but not definitive support. Twin studies show that the rate of concordance of sexual orientation is higher for monozygotic (identical) twins than for dizygotic (fraternal) twins or for other siblings. However, the concordance rate is not 100%, which is what one would expect if same-​sex orientation is entirely genetically determined. Molecular genetics studies have been done attempting to identify the particular genes responsible for sexual orientation. The most famous of this is the previously mentioned study by geneticist Dean Hamer, in 1993. Hamer collected DNA from pairs of homosexual brothers, and looked for chromosomal segments that were shared more often by these brothers than one would expect by chance. Hamer found one chromosomal region with increased sharing, located at the tip of the X chromosome, suggesting that homosexuality is inherited through the mother. However, Hamer’s results have not been replicated, and a more recent study of 500,000 subjects found genetic differences between same-​sex and opposite sex individuals –​but many genes were implicated, and together these genetic differences only accounted for about a third of the variation in sexual orientation (Ganna, 2019).

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By chance, we have the results of one unintentional real-​life test of the influence of nurture on sexual orientation and gender. Between 1960 and 2000, many doctors believed that infants born with malformed penises (or in at least one case, a penis lost in a surgical accident) would be better off raised as girls. These were not infants who had an unusual amount of fetal androgens, so their brains were male. They were raised as females and in many cases did not know they were chromosomal males until adulthood. In other words, the ‘nurture’ factors were entirely female. But in the seven cases with published results, all were attracted to females and not males, which would be expected if sexual orientation is determined before birth, for example, nature. In six of the seven cases, as adults they also chose to live as males. This also seems to be an apparent triumph of nature over nurture. Thus, despite being raised as girls, the impact of ‘nurture’ was not enough to change the sexual orientation and gender identity apparently ‘hard-​wired’ from birth (Meyer-​Bahlburg, 2005). Evolutionary psychologists have long pondered how a trait like homosexuality, which clearly does not confer a reproductive advantage, could exist over tens of thousands of years of evolution. Two theories have been advanced to explain this, the kin selection hypothesis and the sexually antagonistic gene hypothesis. The first holds that the genes for male androphilia (attraction to men) could be maintained if homosexual males help their close relatives reproduce more than they otherwise would have. Although this theory has not been borne out in studies of same-​sex-​oriented males in Western cultures, it has been shown to be true in Samoa for the transgender androphilic males called the fa’afafine (Vasey, 2017). The second theory, the sexually antagonistic gene hypothesis, speculates that male homosexuality has endured because something about this gene confers enhanced reproductive abilities to the mothers of gay male children (Iammola and Cianti, 2009). The has been shown to be true in Western Europe, where the mothers and maternal aunts of androphilic males have more children than other women. It has not been shown to be true elsewhere. But if genes and prenatal hormonal influences account for only a portion of homosexuality, and there is no proof that social environment, family/​parental rearing influences sexual orientation, what else could be at work? We tend to forget that ‘environmental influences’ include far more than social factors. One of the most consistent findings in male sexual orientation research is the fraternal-​birth-​order effect. Gay men, but not gay women or heterosexual women or men, tend to have a greater number of older brothers. It appears that mothers who have sons may have become progressively immunized against a male-​specific protein that affects brain development in the male fetus, and results in the male child having an increased likelihood of same-​sex attractions. This factor appears to be present in between 15% and 29% of gay males (Balthazart, 2018).

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To summarize this research, there is evidence both for genetic factors and for non-​social environmental factors like birth order or pre-​natal hormonal exposure in the etiology of same-​sex attraction. None of these factors are found in all same-​sex-​oriented people, leaving room for other environmental factors to play a role in the formation of sexual orientation. But there is no evidence that social factors, such as peer influence, ‘recruitment’ by other gay men, parental behavior, or social acceptance has any influence on sexual orientation, although increased social tolerance may facilitate more open expression of these desires. Virtually all the biological research on sexual orientation has been done on males; we know next to nothing about the development of sexual orientation in women. What about the research on the etiology of being transgender? There is much less of this research, in part because of the lower prevalence of transgender men and women. Also, it is difficult to disentangle research on sexual orientation and gender identity. For example, many transgender women, who were assigned male at birth, are attracted to men. From a research perspective, should these individuals be considered a type of ‘androphilic (male-​ attracted) males’ or should they be distinguished from males who do not question their gender identity but grow up to be gay? This is made more complicated by the fact that the childhood precursor of both being transgender and being gay is gender nonconformity, suggesting some common developmental pathways between gender diversity and non-​heterosexual sexual orientation. Studies of the digit ratio of transgender men and women yields results similar to that of gay men and women; that is, the digit ratio resembles that of their affirmed gender more than that of their birth gender (Kraemer et al., 2009). This suggests that prenatal androgen exposure, perhaps at a different prenatal stage than for sexual orientation, may be involved in the etiology of transgenderism. In addition, studies of monozygotic versus dizygotic twins show a high likelihood of concordance for being transgender, although, just as with sexual orientation, the concordance rate is not 100%. Post-​mortem brain studies reveal that the brains of transgender women anatomically appear to be an intermediate range somewhere between that of natal males and natal females. In short, although these studies are in their infancy, evidence points to innate factors in the origins of being transgender. What about other environmental factors? Research on early parent-​child relationships and sexual orientation have failed to yield reliable or consistent correlations between these relationships and adult homosexuality. Bell, Weinberg, and Hammersmith (1981) analyzed retrospective reports of thousands of gay men and women. While poor father-​son relationships were weakly correlated with adult male homosexuality, by far the strongest childhood factor for both men and women was childhood gender nonconformity. Other studies have similarly found no or weak evidence of the impact

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of early parent-​child relationships. Moreover, it is not clear which direction the causality flows even when there is a correlation. Given that gay men are frequently gender nonconforming in childhood (read:  girly), are their poorer relationships with their fathers a cause of or a result of homosexuality? Fathers notoriously have difficulty with ‘girly’ boys, and the reported closeness between mothers and gay sons may be mothers’ attempts to protect their sons or buffer them from rejection by fathers. The early psychoanalytic theories of the origins of homosexuality in family dynamics seem to be thoroughly debunked by science. As for other social theories –​peer influence, a social contagion effect, relationship to childhood abuse  –​not a shred of evidence exists that supports any of these hypotheses. What Does This Mean for Clinicians? What are the implications of this research for psychotherapy? It seems clear that although we are not sure why some people are gay or transgender, we can be certain that their sexual orientation and gender identity were not created by social factors such as parental or peer influence, or even early childhood sexual abuse. Reparative or conversion therapies, however, both for sexual orientation and for gender identity, are based on psychological theories. In the case of sexual orientation, most of these theories speculate that the mothers of gay men are ‘suffocating,’ or overprotective and that the fathers are distant, or that they are the result of feelings of inferiority. In the case of gender identity, proponents of behavioral modification of gender-​ nonconforming children believe that these children suffer from overly permissive parents. Before the APA removed homosexuality from its list of mental disorders, conversion therapies for sexual orientation were practiced by psychoanalysts or behaviorists, whose techniques included aversive electric shock treatment or even lobotomies or chemical castration. Today, the advocates of conversion therapy tend to be fundamentalist Christian groups, and while treatment methods are not quite as horrifying as ice-​pick lobotomies or electric shocks to the genitals, they are harmful –​and unsuccessful. A study published in 2002 of 202 subjects who had undergone conversion therapy found that only 3% reported changing their orientation, and that many felt harmed by the treatment, reporting depression, suicidality, social isolation, and poor self-​ esteem (Shidlo and Schroder,2002). Currently, most major professional organizations in the field of mental health consider attempts to modify sexual orientation or gender identity unethical. In January of 2019, New York became the fifteenth state to make conversion/​ reparative therapy illegal, and Utah is poised to become the sixteenth state to ban such treatment. These results make sense in the light of research suggesting that social factors, including early childhood experiences, appear to be irrelevant

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in the formation of either gender identity or sexual orientation. If orientation is determined by some combination of genes and perinatal hormonal exposure, and if these factors appear to actually manifest in differences in the brains of gay and transgender people, it is likely that orientation and gender identity are ‘hard-​wired’ –​that is, relatively unchangeable. While it is true that some people are sexually fluid, meaning that their sexual orientation appears changeable depending upon context, there is no evidence that fluid people have any more control over the direction of their attractions than do individuals who are exclusively gay or exclusively heterosexual. And it also makes sense that therapy that aims to change orientation or gender identity is doomed to fail. From a practical point of view, accepting a client’s request to help change their sexual orientation is not only unethical and possibly illegal –​it is also a bad contract, because you as a therapist have little chance of being able to help that client attain their goal. In later chapters we will discuss more how to handle clients who make this request. References Bagemihl, B. (1999). Biological Exuberance: Animal Homosexuality and Natural Diversity. Macmillan. Bailey, J. M., Vasey, P. L., Diamond, L. M., Breedlove, S. M., Vilain, E., and Epprecht, M. (2016). Sexual orientation, controversy, and science. Psychological Science in the Public Interest, 17(2), 45–​101. Balthazart, J. (2018). Fraternal birth order effect on sexual orientation explained. Proceedings of the National Academy of Sciences, 115(2), 234–​236. Bell, A. P., Weinberg, M. S., and Hammersmith, S. K. (1981). Sexual Preference:  Its Development in Men and Women. Indiana University Press. Ganna, A., Verweij, K. J., Nivard, M. G., Maier, R., Wedow, R., Busch, A. S., … and Lundström, S. (2019). Large-​scale GWAS reveals insights into the genetic architecture of same-​sex sexual behavior. Science, 365(6456), eaat7693. Grimbos, T., Dawood, K., Burriss, R. P., Zucker, K. J., and Puts, D. A. (2010). Sexual orientation and the second to fourth finger length ratio: A meta-​analysis in men and women. Behavioral Neuroscience, 124(2), 278. Hamer, D. H. and Copeland, P. (1994). The Science of Desire: The Search for the Gay Gene and the Biology of Behavior. Simon & Schuster. Herdt, G. H. (1997). Same Sex, Different Cultures:  Gays and Lesbians Across Cultures. Westview Press. Hines, M. (2011). Prenatal endocrine influences on sexual orientation and on sexually differentiated childhood behavior. Frontiers in Neuroendocrinology, 32(2), 170–​182. Iemmola, F. and Ciani, A.S. (2009). New evidence of genetic factors influencing sexual orientation in men: Female fecundity increase in the maternal line. Archives of Sexual Behavior, 38, 393–​399. Kraemer, B., Noll, T., Delsignore, A., Milos, G., Schnyder, U., and Hepp, U. (2009). Finger length ratio (2D:  4D) in adults with gender identity disorder. Archives of Sexual Behavior, 38(3), 359–​363.

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LeVay, S. (1991). A difference in hypothalamic structure between heterosexual and homosexual men. Science, 253(5023), 1034–​1037. Meyer-​Bahlburg, H. F. (2005). Gender identity outcome in female-​raised 46, XY persons with penile agenesis, cloacal exstrophy of the bladder, or penile ablation. Archives of Sexual Behavior, 34(4), 423–​438. Meyer-​Bahlburg, H. F., Dolezal, C., Baker, S. W., and New, M. I. (2008). Sexual orientation in women with classical or non-​classical congenital adrenal hyperplasia as a function of degree of prenatal androgen excess. Archives of Sexual Behavior, 37(1),  85–​99. Roughgarden, J. (2009). The Genial Gene: Deconstructing Darwinian Selfishness. University of California Press. Roughgarden, J. (2013). Evolution’s Rainbow: Diversity, Gender, and Sexuality in Nature and People. University of California Press. Shidlo, A. and Schroeder, M. (2002). Changing sexual orientation: A consumers’ report. Professional Psychology: Research and Practice, 33(3), 249–​259. Vasey, P. L. (2017). Birth order and recalled childhood gender nonconformity in Samoan men and fa’afafine. Developmental Psychobiology, 59(3), 338–​347.



 abitha was a 42-​year-​old woman living with her husband and three children in a middle-​class suburb in New Jersey. She sought my help because she was confused about her identity. Nervously, she began:

All my life, ever since I was a teenager, I’ve been attracted to men and been romantically involved with men. I’ve had a pretty good sex life with my husband Steve. Then, two years ago, I became very close to my neighbor Lyndsey, who is gay. We talked to each other every day, we took our kids to places together, shared information about community resources, went shopping together –​BFF’s. About six months ago after Lyndsey and I had spent the afternoon together hanging out and having a couple of glasses of wine, she teased me about being ‘secretly gay.’ One thing led to another and we kissed. Ever since then –​well, it’s the most amazing sex I’ve ever had and I feel like I’m in love with her. But I’m not gay! … Or am I?

Up until now, we have been talking as though there is a condition called ‘gayness’ that we can all agree upon. But in fact, part of the problem with understanding the literature on homosexuality, from scientific research to accounts of personal experience, is that we don’t agree upon a common definition. And that’s because –​it’s complicated. We have already seen the multitude of forms that the expression of sex and gender diversity takes across history and different cultures. Even within one culture –​say, the twenty-​first-​century United States –​words like ‘gay,’ ‘homosexual,’ and ‘transgender’ mean different things to different people.

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Let’s use same-​sex orientation as an example. Scientists do not even agree on what constitutes an ‘orientation’: is it an inclination, a desire, is it a choice or hard-​wired? What are the salient components of an ‘orientation’? Is it sexual desire, the capacity to be sexually aroused by persons of the same sex? Is it sexual fantasy –​who a person thinks of while masturbating? Is it who a person falls in love with? Or is it an identity? What is the sexual orientation of a man who is married to a woman, fantasizes about men during sex, but identifies as heterosexual –​is he gay, straight, or in between? How about a woman who is strongly sexually aroused by men but only falls in love with women? Most of us, without thinking much about it, use identity as the definition of sexual orientation. But that might be the worst indicator of sexual orientation. Research has shown that self-​proclaimed identity is only loosely correlated with behavior and arousal patterns. For this reason, scientists who study HIV transmission decided decades ago to ignore identity labels. In literature about HIV, you will see terms like ‘MSM’ ‒ men who have sex with men –​‘MSW’ –​men who have sex with women –​and ‘MSMW’ –​men who have sex with men and women. When studying a sexually transmitted disease, clearly it is behavior that is important, not desire or self-​labeling. Most social science research on sexual orientation relies on self-​identification, the label an individual claims to describe themselves. Other researchers rely on sexual arousal as measured by physiological indicators, even though an individual’s personal experience of arousal does not always correlate with physiological indicators, something especially true for women. Sex researchers LeVay and Baldwin have defined sexual orientation as an internal mechanism that directs a person’s sexual and romantic disposition toward men, women, or both (2009). But other experts, notably Lisa Diamond, have proposed that the processes underlying sexual desire and affectional bonding are independent (2003). That is why someone might be more strongly sexually attracted to men but more romantically attracted to women. Women tend to become aware of their same-​sex attractions a bit later than men –​in late adolescence rather than early adolescence or pre-​puberty. But women like Tabitha, attracted to a woman later in life, are not that unusual. Furthermore, Tabitha might find that Lyndsey is the only woman she is ever attracted to –​or she might discover her attractions to men diminish and she is primarily drawn to women. The Complexity of Sexual Orientation Confused yet? You should be. This complexity is one of the reasons the search for a ‘cause’ of homosexuality is so difficult. And it complicates therapy as well. What would you tell Tabitha if you were her therapist?

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Let’s break this down a little further. Let’s start with the numbers. For some years now, population surveys of sexuality among people in the United States have included questions about sexual attraction, behavior, and identity, as have similar surveys in the UK and Australia. They all yield similar results: about 3.5% of adults identify as gay, lesbian, or bisexual (Gates, 2011), although a 2018 poll by Gallup found that number had increased to 4.5% (Newport, 2018). Younger people are more likely to identify as non-​heterosexual than older people, and Latinos, African Americans, and Asians are slightly more likely to identify as non-​heterosexual than are non-​ Hispanic Caucasians. About half of those identifying as non-​heterosexual claim a bisexual identity, and actually more non-​ heterosexual women identify as bisexual than as lesbian. But the same surveys show that larger numbers have engaged in some same-​sex behavior –​about 8%, according to Gates’ 2011 Williams Institute research –​and still more acknowledge same-​ sex attractions –​11% in the Gates survey. Moreover, same-​sex behavior is not confined to those who identify as gay or bisexual: a US national survey showed 2% of self-​proclaimed heterosexual men had had at least one homosexual experience and 10% of heterosexually identified women had done so (Copen, Chandra, and Febo-​Vazquez, 2016). The discrepancy for self-​identified gay men and lesbians is even greater:  an Australian survey found 53% of self-​labeled gay men and 76% of lesbians had had heterosexual sexual encounters (Richters et  al., 2014). Thus the numbers of gay or bisexual people vary enormously depending upon whether you use the criterion of attractions, behavior, or identity. The numbers change yet again if you use what are called ‘indirect’ measures of sexual orientation. A typical social science survey on sexual orientation offers respondents three categories of identity to choose from: gay, straight, bisexual. Faced with these choices, most pick ‘heterosexual.’ However, if, instead, you offer respondents a gradient, the results are different. For example, you might say, ‘Here is a scale from 1 to 10, where 1 is exclusively heterosexual and 10 is exclusively gay. Circle the number that best represents your orientation.’ When this approach is used, surprising numbers of people circle ‘2’ or ‘3’ despite calling themselves straight. The social scientist Ritch Savin-​Williams has studied what he calls ‘Mostly Heterosexual Men’ –​men who would choose the 2 or 3  –​and concludes that this group contains more people than gay and bisexual men combined (2017). Savin-​Williams’ research has been extended to include women. A 2012 study by Vrangalova and Savin-​Williams in which researchers studied both men and women using five categories instead of three showed that while 81% of men and 71% of female respondents identified as entirely heterosexual, 9% of men and 20% of women chose the label ‘mostly heterosexual.’ The percentages of ‘mostly heterosexual’ men and women exceeded the combined totals for the other three categories –​bisexual, mostly gay, or exclusively gay. Moreover,

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with few exceptions, the pattern of self-​reported attractions and same versus opposite sex partners matched these categories. These results seem surprising to us because, as the authors write: ‘These three categories have become so culturally and politically entrenched in contemporary societies that they have achieved the status of “natural kinds,” that is, naturally occurring rather than socially constructed distinctions’ (p. 85). But we should not be astonished by these findings, especially if we look at earlier research. Many people have forgotten the work of Alfred Kinsey and Fritz Klein on sexual orientation, but these two scientists both proposed models that characterized sexual orientation as a continuum rather than a two-​or three-​category system. Alfred Kinsey, arguably the most important sex researcher of the twentieth century, collected detailed sexual histories from thousands of interviews of men and women across the United States. His research led him to believe that same-​sex attractions, fantasies, and behavior varied tremendously from individual to individual, and within one individual’s lifetime. Kinsey proposed that we conceptualize orientation on a seven-​point continuum, which has been named the Kinsey Scale, where 0 represented exclusive heterosexuality and 6 exclusive homosexuality (Drucker, 2010). Fritz Klein was an Austrian-​born psychiatrist whose major work was published in the 1970s and 1980s. Klein was primarily interested in bisexuality, founding the Bisexual Forum in New York City in 1982, the Journal of Bisexuality, and in 1998, the American Institute of Bisexuality, which has funded and continues to fund a great deal of research on sexual orientation. He is best known for his expansion and elaboration of Kinsey’s continuum idea, called the Klein Grid (KSOG), first published in 1978. The Klein Grid measures actual sexual experiences, but also sexual attractions, fantasies, emotional preference, social preference, lifestyle, and self-​identification as they relate to a person’s past, present, and ideal future (Klein, Sepekoff, and Wolf, 1985). Thus Klein acknowledged the possibility of discrepancies within one person between, for example, sexual attractions and experiences, and his paradigm also allows for fluidity of orientation within one person. Klein and Kinsey both viewed sexual orientation as much more complex than the three-​category system that has become standard today. Even More Complexity By now, it should be clear that ‘sexual orientation’ –​as it relates to same vs. opposite sex preferences –​varies depending upon whether you are talking about attractions, behavior, or identity. I haven’t considered fantasy for one reason: while it is true that people’s sexual fantasies often reflect their real-​life sexual orientation, the relationship is very far from perfect. In fact, sexual fantasy is, in general, a very poor predictor of behavior. As we will see in later chapters, recent research on sexual fantasies show that most people

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entertain sexual fantasies that they have not –​and don’t even want to –​put into action. A  friend of mine, an accomplished sex researcher and one of the most open-​minded people I  know, is entirely heterosexual in terms of behavior and attractions, but her favorite reverie during sexual activity is a fantasy of lesbian sex. Not only is there an imperfect relationship between attractions, behavior, and identity, population surveys for the last 50 years or more have indicated that more people experience same-​sex attraction than engage in same-​sex behavior, and fewer people still identify as gay, lesbian, or bisexual. The reason for this seems apparent. Even though Western culture is far more accepting of homosexuality today than it was decades ago, there is still some stigma attached to being gay. Thus there is social pressure to not act upon same-​sex impulses, and even more pressure to stay within the ‘Heterosexual Club’ in terms of identity. ‘Coming out’ –​claiming a gay identity –​is an act of courage, even in the twenty-​first century. But the issue of orientation gets even more complex. Consider that we define ‘sexual orientation’ purely in terms of same versus opposite sex sexuality. There are many more dimensions to sexuality, and it is a bit peculiar that we have defined ‘sexual orientation’ only according to the gender(s) to whom one is attracted. Indeed, some people are noting this peculiarity –​and challenging it. More and more sub-​groups within the LGBTQ+ umbrella are claiming that their sexuality is an orientation. Many people who are polyamorous, people within the kink community, and asexuals all consider that their sexual dispositions are ‘orientations,’ and it has been hypothesized that pedophilia is a sexual orientation as well. This has led sex researchers to attempt to define the characteristics of an ‘orientation.’ Seto (2012) has suggested that there are three criteria that need to be considered in determining a sexual orientation: age of onset (does the disposition appear to be innate or acquired?); sexual and romantic behavior; and stability over time. By these criteria, there are many more ‘orientations’ than simply same versus opposite sex attraction. Many of the ‘+’ groups described in this book could legitimately be called ‘orientations.’ Another factor that complicates our discussion of sexual orientation is the breakdown of the gender binary. If, for example, I am attracted to someone who is nonbinary, who expresses characteristics of both males and females, what orientation am I? There is a word in current usage, ‘skoliosexual,’ that expresses just such attractions. Skoliosexual is defined by Wiktionary and the Urban Dictionary as a primary attraction to genderqueer, transgender, or gender nonbinary people. The point here is that as more and more people identify as neither completely male or completely female, our notions of same versus opposite sex orientations begin to break down. A 2018 survey by the Pew Organization revealed that 35% of Gen Z, people born after 1996, know a nonbinary person. The same survey showed that this is a generation-​related

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phenomenon: 25% of Millennials know someone nonbinary, with only 16% of Gen X and 12% of Baby Boomers knowing someone who doesn’t use ‘he’ or ‘she’ (Parker, Graf, and Igielnik, 2019). Finally, any model of sexual orientation must incorporate recent findings about sexual fluidity. Remember Tabitha, who was described at the beginning of this chapter? It used to be believed that women like her were anomalies, the rare exception that proved the rule of the immutability of sexual orientation. We now know that women like Tabitha are common, and that men can be fluid as well. The primary research in this area was done by psychologist Lisa Diamond (2003), who followed a group of nearly 100 women, between the ages of 16 and 23 when the study began, over a ten-​year period. Diamond’s initial criteria for study inclusion was that her subjects had experienced some same-​sex attraction, although they did not need to label themselves gay or bisexual. More than half of the women in Diamond’s study changed the way they identified sexually at some point during the study, and a significant percentage went through periods when they chose not to label themselves. Moreover, there was no consistent pattern to the changes:  some women changed from lesbian to bisexual or heterosexual, some self-​labeled heterosexual women changed to bisexual or lesbian, and so on. In other words, Diamond disconfirmed the idea that these women were merely ‘experimenting’ with lesbianism and then ‘grew out’ of it. The changes were unpredictable and variable. The women themselves were not dismayed by their changes, and made no attempts to repudiate earlier experiences or identifications. They clearly did not see their sexual identities as fixed and immutable, although that is still, culturally and scientifically, the predominant view of orientation. Diamond ultimately came to believe that some women possess what she calls sexual fluidity, which she defines as situation-​ dependent flexibility in their sexual responsiveness. According to Diamond, this flexibility makes it possible for some women to experience sexual and/​ or romantic desires for either men or women under certain circumstances, regardless of their overall sexual orientation. It is this characteristic of fluidity that, for example, made it possible for the actress Anne Heche to fall in love with Ellen DeGeneres after an exclusively heterosexual past, or for a lesbian icon like the folk singer Holly Near to fall in love with a man. It is why Tabitha could become romantically and sexually entwined with her neighbor despite over 40 years of heterosexuality. Originally, Diamond believed that only women were capable of sexual fluidity, and that this characteristic was one of the things that differentiated male and female sexuality. Over the years, however, there are indications that men can be fluid as well, and even Diamond has acknowledged this, acknowledging male fluidity in a 2016 paper. Ritch Savin-​Williams has done the most research on male fluidity, studying people he calls ‘mostly heterosexual men,’ men whose primary orientation is

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toward women, who acknowledge some attractions and sexual behavior with men but do not consider themselves ‘bisexual.’ A 2015 YouGov survey found that one-​third of their respondents between the ages of 18 and 30 classified themselves as neither entirely straight nor entirely gay. Among men 18 to 24, 6% marked their attractions as ‘mostly opposite sex.’ This is more than the number who maintained they were exclusively gay. Savin-​Williams (2017) intensely interviewed 40 men who categorized themselves as ‘mostly straight’ and followed them up 18 months later, as well as taking their sexual histories and noting incidences of same-​sex attractions and behavior prior to being interviewed. All of these men had experienced fluctuations in their levels of attractions or behavior over time, just like Lisa Diamond’s young women. And the same-​sex attraction was usually situation-​specific: some men only interacted sexually with other men during group sex experiences, or they were only attracted to certain types of men or certain types of sexual interactions. The Savin-​Williams and Vrangolova study mentioned earlier surveyed more than 1,600 individuals online and used a five-​category system –​heterosexual, mostly heterosexual, bisexual, mostly gay, and entirely gay. Twenty percent of their female respondents listed themselves as ‘mostly heterosexual,’ while 6% chose ‘bisexual’ and only 3% endorsed ‘mostly’ or ‘entirely’ gay. Nine percent of men endorsed ‘mostly heterosexual,’ with 3% choosing ‘bisexual’ and 7% mostly or entirely gay. While all this data, taken together, suggests that many people, men and women, are somewhat sexually fluid in their same versus opposite sex orientation, it does not mean that either their orientations or their fluidity is ‘chosen.’ Tabitha did not choose to fall in love with Lyndsey; the experience seemed to come ‘out of the blue’ and took her entirely by surprise. Sexually fluid people often identify as bisexual or pansexual. They are aware that they are flexible, and they understand that they have choice over whether or not to act upon their attractions. But they did not consciously develop as sexually flexible or oriented to both sexes, and they have no more choice over who they find attractive than people who are attracted to only one gender. The data on fluidity has, however, been used as an argument against gay rights. Lisa Diamond, a self-​identified lesbian, was appalled to find her work cited in an amicus brief filed against gay marriage. The argument was that fluidity proved that gay people do not constitute a discrete group because they are not ‘born that way,’ and thus not entitled to protection. In fact, civil rights do not depend upon immutable characteristics. For example, you are entitled to not be discriminated against on the basis of your religion whether you were born into that religion or converted. And the researchers on fluidity do actually hypothesize that people are ‘born that way’ –​but for some people ‘that way’ means flexibility in the gender of the people to whom they are attracted.

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My own interest in these issues is personal as well as professional. In puzzling about my own sex/​gender, it’s always been apparent that I don’t fit into a simple category. As a child, I  didn’t consider myself either male or female, and I was extremely gender nonconforming. Before I was ten years old, I was masturbating to bisexual/​gender-​fluid BDSM fantasies, where I was in the role of a submissive suffering bondage, pain, and humiliation at the hands of unspecified men and women. My first sexual experiences were with another little girl, but when we were caught by her mother I did my best to submerge my attractions to women for a decade. Sexual and romantic feelings for, and experiences with, boys followed. I came out as bisexual in 1970 and lesbian in 1975. In the mid-​1980s I acknowledged openly that my attractions remained bi/​pansexual, and reclaimed a bisexual identity, around the same time I came out as kinky. I was involved in polyamorous relationships in the 1970s and 1980s. I am a clichéd stereotype –​some might say caricature –​of a certain type within my early Boomer generation! But it has given me a front row participatory seat at lots of the cultural changes I have described in these pages. And it has given me a very personal understanding of the complexity of sexual orientation. Takeaways for the Clinician What is the significance of all of this for therapists? The major takeaway is that sexual orientation is complicated, and that self-​proclaimed sexual identity, while important, does not tell us that much. The group of self-​identified lesbians, for example, includes women who have never had an attraction or sexual experience with a man, women who have a stable mix of male versus female attractions, women who are sexually attracted to both but only fall in love with females, women whose lifetime experience is mostly heterosexual but who are currently involved with a woman, transgender women who were attracted to women both before and after transition, women who will have male partners within a few years –​and many more. It is important to know something of your client’s sexual and romantic history, not just their identity. If their attractions and/​or history are discrepant with their identity, it can sometimes be important to explore how they feel about the discrepancy. While some people are comfortable with fluidity, others harbor shame. Shame is not confined to heterosexually identified people who have same-​ sex attractions; gay men and women may also feel embarrassed about their heterosexual inclinations, and it can be important for you, as a clinician, to explain to them some of what is contained in this chapter and in the later chapter on sexual fluidity. ‘Heterosexual panic’ is as real for self-​identified gay men and lesbians as ‘homosexual panic’ is for some heterosexuals. Clinicians also must not confuse fluidity with control or choice, that is,

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do not assume that your fluid clients can decide, for example, to only be attracted to men or only be attracted to women. While clients with mixed capacity to be attracted to men and women may arguably have more options over their behavior, they did not choose their orientation nor do they choose how their orientation fluctuates. A bisexual client who desperately wants to live as a heterosexual may have an easier time doing so than a client who is purely same-​sex-​oriented, but neither of these people can successfully eradicate their same-​sex attractions. Clinicians would also do well to keep in mind the research described in this chapter when working with self-​identified heterosexual clients. Some apparently ‘straight’ people have sex with same-​sex partners, and larger numbers harbor some same-​sex attractions, which may be very ego-​dystonic and disturbing. The moral of this chapter: don’t presume to think you know about someone’s sexuality just because you know how they label themselves. Comprehensive sexual histories are important for all clients, not just LGBTQ+ ones. References Copen, C. E., Chandra, A., and Febo-​Vazquez, I. (2016). Sexual behavior, sexual attraction, and sexual orientation among adults aged 18–​44 in the United States: Data from the 2011–​2013 National Survey of Family Growth. National Health Statistics Reports, 88,  1–​14. Diamond, L. M. (2003). What does sexual orientation orient? A  biobehavioral model distinguishing romantic love and sexual desire. Psychological Review, 110(1), 173. Diamond, L. M. (2016). Sexual fluidity in male and females. Current Sexual Health Reports, 8(4), 249–​256. Drucker, D. J. (2010). Male sexuality and Alfred Kinsey’s 0–​6 Scale:  Toward ‘A sound understanding of the realities of sex.’ Journal of Homosexuality, 57(9), 1105–​1123. Gates, G. J. (2011). How many people are lesbian, gay, bisexual and transgender? Report of The Williams Institute. https://​​publications/​ how-​many-​people-​lgbt/​ Klein, F., Sepekoff, B., and Wolf, T. J. (1985). Sexual orientation: A multi-​variable dynamic process. Journal of Homosexuality, 11(1–​2),  35–​49. LeVay, S. and Baldwin, J. (2009). Discovering Human Sexuality. Sinauer Associates. Moore, P. (2015) A  third of young Americans say they aren’t 100% heterosexual. https://​​topics/​lifestyle/​articles-​reports/​2015/​08/​20/​third-​youngamericans-​exclusively-​heterosexual Newport, F. (2018) In US, estimate of LGBT population rises to 4.5%. https://​ com/​poll/​234863/​estimate-​lgbt-​population-​rises.aspx Parker, K., Graf, N., and Igielnik, R. (2019). Generation Z looks a lot like millennials on key social and political issues. Pew Research Center’s Social & Demographic Trends Project.​2019/​01/​17/​generation-​z-​looks-​a-lot-​like-​millennials-​onkey-​social-​and-​political-​issues/​ Richters, J., Altman, D., Badcock, P. B., Smith, A. M., de Visser, R. O., Grulich, A. E., … and Simpson, J. M. (2014). Sexual identity, sexual attraction and sexual experience: The second Australian study of health and relationships. Sexual Health, 11(5), 451–​460.

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Savin-​Williams, R. C. (2017). Mostly Straight:  Sexual Fluidity among Men. Harvard University Press. Seto, M. C. (2012). Is pedophilia a sexual orientation? Archives of Sexual Behavior, 41(1), 231–​236. Vrangalova, Z. and Savin-​Williams, R. C. (2012). Mostly heterosexual and mostly gay/​ lesbian:  Evidence for new sexual orientation identities. Archives of Sexual Behavior, 41(1), 85–​101.



ickie approached me slowly, even warily. She was dressed in faded jeans, a denim workshirt, and honey-​colored steel toe boots, short sand colored hair slicked back around her ears. She dropped down emphatically into the worn sofa opposite my chair in the women’s center where I  worked in the late 1970s and spread her legs in a gesture of bravado. She eyed me for a minute and then asked ‘How old are you? Are you really gay?’ I fumbled a bit. Nickie was easily 20 years my senior and from a world so different from mine she was right to suspect I could not understand her. I evaded her first question. ‘Yes, I’m a lesbian. Did you think I wasn’t?’ The women’s center I helped found and worked in was staffed with militant feminists, most of us lesbian-​identified. We ran a support group for gay women, and it was the only such group in New Jersey at the time. Nickie had come to talk to me about joining the group on the advice of a friend. But she was clearly skeptical that us NOW ladies (yes, most of us had met as members of a particularly lefty chapter of the National Organization for Women) could understand women like her. I explained that the group was led by ‘out’ lesbian facilitators and that our only agenda was to provide a place where gay women in our working-​ class area of the Jersey Shore could meet for mutual support and validation. I asked her to tell me a little about herself. The story she told shocked and saddened me. It was the first of many like it that I was to hear over the next several years, first at the Center and then in a small private practice in my nearby home. Nickie called herself a ‘stone butch.’ She identified with the male role and was only attracted to ‘femme’ women. She believed in holding doors for her partners, protecting them

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from unwanted male attention, physically if need be, and she preferred they not work outside the home if possible. In bed, she enjoyed giving pleasure to her partners but would not allow herself to be touched –​at least not breasts or genitals. Nickie had spent her early years in western Pennsylvania. As a teenager, her extreme gender nonconformity had earned her the disapproval of her parents. When she was 16 they discovered a love letter in her bedroom from a girl, and they had her institutionalized in the county psychiatric facility for six months. Upon her release, Nickie ran away to New  York and lived on the streets until she was old enough to join the Navy. Her military career was short-​lived, however. It ended when she was found in bed with another female recruit, and both were dishonorably discharged. She told me about the underground, shadowy world of gay bars in the 1950s and 1960s, where police raids were frequent and often involved sexual or physical assault. Nickie had lived her entire life on the margins of society. She wasn’t a man, but she didn’t really pass as a woman, either, so simply walking down the street was an ordeal much of the time. She couldn’t understand lesbians like me, who proudly proclaimed we had ‘chosen’ to be gay. ‘Why would you choose this life?’ she would say. ‘No one in their right mind would choose this.’ It took Nickie months to open up in the group, and when she did she revealed more of her extremely difficult past. She had received so many negative messages over the years that she had incorporated them into her sense of self. It’s what is called in the world of gay-​affirmative therapy internalized homophobia. One night in group, Pat, a facilitator, said to her, ‘Nickie, I’m so glad you are here! You are so smart, you always know the right thing to say when someone is upset.’ Nickie tried to deflect the compliment, and when Pat continued, tears arose in Nickie’s eyes and she turned away so no one could see her face. Quietly, she said, ‘It’s hard to hear that because I can’t believe that. I can’t believe anything good about me.’ Over the years, being treated like a pariah had deepened her internalized homophobia and had poisoned Nickie’s image of herself. In turn, her self-​hatred contributed to behavior that made her sabotage jobs, friendships, and even love relationships. For Nickie, hearing ‘gay is good,’ the activist slogan of the 1970s, seemed ridiculous at first. But in time, this message, repeated over and over again by women who clearly felt pride in their lesbianism, contributed to a profound healing. Case Vignette Arnold was a shy, quiet man in his mid-​60s when I first counseled him in 1982. He had seen an ad I placed in the local paper for ‘gay and lesbian peer counseling.’ Arnold told me he had picked up the phone and then put it down a dozen times before he had the courage to call me, and he trembled throughout our first interview. He had known he was gay, or ‘homosexual,’ as he said, since

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he was a teen, but never acted upon it. As a 20-​something young man still living at home, he had ‘confessed’ to his mother his attractions to men. She was deeply religious and afraid for his mortal soul. The priest she sent him to for advice counseled Arnold to pray –​and to never act upon his sinful impulses. The psychiatrist he consulted in his 30s similarly warned against indulging his deviant desires and suggested that, with enough psychotherapy, he might quell them and even discover attractions to women. That never happened, although Arnold never stopped hoping that one day he would awake to find himself a ‘normal’ heterosexual. Arnold lived an isolated life with no relationships, even friendships, for decades. For the last 20 years he had devoted himself to caring for his ailing mother until she died. Her death left Arnold completely alone in the world. When Arnold saw my ad and called me, some months after his mother’s death, at that point he felt he quite literally had nothing to lose. For many months, I did everything in my power to counteract the lifetime of negative messages Arnold had absorbed. I  talked to him and gave him some of the new gay-​affirming books to read, books like Don Clark’s Loving Someone Gay, Betty Berzon’s Positively Gay and John McNeill’s The Church and the Homosexual. Finally, I  persuaded Arnold to attend a meeting of Dignity, the gay Catholic group, which had a chapter in New York and an offshoot in Montclair, New Jersey. For Arnold, hearing a priest tell him that God loves him as a gay man was a transformative experience. Arnold never did have a sexual partner, but at least some of his self-​hatred dissipated and he was able to believe he wasn’t going to suffer eternal damnation. And the Dignity organization became a support group for him. Because of Dignity, Arnold lived out his remaining senior years with friends and a social life, no longer isolated and alone. In the early days of gay-​affirmative therapy, not all stories were as dire as Nickie’s or Arnold’s. Younger people, who had not lived decades hiding their secret shame in the closet, often had more rapid courses of treatment. In 1983 I saw a 20-​year-​old Rutgers student, Eric, who came to therapy to explore his sexual orientation. It rapidly became clear to both of us that his orientation needed no exploration –​he had been aware of attractions to boys and men from an early age, and had never experienced attractions to women. Simply receiving validation from me, as an ‘authority,’ and later from peers after attending meetings of the Rutgers campus lesbian and gay group, was enough for him to shift from intense anxiety and self-​hatred to an ‘out and proud’ stance. In the early days of the Institute for Personal Growth, we saw many clients like Eric who, once they were exposed to a community that affirmed their gayness, had no need for therapy. They were basically mentally healthy people suffering the impact of living in a severely homophobic culture, but between their youth and their relatively advantaged lives (most were middle class, white, and well-​educated), the damage done to them was rather quickly ameliorated.

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When It’s Not Just Homophobia If you are working in a liberal area of the country, with middle-​aged or younger clients, you will less frequently encounter people whose lives have been totally crippled by internalized homophobia –​and if you do, there may be something else going on. In the early 2000s I began therapy with a 40-​ year-​old man in Central New Jersey whose first words to me were: ‘I’m not sure I am entirely heterosexual.’ I did my best to keep a poker face –​Richard set off all my gaydar alarms just walking into the room. Richard had been a teen in the 1970s, when the general attitude toward gay people was still virulently homophobic. But he was caught in a time warp. He was a highly educated man working for a liberal publishing company near New York City, but deeply closeted and constantly fearful of being ‘found out,’ despite the fact that he had openly gay co-​workers. Richard was aware of attractions to men, and none toward women, yet he labored under the delusion that ‘maybe’ he wasn’t really gay. As a result, he had never experienced sex with anyone, and his homoerotic masturbation fantasies made even pleasuring himself fraught with shame. But internalized homophobia wasn’t Richard’s only problem. He still lived with his parents, even though both his sister and brother had long since moved out and established domiciles of their own. Not only had he never had a relationship, he had only two friends, both straight men he had befriended during college, and both rather superficial friendships. It took several years of therapy to convince Richard that times had changed. He did eventually accept that he was gay –​‘but I will never be happy about it,’ he said. He did come out to his two friends and his siblings, and was surprised to find that they were completely supportive. I convinced him to attend a ‘coming out’ group at the local LGBT Pride center for a while, though that never led to friendships or romantic relationships. When traveling to other countries for work, he occasionally went to a gay bath house or got a massage with a ‘happy ending,’ so he eventually had sex a handful of times. But I came to realize that Richard’s deeper problems had to do with his inability to connect to people. He was extremely attachment averse, and it wasn’t clear that he had ever experienced deep love for anyone, even the parents he ultimately cared for in their old age. His sexual orientation, and his internalized homophobia, complicated his problems and his life, but they were not his fundamental issues. Anthony was much younger when he started therapy with me; he had been born in the late 1970s and although he experienced bullying as an effeminate boy, when he got to college in Manhattan in the 1990s the atmosphere at his school couldn’t have been more accepting. Yet after years of therapy, which included Eye Movement Desensitization and Reprocessing (EMDR) treatment for his childhood bullying trauma, Anthony still remained bitter,

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alone, and nearly friendless. He still attributed his isolation to the early bullying, unable to get past it or to accept responsibility for the off-​putting behaviors and excessive drinking that tended to alienate his acquaintances fairly quickly. For Anthony, thinking of himself as a victim of anti-​gay discrimination became a way for him to justify his alcoholism and his inability to form good relationships. Both Richard and Anthony are people who, in pre-​DSM 5  days, would probably have been diagnosed with character disorders. Their problems, while exacerbated by their sexuality, were more fundamental and deeply entrenched. The point I  am making here is that internalized homophobia, while real, may mask other, more intransigent issues. If you have clients who do not seem to get better despite validation and support for their gayness, maybe you need to re-​think the diagnosis. This is not to say that homophobia does not still exist, or that it does not result in the internalization of self-​hatred. In our culture, lesbians and gay men frequently encounter bias, sometimes blatant hatred and violence. According to the F.B.I., about 16% of reported hate crimes in 2017 were committed against LGBT people, over 1,000 incidents, and the percentage of hate crimes is rising in the Trump administration. Most bullying in schools is directed against children perceived to be LGBT, especially boys seen as gender nonconforming. As a clinician, you need to be prepared to hear histories of bullying from your gay and lesbian clients, and to consider and treat this bullying as trauma. And certainly lesbian and gay people can still be rejected by family, friends, co-​workers, and by their churches and communities. But this will vary according to several parameters. The gay comic Robin Tyler was 17 in 1959 when she encountered the lesbian magazine The Ladder. ‘In it was an article by Del Martin and Phyllis Lyon,’ Tyler writes, ‘Who said there was nothing wrong with being a lesbian, but to think about moving to a big city immediately.’ This wisdom still rings true 60 years later. There is a wide variability in what it is like to ‘grow up gay.’ The parameters include: 1) Younger clients will be less likely to have encountered discrimination, including peer discrimination, than older clients; 2) Clients growing up/​living in liberal and/​or urban areas are less likely to be victims of bias or hate; 3) Those growing up in deeply religious households are more likely to encounter homophobia from families and religious institutions; 4) Highly educated communities are less likely to be homophobic than less educated communities; 5) While there is no evidence that non-​whites are more homophobic than white people, people of color are struggling with the intersectionality

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of race and sexual orientation, and this compounds the impact of homophobia. Assessing the Impact of Growing Up Gay No matter what your client’s circumstances, it is likely that they have suffered at least microagressions as a result of being ‘different,’ so you always need to assess for a possible history of homophobia-​related trauma. As a clinician, how do you determine if your client has endured such trauma and concomitant internalized homophobia? Clients do not always connect these experiences to their current problems. The key of course is taking a good and thorough history that includes an account of how and when they determined they are gay. You are not just interested in when they came to that identity label. You need to know: • • • • • •

When they first felt ‘different’ from others, usually as a child; What it was that made them feel different; How they felt about it, who they told, if anyone, and how they handled it; Whether others noticed the ‘difference’ and how they responded; When they first realized same-​sex attractions; When they first acted upon these attractions, and the repercussions of their actions.

Frequently, the first ‘sign’ of being gay is gender nonconformity. As I  mentioned in Chapter  4, social scientists Bell and Weinberg (1981) did a large retrospective study in which they asked lesbian and gay-​identified adults about family dynamics, relationships with parents and siblings, and other childhood experiences. The only variable that was correlated with adult sexual orientation was childhood gender nonconformity, and that continues to be true today. In other words, girls who were tomboys and boys who exhibited more feminine interests and behaviors were likely to grow up gay. The relationship was particularly strong for boys. Later, Richard Green (1987) studied young boys brought to a gender identity clinic because of gender atypical behavior. These boys wanted to dress in girls’ clothes, play with dolls, preferred girl friends to boy friends, and eschewed rough-​and-​ tumble play. Green followed them into adolescence and found to his surprise that most of them, instead of becoming transgender as expected, were gay or bisexual. Thus, in taking a history, pay special attention to gender atypical behavior. Gender nonconformity is often evident many years before sexual or romantic attractions emerge. Note how others responded to your client’s nonconformity and how the client handled these early indications of being different. Jeffrey remembered having crushes on boys from the

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time he was six, and by that age he also envied his older sister’s dresses and make-​up. But he was shrewd enough to realize that his feelings were unconventional, and that he could be ridiculed for them. So he worked hard to conceal any ‘feminine tendencies’ and struggled to achieve proficiency in sports. Allen, on the other hand, also preferred ‘girl toys,’ female friends, and frilly pastel clothes, but was less successful at hiding his proclivities. Despite his best efforts, his slight, delicate stature and his soft, feminine gestures made him the butt of laughter and scorn from classmates. Jeffrey and Allen were both born in the 1970s, and both suffered, but in different ways. Allen was the brunt of more obvious and overt trauma, but Jeffrey was damaged by the knowledge that his popularity came at the cost of hiding his authentic self. By adolescence, Allen had long since given up trying to be accepted. He ‘came out’ as gay when he was 16, left home at 18, and established a life and a strong support system in a nearby city. Jeffrey, on the other hand, didn’t acknowledge his sexual orientation until he was nearly 30, and spent a number of unsatisfying years attempting to ‘fit in’ to a heterosexual lifestyle. Gender nonconformity in girls is generally more accepted, at least until adolescence. Evelyn hated dresses and frills from as far back as she could remember. She excelled at sports, and was a star soccer player throughout grade school, high school, and college. Because of her athletic prowess, she suffered little pressure to ‘act like a girl’ even when she was a teen. And when Evelyn realized at around age 14 that she was attracted to women, she found other lesbian soccer players, making her ‘coming out’ less isolated than it might have otherwise been. Charlotte was also a tomboy, and although she enjoyed playing Little League and soccer, it was never a passion for her. In adolescence her family began to question why her interests didn’t shift to fashion and flirting, and for the first time Charlotte felt like an outsider with peers. Charlotte felt betrayed by her family members, who were now criticizing the same traits that had been accepted when she was younger, and she was estranged from people her own age. The attractions she felt to girls and women as a teenager made her feel even more isolated, and she struggled to hide them. The point of these examples is that it is important for clinicians to carefully note how early experiences of being different, which most commonly will be experiences of being gender nonconforming, are responded to by the child’s environment, and how the child chooses to handle their difference and others’ reactions. The negative impact of diverging from heteronormative expectations will vary, not only in intensity, but also in the form it takes. Not only will it impact self-​esteem, it will affect the degree to which your client reveals their genuine self to others, their capacity to trust others, and their ability to form attachment bonds, among other things. When children perceive that others judge them negatively, they often develop a deep sense of

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shame about themselves, and shame is implicated in most forms of mental illness including depression, eating disorders, and addiction. Helping Clients Heal from Homophobia-​related Trauma and Shame As a therapist, how do you ameliorate the impact of early trauma related to homophobia, and the associated sense of shame? The most important thing you can do is validate the pain and the unfairness of these experiences. By definition, internalized homophobia is an example of blaming oneself for painful events instead of blaming others or the society at large. Your clinical work with clients who have ‘blamed the victim’  –​themselves  –​will include working with maladaptive cognitions and perhaps even challenging their world view, including their view of their family, their parents, their community, and their church. Therapists who work with childhood trauma recognize that sometimes children blame themselves rather than their abusers. It may be easier for a client to take personal responsibility for the abuse they suffered than to recognize that an otherwise loving parent behaved cruelly and unfairly with regard to the child’s emerging sexual orientation. As a therapist, you can give a socio-​political context that helps to shift out of a victim-​perpetrator blame model: unfair, biased, harshly negative cultural norms are the culprit. The parent has been a victim of these anti-​gay cultural standards as well. Many parents believe they are protecting their child by trying to prevent them from acting upon their same-​sex desires, unaware that their own views have been distorted by socially inculcated homophobic beliefs. When a client realizes that they have suffered needlessly and irrationally for attributes for which they are blameless, it can be as though a veil has been lifted from their eyes. The result is often a period, usually temporary, of intense anger, a righteous fury at how they have been treated. This is a healthy response, although they may need help in figuring out how to channel the anger constructively. The client may need to confront family members or others who were critical of their gayness, and therapy can help people do this in a productive way. The result can be healing for both your client and their family members and can lead to closer bonds, as Michael LaSala has documented in his work with families with a gay child (2010). In some cases, though, when a client realizes that a parent is intransigently critical, the healthiest response may be to distance from the family. Gay people are still sometimes treated harshly, even thrown out of their homes, when parents discover their sexual orientation. It is not always possible, or even desirable, to maintain closeness in such a situation. You need to be prepared to help your client heal ruptures with their family, when possible, or to distance from the toxic family environment if rapprochement is impossible.

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As a therapist you can also help by knowing the resources in your community. Bibliotherapy is often helpful, and you should be able to suggest books and websites that provide information that counters homophobia. Peer support groups of other gays and lesbians are indispensable. Finding others who have had the same experiences is often more validating than anything you can say as a clinician. PFLAG  –​Parents and Friends of Lesbians and Gays –​is primarily for family members, but gay people who are estranged from their own families often find comfort from meeting parents who are supportive of homosexuality. In 2018, a woman named Sara Cunningham made news by offering to be a ‘stand-​in’ mom at weddings for gay couples who were estranged from their own parents. She received many requests for help, and inspired other women to make the same offers. If your own parents disapprove of homosexuality, it can be healing to make the acquaintance of parents who have been accepting. The loudest cheers at every Gay Pride Parade are for PFLAG. When your client is religious and has been rejected by their church, you will need to be familiar with books like God vs. Gay (Michaelson, 2011), God and the Gay Christian (Vines, 2014), and The Church and the Homosexual (McNeill, 1976). There are now gay-​affirmative groups affiliated with almost all major organized religions. To name a few:  Believe Out Loud, Dignity, Reconciling Ministries, and Integrity are some of the many groups serving gay Christians; Al-​Fatiha Foundation is one of the groups for gay, lesbian, and transgender Muslims; Keshet and many others serve gay Jews; Queer Dharma is a community for gay Buddhists. Religious gay people can feel as though God does not love them, and a religious organization similar to the faith of your client’s childhood can be more affirming than any argument you can make. Some gay people are subjected to a particularly virulent form of religiously based discrimination:  reparative therapy, also called conversion therapy. Remember that only slightly more than half of the medical doctor (M.D.) members approved the American Psychiatric Association’s removal of homosexuality from the list of psychiatric illnesses in 1973. Many psychiatrists and psychologists never agreed with that decision and continued to maintain psychotherapy practices that offered to help gay people become heterosexual. Moreover, many religious organizations maintained the belief that homosexuality, considered a sin, was curable. In 1976 Exodus International, an interdenominational Christian organization, was founded with the express purpose of ‘helping people who wished to limit their homosexual desires.’ Exodus International was primarily associated with Protestant and evangelical denominations, and at its height in 2006 had 250 ministries in the United States and 150 in other countries. In 1992, the psychiatrists Charles Socarides and Benjamin Kaufman and the psychologist Joseph Nicolosi founded the North American Association for Research and Therapy of

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Homosexuality (NARTH). NARTH became the leading professional proponent in the United States of reparative/​conversion therapy, that is, ‘curing’ homosexuality. It was inevitable that NARTH would become allied with religious groups, providing the professional/​theoretical rationale for conversion therapy practices. Between Exodus and NARTH, the 1990s saw a resurgence of these approaches, almost all affiliated with various religious denominations. However, the publication of research studies showing that conversion therapy did not effect the cures it claimed helped convince major professional organizations to decry the practice (Haldeman, 1994, 2002). This was coupled with some high-​profile defections from ranks of the conversion therapy promoters: in 2006, Ted Haggard, President of the National Association of Evangelicals, admitted to having sex with a male prostitute despite having undergone reparative therapy, and in 2013, Alan Chambers, President of Exodus International, closed down the organization after admitting he had never met anyone successfully ‘converted’ by its methods. As you might expect, gay activists have long made conversion therapy a target of their efforts. To date, 18 states in the US plus the District of Columbia and Puerto Rico outlaw such therapy with minors. But the practice continues. A Williams Institute report from 2018 estimated that 698,000 Americans have undergone conversion therapy; about half received this treatment as minors forced into treatment by their parents (Mallory, Brown, and Conron, 2018). Studies suggest that people who have undergone conversion therapy experience elevated rates of depression and suicidality. So if you work with a client who was forced into this kind of treatment, there is a good chance your client has post-​traumatic stress disorder (PTSD) from the therapy itself, as well as issues resulting from rejection by family and church. The Takeaways for the Clinician If you work in a conservative area of the country, a rural area, a very traditional, or highly religious community, the clients and issues I have described in this chapter may comprise the bulk of your lesbian and gay clients. If you work with older gay people, this chapter may describe many of your clients. The hallmark of this kind of person is that being gay has had a major negative impact on their life, particularly as children and adolescents. Being gay has been traumatic for them, and it may be that the most important thing you can do as a clinician is help them heal from the trauma. Many of the techniques you will use to do this will be similar to trauma-​informed methods you already employ. Others, suggested here, for example, bibliotherapy, connection with community resources, and so on, will supplement that work. In summary, while some types of clients  –​older, more religious, those from more traditional communities  –​are more prone to the trauma of

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homophobia than others, it is important through careful history-​taking to assess internalized shame and self-​hatred related to sexual orientation in all your clients. Once assessed, there are concrete steps you as a therapist can take to ameliorate this shame, steps that are usually very successful, and gratifying to both your client and you as a helper. References Bell, A. P., Weinberg, M. S., and Hammersmith, S. K. (1981). Sexual Preference:  Its Development in Men and Women. Indiana University Press. Berzon, B. and Leighton, R. (1979). Positively Gay. Celestial Arts, pp. 1–​14. Clark, D. and Clark, D. H. (1977). Loving Someone Gay. Lethe Press. Green, R. (1987). The ‘Sissy Boy Syndrome’ and the Development of Homosexuality. Yale University Press. Haldeman, D. C. (1994). The practice and ethics of sexual orientation conversion therapy. Journal of Consulting and Clinical Psychology, 62(2), 221. Haldeman, D. C. (2002). Therapeutic antidotes: Helping gay and bisexual men recover from conversion therapies. Journal of Gay & Lesbian Psychotherapy, 5(3–​4), 117–​130. LaSala, M. C. (2010). Coming Out, Coming Home:  Helping Families Adjust to a Gay or Lesbian Child. Columbia University Press. Mallory, C., Brown, T. N., and Conron, K. J. (2018). Conversion Therapy and LGBT Youth. Williams Institute, UCLA School of Law. McNeill, J. J. (1976). The Church and the Homosexual. Beacon Press. Michaelson, J. (2011). God vs. Gay? The Religious Case for Equality (Vol. 6). Beacon Press. Vines, M. (2014). God and the Gay Christian: The Biblical Case in Support of Same-​sex Relationships. Convergent.



hen I was an adolescent, I was struggling to hide both my gender non-​conformity and my attractions to women. I buried my lesbian feelings so deep I didn’t even acknowledge them to myself again until I  was in my 20s. I  was raised in a suburb of New  York, but it may as well have been Oklahoma or Nebraska. For years, as a teen, I  just felt ‘wrong,’ and I dared not confide in anyone, not family, peers, or even a therapist I saw for depression when I was 18. I didn’t know any gay men or lesbians. In the 1960s my liberal East Coast college had no groups for non-​ heterosexual men or women. The depictions I saw in the media were few and far between, and invariably negative. Gay men were portrayed, when they were mentioned at all, as predators who hung around school yards hoping to entice an unsuspecting and naïve young boy. Gay women received no mention at all, except in the occasional cautionary tale like ‘The Children’s Hour,’ the Lillian Hellman play in which the apparently lesbian character hangs herself. In high school, I was not allowed to wear pants or slacks. I was not an athletic kid, but even had I been, these were the days before Title IX, when sports for girls were unheard of. Contrast this with the life of one of my daughter’s friends, a girl born in 1994 in Jersey City, a brief subway ride from Manhattan. Briana was an athletic tomboy who played soccer throughout high school and thus was surrounded by other girls who were not ‘femmes,’ as well as a few who were not entirely heterosexual. Her high school had a GSA –​Gay Straight Alliance –​which she joined when she was 16 and which formed the basis for her closest friend group. She took a girl to her senior prom with very little blowback from her peers and the support of teachers and the school administration.

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Briana struggles a bit with her identity, sometimes identifying as bisexual, sometimes pansexual, and sometimes as gay, mostly eschewing labels as too ‘limiting.’ She grew up seeing gay men and lesbians portrayed fairly sympathetically on TV and in film: Ellen de Generes, ‘Will & Grace,’ Brokeback Mountain, ‘The Kids Are All right,’ ‘Modern Family.’ Briana ‘came out’ to her parents while in high school. After Mom and Dad spent some time in denial, they eventually became relatively accepting, although they periodically let her know they are hoping that the ‘straight’ side of her bisexuality will prevail and that she will end up married to a man. They found other parents in PFLAG (Parents and Friends of Lesbians and Gays) who offered them emotional and practical support. Her parents are polite and welcoming to the occasional girlfriend she brings home. In college Briana got involved with a gay group on campus; most years she goes to the NYC Gay Pride March at the end of June. Briana maintains an androgynous appearance and occasionally in public she hears a muttered ‘dyke’ from a passerby, which enrages her. She doesn’t feel shame or humiliation when that happens –​she knows she has just encountered a jerk. Now in her 20s, she is ‘out’ to everyone, including her boss and co-​workers at the pet grooming store she manages. She intends to have children someday and anticipates no barriers to this regardless of the gender of her eventual partner. Currently, she identifies as ‘polyamorous,’ although in practice whenever she has a romantic partner she is monogamous with that partner. Twenty-​first-​century LGB  Youth Today’s young gay person is different from the same-​sex-​oriented youth of even 20 or 30 years ago. But just how different still depends upon social class, educational level, and geography, as well as family variables such as openness and extreme religiousity. Research on gay adolescents began in the 1970s, and for a long time focused primarily on young gay men who were recruited to study from the mental health facilities where they received treatment. This methodology, besides ignoring gay women, almost insured that subjects would be more mentally unstable than a representative sample would have been. In the 1980s and 1990s, school populations began to be used, rather than samples from mental health facilities, and women were included as well as men. All of these studies, taken together, and continuing until today, show that lesbian, gay, and bisexual youth are at greater risk for depression, suicidality, drug and alcohol abuse, academic failure, and sexually transmitted infections, including HIV. For example, a 2006 study by Eisenberg and Resnick found that over 50% of LGB youth reported suicidal ideation, and that nearly 40% had attempted suicide, a rate more than four times that of non-​LGB youth. These elevated rates of distress appear to be

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related to the fact that LGB youth suffer more abuse of all kinds than do heterosexual youth (Marshal et al., 2011): a meta-​analysis of studies (Friedman et  al., 2011)  showed that they suffer more sexual abuse, physical abuse by parents, and physical assaults at school. School bullying of LGB youth is extremely prevalent, and research has established a clear link between school climate and LGB youth fragility (Murdoch and Bolch, 2005). The amount of oppression LGB students face, both in the form of stigma from teachers and school personnel, and bullying from peers, is directly related to the extent to which these students will develop depression, suicidality, and other signs of instability. Certain factors can ameliorate the effects of victimization, however. A 2013 study showed that lesbian, gay, and bisexual students in schools with Gay Straight Alliances had half the suicidal ideation of students in schools without GSAs (Heck, Flentje, and Cochran., 2013). And a growing body of research shows that family support can also act as a buffer against peer bullying (Ryan et al., 2010; van Beusekom et al., 2015). Parental acceptance acts as a protective shield for many young LGB people. These findings highlight the importance of clinical work with the families of non-​heterosexual young people as well as the need for clinicians to be school advocates. Parents need to hear that the negative outcomes they fear for their children can be in part prevented through their own actions, and schools need to be confronted when they fail to protect the safety of students. While it does appear to ‘get better’ –​Birkett, Newcomb, and Mustanski (2015) followed gay teens over several years and found their level of distress was reduced as they got older –​it is also clear that initial levels of distress are related to level of victimization. In 2009 Ritch Savin-​Williams published the ground-​breaking book, The New Gay Teenager. In it, Williams challenges the view that LGB young people are invariably damaged by their experiences. He correctly critiques the negative bias of research that used consumers of mental health services as subjects. Savin-​Williams emphasizes the resiliency and strength of gay teens over their fragility. The more controversial thesis of the book, however, is that the ‘new’ LGB teen is ‘post gay’ –​that is, he/​she does not care about labels, considers those labels confining, and does not view their sexual orientation as the most important defining characteristic of their identity. Savin-​Williams work has been criticized in part because many of his subjects were students at elite colleges, but he clearly foresaw the future in some way. His central premise, that labels are obsolete, is objectively not true. In fact, as we have seen, more young people than ever identify as lesbian, gay, or bisexual. But it is also true that the labels have proliferated to a degree that no one would have imagined a few decades ago, and that non-​heterosexual people are exhibiting, or at least admitting to, far more sexual fluidity than we thought possible.

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The Stress of Growing Up Gay So what is it like to grow up lesbian, gay or bisexual in the twenty-​first century? While Briana, the girl described in the beginning of this chapter, had a relatively easy time of it, it is not true for all young sexual minority youth. Most still suffer from some type of minority stress. The concept of minority stress was first developed by social scientists like Erving Goffman and Gordon Allport when describing the pressures of discrimination experience by stigmatized minorities such as African Americans. It was hypothesized that the members of these minorities face multiple difficult and discriminatory social situations, and that the stress of these situations leads to poor physical and mental health. The stress response –​also known as the ‘fight or flight’ response –​is a physical reaction the body has when the brain perceives danger. Changes in the body are triggered to prepare it to respond: adrenaline and cortisol are released into the system, and changes like increased heart rate, pulse rate and blood pressure, and increased blood flow to the extremities ensue. But the stress response was meant to be an instantaneous response to a discrete danger, not a prolonged state of being. When the response becomes chronic, as is true for many minority people who face discrimination on a daily basis, our physical wellbeing suffers. Prolonged surges of adrenaline and cortisol can cause chronic high blood pressure, damage to blood vessels, increased weight gain, sleep problems, and mood problems like anxiety or depression. In 2003, psychologist I. H. Meyer proposed that the minority stress model applied to lesbian and gay people and that stigma, prejudice, and discrimination create minority stress that accounts for their higher rates of mental and emotional illness. He identified three types of chronic stress for LGB people:  ‘(a) external, objective stressful events and conditions (chronic and acute), (b) expectations of such events and the vigilance this expectation requires, and (c) the internalization of negative societal attitudes’ (Meyer, 2003, p. 5). Minority stress includes both macro and micro aggressions. An example of a macro aggression is being physically assaulted because someone knows or believes you are gay. An example of a micro aggression is being excluded from a social group because you are believed to be gay, or being asked about opposite sex partners because you are assumed to not be gay. Minority stress is also created by the anticipation of macro and micro aggressions and the hypervigilance this anticipation creates, and by the damage to self-​esteem created by internalizing cultural stigma. Given the kind of stresses LGB people experience, it is not surprising that they would suffer poor mental health in comparison to heterosexuals. And they do: a large body of research supports the conclusion that LGB people, especially youth, are more depressed, more subject to substance abuse, and more suicidal than non-​LGB people (Bryan and Maycock, 2017). Non-​Caucasian minorities within the LGB community

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have higher rates still (LaSala, 2010), which is also predicted by the minority stress model and the concept of intersectionality, the idea that people who are members of more than one stigmatized group will have heightened reactions to multiple stigma. There is no doubt that lesbian, gay, and bisexual people are still subjected to minority stress, despite increases in overall social acceptance. What is it like to grow up as a non-​heterosexual in today’s culture? To begin with, the recognition that one might not be heterosexual starts young: Pew Research Center data indicates that the median age at which children recognize they are probably not straight is ten years for boys and 13 for girls. However, children who are gender nonconforming, especially males, may be subjected to teasing or accused of being gay at far younger ages. In some very liberal and supportive families, children may actually reveal this to their parents at a fairly young age. But the same Pew Center survey found that the median age for telling anyone else about one’s sexual orientation was 18 for boys and 21 for girls. This means the average LGB young person spends eight years keeping a secret about their identity, a secret kept for fear of reprisals if discovered, a secret bound to inculcate some sense of shame. The 2017 Human Rights Campaign Youth Survey found that 67% of respondents reported hearing their families make negative comments about LGBT people, which may be a reason it takes so long for young LGB people to tell anyone else (Kahn et al., 2018). The 2017 HRC survey reveals more about the stresses contemporary ‘queer’ youth face:  85% rate their average stress level as ‘5’ or higher on a 1–​10 scale; 70% have been bullied at school because of their sexual orientation; and 74% have experienced verbal threats at school or elsewhere. When they are ‘out’ to anyone, it is most frequently a LGBTQ friend, next is most commonly a sibling or non-​LGBTQ friend. Only 22% of these 13–​17 year olds surveyed had told their parents they were gay, and only 5% told a teacher or healthcare provider. And as we have already seen, research indicates that LGB children are subjected to more physical and sexual abuse, by parents, peers, and others, than heterosexual children. Thus growing up gay, lesbian, or bisexual still nearly invariably involves two things: some harassment or discrimination; and a good deal of hiding or secrecy. Given this inauspicious beginning, it is remarkable that Pew survey results indicated that only 7% of LGB people believe being gay was a negative factor in their life. LGB Youth Resiliency So how does an individual move from stress, discomfort, and secrecy to self-​ esteem and openness? Developmental psychologists and researchers have suggested several models for how this comes about. The Australian psychologist Vivenne Cass

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proposed the first of these in 1979. Cass outlined six stages, beginning with ‘Identity Confusion’ and culminating in ‘Identity Synthesis.’ She theorized that the process starts with the individual having a sense that they are different from –​and alienated from –​their peers. From that point, they move through stages of identity comparison, tolerance, and acceptance, culminating with a feeling of pride in one’s gayness and finally to a stage in which one’s sexual orientation is fully integrated into the sense of self and is seen as important, but as only one aspect of the self. Following Cass, others have proposed similar models. D’Augelli’s theory (1994) is notable because it includes identity processes, not stages, which can occur concurrently or sequentially. This addresses a common critique of all stage models of development, namely that they are linear and imply that everyone goes through stages in the same way. D’Augelli posits the following processes:  exiting heterosexuality, developing a personal LGB identity, developing an LGB social identity, becoming an LGB offspring (dealing with parents and family of origin), developing an LGB intimacy status, and becoming part of an LGB community. In contemporary LGB culture, that community is often a virtual one. Moreover, if Savin-​Williams’ research is accurate, some young LGB people will reject or downplay the importance of claiming any sexual orientation identity, and others will see their identity as fluid and subject to change. Some have hypothesized that today’s LGB young people go through these stages much more rapidly than was true when the models were first constructed in the late 1970s and 1980s. This was true for Briana, described earlier, who experienced ‘identity pride’ before she had finished high school. Coming Out All models of sexual orientation identity development focus on the issue of ‘coming out.’ The phrase has two meanings: ‘coming out’ to self, and ‘coming out’ to others. Coming out to one’s self is the point in time when the dim recognition that one is ‘different’ gels into the certainty of what that difference is. Not everyone reaches this self-​acknowledgment. Richard, the man I described in the previous chapter who, at first meeting, told me he wasn’t sure he was heterosexual, spent most of his life fighting the recognition that he was gay despite a complete absence of heterosexual attractions, fantasies, or behavior. His shame about being gay was so deep that even when he finally admitted who he was, he invariably followed the statement ‘I’m gay’ with ‘But I’m not happy about it.’ Most people who were born in Gen X or more recently are able to come out to themselves and to not be filled with self-​hatred. The second meaning of ‘coming out’ is to reveal one’s sexual orientation to others. Coming out to others is a complex act with nuanced meanings

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and a multitude of possible repercussions. In the early days of gay activism, the cry was ‘Come out, come out, wherever you are!’ Getting people to be open about their orientation was arguably the single most important tactic of the LGBT movement. There is ample evidence that it is more difficult to hate people with whom you are in close proximity. In the 1960s, for example, very few people knew a gay person. In the absence of personal experience, it is easier to imagine a ‘homosexual’ as bad, evil, or sick. It is harder to maintain that view if, say, your niece, neighbor, or co-​worker is openly gay. When activists in the 1970s sounded the call to action, tens of thousands of gay people did come out, to parents, family, friends, and sometimes employers. This radically changed public opinion. Today, in most parts of the US, very few people have never met a gay person and, consequently, fewer people see LGB people as the ‘Other.’ However, the suggestion to ‘come out’ to others at times became pressure. It is not uncommon to find gay people who feel stigmatized by their LGB peers if they are relatively private about their sexual orientation. It is also undoubtedly true that coming out to others can be very important to self-​esteem. It is difficult to escape a feeling of shame if you are hiding something so crucial to who you are as a person. And hiding your sexual orientation also means hiding your partners and many details about your personal life, which can lead to a sense of isolation and invisibility. Therefore, coming out to others remains a highly individual experience, and it is not always wise to do so. In general, there are some situations in which coming out is inadvisable. Here is what I suggest to my LGB clients pondering coming out: 1) If you are a minor, living at home and dependent upon parents for financial support, and you know or suspect that your parents are disapproving, coming out to them may make your home life much more difficult, and in extreme cases it may trigger them to find a reparative therapy camp for you, to refuse to pay for college, or even to throw you out. Even if they don’t do any of that, they could make you miserable with their negativity. 2) If you are not entirely sure you are LGB, or if you still feel bad about it, wait. Depending on your social environment, you may be surrounded by people who will shrug off the revelation as no big deal and are both comfortable with and knowledgeable about being gay. But if the people around you are not familiar with other gay people, they will look to you for information and for how they should react to your disclosure. Don’t come out if you are feeling insecure or shaky in your identity, or if you aren’t prepared to educate people who don’t know much about being gay. 3) Don’t come out if it would be dangerous to do so. Again, depending upon where you live, an openly gay person may risk such social stigmatization

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that they are at risk for physical or emotional abuse, or encounter rejection and isolation. In this environment, LGB people must be very discriminating in whom they choose to tell and with whom they must keep a secret. 4) It’s often a bad idea to come out at work. Again, this is dependent upon environment. But losing your job usually has a whole lot of other negative consequences. I know lots of LGB people who are out everywhere but at work, for very practical reasons. In general, LGB people need to think carefully about the consequences of coming out versus hiding. If your LGB client, for example, has a socially liberal family and lives in a progressive urban environment, if they are in a gay-​friendly profession, then there may be nothing but positives and little risk no matter to whom they reveal their orientation. In these circumstances, coming out to family, friends, school and/​or work, and neighbors might be nothing but liberating. Your client may feel relieved of any lingering shame they carried about their ‘secret,’ will feel seen, respected, and loved. There may be no bad reactions from anyone. But if, on the other hand, your client has a culturally conservative family and environment and can anticipate a high likelihood of negative reaction from others crucial to their life if they disclose –​or if they are in a heterosexual marriage with children and their partner is unsuspecting –​you may want to advise that person to think through to whom, when, and where they want to ‘come out,’ to plan it strategically and perhaps role play with you. Marriages and children are particularly difficult situations to navigate, usually requiring much thought, discussion, planning, and potential grief. In short, ‘coming out’ to self is a crucial part of development for all LGB people, whatever identity –​or principled non-​identity –​they embrace. But coming out to others is a mixed bag, and it is hard and in some cases impossible to go back into the closet. My own experiences have been mixed. My mother was initially very rejecting, and for a while we didn’t speak to each other. She came around slowly but by the end of her life had a ‘live and let live’ attitude about my sexual orientation. And she loved my partner Nancy and adored our son Cory. I went through a period where being ‘out’ was so important to me I practically introduced myself to the check-​out person at every store I  patronized  –​‘Hi, I’m Margie, I’m a lesbian’ with an implied ‘And you better be ok with that.’ I never came out to members of my family of origin about being kinky or nonmonogamous, partly out of a sense of personal privacy and partly because I didn’t want to take the time to educate them and bring them along. Ultimately, the solution to the coming out problem for me is that I have spent my life living within the LGBTQ+ community. In other words, I live ‘out’ in a safe world: I surround myself with like-​minded people who won’t reject me for being queer. Most people choose

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not to live in a world as restricted as mine, or might not have the means to do so. For most people, ‘coming out’ is not just an issue of ‘yes’ or ‘no,’ it is more complex and multi-​leveled: they may be ‘out’ in some social situations but not all, for example. It is also nuanced in another way. There are degrees of being ‘out.’ Let’s take the situation of a lesbian woman living with her partner, and the issue of how ‘out’ she is to her parents. There are many variations of this situation: there is a ‘deep closet’ version in which she and the partner have separate bedrooms, don’t spend holidays together, and may even pretend to have boyfriends to the parents. Then there are a couple of versions of ‘don’t ask, don’t tell’: for example, she and the partner don’t maintain separate bedrooms, but they never mention it, parents pretend not to notice, the pretense is still they are friends. Alternatively, they maintain the same arrangement except that parents are told once that she and the partner are partners, but it is never mentioned again, and the two women act like friends in front of parents (no hand holding, kissing, etc.). Then there is a fully ‘out’ option: the two women engage in ‘partner’ activities like holding hands in front of the parents, the relationship is a subject of family discussion as if it were a heterosexual relationship, and so on. The benefits of the last option are obvious, but some parents are not capable of that level of acceptance. Some parents are okay knowing (sort of), but with plausible deniability. They may want to be nurturing, welcoming, to both their child and their child’s partner, if there is one, but the idea of accepting homosexuality engenders a great deal of cognitive dissonance. Perhaps the parents have deeply held anti-​gay religious beliefs, or a strong cultural tradition of non-​acceptance. The parents feel in a position of having to betray either beliefs or their child. The easiest way for the parents to handle this cognitive dissonance may be to be nurturing and accepting of their child but never openly acknowledge that the child is gay. Some gay people can tolerate and be comfortable with this attitude from their parents, knowing that the parents are trying to be loving but struggling with a difficult dilemma. What You Can Do to Help the Parents Early in my career, I used to love working with adolescents, but sometimes made the error of siding with my client’s rebellion against school and/​or parents a little too much. That changed when I had kids. Suddenly I understood the position of the parents. One of the first things I learned about being a parent is how scary it is, and how many times you feel helpless and clueless. And you just pray or cross your fingers or otherwise hope for good fortune. It is helpful to be in touch with those feelings a bit when working with a parent or parents who have learned they have a gay or lesbian child. These days, many parents won’t need professional help coping with this disclosure,

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even from a teenager. Indeed, some children come out to their parents before puberty, age ten or younger. There are dozens of books written for parents of gay kids, dating back to 1979 with the classic Now That You Know (Fairchild, 1998), up to the more recent book, Coming Out, Coming Home, a study of how families adjust and change as a result of having a gay child (LaSala, 2010). There is an entire sub-​genre of ‘Mommy blogs’ about raising gay and gender non-​conforming children, including ‘My Son is Gay’ by Susan Hope Berland, ‘Raising My Rainbow’ by Lori Duron, and supportive blogs for Christian households like Susan Cotrell’s at Reading these books and blogs can be very helpful. PFLAG –​Parents and Friends of Lesbians and Gays –​is also a wonderful resource for parents. In 1972, Jeanne Manford marched in New York City’s Gay Pride Parade with her son and was approached by many marchers who begged her to talk to their parents. As a result of that experience, she decided to start a support group for parents. Twenty people showed up for the first meeting in March 1973 at a Methodist church in New  York City. Today PFLAG has 400 chapters in all 50 states, the District of Columbia, and Puerto Rico. They provide a nonjudgmental system of comfort, information, and validation for parents with gay, lesbian, bisexual, and transgender children. In my experience, peer support groups like PFLAG are the best way for parents to get help dealing with a child’s disclosure of sexual orientation. But besides providing resources, there are times when it makes sense for you as a therapist to work with parents. If your primary client is the gay child, in order to work with the parents you need to deal with any counter-​ transferential feelings you have that come from wanting to protect your gay client. It is useful to remember that most parents actually love their children and want to do right by them, and that what seems negative is coming from a desire to protect their kids from harm. If the parents have agreed to see you, this is almost always a sign that they want to overcome their prejudices. When working with parents, it helps to understand the dynamics of how parents deal with a child’s coming out. First, many parents experience a grieving process that can include denial, anger, and sadness. This stage may last some time: they are grieving the loss of the child they thought they had. Parents need to let go of the image they have in their heads of who their child is, and the dreams they have of what that child’s future will be. They frequently have fantasies of weddings, grandchildren, and a lifestyle that they now see as unattainable, and they have to mourn the loss of that imagined future before they can accept the child they actually have. Second, parents often see having a gay child as a failure, and blame themselves. As a therapist, you need to help the parent get out of the trap of personalizing their child’s sexual orientation so that they can see that they did not cause it, nor did their child ‘choose’ this somehow to hurt or alienate them. Psychoeducation can help here. They may be angry at themselves or their child, and therapy can

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aid in their understanding that this is no one’s ‘fault,’ and no one is to blame. If the parents see homosexuality as a ‘choice,’ it can enhance their belief that their child is intentionally harming them. Finally, parents of gay children can experience what is known in social science as ‘courtesy stigma.’ That is, the stigma of being lesbian or gay attaches to them because of their child. This takes two forms: vicarious stigma and public stigma. Vicarious stigma means the parents will suffer themselves from the rejection and prejudice that they perceive, or assume that their child experiences. Many parents explain to me that they fear that their son or daughter is facing a difficult and lonely life, and this causes them, the parent, much pain because they feel unable to protect the child. Here again, psychoeducation can be very helpful, as is meeting older gay people with successful lives. Public stigma, on the other hand, is the very real discrimination and bias they may face as it becomes known that their child is gay. This is why, for some parents, the most troublesome aspect of their child’s disclosure may be anticipating that their extended family or their community will find out. For some, this may be their very first experience of being treated like an ‘outsider,’ and it is an experience that is unpleasant and unwanted. Therapy can help parents adjust to this massive change in their lives and lessen the resentment they may feel by being forced into a stigmatized status. Finally, whether or not you see their parents, you can help your gay client and his or her parents by coaching the gay client through this process. A gay person coming out to their parents needs to anticipate that their parents may not be able to be instantly supportive. I  frequently tell clients:  ‘Your parents’ first reaction will not be their last reaction’ and suggest that, just as it undoubtedly took them some time to adjust to their own sexual identity, their parents will also need to process and absorb this new event in their lives. I try to explain the parents’ perspective and point out how the parents’ distress is related to their love for the child, my client. As a therapist, it is well worth your time to help parents adjust to their gay children. There is a sizable body of research (Ryan et al., 2010; Grafsky, 2018) showing the harmful impact of family rejection; for example, LGB youth and young adults who report such rejection are more than eight times as likely to report suicide attempts. Similarly, data indicates that young people who perceive their families to be accepting are more likely to report higher self-​esteem, less depressive symptoms, substance abuse, and suicidality than those with unsupportive families. If you have young clients who are LGB, this family work may be the most significant therapeutic assistance you can give. Created Families vs. Families of Origin While all young people normally ‘break’ from the families in which they grew up to some extent, it is common in the LGBTQ+ community to find

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people with extensive support networks of what might be called ‘created’ or ‘chosen’ families. These created families serve an important purpose: they provide support to people whose biological families reject them, and they provide comfort and understanding that families of origin simply cannot offer. The ‘horizontal identities’ of most LGBTQ+ people foster, by definition, some sense of estrangement from the families of childhood and adolescence. As a therapist, you need to support and encourage your clients in creating these networks, especially if the families they grew up in are less than fully welcoming. In addition, there is a strong tendency for many LGBTQ+ people to remain friends with ex-​lovers and partners, something much less common in the mainstream culture. My holidays are spent with two partners/​ex-​partners, the various new partners of the old partners, my children, and an assortment of long-​term friends. This is not unusual in the queer community, but raises eyebrows among my mainstream friends and colleagues. Intersectionality One more characteristic of today’s lesbian or gay-​identified client is worth noting. In 1989 the black feminist scholar Kimberlé Crenshaw proposed a theory of intersectionality, an exposition of the ways marginalized groups overlap with each other and how this overlap results in individuals whose ‘minority stress’ is amplified by being members of more than one stigmatized group (Crenshaw, 1990). Moreover, within any marginalized group, there are individuals whose experiences are radically different from each other by virtue of intersectionality. The problems of white, educated, middle-​class straight women are different from those of black women, women growing up in poverty, and women who are non-​heterosexual. It is difficult, if not impossible, to understand any group without taking into account the variation produced by intersectionality. Within the lesbian and gay community, intersectionality means, for example, that the issues faced by a Latinx immigrant gay adolescent may have little in common with the problems of an older, well-​ educated Caucasian lesbian. But there is another way in which intersectionality affects gay people: there is considerable overlap between sex and gender-​ variant minority groups. In your office you will encounter gay people who are also transgender, interested in kink, and engaged in consensually nonmonogamous relationships  –​sometimes all in the same person! This is why, in the twenty-​first century, you cannot work with gay or lesbian clients without understanding all the other facets of sex and gender diversity. Intersectionality in the LGBTQ+ community is the norm, not the exception.

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Takeaways for the Clinician Because cultural attitudes toward homosexuality have shifted dramatically in the last few decades, the experiences of a Millennial or Gen Z gay or lesbian may be unlike those of their older counterparts. Nevertheless, most gay people experience some difficulties growing up as a result of being, or being perceived to be, ‘different.’ If this difference has triggered abuse from family, peers, or school, you as a therapist will need to help your client determine if their trauma has had lasting effects. Children and adolescents may require your direct advocacy and intervention with educational institutions, and/​or therapeutic work with families so that the young person can get support at home. Older clients may benefit from a review of their development as gay people in order to understand the role their sexual orientation has played in their lives. I will go into further detail about the special issues faced by gay, lesbian, and bisexual adults in the chapters that follow. But all LGB clients benefit from having therapists who understand concepts like minority stress, stigma, and intersectionality. References Birkett, M., Newcomb, M. E., and Mustanski, B. (2015). Does it get better? A longitudinal analysis of psychological distress and victimization in lesbian, gay, bisexual, transgender, and questioning youth. Journal of Adolescent Health, 56(3), 280–​285. Bryan, A. and Mayock, P. (2017). Supporting LGBT lives? Complicating the suicide consensus in LGBT mental health research. Sexualities, 20(1,2),  65–​85. Cass, V. C. (1979). Homosexuality identity formation:  A theoretical model. Journal of Homosexuality, 4(3), 219–​235. Crenshaw, K. (1990). Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Review, 43, 1241. D’Augelli, A. R. (1994). Identity development and sexual orientation: Toward a model of lesbian, gay, and bisexual development. In E. Trickett, R. Watts, and D. Birman (eds.), Human Diversity: Perspectives on People in Context. Jossey-​Bass, pp. 312–​333. Eisenberg, M. E. and Resnick, M. D. (2006). Suicidality among gay, lesbian and bisexual youth: The role of protective factors. Journal of Adolescent Health, 39(5), 662–​668. Fairchild, B. and Hayward, N. (1998). Now That You Know:  A Parents’ Guide to Understanding Their Gay and Lesbian Children. Houghton Mifflin Harcourt. Friedman, M. S., Marshal, M. P., Guadamuz, T. E., Wei, C., Wong, C. F., Saewyc, E. M., and Stall, R. (2011). A meta-​analysis of disparities in childhood sexual abuse, parental physical abuse, and peer victimization among sexual minority and sexual nonminority individuals. American Journal of Public Health, 101(8), 1481–​1494. Grafsky, E. L. (2018). Deciding to come out to parents: Toward a model of sexual orientation disclosure decisions. Family Process, 57(3), 783–​799. Heck, N. C., Flentje, A., and Cochran, B. N. (2013). Offsetting risks:  High school gay-​ straight alliances and lesbian, gay, bisexual, and transgender (LGBT) youth. School Psych. Quarterly, 26(2), 161‒174.

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Kahn, E., Johnson, A., Lee, M., and Miranda, L. (2018). LGBTQ Youth Report 2018. Human Rights Campaign.​resources/​2018-​lgbtq-​youth-​report LaSala, M. C. (2010). Coming Out, Coming Home:  Helping Families Adjust to a Gay or Lesbian Child. Columbia University Press. Marshal, M. P., Dietz, L. J., Friedman, M. S., Stall, R., Smith, H. A., McGinley, J., … and Brent, D. A. (2011). Suicidality and depression disparities between sexual minority and heterosexual youth: A meta-​analytic review. Journal of Adolescent Health, 49(2), 115–​123. Meyer, I. H. (2003). Prejudice, social stress and mental health in lesbian, gay and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–​697. Meyer, I. H. and Frost, D. M. (2013). Minority stress and the health of sexual minorities.​publication/​289008046_​Minority_​Stress_​and_​the_​Health_​of_​ Sexual_​Minorities Murdock, T. B. and Bolch, M. B. (2005). Risk and protective factors for poor school adjustment in lesbian, gay, and bisexual (lgb) high school youth: Variable and person‐ centered analyses. Psychology in the Schools, 42(2), 159–​172. Pew Research Center (2013). A survey of LGBT Americans.​ 2013/​06/​13/​a-​survey-​of-​lgbt-​americans/​ Ryan, C., Russell, S. T., Huebner, D., Diaz, R., and Sanchez, J. (2010). Family acceptance in adolescence and the health of LGBT young adults. Journal of Child and Adolescent Psychiatric Nursing, 23(4), 205–​213. Savin-​Williams, R. C. (2009). The New Gay Teenager (Vol. 3). Harvard University Press. van Beusekom, G., Bos, H. M., Overbeek, G., and Sandfort, T. G. (2015). Same-​sex attraction, gender nonconformity, and mental health: The protective role of parental acceptance. Psychology of Sexual Orientation and Gender Diversity, 2(3), 307.



n 2004, 19-​year-​old Garrard Conley, raised in Arkansas in a highly religious conservative Southern Baptist family, was ‘outed’ to his family by a man who had raped him at college. Conley’s father’s response was: ‘You’ll never set foot in this house again if you act on your feelings. You’ll never finish your education.’ Conley agreed to be admitted to a program called ‘Love in Action,’ a conversion therapy treatment facility designed to ‘cure’ gay and lesbian young people of their ‘sickness.’ In this program, run by an ‘ex-​gay’ man (a gay man who claimed to have been cured by God), Conley was told he was a sexual deviant and enjoined to follow the rules in a 274-​ page handbook that outlined 12 ‘steps’ to recovery loosely modeled on AA. Conley soon fled the program and later wrote about it in a memoir that was made into the 2018 film Boy Erased (Conley, 2019). According to studies by the UCLA Williams Institute, more than 700,000 LGBTQ people have been subjected to conversion therapy, half of them teenagers, and an estimated 80,000 LGBTQ youth will experience programs like LIA in coming years, often at the insistence of well-​intentioned but misinformed parents or caretakers. Conley’s experience is an example of the one of worst experiences possible for a young gay man:  not only to have one’s gayness made visible against one’s will, but then to suffer negative consequences from this ‘outing.’ Fortunately, these kinds of situations are becoming less common. While there are certainly still families who reject their gay children, that number is decreasing. The Pew Research Center found that from 1985 to 2015, the percentage of people who said they would be upset if a child told them they were gay fell from 89% to 39%, and the percentage who said they would not be upset rose from 9% to 57% (Gao, 2015). That is important because

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numerous studies have shown that ‘Family acceptance predicts greater self-​ esteem, social support, and general health status; it also protects against depression, substance abuse, and suicidal ideation and behaviors’ (Ryan et al., 2010). To an extent, having a supportive family even compensates for harassment and bullying from peers. Unfortunately, peer harassment of LGBT youth is still common. A 2017 nationwide survey showed that 33% of LGB youth reported being bullied on school property in the prior year, 27.1% were cyberbullied, and 10% reported not going to school because of safety concerns; these numbers were twice that of their non-​LGB peers (Kahn et al., 2018). Of those LGB students who are bullied, the most persecuted are gay boys and teens who do not conform to masculine stereotypes. While not all gay men are ‘girly’ as children, multiple studies have shown a strong correlation between childhood gender nonconformity and adult male homosexuality. This puts gay boys at high risk for peer harassment. Harold Daniel, a young gay man who shared his story with GLAAD (‘Gay & Lesbian Alliance Against Defamation,’ a non-​governmental media monitoring organization), wrote: ‘I feared going to school throughout my elementary and middle school years. Being mocked for my feminine mannerisms affected my mental health. I was called names, names that I didn’t know the meaning of at the time.’ Tae Johnson said: I first experienced bullying when I  was in elementary school, but the most extreme point was when I reached middle school. I used to get verbally and physically harassed every day to the point I hated waking up in the morning & I seriously battled with finding the strength to continue living. Daniel Segobiono wrote: I’m a femme, gay man … I was bullied for being ‘too femme’ and to avoid being teased I’d deepen my voice around others. In P.E. I’d always be told that I ‘played like a girl’ or that I was not good enough to play with the other boys because I was ‘too gay.’ (Kenny, 2018) All of these young men were traumatized by peer violence, and sometimes by violence that came from within their families (Friedman et al., 2011), as it has been shown that LGB youth are subject to more parental abuse than non-​LGB childen. The links between trauma, stress, and mental illness have been well established. Given these childhood experiences, it is not surprising that many adult gay men suffer from psychological problems and mental disorders. According to the American Psychiatric Association (2018), gay

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men are two to three times more likely than heterosexual men to suffer from mood disorders, including depression and anxiety. They are more likely to report suicidal ideation, plans, and attempts than heterosexual men: one in six gay men have made one or more suicide attempt in their lifetime. They display higher rates of alcohol and drug use and dependence. Mental Health Issues of Gay Men The elevated rates of psychological problems in gay men means that therapists working with gay male clients must be prepared to deal with a wide range of mood and behavioral disorders. Three in particular are worth commenting upon: substance abuse, eating disorders, and intimate partner violence. Early theories of why drug and alcohol problems are more common among gay men and lesbians centered on bars: before the Internet, bars were the social venues of choice for gay people, and the constant proximity to alcohol seemed to encourage use and abuse. Since online venues have in part replaced the ‘bar scene,’ this is less true. However, the Internet did not replace the events called ‘circuit parties.’ Circuit parties are large, professionally produced events that include a dance event that lasts all night into the next day as well as other parties and events planned around the main party. They are highly publicized, often occur in the same place every year –​for example, the White Party in Palm Springs, the Black Party in New York –​ and attract thousands of men often from around the world. Besides dancing, circuit parties are known for sex and drugs, and have given rise to the phenomenon called ‘Party and Play,’ or PNP, also called ‘chemsex,’ the tendency to combine certain drugs like ecstasy and crystal meth with sexual activity. It is likely that PNP contributes to higher rates of substance abuse, as well as to unsafe sexual practices and new incidences of HIV infection. Chemsex/​PNP remains a problem in many gay male urban communities. Gay men are seven times more likely to report binge eating and 12 times more likely to report purging behaviors than heterosexual males, and they represent over 40% of males with eating disorders (Feldman and Meyer, 2007). This may have its roots in particular aspects of gay male culture. Heterosexual men, compared to heterosexual women, are often very focused on the physical beauty of their partners. Gay men are just as likely to value attractiveness as heterosexual men, perhaps because men in general have sexual arousal patterns more dependent upon visual stimulation. Moreover, because so many have suffered from being perceived to be ‘effeminate,’ gay men often place a high value on hyper-​masculine beauty. So personal ads written by gay men often include phrases like ‘straight acting, straight appearing’ or ‘no femmes or fatties wanted.’ It is believed that eating disorders in women are rooted in social pressure to be attractive; gay men suffer from a comparable social pressure to be attractive.

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Gay men in relationships experience domestic violence at the same rate as heterosexual women in relationships. About one-​third of gay male couples experience such violence. One 2018 study showed 46% of gay men in couples had experienced intimate partner violence in the last year (Suarez et  al., 2018). However, the same machismo-​based stigma that prevents heterosexual men from disclosing if they are victims of intimate partner violence contributes to silence in the gay community. In fact, gay men are more likely to disclose being a perpetrator than a victim, probably because of the shame in admitting victimhood. Therapists working with gay men should be aware that clients may not be forthcoming about violence in their relationships. Perhaps as a reaction against the accusation of ‘effeminacy,’ hypermasculinity has been a norm in gay male culture from at least the 1970s. It is not an accident that the Village People, the rock band formed in 1977 specifically to appeal to gay disco-​goers, contained members dressed as a policeman, an American Indian chief, a soldier, construction worker, and a guy dressed entirely in black leather. It is tempting to speculate that the fetishization of hypermasculinity, as epitomized in the very popular drawings of Tom of Finland, represent a subtle form of internalized homophobia. Just as women have been damaged by unrealistic norms of feminine beauty, many gay men have been damaged by the inculcation of macho norms that are difficult, if not impossible, to attain. The Role of Sex in Gay Male Culture Gay male culture, since the 1970s or earlier, has not only incorporated hypermasculine norms, it has often revolved around sexuality, perhaps because the uber-​masculine is connected to the uber-​sexual. Researcher James Martin has written: Across the sweep of modern history, men such as these have risked their careers and reputations in order to have erotic contact with other men. Is it surprising, then, that the erotic is so central to gay men’s identities and culture? (p. 214) Martin grounds this centrality of the erotic in the centuries of stigma that have surrounded homosexuality. But the centering of sex in the gay male ethos may also have a simpler explanation: at least as indicated by behavior, sex is more important to all men, regardless of sexual orientation, than it is to women. For example, research has shown that all sex acts, from masturbation through all forms of partner sex, are more common among males than females. Men become sexual at an earlier age than women and continue this throughout the life span (Peplau, 2003). In fact, it could be hypothesized that

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heterosexual men would be far more sexual if their sexual desires were not to an extent constrained by the lower sex drive of heterosexual women. As my deceased friend and colleague, the social worker, writer, and activist Michael Shernoff, used to say: ‘Gay men have the sex lives that straight men can only dream of.’ Gay men don’t have to wine and dine their prospective partners before sex; indeed, often they don’t even have to say their name. The gay male culture that emerged in urban ‘gay ghettos’ in the 1970s glorified and celebrated male-​male sexuality, not only with its norms and ethos but with physical spaces. Bars, back rooms, bath houses, ‘cruising’ areas in parks and other public spaces all became venues for sex that was casual, commitment-​ free, and often anonymous. Studies of male homosexuality done in the 1970s (Bell and Weinberg, 1978) revealed that many men numbered their sex partners in the hundreds or even thousands. Gay male couples incorporated this into the norms for relationships:  Mattison and McWhirter’s ground-​ breaking book, The Male Couple, published right before the AIDS epidemic hit, reported that of their international sample of long-​term male couples, 100% were nonmonogamous (Mattison and McWhirter, 1984). HIV and Gay Male Sexuality HIV changed this. At the beginning of the AIDS blight, gay men protested the suggestion that HIV was sexually transmitted. I  can remember being at a meeting of the National Association of Gay and Lesbian Health Care Professionals in 1981 when the gay men in attendance shouted down US Center for Disease Control representatives who were trying to explain their theory of HIV transmission. The gay male professionals believed that the idea of sexual transmission was a myth promulgated by the government specifically to destroy gay male communities. This paranoia contributed to the resistance to closing bath houses and back rooms, as documented in Randy Shilts’ book And the Band Played On (2011). And when gay men finally accepted that AIDS was transmitted through sex, it had a devastating impact on mental health. Many men retreated into complete celibacy, the practice of nonmonogamy decreased in gay male couples, and most men struggled with feelings that they (or their semen) were toxic, contaminated, and poisonous. Community organizations like GMHC (Gay Men’s Health Crisis) in New York City focused on prevention efforts, not on promoting monogamy or celibacy, but rather on educating men about ‘safer sex.’ They focused on the fact that it was not the number of partners that mattered in transmission, but the nature of the sex acts:  condomless sex, especially for the receptive anal sex partner, was the culprit. And so besides emphasizing condom use, gay men’s health organizations promoted sex acts, like mutual masturbation, that did not carry a transmission risk. To an extent, back rooms and bath

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houses were replaced by ‘J.O. Parties’ (jerk off). Condoms were available in places that were venues for gay male sex. During the 1980s and 1990s, I frequently vacationed in the Fire Island, New York communities known to be gay-​dominated. During one of those summers, our son, about eight or nine years old at the time, came back to our bungalow with a huge box containing hundreds of condoms that he had found on the ‘Meat Rack,’ a part of the sand dunes known to be a gay cruising area. He had no idea what they were, and his discovery provided a teaching moment for sex education! As a result of prevention and education efforts and behavioral changes, the number of new HIV infections in the United States declined dramatically from a high of approximately 130,000 in 1985 to an estimated 50,000 in 2010. However, from 2010 to the present, the rate of new infections has stabilized at about 39,00 per year, and gay men account for two-​thirds of new infections, with the rates for African American and Latino gay/​bi men higher than those for whites (Centers for Disease Control and Prevention (CDC), 2020). There are many reasons for this: new infections are concentrated in the South, where HIV resources are scarce; an estimated 14% of HIV positive people are unaware of their status; the stigma associated with HIV prevents many people from getting tested or seeking help. Indeed, even though many gay men in the 1980s developed the feeling that their semen was ‘toxic,’ that feeling seems to have shifted or disappeared. Certainly, the advent of antiretroviral treatments in 1996 helped transform HIV from a death sentence for all to a lifelong chronic disease for many, at least those who could afford these medications. And as the generation most affected by HIV has aged, younger gay men often have never known anyone to die from the disease. This has contributed to a lessening of fear. But beginning in the late 1990s there has been a resurgence of what is called ‘barebacking,’ or condomless anal sex (Shernoff, 2013). In 2013, the CDC reported that the number of gay men who had unprotected anal sex at least once in the past year had jumped from 47% in 2005 to 58% in 2011 (Paz-​ Bailey et  al., 2013). Part of this resurgence is undoubtedly a reaction to the ‘semen-​shaming’ of earlier days of the AIDS epidemic. Gay men often report, not simply that condomless sex provides more stimulation, but also that it leads to a sense of greater intimacy. Chemsex is also associated with barebacking, so the prevalence of the ‘Party and Play’ ethos contributes to unsafe sex. But a great deal of the resurgence of barebacking can be attributed to two things that are now common knowledge among many gay men. First, HIV positive men on antiretroviral drugs have undetectable amounts of HIV in their semen, meaning they cannot transmit the virus to another. Second, since around 2012, a drug regimen called PrEP –​Pre Exposure Prophylaxis –​ has been increasingly available in the United States. PrEP is a combination of two medicines that are commonly used to treat HIV, and when taken daily, this regimen reduces the chances of HIV by over 90%. When initially

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introduced, PrEP (often known by the trade name of Truvada) was controversial. Some feared that it would increase the incidence of unprotected anal sex among gay men so much that the protective effects would be overridden; 10% risk is not negligible. In fact, those fears have not been borne out. New infections among gay men, while they have leveled off and not decreased in recent years, are not the result of PrEP failure. They are related to factors such as inconsistent use of PrEP or ignorance about one’s HIV status or the status of one’s partner. Gay male sexuality, despite HIV, is robust, enthusiastic, and varied. It includes acts which are alien to many heterosexuals or lesbians, such as fisting, or the insertion of the entire hand into the rectum. BDSM practices, called ‘leathersex,’ are so common as to be unremarkable. Gay men are usually very forthright about declaring their sexual preferences. For example, ‘top,’ ‘bottom,’ or ‘versatile,’ referring to one’s preferred position for anal sex, are standard terms on gay dating apps. Although there are fewer gay bars, bathhouses, and backrooms than there were 30 or 40 years ago, they have been replaced by apps like Grindr and Scruff, which allow gay men to find nearby partners for casual sex at any time and any place. Clinical Work with Gay Men What does all this mean for therapists working with gay men? First, as I  mentioned in the prior chapter, it means you should be prepared to do trauma work with clients who were victimized in childhood by family or peers. I  have found PTSD to be so common among adult gay clients that it influenced me to learn Eye Movement Desensitization and Reprocessing (EMDR). I suggest that all therapists working with this population be well versed in some methods for handling PTSD. Second, be aware that family relations may be fraught. In particular, gay men who were effeminate as children may not only have suffered bullying from peers, but from family members, especially fathers. If your client has not ‘come out’ to their family, they may have good reasons for staying in the closet, reasons you need to appreciate and respect. Low self-​esteem is common among gay men, and it may frequently be focused upon perceptions of attractiveness and body image. Your gay male client is more likely to suffer from depression, anxiety, or an alcohol or substance abuse issue than a heterosexual male, and much more likely to have an eating disorder, while less likely to disclose this to you. He is just as likely to be involved in intimate partner violence as his heterosexual counterpart. The gay male client may have effectively conquered his internalized homophobia. What is less likely is that he has evaluated his internalization of heterosexual male norms and that he acknowledges the destructive role they play in his psyche. In other words, he is not necessarily questioning the

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wisdom or appropriateness of the ‘macho’ norms that impact him, and that often make him feel like a failure. To the extent that your client is involved in an urban gay community, it may be difficult for him to recognize the macho norms of this community and the impact of these norms upon his self-​image. Many gay men can benefit from some basic lessons of feminist theory. As his therapist, you may be able to help him understand how ‘the patriarchy’ has negatively affected him by imposing unrealistic and unattainable standards for his behavior. If he stops internalizing those standards, he may be able to stop feeling like he is deficient. Your gay male client is as likely as a heterosexual man to value sex highly, and more likely to have an extensive sexual history with many partners. He is likely to have, or desire, nonmonogamy in his relationships. In fact, if he wants to be monogamous he may experience negative judgments from his peers and/​or partner. He may be HIV positive and feel some shame about that. If he is HIV negative, he may use PrEP, or he may not use it for fear of the stigma attached to this. A 2018 study of men using PrEP found that 20% had experienced ‘slut shaming’ from other gay men for their use of this protocol (Whitfield et  al., 2018). If your client engages in barebacking, he may be reluctant to tell you, fearing judgment. As a therapist working with gay men, it is important that you examine your own values and beliefs. It is not enough to be gay positive. You also need to be sex positive, and nonjudgmental about sex acts that you have possibly never heard of before! Case Vignette: a Harm-​reduction Approach with a Barebacking Man The therapist in this case was my late colleague Michael Shernoff. The year was 2002, and Anthony was a 35-​year-​old HIV negative man who entered therapy because he was concerned that his barebacking activity was putting him at risk of infection. He was single and had mostly anonymous sex with several different men a week, men whom he met online and who also desired only casual sex. Indeeed, his activity was putting him at risk: he was engaging in condomless anal sex, as a ‘bottom’ or recipient, with men whose HIV status he did not know. Michael’s first task was to assure Anthony that he did not judge him negatively for barebacking, that in fact he understood the allure of the practice and knew many men who engaged in condomless anal sex, and that he certainly did not judge him for his taste for casual sex and multiple partners. (Note: Michael felt a need to explicitly reassure Anthony despite being a gay man himself; if you are the therapist in a situation like this and are a woman and/​or non-​gay, you will need even stronger statements of acceptance.) Anthony’s history included a period where he had been overweight during which he developed a great deal of insecurity about his attractiveness. Despite now being thinner, he still lacked confidence. His confidence could be temporarily restored by having sex with very

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attractive men. Anthony believed that his willingness to be penetrated anally without a condom increased his desirability, and that without barebacking he would have far fewer sexual partners. Clearly, Michael needed eventually to work with Anthony’s low self-​esteem and to help him find other ways of boosting his regard for himself. But in the short term, not only was controlling the barebacking Anthony’s presenting problem, it was by anyone’s standards very risky behavior in need of intervention. When Michael saw this patient, PrEP did not yet exist, or he would have suggested this immediately. However, even today some men reject the PrEP alternative for many reasons, including the fear that they won’t follow a daily regimen, concerns about stigma, and worries about putting powerful chemicals in their body. Thus Michael’s approach is still relevant. Without PrEP, Michael instead needed to work on Anthony’s behavior. Anthony knew he should be using condoms but didn’t trust that, when he was seeking sex with a new and unknown partner, in the heat of the sexual moment he would have the impulse control to say no. Michael suggested a technique that is sometimes used by HIV negative gay men who bareback: serosorting or, in simple terms, finding out the HIV status of a partner and only barebacking with other HIV negative partners. While Anthony in principle agreed that serosorting was a great alternative, he confessed that he did not feel able to approach potential partners, whom he met online, with this question. His fear of rejection was too great. To combat this, Michael suggested Anthony at first attempt to ask only men he did not find attractive. Anthony was actually able to do this, and he learned through experience that while some men were indeed offended by the question and rejected him, many others didn’t and some seemed relieved that Anthony had raised the issue. Once Anthony was able to ‘ask the question’ of men he did not find attractive, Michael had him repeat this exercise with men he was slightly attracted to, then moderately attracted. In about three months Anthony was able to ask all the men he interacted with online about their serostatus and only bareback with those who were HIV negative. This method was not foolproof, but it greatly reduced Anthony’s chances of being infected. Once this problem was addressed, it was possible for Michael to help Anthony work on the underlying lack of self-​esteem that led to his risky behavior. It is important to note that Anthony’s therapist needed to be not only gay-​affirming, but sex positive in a way that encompassed a comfort with a wide range of non-​traditional sexual practices. Case Example: A Gay Man with Trauma-​induced Alcohol Abuse and Self-​defeating Behavior David was a 27-​year-​old man seen at our IPG practice not long ago. Attractive and personable, he asked for help with procrastination. The therapist who

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treated him was a psychology intern I supervised who was about the same age as David. In the first session, the intern, whom I will call Jules, told David that he himself was not gay, that he hoped that wouldn’t be a problem, and that he was very gay-​affirming and knowledgeable. This openness created an immediate bond between David and Jules, a bond that became more solid as therapy progressed. David reported that he had recently moved back home to Central Jersey after several years living in Manhattan where he was attempting to establish himself as a dancer. After many auditions and rejections, David gave up, moved into his mother’s house, and got a job as a bartender. The procrastination he complained about was that he could not get himself to apply for other jobs. Although he was quite good at it, he hated being a bartender. Over time Jules learned that David frequently drank to excess and that the bar job increased his alcohol consumption. He also found that David was prone to mood swings and that he comforted himself by buying things on the Internet; as a result, David was not even close to his goal of saving enough to move out of his mother’s house. David minimized these issues and did his best to conceal his depressed moods, even from Jules. But slowly David began to talk about his painful past. As a child, he was seen by his father as ‘effeminate’ and this provoked contempt and anger toward David. He was not beaten, but his father took every opportunity to criticize and belittle his son. Moreover, his interests in dance, art, and fashion made him stand out as ‘different’ and ‘girly’ in the working-​class traditional community in which he was raised, and he was often the target of bullies at school. High school was marginally better because his school had a Gay Straight Alliance (GSA) that provided some refuge. After high school he escaped to New York where he quickly became absorbed in a community of other gay Millennials. His move back home had been precipitated by a depressive episode during which David spent too much money and drank too much. This had forced David to go back to an environment that had been hostile growing up. True to nature, when Jules pointed out the likely trauma induced by childhood events, David initially minimized the impact of them. But slowly Jules returned to these themes in sessions, speculating that the depressed moods David finally admitted to had their origin in the childhood contempt and disapproval he experienced coming both from his father and his classmates. He was even capable eventually of being in touch with the feelings triggered by memories of his childhood, and he cried in session, a big milestone. Since interns only see clients for one academic year, it was inevitable that David would ‘lose’ Jules. Before this could happen, David decided to move to Los Angeles, where he had friends he could live with temporarily. It is unclear whether the knowledge that his sessions with Jules were ending factored into this decision. However, it did mean that David ‘left’ Jules before he could be abandoned. Treatment ended with David’s commitment to seek therapy in Los

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Angeles, and to look for a practitioner who could help him heal from his earlier trauma. This case is an example of how non-​gay therapists might handle having a gay client. In retrospect, it was clear that Jules’ ‘coming out’ as heterosexual facilitated bonding. It showed David that he was aware of their differences, unafraid to address them, and very eager to be helpful in any way he could despite them. Not all therapists might be quite so forthright in this kind of declaration. However, all therapists should be prepared to answer their clients’ questions about their sexual orientation. Given the degree of homophobia that still exists in our culture, it is rational for gay clients to be wary of therapists and need to assess the therapist’s knowledge, background, and attitudes toward homosexuality. Many gay men entering therapy look specifically for a gay male therapist. It makes sense for gay male clients to need to size up a non-​gay therapist. Takeaways for the Clinician Doing clinical work with gay male clients requires both an acceptance of same-​sex orientation and some knowledge of specific issues. Your gay male clients are more likely to have suffered from bullying as children than female or heterosexual male clients, and to have self-​esteem injuries related to mainstream standards of machismo, standards that may be to an extent reinforced by gay culture. Sex may play an important role in his life, and his sexual experience may challenge your knowledge, and your own standards. His support network may include his family of origin, but it may also be centered around ‘chosen’ family more than blood relations. You need to be equipped to do trauma-​informed treatment. However, you should also be prepared to be awestruck by the resilience of clients who have triumphed over discrimination, rejection, and stigma. References American Psychiatric Association. (2018). Mental health facts for gay populations www.​psychiatrists/​cultural-​competency/​education/​lgbtq-​patients Bell, A. P. and Weinberg, M. S. (1978). Homosexualities: A Study of Diversity among Men and Women. Simon & Schuster. Centers for Disease Control and Prevention. (2020).​hiv-​basics/​overview/​ data-​and-​trends/​statistics Conley, G. (2019). Boy Erased. Autrement. Feldman, M. B. and Meyer, I. H. (2007). Eating disorders in diverse lesbian, gay, and bisexual populations. International Journal of Eating Disorders, 40(3), 218–​226. Friedman, M. S., Marshal, M. P., Guadamuz, T. E., Wei, C., Wong, C. F., Saewyc, E. M., and Stall, R. (2011). A meta-​analysis of disparities in childhood sexual abuse, parental

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physical abuse, and peer victimization among sexual minority and sexual nonminority individuals. American Journal of Public Health, 101(8), 1481–​1494. Gao, G. (2015). Most Americans now say learning their child is gay wouldn’t upset them. Pew Research Center. June 29, 2015.​fact-​tank/​2015/​06/​29/​ most-​americans-​now-​say-​learning-​their-​child-​is-​gay-​wouldnt-​upset-​them/​ Kann, L., McManus, T., Harris, W. A., Shanklin, S. L., Flint, K. H., Queen, B., … and Lim, C. (2018). Youth risk behavior surveillance ‒ United States, 2017. MMWR Surveillance Summaries, 67(8), 1. Kenny, C. (2018). LGBTQ youth share their stories,​amp/​lgbtq-​youthshare-​stories-​offer-​advice-​adults-​to-​end-​bullying Martin, J. I. (2006). Transcendence among gay men:  Implications for HIV prevention. Sexualities, 9(2), 214–​235. Mattison, A. M. and McWhirter, D. P. (1984). The Male Couple:  How Relationships Develop. Prentice-​Hall. Paz-​Bailey, G., Hall, H. I., Wolitski, R. J., Prejean, J., Van Handel, M. M., Le, B., … and Valleroy, L. A. (2013). HIV testing and risk behaviors among gay, bisexual, and other men who have sex with men ‒United States. MMWR. Morbidity and Mortality Weekly Report, 62(47), 958. Peplau, L. A. (2003). Human sexuality: How do men and women differ? Current Directions in Psychological Science, 12(2),  37–​40. Ryan, C., Russell, S. T., Huebner, D., Diaz, R., and Sanchez, J. (2010). Family acceptance in adolescence and the health of LGBT young adults. Journal of Child and Adolescent Psychiatric Nursing, 23(4), 205–​213. Shernoff, M. (2013). Without Condoms:  Unprotected Sex, Gay Men and Barebacking. Routledge. Shilts, R. (2011). And the Band Played On:  Politics, People, and the AIDS Epidemic. Souvenir Press. Suarez, N. A., Mimiaga, M. J., Garofalo, R., Brown, E., Bratcher, A. M., Wimbly, T., … and Sullivan, P. S. (2018). Dyadic reporting of intimate partner violence among male couples in three US cities. American Journal of Men’s Health, 12(4), 1039–​1047. Whitfield, T. H., John, S. A., Rendina, H. J., Grov, C., and Parsons, J. T. (2018). Why I Quit Pre-​exposure Prophylaxis (PrEP)? A mixed-​method study exploring reasons for PrEP discontinuation and potential re-​initiation among gay and bisexual men. AIDS and Behavior, 22(11), 3566–​3575.



he Boys in the Band’ was groundbreaking for its portrayal of gay male life when it premiered Off-​Broadway in 1968 and then became a movie in 1970. It was considered revelatory at the time, but is now notable for the prominence of gay stereotypes of the times, not only the over-​the-​top campiness of friends gathered together for a birthday party, but also for the depiction of homosexuality as a lonely, loveless lifestyle. ‘Gay relationships never last’ was one of the messages. It was the belief not only in the mainstream but among gay people themselves. It was something I heard many times from gay clients in the 1980s and 1990s. But now we actually have data. And not only is the ‘gay relationships don’t last’ trope out of date, it turns out male couples seem to stay together longer than heterosexual and lesbian ones! The Research on Same-​sex vs. Mixed-​sex Couples Most of the research on same-​sex couples lumps gay and lesbian relationships together, so before we focus on male couples, let’s review this research. Blumstein and Schwartz published the first study comparing straight, gay male, and lesbian couples in the influential 1983 book American Couples: Money Work, Sex. Some of their findings have been replicated many times over. For example, they found that same-​sex couples were in general more egalitarian than heterosexual pairings. They shared housework and other domestic responsibilities more fairly, and made more decisions together. Gay male couples had more sex than anyone else, and lesbians less. Surprisingly, when contacted at follow-​up, gay male couples were also more likely to be together than other couples. They found that men, straight and gay, tended

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to cede more power to the partner who made more money while lesbians did not. Blumstein and Schwartz looked at married heterosexual couples and cohabiting heterosexual and gay couples and found married couples to last longer than unmarried, regardless of gender or sexual orientation. At the time, these findings were used to argue for marriage equality as a stabilizer of relationships. Since then, research findings have been a bit more equivocal about the advantage conferred by marriage. Much of the research that has followed the publication of American Couples has validated the strengths and resiliencies of lesbian and gay couples (Bryant and Demian, 1994; Connolly, 2005; Gotta, et. al., 2011; Gottman, et. al., 2003; Kurdek, 2005; Peplau and Fingerhut, 2007; Solomon, Rothblum, and Balsam, 2005). Lesbian and gay couples indeed tend to have egalitarian relationships where power differentials are minimized. They express levels of satisfaction with their relationships that are as high as for heterosexual couples. They value intimacy, communication, and relational attunement, and have skills to resolve conflict constructively (Ashton, 2011; Lev and Nichols, 2015). There are some distinctive demographic characteristics of gay and lesbian couples. Not surprisingly, the number of legally married gay couples has increased substantially since the Supreme Court legalized same-​sex marriage in 2015 with the Obergefell decision. Prior to this, only a few states had legalized same-​sex marriage, but many states allowed legal domestic partnership arrangements. Gallup estimated that pre-​ Obergefell about 12.8% of same-​sex couples were in domestic partnerships. Two years after Obergefell, in 2017, Gallup found that 10.6% of all same-​sex couples, or 61% of cohabitating same-​sex partners, had legally married, while the percentage in domestic partnerships had fallen (Jones, 2017). US Census Bureau data indicate that in 2016 there were approximately 887,456 same-​sex couples in the United States, with slightly more being female couples than male couples (Phillips, 2018). Same-​sex couples were somewhat younger than opposite sex couples, and were more likely to have at least one member with a college degree. Same-​sex and opposite sex couples were equally likely to be white (about 80%), but there were more interracial same-​sex couples than opposite sex, 15.9% compared to 7.3%. Gay male couples were most likely to be interracial (18.1%). Same-​sex male couples had the highest median household income ($108,614) while lesbian couples had a median household income slightly less than that of their opposite sex counterparts ($80,755 compared to $85,581). Both lesbian and gay male couples had a high percentage of households with two working adults, at about 60%, while only 48% of opposite sex couples had two employed partners. Thirty-​ nine percent of opposite sex households contained children, compared to 16.5% of same-​ sex households with children. Lesbians were substantially more likely than gay men to be raising children: 23.3% compared to 9.5%. The states with the

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highest numbers of same-​sex couples were California, Florida, Texas, and New York. The most interesting data on same-​sex couples concerns relationship quality and style. Kurdek and his associates have conducted longitudinal research and concluded that while gay couples seem to emphasize more autonomy and report more equality than heterosexual pairs, in general ‘the correlates of relationship quality have been found to be very similar for gay and lesbian couples’ (Kurdek, 1992, p. 130). The most striking difference between mixed and same-​sex couples, one found consistently in research, is that gay male and lesbian couples are more egalitarian in almost every way than male-​female couples (Gotta et al., 2011; Solomon, Rothblum, and Balsam, 2005; Peplau, 2003). In mixed-​sex couples, women do more housework than men and the chores are more likely to be split along traditional gender lines, while same-​sex couples share housework equitably and do equal amounts of ‘feminine’ vs. ‘masculine’ chores. Same-​sex couples have more equal levels of communication with each other, contribute equally to the maintenance of the relationship, and have equal power in decision making. In other words, same-​sex couples are free of the gender stereotyping and power imbalances inherent in the still-​sexist culture in which we live. John Gottman has done interesting observational research on gay male, lesbian, and mixed-​sex couples (Gottman et al., 2003). He and his colleagues studied 40 same-​sex and 40 mixed-​sex couples. In addition to filling out batteries of psychological tests designed to measure both individual and couple attributes and health, each couple participated in three ‘lab sessions’ of two or three hours each. In these sessions both partners were attached to devices that recorded physiological measures of arousal, and the couple engaged in three conversations: 1) discussing events of the day; 2) discussing an area of continuing conflict in their relationship and 3) discussing a mutually agreed upon ‘pleasant’ topic. These discussions were video recorded for later analysis, and data was presented on the ‘conflict’ discussion. Gottman found, for both gay male and lesbian couples, the ‘conflict’ material was both presented and received by the partner in a way that was generally positive, and for mixed-​sex couples, it was generally negative. During the conflict discussion, gay and lesbian partners showed less belligerence, were less domineering and there was less tension. Moreover, gay couples showed more positive emotions during the conflict discussion:  more humor, and more joy and excitement. Perhaps most importantly, same-​sex couples overall focused more on positive interactions than negative ones, the reverse of what Gottman finds for heterosexual couples. In fact, Gottman concluded that heterosexual relationships may have a great deal to learn from homosexual relationships insofar as homosexual relationships seem to have

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found a way to begin conflict discussions in a more positive and less negative manner, and to continue to have a positive rather than negative influence on one another. (p. 87) Gottman and his collaborators also found evidence of the strength and resiliency of same-​sex relationships in a more recent study of the impact of Gottman Method couples therapy with same-​sex couples (Garanzi et  al., 2017). Researchers found that the therapy was at least as effective with gay couples as with mixed-​sex pairs, and was accomplished with fewer sessions. The findings of Blumstein and Schwartz regarding longevity of relationships still appear to be true. A 2017 study that followed couples for 12  years found that lesbian relationships were one-​and-​a-​half times times more likely to break up than heterosexual relationships and twice as likely as gay male couples (Balsam, Rothblum, and Wickham, 2017). This is less surprising when one considers that for decades in the United States, women have initiated divorce in heterosexual marriages much more frequently than men. Women appear to have higher standards for relationship quality than men, regardless of sexual orientation, and are thus more likely to be dissatisfied. The same study found that breakup rates for gay and lesbian couples were related to how long they had been together at the beginning of the study  –​the longer the relationship, the less likely to break up. Rates were lower for more highly educated and for older people as well. Issues Common to Both Gay Male and Lesbian Couples Most lesbian and gay couples who enter therapy complain of the same issues as heterosexual couples. These include:  problems with communication, feeling ‘unheard’; conflicts over money, kids, or housework; issues related to the mental health or addiction problems of one spouse; recovery from or the discovery of an affair; sexual conflicts or lack of desire. But there is sometimes a ‘gay twist’ to the problems of same-​sex couples. For example, the two members may be in different places regarding their personal ‘outness.’ I have seen couples where one person was not out to their parents and insisted on keeping a pretense that each partner had their own bedroom in order to conceal the true nature of their relationship from the parents. This secrecy can feel burdensome to the more ‘out’ partner. ‘Work stress’ can cause havoc for any couple, and for a same-​sex couple this may be exacerbated if one member feels oppressed or discriminated against at work for being gay. Decisions about having children are more complex for gay and lesbian couples because the easiest method of obtaining parenthood is not available for same-​sex partners. Mental health and addiction cause problems in all relationships, but it is more likely in a same-​sex relationship that one person will have such

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issues. Domestic violence is perceived and handled differently –​and more of a source of shame –​especially for gay male couples where admitting to being victimized is a blow to masculinity. Because both lesbian women and gay men have more varied sexual repertoires than heterosexuals, sex therapy will look a little different, with different complaints and different strategies. ‘Infidelity’ is defined differently in those same-​sex relationships that are consensually nonmonogamous. Both male and female same-​sex couples may need to deal with problems that can come when one member is bisexual or transgender, and the issues are different than for an opposite sex couple with a bi or trans partner. The legalization of same-​sex marriage has unearthed differences between couples when one wants to marry and the other doesn’t. However, in addition to these ways in which same-​sex relationships share similarities, there are some ways in which gay male and lesbian couples are distinct from each other. Working with Male Couples Any therapist who has worked extensively with gay male couples will resonate with the findings showing that gay couples use more humor, have what Gottman calls ‘soft start up’ when discussing conflicts, and are able to relate to positive attributes of the relationship. Many male couples are interracial –​ nearly one-​fifth statistically –​and accommodate substantial age differences –​ ten years or more ‒ between the two partners. Perhaps the most outstanding features of gay male relationships, especially to a non-​gay provider, are the prevalence of nonmonogamy –​and the threat of HIV. As mentioned in the earlier chapter on gay men, nonmonogamy has gone from being a nearly universal feature of gay male relationships before the advent of the AIDS epidemic, to becoming much rarer during the first 15 years of the epidemic –​and then rebounding. Current estimates are that about 50% of gay male relationships are consensually ‘open,’ but that may be an underestimate (LaSala, 2001, 2004; Shernoff, 2006). Many couples are what Dan Savage calls ‘monogamish’: they occasionally invite a third person into the bedroom for a session, but have no extra-​couple sex other than this. These couples often don’t consider themselves nonmonogamous. It is useful to understand the nature of gay male nonmonogamy. Relatively few gay men participate in polyamory  –​that is, their nonmonogamous partners are not also romantic partners, as a rule. Instead, they have more limited outside sexual encounters and each couple tends to have its own set of ‘rules’ about what is permissible. Partners experience rule violations as infidelity, which is an unfamiliar view of ‘adultery’ for most non-​gay people. Therapists are often called upon to help male couples negotiate rules of nonmonogamy and/​or recover from the harm done when rule boundaries are not observed.

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While same-​sex couples are more egalitarian, the ‘equality’ doesn’t necessarily translate into equal roles in sex. One man may more frequently assume an ‘active’ or ‘passive’ role than the other, especially regarding anal sex, where one person is by necessity the ‘top,’ or ‘insertor,’ and the other is the ‘bottom,’ or ‘insertee.’ Many men are flexible in these roles, but problems can arise when both men prefer one role over the other. This aspect of sexuality is so important that, for example, most profiles on Grindr, the dominant dating/​ hook-​up app for gay men, designate the person as ‘top,’ ‘bottom,’ or ‘versatile.’ Somewhat counter-​ intuitively, research has shown that the majority of HIV transmission occurs within serious relationships (Sullivan et  al., 2009). Gay men may enter relationships, and engage in unprotected anal sex, without knowing that they are HIV positive, especially because there can be an interval of as long as six months between infection and detectable test results. Alternatively, they may have unprotected sex in outside sexual encounters and carry HIV into the primary couple relationship. While fewer gay male couples raise children than lesbian or mixed-​sex couples, since marriage equality the number is increasing, and men are finding atypical methods for becoming parents. For some, adoption is an option, often in combination with, or preceded by, foster parenting. Others find lesbian couples or single women who want to raise children with a male parental presence. A lucky and wealthy few become fathers through surrogacy, which is legal in some US states and some foreign countries. With this method, gay men may use their own sperm to inseminate a surrogate who then carries the baby to term, or they may use their own sperm, a egg from a donor woman, and a gestational carrier who has the fertilized egg implanted in her own womb. Case Example: A Gay Couple Considering Parenthood Austin and Amauris had been together for five years when Austin’s friend Jamie approached him about being a sperm donor for her and her partner, Sharon. Austin was enthusiastic, but his partner was opposed to the idea, and so the couple sought out counseling to help them resolve this important dilemma. Amauris’ concerns were two-​fold: first, he was not sure he wanted to be a parent, and he worried that parenthood would destabilize the solid, secure relationship that the two men had built over the years. Second, he was nervous because Jamie and Sharon were unclear about the role they wanted Austin to have in the life of their child. Amauris feared that he and Austin would get ‘onboard’ with the idea of being parents but that the women would decide they did not want to share parenting. Initially, Austin was angered by Amauris’ doubts, but the counselor helped him see that the fears were rational, and Austin realized that, since he wanted to be more than a ‘sperm donor,’ the arrangement needed

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to be clarified before he could agree. The men were encouraged to speak honestly with Sharon and Jamie to express their worries. When they did so, the two women came to recognize that they really didn’t want to co-​parent with anyone outside of their relationship, and decided to use an anonymous sperm donor instead of someone they knew. The incident spurred Amauris and Austin to reflect on their own desires to parent, and together they explored the option of fostering a young child with the possibility of adoption. In this case, it was important that the therapist knew something about parenting options for gay men and lesbians, especially the difficulties of negotiating shared parenting among two couples. Case Example: Sex after Seroconversion Michael and Roberto came to treatment for help restoring a sex life that had flagged after Michael discovered in a routine annual physical that he had seroconverted, that is, his HIV status had gone from negative, uninfected, to positive, infected with the AIDS virus. Michael realized he had been deceived by an outside partner who had claimed to be HIV negative and with whom he had an ongoing sexual relationship that included ‘barebacking.’ The first issue the men had to deal with was infidelity: although they had a consensually nonmonogamous relationship, part of their understanding included a commitment to have only safe sex with outside partners. The therapist was able to help Roberto forgive Michael, in part because Michael had not transmitted the virus to Roberto, and in part because Roberto could easily relate to the temptation to ‘bareback.’ Michael was diligent about taking the ‘cocktail’ of drugs aimed at preventing his HIV from becoming active and/​ or transmissible, but his sexual desire, not only for Roberto but for anyone, had disappeared, and the most pressing clinical issue was Roberto’s dissatisfaction with the sudden absence of sex in the relationship. The therapist first investigated and ruled out the possibility that Michael’s decreased sex drive was a side effect of the medications. In therapy, Michael revealed feelings of deep shame and humiliation for having contracted HIV, and thoughts that his body was ‘toxic.’ Michael needed some individual sessions to work through these feelings. EMDR and cognitive-​behavioral reframing of his thoughts helped diminish the intensity of these negative feelings considerably. Roberto, once he worked through his anger about Michael’s betrayal, was able to be extremely patient, consistently reassuring, and was willing to wait over a year for Michael to be able to be sexual again. This was easier for Roberto because of their open relationship; during this time period, Roberto had encounters with other men that relieved his sexual tension. In addition, in therapy the men learned the value of frequent, tender, cuddling and physical contact. They came to recognize that they didn’t need to be sexual to fulfill their needs

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for physical affection. Slowly they were able to resume a sex life with each other, albeit more limited than it had been before. Moreover, Michael was never comfortable with having his own extra-​marital sex again. After his HIV infection, Michael never prioritized sex in his life quite as much as he had done before, and his relationship with Roberto was enough to satisfy his needs for sex and physical closeness. The therapist working with Roberto and Michael needed to know some facts about seroconversion and the role of anti-​retroviral drugs. It was also helpful that the therapist recognized that ‘infidelity’ is often not as explosive an issue for gay men as it is for heterosexual couples, and that some male sexual behavior serves the function of fulfilling affectional needs that can also be satisfied with non-​sexual  touch. Case Example: Nonmonogamy as a Solution to Sexual Script Incompatability Joe and Harold had been committed partners for two years when they came to therapy because their sex life had deteriorated drastically. They were, respectively, 21 and 23 years old, and both were relatively inexperienced when they met. What emerged in treatment was that both men preferred the ‘top’ role in sex, and although they had been attempting to switch roles, neither man was very happy being a ‘bottom,’ particularly in anal sex. They both had traditional views on monogamy, however. The therapist in this case took an approach one would might be cautious about using with a heterosexual couple: he recommended nonmonogamy. Neither Joe nor Harold was shocked by this suggestion, but Harold in particular feared he would get too jealous to be able to handle this. The therapist explained the concept of setting rules and boundaries and taking a gradual approach to opening up the relationship. He suggested they start by going to a ‘jack off ’ club. Very popular during the height of the AIDS epidemic, J.O. clubs or parties still exist in most major cities. At a J.O. club, men masturbate themselves watching other men, or they masturbate each other. No other sex acts are allowed. Joe and Harold attended several parties given by the New York Jacks, starting by just watching and masturbating each other, but eventually allowing other men to touch and fondle them. Harold discovered that although he had twinges of jealousy, he found the activity very sexually arousing and was able to overcome his fears. Eventually, the men graduated to ‘threesomes’:  they found men who were ‘bottoms’ and who enjoyed partnering with two men who were ‘insertors’ in anal sex. This ‘monogamish’ arrangement suited Harold and Joe very well. They found they had an easier time ‘switching’ with each other when they knew they could be fulfilled during the three-​way encounters. When therapy ended, the two were having sex with others regularly, and contemplating opening their relationship a bit more to allow encounters that did not involve both partners.

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Case Example: Children from a Prior Marriage Owen and Vinnie were both in their mid-​40s and had been romantically involved for ten years. However, during this entire time Vinnie was heterosexually married and deeply in the closet about his gayness. Therefore, the ten-​year relationship was hidden and secretive, and the two men could only be together for hours at a time. Owen had other sexual partners during this time, but was only romantically attached to Vinnie, hoping and waiting for him to end his marriage. Finally, Vinnie ‘came out’ to his wife and they separated in a rancorous divorce. Owen had high hopes that his dreams of a ‘normal’ relationship would finally be realized and that the two could live together as a couple. But Vinnie had joint legal custody of their two adolescent children and visitation rights every other weekend and once during each week. His children, influenced by their mother, believed that Owen had destroyed their family and refused to be in his presence. Owen felt that Vinnie should ‘stand up’ to his children or, if they refused to change, forgo contact with them until they accepted their father’s relationship. The conflict brought the pair to counseling. The therapist used the ‘intentional couples dialogue,’ a technique developed within the framework of Imago Relationship Therapy. The goal of this approach is get each partner to fully appreciate and understand the partner’s point of view, even if it is a perspective with which they did not agree. While using this dialogue, Owen expressed the deep pain of waiting for ten years in a part-​time love relationship, only to have his hopes dashed even after Vinnie left his wife. Vinnie, for his part, showed the intense love he had for his children and the agony of feeling torn between his kids and Owen, whom he also loved profoundly. When these dialogues were finished, over the course of several sessions, both men were able to understand each other, to appreciate the seemingly insoluble nature of their dilemma, and to know that their partner was not purposely causing pain. The men both hoped that eventually the children’s anger and pain would dissipate, but they realized this could take years. In the meantime, Vinnie needed to have a relationship with his children and could not sacrifice that for Owen. Ultimately, they agreed that Vinnie would need to keep an apartment of his own where he could spend time with his children, while living with Owen when the children were not around. The men were sustained by the realization that, even if the children did not ‘come around,’ they would become adults, and Owen and Vinnie could have their dream of one shared home at some point in the future. In this case, the therapist was helped by their knowledge of the external environment influencing the family. The clinician knew that Vinnie’s children were not simply influenced by their mother; they were being raised in a relatively conservative neighborhood where even the family and peer friends of the children were unsupportive of Vinnie’s actions. If Vinnie had attempted to assert the legitimacy of his relationship with Owen with his kids, he would have undoubtedly been unsuccessful. The children had too much support for their

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view that Vinnie had abandoned the home for an immoral, sinful lover and that they were justified in refusing contact with that partner. A Word on Working with Mixed-​orientation Couples Sometimes you will find yourself providing therapy to a couple where one is a gay man and the other is either bisexual or a straight woman. I will write about the first situation in the chapter on bisexuality. Here I am discussing gay men married to straight women. Although this situation is less common than it was in the past, there are still many gay men in heterosexual marriages. This happens for many reasons:  some men know they are gay before they marry women, but choose heterosexual marriage for religious reasons; others genuinely fall in love with their wives and feel heterosexual life to be a better option; some men don’t realize they have a primarily same-​sex attraction until after marriage. Correspondingly, most women married to gay men don’t know of their spouse’s orientation when they marry, but some do and marry in spite of it or in the hopes that their partner will change. Just as there are multiple reasons for such marriages, there are a variety of possible outcomes (Kays and Yardhouse, 2010). If you are counseling a gay man married to a woman who has not disclosed his orientation to his wife, be aware that the decision to ‘come out’ is extremely complex, and that there is a high likelihood that his disclosure will result in the dissolution of the marriage. A 20-​year review of studies of these couples indicated that approximately 15% stay together (Hernandez, Schwenke, and Wilson, 2011). If you are counseling a couple in which the wife has recently learned of her husband’s orientation, there are many issues to consider. First, many wives react with guilt and shame to the disclosure: she needs reassurance that she did not ‘turn her husband gay,’ and that there is nothing wrong with her for not realizing his orientation sooner. Although it is difficult, she needs help to depersonalize the situation. She didn’t cause the problem, she can’t change him, and he didn’t become gay ‘on purpose’ to harm her. The Straight Spouse Network ( can be enormously helpful. Founded by Amity Pierce Buxton, herself a heterosexual woman married for 25  years before she discovered her husband was gay, the Network sponsors over 50 active support groups in the US, more in the UK, Canada, and Australia, and several online forums and chat groups. They have facts and resources on their website, a podcast, and a triage team that handles approximately five requests per help every day. Usually the biggest question facing mixed-​orientation couples is the issue of whether to stay together or break up. If they stay together, will there be any outside sexual activity permitted for the husband, or for both? When I  have counseled couples like this, I  have often perceived a subtle type of pressure from the husband that goes like this (though perhaps not articulated

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this clearly): ‘I love you, but I’m gay, and I need to have sexual contact with men. If you love me, you will allow this, and we can make this marriage work.’ There are some big obstacles to mixed-​orientation couples negotiating an open relationship. First, some wives agree to this arrangement without realizing that, in fact, they won’t be able to emotionally tolerate it. Second, some gay husbands start out believing all they want is some outside sexual contact –​and then eventually discover that they won’t be content until they are living an entirely gay lifestyle. The Straight Spouse Network estimates these kinds of arrangements last around three years. Nevertheless, despite what is perhaps a low survival rate of these kinds of marriages, if your couple wants to try this it is your job to help them. When a couple like this ‘opens’ the marriage, it is important that there be a clear set of rules and boundaries in place. I discuss how to help with this in my later chapters on consensual nonmonogamy. If the couple decides to dissolve the marriage, it is best for both spouses to have individual therapy to help support them. There will be a lot of grief work for both of them, but perhaps more for the wife. Both of them are losing a marriage, lifestyle, and home that they have valued and become used to. The husband, however, has a new life waiting for him that he probably views as exciting, if scary. The wife often has no such life to look forward to; while of course she can and usually will build a new and satisfying life for herself, at the time when the marriage dissolves often she experiences nothing but an overwhelming sense of loss and betrayal. Takeaways for the Clinician It is important to reiterate that many of the problems you will deal with when counseling gay male couples are no different from issues faced by their heterosexual counterparts, and no specialized knowledge is required when working with them other than quality relationship counseling skills. But the examples provided show that there are some issues where knowledge of gay men and gay male relationships is important and factors into the success of treatment. First, as a clinician, you should be aware of your community’s attitudes about gay people, and whether there is a gay and lesbian sub-​culture available. You need to understand that the men probably treat each others as equals in day-​to-​day life, no matter what their roles in the bedroom. You must appreciate the role of sexuality in the gay male ethos, and understand something about consensual nonmonogamy and BDSM. It is helpful to gain some knowledge of HIV, PrEP, and the medications used to keep the virus under control, and you will need to find out how HIV has impacted your gay male clients. Older gay men may still carry wounds from the horrors of the AIDS epidemic of the 1980s and 1990s, and they may be HIV positive themselves. Younger men may fear HIV but not be fully aware of their own risks.

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Finally, male couples may exhibit more independence from one another than the average opposite sex couple. For example, it is not uncommon for gay male couples to take some vacations separately, and not unheard of for them to each have their own domicile. It is important to not impose mainstream marriage standards; if you are open-​minded, your gay male couple clients can show you ways of being in a relationship you had not imagined. References Ashton , D. (2011). Lesbian, gay, bisexual, and transgender individuals and the family life cycle. In M. McGoldrick, B. Carter, and N. Garcia-​Preto (eds.), The Expanded Family Lifecycle. Allyn and Bacon, pp. 115–​132. Balsam, K. F., Rothblum, E. D., and Wickham, R. E. (2017). Longitudinal predictors of relationship dissolution among same-​sex and heterosexual couples. Couple and Family Psychology: Research and Practice, 6(4), 247. Blumstein, P. and Schwartz, P. (1983). American Couples:  Money, Work, Sex. William Morrow. Bryant, A. S. and Demian, R. (1994). Relationship characteristics of American gay and lesbian couples: Findings from a national survey. Journal of Gay and Lesbian Social Services, 1(2), 101–​117. Connolly, C. M. (2005). A qualitative exploration of resilience in long-​term lesbian couples. The Family Journal, 13, 266–​280. Garanzini, S., Yee, A., Gottman, J., Gottman, J., Cole, C., Preciado, M., and Jasculca, C. (2017). Results of Gottman Method couples therapy with gay and lesbian couples. Journal of Marital and Family Therapy, 43(4), 674–​684. Gotta, G., Green, R., Rothblum, E., Solomon, S., Balsam, K., and Schwartz, P. (2011). Heterosexual, lesbian, and gay male relationships: A comparison of couples in 1975 and 2000. Family Process, 50, 353–​376. Gottman, J. M., Levenson, R. W., Gross, J., Frederickson, B. L., McCoy, K., Rosenthal, L., Ruef, A., and Yoshimoto, D. (2003). Correlates of gay and lesbian couples’ relationship satisfaction and relationship dissolution. Journal of Homosexuality, 45(1),  23–​43. Gottman, J. M., Levenson, R. W., Swanson, C., Swanson, K., Tyson, R., and Yoshimoto, D. (2003). Observing gay, lesbian and heterosexual couples’ relationships: Mathematical modeling of conflict interaction. Journal of Homosexuality, 45(1),  65–​91. Hernandez, B. C., Schwenke, N. J., and Wilson, C. M. (2011). Spouses in mixed‐orientation marriage: A 20‐year review of empirical studies. Journal of Marital and Family Therapy, 37(3), 307–​318. Jones, J. M. (2017). In US, 10.2% of LGBT adults now married to same-​sex spouse. https://​​poll/​212702/​lgbt-​adults-​married-​sex-​spouse.aspx Kays, J. L. and Yarhouse, M. A. (2010). Resilient factors in mixed orientation couples: Current state of the research. The American Journal of Family Therapy, 38(4), 334–​343. Kurdek, L. A. (1992). Relationship stability and relationship satisfaction in cohabiting gay and lesbian couples: A prospective longitudinal test of the contextual and interdependence models. Journal of Social and Personal Relationships, 9(1), 125–​142. Kurdek, L. A. (2005). What do we know about gay and lesbian couples? Current Directions in Psychological Science, 14(5), 251–​254.

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LaSala, M. (2001). Monogamous or not: Understanding and counseling gay male couples. Families in Society: The Journal of Contemporary Human Services, 82, 605–​611. LaSala, M. (2004). Monogamy of the heart: Extradyadic sex and gay male couples. Journal of Gay and Lesbian Social Services, 17(3)1–​24. Lev, A. I. and Nichols, M. (2015). Sex therapy with lesbian and gay male couples. In K. Hertlien, G. Weeks, and N. Gambescia (eds.), Systemic Sex Therapy. Routledge, pp. 245–​266. Peplau, L. (2003). Human sexuality: how do men and women differ? Current Direction in Psychological Science 12(2), 37‒40. Peplau, L. A. and Fingerhut, A. W. (2007). The close relationships of lesbian and gay men. Annual Review of Psychology, 58, 405–​424. Phillips, J. (2018). A brief look at same-​sex and opposite-​sex couple households in the United States:  2010–​2016. https://​​sites/​default/​files/​dc/​sites/​op/​ page_ ​ c ontent/ ​ attachments/ ​ S ame- ​ S ex%20and%20Opposite-​ S ex%20Couple%20 Households%20in%20the%20US-​2018.pdf Romero, A. P. (2017). 1.1 Million LGBT Adults Are Married to Someone of the Same Sex at the Two-​year Anniversary of Obergefell v. Hodges. Williams Institute, UCLA School of Law. Shernoff, M. (2006). Negotiated nonmonogamy and male couples. Family Process, 45, 407–​418. Solomon, S., Rothblum, E., and Balsam, K. (2005). Money, housework, sex and conflict:  Same-​sex couples in civil unions, those not in civil unions, and heterosexual married siblings. Sex Roles, 52(9/​10), 561–​575. Sullivan, P. S., Salazar, L., Buchbinder, S., and Sanchez, T. H. (2009). Estimating the proportion of HIV transmissions from main sex partners among men who have sex with men in five US cities. Aids, 23(9), 1153–​1162.



ottie was a 45-​year-​old woman when she first came to the lesbian support group at our women’s center in 1979. Fifteen years earlier she had been living in a New Jersey suburb as a married heterosexual homemaker with two young children when she fell in love with Carmen, a woman who owned the local hardware store. Carmen was deeply closeted, confining her same-​sex activities to the time she spent in Greenwich Village. As a young woman, Carmen had enlisted in the armed forces, but was dishonorably discharged during one of the periodic witch hunts conducted frequently before gay people were allowed to serve. She had also experienced a brutal assault by the police when the gay bar she frequented was raided. As a consequence, Carmen was very fearful of exposure in the community in which she lived. Nevertheless, she overcame her fears to be in a relationship with Dottie. For several years, Carmen and Dottie met clandestinely and kept their relationship secret. When her children were both teenagers, Dottie felt she could no longer keep up the heterosexual charade of her marriage and family life. She left her husband to live with Carmen. As a result, Dottie’s husband successfully sued to prevent her from being involved in her children’s lives, and the children blamed her for the breakup of their home. I once asked Dottie if she regretted her choices. ‘It kills me that my kids are estranged from me. It hurts me every day,’ she replied. ‘But I am completely happy with Carmen.’ She added: ‘Lesbianism isn’t about sex. It’s actually very romantic. The only reason to be a lesbian is for love.’ It is love that has motivated gay women to seek each other out through the ages despite the substantial social forces arrayed against them until very recently.

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History of Lesbianism There is less historical record regarding women who love other women than there is for male homosexuality, just as there is more historical record about men in general, reflecting the lower status with which women have been regarded in most cultures. Many historians believe the earliest recorded reference is in the Code of Hammurabi (ca. 1700 B.C.) which makes reference to ‘daughter-​men’ and gives them the right to marry other women. Note that it is impossible to know for sure whether this refers to women we would today consider lesbian, or those we would consider transgender. Just as with male homosexuality, lesbianism has been conflated with gender non-​conformity throughout the ages until relatively recently. Although the Code of Hammurabi suggests that early (Bronze Age) humans may have been accepting of some forms of female homosexuality, we have little other information about lesbians until Ancient Greece (ca. 776–​480 B.C.). There are some references to lesbianism in early Greek literature. The most famous are the poems by Sappho, a Greek female poet born around 630 B.C. on the Isle of Lesbos. While her sexuality is still debated, it seems clear that Sappho was a lover of women, as described in the few poems and fragments of poems by Sappho that still exist. Sappho has long been associated with women loving women. In 1890 a medical dictionary first used the term ‘lesbianism’ to refer to gay women; we have no way of knowing how long the term was used popularly before that (Aldrich, 2006). Ancient Romans and the early Christians appear to have been less tolerant of female homosexuality than of male homosexuality, and less tolerant than the Greeks. By the early Middle Ages, the Christian Church became stricter about same-​sex relations in general, and by the later Middle Ages the Church proscribed death by burning for lesbian acts, although this does not appear to have happened frequently. This pattern, social disapproval of lesbianism accompanied by ‘benign neglect,’ is the most common cultural attitude found in the West until the twentieth century. The early American colonists, for example, disapproved of homosexuality and sometimes enacted laws against it, but there are only a couple of recorded cases of these laws being used to prosecute lesbians. Although a number of Native American tribes sanctioned and even revered ‘Two Spirit’ people, including some born female, colonists condemned these practices. There were a couple of ways that women loving women could exist in society before the mid-​twentieth century. One is by ‘passing’ for male, that is, dressing and presenting as a man and living in the male role. However, we have no way of knowing whether the women who ‘passed’ were actually male-​identified, that is, what we would now call ‘transgender,’ whether they

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were simply escaping from the narrowly proscribed female role, whether they were attracted to other women, or some combination of these motives. There are a number of recorded instances of these women who were discovered to be passing, some after enlisting as soldiers in the American Revolution or the Civil War. From historical accounts we know these ‘passing’ women existed in the colonies as far back as the 1600s (Braunschneider, 2004). A second way that women circumvented the social and legal disapproval of lesbianism was by what were called ‘Boston marriages,’ common from the mid-​nineteenth century into the twentieth century, ‘Boston marriages’ were romantic friendships between two women who lived together and were not financially supported by men. The practice was explored in depth by historian Lillian Faderman in her book Surpassing the Love of Men (1981). The early twentieth century saw an increase in lesbian visibility in some parts of Europe, notably Paris, where there was a community of artists like Gertrude Stein, Djuna Barnes, and Collette who hosted salons where lesbian women could socialize. In the United States, the only comparable community of gay women was among the African American ‘Blues Women’ of Harlem, including Ma Rainey and Bessie Smith. It was not until the 1950s that gay activism began in the US with the formation of the Mattachine Society and Chicago’s Society for Human Rights, both gay male groups. In 1955 Del Martin and Phyllis Lyon formed the Daughters of Bilitis, the first lesbian group, and in 1956 the group began to publish The Ladder, a monthly lesbian magazine that was distributed nationally. For many lesbian women, The Ladder was a lifeline and the only way they could connect to others like them. Lesbian community building and political activism, like that of gay men, began in earnest in the 1970s after the Stonewall Riots of 1969. Initially, gay men and gay women formed very separate organizations, and the culture being developed was different as well. Lesbian culture in the 1970s was dominated by white, middle-​class feminists. In 1970 the group ‘Lavendar Menace’ staged a demonstration at a conference of the National Organization for Women (NOW), protesting the anti-​gay stances of NOW and other feminist organizations. This resulted in more inclusive policies in these groups. Lesbian feminism was a distinct cultural movement that urged women to focus their energies on other women, often to the exclusion of men. Ti-​Grace Atkinson, an early leader in that movement, is credited with the statement ‘Feminism is the theory, lesbianism is the practice.’ Radical lesbian feminists saw heterosexual women as ‘sleeping with the enemy.’ Some feminists translated this to believe that women should have as little as possible to do with men, and declared themselves ‘political lesbians,’ that is, lesbians in lifestyle if not sexual orientation. Lesbian separatism was an offshoot of lesbian feminism that espoused not only separate spaces for women –​such as the Michigan Womyn’s Music Festival, established in 1976  –​but also the

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practice of living in all-​female communes. Some feminists, like Charlotte Bunch, saw separatism as a first stage of the feminist movement, akin to the Black Power movement, a way of detecting and expunging patriarchal conditioning from one’s self and then from one’s community. Many saw lesbianism as a choice, a stance that clashed with the early gay rights activist trope of ‘born that way.’ I have vivid memories of lesbian feminism because it is how I came out in 1975. Prior to that, I identified as bisexual and had relationships with both men and women. In 1975 I ‘chose’ to be lesbian in that I rejected the idea of being involved with men sexually or romantically. I was a member of a chapter of NOW that was mostly made up of gay women, many of whom were formerly heterosexually married and, like me, came out with the ideological and practical support of lesbian feminism. My life partner, Nancy Musgrave, was also a member of that group and from the start our relationship was political as well as romantic. In 1976, together with Nancy and other women from this NOW chapter, I founded a women’s center in New Jersey that provided counseling to rape victims, counseling and shelter to victims of domestic violence, and counseling for lesbian women by lesbian women. We indulged our separatist inclinations by not allowing men to physically set foot in our facility. As an attempt to rid myself of patriarchal brainwashing, for a couple of years I did not shave my legs or wear make-​up. I listened to lesbian feminist music by artists like Chris Williamson and Meg Christian and did little socializing with men, even gay men. I  remember that time as exciting and intense, but also somewhat confining. ‘Political correctness’ could be so extreme as to become petty and divisive, leading Rita Mae Brown, an early lesbian feminist and author of the iconic lesbian coming of age story, Rubyfruit Jungle (1973), to declare that a movement that argued over nail polish was doomed to fail. Lesbian feminism was a powerful force that united many gay women for the first time in the 1970s. Lesbian women were involved in the demonstrations against the American Psychiatric Association that eventually led to the removal of homosexuality from the DSM in 1973. Gay women also made their presence known in the Democratic party; in 1973, Elaine Noble became the first openly gay person elected to state office, in Massachusetts. And many lesbians who were not separatists worked with gay men, for example, to defeat the Briggs Initiative in California, a proposition that would have outlawed gay and lesbian teachers. Lesbian women and gay men worked together to form the first National March on Washington for Lesbian and Gay Rights in 1979. Bisexual and transgender people did not become part of this movement until later. The 1980s were notable in lesbian culture for three things. First, working-​ class women and lesbians of color protested their exclusion from the mainstream feminist movement. This Bridge Called My Back was a 1981 anthology

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of writings by women of color that is now a feminist classic and formed part of the foundation for third-​wave feminism, and 1980 saw the first black lesbian conference in the United States. Second, the differences of perspective between so-​called ‘cultural feminists’ and more radical feminists came to the fore in what have been called the ‘lesbian/​feminist sex wars.’ For example, cultural feminists tended to decry all pornography and all sado-​masochistic sexual practices as violence against women, and denigrated butch-​femme lesbian dynamics as imitations of patriarchy. The ‘sex wars’ exploded at the 1982 Barnard Conference on Sexuality when members of the cultural feminist group Women Against Pornography (WAP) picketed to protest the inclusion of lesbian S/​M activists like Gayle Rubin in the conference. Rubin and other women like her had founded an organization for lesbians who practiced S/​M. Their ethic was: ‘feminist sexuality is any sexuality practiced by women,’ in contrast to the WAP belief that S/​M was a male-​influenced form of rape. The collection of essays that came from that conference, Pleasure and Danger (Vance, 1983), is a feminist classic, and other influential writings were inspired by the conference as well, such as Joan Nestle’s The Persistent Desire (1992), a feminist defense of lesbian butch-​femme erotic dynamics. Third, the AIDS epidemic that exploded in the 1980s eroded the separation that had existed between lesbian women and gay men and their organizations. In 1985, I  was instrumental in founding an AIDS social service organization in New Jersey, the Hyacinth Foundation, and half of our volunteers were lesbians who felt compelled to help their brothers. Starting in the 1990s, lesbians became increasingly visible in politics and entertainment. In 1998 Tammy Baldwin became the first openly lesbian woman elected to Congress and in 2012 she was the first to become a US Senator. In 1997 Ellen DeGeneres came out, and a year later her television character came out s well. In 2004 Phyllis Lyon and Del Martin became the first same-​sex couple in the US to be married in San Francisco. In 2013, Edie Windsor brought a legal case that resulted in the Supreme Court striking down the part of DOMA (Defense of Marriage Act) that denied federal benefits to same-​sex couples. In entertainment, Rachel Maddow was the first openly gay TV anchor on MSNBC, and in 2012 Kate McKinnon was the first lesbian cast member of Saturday Night Live. Gay women are increasingly visible, and increasingly mainstream, in the twenty-​first century. Today’s Lesbian Client Today’s lesbian client is different from the first clients I saw in the 1970s and 1980s. For example, a 2011 study of nearly 500 lesbian women age 55 or older showed that more than 50% had been married to a man at some point in their lives, and that their first emotional or sexual relationship with a woman did not occur until they were nearly 25 years old (Averett, Yoon, and Jenkins,

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2011). Many reported encountering rejection by family, employment discrimination, discrimination in social situations, housing, and healthcare. Their life histories included long periods of hiding their sexual orientation from others, and many struggles for acceptance. A  Pew Research survey done in 2013 of 1,197 LGBT people, the majority of whom were under 50, showed that overall, LGBT respondents to the survey were younger than the general public and tended to be more liberal and less religious. Gay female respondents reported that they first thought they were gay at age 13, came out to themselves definitively at age 18, and told someone else at age 21. Further, 71% were ‘out’ to all or most of the important people in their lives, and only 8% said that being gay is a negative factor in their life. Most who had come out to their parents reported that their disclosure either didn’t change their relationships, or that it actually made the relationship stronger. Within the survey group, younger people had ‘come out’ to their parents at an earlier age than older respondents. In short, younger lesbian women, like younger gay men, seem to have encountered fewer obstacles in life related to their sexual orientation, have come out to themselves and others at a younger age, and thus have spent less time hiding their sexuality. So the young or middle-​aged lesbian client you are seeing today may have struggled with self-​ identification, peers, or family in the past, but she is less likely than older lesbian clients to be bringing these issues into the therapy room. It is very possible that she already knows she is gay, has been out for a while, and has dealt with the repercussions of this disclosure. A 2002 report from the American Psychological Association emphasizes the generational differences between older lesbians and older ones (De Angelis, 2002). Younger people are more likely to identify as queer and express gender and/​or sexual fluidity. Gender expression is more nuanced: terms like lipstick lesbian (traditionally feminine), chapstick lesbian (in between traditionally feminine and masculine), soft butch (similar to chapstick lesbian), and stem lesbian (dresses butch but has a soft side) suggest a range of presentation, rather than the old ‘butch-​femme’ binary. African-​American lesbian women may use terms like ‘AG’ (aggressive) or ‘stud’ to denote more male-​presenting gay women. A 2019 article in the online lesbian news source Autostraddle exemplifies some differences. Titled ‘5 Unofficial Lesbian Relationship Milestones,’ it includes: following each other on Co-​Star, an astrology app; getting meaningful tattoos together; and sharing your streaming accounts, three ‘milestones’ that did not even exist 20 years ago. Younger gay women are also less likely to associate their sexual orientation with feminism. For these women, defying the patriarchy is neither a reason nor rationale for being gay. However, younger gay women are much more accepting of transgender men and women than their older counterparts. Unlike their older sisters, millennial and Gen Z lesbian women are much less likely to meet each other in gay bars. Like their heterosexual and gay

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male counterparts, they meet through dating apps, and the apps have taken note. Tinder, for example, used by many lesbians, has added an ‘orientation’ tab that allows users to select up to three terms that describe them from a list that includes straight, gay, lesbian, bisexual, asexual, demisexual, pansexual, queer, and questioning. The degree of intersectionality in the gay community has increased in recent decades. The percentage of adults identifying as LGB doubled from 2008 to 2016, and most of the growth has come from young people, particularly women and racial and ethnic minorities (Gates, 2017). Lesbians of color face different issues and have different patterns of behavior than white lesbians. A 2004 study comparing black, Latina, and white non-​Hispanic lesbian women found that white women self-​identified as lesbian on average two years later than their non-​white counterparts, and that black and Latina women were as likely or more likely to be ‘out’ to their families, but less likely to be ‘out’ to others outside the family (Parks, Hughes, and Matthews, 2004). African American and Latin lesbian women may feel a primary identification with and attachment to their racial/​ethnic community, which can put them at times in conflict with their ‘gay families.’ Intersectionality manifests in other ways in the lesbian community. In addition to the high numbers of non-​white lesbians and the existence of trans women and trans men in the lesbian community, lesbian women are also more likely than heterosexual women to engage in BDSM practices and to practice consensual nonmonogamy. And the relatively casual way in which some younger lesbians approach sexual fluidity may mean that the self-​identified lesbian client you are seeing today may be involved with a man in six months. One more way in which younger gay women are different is that they do not assume that they will not marry and have children. When I  came out in 1975, lesbians with children were lesbians who had been heterosexually married before coming out. In fact, when my partner Nancy and I decided to have a child in the early 1980s, ‘lesbians choosing motherhood’ was a practically unheard-​of phenomenon. The widespread social assumption was that it would damage a child to be raised in a non-​traditional family, and even gay people half-​believed this. Many sperm banks would not sell specimens to lesbian couples. Today, same-​sex marriage is legal in the US, there is a rather large body of research showing that children raised in gay households are at least as healthy and well-​adjusted as those raised in heterosexual families, and there are a wide variety of ways to accomplish having a family (Patterson, 2017; Miller, Kors, and Macfie, 2017). If gay male community often revolves around sex, lesbian community often centers on connection and warmth. Just as gay men have ‘circuit parties,’ lesbians have festivals, which certainly involve partying and sex, but also often contain workshop events, music, and entertainment. One might go to

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a lesbian festival and hear lesbian singers and comics, dance and drink –​but during the day attend a workshop on spirituality or one on self-​forgiveness. Some of the best known of these festivals are the Dinah in Palm Springs and Girl Splash in Provincetown. Issues of Today’s Lesbian Woman I’ve outlined the ways in which the twenty-​first-​century gay woman is different from her older predecessor. But in many ways, of course, ‘today’s’ lesbian is no different from the gay woman of 40 years ago. A perusal of common online sources of information for lesbians like Autostraddle, LesbianNews, and AfterEllen reveals articles on lesbian bed death and the risks of emotional affairs, and the use of the term ‘U-​Hauling’ to indicate the rapidity with which many lesbians tend to partner together. ‘Butch-​femme’ has lost its political connotation but not its erotic charge. And although discrimination and family rejection is not nearly as widespread as it was, it is still a factor with which lesbian women must contend. Therapists must still be able to help clients deal with the repercussions of ‘minority stress,’ even if that stress is in most cases not as extreme as it was in the past. Gay women, like gay men, have higher rates of mental disorders than non-​gay people, although lesbian women do not differ from gay men except that rates of depression appear to be higher (King et al., 2008; Russell and Fish, 2016). While younger lesbian women may have come out to their parents and family, they still grapple with post-​coming-​out problems. Marney, age 24, complained to me: They say they accept me for who I am, but they don’t take my relationships as seriously as they take my brother’s marriage to a woman, and they don’t automatically assume I will bring my partner to family events. I’m not rejected, but I still feel like the ‘black sheep’ of the family. Marney was never thrown out of her house or openly denigrated for being gay, but nevertheless she felt ‘less than’ other family members. It caused her great pain and was a blow to her self-​esteem, and was an issue in treatment for a long time. Eventually, she was able to confront her parents and point out how they treated her as a ‘second-​class citizen,’ and this effected some change in their behavior. Interracial relationships are common among lesbians, and this creates an added stress for both partners. Anita, a 29-​year-​old white woman in a relationship with an African American partner, commented, ‘My family could deal with my being a lesbian. It was a whole other thing for them to absorb that my partner is black  –​and that we want to raise children together!’ Perhaps not surprisingly, Anita’s partner Bette had the same issues with her

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family, who felt Bette’s commitment to a white woman was in some ways a betrayal of her black heritage, and who worried that Anita would not be able to handle the stigma of being part of a black family. A therapist who sees younger gay women today will inevitably encounter some who, after identifying as lesbian, determine that they are transgender and transition to male, often while remaining within the queer community and choosing to date lesbian or bisexual women rather than heterosexual females. Gay women transitioning to male can need help to process a huge number of conflicting feelings. They often feel they are betraying the lesbian community, women, and feminism, and unfortunately this may be reinforced by other lesbians who also see them as traitors. If they identify as feminists, they may feel guilty about acquiring ‘male privilege.’ They may feel that by being true to themselves they are dooming themselves to an isolated existence. As their therapist, it is crucial that you know the resources in your community that support transgender men. Therapists will also encounter transgender women who are attracted to women and identify as lesbian. Transgender lesbians, like bisexual women, struggle with discrimination from within the gay community. Jackie, a 35-​year-​old trans woman living in Manhattan, complains that even in this liberal community she regularly encounters women who are initially attracted to her but break off contact once they realize she is transgender. It can be particularly disheartening when clients encounter discrimination from a community they have assumed will be supportive. For some clients like this, you as their therapist may be one of the only people who fully and unconditionally supports them. Case Vignette: Fears of Losing Motherhood Status Arlene started to see me after her relationship of ten years collapsed. She and her ex-​wife, Lucia, were raising two children together, and Arlene had remained in the marriage even after feeling estranged from Lucia because it pained her to be separated from the children. The couple had been legally married when Lucia carried the two children, had used donor sperm, and both women’s names were on the children’s birth certificates. Nevertheless, Arlene, 37 and a product of conservative mid-​western upbringing, feared losing the right to parent. Her anxiety reached irrational proportions and helped fuel her drinking, which had always been problematic. After Arlene and Lucia separated, her grief and anxiety triggered a depression, which caused her to increase her alcohol consumption. Therapy with Arlene involved helping her cope with her grief, her drinking problem, and her underlying depression, but she also needed reassurance that her status as a mother was secure. I was able to refer her to an attorney who specialized in lesbian and gay family issues, and the lawyer gave her the information and support she needed to quell her anxiety about losing her kids.

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Arlene and I  also explored the reasons why her marriage had failed. We talked about sexuality, and it emerged that Arlene had many ‘kinky’ interests that she didn’t feel comfortable exploring with Lucia. As a result, her sex drive had flagged in the relationship, contributing to the couple’s problems. She became more optimistic about future relationships when she realized that she could express her BDSM interests early on in a new relationship, to make sure that she and a potential partner were well matched sexually. As trust developed between Arlene and me, I  was able to confront her about her drinking. It had in fact been a factor in the dissolution of her marriage, and was beginning to impact her work life as well. Arlene had, in the past, tried AA but didn’t like it. I helped her find some gay and lesbian AA meetings, and Arlene attended for a while. But she ultimately felt she wasn’t ready for abstinence; she wasn’t convinced it was a necessary strategy for her. On her behalf, I  contacted some providers who offered a harm-​reduction approach to alcohol and substance abuse problems. I found a provider who was extremely gay-​friendly and knowledgeable. The provider ran a ‘moderation management’-​type group that was primarily women, and Arlene agreed to attend. When we ended treatment, Arlene’s drinking was controlled in a way that both she and the group facilitator felt was healthy, and Arlene was tentatively beginning to date again. Case Vignette: The Slightly Supportive Family Gabriella came to therapy for help dealing with her family. She was 43 and had grown up in a large Italian extended family. She had three brothers and a younger sister, who had always looked at Gabriella as a mother figure. Gabriella wasn’t exactly ‘out’ to her family; they practiced a ‘don’t ask, don’t tell’ policy. Gabriella had been in a relationship with Trudy for 11 years, but the two women did not live together. They maintained separate domiciles because this suited their lifestyles and personalities, but it helped contribute to the ‘family delusion’ that Gabriella was straight and had just never met the right man. Nevertheless, Trudy was accepted warmly by Gabriella’s family members and invited to all holidays and family functions. Gabriella’s problems stemmed from the fact that both her mother and father were in poor health and needed a lot of assistance. Because the rest of the family viewed Gabriella as single with no children, she was expected to take on the greatest burden of care, and it was beginning to wear on her. With the help of therapy, Gabriella was able to talk openly to her siblings about being gay, and to establish the importance of her relationship with Trudy. Gabriella had a hard time standing up to family members, in part because a small piece of her believed the family myth that being with a woman wasn’t a legitimate relationship. Once she examined this belief and recognized its irrationality, she was eventually able to learn to set limits with other family members.

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Here is a case study of someone who in many ways epitomizes the changes that are taking place now in the lesbian community. Case Vignette: On the Cutting Edge of Diversity Charlie came to IPG in 2002, when she was 30, and continued to see IPG therapists off and on for ten years. Her birth name was Catherine, but she started to use the name Charlie because it allowed her to express her male persona while still remaining somewhat androgynous. Charlie was a graduate student in sociology at a nearby university when she began treatment; she started treatment, and continued, because she saw IPG as a place where she would not be ridiculed or pathologized and where her therapists would be knowledgeable about her struggles. When Charlie initially filled out her paperwork, which had in 2002 not yet been updated to reflect transgender and nonbinary identities, she checked off ‘F,’ ‘M,’ and ‘Other’ with a smiley face written after ‘Other.’ When asked to describe her sexual orientation, she checked ‘bisexual,’ ‘gay,’ ‘lesbian,’ and ‘unsure.’ Charlie’s sexual history included both men and women, although she had not been active with heterosexual cisgender men for several years. At the time she started treatment, she had just ended a relationship with Jared, a transgender man who had, before transition, identified as a ‘butch’ lesbian. Jared had had ‘top’ surgery  –​double mastectomy and chest reconstruction ‒ and was taking testosterone. After he transitioned, Jared, who had been exclusively attracted to women before, started to experience attractions toward other trans men. In essence, the same thing had happened to Charlie: once she started to identify as ‘gender fluid’ –​again, nonbinary was not an identity choice in 2002  –​she found herself attracted to other gender-​fluid people and to trans males. Charlie, who identified as ‘kinky’ and ‘polyamorous,’ as well as gender fluid, had a distinctive sexual arrangement with Jared: he was her ‘Daddy’ and she was his ‘boy’ in a BDSM relationship. After Jared, Charlie entered a number of BDSM and polyamorous relationships, primarily with cisgender lesbians or trans men. She has now had a primary partner for several years with whom she is imperfectly matched sexually. Both Charlie and Leslie, her partner, get some of their sexual needs met through other partners. Charlie has had several female-​bodied butch lesbian ‘Daddys’ to whom she is ‘boy,’ and been ‘Daddy’ herself to butch lesbian ‘boys.’ For most of the time Charlie was in treatment, she expressed no dissatisfaction with her female body. At the time she left therapy because she had gotten an academic job in another state, she was considering double mastectomy. Moreover, she had begun to use ‘they/​them’ pronouns. Charlie was a forerunner of the many nonbinary identified female-​bodied women we see today, and her sexual attractions and history, as well as her changing feelings about her body, reflect a common phenomenon in today’s lesbian community. Charlie’s story illustrates the many dimensions of gender and sexuality, and how describing

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sexual orientation simply in terms of attractions to men or women is a simplistic model in the twenty-​first century. Takeaways for the Clinician Working with lesbian women in therapy in some ways differs from working with heterosexual women. In my own experience, lesbians tend to be more independent; for example, they less often stay in a relationship in order to have someone take care of them, financially or otherwise. They tend to care a little less about mainstream standards of physical appearance:  no matter your size, body shape, physical appearance, or age, there will be other gay women who find you attractive. Younger gay women in particular are very sophisticated about gender, often change or repudiate gender and sexual orientation labels, and are knowledgeable about nonmonogamy and kink. So your gay female clients may be very interesting and thoughtful people to work with. But most have also experienced some difficulties connected to being gay. They may not have been bullied as kids, but they have likely encountered negative attitudes and prejudice from family, church, employers, and community. Lesbian women who present as ‘butch’ or more masculine in appearance in particular are often targets of hostility and even hate crimes, while those who present in a more feminine way often have to cope with the unwanted attention of males who think they can ‘turn her straight.’ As a therapist, you need to help your lesbian clients heal from these socially induced traumas. You may need to help with family of origin issues and dilemmas about ‘coming out.’ And, you should expect many of your lesbian clients to have children. One-​third of female couples are raising children, and in addition, single lesbians may be raising children as well. If you yourself don’t work with children, be prepared to help your adult lesbian clients find counseling for their kids, if needed, from gay-​ affirmative clinicians. References Aldrich, R. (ed.). (2006). Gay Life and cClture: A World History. Thames & Hudson, p. 120. Averett, P., Yoon, I., and Jenkins, C. L. (2011). Older lesbians: Experiences of aging, discrimination and resilience. Journal of Women & Aging, 23(3), 216–​232. Bradford, J., Ryan, C., and Rothblum, E. D. (1994). National lesbian health care survey: Implications for mental health care. Journal of Consulting and Clinical Psychology, 62(2), 228. Braunschneider, T. (2004). Acting the lover: Gender and desire in narratives of passing women. The Eighteenth Century, 45(3), 211–​229. Brown, R. M. (1977). Rubyfruit Jungle. 1973. Bantam. DeAngelis, T. (2002). A new generation of issues for LGBT clients. Monitor on Psychology, 33(2),  42–​44.

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Faderman, L. (1981). Surpassing the love of men: Romantic friendship and love between. Women from the Renaissance to the Present. Junctions. Gates, G. J. (2017). LGBT data collection amid social and demographic shifts of the US LGBT community. American Journal of Public Health, 107, 1220‒1222. King, M., Semlyen, J., Tai, S. S., Killaspy, H., Osborn, D., Popelyuk, D., and Nazareth, I. (2008). A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry, 8(1), 70. Miller, B. G., Kors, S., and Macfie, J. (2017). No differences? Meta-​analytic comparisons of psychological adjustment in children of gay fathers and heterosexual parents. Psychology of Sexual Orientation and Gender Diversity, 4(1), 14. Nestle, J. (ed.). (1992). The Persistent Desire: A Femme-​butch Reader. Alyson Books. Parks, C. A., Hughes, T. L., and Matthews, A. K. (2004). Race/​ethnicity and sexual orientation:  Intersecting identities. Cultural Diversity and Ethnic Minority Psychology, 10(3), 241. Patterson, C. J. (2017). Parents’ sexual orientation and children’s development. Child Development Perspectives, 11(1),  45–​49. Pew Research Center. (2013). A survey of LGBT Americans: Attitudes, experiences and values in changing times. http://​​wp-​content/​uploads/​sites/​3/​ 2013/​06/​SDT_​LGBT-​Americans_​06-​2013.pdf Rachel (2019) 5 unofficial lesbian relationship milestones.​ 5-​unofficial-​lesbian-​relationship-​milestones/​ Russell, S. T. and Fish, J. N. (2016). Mental health in lesbian, gay, bisexual, and transgender (LGBT) youth. Annual Review of Clinical Psychology, 12, 465–​487. Vance, C. S. (1984). Pleasure and danger:  Toward a politics of sexuality. Pleasure and Danger: Exploring Female Sexuality, 1(3).



e have already discussed the research on how gay and lesbian couples differ from heterosexual couples. In general, same-​sex couples tend to live more in urban and coastal areas, are slightly younger, somewhat better educated, and more interracial than heterosexual couples. Same-​sex couples are notably more egalitarian in the way they divide responsibilities and in the way they interact. According to research, lesbian relationships tend to not last as long as either gay male or mixed-​sex couples. This may be linked to gender: women are more likely than men to initiate divorce in heterosexual marriages (Science Daily, 2015). It may also be related to the rapidity with which many lesbians move from dating to moving in together. The phrase ‘U-​Hauling,’ used among gay women, has its origins in a joke about the rapidity with which women decide to live together (Q: What does a lesbian bring to the second date? A: A U-​Haul). Lesbian households have less income than either gay male or heterosexual households, and lesbians are more likely than gay men to be raising children, although still less likely than heterosexual couples. Many researchers have found that lesbian couples have slightly less sex than gay male or mixed-​sex couples (Blumstein and Schwartz, 1984; Blair and Pukall, 2014; Solomon, Rothblum, and Balsam, 2005), and this finding is worth examining. The Blumstein and Schwartz finding from the early 1980s resulted in a common stereotype of gay female relationships: that they are sexually boring, that sex dies out quickly. This has been called ‘lesbian bed death’ and has been debated endlessly among feminist and lesbian academics, researchers, and clinicians (Blair and Pukall, 2014; Hall, 1984; Iasenza, 2002; Nichols, , 2004, 2005). The truth is much more complicated than that. To begin with, the lesbian community has long fostered a strong sex radical

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movement unparalleled among heterosexual women (Nichols, 1987). There have been organizations devoted to lesbian BDSM since the 1970s. Gay women have always explored sensuality and erotic expression in ways not limited to the standard heterosexual fare of penis-​in-​vagina sex. Moreover, the lesbian community is home to trans women, trans men, and nonbinary people, whose bodies have unique sexual expressions and concerns. Further, lesbians are active in the polyamory community (Munson and Stelbourn, 2013). Finally, recent research (Frederick et  al., 2018; Garcia et  al., 2014) indicates that while the frequency of lesbian sex may be slightly less than that of heterosexual or gay male couples, the quality may be as high or higher. Sexual encounters between women tend to last longer, incorporate more varied sexual techniques, and, notably, almost always result in orgasm for both women. The 2018 study, for example, found that 86% of lesbian women reported always/​usually orgasming during sex, compared to 65% of heterosexual women. In this study, women who orgasmed frequently tended to receive more oral sex, more deep kissing and manual genital stimulation, and have longer lasting sexual encounters. They were more likely to incorporate a variety of techniques, including role playing, sexy talk, anal stimulation, and acting out fantasies. In other words, ‘frequency’ was replaced by variety and intensity of sex. This data calls into question the practice of equating sexual frequency with quality (Blair and Pukall, 2014). If you work with lesbian couples, you must give up two ideas that we tend to take for granted: first, the myth that all sexual problems stem from relationship problems, and second, that sex is necessary for happiness in a relationship. And be prepared to have this issue raised: the myth of lesbian bed death is commonplace, and it generates fear among gay women. In fact, it is one of the most common concerns we at IPG hear from lesbian couples. Clinical Issues of Lesbian Couples As is true of working with gay male couples, many of the treatment concerns your female couples bring to you will be similar to what you encounter counseling opposite sex couples. Some problems are the same, but with a lesbian twist:  for example, a couple where both women have demanding, high-​ pressure jobs that impact the women’s relationship –​but on top of that, one woman can’t afford to be open in the workplace about her same-​sex partner. Women’s sexuality in general is more subject to outside ‘interference’ than male sex drive, and women are reluctant to pressure their partners for sex, so you will sometimes work with couples where the relationship problems have led to a temporarily sexless union. For these couples, the sexual problems really are a direct result of relationship problems. But you will also see sexless relationships which are otherwise high functioning and satisfying to both partners. Don’t assume that the couples who aren’t having sex have

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relationships that need fixing. Some of these couples do not consider the lack of sex a problem. Those who are distressed about this may need your help jump-​starting the erotic component of the partnership. And as a counselor, you just waste time by assuming there is a ‘problem’ blocking sexual functioning. When you work with a couple like this, one who has come for help re-​igniting passion in an otherwise well-​functioning partnership, you will do less ‘couples counseling’ and more sex therapy and sex coaching. Fourteen percent of female couples are interracial, double the rate for mixed-​sex couples, and another potential source of problems in interacting with families and communities of origin. You will need to be able to help couples navigating problems with parents and in-​laws who have homophobic and/​or racist attitudes. Same-​sex female couples are not necessarily comprised of two lesbians. First, a significant number of female couples will have one member who is actually bisexual, since bisexual women outnumber lesbians. There is still fear among lesbians that bisexual women will inevitably revert to heterosexual privilege and leave for a male partner. Some women with multi-​ gender-​oriented partners feel threatened, feeling they can’t compete with the advantages conferred by having a male partner. Other couples will have a partner who is a transgender woman. This can create problems because there is still a good deal of transphobia among some gay women. The couple may find themselves shunned by some, and criticized by others. They may feel as though they don’t belong anywhere. While couples with one transgender female partner have some special problems, it is even more difficult when one member of a female couple decides to transition to male. If you are counseling the latter type of couple, be aware that there is a significant chance that the relationship will dissolve, especially if the non-​transgender partner has been taken by surprise. Sometimes the non-​transgender partner is simply not attracted to male bodies, and may not be attracted to her mate after transition has effected physical changes. Other times, the non-​transgender partner feels solidly invested in her lesbian identity, and cannot tolerate the fact that, post-​transition, the two will be seen by most as a heterosexual couple. In any case, counseling can help these couples accept their basic incompatability without blaming the other or personalizing what is happening. And finally, many couples will have one or both members who are involved in BDSM practices or consensual nonmonogamy. We will deal in more depth with these situations in later chapters on kink and consensual nonmonogamy (CNM). Of course infidelity is sometimes an issue in lesbian couples. This can be complicated by the fact that in some areas the lesbian community is small enough to become incestuous. It is very common that the affair is happening with someone both women know. This complicates recovery, when recovery

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from an affair is the goal. Often lesbian affairs are a ‘ticket out’ of the primary relationship; by the time the affair occurs, the ‘cheating’ partner has already lost all passionate love for her spouse and is looking for a way to leave. And while lesbians have affairs just as gay men and opposite sex partners do, you will frequently encounter situations where one partner is not actually sexual with another woman, but is engaged in an ‘emotional affair’: one characterized by intense love and desire to be with each other, but which is not consummated in a physical, genital sex act. These are difficult situations. The line between intense friendship and an ‘emotional affair’ is thin, and when the partner of someone with this kind of relationship is jealous, as she often is, it can be unclear whether she is trying to limit her partner’s friendships and independence or reacting to a genuine source of anxiety. Therapists working with lesbian couples need to consider the role of children in the relationship. The 2017 Census Bureau American Community Survey found that nearly one-​quarter of female couples had a child in the household, compared to 39% of mixed-​sex couples and only 9% of male couples. Moreover, many couples who do not have children will be considering parenthood, and this may be a topic for the counselor’s office. Unlike heterosexual couples, many lesbian couples are not supported in child-​rearing by their extended families, and this becomes a source of added stress. When Nancy and I decided to have a child in 1983, there was little guidance available. I was to be the gestational parent, and after much agonizing about the pros and cons of anonymous donors versus a known donor, we asked Nancy’s brother to be the biological father. Tom and his wife Patty did not intend to have children themselves, and both were enthusiastic about being able to help us out in this way. Our parents had a varied response. My mother, who had given up the idea that she would ever be a grandparent after I came out to her, was initially shocked but ultimately thrilled, as was Nancy’s father. Nancy’s mother, however, was horrified, and she did not come around in her views until after our son Cory was born. Therapists working with lesbian couples who are considering parenthood need to be prepared to guide them through a number of sticky issues, the first of which is the method of achieving parenthood. Adoption is now possible in all 50 states. A 2016 federal court ruling struck down a Mississippi law banning same-​sex adoption. This ruling, together with the 2016 Supreme Court marriage equality ruling, makes it possible for lesbian and gay couples to adopt domestically. There are still some countries that ban same-​sex couple adoption, so international adoption is more difficult. For couples who plan to get pregnant, there are decisions about anonymous versus known donors, and there are now laws to protect the rights of gay couples using a known donor. When Nancy and I got pregnant, before these laws were in place, one of our fears was the (extremely unlikely) possibility that Tom and Pat would have a change of heart and sue for custody. There are other decisions as well

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that need to be considered. Nancy and I chose to move from a relatively rural part of New Jersey to Jersey City, which borders Manhattan and was just becoming a desirable location for transplanted New Yorkers, and which was developing a ‘gayborhood.’ We moved because we were concerned about where our child would go to school and how his peers would react to a child with two mothers. We were fortunate enough to have the financial means to do this, and our move panned out. We were always able to be open about our relationship with the teachers and administrators of his schools, and we could send him to schools where we were regarded as a valued family in a diverse community. Thus Cory was always surrounded by school personnel and peers who were supportive. For couples who live in less gay-​welcoming places, and do not have the resources or ability to move, the therapist will need to help them consider their options for child-​care and schooling. For such couples, even deciding what the child will call the non-​gestational parent can be an issue. Lesbian couples raising children have extra burdens besides the ordinary problems encountered in child-​rearing. Their families of origin may not be supportive of them, and so they may have fewer resources for help with finances or with childcare, for example. If the family lives in a conservative area, they may feel a need to conceal the nature of the women’s relationship, which means needing to coach their children to lie. If their lesbianism is known or suspected, they may have to help their child ward off the negative attitudes of others, including perhaps bullying from peers. Lesbian women, like gay men, tend to stay friends with their partners after a breakup. In part, this reflects the incestuous nature of lesbian communities outside of big cities. In many areas of the country, the community is small and intertwined enough so that it would be difficult to avoid encountering former partners in social situations. But it also reflects a different ethos in gay communities. Since so many lesbian women (and other queer people) are estranged from their families, they create ‘chosen families’ in sometimes very extensive networks, and these networks include not only ex-​partners, but new partners of ex-​partners. Moreover, in my own clinical and personal experience, gay breakups tend to be less rancorous than heterosexual divorces. This is baffling to non-​gay therapists without experience in the queer community. Heterosexuals often take for granted the idea that an ex-​partner is somehow a ‘threat,’ and it is somewhat unusual for ex-​partners to remain friendly. So some therapists may encounter some counter-​transference in working with couples where one or both partners is still close to an ex. Generational Issues In general, younger gay people see themselves differently than older generations: they are less attached to labels, more likely to parse both their

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sexual orientation and gender identity finely, at the same time as they understand they may be fluid in those identities. In some ways, younger lesbian women conduct their relationships a bit differently than older gay women. To begin with, they are more likely to identify as ‘queer’ or ‘pansexual.’ They don’t generally meet each other in bars. ‘Bar culture’ has declined in general, but more dramatically for lesbians. They meet online, which means there are more long-​distance relationships than in the days when all the lesbians you came in contact with lived in your town. Lesbian women use Tinder and OkCupid, which are dating sites for everyone, but there are also lesbian-​specific apps like Her and Hinge. In addition, gay women can find partners in the multitude of LGBT or lesbian-​specific meet-​up groups that abound, and in larger cities and university towns there are ‘queer collectives’ that function as social and support groups, although they may have other purposes as well. ‘Brooklyn Boi Hood’ (Boi= butch), whose website describes them as ‘queer and trans’ bois of color who create spaces for our community to bloom,’ runs parties, story-​telling events, and camping trips, as well as featuring and selling members’ art and literature. Younger gay women are more likely to be involved with trans women (and men). They are more likely than heterosexuals to be nonmonogamous: a 2015 survey by Autostraddle, the lesbian website and newsletter, indicated that 15% of their nearly 9,000 respondents, most of whom were between the ages of 18–​35, were currently in consensually nonmonogamous relationships. This is much less than the approximately 50% of gay with open relationships, but much more than the 2–​5% or so that general population surveys find when polling heterosexuals. Queer-​identified, pansexual, and sexually fluid women were more likely to practice consensual nonmonogamy than those who simply identified as ‘lesbian.’ The young Autostraddle respondents were also very likely to practice BDSM:  61% of the nonmonogamous women and 18% of the monogamous women enjoyed kink, rates that are substantially higher than their heterosexual sisters. Case Vignette Keandra and Anna, both African-​American self-​identified lesbians in their early 40s, came for help with their relationship of six years. They presented physically and sexually as a butch-​femme couple, and although the gender-​ based roles did not extend beyond the bedroom, they did affect the women’s psychological attitudes toward the relationship. For example, Keandra felt bad because she could not be the main financial support for the family, and Anna felt she needed to defer to Keandra on major decisions. Keandra, the AG (butch) partner,was estranged from her conservative religious family, while Anna was over-​involved with her extended family. Anna identified as gay but had a bisexual history. She had been married to a man with whom she had

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two children. Anna had become gradually estranged from her husband, whom she regarded as immature and irresponsible  –​more like a ‘third child.’ As Anna’s relationship with her husband deteriorated she became aware of being attracted to Keandra, who was the manager at a local grocery store. Anna had experienced ‘crushes’ on girls as an adolescent but did not consider herself gay until she fell in love with Keandra. Now, she identified as a lesbian women, not as bisexual, because, as she pointed out, everyone in the ‘outside world’ sees her as a gay woman. Anna and Keandra initially came for help with a waning sexual relationship. The lack of sex made them feel distant from one another. However, it quickly became apparent that other issues contributed to their estrangement, and to the lack of sex. Anna’s parents, her brother and extended family, and her ex-​ husband all refused to believe she was gay and did not respect her relationship with Keandra. Even though the two women had purchased a home together and lived there with Anna’s two adolescent childen, Keandra was regarded as an interloper in the home. And even though Anna’s husband paid no child support, and Keandra actually helped financially support the children, the ex-​husband was regarded by the family as a legitimate parent and Keandra’s right to act in an authority role with the kids was ignored and undermined. Anna’s extended family and her ex-​husband lived nearby, and thus were able to meddle in the couple’s lives with regularity. Anna, as the eldest daughter, was expected to play a caretaking role in the extended family. When a nephew needed a place to live, Anna took him in; when a drug-​addicted relative needed help, Anna opened her home to him as well. Keandra was a nearly invisible and ineffectual member of the family structure, because Anna’s teenage children, eager to escape authority, readily absorbed the attitudes of their grandparents, aunts and uncles, and father. To make matters worse, Anna ran a beauty-​oriented business from her home that relied on customers from the church she had frequented since childhood. Anna could not be ‘out’ to the ‘church ladies,’ and so when they came to her home, Keandra had to pretend to simply be a boarder in the home. Keandra felt marginalized in her own home, which made her feel distant from Anna, but because she had been raised in the same culture, Keandra unconsciously took for granted the right of Anna’s family to treat them in this way. The other problem that beset the couple was that both suffered from the lack of a supportive spiritual community. Keandra had withdrawn from religion at about the same time she came out as gay as a young adult. Anna was still active in the church of her childhood, but increasingly felt out of place and hypocritical in this community. Both women yearned for spiritual connection, yet felt hopeless about achieving it. This couple needed family therapy. In particular, they needed to create boundaries around their family unit that would be recognized and honored by others. I did some individual sessions with Anna to help her see that she was caught in

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a conflict between her partner and her family of origin. She came to understand that her family valued her marriage to a man, in which she had been neglected and mistreated, over her current, loving and healthy commitment to Keandra, and that they expected her to be a caretaker because they actually regarded her as ‘single.’ This made Anna angry, and she began to set limits with her extended family and with her ex-​husband. I also put the couple in touch with a church headed by an openly lesbian African American minister, and this minister helped the women reconcile their sexual orientation with their religion. Moreover, by attending the church together, Anna and Keandra were able to share a spiritual connection within a community that celebrated and honored their relationship. Eventually, we held family sessions with the children. With my help, Anna affirmed Keandra’s role as co-​parent with the teens present, and gave Keandra authority to set rules for and discipline them. The children accepted this with very little resistance, to Anna’s surprise. It may have been because they recognized that their father, while loving, was unreliable. Keandra coached local sports, and both children were athletic, so this enhanced her credibility in their eyes. In any case, they did not resist Keandra’s authority, and even seemed to welcome it. Anna’s son developed a strong attachment to Keandra, perhaps because her being a butch/​AG woman made her a model for male characteristics even though she was female-​bodied. Over time, the two women increased their bond as a couple, and the family unit became strong and clearly delineated. Once their relationship improved, so did the sex, with very little need for therapeutic intervention. Occasionally they contacted me for ‘tune-​ups,’ but the relationship never deteriorated, and they remained committed, loving, and attracted to each other. When marriage equality became the law of the land, they married  –​and even Anna’s family attended the wedding. Case Vignette Teresa and Billie were both in their late 20s and had been together for five years. Teresa, a Latina artist, met Billie, who identified as AG when they met, at a queer collective block party. When the relationship began, Billie was content to present as a ‘boi,/​butch’ even though she had questioned her gender identity privately since childhood. The couple lived together, and had a polyamorous relationship. The nonmonogamy was more important to Billie, who was also kinky and was able to find partners that matched her proclivities outside the relationship. Teresa, while not ‘turned off’ to BDSM, was not particularly interested, and was quite happy to have Billie meet her desires for kink outside the relationship. In the year before coming to therapy, Billie had grown distant from Teresa, and when confronted, she finally acknowledged that she was growing more

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and more discontent with her female gender identity, and with her female body. Teresa was initially supportive, but recently had started to question Billie about whether she ‘really’ needed to take testosterone, the male hormone that would produce male secondary sex characteristics, including facial hair and a deeper voice. This is what propelled the couple to seek out counseling. The two were an easy couple to work with. They were quite loving toward each other, respectful, and communicated openly. We worked on some minor issues about their managing outside relationships and dividing household chores before tackling the elephant in the room. Teresa insisted that her concerns about Billie were purely related to her fears about the side-​effects of medication and the difficulties of the surgeries Billie was contemplating. Billie, on the other hand, was sure that something more personal was at stake for Teresa. In an attempt to break the gridlock, I asked Teresa to have an individual session with me. She was reassured by the fact that I pledged to keep the contents of the session confidential, including from Billie. For the first 20 minutes of the session she delivered a politically correct speech about the importance of supporting trans people, insisting that she was fully supportive of Billie’s transition. Finally, I asked how she felt about being seen as heterosexual –​after all, I said, once Billie’s transition was complete the two would be perceived by the outside world as a straight couple. After a long silence, Teresa started crying. ‘I’m a lesbian!’ she cried. ‘It took me a long time to come out, but I did and I love being a lesbian. I love women’s bodies, and I love my community. I don’t know if I can handle this!’ Teresa needed a lot of support and validation that her feelings did not constitute a lack of support for trans people. We spoke about how much the loss of her lesbian identity meant to her, and I encouraged her to talk to Billie about this. By the time of their next session together, Teresa and Billie had had several conversations about Teresa’s feelings. For the first time, the two contemplated the possibility that they might break up –​or, in their words, ‘we might not be “primary” with each other.’ Over the next few months, this remained an ongoing conversation in therapy. While this was painful, it was something of a relief for Billie to have their intuition validated. ‘I felt crazy when Teresa was saying she was fine with this when I knew she wasn’t,’ said Billie. For her part, Teresa realized that once the possibility of ending the primary relationship was on the table, she felt relieved and, interestingly, it made it easier for her to support Billie’s transition. Ultimately, the couple decided to continue to live together as best friends/​non-​intimate partners while pursuing other sexual relationships. Whatever happens in the future, the two have remained loving toward each other, in great contrast to, for example, many of the heterosexual couples I have counseled facing the transition of one partner.

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Case Vignette Beverly and Joan were a ‘power’ couple in their mid-​30s, together for eight years. Beverly was a successful lawyer with a national civil rights group who traveled all over the country when working on cases. Joan was an architect at a prominent New York firm. The two were considering parenthood, and came to see me because they wanted to ‘get things in order’ before adding a child to their relationship. What needed ‘getting in order’ was their sex life: for the last three years sex had dwindled to a few times a year, and while Joan maintained that she was okay with that, Beverly most certainly wasn’t. Upon questioning, they revealed that their sexual encounters had dwindled because Joan had stopped initiating sex, and, feeling rejected, Beverly eventually ceased all efforts to approach Joan sexually. Joan was not sure what had changed in her; she cited increasing demands from her job and consequent fatigue. Other aspects of their relationship had changed as well. While both women were successful, Beverly was a ‘superstar’ in her field, and Joan was intimidated by this as well as feeling a bit personally diminished by Beverly’s success. Joan felt she had gradually handed over much of the decision making in the relationship to Beverly, who had a strong, forceful personality and was able to articulately advocate for what she wanted. For a time, therapy focused on helping the couple re-​balance the power in their relationship, which involved helping Joan become more assertive and assisting Beverly in ‘backing off ’ a bit. Eventually we started sex therapy, and I  prescribed ‘sensate focus’ exercises:  non-​threatening, sensual touching encounters designed to help couples learn about their own and their partner’s sexuality and to gradually re-​introduce physical intimacy. The exercises were a complete failure. After several attempts, Beverly refused to continue. ‘Joan is just going through the motions,’ she complained. ‘I can tell, her heart isn’t in it at all.’ In one of the sessions following the failure of this intervention, Joan quietly mentioned that in the beginning, sex had been more adventurous. Probing revealed that when the two were first involved, Joan was not only the initiator of sex, she was effectively a ‘dominant,’ taking charge of sexual encounters. When she was in control, Joan incorporated a number of ‘kinky’ elements into their sex life, including some bondage, blindfolds, and spanking. Both women remembered these sessions fondly. ‘What keeps you from doing that now?’ I asked. ‘I don’t feel like I can take charge like that anymore,’ responded Joan. Joan’s feelings of inadequacy when comparing herself to Beverly had permeated her sexual persona as well, and she lacked the self-​confidence to be so sexually assertive. Once this emerged, Joan was referred to an individual therapist to work on her own lack of self-​esteem. Eventually, Joan regained her own ‘dominant’ sexual persona, and with it, her passion. A sexual re-​balancing, in addition to a fine-​tuning of the power dynamics of the relationship, had been required to restore some sexual excitement to the couples’ life together.

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Takeaways for the Clinician Lesbian women are big users of psychotherapy, and that includes lesbian couples. So if you have an LGBTQ+ affirming practice, you will likely have many requests for help from same-​sex female couples. In many regards, lesbian couples seek counseling for the same reasons as heterosexual couples: help with conflict resolution, problems with sex, money, or children, a sense of decreasing intimacy on the part of one or both members. There are some distinctive aspects of counseling lesbian couples, however. First, female couples are more likely than opposite sex couples to be inter-​racial and/​or to have an age disparity between the members, and this sometimes impacts the relationship. They may frequently ask for help for a relationship with low sexual frequency; in some cases, this is a result of dysfunction in the entire relationship, but in many situations the sexual problem exists in an otherwise high-​functioning couple. Female couples may not always consist of two lesbian women. One member may be a bi woman or pansexual. One may be a transgender woman. And one may be considering transitioning to becoming male. Many lesbians are involved in BDSM or polyamory, which can sometimes produce conflicts or new issues. And many lesbian couples will be raising children –​ or considering raising children. They may need help sorting out their parenthood options. If there already are children, they may need family counseling or therapy for a child. References Autostraddle. (2015).​tag/​ultimate-​lesbian-​sex-​survey/​ Blair, K. and Pukall, C. (2014). Can less be more? Comparing the duration vs. frequency of Sexual encounters in same-​sex and mixed-​sex relationships. Canadian Journal of Human Sexuality, 23(2), 123‒136. Blumstein, P. and Schwartz, P. (1984). American Couples:  Money, Work, Sex. William Morrow. Family Equality Council. (2017). LGBTQ Family fact sheet.​cac/​nac/​ meetings/​2017-​11/​LGBTQ-​families-​factsheet.pdf Frederick, D. A., John, H. K.  S., Garcia, J. R., and Lloyd, E. A. (2018). Differences in orgasm frequency among gay, lesbian, bisexual, and heterosexual men and women in a US national sample. Archives of Sexual Behavior, 47(1), 273–​288. Garcia, J. R., Lloyd, E. A., Wallen, K., and Fisher, H. E. (2014). Variation in orgasm occurrence by sexual orientation in a sample of US singles. The Journal of Sexual Medicine, 11(11), 2645–​2652. Hall, M. (1984). Lesbians, limerance, and long-​term relationships. In J. Loulan, Lesbian Sex. Spinsters Ink, pp. 141–​150. Iasenza, S. (2002). Beyond ‘lesbian bed death’: The passion and play in lesbian relationships. Journal of Lesbian Studies, 6, 111–​120. Munson, M. and Stelboum, J. (2013). The Lesbian Polyamory Reader: Open Relationships, Non-​monogamy, and Casual Sex. Routledge.

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Nichols, M. (1987). What feminists can learn from the lesbian sex radicals. Conditions Magazine, 14, 152–​163. Nichols, M. (2004). Leading comment: Rethinking lesbian bed death. Journal of British Association for Sexual and Relationship Therapy, 19(4), 363‒372. Nichols, M. (2005). Is ‘lesbian bed death’ for real? The Gay & Lesbian Review Worldwide, 12(4), 18. (e) Science News. (2015). Women more likely to initiate divorce, but not non-​marital breakups. http://​​articles/​2015/​08/​26/​ Solomon, S., Rothblum, E., and Balsam, K. (2005). Money, housework, sex and conflict:  Same-​sex couples in civil unions, those not in civil unions, and heterosexual married siblings. Sex Roles 52(9/​10), 561–​575.

12 BI ANY OTHER NAME Science Grapples with Multiple Gender Attractions


et’s start by defining bisexuality. Many people assume that to be bisexual means being equally attracted to both men and women. In fact, there are probably very few people who fit that description. The research findings described in this chapter pertain to anyone who has a mixture of sexual attractions –​who are not ‘monosexual.’ Most research on bisexuality uses as subjects those who self-​define as bisexual, and this group encompasses a wide range of behaviors and attractions. But for the most part, those who self-​define as bisexual have mixed attractions and some mixture of sexual experience that is both same and opposite sex. In some ways, it is ironic that contemporary culture and science has so much difficulty dealing with people who are attracted to both men and women, because throughout history most people with same-​sex attractions have also been heterosexually active. A 2002 study by Herek of heterosexual attitudes found that bisexuals were evaluated more negatively than any other group mentioned in the survey –​e.g., gays, lesbians, Jews, and so on ‒ with the exception of injection drug users. A more recent study, using a nationally representative probability sample of heterosexual, lesbian and gay adults (Dodge et  al., 2016) showed some shift in these attitudes. The researchers asked questions such as ‘People should be afraid to have sex with bisexual men because of HIV/​STD risks’ and ‘Bisexual women are incapable of being faithful in a relationship’ with answers recorded on a 7-​point scale. The largest number of responses for all these questions was ‘neither agree nor disagree,’ indicating some confusion, lack of information, or ambivalence about bisexuals. Statements indicating that bisexuals are confused and those suggesting they present health risks were agreed with more than they were disagreed with, but statements about relationship fidelity, promiscuity, and

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bisexuality as ‘a phase’ garnered more disagreement than agreement. Fifteen percent of people surveyed do not believe bisexuality exists. Overall, this suggests some shifts in public attitudes about bisexuality toward neutrality or even acceptance, but these appraisals of bisexuality are still far more negative than attitudes toward being gay or lesbian. In both studies, men hold more negative beliefs than women, and bisexual men are judged more critically than bisexual women. A 2014 study indicated that both heterosexual and gay people indicate a low level of willingness to be romantically involved with someone who is bisexual, especially in a committed relationship. The 2016 survey distilled negative attitudes to five beliefs: • • • • •

Bisexuals are ‘confused’ about their identity; Bisexuals often transmit HIV; Bisexuals are unfaithful to their partners; Bisexuals are promiscuous; Bisexuality is ‘just a phase.’

The idea that sexual orientation was more than ‘homosexual’ or ‘heterosexual’ was first introduced by Kinsey in his work in the 1940s, which we described in Chapter  1. As a result of his extensive interviews with men and women, Kinsey developed a 7-​point scale to describe how his subjects varied in their relative attractions to same and opposite sex partners. People who were exclusively heterosexual were designated ‘0,’ those who were exclusively homosexual were designated ‘6’ and those with mixed attractions varied from ‘1’ –​low/​incidental attraction to same sex ‒ through ‘3’ –​equal attractions to men and women –​to ‘5’ –​low/​incidental attraction to opposite sex. This continuum concept of sexual orientation was not immediately embraced either culturally or scientifically. Over the years, the Kinsey Scale has been critiqued by researchers on many dimensions. First, Kinsey classified his subjects according to an analysis of their interviews and sexual history, not by self-​identification, while most research on sexual orientation uses self-​labeling to designate sexual orientation categories. Unfortunately, self-​ identification is not highly correlated with behavioral history (Mustanski et al., 2014); in general, people tend to sort themselves into ‘gay’ or ‘straight’ identity categories, when in fact many of those who identify as ‘exclusively heterosexual’ have at least some same-​sex experience. The correlation between self-​identification and attractions is even lower. Copen, Chandra, and Febo-​Vazquez, (2016), using data from the National Survey of Family Growth, illustrated the unreliability of self-​identification for predicting actual sexual experience. Ten percent of those identified as heterosexual had same-​sex experience, and 59% of gay and lesbian respondents had heterosexual sexual experience. The labels did not even precisely depict

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the sexual experience of respondents in the last year: while less than 1% of heterosexually labeled men had a same-​sex experience in the past year, 2% of heterosexual women had same-​sex contact in the last year, 5% of gay men had sex with women, and 18% of self-​identified lesbians had had sex with men in the past year. Second, not only does the Kinsey Scale not differentiate between identity and behavior (or attractions), it does not differentiate between romantic attractions and purely sexual ones. While for many people sexual and romantic attractions are the same, this is not always true. For example, Austin, a 35-​ year-​old man who identifies as ‘heteroflexible’ is sexually attracted to both men and women, but is only romantically drawn to women, while Denise, a 54-​year-​old woman who identifies as lesbian, enjoys sex with men occasionally but has only ever fallen in love with women. Finally, some researchers, predominantly J.  Michael Bailey and his associates (Rieger, Chivers, and Bailey, 2005), have claimed that bisexuality only exists in women, not in men. A New York Times article in 2005 (Carey) described the conclusions of this research as: ‘Straight, Gay or Lying,’ giving new credence to an old stereotype that bisexuals are simply gay people who are afraid to admit their true orientation. In response to the first two critiques, variations on the Kinsey Scale were developed, the most notable of which is the Klein Sexual Orientation Grid, introduced in Fritz Klein’s 1978 book, The Bisexual Option. Klein introduces seven dimensions of orientation:  sexual attraction, behavior, fantasies, emotional preference, social preference, lifestyle, and self-​ identification. Individuals filling out the grid rank each of these dimension on a 7-​point scale, like Kinsey’s scale, and they rank each dimension according to the past, present, and (imagined) future. While the Klein Scale undoubtedly gives a richer picture of an individual’s orientation, it is an unwieldy instrument and rarely used in research. This is unfortunate, because in the absence of an instrument like this, most researchers simply assume that self-​identification can represent all the other dimensions. Bailey’s denial that bisexuality existed in men generated a lot of controversy for about ten years. He based his assertion on one study (Rieger, Chivers, and Bailey, 2005). In this study, self-​identified bisexual men were shown sexually explicit images of both men and women and their patterns of genital arousal were measured using physiological indicators of penile tumescence. Bailey found most of the men only showed arousal to images of other men, and a few only to images of women –​but none showed arousal to both. This study was heavily criticized, and in 2011 Rosenthal and Bailey replicated the study with more stringent selection criterion for their subjects. This yielded results showing that the subjects indeed exhibited arousal to both same and opposite sex sexual stimuli, and Bailey was forced to concede that ‘some’ bisexual men exist.

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Bisexuality: Current Attitudes Unfortunately, much of the prejudice against bisexuals has come from gay men and lesbians. The predominant beliefs within the gay community have been: 1) bisexuality doesn’t exist, it is just a phase in the transition to coming out as gay; 2) bisexuals are gay people without the guts to come out; 3) bisexuals are just confused; 4) bisexuals can’t be trusted –​in the end, they will leave you to be in a mixed-​sex relationship because they can’t give up heterosexual privilege; 5) bisexuals are promiscuous –​Ann Landers reportedly once called bisexuality ‘lust run rampant’; 6) bisexuals bring disease into the lesbian community. When I came out as bisexual in the late 1980s, the reaction from the lesbian community was swift and negative. I was told I was a traitor, that I had betrayed the community and the cause. By that time, I had several published articles on lesbian sexuality, including two chapters in the widely read book Lesbian Psychologies (Nichols, 1987). After I came out as bisexual, I heard reports of other lesbian psychologists and psychotherapists telling people to disregard what I  had written because the articles weren’t written ‘from a lesbian perspective.’ Somehow, a ‘bisexual perspective’ was considered contaminated. Today, there is much less prejudice against bisexuality from younger lesbians and gay men. However, there is also an increasing trend for young queer people to identify as ‘pansexual’ rather than ‘bisexual,’ something we will discuss in later chapters. According to the Human Rights Campaign’s 2017 Youth Survey (Kahn et al., 2018), 14% of young queer people ages 13–​ 18 identified as pansexual, twice as many who identified this way in 2012. Some research is calling into question the way we conceptualize sexual orientation. Lisa Diamond’s findings on sexual fluidity represent perhaps the greatest challenge to our beliefs about the immutability of sexual orientation identification. Beginning in the 1990s, Diamond (2008), following a cohort of 79 young women for ten years, showed that most of these women were ‘sexually fluid.’ Over that ten year period, 67% of her subjects changed their identities at least once, and 36% changed identities two or more times. Notably, most of the women who identified as bisexual at the beginning of the study also identified as bisexual or unlabeled at the end, leading Diamond to conclude that bisexuality is a fairly stable identity, that is, there was no evidence that bisexuality was a ‘transitional phase’ for any of the women. However, the larger point of her work is that sexual identity is fluid –​and that younger people may view ‘identity’ as a temporary status rather than an immutable characteristic, a point echoed by Ritch Savin-​Williams’ work in The New Gay Teenager (2009) and Mostly Straight (2017). Research on ‘mostly heterosexual’ men and women suggests that when provided with five identity categories (heterosexual, mostly heterosexual, bisexual, mostly gay, gay), ‘a significant minority of heterosexuals and the majority of gays/​

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lesbians reported some attraction and/​or partners toward their nonpreferred sex’ (Vrangalova and Savin-​Williams, 2012, p.  85). In addition, ‘findings also supported a sexual orientation continuum as consisting of two, rather than one, distinct dimensions (same-​and other-​sex sexuality). Having more same-​sex sexuality did not necessarily imply having less other-​sex sexuality, and vice versa.’ To complicate the issue further, there are people  –​who identify as ‘skoliosexuals’ ‒ who are specifically attracted to transgender and/​ or nonbinary people. If sexual orientation is defined as an attraction to same-​ sex or opposite-​sex, where do these individuals fit in? And what does it say about what orientation is ‘oriented’ to? Is it genitalia? Gender expression/​ presentation? It should be clear by now that defining sexual orientation is problematic, and that people who are not monosexual –​only attracted to one gender –​can define themselves in a variety of ways. The Demographics of Bisexuality Despite the complexities of sexual orientation, almost all current research uses three categories: gay/​lesbian, heterosexual, or bisexual. What do surveys and population studies tell us about people who identify as bisexual? First, there are more bisexually identified people in the United States than people who identify as gay or lesbian. According to data collected by the Movement Advancement Project, 52% of LGB people identify as bisexual (2016). CDC population surveys from 2011–​2013 indicate that 5.5% of women and 2% of men identify as bisexual, compared to 1.3% who identify as lesbian and 1.9% gay men (Dahlhamer et al., 2014). These numbers are up from CDC surveys from 2006–​2010, when 3.9% of women and 1.2% of men identified as bisexual. The increase is related to age; younger people are more likely to identify as bisexual. Americans are even more bisexual if one looks at behavior and attractions: 17.4% of all women and 6.2% of all men have had some same-​sex sexual experience, and over 25% of men and women acknowledge some same-​ sex attractions. Even those who self-​label as gay have bisexual sexual histories: 89.7% of self-​identified lesbians and 67.9% of gay men have had some heterosexual sexual contacts (Dahlhamer et al., 2014; England, Mishel, and Caudillo, 2016). Self-​labeled bisexual people are more likely to be non-​white, and more likely to be transgender. Bisexuals are strikingly less likely to be ‘out’ to significant people in their lives: only 28% of bisexuals are open about their orientation, as opposed to 77% of gay men and 71% of lesbians (Taylor, 2013). They are poorer:  48% have family incomes less than $30,000 per year, compared to 28% of all US adults, 39% of lesbians, and 30% of gay men. They are more likely to be parents. In fact, two-​thirds of LGB people

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with children are bisexual  –​59% of bisexual women have kids and 32% of bisexual men. A  significant number are heterosexually married as well:  32% of bisexual women and 23% of bisexual men are married to opposite sex partners, and the majority of bisexual people in relationships have opposite sex partners. Bisexuals tend to be aware of their bisexuality in adolescence, and often are aware of opposite sex attractions before they acknowledge their same-​sex attractions. Some investigators have noted the high percentage of self-​identified bisexuals within the BDSM community (Sprott and Haddock, 2018), although we have no survey data to precisely determine the degree of overlap. There is a relatively high rate of bisexuality among transgender people. There also appear to be many bisexuals who practice consensual nonmonogamy (Mark, Rosenkrantz, and Kerner, 2014). Bisexuality and Mental Health One of the most striking findings in the research on bisexuality is that bisexuals have more mental health problems than either heterosexuals or gay people (Persson and Pfaus, 2015). One of the earliest of these studies (Jorm et  al., 2002) was done in Australia and compared self-​identified gays, lesbians, heterosexuals, and bisexuals. Bisexuals scored the highest of any group on measures of anxiety and depression; they reported more current adverse life events, greater childhood adversity, less positive support from family, and more negative criticism from friends. Other studies have replicated these findings and, in addition, documented a higher prevalence of childhood abuse, adult sexual victimization, and adult risky sexual behaviors in bisexual individuals (Friedman, 2011; Ross et al., 2018). Several theories have been proposed to explain these results, all related to the concept of minority stress. First, bisexuals may experience more minority stress than gay men and lesbians because they encounter discrimination from within the LGBTQ+ community as well as from mainstream society. Second, bisexuals are less likely to be ‘out’ to significant people in their lives, and this may increase their stress; there is additional pressure that is experienced because of having to hide and keep secrets from those around you. Additionally, bisexual people are less connected to the gay community, and this may leave them more isolated and less supported. A  2018 study showed that bisexuals who reported experiencing a great deal of ‘identity denial’ –​being told by others that bisexuality doesn’t exist, or being treated as though they were not bisexual –​were more depressed, and also felt less of a sense of ‘belonging’ to community (Maimon et al., 2019). In any case, whatever the reasons, bisexuals have worse mental health than their lesbian and gay male counterparts, including anxiety, depression, suicidality, and substance abuse problems.

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What Therapists Need to Know about Bisexuality Case Vignette Julian was 16 when he came to see me because he was ‘uncertain’ about his sexual orientation. He was Puerto Rican but had lived in New Jersey with his parents and two older sisters since he was two. As a small child he was slight in stature and more interested in art and music than in sports. He was bullied at school, called a ‘fag’ and ‘queer,’ but his family supported him and, to whatever extent they could, shielded him from negative peer pressure. Julian was aware of having crushes on male teachers from before the age of ten, but kept these feelings private. By the time he was 13, however, he also felt attracted to other boys his age, and the burden he experienced from keeping his feelings secret became too much. First he told one of his sisters, who was completely accepting, and helped him ‘come out’ to his parents. Julian’s parents were not surprised, and although his father had some difficulty with the idea that his only son was gay, both parents affirmed that their love for Julian was unwavering no matter what his sexual orientation was. A few months before Julian came to see me, he had realized he was attracted to his closest female friend. They had kissed and Julian was disconcerted to find that he found this arousing. When he told his sister, and later his mother, both expressed happiness that he had ‘changed his mind.’ They told him that his attractions to boys were obviously a ‘phase,’ and that now that he had discovered his heterosexual impulses, the phase would soon end. It was at this point that Julian asked to see a therapist, and his parents brought him to me. ‘I’m not sure what’s happening,’ he said. ‘My family thinks I’m straight now, but I still like boys. What’s happening to me?’ A lot of the work with Julian was psychoeducational. He knew nothing about bisexuality, and when he understood more he felt vastly reassured. I told him that his sexuality might still be emerging, and that as time went on he would discover more about the nature of all his romantic and sexual attractions. In the meantime, I urged him to try to accept that his attraction to his friend was real, but that it did not mean that he would not also experience attractions to boys. The real work was with Julian’s parents. They could accept him being gay, but the concept of bisexuality eluded them. Moreover, they felt that if Julian genuinely experienced attractions to both males and females, then that meant he could ‘choose’ to be heterosexual, something they urged him to do. Family therapy helped them eventually understand that Julian could not ‘choose’ to obliterate or ignore either side of his orientation, and that they needed to be willing to accept whatever partner he was with, regardless of gender. Julian was fortunate to have a family that was so able to overcome their own biases and embrace his sexuality despite its unfamiliarity. Bisexuality is not as well-​studied as homosexuality, but we can reach some conclusions about people who self-​label in this way, conclusions that are

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important to mental health providers working with bisexual people. First, bisexuals experience sexual attraction for both same and opposite sex partners, but it is rare to find someone whose levels of sexual attraction to both genders are equal. Bisexual people also vary in the degree to which they experience romantic feelings for male and female partners; some are both romantically and sexually inclined to men and women, others may be romantically attracted to only one gender. What this means is, when someone tells you they are ‘bisexual’ it is important to find out that person’s unique definition of what it means for them. No two bisexual people will be exactly alike in attractions and behavior. As we’ve seen, bisexual men and women are more likely to be heterosexually married than are lesbians or gay men, they are more likely to have children, and less likely to be ‘out’ to significant people in their lives. They are more likely to be non-​white, to have lower family income, and to have mental health problems than their gay and lesbian counterparts. They suffer from invisibility: others are likely to assume them either to be straight or gay, depending on the gender of their current partner. They endure stigma and negative attitudes, not only from the culture at large, but also from within the ‘queer’ community. A therapist needs to be aware of her/​his assumptions:  whether you are working with a mixed-​sex couple or a same-​sex couple –​one or both members of that couple may in fact be bisexual, not monosexual. References Carey, B. (2005). Straight, gay or lying: Bisexuality revisited. New York Times, 5. Copen, C. E., Chandra, A., and Febo-​Vazquez, I. (2016). Sexual behavior, sexual attraction, and sexual orientation among adults aged 18–​44 in the United States: Data from the 2011–​2013 National Survey of Family Growth. National Health Statistics Reports (88), 1–​14. Dahlhamer, J. M., Galinsky, A. M., Joestl, S. S., and Ward, B. W. (2014). Sexual orientation in the 2013 National Health Interview Survey: A quality assessment. Diamond, L. M. (2008). Sexual Fluidity. Harvard University Press. Dodge, B, Herbenick, D, Friedman, M. R., Schick, V., Fu, T-​C., Bostwick, W., Bartlett, E., Munoz-​Laboy, M., Pletta, D., Reece, M., and Sandfort, T. (2016) Attitudes toward bisexual men and women among a nationally representative probability sample of adults in the United States. PLoS ONE 11(10). England, P., Mishel, E., and Caudillo, M. L. (2016). Increases in sex with same-​sex partners and bisex-​ual identity across cohorts of women (but not men). Socio-​logical Science 3, 951–​970. Friedman, M. S., Marshal, M. P., Guadamuz, T. E., Wei, C., Wong, C. F., Saewyc, E. M., and Stall, R. (2011). A meta-​analysis of disparities in childhood sexual abuse, parental physical abuse, and peer victimization among sexual minority and sexual nonminority individuals. American Journal of Public Health, 101(8), 1481–​ 1494. doi:10.2105/​ ajph.2009.190009 Herek, G. M.  (2002). Heterosexuals’ attitudes toward bisexual men and women in the United States. The Journal of Sex Research, 39, 264–​74.

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Jorm, A. F., Korten, A. E., Rodgers, B., Jacomb, P. A., and Christensen, H. (2002). Sexual orientation and mental health: Results from a community survey of young and middle-​ aged adults. British Journal of Psychiatry, 180(5), 423–​427. Kahn, E., Johnson, A., Lee, M., and Miranda, L. (2018). LGBTQ Youth Report 2018. Report of the Human Rights Campaign.​resources/​2018-​lgbtq-​youthreport Klein, F. (1978). The Bisexual Option. Haworth Press. Maimon, M. R., Sanchez, D. T., Albuja, A. F., and Howansky, K. (2019). Bisexual identity denial and health: Exploring the role of societal meta-​perceptions and belonging threats among bisexual adults. Self and Identity, May 31, 1–​13. Mark, K., Rosenkrantz, D., and Kerner, I. (2014). ‘Bi’ing into monogamy:  Attitudes toward monogamy in a sample of bisexual-​ identified adults. Psychology of Sexual Orientation and Gender Diversity, 1, 263–​269. http://​​10.1037/​ sgd0000051 Movement Advancement Project. (2016). Invisible majority:  The disparities facing bisexual people and how to remedy them.​policy-​and-​issue-​analysis/ invisible-​majority Mustanski, B., Birkett, M., Greene, G. J., Rosario, M., Bostwick, W., and Everett, B. G. (2014). The association between sexual orientation identity and behavior across race/​ ethnicity, sex, and age in a probability sample of high school students. American Journal of Public Health, 104(2), 237–​244. Nichols, M. (1987). Lesbian sexuality: Issues and developing theory., In Boston Lesbian Psychologies Collective, Lesbian Psychologies. University of Illinois Press. Persson, T. J. and Pfaus, J. G. (2015). Bisexuality and mental health:  Future research directions. Journal of Bisexuality, 15(1),  82–​98. Rieger, G., Chivers, M. L., and Bailey, J. M. (2005). Sexual arousal patterns of bisexual men. Psychological Science, 16(8), 579–​584. Rosenthal, A. M., Sylva, D., Safron, A., and Bailey, J. M. (2011). Sexual arousal patterns of bisexual men revisited. Biological Psychology, 88(1), 112–​115. Ross, L. E., Salway, T., Tarasoff, L. A., MacKay, J. M., Hawkins, B. W., and Fehr, C. P. (2018). Prevalence of depression and anxiety among bisexual people compared to gay, lesbian, and heterosexual individuals: A systematic review and meta-​analysis. The Journal of Sex Research, 55(4–​5), 435–​456. Savin-​Williams, R. C. (2009). The New Gay Teenager (Vol. 3). Harvard University Press. Savin-​Williams, R. C. (2017). Mostly Straight:  Sexual Fluidity among Men. Harvard University Press. Sprott , R. and Hadcock, B. B. (2018). Bisexuality, pansexuality, queer identity, and kink identity. Sexual and Relationship Therapy, 33(1–​2), 214–​232. Taylor, P. (2013). A  Survey of LGBT Americans:  Attitudes, Experiences and Values in Changing Times. Pew Research Center. Vrangalova, Z. and Savin-​Williams, R. C. (2012). Mostly heterosexual and mostly gay/​ lesbian:  Evidence for new sexual orientation identities. Archives of Sexual Behavior, 41(1), 85–​101.



s we’ve established, given that people who identify as bisexual outnumber those who identify as gay men or lesbians, you are likely to encounter many in your practice. Given that bisexual people are much less likely to be ‘out’ than lesbians or gay men, you are likely to not know which of your clients are bisexual. One way to remedy that is to make sure your initial client paperwork asks for sexual orientation and gender identity and includes many options, for example, ‘sexual orientation’ should allow someone to check heterosexual, gay, lesbian, bisexual, pansexual, asexual, queer, and ‘other,’ at a minimum. When a client indicates they are bisexual or pansexual, ask about it, and if they have a partner, ask the partner how they feel about being in a relationship with a bi person. Remember that your bisexual clients, statistically, will be more likely than gay, lesbian, or heterosexuals to have suffered from depression, anxiety, suicidality, or substance abuse. And be mindful of the overlap between the kink, consensual nonmonogamy, and transgender communities. In addition, you need to find out your client’s personal definition of bisexuality. Very few people are literally 50–​50 bisexual, that is, with exactly equal attraction to males and females. Some people who define themselves as bisexual will tell you they are more attracted to one gender than another; some will say that the nature of their attractions are different for men and women; some feel they need to have both a male and a female partner at the same time; others are serial monogamists. Some will say they are attracted to personal qualities, not gender; others, to aspects of gender presentation not necessarily confined to one type of body. For example, I have realized that I am attracted to ‘butch’ presentations from male, female, and trans bodied people. So, my ‘orientation’ is to typically masculine male-​bodied people,

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‘butch,’ or ‘dyke’ female-​bodied people, and trans men and some nonbinary individuals. Finally, you need to know what the ‘bisexual’ identity is freighted with for your client. Some people will embrace their identity, while others are conflicted about being bisexual. Case Vignette Preston struggled to come out as gay until his mid-​20s. In law school he had a female partner whom he loved very much, but since adolescence his strongest sexual urges had been for boys and men. Gail, a more recent partner, ended the relationship when she became aware of the strength of his attractions to men, and when Preston could not assure her that he wasn’t eventually going to want a full-​time relationship with a man. Preston’s next partner was a man, and for a time he was satisfied in a marriage-​like commitment with Randy. When they opened the relationship after two years, Preston found, to his dismay, that he was attracted to a female lawyer at his firm and that, when he consummated the relationship, the quality of the sex was as good as his sex with men. At this point, Preston began therapy with a gay male colleague. In the first session, Dan suggested that Preston might be bisexual, not gay. ‘No!’ Preston insisted. ‘I don’t want to be bisexual, I don’t want to be with a woman. I’m gay!’ He went on to explain, ‘I’ve always been the kind of person that belonged to clubs. When I was a kid, I loved being a Boy Scout, in college I was in a fraternity. I like the feeling of being part of a group. I want to belong to the gay club, there is no bisexual club. And if I’m with a woman I’ll be seen as heterosexual.’ Preston ultimately came to view his orientation as different from his identity. He realized he could be as strongly sexually attracted to certain women as he could be to men, although his most common attractions were to men. He knew he could fall in love with both men and women. But Preston chose to consciously suppress his attractions to women because, as he said, he wanted to belong to the gay club. Preston ended the relationship with the female lawyer and has been sexually active only with men since then. He ultimately left his law firm for a private practice of almost exclusively gay men and lesbians as clients, and became one of the attorneys known for his work advocating for marriage equality. In Preston’s case, the gay identity meant far more than simply the gender of who you are with. It signified a community, a lifestyle, a belief system, ultimately a career, and these things were of equal or more importance than sex. As we wrote about in Chapter  12, bisexual people have higher rates of mental disorders than gay men or lesbians. Earlier in the book we discussed the concept of minority stress as a factor in creating emotional/​psychological disturbances. In addition to the stress created simply by being ‘non-​ heterosexual,’ bisexual women and men must cope with highly negative attitudes from both queer and mainstream society, and invisibility and/​or

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denial from those around them who are supposed to support them. And at least one study has directly linked invisibility/​denial to bisexual subjects feeling less connected to community and more depressed and anxious (Maimon et al., 2019). Finally  –​it can be confusing to be bisexual. Tim was a 42-​year-​old man who came to see me, distressed because he felt the turns and twists of his sexuality were wreaking havoc with his life. Up until his mid-​20s he had thought of himself as bisexual, and even as a teenager he was sexually active with both boys and girls. But then, suddenly, around his 29th birthday, he found himself strongly attracted to men –​and only men. Tim was baffled by his sudden apparent change in orientation, but thought to himself, ‘Maybe everyone is right and it was just a phase.’ Tim eventually moved in with Jeff, and they were partners until Tim was 41. After that relationship ended, Tim suddenly experienced another shift in orientation. He fell in love with a woman in his Tai Chi class, and at the same time lost interest in men. He came to me for reassurance that he wasn’t crazy and to help him sort out his direction. Tim’s version of bisexuality isn’t that common, but it does exist. There are people who experience apparently sudden, abrupt changes in their orientation, and it can be very distressing. We will discuss this more when we talk about sexual fluidity. Case Vignette The stress of invisibility and denial appears subtle but it is powerful enough to destroy self-​confidence and induce shame. Alicia was 14 when she was ‘discovered’ in a Manhattan pocket park by someone walking by who worked at a modeling agency. At the time she was just beginning to explore her own attractions, and the intensely sex-​and drug-​fueled world of high fashion provided a place she could try out sex and relationships with both men and women, often in a self-​destructive way. Alicia developed a cocaine problem by age 16. Her parents swiftly intervened, withdrew Alicia from modeling, and put her in a rehab facility. Alicia overcame her dependency but within a few years she resumed drinking and doing ‘softer’ drugs, and by her mid-​20s it was clear she was prone to periods of excessive alcohol use. Alicia’s family could never comprehend her bisexuality. They alternated between telling her she was just trying to avoid ‘the truth’ of her homosexuality and assuring her she was really heterosexual and her attractions to women had just been a phase. Alicia’s only live-​in relationship, with a woman, occurred while she was attending art school in California, so her East Coast Italian extended family never even met her partner. Back home, she felt more at home in the queer community of New York, but her lesbian friends seem to cool off when she dated a man. Alicia came to see me to help learn to control her drinking but also to examine her complicated feelings about bisexuality. At the time she was 34,

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feeling pressure from her family to ‘settle down’ and get married –​to a man ‒ and feeling pressure from her queer support system to get a girlfriend. At first, Alicia didn’t think her problems were in any way related to her bisexuality. But as we explored her drinking behavior she realized she drank to self-​ medicate, and when she started to identify the triggers to drinking, it became apparent that some of the triggers were instances where Alicia felt discredited, disrespected, ignored, or disbelieved regarding her sexual orientation. This recognition sparked anger in Alicia. She recognized that much of her depression was part of a cycle where she felt invalidated and where even her anger about being invalidated was disallowed. This resulted in shame, and ultimately depression, which she avoided by drinking. I validated Alicia’s anger as well as the underlying feelings of pain and betrayal at the way she was being treated by those who were supposed to be accepting and supporting her. I noted her isolation. Despite a large, extended family and a far-​ranging friend group, Alicia felt there was no one who truly ‘got’ her. I recommended that she contact some specifically bisexual groups. When she encountered the online Facebook group of the New  York Area Bisexual Network, she found these words on their ‘About page’: Tired of feeling like an after-​thought (or worse, a joke) to the mainstream #LGBT+ Community? Wish there was a place that talked about our issues and concerns? Looking for things to do where we can just be ourselves? Alicia immediately felt encouraged. She joined the group and eventually navigated her way to some bisexual events in the area. This helped her immensely, not only because she felt less alone, but also because she could surround herself with people who acknowledged her sexual orientation and didn’t try to ignore or dismiss it. The greater difficulty was her family. No matter how hard she tried, she couldn’t get her parents or even her siblings to understand or accept her bisexuality. They were not hostile –​they just couldn’t take it seriously, and couldn’t really understand why Alicia was so bothered by their reaction. Eventually, in therapy we worked toward Alicia accepting that she would never have the supportive family she wanted. She learned to appreciate them for the love they could give, and to not focus so much on what was beyond their capabilities. Alicia did, however, cull and change her friendship group. She reasoned that she couldn’t choose her family but she could select her friends. One by one Alicia had a ‘talk’ with all her friends, explaining why it was so important to her that they neither deny nor invalidate her orientation. Some had difficulty with this –​ and Alicia removed them from her support group. By the end of treatment, Alicia had some new friends she had met through NYABN (The New York Area Bisexual Network), her ‘old’ friends were on board with her bisexuality, and she had put up some protective walls around her relationships with her family.

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Case Vignette Invisibility and stigma can also negatively affect ‘mixed-​orientation’ same-​sex couples. Julie, age 35, and Dorothy, age 38, came to therapy to repair their ailing relationship. They were together for seven years but the last two had been difficult, with frequent bickering and infrequent sex. The arguments the women had were over trivial concerns; both knew that, yet they could not control the venomous fights that ensued over apparently unimportant issues. We used the couples dialogue developed by Imago Couples counselors to deconstruct some of the fights and attempt to uncover deeper issues that were at the core of their differences. During one therapy session, we explored why Dorothy was so full of rage when Julie had failed to notice a new hair style. As Dorothy spoke, and Julie ‘mirrored’ her words, at one point I  prompted Dorothy with a sentence stem, ‘And what hurts me about this is …’ The prompt elicited far more than I expected. After a short pause, Dorothy burst forth with, ‘What hurts me about this is it’s just like how you refuse to acknowledge that I’m bisexual. You won’t even tell our friends I’m bi, and you don’t want me to tell anyone either. It’s like either you can’t see me or you are ashamed of me.’ Although I knew from initial interviews that Dorothy identified as bisexual, it had never come up in couples sessions before. It emerged that Dorothy’s bisexuality had in fact been an issue at the beginning of the relationship. The two women dated for several months before Dorothy revealed her orientation to Julie. Julie’s initial reaction was anger at Dorothy’s deception –​and fear of contracting a sexually transmitted disease! This tension eased a bit when it became clear that neither women had sexually related health issues, and when Dorothy assured Julie that she was bisexual in orientation, but monogamous in practice. Dorothy at one point expressed a desire to be ‘out’ as bisexual, but Julie responded, ‘Why would you want to do that? You’re in a lesbian relationship now and you’re not looking to hook up with a man. It will only cause problems –​lots of women mistrust bisexuals, and I don’t want people looking weird at us or feeling sorry for me because they assume you’re going to leave me for a man.’ Dorothy saw the logic in Julie’s position and acquiesced. For years, the two women almost never discussed the issue of Dorothy’s sexual orientation, until it came out in that session via couples dialogue. Julie had a very hard time empathizing with Dorothy’s perspective. She saw Dorothy as a lesbian who had had sex with men in the past –​like lots of other gay women. By viewing Dorothy this way, Julie protected herself from fears that her partner would leave her, and she rendered irrelevant the issue of Dorothy’s ‘coming out.’ Julie was objecting to taking on what has been called ‘courtesy stigma’  –​the stigma that accrues to an individual because someone close to them is a member of a marginalized group. The desire to avoid courtesy stigma is at the root of many people’s difficulty in accepting an LGBTQ+ partner, family member, child, or friend. Julie felt she needed the support of the lesbian

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community to protect her from the stigma of being gay. She was not prepared to take on another identity –​partner of a bi woman –​that might alienate her from her support system. As therapy progressed, Julie was able to identify these fears and challenge their rationality; as she did so, she was better able to empathize with Dorothy’s need to be ‘visible.’ The two women first ‘came out’ about this to a couple of close friends who, to their relief, were accepting and supportive. Eventually, Dorothy told all their friends, and not only did she get very few negative reactions, one friend confided that they, too, were bisexual and hiding it. While this did not solve all the problems in the women’s relationship, it helped a lot and brought them closer. When they ended therapy, Dorothy was attending a monthly support group for bisexual lesbians at New York City’s Lesbian and Gay Center. Mixed-​orientation Couples –​When One Couple is Bisexual As we mentioned in the chapter on gay male couples, so-​called ‘mixed-​ orientation’ couples where one partner is heterosexual and the other gay or bisexual are surprisingly common (Hernandez, Schwenke, and Wilson, 2011). In part, this is because of the difficulties gay men and lesbian women face in coming out to themselves and others, and their desire to attempt to live a ‘normal’ life. We do not know how many of these couples exist. A figure commonly cited is 2 million, but that is an estimate from a 2004 paper by Buxton; he derived that estimate by calculating the number of gay men and lesbians who were married. It is safe to assume, however, that the number is declining, because as the stigma against homosexuality decreases, fewer individuals will feel compelled to hide behind an inauthentic relationship. Clinically, at IPG we see far fewer couples like this today than we did in the 1980s. And more of the mixed-​orientation couples we see entered into the relationship with full openness about the one partner’s bisexuality. In this section, I  discuss issues of couples where the disclosure of one partner’s bisexuality comes after the marriage has been established, and it comes as a shock to the heterosexual partner. While many ‘mixed-​orientation’ couples are comprised of one gay and one straight partner, many include a straight and a bisexual member. We have no data about the breakup rates of couples with a gay versus bisexual partner. However, when one partner is bisexual, as opposed to gay, the bisexual partner is often genuinely in love with and attracted to their straight spouse, which makes staying together in a meaningful marriage a more viable possibility. Estimates are that about a third of mixed-​orientation marriages stay together after disclosure to the straight partner, and about half of these who stay last for three or more years (Hernandez, Schwenke, and Wilson, 2011) and it is likely that many of these relationships are bi/​straight rather than gay/​straight

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partnerships. Few studies have actually compared couples where a partner is bisexual rather than gay. Buxton (2004) looked at couples where the wife was either lesbian or bisexual, and did find some differences: bisexual wives were more likely to give ‘love’ as their reason for staying in the marriage while lesbian wives were more likely to say that financial considerations were paramount. All of the research on couples who stay together, however, suggest that open, honest communication, support from family and peers, and having a closely bonded marriage before disclosure are factors that increase resiliency for the couple. Usually, the disclosure itself is the first and perhaps most serious crisis the couple may face. Moreover, most bi/​straight marriages that stay together remain sexually active, and the sexual connection also serves to enhance intimacy. Some couples negotiate consensually nonmonogamy after disclosure, other use a ‘don’t ask/​don’t tell’ approach, and some remain monogamous. As consensual nonmonogamy becomes more commonplace in the culture at large, it will be interesting to see how this impacts mixed-​ orientation marriages. As a clinician, it is important that you be open-​minded yourself about how the couple decides to negotiate their relationship. Researchers who study these marriages have noted the difficulties that partners report in finding a counselor who is knowledgeable and who does not have pre-​conceived ideas about the outcome of the marriage. Initially, if you are working with a couple shortly after the bisexuality has been discovered, you are helping calm a crisis and, in particular, helping the heterosexual partner cope with the shock, pain, and anger they feel in a situation similar to when an affair has first been revealed. Once the immediate crisis has resolved, you must help decide on the path forward. This may not be possible without both partners having some individual therapy. The bisexual partner may have already done work to determine whether he or she wants to remain married and how they feel about monogamy. The heterosexual partner may need some time to sort this out. However, when the love and bond between the two are strong, this kind of couple has a fighting chance of keeping the marriage viable and happy, for both partners. Case Vignette Leo and Delia are typical of the kind of mixed-​orientation marriage where the heterosexual partner is unaware of their partner’s orientation. Leo was aware of attractions to men from the time he was a teen, but he resisted these impulses. He was raised in a conservative family, was popular and good-​looking as a child and young man, and he did not want to suffer the social stigma associated with being gay. Moreover, he was also attracted to some women. He met Delia when both were in their early 20s and they fell deeply in love with one another. They married and for 15 years had a reasonably successful marriage, with two

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children and a close community support system in the suburban town in which they lived. Although Leo was still attracted to men, he never acted upon those urges and they did not appear to intrude upon his feelings for Delia. But when both were in their late 30s, Leo found his sexual desires for men growing stronger and harder to resist. As midlife approached, Leo found himself musing more and more about what it would be like to have male partners. He started to find excuses to go by himself to a nearby town that had a gay bar. On one of those occasions he met a man to whom he was strongly attracted, and Leo had ‘gay sex’ for the first time. Soon after, he was overcome with guilt and decided to reveal himself to Delia. Delia reacted with shock, anger, and despair, and declared her desire to divorce. When Leo pleaded with her, Delia agreed to go to couples counseling and the couple found IPG. We recommended some individual counseling for each of them as well as couples sessions; the marital therapy was postponed while each struggled to sort out their own feelings. Leo had to decide how important it was to have sexual relationships with men. He maintained that he loved Delia and did not want a male spouse, but it was difficult for him to resist his sexual desires. Before she could decide what she wanted to do about her marriage, Delia had to work through her anger about Leo’s betrayal, her shock and confusion about how she could have been deceived for so many years, and her grief about losing the marriage she thought she had. For a ‘straight spouse,’ finding out the truth is a genuine trauma. Delia was referred to the Straight Spouse Network, mentioned in Chapter 9. One of the worst problems spouses like Delia face is isolation. Many feel ashamed of their situation and have no one with whom they can share their feelings. Many feel they are the ‘only ones’ this has ever happened to. SSN provides this support without judgment. Most ‘straight spouses’ are women with gay/​bi male partners, but about a fifth are men married to lesbian or bisexual women. Among other things, the website contains personal stories of spouses, which help women like Delia feel less isolated even if they do not have a physical support group to attend. After several months of individual work, Delia and Leo started sessions together. Their therapist first needed to educate them both about bisexuality, about the difference between being bisexual versus being entirely gay, and about the fact that bisexuality did not preclude monogamy. Both Leo and Delia seemed to equate Leo’s sexual orientation with a need to have two partners at the same time. Their therapist was clear that Leo’s bisexuality was independent of a decision to be monogamous or not, and that allowed Delia to be assertive with her husband. If he could not be monogamous, she would not stay. Leo wrestled with this decision but concluded that his relationship with Delia and the life they had created together was more important than continuing his explorations with men. Delia and Leo’s marriage had a better chance of survival than most because Leo was genuinely sexually attracted to Delia and their sex life had been good before disclosure. At the end of treatment, the couple

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remained married. They both had their doubts about the long-​term possibility for their relationship, but they were committed to openness and honesty, and this allowed Delia to regain the trust for Leo that she needed to remain. Takeaways for the Clinician Counseling Bisexual Clients Bisexuality is extremely common  –​more common than being exclusively gay or lesbian –​but there are an infinite variety of ways to be bisexual. As a therapist working in an LGBTQ+ affirmative way, your sensitivity to bisexuality begins with your initial questions about identity and sexual orientation. Offer your clients options to describe themselves, not only as gay or lesbian, but as bisexual, pansexual, sexually fluid, or ‘do not label myself.’ Next  –​ find out what the identity label means to that particular person by asking and by taking a careful history of sexual behavior and sexual and romantic attractions. Be aware that your bisexual client may themselves need psycheducation about bisexuality, especially if they are still struggling with their identity. Be sensitive to the ‘double jeopardy’ bisexuals face in terms of stigma and discrimination both from the culture at large and the LGBTQ+ community. You should know the resources, such as support groups, in your community for bi/​pansexual people. Assess your bisexual clients carefully for depression, anxiety, and substance abuse, knowing these problems are more common than for the straight or lesbian or gay people you see. If your client is in a relationship, there may be particular issues for the partner. You may need to educate partners and also family members, who may see bisexuality as ‘not real’ or ‘a choice.’ References Buxton, A. P. (2004). Works in progress: How mixed-​orientation couples maintain their marriages after the wives come out. Journal of Bisexuality, 4(1–​2),  57–​82. Hernandez, B. C., Schwenke, N. J., and Wilson, C. M. (2011). Spouses in mixed‐orientation marriage: A 20‐year review of empirical studies. Journal of Marital and Family Therapy, 37(3), 307–​318. Kays, J. L. and Yarhouse, M. A. (2010). Resilient factors in mixed orientation couples: Current state of the research. The American Journal of Family Therapy, 38(4), 334–​343. Maimon, M. R., Sanchez, D. T., Albuja, A. F., and Howansky, K. (2019). Bisexual identity denial and health: Exploring the role of societal meta-​perceptions and belonging threats among bisexual adults. Self and Identity,  1–​13. Yarhouse, M. A., Gow, C. H., and Davis, E. B. (2009). Intact marriages in which one partner experiences same-​sex attraction: A 5-​year follow-​up study. The Family Journal, 17(4), 329–​334.

14 ‘ACES AND AROS’ Asexuals, Aromantics, and Other Variations on a Theme


couple of years ago I received a call from a former client. Antoine and his wife had been in sex therapy with me some eight years before. This had been an ‘unsuccessful’ case: they had a sexless marriage, indeed, an almost entirely sexless relationship, and I  was unable to help Antoine revive what seemed to be his nonexistent sex drive. Usually therapists don’t ever find out what happens long term to their clients. I  was grateful that Antoine called. ‘I’m asexual!’ he proclaimed over the phone. I just wanted to let you know that that was the issue. I never realized it before, but once I started to learn about asexuality, I just knew it was me. I’m much happier now, and my wife feels better because she knows my lack of sex drive has nothing to do with her. Antoine’s phone call changed my practice. From that time on, I  have viewed clients with low or no sex drive differently. His experience is a perfect example of how discovering and embracing an identity can help heal someone. He is also an example of the proliferation of sex-​and gender-​diverse identities in the twenty-​first century. OK Cupid, the popular dating site, allows users a choice of 12 different sexual orientations, including bisexual, pansexual, and sapiosexual. It also allows the user to choose up to five of those 12 to describe themselves. A Google search for ‘sexual orientation types’ yields results advising you of 17 varieties, dozens of orientations, and terms like ‘demisexual,’ ‘aromantic,’ and ‘multisexual.’ Before we consider asexuality as an identity, let’s try to make sense of this larger trend. How did we get from

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‘straight vs. gay’ to this? Asexuality is the poster child for the cultural forces involved in the creation of new identities. What Is Identity? Let’s refer back to the beginning of this book. Some trends that started in the twentieth century that are gaining more importance in the twenty-​first are the move toward ‘identity politics,’ the trend toward considering attributes formerly considered disabilities or disadvantages as identities, and the desire to live ‘authentically.’ Let us first consider identity. The American Psychological Association defines identity as: an individual’s sense of self defined by (a) a set of physical, psychological, and interpersonal characteristics that is not wholly shared with any other person and (b) a range of affiliations (e.g., ethnicity) and social roles. All individuals have multiple identities:  I am a white bisexual cisgender female, a mother, a psychologist, someone with Italian heritage, a Baby Boomer  –​to name a few. Some aspects of identity are not chosen, for example, my Italian heritage, the generation into which I  was born, while others are, such as being a mother or a psychologist. Identity serves multiple purposes: it is how we distinguish ourselves from others, it provides us with a sense of continuity over time –​and it tells who/​what our affiliations are. Although identity changes throughout the life cycle, as the work of the psychologist Erik Erickson first established, adolescence tends to be the most salient time for identity formation and consolidation. Paradoxically, those aspects of self which are most socially stigmatized are often the most important components of identity. Each individual must reckon with those aspects of self which are socially stigmatized. They can deny or hide that portion of the self; they can acknowledge it but internalize the stigma as poor self-​esteem; or they can acknowledge the problematic quality/​attribute and come to accept or feel pride in it. When an aspect of identity is socially stigmatized, there is powerful incentive to hide it in order to maintain valued social connections. However, another option is available for many characteristics. Over the past 50 years we have seen social movements emerge whose purpose is to de-​stigmatize formerly denigrated social categories. These categories include ethnic and racial categories, sexual and gender identities, and physically based identities such as deafness or neuroatypicality. Increasingly, individuals who possess these attributes are motivated, not only not to hide them, but to assert them proudly as cherished characteristics and to affiliate with others who share them. In this way, these individuals combat internalized shame derive social support –​and feel they are living their lives authentically.

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The Asexual Identity Asexuality is a prime example of the creation of an identity that de-​stigmatizes something formerly considered a ‘disorder.’ In fact, the errors I  made in the treatment of Antoine and his wife stemmed from the assumption that ‘lack of sex drive’ is a sexual/​mental health dysfunction, specifically, HSSD (hypoactive sexual desire disorder). As a psychologist and sex therapist, I was taught that sexual desire is a normal human drive, but it was implied not only that it was normal, but that the absence of this drive was pathological. Asexuals have turned this idea on its head. Interestingly, biologists have long known that asexuality occurs with regularity in the animal kingdom. For example, lab-​based animals such as rats are noted for their sexual variability, with some designated ‘studs’ –​the highly sexual ones –​and others ‘duds,’ asexuals uninterested in sexual contact. As high as 12% of rams have been observed to be completely asexual. It is much harder to determine the prevalence of asexuality in human history because the absence of sexual behavior is not necessarily an indicator of asexuality. Especially given the fact that many cultures and religions have valorized celibacy as an advanced spiritual state, it is impossible to determine the motives of people who are known to have abstained from sexual behavior. Asexuality was mentioned by Kinsey in his work in the 1940s and 1950s; in fact, he had a category ‘X’ that was added to his famous Kinsey Scales that designated asexuality. In 1979, Michael Storms proposed a two-​dimensional model of sexuality that included a category for lack of orientation toward males or females  –​essentially, asexuality (Storms, 1980). But otherwise, asexuality was ignored by sexologists and the general public. Until the advent of the Internet, asexual people had no way to connect with others like them. In the late 1990s, an online asexual community began to emerge, and in 2001 David Jay, an asexual activist, started AVEN, the Asexual Visibility and Education Network, which remains the primary website and point of contact for asexual people ( Asexuals as a group have affiliated with the larger LGBTQ community, marching in Pride Parades in Great Britain and North America since 2009. The first sexologist to study asexuality was Anthony Bogaert who, in 2004, published a paper based on a British survey that showed a little over 1% of people identified themselves as asexual. Since then Bogaert and others, like fellow Canadian Lori Brotto, have published on this topic, but there is little hard data on this population (Bogaert, 2015; Brotto, 2017). Within the field of sexology, there has been much controversy about asexuality. In fact, most of the articles in the scientific literature are about ‘what’ it is; researchers have variously taken the position that asexual people are simply suffering from hypoactive sexual desire disorder, that asexuality is a type of fetish, or that it is an actual ‘orientation,’ with the predominant view that it

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is an orientation, that is, a legitimate and distinct sexual identity. There has even been push-​back against the concept of an asexual identity from within the gay community. Dan Savage, an iconic gay sex and relationship guru, said this about demisexuality (a type of asexuality where the person only develops sexual attraction for someone after a strong emotional bond has been formed): We used to call people who needed to feel a strong emotional bond before wanting to fuck someone people who, you know, needed to feel a strong emotional bond before wanting to fuck someone. But a seven-​syllable, clinical-​sounding term that prospective partners need to Google  –​ demisexuality –​is obviously superior to a short, explanatory sentence that doesn’t require Internet access to understand. Despite the skepticism of some, many asexual people find a home within the larger LGBT+ community. The British survey described by Bogaert is to date the only large probability sample of the general population that has indicated the proportion of people who identify as asexual. Rothblum et al. (2019) published a study of a population-​based sample of only LGBQ people and found 1.7% of ‘queer’ people identified as asexual. The 2018 Human Rights Campaign Youth Report of 13–​17 year old LGBTQ identified people found 5% identified as asexual and another 0.5% identified as demisexual. It appears that younger LGBTQ+ people may be more inclined to identify as asexual (Kahn et al., 2018). The definition on the AVEN website is:  ‘an asexual person is a person who does not experience sexual attraction.’ Research with asexually identified women has shown that their genital responses to sexual stimuli are similar to responses from non-​ asexual women, but asexual women do not experience themselves as sexually aroused to this stimuli, that is, they experience genital arousal without the internal psychic experience of being ‘turned on.’ Most asexual people have had sex, if only to ‘test the equipment,’ before realizing they are asexual. Asexual men and women do not find sex disgusting or repulsive, and some have sex with sexual partners and are capable at times of enjoying sex. Many asexual people masturbate for relaxation or tension relief. Many report a self-​discovery process similar to that of LGB people: feeling ‘different’ from an early age, questioning their identity, finding their first support from online communities, concealing their feelings for a period of time, and eventually ‘coming out’ to themselves and then others about their asexuality. There appear to be more asexually identified women than men, possibly by as much as 2:1, and as indicated earlier, compared to the LGBTQ population in general, they are younger. For Antoine, described in the beginning of this chapter, the asexual label was liberating, explaining a personal characteristic that had previously made him feel deficient, defective, and abnormal.

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Many asexual people are in relationships, and some are in relationships with sexual people. Asexual people can be romantically attracted to other people. Indeed, many if not most experience these attractions, but without a sexual component, and many ‘aces,’ as they call themselves, define a sexual orientation for themselves based on their romantic attractions. Some asexual people identify as aromantic as well, meaning that they do not experience romantic attractions either. A 2008 survey done by AVEN found that only 17.5% of respondents classified themselves as aromantic (‘aros’); 31.4% were hetero-​romantic, 6.5% homo-​erotic, and the rest held some kind of bi or pan romantic identity. There are a number of sub-​groups under the asexual umbrella. People may define themselves as asexual and aromantic or as asexual and either heteroromantic, homoromantic, or bi or panromantic. They may identify as demisexual, meaning they are only capable of sexual attraction when in a strong, emotionally connected relationship; or as ‘gray-​A’ or gray asexual, meaning they only occasionally experience sexual attractions to people. Gray-​a’s may perceive their sexual orientation as more fluid, with periods when they have sexual attractions and other times when they don’t. It could be argued that people who identify as ‘gray-​a’ are no different from non-​ asexual people who happen to be going through a period where no one catches their fancy. Indeed, with both demisexuals and gray-​asexuals, it is not clear whether we are talking about a substantive difference or a difference of degree. The salient issue is that, for various reasons, the demi or gray-​a considers asexuality an integral part of their identity. This is of clinical significance: when working with someone who identifies this way, it is important to find out why asexuality is so primary. When Cary, a young trans man told me he was asexual but panromantic, I understood that he meant that he experienced no sexual attractions but had ‘crushes’ on males, females, and transgender people. His asexual identity freed him from feeling pressure to be sexual with his partners. Further, because asexual men and women are not necessarily aromantic, they can be polyamorous, meaning they are interested in having multiple romantic partners at the same time, even though they might be sexual with none of them. Moreover, some asexual people can enjoy physical/​sexual/​ sensual sensations without experiencing sexual attractions to a particular person. Thus they may masturbate –​or, they can they can be interested in BDSM activities, which do not necessarily involve genital sexuality. Attitudes and Beliefs about Asexuality Asexual people suffer from invisibility even more than bisexuals. Unless they ‘come out,’ they are seen as ‘like everyone else,’ or, if they do not have relationships, as single people who haven’t yet found the right partner. While

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research suggests they ‘come out’ frequently to close friends and family, they are less likely to come out to health care providers. One reason for this is undoubtedly that most of us, including therapists and sex therapists, unconsciously project the attitude that sex drive is a universal human characteristic. Even the assessment questions we ask display this bias. Questions like: ‘Are you attracted to men, women, or both?’ ‘Have you been sexually active with men, women, or both?’ do not allow for an asexual option, and they subtly convey a sense that asexuality is not normal. It is not surprising that many asexual people simply stay quiet about their orientation; they are subject to anti-​asexual attitudes on a daily basis. They are routinely told that they are just going through a phase, that they haven’t met the right man/​woman yet, that they will grow out of this, that they are just depressed, that they have intimacy issues, or that they are suffering from a sexual dysfunction. Asexually identified people do not report unhappiness or distress about their orientation, but they frequently report distress about how they are regarded by others. The experience Antoine had in my office is common. Antoine never questioned my assessment that he suffered from low or inhibited sexual desire, and therefore was willing to subject himself to a number of psychotherapeutic interventions aimed at ‘curing’ his problem. In the long run, all my treatment did was to further shame Antoine about his own asexuality while wasting time trying to solve a problem that did not exist. Asexuality is not the same as ‘hypoactive sexual desire,’ it is not an abnormality of genital or hormonal functioning, and it is not a result of trauma or early sex-​negative conditioning. It is not an avoidance of intimacy: many asexual people have romantic relationships and/​or marriages, and even those who are aromantic have close friendships and family relationships. It is not a manifestation of mental illness or a sign of overall unhappiness. For example, the Rothblum et al. (2019) research comparing asexual and nonasexual LGB people showed similarity in general well-​being, life satisfaction, and social support, including experiences of intimacy and sense of connection to the ‘queer’ community. In the Rothblum study, however, asexual people reported that they felt more stigma about their identity than did gay, lesbian, or bisexual respondents. Working with the Asexual Client As a clinician, how can you work with this population? First, examine your own biases about sex and love. Do you believe that people need to be sexual to be healthy and happy? Or that they need to be in partner relationships? Do you believe that sex and romance are inextricably intertwined? If so, you need to question your own beliefs. Second, you need to start asking questions and doing assessments in a way that ‘allows’ people to be asexual. Include asexuality in your list of possible sexual orientations on the forms you use and the information you gather about new clients. Be alert to people

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who report little or no sexual experience –​but also seem unclear or vague about their attractions. There is a difference between someone who stopped experiencing sexual attractions after a really rough relationship breakup, and someone who reports few or no sexual attractions in their life. The former may indeed be ‘going through a phase,’ or more specifically, a depression or trauma-​induced lack of desire. The latter may be asexual, and you should not be afraid to suggest this possibility, do some psychoeducation, and refer your client to online resources like the AVEN website. Case Vignette Daniel was a 22-​year-​old man who approached me for help with erectile dysfunction. ‘I’m in a relationship with Erica, and I love her very much. But I find it very difficult to get an erection and have sex, and I never initiate sex, and it’s really upsetting to her.’ From the beginning, Daniel’s lack of sexual desire was striking, and this seemed more a problem of desire than genital function. A visit to a urologist skilled at sexual medicine confirmed that Daniel had nocturnal tumescence and morning erections, two indicators of organic functionality, and no hormonal or circulatory issues that would be contributing to his problem. A sexual history revealed that Daniel did not masturbate until he was 17, that he masturbated infrequently, and that he had had only one sexual partner before Erica, a woman with whom he experienced the same erectile dysfunction. It was only when I asked pointed questions to try to differentiate if Daniel’s attractions to women were sexual or romantic in nature that the truth began to emerge. Daniel was very capable of determining if he found a woman attractive, but when he described what made him feel he wanted to ‘connect’ with a woman, he mentioned only personality characteristics, common interests, or having fun together. He never described any feelings that sounded remotely sexual. Upon further questioning, Daniel admitted that he always felt ‘weird’ when he heard men talk about wanting to have sex with women based on their physical beauty, because he had never had the urge to have sex with a woman he didn’t know, and even in his two relationships, sex was initiated by his partners, not him. He was sometimes able to get an erection when Erica initiated and he reported finding the sexual experiences pleasurable on these occasions, but the pleasure never led to him wanting to have more sexual experiences. Daniel’s initial reaction to my suggesting that he was asexual was negative. Although he did not feel personally bad about not feeling sexual desire, he associated being sexual with being masculine. Moreover, he was afraid he would not only lose Erica, but also his chances of ever having a long-​lasting love relationship –​‘It would make me a freak,’ he exclaimed. I encouraged Daniel to ‘check out’ the AVEN website and did not push further. A month later, Daniel came to a session and announced, ‘I think you were right. I’ve been in some chats with some other AVEN guys, and they sound a lot like me. Not only that,

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some of them have partners and they all feel ok about being asexual. Maybe that’s what I am.’ From that point on, therapy focused on Daniel’s new identity and what it meant for his life. His relationship with Erica did, in fact, break up; she was not prepared to have an asexual partner. But Daniel found that he was able to find some women for whom this was not a barrier, women who themselves identified as asexual or who confided in him that they had sex drives that were pretty low. For these women, their lack of sexual desire had been problematic for them in other relationships, and finding Daniel was something of a relief. Daniel experimented with his own sexuality and his body, and eventually discovered that he was able to have erections occasionally under certain circumstances and with abundant stimulation, and that he could have partners who were satisfied with a relatively quiet and infrequent sex life. Takeaways for the Clinician Asexuality is a perfect example of the convergence of various twentieth-​ and twenty-​first-​century social trends discussed in the beginning of this book: sexual liberation, the proliferation of horizontal, rather than vertical, identities, the push for authenticity, the tendency to redefine ‘disabilities’ or ‘illnesses’ as identities, and the expansion of the LGBTQ community. As clinicians and sexuality professionals, we have a lot to learn from asexual people. To begin with, asexuals make it clear that sex is not a universal human drive and that sex is not necessary for a happy life –​or even a happy relationship! We also see from the asexual experience that sexual desire and romantic love are not inextricably linked. It is fairly common knowledge that people can experience sexual attraction without love. What is less understood is that it is possible to be in love with someone without feeling sexually attracted to them. Sexless relationships are often denigrated by others as ‘just friendships’ or ‘just roommates,’ but many are much more and involve a level of intimacy and commitment equal to that found in marriages or other more traditional pairings. Finally, asexual people who are also aromantic, or asexuals who choose not to be in partner relationships, are showing us that not all people need to be in an intimate partner relationship to be happy. These are important lessons for mental health and sexuality professionals to embrace. References American Psychological Association Dictionary. https://​​identity AVEN 2008 report.​?q=2008_​stats.html Bogaert, A. F. (2004). Asexuality: Prevalence and associated factors in a national probability sample. Journal of Sex Research, 41(3), 279–​287. Bogaert, A. F. (2015). Asexuality: What it is and why it matters. Journal of Sex Research, 52(4), 362–​379.

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Brotto, L. A. and Yule, M. (2017). Asexuality: Sexual orientation, paraphilia, sexual dysfunction, or none of the above? Archives of Sexual Behavior, 46(3), 619–​627. www.​life/​963961/​savage-​love-​demisexuality-​real Kahn, E., Johnson, A., Lee, M., and Miranda, L. (2018). HRC 2018 LGBTQ Youth Report. Report of the Human Rights Campaign.​resources/​2018-​lgbtqyouth-​report Rothblum, E. D., Krueger, E. A., Kittle, K. R., and Meyer, I. H. (2019). Asexual and non-​ asexual respondents from a US population-​based study of sexual minorities. Archives of Sexual Behavior, 49,  1–​11. Savage, D. (2017). Savage love: is demisexuality real? Savage Love Column, Stranger, 13 September 2017. Storms, M. D. (1980). Theories of sexual orientation. Journal of Personality and Social Psychology, 38(5), 783.



reena’s story was one that was familiar to me. ‘I don’t know what I am,’ she said.

I always assumed I  was straight. I  dated guys in high school and college, had sex with a few. All my crushes were on guys. I married Saul ten years ago, our sex life is good, I never thought twice about it. I have friends who are gay and that’s fine, I just never thought it applied to me. Then I started taking yoga classes at my gym, and I met Nora. At first we were just friends. We got closer and closer, and spent more and more time together. And then I fell in love.

She continued, ‘I’m completely confused. What does this mean? I didn’t think people could change their orientation. Am I gay now?’ Breena is an example of someone whose sexual orientation was context-​ specific. In certain situations –​like the intimate relationship with Nora –​she is capable of being attracted to women, even though her dominant orientation is toward men. Breena, like some others I have described in this book, is sexually fluid. Lisa Diamond (2008), whose worked was described in Chapter 5, set out originally to study bisexuality and to determine if it was, as widely believed at the time, a temporary stage of denial or transition. Diamond followed 79 lesbian, bisexual, and ‘unlabeled’ women for ten years. Over this time, two-​thirds of the women changed the identity labels they had claimed at the beginning of the study, and one-​third changed labels two or more times. However, more women adopted the bisexuality or unlabeled identity over time than relinquished them, and few of the bi/​unlabeled women adopted

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lesbian or heterosexual identities. Diamond’s research not only disproved the ‘temporary stage’ theory of bisexuality, it documented the prevalence of something previously believed impossible: sexual fluidity. We discussed sexual fluidity in Chapter 5. Here we consider it in the light of new sexual identities, especially pansexuality. Until Diamond’s research, the prevailing beliefs about sexual orientation were, first, that there was general congruence within an individual between their sexual/​romantic attractions, their behavior, and their embraced identity; and second, that orientation, as defined by identity, attractions, behavior, did not vary within one individual over time. In the last 20 years, we have accumulated a great deal of evidence that neither of these propositions are true. In other words, we know that orientation is a good deal more fluid than we thought. What is sexual fluidity? Lisa Diamond, in a 2013 talk at Cornell, described what she calls the ‘three pillars of sexual fluidity’: •

Attractions/​behavior/​or identity that is not ‘monosexual’ ‒ attracted to only one gender ‒ but is rather ‘multisexual’; • Inconsistency across the three domains of attraction, behavior, and identity ‒ e.g., a self-​labeled lesbian may have bisexual attractions and/​ or behavior; • Variability in one or more of these domains over time. Diamond’s original research focused mostly on sexual fluidity as changes in identity labels. She did find, however, that significant numbers of her subjects also changed behavior and even attractions over time. Not surprisingly, self-​ identified bisexual women and unlabeled women changed attractions and behavior more than self-​identified lesbians. In other words, ‘total’ sexual fluidity  –​not simply changing how one identifies, but also how one behaves and even to whom one is attracted  –​is more common among those who do not identify as lesbian. Lisa Diamond has equated bisexuality and sexual fluidity: ‘Perhaps the broadest and most flexible conceptualization of bisexuality views it as a strong manifestation of all individuals’ capacities for relatively malleable, situation-​dependent, socially constructed sexual desires’ (Diamond, 2008, p. 23). In other words, sexual fluidity. This concept, which has variously been called bisexuality, multi-​sexuality, or pansexuality, has been around since Freud declared bisexuality to be natural to all humans. Sexual fluidity is now used in the scientific literature almost as a stand-​in for multisexuality, the capacity to experience attractions to all genders/​gender presentations/​agender/​genderfluid /​gender blind humans. As described in Chapter  5, since Lisa Diamond’s original work, her colleague Ritch Savin-​Williams has expanded the research on sexual fluidity to include men (2017, 2018), and Diamond has followed up with studies analyzing data from the National Survey on Adolescent Health (2016).

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Savin-​Williams’ findings indicate that our beliefs about sexual orientation have been influenced by our research methodology. If you ask people if they are heterosexual, gay, lesbian, or bisexual, very few –​less than 10% –​indicate that they are anything other than straight. Savin-​Williams asked his male subjects a similar question but added the categories ‘mostly heterosexual’ and ‘mostly gay/​lesbian’ to his questions and found large numbers of men endorsed ‘mostly heterosexual’ if offered that option –​but checked off ‘heterosexual’ if gay/​straight/​bi were the only options. Since then, using similar methodology, large-​scale surveys like YouGov found fewer exclusively heterosexual respondents than expected: 78% in 2015, only 69% in 2018. They also found that the majority of ‘non-​heterosexuals’ are not exclusively gay: 16% in 2015 and 20% in 2018 described themselves as somewhere between completely straight and completely gay. Diamond and Savin-​Williams’ work suggest that the majority of these ‘in between’ people are ‘mostly heterosexual’ –​making this group the largest non-​heterosexual orientation we have! Diamond, Dickenson, and Blair (2017), in a study of men and women in Salt Lake City, tested the correlation of identity, behavior, and attractions and found great discrepancies, especially among people who identified as gay or lesbian: 48% of the self-​identified lesbians reported attractions to men in the year prior to the study and 40% of gay men indicated attractions to women in the same period, with substantial percentages of both gay women and men who had had sex with an opposite sex partner in the previous year. Taken together, this research has interesting implications for sexuality researchers. First  –​Kinsey was right, attractions run along a continuum. Second –​there is a substantial proportion of people who ‘look’ heterosexual but who have some same-​sex attractions or interactions, and this proportion is far larger than we previously thought. In fact, these people, whom you might call ‘slightly gay,’ make up the majority of not-​entirely-​heterosexual people. Third –​bisexuals –​those with attractions to both men and women, no matter what the proportion of those attractions –​far outnumber people with exclusively same-​sex attractions. Fourth ‒ bisexuality is sexual fluidity, especially if you define fluidity as the ability to change sexuality in a way that is context dependent. ‘Changing context’ could mean you run across someone of a gender you are not currently interested in but they are so attractive it triggers your interest. Or, it could mean, as Diamond has surmised, the cultural context changes, making it more acceptable to acknowledge your same-​ sex attractions. What does this tell us about sexual fluidity? First, if you define ‘sexual fluidity’ as a lack of congruence between identity, behavior, and attractions, many people who identify either as heterosexual or as lesbian or gay are to an extent ‘sexually fluid.’ If these people are aware of the discrepancy, aware that some of their behavior or feelings don’t match their identity, one could argue that they are people who are actually bisexual but who have adopted an

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identity that is not entirely accurate. Indeed, when Diamond conducted her Salt Lake City study, 11% of the lesbians and 18% of the gay men identified as bisexual in addition to identifying as gay. As we have discussed in earlier chapters, this indicates the importance of taking a sexual history with clients and probing more deeply than the identity they first offer. Identity terms, we have shown, are adopted for many reasons, including in order to affiliate with a peer community, and many gay men and lesbians are hesitant to affiliate with a bisexual community. In short, identity is not the best way to predict someone’s past, present, or future behavior. What Does This Mean for Clients? Breena, the woman at the beginning of this chapter, exemplifies a different type of sexual fluidity. Until meeting Nora, Breena had not consciously experienced any attractions to women. Her orientation really did seem to shift, if not from straight to gay, at least from straight to some version of ‘multisexual.’ Breena is someone you might see in your practice. Women like Breena benefit from psychoeducation. Knowing that she is ‘sexually fluid,’ that many women are sexually fluid, defining fluidity as attractions that are context-​dependent –​and that in Breena’s case, the ‘context’ was meeting Nora –​helped Breena enormously. It also helped her understand that this did not mean she is ‘really’ lesbian. It did not invalidate her prior sexual and romantic relationships with men and her marriage to Saul. It was also helpful for Breena to learn that she couldn’t necessarily predict her future attractions to men or women. It gave Briana space to breathe and introduced the element of choice into her situation. In the end, Breena stayed in her marriage, because she felt divorce would bring more chaos, pain, and tumult into her life than she could bear and because she genuinely loved Saul as well as Nora. Breena laughed in her last session to me when I told her that not only was she multisexual, she is also polyamorous –​able to romantically love more than one person at a time! I have known many women like Breena and the outcomes vary vastly, from women who leave their marriages and embrace a lesbian identity and lifestyle to those who leave and go back and all variations. The hallmark of this kind of situation is that the person feels a rather sudden, very intense, romantic and sexual attraction to another woman and is completely blindsided by these feelings, having presumed themselves to be heterosexual until then. While I  have worked with many married and bisexual men, I  have not encountered men who were completely unaware of their same-​sex attractions until adulthood or even middle age. I think this is because men, on average, become aware of same-​sex attractions usually by adolescence or earlier, while the average age for women of such awareness is late adolescence or 20s. At any rate, you are more likely to have women as clients who have such sudden and intense first experiences of same-​sex attractions.

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People like Breena exemplify one type of sexually fluid/​ bisexual/​ multisexual person. Other sexually fluid people are fully aware that they are multisexual, but experience the relative proportion of attractions to men versus women as changeable, and usually unpredictable. Charlie told me: I’ve noticed that my attractions tend to shift back and forth. My first long-​term relationship was with a woman. When we split up, for a while I only wanted to be with men. After a few years of just dating and sleeping with guys  –​I  suddenly found myself attracted to one of the women I work with. I haven’t figured out a reason for this, it just seems to change over time. Still other ‘fluid’ people experience multisexual attractions but the relative strength of these attractions remains stable over time. And some sexually fluid people maintain a heterosexual identity. Silva (2017) studied rural men who had sex with men. Most of these men had sexual but non-​romantic relationships with other men and constructed a narrative of themselves in which this typically ‘unmasculine’ activity could be integrated within their heterosexual identities. They called it ‘bud sex’ and maintained that they were straight. One clinical issue you may encounter is that of a sexually fluid person who feels conflicted about their identity. We have previously written about ‘bisexual invisibility’ or ‘bi erasure,’ the tendency for cultural bias to label people gay or straight, not bisexual, usually on the basis of their current partner. If you are in a mixed gender relationship, it is very easy to find your life becoming part of the mainstream, centered on family and (mostly heterosexual) community. And if you are in a same-​sex relationship, you gravitate toward the gay community as ‘your people,’ and facilitate being seen as gay yourself. In either case, your multisexuality is hidden and becomes lost. There simply is not enough multisexual presence in the queer community to feel safe in that identity. But that may be changing. Younger generations, Millennials and Gen Z, are acknowledging their multisexual nature more and more. Surveys are showing that the proportion of people, at least in the United States and the UK, who identify as something other than strictly heterosexual is increasing. For example, YouGov surveys (2015) from the UK show that while, overall, 23% of respondents endorsed a non-​heterosexual identity, 46% of 18–​24 year olds said they were not completely straight. A  comparable survey in the United States in 2018 indicated that overall 20% were not entirely heterosexual, with 31% of under-​30 respondents indicating this. The proportion of people identifying as exclusively gay or lesbian does not appear to be changing, and within the non-​heterosexual group, respondents are clustered in the mostly/​primarily heterosexual range. But to the extent that sexual fluidity

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is seen as multisexuality, more and more people of all genders identify this way. We’ve discussed sexual fluidity, monosexuality, and bi/​multi/​polysexuality. What, then, is pansexuality? The term ‘pansexual’ is very old, but has only recently attained its current meaning. In the early twentieth century, it was a Freudian term meant to signify that sexuality was the underlying motivator for everything. In the 1980s, it was used in some alternative lifestyle cultures (nonmonogamy, BDSM) to mean an interest in all forms of sexual expression. But by 2002, there was a LiveJournal community called ‘I am Pansexual,’ and by then it was being used in its current meaning, which is, attraction to all genders/​attraction to people independent of gender. In 2018, ‘pansexual’ became one of the most widely searched terms in the Merriam Webster dictionary after the singer Janelle Monae ‘came out’ as pansexual. Pansexuals often distinguish themselves from bisexuals because they feel that ‘bisexual’ implies an attraction to both men and women while pansexual denotes either attractions to ‘all’ genders –​male, female, transgender, gender nonconforming, and gender nonbinary –​or attractions that are ‘gender blind.’ Since 2010 there has been a ‘pansexual flag’ with pink, yellow, and blue stripes to designate attractions to males, females, and all other genders. In fact, there does not appear to be a difference, aside from age, between those who identify as ‘pan’ versus ‘bi’ (Flanders et al., 2017; Belous and Bauman, 2017). It is useful to remember at this point that identity labels are not representative of ‘real’ material things; they are heuristics that allow us to simplify enormously complicated patterns of experience. And there is no ‘official’ meaning of these terms; they derive their meaning from their cultural usage. Many bisexuals would describe themselves as attracted to all genders, or as attracted to people independent of their gender. Moreover, many people consider the term ‘bisexual’ to be an ‘umbrella term’ that subsumes under it terms like pansexual, heteroflexible, and homoflexible. So what does pansexual really mean? The dictionary defines it as ‘sexual desire or attraction that is not limited to people of a particular gender identity or sexual orientation.’ The term certainly brings awareness to our limited definition of sexual orientation, which is centered upon whether an individual is attracted to males, females, or both. It makes us realize that not all ‘orientations’ are focused upon gender, that some people genuinely seem to be gender blind in their attractions, with other traits of the individual more important than gender, whether those traits are physical (race, coloring, height, body type, age) or characterological (gentleness, humor, intelligence; some people define themselves as ‘sapiosexuals,’ attracted to intelligence above gender or physical characteristics). Some feel that the term ‘bisexual’ reinforces the gender binary  –​the idea that there are only two genders, something we’ll discuss at length in the next section  –​while ‘pansexual’ does not. Many feel ‘bisexual’ is a more limiting term than

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‘pansexual.’ Those who feel that ‘bisexual’ reinforces the gender binary have an important point. In the next chapters I’ll be writing about transgender, gender queer, and gender nonbinary people. Suffice it to say here that as genders proliferate, ‘bi’ sexual does not seem to represent all the possibilities. How about someone who is attracted to butch lesbians and transgender men? Calling that person ‘bisexual’ doesn’t capture the essence of their attractions; they are not ‘bisexual’ in the same way as someone attracted to cisgender males and cisgender females. Whether or not it is more scientifically correct, the term pansexual has a current cultural meaning, and at the time of the writing of this book the meaning is this:  if you identify as pansexual you are probably young. Morandini, Blaszczynski, and Dar-​Nimrod (2017) found not only that those adopting a pansexual identity were younger, but also that they were five times more likely to be women, and very likely to also have a non-​ traditional, non-​cisgender identity, for example, gender queer, gender fluid, nonbinary. But, just as happens with all sub-​cultural identities, over time, pansexual will become more common and spread to more traditional and older individuals. Case Vignette Nineteen-​ year-​ old Addison, a sophomore at nearby Rutgers University, consulted with me because they wanted help with depression after the breakup of a significant relationship. Addison had been born and identified as female until adolescence, when they began to feel that a female identity didn’t entirely ‘fit.’ Since age 16 Addison has identified as ‘nonbinary’ and preferred that others use the gender neutral pronouns ‘they/​them’ when addressing them. Addison also identified as pansexual. ‘At first I thought I was bisexual. Then last year I had a really intense crush on a trans man and I realized that ‘bisexual’ was too limiting. The truth is, gender isn’t really important to me in a partner. It’s more the person.’ Addison is typical of the kind of young person we see at IPG who identifies as pansexual. The trend is toward younger people using the more inclusive term. Addison was a challenging client, for reasons having nothing to do with their orientation or identity. When you get a client like them –​which you will if you work with college students –​you must realize you are working with someone very politically aware, particularly of issues regarding minority rights, bias, and cultural insensitivity. Addison was not only aware, but very committed to living a politically sensitive life and had high standards for themself and for others. Addison questioned whether I  could be an ally of nonbinary people because I had been a lesbian feminist back in the days when many were transphobic. Although they had chosen me because of my background, I was held to very high standards of ‘political correctness.’ This went on for a while until I pointed

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out that we were spending a lot of Addison’s therapy time establishing my ideological purity, and I wondered if it were really necessary that I be that ‘pure’ in order to help them. Eventually Addison came to see their behavior as, to an extent, an attempt to keep people at a distance. Addison began to recover from their depression and to examine why their relationship had ended. Addison’s rigidity was a factor in the breakup, and our discussions about pansexuality were the beginning of their work on their fears of intimacy. In the end, Addison’s pansexual identity was clinically important because it signified their political beliefs, the problems they had trusting anyone whose beliefs were not identical, and the way they used ideology as a protection against intimacy. Takeaways for the Clinician As we’ve established, most people who are not entirely heterosexual are sexually fluid, meaning they can be attracted to more than one gender. The identity terms used for multi-​sexuality –​whether one calls oneself bisexual, pansexual, or fluid –​are largely culturally determined, with younger, more liberal people using the latter two terms. Our culture still tends to see sexual orientation as binary  –​gay or straight  –​and many people do not believe that bisexuality or sexual fluidity exists. Therefore, you will sometimes be called upon to help sexually fluid clients understand their identity. However, you will also encounter clients who maintain a heterosexual identity despite same-​sex attractions and/​or behavior. A wise therapist will not challenge the identity labels chosen by clients, but instead simply explore the reasons why the label feels ‘right.’ Do not confuse sexual fluidity with choice. Sexually fluid people have no more control over their attractions than do heterosexual or gay people, but they may be surrounded by peers and family who either negate their identity or believe it means they can ‘choose’ to be straight. You may need to validate sexually fluid clients in the face of a lack of social support, particularly if they are older and in more conservative environments. References Belous, C. K. and Bauman, M. L. (2017). What’s in a name? Exploring pansexuality online. Journal of Bisexuality, 17(1),  58–​72. Diamond, L. (2013) Just how different are male and female sexual orientation? www.​video/​lisa-​diamond-​on-​sexual-​fluidity-​of-​men-​and-​women Diamond, L. M. (2008). Sexual Fluidity. Harvard University Press. Diamond, L. M. (2016). Sexual fluidity in male and females. Current Sexual Health Reports, 8(4), 249–​256. Diamond, L. M., Dickenson, J. A., and Blair, K. L. (2017). Stability of sexual attractions across different timescales:  The roles of bisexuality and gender. Archives of Sexual Behavior, 46(1), 193–​204.

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Flanders, C. E., LeBreton, M. E., Robinson, M., Bian, J., and Caravaca-​Morera, J. A. (2017). Defining bisexuality: Young bisexual and pansexual people’s voices. Journal of Bisexuality, 17(1),  39–​57. Katz-​Wise, S. L. (2015). Sexual fluidity in young adult women and men:  Associations with sexual orientation and sexual identity development. Psychology & Sexuality, 6(2), 189–​208. Manley, M. H., Diamond, L. M., and van Anders, S. M. (2015). Polyamory, monoamory, and sexual fluidity: A longitudinal study of identity and sexual trajectories. Psychology of Sexual Orientation and Gender Diversity, 2(2), 168. Morandini, J. S., Blaszczynski, A., and Dar-​Nimrod, I. (2017). Who adopts queer and pansexual sexual identities? The Journal of Sex Research, 54(7), 911–​922. Savin-​Williams, R. C. (2017). Mostly Straight:  Sexual Fluidity among Men. Harvard University Press. Savin-​Williams, R. C. (2018). An exploratory study of exclusively heterosexual, primarily heterosexual, and mostly heterosexual young men. Sexualities, 21(1–​2),  16–​29. Silva, T. (2017). Bud-​sex: Constructing normative masculinity among rural straight men that have sex with men. Gender & Society, 31(1),  51–​73. YouGov. (2015). https://​​topics/​lifestyle/​articles-​reports/​2015/​08/​16/​halfyoung-not-​heterosexual YouGov. (2018). https://​​topics/​relationships/​articles-​reports/​2018/06/​ 18/​more-​young-​americans-​now-​identify-​bisexual



ndrea sits across from me in my office, twisting her hands in her lap. Her five-​year-​old child, assigned male at birth, has progressed from insisting he’s a girl to refusing to go to kindergarten in ‘boy clothes.’ He’s profoundly depressed, one of the saddest kids I’ve ever seen. Gently, I ask her, ‘When did you first notice that your child was different?’ Andrea takes a long breath. ‘When Brandon was 2 and a half, we took him to a football game,’ she says. ‘About halfway through, I pointed to the football players and said to him, “Maybe when you grow up, you’ll be like those guys.” Brandon swiveled and pointed to the cheerleaders. “No, I want to be like them.” ’ Fifteen-​year-​old DJ ambles into my office wearing a pink tee, ripped jeans, earrings in both ears, and hair shorn to a semibuzz cut. Dispensing with preliminaries, my new client announces, ‘I’m agender and pansexual.’ Assigned female at birth, DJ declares a preference for the neutral pronoun ‘they,’ and explains their identity to me. ‘I don’t think of myself as any gender, and I don’t think of other people that way either,’ DJ says. ‘I don’t really notice gender.’ DJ is contemplating top surgery ‒ a double mastectomy and chest ­reconstruction ‒ but is uninterested in taking male hormones. The next day Marina comes in. Now in her early 50s, she transitioned surgically from male to female about ten years ago. Like Brandon, Marina (then Martin) had felt like a girl from an early age. Unlike Brandon, Martin had parents who were horrified by their son’s gender nonconformity. His attempts to express it were quickly beaten out of him, and his gender dysphoria remained hidden for decades. When Martin first entered my office 15 years ago, he reported a history of secretly hoarding female clothes and being nearly immobilized by shame. Married with two young daughters, he

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eventually left his wife and transitioned to Marina, after heartbreaking pain for everyone involved. A couple of decades ago, the only ‘transsexual’ most people knew about was Renée Richards, the transwoman who made the news in 1976 by attempting to enter the US Open Tennis Championships as a woman. Fast-​ forward to the present and a transgender teenager, Jazz Jennings, has her own TV show on TLC, and Charlize Theron and Cynthia Nixon openly celebrate their transgender children. But how do kids like this know that they’re the wrong gender? And what does this mean for our deeply held assumptions about males and females, about opposite sexes? In the therapy world, these questions abound. Unless you graduated in the last few years, you were probably trained to view gender variance as pathological. For many years, merely feeling a sense of incongruence between one’s internal sense of gender and one’s body was enough to earn the DSM diagnosis of gender identity disorder (GID). As I  wrote about in Chapter  2, it was not until 2013 that the psychiatric establishment adjusted its attitude, declaring in the DSM-​5 that gender variance is in itself normal, renaming GID as gender dysphoria, and emphasizing distress as the salient feature of the diagnosis. The organization responsible for issuing international standards of care for the medical and mental health treatment of gender-​ variant people, WPATH, declared in 2011 that gender diversity is normal in humans. The seventh edition of the WPATH SOC cautions that treatments aimed at promoting conformity to birth gender are unethical (WPATH, 2012). This paved the way for activists to deem such therapies ‘reparative therapies,’ just like interventions aimed at ‘curing’ homosexuality. Now, many laws prohibiting reparative therapy for sexual orientation also include gender identity. And so treatments for children that were once first-​line behavioral interventions to promote gender-​conforming behavior are now illegal in several US states and Ontario. Thus in contemporary culture, any therapist who deems transgender people mentally ill is clearly politically incorrect. Despite this, privately many therapists wonder how anyone who wants to alter his or her body so drastically could not be ‘disturbed.’ It can be hard to understand the forces that could compel a person to change in a way that courts widespread revulsion and rejection from family and society, loss of employment and housing, and even physical violence. Where do these folks get the courage to come out? Shunned and Shamed: A History When I  came out as lesbian in 1975, shortly after homosexuality was removed from the DSM, the gay community could be downright hostile to gender-​variant people (Beemyn, 2014). A  problematic trend that came out of radical lesbian feminism was the condemnation of male to female

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transgender people, as epitomized in Janice Raymond’s 1979 book, The Transsexual Empire: the Making of the She-​Male. As a result of this ideology, some feminists, like Sandy Stone, a trans woman who worked at the women’s music company Olivia Records, were forced out of the movement (and their jobs). The anti-​trans woman ideology persists today, 50 years later, among a group of feminists labeled by their opponents as ‘TERFS’ ‒ trans exclusionary radical feminists. Some of the leaders of the TERF perspective are older second-​wave feminists like Germaine Greer and Sheila Jeffreys, but many younger women subscribe to the theory as well. In the United States in recent years they have become part of a group that includes the Christian Right that is lobbying against the acceptance of transgender children. Gay men had an uneasy relationship with gender nonconformity: drag queens were revered but ‘queeny’ men ‒ those whose manner marked them as e­ ffeminate ‒ were considered a bad image for the gay activist movement. Biological males transitioning to female were labeled fake women and mistrusted, even hated, by the lesbian community. And as far as we knew, birth-​assigned women who wanted to become men didn’t even exist. I didn’t know any trans men until the 1990s –​they existed all along, but were nearly invisible. By and large, all transgender people were hidden from sight in the larger culture. Earlier in this book, I described how in the 1970s and early 1980s, among the requirements for obtaining hormones and surgery from many university-​ based sex change clinics was giving up one’s previous male identity and life, and constructing a new life as a woman, complete with a made-​up history. Professionals believed that a transsexual’s only chance for relationship and community lay in pretending to be a biological woman. Renée Richards labeled this ‘woodworking’: ‘You merged into the woodwork after your transformation,’ wrote Richards, ‘and you tried to lead a new life without people knowing what your previous life had been.’ Such clandestine circumstances eliminated any possibility of a transgender or transsexual community. Even as a therapist interested in gender nonconformity in the 1980s, I now realize how clueless I was about the inner experience of gender-​variant people. I remember working with a lesbian named Sally who called herself Sal and made every effort to look like a guy. She told me she loved making love to her very feminine partner, but that she bound her own breasts and wouldn’t allow her genitals to be touched. The sex therapist in me chalked that up to internalized homophobia without seeing the obvious: Sal was profoundly uncomfortable in her female body. In 1990, seven years after terminating therapy, Sal called me to tell me about his transition ‒ and to point out the prejudices that wouldn’t allow me to consider that a woman like her might actually be a trans man, a biological female transitioning to male. ‘I told you I wished I were a man, felt like I should have been born a man. You didn’t listen.’

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Sal was right ‒ in my mind, female-​to-​male transgender people didn’t exist. Looking back, I  can think of many clients who were self-​identified butches who were ill-​served because of my blindness. Today, trans men are at least as common as trans women. And I’m embarrassed by my old views. The Internet as Healer So what’s changed since the days when transgenderism was considered a rare disease, found almost exclusively in genetic males? One important answer is the Internet, and the connections it allowed people to make. My Italian American mother drew her identity from her immigrant parents, her extended family, and the Italian neighborhood that surrounded her. But those of us who differ greatly from our parents and our immediate community often have a harder time. If the traits that make us different are the aspects of self that we feel define us most strongly, and especially if our family of origin rejects us for those traits, we search out others like us. We go out in a quest for our tribe ‒ the community of support that allows us to feel validated and protected ‒ and, indeed, we are more armed and shielded from harm when we’re together. Until the mid-​1990s, many transgender people had no tribe. Between their exclusion from the gay community and the requirement that they ‘go stealth’ if they surgically changed their bodies, they were largely alone, often burdened by a sense of deviance, shame, and self-​hatred. With the advent of the Internet, and with it the explosion of trans-​dedicated chatrooms and listservs and, later, websites and blogs, trans people began to communicate with each other and experience the validation that can only come with numbers. The transgender community, both virtual and real, exploded. Many became activists on behalf of greater rights for, and acceptance of, trans folks. The increase in the numbers of transgender men at first came largely from the lesbian community. In other words, women who had been ‘butch lesbians,’ like my former client Sal, came to realize that the butch identity was a compromise. They really felt they were men, not women. While some gay women complained about ‘losing all the butches’ from lesbian life, many more supported the transition of people who had been long-​time friends, partners, and often fellow activists. For this and other reasons, gradually, the gay community embraced the trans tribe as a partner. In the late 1990s, the T was added to LGB, which both reflected and facilitated a huge coming-​out party for transgender people. Back then, I recall asking Ashley, a 15-​year-​old who’d been assigned male at birth but identifed as female, what made her think she was transgender. She immediately replied, ‘I saw it on the Internet. I read stuff. I went to trans websites, and chatted with other trans and genderqueer kids. And that’s when it all came together for me.’

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Today, Ashley can see trans people portrayed sympathetically on TV (‘Orange Is the New Black’ and ‘Transparent’) and on film (The Dallas Buyers Club and The Danish Girl). She can see them as guests on news and interview shows (Laverne Cox and Janet Mock), or as hosts of their own reality shows (‘I Am Cait and I Am Jazz’). Ashley can also be exposed to nonbinary people of her own generation. Janelle Monae and Sam Smith have publicly come out as genderqueer, while Will Smith and Jada Pinkett-​Smith’s son, Jaden, wore a dress to his senior prom and was the face of Louis Vuitton’s 2016 Spring Women’s Wear collection. But in the 1990s, for the most part, there was just the Internet. Parents Support Their Kids While the Internet was inviting trans individuals into a larger tribe, parents were getting into the act, too. As the Boomer generation became parents, child-​raising practices began to change, putting a stronger emphasis on becoming more attuned to kids’ needs. Around the same time, gender norms were beginning to loosen. Even so, supporting a child’s nontraditional gender choices was no easy matter. In 1983, my partner Nancy and I gave birth to a son, Cory. When he was four or five, he became passionate about wearing a pink skirt. Nancy and I were torn. On one hand, we’d been chanting the mantra of gender equality since he’d been in the womb. And it certainly wasn’t a shocker: we knew plenty of gay men who loved skirts and dresses. But we were already vulnerable as lesbian parents. Among my colleagues, the prevailing wisdom about gender-​variant boys was that they were the product of sissifying mothers. How would Cory’s choices play out as the child of two mothers widely believed by the general public to be invested in producing gay children? We felt we couldn’t risk allowing him to go out in public in a skirt, even in our semi-​gayborhood in Jersey City, New Jersey. There was zero social support for a boy who dressed like a girl. He would have been ridiculed and bullied, and we would have been considered unfit parents. The stakes were too high. Luckily, that summer we had another option:  an extended vacation on Fire Island, in one of the two vacation communities on the Island that are nearly entirely gay. Cory wore his pink skirt every day, and he was a big hit. As it happened, by the fall he’d lost interest in wearing skirts. But if he’d been transgender and had clung to his need to express his gender nonconformity, we’d have had to keep this part of him private – which would’ve caused him terrible pain. Social transition was an unheard-​of concept in an era when it was considered pathology-​inducing even to allow a child like Cory to play with dolls at home. Once again, the Internet played a pivotal role in offering tribal support to the transgender community ‒ in this case, the parent community. By the

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mid-​1990s, mothers and fathers of gender-​nonconforming kids began to find each other in online newsgroups, chat rooms, and message boards. Unwilling to follow the advice of traditional therapists who warned against gender-​ identity permissiveness, these parents sought out more forward-​thinking mental health professionals. Initially, most of these were people like myself, therapists already specializing in work with the LGBT community. The late 1990s saw the birth of gender-​affirmative therapy, a model that draws from gay-​affirmative treatment and that views gender variance as normal and healthy. More therapists began to see social intolerance, not gender diversity, as the problem, and began to include advocacy as part of their role as clinicians. For those of us already versed in the principles of the gay-​affirmative model, this was an easy and natural transition. The 2004 publication of Transgender Emergence, by the queer social worker Arlene Lev was an early, and still relevant, exposition of gender-​affirmative therapeutic interventions. But the original uptick in visibility for gender-​variant young children was largely the result of parental passion and initiative. In 2010, when Cheryl Kilodavis was raising a young son who favored dresses, she wrote a children’s book about him, My Princess Boy, and started a foundation to promote acceptance of gender diversity in schools. Both the market for gender-​affirmative therapy and the impetus for anti-​reparative therapy laws first came from mainstream parents with modern views, not just ‒ or even mainly ‒ sympathetic clinicians or trans healthcare activists. More recently, transgender mental health activists and their allies have taken up the cause of gender-​variant children, as we shall see in the chapters on adolescents and pre-​pubertal  kids. What’s It Like to Feel This Way? Still, confusion persists. When I train psychotherapists on gender issues, the most common response is ‘I just don’t get it. How can someone not “feel like” their gender? How can someone born a guy “know” what a woman feels like?’ To understand this, let’s first breakdown the components of gender: • • • •

Birth Gender is the gender assigned a newborn, almost exclusively by the appearance of their genitals; Gender Expression is the way we communicate our gender to the outside world –​our clothes, appearance, and so on; Gender Roles are the ways society dictates we behave as males or females –​ e.g., men are expected to be strong and aggressive, women to be soft and nurturing; Gender Identity is the internal sense you have of your gender –​whether you ‘feel like’ a male or a female;

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Sexual Orientation is actually independent of gender. It refers to the gender of whom you are sexually and romantically attracted to. Sexual orientation doesn’t change when people transition, but the label will change. In other words, someone assigned male at birth and attracted to women will be perceived as heterosexual before they transition, but once they are trans women –​they are lesbians!

Most of us are what’s now known as cisgender: we feel no sense of dissonance between our sense of who we are and what is listed on our birth certificate. A cisgender person has an assigned gender that matches his/​her body, a subconscious sex and gender identity that are concordant, and gender expression ‒ ways they show that they’re male or female ‒ that’s more or less conventional. Others relate to them in a way that matches their own sense of gender. For most of us, these aspects of gender are so harmonious that we don’t even realize they’re distinct elements. By contrast, transgender people experience a profound sense of dissonance. They don’t feel like their assigned gender. Try this experiment: imagine waking up tomorrow morning and discovering that your body is that of the ‘opposite’ sex. Intriguing as it might be for a while, most of us would feel that our body is lying, that it’s a mask hiding our true self. Most transgender people feel this way about the bodies they actually have. If you’ve ever been misgendered ‒ called sir if you’re female or ma’am if you’re male ‒ it was probably a somewhat jarring experience. You may have even felt offended. Imagine these feelings intensified a hundred times and occurring multiple times a day. And imagine that each time you were misgendered in public, or were perceived as transgender, you could be taunted, beat up, or worse. It’s not hard to imagine how your life could be crazy-​ making, even despair-​making. A recent US study of youth found an overall suicide attempt rate of 14%, but rates of 50.8% for transgender boys, 29.9% for transgender girls, and 41.8% for nonbinary teens (Toomey, Syvertsen, and Shramko, 2018). A 2015 Canadian study found that more than a third of transgender adolescents had tried to kill themselves (Bauer et al., 2015). I’ve seen transgender people break the law and risk their health to obtain and use illegal female hormones because the sense of congruence they experienced when using these hormones was as essential as life itself. For others, it’s not hormones or surgery that made the difference, but simply the freedom of gender expression that emerged when others viewed them the way they viewed themselves. But while finding an affirming tribe has become easier for younger trans people, many older individuals have spent a large part of their lives without the support necessary to experience gender congruency. Tony, for instance, came to see me ten years ago, when he was in his mid-​ 40s. From toddlerhood, he’d battled feelings that he was female, but had

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hid them from his deeply religious Catholic parents. He grew up in a small town in Maryland where everyone knew each other’s business. In his 20s, attending college in another state, he enrolled in a gender-​change clinic and took female hormones for long enough to develop breasts. Then, when his father died and his mother became ill, he returned home to care for her and felt he had no choice but to revert to a masculine persona. He stopped taking hormones, submitted to a double mastectomy to remove his breast tissue, and spent 20 more years living as a male. His mother’s death and a midlife depression jolted him into taking stock of his life. Today, at 55, Tony is Tanya. Though she regrets her lost years, she feels comfortable in her body and is coming to terms with her past decisions. ‘I feel bad, but I couldn’t do that to my mother. She’d never have understood,’ she says. ‘I just focus now on how fulfilled I feel. I finally feel like myself.’ Twenty-​five years ago, all my transgender clients were 40 or older, most of them having suffered greatly, along with their families, in order to be themselves. Today, my trans clients are all under 30, and they’re in therapy to take a closer look at their gender identity and how they need to define and express it, or to gain support for coming out to loved ones. They also come in for the commonplace reasons that propel people into treatment ‒ depression, anxiety, and life stress in all its forms. Wait: Gender Isn’t Binary? Gender-​ diverse people are found in many cultures throughout history. What varies is how they’re treated:  whether they’re stigmatized, accepted, or even integrated as a third gender, as they are in some non-​Western countries. Thanks to anthropologists, archeologists, and sociologists who are now peering through a queer lens, we’re learning just how common gender diversity is. Thanks to the same queer lens, we’re learning from biologists like Joan Roughgarden about gender expansiveness in animals, like the female spotted hyena that’s physically and socially dominant and has a clitoris so enlarged it’s called a pseudopenis, and the New Jersey sunfish, which includes two versions of male and one of female. In other words, in nature, gender isn’t always binary. Until pretty recently, we tended to divide the world into males and females, along with a few ‘mistakes’ ‒ intersex and transgender people. But now we’re learning that there’s no such thing as the ‘opposite sex.’ In reality, most sex-​linked characteristics exist in both males and females, although some characteristics predominate in women and others in men. This is true of not only psychological traits, but also physical ones. Think of height, for example. Or hirsuteness. My Aunt Philomena had a mustache her whole life, while my father couldn’t grow one. But since we tend to ignore and minimize

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characteristics that don’t align with assigned gender, we certainly don’t think of people like my aunt or father as genderqueer. But gender is pretty blurry even on the physical level, as biologist Anne Fausto-​Sterling has pointed out in her influential book Sexing the Body (2000). Intersex people, those with a mixture of male and female biological features, are more common than most people realize. According to the Intersex Society of North America, an estimated 1 in 100 people are born with a reproductive or sexual anatomy that doesn’t fit the typical definition of female or male. But male and female bodies that aren’t intersex are also much more similar than different. In fact, our biological sex is so complex, with so many variations, that a February 2015 Nature article by Claire Ainsworth declared: ‘Almost everyone is, to varying degrees, a patchwork of genetically distinct cells, some with a sex that might not match that of the rest of their body.’ Ainsworth goes on to quote John Achermann, a London researcher and endocrinologist, as saying, ‘I think there’s much greater diversity within male or female, and there is certainly an area of overlap where some people can’t easily define themselves within the binary structure.’ For centuries, Western cultures have polarized the sexes, but biologists are now suggesting that a gender continuum is a more accurate model. This would demand that we literally see people differently. Think about it: what’s the first thing you notice about a person? What’s the first thing you ask about a baby? We organize our encounters with others around two genders. And if our binary system of gender is inadequate, so is our language. Throughout this article, I use male and female pronouns. There are those who advocate gender-​neutral language or pronouns to designate gender other than female or male, such as the ‘they’ pronoun used in the singular. Others prefer new pronouns like ‘hir’ and ‘ze.’ Although it’s sure to throw copyeditors for a temporary loop, using this kind of language might help the gender spectrum emerge more clearly. Perhaps it’s already happening: in January 2016, the singular pronoun ‘they’ was designated the American Dialect Society’s Word of the Year, and Merriam-​Webster, the Oxford Dictionary, and the American Psychological Association guidelines all designate ‘they’ and ‘them’ as singular at times. One more word about the ‘gender spectrum.’ As young people increasingly accept the concept of a continuum of gender identities and expressions, we are seeing varied ideas of how gender dysphoria can be resolved. Gender dysphoria is often resolved by ‘transitioning’ from the gender assigned at birth to the ‘opposite’ gender. There are two types of transition. Social transition refers to changing gender expression, names, pronouns, and so on, so that one is recognized as their affirmed (internally experienced) gender identity rather than their birth-​assigned gender. Medical transition refers to the medical interventions –​hormones and surgery –​used to change one’s body to

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conform more to their affirmed gender. Prior to the last 20 years, transgender people invariably chose to avail themselves of all medical interventions possible, as well as undergo a social transition. With the recognition of a ‘gender continuum,’ transgender people are feeling freer to ‘mix and match’ the interventions that are right for them. So, for example, some may choose to socially transition with no medical transition, some may prefer surgical or hormonal treatments but not both, some want medical transition without social transition, and some may choose some surgical interventions but not all. The Queer Revolution In the LGBTQ community, gender boundaries have always been considered permeable. Think butch/​ femme and lipstick lesbians, drag queens and slender, boyish twinks. But these designations still reflected a binary model. In a single generation, a new paradigm has emerged that’s variously called a gender spectrum, a gender continuum, and a gender web. In the 1990s, the umbrella term transgender came into widespread use within the LGBTQ community. It was meant to include all categories of people who felt gender discordant ‒ not only transsexuals (a word used less frequently now, signifying people who want a full medical and social transition to the ‘opposite’ sex), but also those who felt neither male nor female, those who felt both, and those whose inner experience of gender varied from their assigned sex but were content with a nontraditional gender expression and didn’t want to change their bodies. Aided in no small part by the Internet, with a common history and much common experience, these groups evolved into a tribe. Today, it’s common to see lesbian couples in which one or both partners is a trans woman. We see some lesbians evolve into trans men with cisgender female partners who remain in the relationship. We see gay men coupled with gay trans men. The LGBTQ+ community has already succeeded in separating gender from genitalia in a big way. This new community has rejected old categories and created new identities. Few people under the age of 40 describe themselves as transvestites, cross-​dressers, or transsexuals. Many describe themselves as genderqueer ‒ a term that connotes feeling neither entirely male nor entirely female. Others use the term gender fluid. Lee, an 18-​year-​old assigned male in the adolescent group we run at IPG, was coming to terms with his lifelong sense of gender incongruence. ‘I’m gender fluid. There are times when I feel totally male, and want to be perceived that way, and other times when I feel completely feminine.’ And the new community accepts all variations on gender. Michael, a former client who still keeps in touch, has taken male hormones and lived as a man for more than 15 years, yet he’s never had surgery, so he still has breasts

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and female genitals. From time to time, he considers it, particularly chest reconstruction, but for many years, his partner has been a bisexual woman who loves his gender-​blended body. When Michael and Diana decided to have children, they agreed he’d be an egg donor for Diana, who’d carry the child. To accomplish this, he had to discontinue hormone treatment for an extended period of time, and he found his sense of physical discordance returned. He didn’t feel right again until he resumed taking testosterone. He’s still on the fence about whether he’ll ever want surgical intervention, but he now knows the importance of testosterone to his sense of gender congruence. So Michael’s version of ‘the right’ body, one which he can comfortably inhabit, includes male hormones but a more gender-​blended  body. The smashing of the gender binary paradigm has facilitated freedom for people who may fit between the two poles of masculinity and feminity but who do not identify as transgender. Arlene Stein’s book Unbound (2019) follows five young people at a surgical center in Florida who undergo ‘top surgery’  –​breast removal and chest reconstruction. One of those five is a butch lesbian who does not feel she is ‘male,’ but wants a less feminine appearing body. This woman, along with people like Michael, defy our notion of gender completely. Most people have an easier time understanding someone who wants to ‘switch’ genders –​jump from the ‘male’ box to the ‘female’ box, or vice versa –​much better than people like the lesbian in Stein’s book or Michael. In order to understand these people one needs to embrace the gender continuum. It is important to do this, because the number of people who want only some components of ‘gender change’ ‒ only social transition, only hormones, only some surgery –​is increasing. Transgender people with unconventional gender expression, people who feel someplace in between male and female, and those who feel like neither one, boggle our minds far more than the Caitlyn Jenners of the world. We may not understand Bruce Jenner’s deep need to transition but, at least as Caitlyn, she doesn’t challenge our ideas about men and women. It’s the in-​ between people who freak us out most. If there are more than two genders, what does that mean for everything based on the binary gender system, from laws and traditions to personal beliefs and behavior? The Path of Therapy There came a point in my own clinical work when I ‘got it’ about being transgender. The journeys of clients like Martin/​Marina and Tony/​Tanya showed me that gender dysphoria was an urgent, unstoppable need to achieve authenticity in the face of family conflict, social obstacles, and intense personal pain. I remembered my own childhood, which included battles with my mother over my determination to wear pants and cut my hair short. I cried when

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I  realized I  was developing breasts. It was easy to imagine what would’ve happened had I not later grown to like my young woman’s curvy body. But it may have been seeing the gender-​variant college students who started to fill our practice in the late 1990s that clinched it for me. Teenagers like Ashley faced a future with far fewer obstacles than the older trans people I’d seen, a future that actually looked pretty normal. That’s when I  truly understood the parallels between the gay and trans struggles. In the 1970s and early 1980s, my practice was full of lesbians and gay men who’d grown up before the Stonewall Riots, before homosexuality was removed from the DSM. Their stories were terrible and desperate, not unlike the lives of my older transgender clients. Then, as homosexuality became more accepted, gay people started coming out at earlier and earlier ages, and they came out to a world where they were deemed normal, not mentally ill, and where they were embraced by a strong community. And I got it. That was exactly what was happening with gender-​variant people, and what continues to happen now. As therapists, we need to support this transformation. General Principles of Working with Transgender Clients According to the guidelines of WPATH, mental health professionals have the responsibility to enable the self-​determination of transgender clients. This does not mean simply supporting someone who wants total social and medical transition. It means helping each client figure out what, if any, changes are right for them. The following chapters will detail more specifically what is involved in social, hormonal, or surgical transitions. If you are a therapist working with gender-​variant people, you need to know, and keep up to date with, these interventions, at least enough to provide some guidance to your clients, and referrals to appropriate medical providers. Even if you don’t see clients who are trying to figure out their gender identity and desired changes, you will inevitably see transgender people in your practice. You may get transgender clients who’ve already figured this out, who may be thoroughly post-​transition, or whose path is clear to them. They may need your help for issues having nothing to do with their gender identity. If your practice includes lesbian and gay clients, you can’t avoid seeing trans people. Trans women attracted to women, those who were ‘heterosexual’ before transition, ‘lesbian’ after, tend to partner and live within the queer community. Many trans men identified as lesbians before they explored gender identity, and their female partners often stay with them after transition. Some transgender men identify as gay and affiliate with others in the gay male community. Even if you don’t work with many gay people, your heterosexual clients almost certainly have a transgender child, relative, neighbor, or child’s classmate ‒ whether they know it or not. It was once true

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that very few people knew a gay person, or at least knew that they knew. Now everyone does. Soon it’ll be the same for trans people. How should you handle trans clients clinically, or approach issues of gender variance with parents? In the following chapters we will take a deep dive into the specifics of dealing with transgender adults, adolescents, and kids, as well as nonbinary and gender-​fluid individuals. But some general principles apply. First, don’t assume that your clients’ gender choices are inherently problematic or look for reasons why they’re gender variant. They are who they are, and like any client, they need your acceptance and respect. Second, educate yourself. Third, don’t assume that gender issues are relevant to therapy. Many trans or gender-​variant people come into therapy for exactly the same reasons everyone else does: depression or anxiety, relationship issues, loss, trauma, the whole gamut. These problems are sometimes caused or exacerbated by minority stress, the extra pressures and burdens engendered by being a member of any stigmatized group. Despite growing cultural acceptance, many transgender men and women are murdered each year simply because they’re gender variant, especially transgender women of color. It can be physically dangerous if you are perceived by others to be transgender. Younger people, Millennials and Gen Z, are remarkably accepting of gender variance. If you work with adolescents, particularly college kids, you’ll increasingly see teens who identify as something other than cisgender. As we’ve discussed, this doesn’t necessarily mean that they want medical intervention –​but some do. The vital task here is to honor the adolescent’s affirmed gender while helping that young person explore what that means for them and what, if any, changes they want to make. The Shape of Things to Come As social acceptance continues to grow, will we see an increase in the number of people claiming a trans or otherwise gender-​nonconforming identity? Will we see a corresponding increase in those requesting body modification? The answer to the first question is unquestionably yes: as understanding and support expand, more people will come out. But the answer to the second question remains to be seen. As trans people change the definition of identity, some are making idiosyncratic choices with surgery and hormones. Some will modify their gender presentation, but not their bodies. Others will modify their bodies to create nonbinary bodies that match nonbinary identities. Tanner, the 20-​year-​old son of a friend, was assigned female at birth. Tanner takes a low dose of testosterone and presents as male, but doesn’t plan to have either top or bottom surgery. Perhaps the future is already here, in the shape of Millennials and Generation Z. Their support for gay marriage is merely the tip of the iceberg.

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They are familiar with the gender spectrum: many of them have an entirely different paradigm for not only sex and gender diversity, but identity itself. For example, a 2018 Pew Research Center report indicated that a third of Gen Z knows someone who identifies as nonbinary (Parker, Graf, and Igielnik, 2019). They often define both their gender identity and their sexuality precisely and idiosyncratically, while characterizing their identity as a work in progress. And it’s not just trans and gay people who are doing this. In writing this chapter, I asked our son Cory, who once pined for a pink skirt, to describe himself as he is now, in his mid-​30s: ‘Gender is pretty easy,’ he texted, ‘I’m a cismale who likes to range in presentation from fairly butch to slightly gender-​bendy. Nobody would ever think I  was trans, but lots of people think I’m gay, depending on the day. Sexuality is more complicated. For convenience, I say I’m bisexual and heteromantic. But sexuality, at least for me, has far more dimensions than that.’ There’s one thing for sure: the boundaries between male and female are getting fuzzier and fuzzier. In some ways, transgender and gender-​nonconforming people reflect a larger cultural trend. Women can fight in combat, men are stay-​at-​home parents, and gender expression and identity are exploding into forms and flavors we never imagined. If these shifts continue, the cry of my parents’ generation in the 1960s and 1970s ‒ ‘You can’t tell the boys from the girls!’ ‒ may become true. As a society, that’s a profound change in the implicit rules of what’s normal, a change all of us, in one way or another, will have to come to terms with. In the chapters to follow I will help you accomplish exactly that. A Word about Words Words are important and, if you are working with clients who are transgender, it is important that you use language that has been adopted by the trans community in order to be respectful. This of course means not using perjorative language like ‘tranny’ or ‘chicks with dicks.’ But it also means using language in current use. You would not call an African American person a ‘Negro,’ even though 50 years ago that might have been acceptable. Accordingly, in this book, I use the word transgender as an umbrella term to encompass people who want full medical and social transition to the ‘other’ gender (formerly called transsexuals) as well as those who feel dysphoric about their gender but do not necessarily desire all, or even any, body modification. I use ‘trans woman’ or ‘transgender woman’ rather than ‘MtF,’ ‘trans man,’ or ‘transgender man’ rather than ‘FtM.’ I use ‘assigned male at birth’ or ‘assigned female at birth’ rather than ‘biological sex.’

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What You Need to Do as a Clinician I take the next four chapters to write about clinical issues of transgender adults, adolescents, and kids, and of nonbinary people, more space than I  have devoted to any one subgroup in the LGBTQ+ universe. I  do this because: 1) this is a client population that has been and continues to expand rapidly in the US and the West in general, and 2) it is a population about which most clinicians either know nothing, or know things that are wrong and possibly harmful. But before you read about specific problems and approaches, take some time to do counter-​transferential work with yourself. For starters, examine your own beliefs about gender and the binary gender system. Just as you couldn’t work effectively with gay and lesbian clients if you believed homosexuality to be an illness, you can’t work with transgender people if you see gender dysphoria as pathological, or if you are wedded to a traditional paradigm of gender. In addition, working with transgender clients is different from a lot of other clinical work because there is a strong medical component, and because the medical issues are serious. You will be helping clients, and in some cases their parents, make decisions about what can be irreversible medical procedures with life-​long consequences that affect health, well-​being, and fertility. Make sure you are prepared to take this on before you work with transgender clients. If you are, the next four chapters will start you on a journey to learning what you need to know. References Ainsworth, C. (2015). Sex redefined. Nature, 518(7539), 288. Bauer, G. R., Scheim, A. I., Pyne, J., Travers, R., and Hammond, R. (2015). Intervenable factors associated with suicide risk in transgender persons: A respondent driven sampling study in Ontario, Canada. BMC Public Health, 15(1), 525. Beemyn, G. (2014). Transgender history in the United States. In L. Erickson-​Schroth (ed.), Trans Bodies, Trans Selves: A Resource for the Transgender Community, Oxford University Press, pp. 501–​536. Dorment, R. (2015). 5 Transgender Americans on the Hardships of Transitioning, Then and Now.​lifestyle/​a38971/​transgender-​men-​and-​women-​ontransitioning/​ Fausto-​Sterling, A. (2000). Sexing the Body:  Gender Politics and the Construction of Sexuality. Basic Books. Lev, A. (2004). Transgender Emergence: Therapeutic Guidelines for Working with Gender-​ variant People and Their Families. Routledge. Parker, K., Graf, N., and Igielnik, R. (2019). Generation Z looks a lot like millennials on key social and political issues. Pew Research Center, 17. Raymond, J. (1979). The Transsexual Empire: The Making of the She-​Male (Athene Series). Teachers College Press. Richards, R. and Ames, J. (2007). No Way Rene: The Second Half of My Notorious Life. Simon & Schuster.

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Stein, A. (2019). Unbound: Transgender Men and the Remaking of Identity. Vintage. Toomey, R. B., Syvertsen, A. K., and Shramko, M. (2018). Transgender adolescent suicide behavior. Pediatrics, 142(4), e20174218. World Professional Association for Transgender Health. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-​Nonconforming People. 7th version. World Professional Association for Transgender Health. https://​amo_​hub_​​Association140/​files/​Standards%20of%20Care,%20V7%20 Full%20Book.pdf



y wife is afraid I will want a sex change operation. I really like to cross-​dress, but I definitely don’t want to be a woman,’ said Thomas, a 45-​year-​old securities trader who lived in an upscale suburb in New Jersey with his wife and two sons. ‘I want you to tell her she doesn’t have to worry.’ Thomas started cross-​dressing as an adolescent. At first, he found this exciting, and he sometimes dressed in his sister’s clothes and masturbated after looking at himself in the mirror. Soon, however, the erotic charge dissipated, but he still was drawn to ‘dressing up.’ Thomas struggled with his cross-​dressing for 30  years, going through periods where he secretly accumulated and hid articles of women’s clothing and periods where he ‘purged’ his wardrobe in an attempt to rid himself of his clandestine activities. At age 32 he married Audrey during a period of purging. ‘I really believed I would never do it again, so I didn’t see why I should tell Audrey.’ Within a few years of marriage, Thomas again experienced strong urges to cross dress, but was afraid to tell his unsuspecting wife. From outside appearances Thomas’ family looked traditional: Thomas coached his sons’ Little League teams and ran marathons himself, Audrey was a stay-​at-​home wife and mother, they were regular church-​goers and had a wide circle of friends and family. No one knew about Thomas’ secret. When he could do so without Audrey discovering, he accumulated women’s clothing, make-​up, and wigs. On business trips to other cities, which occurred once or twice a year, he always booked an extra night or two at a different hotel. He located gay bars or bars that welcomed cross-​dressers, and spent his evenings there, fully dressed as a woman  –​and feeling wonderful. Afterwards, he experienced

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intense shame and might throw away his women’s attire –​until next time. Audrey never knew. More recently, however, Thomas found it increasingly difficult to contain his desire to cross-​dress, and started surreptitiously dressing on days when his wife and kids were away from the home. Moreover, he started shaving his legs and arms in an attempt to rid himself of the hirsuteness he associated with masculinity. This was impossible to hide from his wife. Audrey found his shaving jarring –​‘weird,’ she called it –​and began to be suspicious. Eventually, her suspicions led her to search the house, and she found Thomas’ stash of clothes, makeup, and wigs. She confronted Thomas, who confessed, but assured her that his ‘dressing up’ was an occasional and harmless pastime that ‘didn’t mean anything.’ Audrey was not satisfied. She told her own therapist about her discoveries, and her therapist warned her that she might be married to a ‘transsexual.’ At this point, Audrey insisted that the two of them see someone who specialized in transgender issues, and they arrived at my office. When I began to work with Thomas and Audrey, I asked for several sessions with Thomas alone to better assess him. I quickly realized that despite the erotic component that was present during his adolescence, his desire to cross-​ dress now had nothing to do with sex. Dressing had long since lost its erotic component, but he reported experiencing a calmness and wholeness when dressed that he did not experience in his male persona. It also emerged that although Thomas protested that he was ‘just’ a cross-​dresser, he frequently day-​dreamed about living as a woman, had done quite a bit of research on medical interventions, and was considering using estrogen! When I reflected this back to Thomas, he admitted that he probably would live full time as a woman were it not for his wife and children. In sessions with the couple, he acknowledged this to Audrey and finally realized he could not guarantee that he would never transition. In his fantasies, he imagined transition when his children were grown and out of the house. Understandably, Audrey found this alarming. I married a man. If you transition, I’ll get a divorce. I  could never be attracted to you as a woman, and I  don’t want to be seen as a lesbian couple. And if you don’t transition for another ten years –​I don’t want to be single in my mid-​fifties. I want to separate now, and I want you to figure this out on your own. If you can give this up, we can get back together. Within months, Thomas had moved into his own apartment and I continued to see him in individual therapy while Audrey worked with another therapist in our practice.

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Once on his own, with the liberty to live in a female persona whenever he was not at work, Thomas grew increasingly unhappy living as a male. It took him less than six months to decide he wanted a full social and medical transition. Today I  am still in contact with Thomas, now Terry. Terry was able to keep her job with employers who were remarkably progressive considering the conservative nature of the financial profession. She is married to another transgender woman and has a good relationship with her grown children. Audrey remarried, and gradually she made peace with Terry’s transition, so that both could celebrate their children’s college graduations together and be comfortable at gatherings of the extended family. Cross-​dressing is a poorly understood and controversial phenomenon. Moreover, it is a disappearing identity: Beemyn and Rankin found, in their ground-​breaking survey of transgender people, that few people under the age of 40 describe themselves as ‘cross-​dressers’ (2011). Those that might have chosen that identity in the past are now more likely to call themselves ‘genderqueer’ or ‘nonbinary.’ We will explore some of the reasons for this in our discussion of nonbinary people. Since the mid-​twentieth century, cross-​dressers, men who dress as women, have been seen as fundamentally different from people who want to fully transition to another gender, even though this bright line distinction was never really accurate. This was largely due to the efforts of Virginia Prince, a cross-​dresser and early transgender activist. Prince published a magazine for cross-​dressers called Transvestia, and maintained that while cross-​dressing was gender related, it was distinct from ‘transsexualism,’ the desire to fully transition to the other gender. In 1976, Prince founded an organization called the Society for the Second Self –​Tri-​Ess –​and the group’s criterion for membership included being heterosexual and uninterested in medical intervention. Today, while some cross-​dressers do in fact eventually decide they want to live full time as women, many feel fulfilled living permanently as two personas, one male and one female. There are many websites devoted to cross-​dressers or their spouses, and Virginia Prince’s group Tri-​Ess still provides a way for them to connect in person at one of the chapters around the country. Some people who cross-​dress, including some who eventually transition to become trans women, begin like Terry did, surreptitiously wearing women’s clothes as an adolescent and sometimes becoming aroused by the sight of themselves so dressed. This led the researcher Ray Blanchard to develop a typology of ‘transsexualism’ (Blanchard, 1989). According to Blanchard’s theory, there were two types of transsexuals:  ‘homosexual transsexuals,’ assigned males attracted to males, and ‘autogynephilic transsexuals,’ assigned males attracted to women who had started their journey via cross-​dressing with an erotic component. Although Blanchard himself did not assert this,

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many who followed his typology believed that ‘autogynephilic transsexuals’ were not ‘true’ transsexuals, and thus undeserving of medical intervention. Because, until recently, mental health professionals controlled all access to hormones and surgery, some people who were deemed ‘autogynephilic’ were denied medical care. Even one reported instance of masturbating while cross-​dressed might cause a therapist to label the client a ‘fetishist’: a sexual deviant, not a ‘genuine’ transgender person, and thus ineligible for the hormones and surgery that can relieve gender dysphoria. This client might be diagnosed with ‘transvestic disorder,’ not ‘gender identity disorder’ or ‘gender dysphoria.’ Transgender activists seeking to change the mental health gatekeeper model have focused on the Blanchard typology as a particularly egregious example of control, and Ray Blanchard’s name is considered a dirty word among most transgender activists. Critics of the Blanchard theory have pointed out that ‘autogynephilia’ is a normal component of eroticism for women, that is, many cisgender women are also erotically aroused by seeing themselves as attractive females, and that this should not be labeled a ‘fetish’ (Moser, 2009). Moreoever, for most teenage boys who cross-​dress and find it a turn-​on, the sexual charge dissipates eventually. These men retain a desire to cross-​dress for gender-​related reasons, not sexual motives. The few for whom cross-​dressing always remains erotic have no interest in either changing their gender or in cross-​dressing outside of sexual situations. Terry’s story is typical for many older transgender clients:  decades of hiding and shame, conflict about identity, and a spouse who leaves once transition is on the table. Sean and Robin represent a different kind of adult client. Sean originally came to treatment at the age of 30 because he and his wife Robin were experiencing sexual difficulties. In sex therapy with me, it gradually became clear that the origins of the sexual problems lay in Sean’s discomfort with his body. Slowly, Sean revealed that since he was six he had felt he was more like a girl, and desired to be a woman. Unlike Audrey, Robin, although surprised, was not alarmed to discover that she was married to a transgender person. Robin was bisexual, and found the idea that Sean might have a female body arousing, not repellant. Moreover, as a bisexual woman she already considered herself part of the LGBTQ+ community, and was unconcerned about being viewed as a lesbian. The couple was childless by mutual agreement, so there were no kids to take into consideration. Robin supported Sean, now Sophia, through hormone treatments and surgery, and the two remain together as a couple. The Job of the Mental Health Professional with Adult Transgender Clients Since the publication of the WPATH SOC (2012), the job of the mental health professional has changed enormously. Prior to SOC 7, as it is called,

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psychotherapists were ‘gatekeepers,’ with the power to grant or limit access to the medical interventions most transgender people deem necessary for their well-​being. The new SOC do not require that a transgender person be in psychotherapy. Hormone treatment can be initiated through an informed consent procedure that does not need to involve a mental health professional, although genital surgery still requires two letters of endorsement from gender specialists. Thus, your job as a clinician with adults who want to transition is similar to your role with cisgender clients: a guide, advocate, and supporter who helps the client discover what is authentically right for them. You may still be asked to write letters for hormones –​as of the time of this writing, some private endocrinologists still require them –​but in general you do not have that responsibility for decision-​making. One fact is not in dispute: medical and social transition is an effective way to ameliorate gender dysphoria. A 2018 Cornell University meta-​analysis of all 55 studies assessing the impact of transition found that 93% concluded that gender transition improves the lives of gender transition, 7% found mixed or null results, and no studies found a negative or harmful impact (Cornell, 2018). Earlier in this book we explained that there are generational differences working with gay, lesbian, and bisexual clients. Older clients are more likely to have suffered trauma growing up gay, they often ‘come out’ at a later age, they may have tried to be straight and be heterosexually married. Their process of self-​discovery is often more conflict-​ridden and fraught with difficulties. The same is true for transgender clients. Just as gay people may marry in order to pass as straight, older transgender people are more likely to spend decades ‘passing’ as their birth-​assigned gender, and to keep their gender issues secret even from their partners. Clinical work often includes working with a couple dealing with an explosive revelation, a couple who may very possibly divorce. If there are children involved, the situation is even more difficult. For many years, almost all the transgender clients at IPG fell into this category: middle-​aged people assigned male at birth, dealing with families, spouses, and children who were all shocked, upset, hurt, and angry about the transgender client’s disclosure. Therapists working with clients like this need to be mindful of their own emotional reactions. It can be hard to see so many people suffering and grieving and hard to stay neutral in a situation where, despite the heartache, no one is to blame. However, most of these situations resolve positively. The transgender person finally gets to live an authentic life, the spouse eventually recovers and creates a new life, the children usually adjust pretty well to the parent’s transformation in time. Terry’s story is a common one. Although everyone involved went through a rough patch at the time of her ‘coming out,’ the story has a happy ending. Some older transgender clients decide that transitioning isn’t worth the life disruption it will cause. I worked with Russell about 15 years ago; he was

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in his mid-​60s, in a second marriage for 20 years, with three grown children. His entire life he had wanted to be a woman, and came to see me to decide, once and for all, to take this big step. I met with Russell for a few months, and had sessions with him and his wife Paula, who loved him very much but couldn’t develop any erotic attraction to Russell in his female persona. One day Russell came to see me and said, I’ve decided not to do this. Even with surgery and hormones, I’m never going to look like the woman I imagine myself to be, I’ll lose the romantic connection I have with Paula, and God knows how my kids will react. It’s just not worth it. Russell terminated treatment. A few years later I learned from someone else who knew him that Russell had passed away. I’ve always wondered whether he continued to feel he made the right decision in not transitioning. And some clients decide to medically transition without a social transition (Rachlin, 2018). There is no data on how many people fall into this category, but there are older transgender people who decide that they do not want the disruption involved in social transition –​living in the gender not assigned at birth –​but that their personal comfort and life satisfaction will be enhanced by undergoing medical interventions that are not visibly prominent. Clients like this may take low doses of hormones, for example, and have genital surgery; their bodies change in ways quite obvious to them but not publicly identifiable, so they continue socially to be treated as the gender assigned to them at birth. Medical Transition It is useful to understand a little about the medical procedures involved in transition, especially if your clients include those who have not yet undergone this process. As mentioned earlier, the WPATH SOC have made it easier for people to determine their own needs for medical intervention without need for approval from mental health providers. The Standards of Care, which are available for free online at, contain very detailed and comprehensive information about the medical interventions I summarize below. Typically, the first medical help transgender people desire is to be placed on cross-​ gender hormones, that is, estrogen for birth-​ assigned males transitioning to female, testosterone for birth-​assigned females transitioning to male. The changes brought about by hormone treatment take place over two or more years, and are for the most part not reversible. Assigned males taking estrogen will fairly rapidly notice a change in skin texture –​drier with smaller pores. They will develop breast buds and ultimately breasts, although this may take several years. Their body fat will redistribute –​rounder hips

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and thighs, softer facial features –​and their muscle mass will decrease. Body hair will thin out, and balding will stop. Emotions may change; the person may cry more, for example, or feel more mood changes than before. Erectile function will decrease, although sexual sensation remains. And the trans person may become sterile, making it important for the trans person to consider banking and storing frozen sperm before beginning estrogen treatment. Because testosterone is itself a very powerful hormone, assigned males transitioning to female will need testosterone blockers, like the drug spironolactone, in addition to estrogen. There may be a somewhat elevated risk of stroke, blood clots, and cancer from long-​term use of estrogen, although the data on this is sketchy. And of course estrogen does not feminize all physical characteristics: voice will not change, nor will bone structure or height. Assigned females transitioning to male are placed on the hormone testosterone. As with estrogen, changes take place gradually over a period of two or more years. The skin changes, and trans men may experience acne after starting testosterone treatment. Fat is redistributed  –​the face becomes more angular, hips and thighs lose fat. Arms and legs will show more muscle definition, and strength may increase. Body and facial hair will become thicker, darker, and grow more quickly. Baldness may occur depending upon age and family history. Unlike estrogen, testosterone impacts vocal cords, so assigned females taking the male hormone will experience a deepening of the voice. Emotions may change; some trans men find they experience a narrower range of emotions and are less emotionally sensitive. Sexuality will change:  the clitoris enlarges, sex drive may increase, and the experience of sex may be different, as I will discuss later. Menstruation eventually stops, but transgender men on testosterone do not necessarily become infertile. In fact, it is quite possible to become pregnant while on testosterone, so birth control must be used if vaginal sex continues. There have been a number of well-​documented instances of transgender men who discontinue testosterone in order to get pregnant and give birth. The health risks of testosterone are less known than those of estrogen, including whether there are changed risks for ovarian or breast cancer. There are a variety of surgeries available for trans men and women, although most are contraindicated until the person has been on hormone therapy for at least two years. These surgeries are commonly termed ‘gender-​affirmation surgeries,’ or ‘gender-​confirmation surgeries.’ The term ‘sex reassignment surgery’ is no longer used. Colloquially, they are grouped into ‘top’ surgeries and ‘bottom’ surgeries and require different levels of clearance according to WPATH guidelines. While an adult may begin hormone treatment after going through an informed consent procedure, one such clearance letter from a mental health professional is required for ‘top’ surgeries and two letters, from different providers, are required for ‘bottom’

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surgeries. Ongoing psychotherapy is not a pre-​requisite for any medical procedures, but some psychotherapists may only feel comfortable writing clearance letters for clients who have been in treatment with them for a substantial amount of time. Other mental health clinicians do such surgical assessments in a few sessions. I’ve included sample template letters in the Appendix. In general, letters establish the credentials of the writer and attest to the client’s maturity, knowledge, and understanding of the medical procedures in question, as well as to their ability to arrange for post-​operative care, in the case of surgeries. ‘Top’ surgery for transgender women is breast augmentation, and is optional and chosen only by those women who feel the breast development they have attained through hormones is inadequate. ‘Top’ surgery for transgender men is more involved: both breasts are removed and the chest skin and tissue are contoured to resemble a male chest. There are a variety of ‘bottom’ surgeries for both transgender men and transgender women. The most common are, for transgender women: • Orchiectomy, or removal of the testicles; • Vulvoplasty, which creates all parts of the vagina except for the vaginal canal; • Vaginoplasty, which creates both the inner and outer parts of the vagina. For transgender men, available surgeries include: •

Hysterectomy and/​or oophorectomy –​removal of the uterus and one or both ovaries; • Vaginectomy, removal of vaginal tissue and closing of the vaginal opening; • Metoidoplasty, removal of the suspensory ligament from the clitoris and separation of the clitoris from the labia, which produces a clitoris of approximately two inches; • Phalloplasty and scrotoplasty –​formation of a phallus and scrotum. In addition, there are a variety of surgical techniques in use for many of these surgeries, and new surgical techniques continue to be developed. Phalloplasty techniques have improved greatly in recent years, and it is now more common for transgender men to seek phalloplasty, especially since, increasingly, health insurance covers transgender surgeries. Other Issues Facing Adult Transgender People Minors who come out as transgender can now avail themselves of puberty blockers and early use of cross-​gender hormones, with parental consent. We

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will explain this in the next two chapters. If these medical interventions are used at an early enough age, most of them will be able to ‘pass’ as cisgender. In other words, their physical characteristics so resemble those of their affirmed gender, their internal sense of gender, that the average person cannot tell that they were assigned a different gender at birth. Older people, however, are not so fortunate. Some ‘gender markers’ –​for example height, body shape and facial angularity, and voice for transgender women –​do not change at all. This puts people who do not transition until adulthood more at risk for employment and housing discrimination and even harassment, physical assault, or death. According to the Williams Institute survey of 2019 (Badgett, Choi, and Wilson), nearly 30% of transgender people live below the poverty line, as opposed to 16% of cisgender people. Employment discrimination is a huge problem. The 2016 National Center for Transgender Equality (NCTE) survey of 28,000 transgender men and women found that 26% of respondents had lost a job because of being transgender and 50% had been harassed at their job (James et  al. 2016). Employment discrimination and poverty together account for the fact that more transgender people enter sex work industries than cisgender people. While approximately 6% of the overall population has at one time or another been paid for sex, nearly 11% of transgender people have participated in sex work, with another 2.3% having traded sex for food or housing. The rates are highest for black, mixed race, and Hispanic trans women (Nadal, Davidoff, and Fujii-​Doe, 2014). Young people may often not even have their first job until after transition has occurred. But people who transition in midlife or later often have established careers, and many would like to stay in the same job post-​ transition, but often they cannot. Thomas/​Terry was fortunate to have an enlightened employer, and many large corporations have recently become transgender-​affirming. The Human Rights Campaign generates a ‘corporate equality’ index every year, which rates US corporations of 500 employees or larger. In 2002, only 5% of surveyed companies protected transgender employees and 0% had transgender-​inclusive health care benefits, that is, insurance plans that covered hormones and surgeries. In 2019, 97% protected trans employees and 83% provided inclusive health care benefits. However, smaller companies may have less progressive policies. No federal laws protect LGBTQ+ employees, and only 21 states have protections for transgender employees. This means your adult clients may be at risk of harassment or termination, without legal protection, if they choose to transition and remain at the same job. Transgender adults often face institutional bias, particularly if they are economically disadvantaged and must rely on social services. Harriet, a 52-​ year-​old transgender woman in treatment with one of the psychology interns I supervise, had spent most of her adult life homeless. She frequently lived in

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parks or other public places because of the discrimination she encountered in homeless shelters where she was sometimes turned away, and at other times forced to sleep in the men’s section. Carmela was a Hispanic trans woman who had been placed in a residential drug treatment center after being arrested for possession of heroin. While there, she was forced to live with the male addicts and, not surprisingly, was taunted and even assaulted while she was there. The inability to ‘pass’ puts transgender people, especially women, at risk of physical assault. The 2016 National Center for Transgender Equality (NCTE) Survey (James et  al. 2016)  found that 46% of their respondents had been verbally harassed in the year before the survey, and 9% had been physically attacked. Violence is most pronounced against black transgender women. Every year two dozen or more transgender people are murdered in the United States, and virtually all of them are black trans women. The murders of trans people are so frequent and horrific that every year in November there is a Transgender Day of Remembrance to honor those killed. The November 2019 TDOR commemorated 22 murdered trans people, and 20 of them were black transgender women. Sexuality Little research has been done on the sexuality of transgender people after gender-​affirmation bottom surgeries. Sexual orientation usually does not change after transition, but the identity label does:  an assigned female transitioning to male, who is attracted to women, will be a ‘lesbian’ before transition but a heterosexual man after. There are reports of transgender people who do expand or change orientation after transition, most notably reports of transgender men who are attracted to men after, but not before transition. One study of post-​operative transgender women (Hess et al., 2018) found high rates of sexual satisfaction, especially with the ability to become aroused and reach orgasm. No such research exists for the surgical results of phalloplasty for transgender men, although medical reports indicate that the newly constructed penis retains sexual sensation and can be implanted with a penile prosthesis after about a year (Monstrey, Ceulemans, and Hoebeke, 2011). Anecdotal reports suggest that trans men and women experience sexuality differently after hormone treatment. Trans men often report increases in sex drive and a more genitally focused sexuality, while transgender women may report a more total body experience of sex after estrogen treatment (Serano, 2016). Some transgender people are challenging our constructs about sexuality because they are challenging our notions about ‘normal’ bodies. Some transgender men are choosing to keep their vaginas, whether or not they undergo

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phalloplasty, and many transgender women choose to keep their penises. Some even devise gender-​consonant names for these body parts: ‘man-​holes’ and ‘girldicks.’ Partners of transgender men and women need to understand that there is tremendous variety, not only in the anatomy of transgender people, but in the ways in which the anatomy is used. For example, increasing numbers of transgender women are choosing what is called ‘zero-​depth vulvoplasty,’ a procedure in which the outer aspects of the vulva –​labia, clitoris, and so on –​ are created without a vaginal canal. These trans women have chosen to forgo vaginal penetration, even though the genitals that they have retain sexual sensation and arousal potential. Some trans women who keep their penises want their ‘girldicks’ touched, and some others are capable of erection (which estrogen makes more difficult). Some trans men with ‘man holes’ enjoy penetration, others do not. Transgender people are expanding the possibilities for sexual and sensual contact in a highly individualized way. Detransition The term ‘detransition’ refers to people who have transitioned from their birth-​assigned gender to another gender and then transitioned back to their birth gender. This may involve social and/​or medical transition and detransition. If you type ‘detransitioners’ into the search bar of YouTube, you will be rewarded with dozens of videos, most done by detransitioners themselves, others by people reacting to the detransitioners. There is little research on detransition, including regret rates, among transgender men and women, and the research focuses on people who have fully medically transitioned. The little that exists, like the 2018 study published in PRS Global Open (Danker et al.) and the Swedish study from 2014 (Dhejne et  al.), indicates that regret is exceedingly rare, with rates under 3%. These regret rates are far lower than, for example, the regret rates for cosmetic surgery in general. However, there has been increased focus in the United States on young adults, primarily those assigned female at birth who transitioned to male, who have transitioned back to their birth-​assigned gender, most after no or partial medical transition. We have no reason to believe these people represent anything but a tiny fraction of people who transition, although we cannot be sure because research on contemporary youthful detransitioners is nonexistent. However, it is informative to watch some of these videos, and is a caution against a practitioner accepting at face value a client’s gender identity without careful assessment. People who detransition report feeling great stress around the process, and feeling very isolated. They are sometimes treated poorly by gender-​affirmative therapists who feel threatened by the detransition, and ­misunderstood by those who don’t regularly work with transgender clients. If you are working

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with transgender adults, it is helpful to explicitly offer help in detransitioning. At IPG, we added a page to our website specifically to welcome those who might be detransitioning and seeking assistance. Working with Partners The experience of Thomas and Audrey outlined at the beginning of this chapter is a common one. We have no data to be certain about this, but it appears that many couples break up after the revelation that a partner is transgender. It is not known whether this is more common for couples where a partner is transitioning from female to male –​couples perceived as ‘lesbian couples’ before transition –​or couples where one transitions from male to female –​couples perceived as ‘heterosexual’ before transition. Platt and Bolland (2018) studied 21 partners of transgender people to identify the issues and obstacles they considered most salient. They found that all participants went through profound change as a result of their disclosure and transition, a process that could be labeled ‘co-​transition.’ Five themes of change were identified in the study: 1) Considerations with physical, sexual, and emotional intimacy, including those related to the transitioning partner’s body change. Like Audrey, not all participants were able to remain attracted to their partners after transition. 2) Changing sexual orientation labels. Couples  –​and thus participants  –​ were viewed differently after transition, necessitating an adjustment to new sexual orientation labels that might result in participants feeling more stigmatized after transition. 3) Safety concerns. Participants expressed fear and worry about their partners’ physical and emotional safety and, in some cases, their own, given that transgender people often meet with hostility and aggression from others. 4) Marginalization and isolation. Participants often felt marginalized as the partner of a transgender person, regardless of whether they were members of the heterosexual or ‘queer’ community. 5) New appreciation for the gender spectrum. Participants expressed positive experiences having their concept of gender expanded by partnering with a transgender person. Similarly to working with couples where one person has disclosed a gay or bisexual sexual orientation, therapists working with couples with a transitioning member must be sensitive to the shock and disorientation a partner experiences after such a disclosure. The goal of treatment is not necessarily to keep the couple together, but rather help the partners discover

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what arrangement works for them and, if they separate, to do so with a minimum of blame and rancor. Men Who Love Transgender Women You may find yourself working with a heterosexual male client who discloses that he is attracted to transgender women who have not had any ‘bottom’ surgery, that is, they still have functioning penises. If so  –​kudos for creating an environment where someone feels safe enough to disclose material so fraught with shame. Because although some men have strong attractions to transgender women, this seems even more shameful to many men than being attracted to a man. Some people consider this attraction a ‘fetish,’ others have maintained it is actually a separate sexual orientation, but it is clear that some significant number of heterosexual and bisexual men are interested in trans women. There is even a new slang term for it, meant to take away the stigma: skoliosexual. If you find yourself working with a man like this, it is important to de-​ pathologize his attractions. There are countless other men like him, and it is accepted enough among younger people that most dating apps have ways for trans ‘admirers’ to connect with transgender women. Takeaways for the Clinician How does this impact you as a clinician? First, you may see older transgender clients who have already transitioned, who come to see you for reasons unrelated to their gender identity. It is useful to remember that these people may have suffered stigma and isolation for many years, since acceptance of transgender people in mainstream culture is recent, and only partial. They may exhibit PTSD-​like symptoms, the result of multiple aggressions and micro-​ aggressions. They may even feel isolated from younger transgender people who did not suffer the same difficulties. These clients may benefit from support groups for older trans people, not because they need help in ‘coming out,’ but because they need to increase their contact with others and build a strong network of nurturing friends. Second, if you are working with adults who are in the process of transitioning, remember that they may not be accurate assessors of their ability to pass. The joy and relief of transitioning may color their perceptions of themselves. This can be a tricky situation for a clinician. Terry, for example, was attracted to women before and after transition, but post-​surgery she became aware of some attractions to men, and she dated men for a while before she met her life partner. She put up a profile on a popular Internet dating site, and at first her profile did not mention that she was transgender. When she talked about this in therapy, I became increasingly nervous, but

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was too afraid of offending her to bring up my concerns. Terry corresponded with a few men via online messaging for a while, and then made arrangements to meet one in person. Within seconds of meeting, the man realized Terry was a trans woman and became enraged at her ‘deception.’ Fortunately, they were in a public place and Terry was able to escape without harm. After that, she made sure prospective dates knew she was trans before she met them. And after that, I  brought up the issue of dating and ‘passing’ with all my transfeminine clients who were seeking to connect with heterosexual men. As I  said earlier, transgender adults may face barriers with institutions such as rehabilitation centers, shelters, or prisons that segregate people by gender. A  few years ago I  was asked to assess Aleah, a 36-​year-​old transgender woman who had entered residential drug treatment as an alternative to jail. For the entire time she was there, she was housed with men who verbally and physically harassed and assaulted her whenever there were no staff members present. And Bernice, a 45-​year-​old trans woman, was homeless and often slept in parks because she found it so frustrating to argue with shelter staff who did not want her in the woman’s shelter. Your role in these situations may be, when possible, to advocate for your client. Transgender men, who often have an easier time ‘passing’ than transgender women, face different challenges. Many identified as butch lesbians for years before ‘coming out’ as trans. They may want to continue to be part of the gay community but face hostility from other gay women. Some trans men, who are attracted to men, identify as gay men after transition and may experience discrimination from the gay male community as well. In summary, working with adult transgender men and women sometimes involves helping them with transition-​related issues, but may also consist of aiding clients in navigating a world where they will face discrimination from cisgender straight people, from institutions and businesses –​and sometimes from gay men and lesbians. Your work thus will include education and advocacy as well as psychotherapy. References Badgett, M. L., Choi, S. K., and Wilson, B. D. (2019). LGBT Poverty in the United States. Report by the Williams Institute. https://​​wp-​content/​ uploads/​National-​LGBT-​Poverty-​Oct-​2019.pdf Beemyn, G. and Rankin, S. (2011). The Lives of Transgender People. Columbia University Press. Blanchard, R. (1989). The concept of autogynephilia and the typology of male gender dysphoria. Journal of Nervous and Mental Disease, October 1989, 616–​623. Cornell University Public Policy Research Portal. (2018). What we know: What does the scholarly research say about the effect of gender transition on transgence well-​being? https:// ​w​topics/ ​l gbt-​e quality/​% 20what- ​doesthe-​scholarly-​research-​say-​about-​the-​well-​being-​of-​transgender-​people%20/​

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Danker, S., Narayan, S. K., Bluebond-​Langner, R., Schechter, L. S., and Berli, J. U. (2018). A survey study of surgeons’ experience with regret and/​or reversal of gender-​ confirmation surgeries. Plastic and Reconstructive Surgery–​Global Open, 6(9S), 189. Dhejne, C., Öberg, K., Arver, S., and Landén, M. (2014). An analysis of all applications for sex reassignment surgery in Sweden, 1960–​2010: Prevalence, incidence, and regrets. Archives of Sexual Behavior, 43(8), 1535–​1545. Hess, J., Henkel, A., Bohr, J., Rehme, C., Panic, A., Panic, L., Rossi Neto, R., Hadaschik, B., and Hess, Y. (2018). Sexuality after male-​to-​female gender affirmation surgery, BioMed Research International, 7. Human Rights Equality Index. (2019).​campaigns/​corporate-​equality-​index James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., and Anafi, M. (2016). The report of the 2015 US Transgender Survey. National Center for Transgender Equality. Monstrey, S. J., Ceulemans, P., and Hoebeke, P. (2011, August). Sex reassignment surgery in the female-​to-​male transsexual. Seminars in Plastic Surgery 25(03), 229–​244© Thieme Medical Publishers. Moser, C. (2009). Autogynephilia in women. Journal of Homosexuality, 56(5), 539–​547. Nadal, K. L., Davidoff, K. C., and Fujii-​Doe, W. (2014). Transgender women and the sex work industry:  Roots in systemic, institutional, and interpersonal discrimination. Journal of Trauma & Dissociation, 15(2), 169–​183. Platt, L. F. and Bolland, K. S. (2018). Relationship partners of transgender individuals: A qualitative exploration. Journal of Social and Personal Relationships, 35(9), 1251–​1272. Rachlin, K. (2018). Medical transition without social transition: Expanding options for privately gendered bodies. Transgender Studies Quarterly, 5(2), 228–​244. Serano, J. (2016). Whipping Girl: A Transsexual Woman on Sexism and the Scapegoating of Femininity. Hachette UK. World Professional Association for Transgender Health (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-​Nonconforming People. 7th version. World Professional Association for Transgender Health, https://​amo_​hub_​​Association140/​files/​Standards%20of%20Care,%20V7%20 Full%20Book.pdf



ifteen-​year-​old Reilly sat in my waiting room with her mother, looking poised and self-​assured. I was a little surprised. Reilly was assigned male at birth and, according to my intake notes, was seeking help because she considered herself to be transgender. In 2008 this was still a comparative rarity, and I was struck by the fact that she wasn’t even a little bit nervous. I was to find out, as I got to know Reilly, that this was part of her personality; for a young person, she had tremendous self-​confidence. In my office that day, she explained that she had always been gender non-​conforming. From toddlerhood, she loved dresses, Barbie dolls, and all things girly and feminine. Her feminist mother supported her, even when she had to battle nursery school teachers and judgmental neighbors. As Reilly got older, she remained gender nonconforming: her friends were girls, not boys, she preferred dance classes to sports, and experimented with pink nail polish and make-​up. By the time she was ten she longed to be a girl, although she didn’t voice this desire immediately. She said she went to bed every night praying that during the night her penis would be replaced by a vagina. In some ways Reilly and I were an unlikely match. The family lived in an exclusive gated community in North Jersey, and though extremely loving and politically liberal, material goods clearly mattered. Reilly herself was somewhat fashion and name-​brand obsessed. She and I could not have made a greater contrast, she perfectly groomed and outfitted in Nordstrom’s best, me in my hippie tie dye and no-​name shoes and bags. I greeted her that first day the way I great all my transgender adolescent and adult clients. ‘Hi, Reilly! Is that the name you would like me to call you? And what pronouns would you like me to use?’ I was the first adult outside her family that acknowledged and respected her affirmed gender. Her fact lit up. ‘Reilly,’ she said, ‘Reilly

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works for a boy or a girl. I’m not changing my name.’ She added, ‘And she, her, thanks for asking!’ Reilly hadn’t officially ‘socially transitioned’ yet –​started living full time as a girl –​but her appearance was already pretty feminine. She had a slim, willowy body, collar-​length blonde hair, wore shorts and a pastel green T-​shirt, and had a lightly made-​up face with just a little mascara and tinted lip gloss. Although Reilly had always liked stereotypically feminine things, she was not one of those kids, like Jazz Jennings, who has been so much in the public eye, who ‘knew’ from toddlerhood that she was ‘a girl trapped in a boy’s body.’ In fact, her gender dysphoria spiked as she approached adolescence and she started to realize her body was changing. I was soon to learn how common a trajectory this is, but at the time Reilly was the first teen I saw with this kind of background, and I was very unsure of myself. So I did what I hope you readers would do in a similar situation: I arranged for supervision on the case from a colleague, Arlene Lev, the author of Transgender Emergence, who has been an expert in trans-​affirmative therapy since the 1990s. I spent some time in the first session talking to Reilly and her mom, Allison, together. I  later got to know the Dad as well. Reilly’s parents and her older sister were fully supportive, something I later came to understand was not so common. Allison, who herself had a sister who was a lesbian, felt comfortable in the gay community and had assumed Reilly was gay from the time her little boy asked for princess dresses and baby dolls. She fought for his right to wear pink nail polish to school, until in about third grade, Reilly realized that to avoid bullies he had to confine his most extravagant self-​ expression to home. Although she was momentarily nonplussed when, at age 13, Reilly announced he was transgender, not gay, Allison quickly recovered and went about making herself as informed as possible. She realized that Reilly was too young for cross-​gender hormones, and information about puberty blockers (more about this later) was not readily available, so she told Reillly that they should wait a couple of years. By age 15, Reilly was restless and impatient to at least socially transition, and so Allison found me. Our Institute for Personal Growth website has a lot of information about transgender issues, and it is clear from what we have that we are affirming and non-​pathologizing, so Allison immediately chose to use our services. It didn’t take long for Reilly to push for social transition at school, and it was hard to say no. WPATH used to require what they called the ‘real life test,’ that is, living openly in your affirmed gender –​before authorizing hormone or surgical treatment. While this is no longer a requirement, it’s often a good idea unless circumstances make it impractical or difficult. Reilly, Allison, and I brainstormed about how and when to make the transition, and I had several conversations with the school principal, who was very supportive, and Reilly’s guidance counselor. I was happy to see Reilly make the change to live

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full time as a girl. Social transition is fully reversible. When feasible, it is a great way to check out the concreteness of one’s affirmed identity. Often young people time their social transition to be over the summer between school years, and frequently when they can enter a new school upon transition. Reilly was already a sophomore in high school so, although she transitioned over the summer before her junior year, she went back to the same school where she had been known as a boy. Allison and I both spoke to the principle and guidance counselor before the beginning of the year. They agreed to change Reilly’s gender on the school roster and to instruct teachers to use she/​her pronouns. Reilly wanted to use the girl’s bathrooms but the school was adamant that she use the single occupancy bathroom in the nurse’s office. Today she might be able to use the girl’s room. There is case law that has used the Federal Law Title IX to protect the rights of transgender students, and they are generally allowed to use all the facilities, including dormitories, of their affirmed gender. The school already had a very tough policy on bullying, so we were less worried about Reilly being actually unsafe. Reilly’s transition at school was remarkably easy. Sometimes it is, particularly in communities of people who consider themselves enlightened and progressive. She was accepted into the same clique of girls she had been hanging with back when everyone thought Reilly was a gay boy. She heard some slurs muttered in the hallways, some online bashing through a website that allowed people to post anonymously. But Reilly was –​and is –​tough as nails. The slurs, for the most part, rolled off her back. If they ‘got to’ her, she responded with anger and self-​defense. Here is a typical Reilly story: she was very sexual in high school. She was stunningly beautiful, and she soon discovered that at parties, many of the high school boys, after a few beers, were happy to have her give them blow jobs in a back room. (I had a hard time as a therapist dealing with her sexuality, even though I consider myself a sex radical. Partly it was because I was afraid for Reilly’s safety –​who knew what one of those boys might do once he fully comprehended that his blow job came from a person with a penis? But in addition, Reilly’s complete lack of shame about sex caught me off guard; most sexually active young girls worry at least a little about being called a slut. Reilly didn’t care.) One boy with whom Reilly had such a liaison actually started to hang out with her, surreptitiously, over a school vacation. Reilly convinced herself there was a relationship between them. When school started up again, the boy acted like he didn’t know Reilly. In hurt and anger, Reilly posted on Facebook: ‘You were happy to acknowledge me when I was giving you a blow job at Mike’s party last month.’ I was astonished to find out that the parents of the boy complained to Reilly’s school about the Facebook post. Their son’s behavior didn’t bother them at all. Reilly was pleased to cause such a stir.

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Although Reilly was mostly finished with puberty when I  first met her, I referred her to a highly experienced pediatric endocrinologist in New York, and he put her on puberty blockers to prevent further deepening of her voice or more height growth. When she was 16, I  referred her for cross-​gender hormones without hesitation; there was no doubt about her gender identity. Reilly was voted queen of her high school prom. The night of the prom I was terrified. My mind kept flashing scenes from the horror movie Carrie, where a socially awkward, bullied girl is pranked by school mates who vote her queen and then douse her in pig’s blood. I urged her to text me afterwards. She was fine, and since that time other trans teens have been prom queens, but at the time it was unheard of. As soon as she was 18 she got ‘bottom surgery’ –​vaginoplasty. One worry I  had about Reilly was that her vision of the future seemed unrealistic to me. She wanted to ‘go stealth,’ which in the transgender community means pretending you are cisgender. Some transgender people are commonly seen by others as transgender: their size, their voice, their mannerisms register with others as a little discordant with their gender presentation. Other transgender people, like Reilly, are rarely suspected to be transgender unless they self-​disclose. People like Reilly have the option of ‘going stealth,’ and if they do, they don’t tell friends, co-​workers, acquaintances, sometimes not even love partners, that they are transgender. In fact, Reilly envisioned never even telling her husband-​to-​be, and somehow having a life in which she replicated the upper-​middle-​class life of her mother, except that her children would be adopted. I quickly gave up trying to get her to closely examine her vision. I  assumed she would learn through experience what worked in her life. When Reilly went to college, she applied as a transgender student, and dormed with female roomates, but neither the school nor she divulged her transgender status to fellow students. Eventually Reilly started to find the secrecy burdensome. When she finished college, she was ‘out’ to many friends, but tended not to tell the guys she dated. This was a dangerous tendency, one I tried to talk Reilly out of. ‘Going stealth’ isn’t foolproof, and it seemed clear that some of the men she dated figured out she was transgender. Reilly was never physically attacked or threatened, but she was ‘ghosted’ several times by guys with no explanation. I’ve stayed in contact with Reilly throughout the years. She is now a successful publicist in Hollywood, totally ‘out’ about being a trans woman, and something of an activist for transgender causes. She recently told me she regretted spending so much time trying to ‘go stealth’: ‘I spent five years trying to pretend I was a cis woman until I finally accepted who I am. Now I’m proud of being trans.’ Reilly’s change of perspective is symbolic of changes in the larger transgender community. While it was once true that the goal of most transgender people was to ‘pass’ as cisgender, more and more trans folk are feeling pride in identifying as transgender.

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The Trans Youth Explosion The number of transgender children and teens has increased dramatically since the turn of the twenty-​first century. Clinics that treat trans kids report that they are seeing at least five times the number of clients they saw formerly, and there is also a change in gender ratio. Trans boys  –​children assigned female at birth who affirm a male identity –​were once rare, and now equal or even exceed the number of trans girls. This is exactly what we have observed at the Institute for Personal Growth. While Reilly was the first early adolescent trans person we saw, in 2008, since then the number of trans youth has grown so rapidly that we now get two new client referrals a week. The explosion of transgender youth is not fully understood. In part, it is driven by parents who are more supportive of diverse gender expression in their children, and a culture that is a bit more flexible about gender roles. In my experience, it mirrors what happened with gay and lesbian youth 40 years ago. As our culture became more accepting of gay people, they started ‘coming out’ at younger and younger ages. Most gay people now recognize their homosexuality, and reveal it to others, when they are teenagers. Similarly, as transgender people are more accepted by, and more visible in, the mainstream culture, it becomes safer to acknowledge one’s divergent gender identity at a young age –​and to tell others. And the data support this conclusion: a 2019 Williams Institute report broke down transgender identified respondents by age and found the percentage increases in younger age groups: 0.5% of adults 65 and older identify as transgender, compared to 0.7% of those 24 or younger (Herman et al., 2017). Most GSA’s –​Gay Straight Alliances –​in high schools now include at least some trans and nonbinary teens, and PFLAG –​Parents and Friends of Lesbians and Gays –​is dominated by parents of transgender kids. It is also not clear why the gender ratio has changed so radically. In retrospect, it seems clear that, in the past, young girls who felt like boys, and were attracted to other girls, became ‘butch’ lesbians. Although not living as men, in the gay women’s community they were able to have a more or less male gender presentation, and were respected and eroticized by more feminine lesbians. Thus, it was easier for some trans men to hide –​to accommodate to living as women, because they were living as masculine-​presenting women. No such niche identity existed for transgender women. Indeed, until recently, most trans boys first identified as lesbians. In the last few years, as trans boys become more common and visible, the intermediary step of identifying as a lesbian has become less common. Moreover, more trans boys are reporting attractions to males instead of, or in addition to, attractions to women. Co-​morbid Conditions in Transgender Adolescents Even though I now consider Reilly an ‘easy case,’ I also understand that working with transgender adolescents is confusing –​and somewhat nerve-​wracking –​for

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many practitioners. Most therapists got little or no training on gender identity in grad school, and certainly no preparation for working with gender dysphoric youth. Hormone therapy is partially irreversible, and the idea of endorsing a medical intervention like this for teens who are in many cases not old enough to drive, drink, or vote is daunting. To complicate matters, many transgender teens have what are called ‘co-​morbid conditions’ –​other mental health problems like depression, anxiety, or suicidality. In fact, a 2018 study in Pediatrics found that about 50% of transgender children and teens suffered from depression, and that their rates of self-​harming behaviors and suicidal ideation were much higher than for similar cisgender adolescents (Toomey, Syvertsen, and Shramko, 2018). There is some evidence as well that the rates of autism spectrum disorder may be higher among transgender youth (Strang et al., 2018), although the jury is still out on that, with some claiming that although rates are higher in clinic populations, they are not higher in the general population. What is clear is that transgender teens with co-​occurring autism spectrum disorder are frequently misdiagnosed. Their gender dysphoria may be considered an ‘obsessive symptom,’ and so they do not receive the treatment they need. In addition, young trans people on the spectrum may express their gender identity in different ways. Some, for example, need medical intervention before any social transition can take place. They simply do not feel comfortable presenting in their affirmed gender identity until they feel their body ‘matches’ their identity a bit more. Teens with co-​morbid conditions can be confusing to a clinician, raising the fear that somehow the transgender identity is related to their other mental distress. I have heard therapists raise the following concerns, among others:  the client’s trans identity is a symptom of their OCD; the client’s trans identity is a symptom of their ASD; a client’s trans identity is a result of past trauma. While I do not rule out these possibilities, it is best to proceed as if the co-​morbid condition is not a causal factor in the client’s gender identity. This is because the evidence points to the opposite being true:  it is more likely that the co-​morbid condition is at least exacerbated by the distress caused by identifying as trans in an environment that is not supportive. Frequently the co-​occurring depression, anxiety, suicidality or self-​ harming behavior dissipates or reduces in frequency when the client’s trans identity is acknowledged and validated. Norman Spack, M.D., is the co-​ founder of the first United States clinic to treat children and adolescents with puberty suppressing drugs, at Boston Children’s Hospital in 2007. In 2012 Spack published a paper in Pediatrics reporting results of the first 97 patients treated in his clinic. At intake, more than 50% of these youth evidenced serious co-​morbid mental disorders, including suicidality and self harm (Spack et al., 2012). After treatment, most of these conditions had dissipated, leading Spack to conclude:

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Our observations reflect the Dutch finding that psychological functioning improves with medical intervention and suggests that the patients’ psychiatric symptoms might be secondary to a medical incongruence between mind and body, not primarily psychiatric. (p. 423) The WPATH SOC affirm that co-​morbid conditions, while they should be treated, should NOT be a barrier to treatment for gender dysphoria. In other words, the most prudent course of action when working with an adolescent who also exhibits signs of another mental health condition is to treat the gender issues, expecting that there may well be improvement in overall mental health as well as an alleviation of distress about gender identity. Case Vignette James’ mother brought him to IPG when he was 13. Besides identifying as a trans boy, James suffered from a host of other disorders. He had been assaulted as a child, which left him with post traumatic stress disorder. He spent a year being entirely mute. He had cut himself extensively, and suffered from severe and chronic depression. James had been hospitalized three times for suicide and undergone treatment in four different Intensive Outpatient Programs. The therapists at IPG were the first people in his life to call him by his chosen name and use his preferred masculine pronouns. His father refused to believe he was transgender; his mother wanted to support her child but was confused about what direction to take. His school simply ignored his trans identity; all teachers and school administrators called James ‘Penelope,’ his birth name, and looked the other way when peers taunted and bullied him. James could be the poster child for the efficacy of affirmation in dissipating mental distress. I saw James for individual sessions while another IPG therapist worked to help his mother become accepting, and James made good friends while attending our group for transgender teens. James’ depression lifted, his self-​harming ceased, and he only had one more instance of suicidality and a brief hospitalization: when his father withdrew permission for James’ treatment and forced him to leave therapy. The good news is, some months later, a family judge gave James’ mom the sole ability to make medical decisions for him. Today, James is in college, taking testosterone, and preparing for ‘top’ surgery scheduled for next year. However, co-​morbid conditions, while not causing young people to be transgender, can occasionally be a reason to slow down transition. Jewel was a 16-​ year-​old trans girl whose anxieties and school phobia had caused her parents to withdraw her from high school and homeschool her. She was so dependent on her mother that it was difficult for Jewel to be alone or even to socialize with peers without her mother present. When Jewel saw me for treatment,

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within weeks she was able to acknowledge that her anxiety and dependency caused her great problems. She was also able to agree that her decision to use cross-​gender hormones might best be postponed. ‘Yeah,’ she said, ‘I guess maybe I should wait to decide about hormones until I can at least go to the corner store by myself.’ For some months, therapy focused on giving her tools to manage her anxiety and on increasing her ability to separate from her mother. We used some CBT (cognitive behavioral therapy) techniques, processed some past memories of situations that caused her pain and fear, and did some sessions with her mother, who needed to learn to let go. Ultimately, Jewel was both able to go to the corner store and begin estrogen treatment. Two Paths to a Trans Identity Just as I  was initially insecure about working with Reilly, many clinicians are a bit nonplussed when presented with a teenage client who affirmed a transgender identity only after hitting adolescence. We have all been exposed to stories of children like Jazz Jennings, who declared she was a girl before the age of five. While many transgender people affirm their gender at an early age, it is actually at least as common for this recognition to not appear until adolescence, especially for children assigned female at birth. For many young people, the discordance between their bodies and their internal experience doesn’t ‘hit’ them until their body starts to develop the secondary sex characteristics of their assigned gender. In addition, many trans boys, assigned as females at birth, have had free gender expression as children: they are viewed as ‘tomboys.’ Often, they are neither teased nor questioned about their atypical gender presentation while young, and they may receive positive accolades for athletic accomplishments. Trans girls rarely are indulged in the same way. The pressure to adopt a transgender identity is stronger, because there is little social tolerance for young boys who act ‘girly.’ Trans adolescents also often go through a period where they are trying to sort the difference between their sexual orientation and their gender identity. This makes sense when one realizes that both gay men and women, and transgender men and women, tend to be gender nonconforming as children. So Reilly, for example, described in the beginning of this chapter, was always attracted to males and briefly considered whether she was a gay man before realizing she was transgender. Similarly, trans boys attracted to girls may first identify as (butch) lesbians before coming out as trans. While this is understandable, it tends to be very confusing, especially for their parents. I have heard many a parent lament with some puzzlement: ‘I was adjusted to having a gay kid, I accepted it no problem. But I don’t understand this.’ My colleagues at IPG who worked with gay adolescents in the 1980s and 1990s often joke that they never imagined hearing a parent say ‘I wish my child was gay.’

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Trauma and the Transgender Child and Adolescent In the last decade or two we have become increasingly attuned to the harm done to young people by others in the form of bullying and/​or exclusion and ‘shunning.’ In Chapter 7 I wrote about the abnormally high rates of bullying suffered by LGBTQ+ young people. Data show that, among LGBTQ+ youth, gender-​nonconforming young people are bullied more than any other ‘queer’ people. Since most transgender adolescents were gender non-​conforming children, many enter puberty with a history of peer-​induced violence and trauma. Adolescence may be no better than childhood. A 2014 study of 7,000 transgender teens found that (Chances, 2014): •​ 83 per cent of trans young people say they have experienced name-​ calling and 35 per cent have experienced physical attacks. •​ Almost a third (32 per cent) of trans young people say they have missed school lessons due to discrimination or fear of discrimination. •​ Over a quarter (27 per cent) of trans young people have attempted suicide. In addition to peer bullying, transgender youth suffer abuse from their parents at higher rates than cisgender young people, and many are thrown out of their homes. The youth homeless population is disproportionately made up of transgender teens and young people. Research has shown that parental acceptance, besides preventing homelessness, has a protective effect on young transgender people. It may mitigate against the trauma of peer bullying. The TransPulse study of 2012 found that the level of suicidality among trans youth not supported by their parents was 57%, while the rate for those with parental support and acceptance was 4% (Travers, Bauer, and Pyne, 2012). These numbers dramatically underscore the importance of working with the parents of transgender adolescents to help them learn to nurture their children. Medical Intervention There are some medical interventions available to teens under appropriate conditions. First, for children at early ages of puberty, puberty blocking medications may be recommended. Puberty blockers (or just ‘blockers’) are Gonadotropin-​releasing hormone (GnRH) agonists used to temporarily inhibit or suppress puberty. Historically, blockers have been used in treating precocious puberty, a condition where children begin puberty at an abnormally early age. More recently, they have been used in treating gender dysphoric youth. Blockers suppress puberty by inhibiting the production of testosterone and estrogens, the hormones responsible for triggering the

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development of physical secondary sex characteristics in children and teens. They have been used in the Netherlands for several decades and in the US since about 2005. There are several reasons to use these medications. First, as we’ve indicated earlier, the physical changes of puberty cause great distress for many transgender children, and puberty blockers alleviate this. Second, since puberty blockers are fully reversible when use is ceased, they provide a safe ‘time out’ for transgender youth to decide if they are fully committed to a gender transition. Typically, it is recommended that the use of puberty blockers be accompanied by social transition. If the young person changes their mind, blockers are withdrawn and the individual commences puberty in their birth-​assigned gender. Finally, if after some time the teen, now living in their affirmed gender, shows certainty about their transition, puberty blockers can be replaced by cross-​gender hormones, allowing the person to experience puberty with the secondary sex characteristics of their affirmed gender. For example a birth-​assigned male with a female gender identity might be placed on blockers at the first sign of male puberty as determined by Tanner Staging, a medical model based on physical changes. At Tanner Stage 2, birth-​assigned males experience an increase in testicular volume. Introducing puberty blockers will prevent the development of facial and body hair, will inhibit a growth spurt, deepening of voice, changes in body contouring, and the development of sperm. If during the two to four years this young person is taking blockers and living as a female they change their mind, blockers are withdrawn and male puberty immediately commences. If, however, the youth continues to affirm a female identity and is later placed on estrogent, puberty will progress as if the person had been born female: height will be more appropriate for a female, and breasts, body contouring, and fat distribution will develop as a female. The advantages are multiple: the teen does not have to experience the extreme distress that would develop as their male body develops, and when they are put on cross-​gender hormones their body will develop to look like a birth-​assigned female. Among other things, this makes the trans person safer:  the violence against transgender people described in Chapter 17 is directed primarily at people who are ‘clocked’ –​ recognized as being transgender  –​and people who use blockers and then cross-​gender hormones are usually indistinguishable from cisgender people of their affirmed gender, except for genitals, of course. However, there are some controversies associated with puberty blockers, and unknowns about the prolonged use of these agents, which will be explained in the next chapter. Cross-​gender hormone treatment is the same for adolescents as it is for adults. The WPATH SOC recommend the use of cross-​gender hormone treatment at age 16 or older. This has caused controversy because natal girls, for example, can be eligible for blockers as early as age nine, and it is problematic to freeze development in these individuals for seven years. Therefore,

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many medical practitioners are administering cross-​gender hormones to kids on blockers much earlier, as early as 13. I will go into more depth about issues raised by these medical practices in the next chapter. The WPATH SOC recommend ‘top’ surgery for assigned females –​double mastectomy and chest reconstruction –​at the ‘age of majority,’ or younger for those living in their desired gender role and taking cross-​gender hormones for at least a year. In the US, chest reconstruction surgery is frequently done at age 15 and sometimes younger. ‘Bottom’ surgery is not typically done on those younger than age 18, although there are exceptions –​and the exceptions will probably become more frequent as time goes on and more young trans people are placed on blockers at an early age. Is it Gender Dysphoria or a Fad? The Truth about ROGD Most of the increase in the numbers of transgender youth seeking treatment is accounted for by an increase in trans teens, and particularly trans boys. This has led to speculation and controversy. Although there is no data to support this theory as of this writing, many observers of adolescents believe that there is a ‘social contagion’ effect that is influencing youth. In other words, the theory is that being transgender has become ‘cool,’ and that clusters of kids from the same school or social group are all declaring they are transgender at the same time. Some studies have shown social contagion to be a factor in suicidality and eating disorders among teens. There are people who believe this is happening in high schools and even middle and grade schools across the United States, people who say they have observed clusters of teens who rapidly ‘come out’ as transgender right after someone in their friend circle has done so. Some of these people feel that ‘gender-​affirmative’ therapists are dangerously aiding and abetting a fad that can have disastrous consequences, leading to irreversible medical interventions that are unnecessary and which the person may come to regret. Groups of parents are working hard to promulgate these ideas, in concert with a few professionals who also object to the gender-​affirmative model I’ve described here. They have given a name to this social contagion effect they believe they are seeing: ROGD (Rapid Onset Gender Dysphoria). Their point of view converges with that of some Christian far-​right activists, and have been used by these activists to introduce legislation in several states that would make medical intervention for any transgender person under 18 illegal. In January 2020, South Dakota became the first state in the US to pass such a law. It remains to be seen what will happen if and when the law is challenged. In the UK, as of April 2020 surgical interventions are banned for transgender youth under the age of 18. The most prominent of the parent groups is the online group www., Parents of ROGD Kids. Trans-​affirmative therapists

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and allies are pushing back against what they see as a dangerous and regressive trend. Many of them, including me, are part of, Gender Dysphoria Affirmative Working Group, and the website contains, among other things, critiques of the ROGD position. There is only one study of ROGD, Lisa Littman’s survey of parents (Littman, 2018). No researcher has talked to actual young people who are alleged victims of this disorder, nor have any studies examined whether the observed ‘clusters’ really exist. So what is the truth of this? I have my own fears about social contagion, but not because I  think being transgender is now ‘trendy’ among young people. I don’t think ‘being cool’ is a sufficient motivation to propel someone to turn their life –​and their body –​upside down by itself. The adolescents I worry about are the kids who have always been a little bit weird, or odd, or on the fringe, who are depressed and feeling isolated. I worry that for some of these kids, being transgender is an identity that gives them a reason for their feelings of differentness and isolation, while also giving them a clear path forward. Rosalinda, birth name Roy, was 18 when she and her mother came to see me six years ago. Assigned male at birth, Roy had always been ‘different’: shy, socially awkward, anxious –​and alone. Four months before coming to see me, Roy began attendance at a very liberal East Coast college with a visible presence of transgender students, and within two months Roy declared she was transgender, and changed her name and pronouns. As Rosalinda, she appeared in my office and demanded a letter for cross-​gender hormones. I  pointed out that she could get hormone treatment without a letter from me, at an LGBT health center such as Callen-​Lorde Center in New York, and that if she wanted to work with me I would not write a letter until we had at least two or three months’ worth of regular sessions. Rosalinda was the first teen I saw whose gender identity I questioned, but even had that not been the case, my policy is not to see people simply for assessments and letters. Furious, Rosalinda fired me. I’ve always been curious about Rosalinda. For a couple of years after she fired me, her public Facebook posts would occasionally appear on my Facebook feed. She appeared to be continuing to live as a female. But this has not happened for some time, so I have no way of knowing whether her gender identity has endured, or whether I was right to be nervous. I have no doubt that there are some young people who will erroneously embrace a transgender identity. I see no evidence, however, that this is widespread, and look forward to seeing some actual research on this currently ‘theoretical’ issue. Working with Transgender Adolescents The role of the therapist is different when working with a trans adolescent, as opposed to an adult. For example, the WPATH SOC do not recommend an informed consent procedure for minors. This means, in the United States,

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that people under the age of 18 must get a letter of support from a mental health practitioner before they can begin hormone treatment. In other words, we are still ‘gatekeepers,’ to a certain extent, a role that gives us power, but also increased responsibility. Parents often look to us for guidance, which is added responsibility. To add to the burden, adolescents are not known for making prudent, well-​thought-​out decisions in general, and the medical decisions made around gender transition will impact them drastically for their entire lives. When I started working with transgender teens and kids, several colleagues politely told me I  was crazy to do so. I  don’t regret my decision, but I empathisize with any clinician who feels that the weight of these responsibilities, combined with the relative lack of knowledge about long-​term outcomes for trans youth, is too overwhelming to want to take on. I greet new adolescent clients the same way I greet adults: I ask for preferred name and preferred pronouns. I respect the adolescent’s gender identity as real and authentic. But I do not assume that they will always endorse that same gender identity. The criterion for determining who is transgender is sometimes distilled to this: the identity is deep-​seated if it is ‘persistent, insistent, and consistent.’ In other words, if the person has endorsed their gender identity over a substantial period of time, without ambivalence, and with a sense of urgency, one can assume it is not only authentic but enduring. When I  see an adult transgender person, they have usually experienced themselves in their affirmed identity for years before taking any steps toward transitioning. But teens and children can run the gamut, with some consistently presenting themselves as their affirmed gender for years  –​and others for mere months. This means the job of assessment cannot simply be a rubber stamp for what the teen tells you. My assessment with young people spans weeks and often months. I want to know the teen’s history of gender nonconformity and having feelings of being the ‘wrong sex,’ to whom, where, and under what circumstances they have expressed this, how much they know about the reality of transition and of living in a gender other than the one to which they were assigned at birth. I want to make sure there are not other explanations for their dysphoria:  general body dysmorphia? A  reaction to trauma? Peer influence? Difficulties with sexuality or the gender roles assigned to their birth sex? I insist that trans teens meet others like them, ideally by attending peer support groups for trans and gender-​ nonconforming young people. I  push for social transition  –​what used to be called the ‘real-​life test’ –​before endorsing cross-​gender hormones. I am rather quick to recommend puberty blockers, because they relieve stress, give a ‘time out’ period, and are fully reversible. But I am also clear that the time on puberty blockers is an experimental period and does not automatically lead to hormones or other medical intervention. And of course, the entire time I am also working with the family to provide support no matter what the ultimate outcome of gender-​affirmative treatment.

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When puberty blockers and/​ or cross-​ gender hormones are being considered, it is crucial to discuss fertility both with the adolescent client and their parents. There are special issues for those placed on puberty blockers, which I will consider in the next chapter. For teens who have not been on blockers, fertility concerns are somewhat more straightforward, but still problematic (Cheng et  al., 2019). Testosterone therapy for trans men can suppress ovulation and alter ovarian histology; estrogen therapy in transgender women can produce testicular atrophy and impair sperm production. These effects are potentially reversible, but there is not enough data to confirm how often this is the case, or how prolonged hormone treatment may alter fertility. Gender-​affirming surgeries may produce permanent sterility, for example, orchiectomy for trans women, which removes testicles. There have been instances of transgender men who have not had hysterectomies or oophorectomies becoming pregnant after discontinuing testosterone treatment, and situations where trans women who have not undergone ‘bottom’ surgery have produced viable sperm. However, it is important to discuss fertility with all your transgender clients. Cryopreservation of sperm or ooctytes or embryos is possible. But egg preservation is expensive, costing tens of thousands of dollars to retrieve, store, and then thaw the eggs. Cryopreservation of sperm is less costly, but still beyond the financial reach of many adolescents and their families. Reilly, the teen described in the beginning of this chapter, chose to freeze some of her sperm before beginning hormone therapy. Most of the adolescents I have counseled were either not interested in this approach or couldn’t afford it. Fertility concerns add to the sense of responsibility many therapists feel about counseling this population; therapists who have biological children of their own may have a particularly difficult time with countertransferential feelings. One other element of paramount importance to a therapist working with this population:  it is critical that you develop a referral system of knowledgeable and affirmative pediatric endocrinologists and pediatricians. Our experience is that medical professionals working with trans teens and kids usually rely on input with trusted clinicians, and that they are eager to collaborate. In this way, some of the responsibility involved in this work is shared among a team of professionals, parents, and child. Takeaways for the Clinician Working with transgender and gender-​nonconforming teens is fraught with uncertainties and difficulties. The clinician who chooses to be in this role will be of necessity a gatekeeper of sorts, helping the child, parents, and medical professionals choose if and when to initiate medical interventions. Therapists working with this population must be versed in family therapy or work closely with colleagues who can assist the families. Family support has been proven

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to be critical to the wellbeing of transgender kids and teens, so clinicians must be able to gain the trust not only of the teen but of their parents. In addition, clinicians must be familiar with medical interventions and have connections to pediatric endocrinologists and other medical experts. Further, therapists may be called upon to educate school personnel and/​or parents of your client’s peers. Advocacy may be required, and you should be familiar with educational policy in your geographic area concerning the treatment of transgender students. If you are prepared for it, this work can be highly rewarding, as you will see some adolescents with abundant histories of co-​ morbid mental health conditions ‘get better’ quickly once gender-​affirmative methods are employed, they are validated and supported, and they get the treatment they need. References Chances, M. Y. (2014). Youth Chances Summary of First Findings:  The Experiences of LGBTQ Young People in England. METRO. Cheng, P. J., Pastuszak, A. W., Myers, J. B., Goodwin, I. A., and Hotaling, J. M. (2019). Fertility concerns of the transgender patient. Translational Andrology and Urology, 8(3), 209. Herman, J. L., Flores, A. R., Brown, T. N. T., Wilson, B. D. M., and Conron, K. J. (2017). Age of Individuals Who Identify as Transgender in the United States. The Williams Institute. Littman, L. (2018). Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria. PLoS One, 13(8), e0202330. Spack, N. P., Edwards-​Leeper, L., Feldman, H. A., Leibowitz, S., Mandel, F., Diamond, D. A., and Vance, S. R. (2012). Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics, 129(3), 418–​425. Strang, J. F., Powers, M. D., Knauss, M., Sibarium, E., Leibowitz, S. F., Kenworthy, L., Sadikova, E., Wyss, S., Willing, L., Caplan, R., Pervez, N., Nowak, J., Gohari, D., Gomez-​Lobo, V., Call, D., and Anthony, L. G. (2018). ‘They thought it was an obsession’:  Trajectories and perspectives of autistic transgender and gender-​diverse adolescents. Journal of Autism and Developmental Disorders, 48(12), 4039–​4055. Toomey, R. B., Syvertsen, A. K., and Shramko, M. (2018). Transgender adolescent suicide behavior. Pediatrics, 142(4), e20174218. Travers, R., Bauer, G., and Pyne, J. (2012). Impacts of Strong Parental Support for Trans Youth:  A Report Prepared for Children’s Aid Society of Toronto and Delisle Youth Services. Trans Pulse.



did a double take when I walked into the waiting room and saw Dinah and Joel with their three year old son, Tal. I  had never worked with a child that young; the parents had brought Tal to see me not because of my expertise in play therapy (I had none), but because of my experience with what are sometimes called ‘gender-​expansive’ or ‘gender-​creative’ children. Tal had been telling them for some time that he wished he were a girl, that he hated his primary color boy’s clothes, that he wanted to grow his hair long like his mother. Now Tal sat on the floor of my waiting room coloring, having been told he was here to see a ‘feelings doctor’ to whom he could talk to about wanting to be a girl. Tal’s parents were trying to be supportive. They had learned as much as they could about children like theirs through information they found on the Internet. They allowed him to play with dolls, dress in scarves he tied around his waist to simulate skirts, and put towels on his head as faux wigs. But they faced a dilemma in a few months. Tal was turning four and it was time to put him in pre-​school. But there was a hitch. Joel and Dinah were Orthodox Jews who wanted their children to attend religious schools, and in the Orthodox community where they lived, nursery schools were strictly divided by gender. Tal, whose friends were all girls, would have to go to an all-​boys program. His parents were sure it would be a disaster, and they didn’t know what to do. I spent a little time with Tal, who was quite verbal for a child his age. Although he clearly stated his wish to ‘grow up and be a girl like Mommy,’ he was just as clear that he was a boy. As I will write about later, pre-​pubescent gender-​diverse children may grow up to be transgender, but they are also likely to grow up to be gay. Young children who say ‘I want to be’ a girl/​ boy are less likely to be transgender than children who say ‘I am’ a girl/​boy.

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I spent most of the session with Joel and Dinah. I explained the data on the likelihood of Tal remaining insistent upon becoming a girl:  at Tal’s age, it was difficult, if not impossible, to predict an outcome. We discussed ‘social transition’ –​the idea that Tal might live as the girl he wanted to be. I advised continuing counseling with another therapist in the practice who specialized in children and play therapy, at first for weekly sessions but then for periodic ‘check-​ins’ once or twice a year. I recommended that they postpone the question of social transition: a ‘wait and see’ approach. We tackled the issue of pre-​school. After hearing about the outcome research, the parents agreed with my recommendation that social transition was premature. I emphasized that, without social transition, it was important to provide Tal with places he could be his authentic self in a protected environment. Dinah and Joel realized that an all-​boys school would be far from a safe and comfortable milieu for Tal. They made a decision I have never forgotten, because it demonstrated to me just how supportive some parents are willing (and able) to be. They knew of another Orthodox community, some 50 miles from where they currently lived, that had a reputation for being more liberal, and that had mixed gender religious schools, including pre-​school –​and they decided to move! Most parents are not in a position to make such a drastic change for their child, nor should they have to. However, all parents of gender-​nonconforming children are faced with extraordinary challenges. Recent History of Treatment of Pre-​pubescent Gender-​expansive Children Gender-​diverse children were first officially labeled as ‘disordered’ in 1980. Gender identity disorder of childhood appeared in the third edition of the Diagnostic and Statistical Manual of the American Psychiatric Association in that year. Beginning in the 1960s, some psychologists and psychiatrists became interested in the ‘problem’ of feminine boys. Effeminacy in male children was seen as leading to a homosexual or ‘transsexual’ outcome, and in the era before even a sliver of cultural acceptance of homosexual or transgender people, it was seen as highly desirable to prevent these outcomes. Homosexuality had always been seen as pathological; Christine Jorgensen’s case became widely publicized in the 1960s and inflamed worries about children growing up to be ‘transsexual.’ At Johns Hopkins and UCLA, in particular, some psychiatrists and psychologists began treating ‘feminine’ boys in an attempt to give these children a ‘normal’ –​that is, cisgender heterosexual –​adulthood. Prominent clinicians/​researchers were Richard Green, John Money, Robert Stoller, and George Rekers (Green, 1987; Rekers, 2009). Rekers developed a behavior modification protocol to change the boys’ behavior from ‘effeminate’ to ‘masculine,’ and this treatment is still practiced by some today. Interestingly, the focus of these professionals was

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only effeminate boys; tomboy girls, while seen by some as problematic, were rarely subjected to this attempted conversion therapy. Follow-​up studies of these children as adolescents and young adults found that most grew up to be gay or bisexual men, while some were transgender women. This treatment was controversial right from the beginning. Children were ‘rewarded’ for stereotypically masculine behavior and ‘punished’ for stereotypically feminine actions and desires. Mothers were encouraged to spend less time with their sons, fathers to spend more. Feminist psychologists critiqued this emphasis on developing stereotypical male behavior and traits as sexist, and considered the treatment to be a perpetuation of the status quo of inequality. Later, after it had been determined that most of these children grew up to be gay or bisexual men, gay psychotherapists labeled this treatment ‘reparative therapy for pre-​homosexual boys’ (Isay, 2010). With the advent of transgender activism in the 1990s, the treatment was condemned as conversion therapy for young transgender and gender-​ nonconforming children. While UCLA and Johns Hopkins abandoned this treatment decades ago, until recently it was used extensively in Canada by Kenneth Zucker and his team at CAMH (the Center for Addictions and Mental Health). In 2015, after Canada enacted a law banning conversion therapy, Zucker was fired and his clinic shut down. However, this decision was contested, not only by Zucker but also by other professional allies of his. In fact, a letter sent in January 2016 to the CAMH Board of Directors protesting Zucker’s firing was signed by more than 500 professionals. Those supporting Zucker feel that the field of transgender mental health has been overtaken by transgender activists motivated more by politics than concern for children. Despite the fact that the WPATH SOC 7 explicitly label attempts to change a child’s gender expression or identity ‘unethical,’ there are still professionals in the field who not only believe these treatments to discourage gender-​nonconforming behavior should still be used, but who also actively oppose gender-​affirmative treatment. These are often the same professionals involved in promulgating the concept of ROGD (Rapid Onset Gender Dysphoria) and who decry medical treatment for adolescents and children. This controversy has become increasingly political in the United States. As I  write this, South Dakota has banned medical treatment for transgender minors, and legislators in Texas, Kentucky, Georgia, and South Carolina have introduced laws to ban such treatment. WPATH has weighed in with a statement outlining the evidence for affirmative treatment methods and opposing laws criminalizing treatment, as have a number of professional organizations, such as the American Psychiatric Association, the American Psychological Association, and the American Association of Sex Educators, Counselors, and Therapists. Treatment of transgender and gender-​diverse children and adolescents has become a somewhat high risk endeavor. In the nearly four decades since I was licensed, the only malpractice suit ever filed

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against me was by the father of a trans teen who blamed me for his child’s transition. The 80% Desistance Myth –​‘Maybe It’s Just a Phase’ The controversies surrounding treatment of gender-​ expansive pre-​ adolescents center on two things: early social transition, and puberty blockers. Arguments against these interventions are often centered on the oft-​repeated myth of 80% desistance, the myth that 80% of gender-​nonconforming children will eventually cease to identify as or want to be the opposite sex. The idea, promoted by those who still believe in the efficacy of behavioral shaping interventions and who fear that affirmative treatment ‘encourages’ a transgender outcome, is that most children who are gender diverse will ‘outgrow’ or ‘desist from’ this tendency by adolescence. Kelly Winters has convincingly rebutted this belief. In her chapter in the 2019 book ‘Families in Transition,’ Winters summarizes how the 80% came to be quoted and what is wrong with it (Winters, 2019). In brief, the four outcome studies upon which the statistic is based are seriously flawed: they studied children who had a nonconforming gender expression, but not necessarily a transgender gender identity, and they included anyone not located for follow-​up as a ‘desister.’ We do not know how many children, of those who are genuinely dysphoric, go on to affirm a transgender identity and how many do not. The psychologist Diane Ehrensaft has conceptualized the problem in an interesting way. She maintains that the pool of gender-​expansive children actually consist of three separate types of kids, whom she calls ‘apples, oranges, and fruit salad’ (2016). Apples are children who are grappling with their gender identity, and who will likely ‘persist’ as transgender adolescents and adults. They are the kids who, over years, will be ‘persistent, consistent, and insistent’ in their gender identification. They tend to say ‘I am a (girl/​ boy)’ rather than ‘I wish I was a (girl/​boy).’ They are also often unhappy with their bodies from an early age. Oranges are children who are experimenting with non-​traditional gender expression. Although they may say ‘I wish I was a (boy/​girl),’ they do not insist that they ‘are’ a (boy/​girl). Instead, they rebel against attempts to make them conform to gender stereotypes of presentation or behavior. Frequently, in adolescence they become aware of same-​sex attractions and identify as gay, lesbian, or bisexual rather than transgender. Fruit salad kids are children who are exploring both gender expression and gender identity. They are likely to become teens and adults who identify as ‘gender queer,’ ‘agender,’ or ‘nonbinary.’ If you conceptualize gender-​expansive children in this way, one does not expect all of them to identify as transgender as adults. The job of the clinician, in part, is to try to determine if they are apples, in which case social transition is a realistic intervention. Education of parents includes informing

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them of the distinctions between different types of gender-​diverse children so that they are prepared for possible changes in their child’s expression or identity. Maybe They Are Too Young to Know Many people find it difficult to believe that young children could possibly know that they are a gender different from that assigned at birth. Kristina Olson, a researcher at the University of Washington, has been tracking gender-​nonconforming and transgender kids since 2013. She compares these kids to a matched control group of cisgender kids and to the study subjects’ own siblings. Several of her findings so far are noteworthy (Olson, Key, and Eaton, 2015; Olson et al., 2016). She has found that, when studying children who have not yet socially transitioned, the strength of their cross-​gender identification predicts whether they will socially transition in the future, independent of how liberal or conservative their parents are or the communities in which they live. Olson has also found that cisgender and transgender children perform identically on tests of gender identity and development; in other words, the trans kids are not ‘confused,’ they are just as clear about their gender as comparable cisgender peers. And finally, the transgender children in her study, who are supported and validated by their parents, experience no more depression, anxiety, or other psychological problems than cisgender children. Thus, her research suggests that they ‘know’ their gender identity at an early age; that gender-​nonconforming children who are very strongly cross-​gender identified will be likely to go on to socially transition later; and that trans kids supported in their identity are no more likely to have mental disorders than cisgender children. Treatment for Transgender and Gender-​nonconforming Children Three-​year-​old Tal’s case is a good illustration of one type of affirmative treatment for gender-​expansive children. Initially, Tal looked more like an orange or fruit salad kid. The approach Tal’s parents and I chose was to allow Tal space to express his gender in authentic ways and to follow his lead as his sense of gender identity emerged and matured, watching to see how it developed. After several months of play therapy sessions with Tal and joint family sessions, the therapist working with this family determined that Tal’s desire to be a girl was not so strong that it led him to be miserable living as a boy, particularly with the latitude allowed him by his parents. She switched the family to a schedule of twice yearly visits to check in on Tal’s progress. The nursery school Tal entered after the family moved was accepting of his desire to play with toys commonly designated as ‘girls’ toys, to affiliate with

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girls, and to wear colorful clothes often perceived as ‘girls’ clothing. The religious elementary school Tal attended after nursery school was similarly accepting. Joel and Dinah stopped short of allowing Tal to wear skirts or dresses to school, sensing that this might push the limits of tolerance shown by school administrators. Outside of school, Tal’s playmates were almost always female, and his extra curricular activities included things like dance classes, not sports. He frequently chose to wear skirts and dresses and his faux wigs at home, but he seemed content to wear more gender neutral clothing to school. For several years, this arrangement worked. Tal was a happy, energetic young boy with an ‘expansive’ gender expression. Then, in fourth grade, when Tal was nine, he began to show some symptoms of depression:  he became withdrawn and irritable. He started to ask when he could become a girl, and was not content with the vague answers his parents gave him. Joel and Dinah brought him back to IPG for more frequent therapy sessions, during which Tal consistently expressed his desire to be a girl sooner rather than later. For the first time, he voiced his dislike of his body, especially his genitals. Tal’s unhappiness became more pervasive and threatened to derail his school performance. After several months of treatment, Dinah and Joel came to realize that their child had developed from ‘gender diverse’ and ‘gender nonconforming’ to ‘probably transgender.’ Tal begged to be allowed to grow his hair long, wear dresses all the time, and to be referred to as a girl. Ultimately, his parents and the therapist agreed that it was time to ‘socially transition’ Tal. Everyone agreed that the best time to do this was over the summer between fourth and fifth grade. One of the significant markers of this transition was the parents’ use of pronouns: Tal’s name was one used for both boys and girls, so her name remained the same but her family started to use ‘she,’ ‘her,’ and ‘hers’ pronouns. At the same time, Tal grew her hair longer over the summer and acquired a distinctly feminine new wardrobe. The therapist working with the family held conferences with school administrators and teachers to help them cope with Tal’s transition and to develop a strategy to inform the parents of other children in Tal’s class about the change. The social transition went smoothly, Tal’s depression lifted, and the parents are now working with a pediatric endocrinologist to determine when puberty blockers will become appropriate. What Therapists Need to Know about Gender-​affirmative Treatment Gender-​affirmative treatment for a younger child includes the following (Hidalgo et al., 2013): •

Assessment to determine the degree to which the child’s nonconformity is a matter of gender expression, as opposed to gender identity;

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• Eschewing attempts to get the child to conform to gender stereotypes of their birth-​assigned sex, and providing the child with a safe space to experiment with gender expression and identity; • Working with parents/​family members to support and validate the child’s gender expression as normal and healthy; • Observing and tracking the child’s progress over the course of childhood, into adolescence; • Working with schools and other social institutions that impact the child to assure that they are validating and supportive; • When appropriate, helping the child make a ‘social transition’ to living as their affirmed gender; • Attempting to find support groups so that the child can experience other kids with divergent gender expression/​identity; • When appropriate, helping parents find knowledgeable pediatric endocrinologists who can administer puberty blockers. Ehrensaft has some guidance about when to consider social transition (2016). She advises first ruling out other possible reasons for the child’s gender nonconformity, especially some other underlying problem. In addition, social transition might be recommended when the child is clearly expressing a divergent gender identity, not simply divergent gender expression; when the child is expressing an urgent need to transition; and when parents and school can offer the support necessary for such a transition. When the child socially transitions, it is important to help both the parents and the child prepare for a ‘change of mind.’ Some professionals have expressed a fear that social transition will short circuit or inhibit the child’s ability to change if they come to feel they want to live in their assigned gender. They are afraid that the socially transitioned child will fear parental or peer disapproval if they want to ‘change back.’ Certainly this is a possibility; we simply do not have enough data to know. However, this assumes that the child who was able to be so assertive about their gender identity that they convinced adults to allow them to transition in the first place, braving parental and social disbelief and/​or disapproval of the transgender identity, will for some reason lose this assertiveness when it comes to changing their mind. This has not been the experience of therapists at IPG or of other professionals of my acquaintance who work with these children. Case Vignette While it does not happen often, young people do sometimes change their minds, and it does not seem to be particularly disturbing to them. Zak, age 11, assigned male at birth, was referred by a pediatric endocrinologist to a psychology intern I supervised. When the intern first saw the child, Zak had socially transitioned

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to Zoe after being placed on puberty blockers. For a year, the intern worked with Zoe as she changed schools, navigated new social situations, handled skeptical parents and family, and got used to living as a girl. Then, after a summer break from therapy, we got a frantic call from Zoe’s mother. Over the summer, the child had abruptly decided to stop taking puberty blockers and to revert to his birth-​assigned gender and name. When we spoke to Zak, he had very little explanation for his change of mind, and was irritated that his parents were so upset. The mother explained: ‘We had just finished telling everyone in the extended family about Zoe and how we now had a daughter, and they were starting to adjust to it.’ She sighed, ‘Now we have to go back to all of them and “come out” a second time.’ The only explanation Zak gave was this: ‘All my life I wanted to be a girl, thought I really was a girl. I guess I had to live as a girl for a while to realize that I’m not. What I am is a girly gay boy,’ he said with a smile. Zak changed schools again, dyed his hair pink, and joined the school’s Gay Straight Alliance. He felt no further need for therapy. One of the most interesting things about Zak’s case was that the adults involved –​the therapists, his family, the pediatric endocrinologists –​were all more confused and upset over his change of mind than he was. We had all lost sight of the fact that puberty blockers, in particular, are meant to provide a ‘time out’ for the child to explore living in their preferred gender. ‘Changing your mind’ isn’t a negative outcome, it is one possible expected outcome of the experiment of using blockers. At IPG, where we have treated more than 800 gender-​expansive kids and adolescents, we have had a handful who reverted to their birth-​assigned sex, usually while on puberty blockers or in the first stages of considering cross-​ gender hormones. In all cases, the children seemed to do this easily, while the adults questioned themselves and their judgment! Most of the pre-​adolescent kids we see at IPG do not socially transition before puberty. Those who do are usually birth-​assigned males who are not only miserable in their social roles and bodies, but who are also experiencing considerable bullying and harassment from peers for being ‘girly boys.’ The children in school settings that are less rigid about gender –​ones that don’t make girls and boys line up separately, don’t separate activities into ‘girl’ and ‘boy’ activities, that fully support and validate expansive gender expression in students –​are less likely to feel the need to socially transition. However, at the end of the day my feeling is that social transition is preferable to seeing a child leading a miserable existence. It is most important, in my opinion, for a child to be happy, have positive self-​esteem, and good peer and social relations. If that requires that the child socially transition, it is an effort worth making despite the risk that the child will revert back to their birth-​assigned gender at some point.

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Controversies Around Puberty Blockers As I’ve discussed, the primary controversy around gender-​affirmative care is the debate about social transition. There are those who advocate what has been called the ‘Dutch approach’ (DeVries, 2012). The first-​line approach in the Netherlands involves ‘watchful waiting’ over children who are gender dysphoric, without social transition, and with the use of puberty blockers when indicated at the beginning of adolescence. This approach has been incorrectly posited as the ‘opposite’ of the gender-​affirmative approach espoused in this book. In fact, most gender-​affirmative therapists do a good deal of ‘watchful waiting,’ as I have described in cases in this chapter. But gender-​affirmative therapists espouse more flexibility, including the flexibility to socially transition a child when that seems best for the child’s well-​being and mental health. There are also medical/​ethical concerns around the use of puberty blockers. On one hand, these drugs appear to be very safe, as evidenced by decades of use with children suffering from precocious puberty. They are also completely reversible; when discontinued, the youth immediately commences with pubertal development in their birth-​assigned gender. However, there are concerns about the impact on bone development. Puberty-​suppressing medications do impact negatively upon the formation of bone mass, and there are some indications from studies of people who undergo this treatment and then progress to cross-​ gender hormones that they do not reach the same peak bone mass as they would have if untreated (Giordano and Holms, 2020). More research is needed to confirm this, but clearly if this is true it is an important consideration in decisions about whether to prescribe this treatment. In addition, there are other medical issues attendant to the use of puberty blockers. Children who begin them at Tanner Stage 2 never develop secondary characteristics of their birth-​ assigned gender, including those related to gonadal development. The gonads of young people on blockers never mature, and this creates two problems. The less serious of this is that, for birth-​assigned males transitioning to female, there may not be enough scrotal skin to perform a traditional vaginoplasty when the person is an adult. Surgeons are experimenting with using skin grafts from other parts of the body to compensate for this. The second, more serious concern, is infertility:  because the gonads have never matured, the person is effectively sterile (Cheng et  al., 2019). This is very different from the situation of an older adolescent who wants to go cross-​gender hormones but has never been on puberty blockers. Such an adolescent has already developed the gonads of their birth-​assigned gender:  they are fertile. Your work with that teen involves facilitating cryogenesis of sperm or ovum if desired. The ovum of birth-​assigned girls placed on puberty suppressors is not impacted by this treatment, and ovum

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can be extracted at a later date. However, the use of puberty suppressors on birth-​assigned males prevents spermatogenesis. The individual can later decide to stop cross-​gender treatment long enough for spermatogenesis to occur, but they must be willing to accept the masculinization that will come when their bodies again produce testosterone. Many practitioners  –​and parents –​feel an ethical dilemma in making a decision about future fertility for, say, a 12-​year-​old, someone too young to fully comprehend the long-​ term implications of these medical interventions. This, combined with the data suggesting that bone development may be compromised permanently in individuals undergoing such treatment, is enough evidence for many to decide that withholding puberty suppressing medication is a safer and more prudent choice. On the other hand, given the data on negative outcomes for transgender children who do not have access to transition, there are those who argue that withholding such interventions is unethical (Ashley, 2019; Leibowitz et al., 2020; Giordano and Holms, 2020). Takeaways for the Therapist Because it is not easy to determine whether a gender-​expansive child is, in Ehrensaft’s terms, an ‘apple, orange, or fruit salad’ treatment of the pre-​ pubertal gender-​diverse child can be more difficult than working with older transgender people. Working with this population requires not only that one be adept at the forms of therapy (play therapy, sand play therapy, therapeutic games) most likely to elicit meaningful information from the younger child, but also that one be able to assess whether the gender expansiveness reflects identity or expression and whether these feelings are ‘persistent, insistent, and consistent.’ The most important thing when working with gender-​expansive children is to ensure that they are validated and supported by their families and schools. This always involves work with parents, and often means the therapist has to advocate for the child with a school system that may have never encountered a child like this before, may be unsupportive, and may actually fail to protect the child from bullying. While social transition is not the first-​line treatment, it is sometimes necessary when the child cannot tolerate living in their birth gender. Clinicians working with this population need to liaison with pediatric endocrinologists willing to work with trans youth, and need to know enough about medical interventions to help educate parents. While this area of clinical work is challenging because it is so new and we still know so little about these children, it is also highly rewarding. Kristina Olson, who has been longitudinally following a group of socially transitioned children since 2013, has found that the mental health problems of these children are indistinguishable from those of cisgender peers (Olson et  al., 2016), and is substantially better than the mental health of gender dysphoric

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children who have not been socially transitioned. As research like that of Kristina Olson has shown, helping and supporting these kids can make the difference between suicidality and a normal mental health outcome. Like working with transgender adolescents, working with pre-​pubertal children carries the counter-​transferential challenge of feeling responsible for important life decisions for others in the face of limited and insufficient data. Be honest with yourself. If this burden will cause too much difficulty, develop a referral list of reliable child clinicians experienced with this population. Working with Parents In Chapter  7 I  discussed working with parents who have a lesbian or gay child. When working with trans and gender-​nonconforming kids and teens, working with the parents is an absolute must. If you yourself are not going to do this work, it is imperative that you connect the parents to another clinician and that the two of you coordinate care. When working with parents, it is helpful to direct them to other resources, such as PFLAG, discussed in Chapter 7. PFLAG these days is heavily populated with parents of transgender kids, so the odds are the parents you refer will find support and validation. Another resource is the Family Acceptance Project, which promulgates research about families with LGBTQ+ youth. The Family Acceptance Project publishes two posters, which can be found online, listing ‘Best’ and ‘Worst’ family behaviors for LGBTQ+ children. ‘Best’ behaviors include: supporting your child’s gender expression; bring your child to LGBTQ groups and events; welcome your child’s LGBTQ friends to your home. ‘Worst’ behaviors include:  trying to change your child’s LGBTQ identity or gender expression; pressuring your child to be more (or less) masculine or feminine; using religion to reject your child’s sexual orientation, gender identity, and expression. Keep a list of books to give to parents. Some of my favorites are Transgender Children and Youth (Nealy, 2017), Families in Transition (Lev and Gottlieb, 2019), Transitions of the Heart (Pepper, 2012), and Transgender 101 (Teich, 2012). Nealy is a social worker and a transgender man, and he shares his personal story and observations in this very smart book about working with trans kids and youth. Lev and Gottlieb have assembled a group of experts in the field to write about various aspects of working with families. Transitions of the Heart is a collection of very moving and honest writings by mothers of transgender people. And Teich is another transgender man who writes from both personal and professional experience. You also need to be able to explain a lot to parents, to give them lots of information. Long before an appointment with a pediatric endocrinologist is appropriate, your parents will want to know all about hormones, puberty blockers, and surgeries. And you will need to assist parents in advocating with schools and community institutions. I once had a talk with the owner of

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a gymnastics facility concerned about putting a young client of mine on ‘the girls team’ when the child had been assigned male at birth. It was part of what the child needed to have a whole life. When working with parents and other family members, it is important to remember that when a child transitions  –​the entire family transitions. Many parents go through profound personal transformations in the process of coming to terms with their child’s identity (Nichols and Sasso, 2019). At a minimum, the child’s transition necessitates changes in relationships with extended family, educational systems, and community and religious organizations. This is a daunting process for any parent. The strongest piece of advice I  can give about working with parents is this: assume that they love their children and want to do the best for them. A  lot of what looks like non-​support to you may feel like protecting their child to them. It must be terrifying to have a child who announces they are transgender when you aren’t expecting it. It would scare me, and I know a lot about the subject. No one wants to think their child may need to undergo medical procedures with such intense and far-​ranging consequences. No one looks forward to having a child that may face additional social pressures and prejudice because of who they are. I am not justifying and certainly not advocating putting a child into conversion therapy, but I understand parents who have done this. And although some parents have known there was something ‘different’ about their child from an early age, and even suspected gender or sexual orientation diversity, many feel blind-​sided by the revelation of their child’s gender identity. It will take time for parents to digest and come to terms with the new reality. It will take even more time if the family is part of a religious or other community that espouses strict traditional roles and values. It is your job, as the clinician, to exhibit the patience that their children may not be able to muster. References Ashley, F. (2019). Thinking an ethics of gender exploration: Against delaying transition for transgender and gender creative youth. Clinical Child Psychology and Psychiatry, 24(2), 223–​236. Cheng, P. J., Pastuszak, A. W., Myers, J. B., Goodwin, I. A., and Hotaling, J. M. (2019). Fertility concerns of the transgender patient. Translational Andrology and Urology, 8(3), 209. De Vries, A. L. and Cohen-​Kettenis, P. T. (2012). Clinical management of gender dysphoria in children and adolescents: The Dutch approach. Journal of Homosexuality, 59(3), 301–​320. Ehrensaft, D. (2016). The Gender Creative Child: Pathways for Nurturing and Supporting Children Who Live Outside Gender Boxes. The Experiment. Green, R. (1987). The ‘Sissy Boy Syndrome’ and the Development of Homosexuality. Yale University Press.

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Giordano, S. and Holms, S. (2020). Is puberty delaying treatment ‘experimental treatment’? International Journal of Transgender Health, 1(20)  1–​9. Hidalgo, M. A., Ehrensaft, D., Tishelman, A. C., Clark, L. F., Garofalo, R., Rosenthal, S. M., Spack, N. P., and Olson, J. (2013). The gender affirmative model: What we know and what we aim to learn. Human Development, 56(5), 285–​290. Isay, R. (2010). Being Homosexual: Gay Men and Their Development. Vintage. Leibowitz, S., Green, J., Massey, R., Boleware, A. M., Ehrensaft, D., Francis, W., Keo-​ Maier, C., Olson-​Kennedy, A., Pardo, S., Nic Rider, G., Schelling, E., Segovia, A., Tangpricha, V., Anderson, E., and T’Sjoen, G. (2020). Statement in response to calls for banning evidence-​based supportive health interventions for transgender and gender diverse youth. International Journal of Transgender Health,  1–​2. Lev, A. I. and Gottlieb, A. R. (eds.). (2019). Families in Transition:  Parenting Gender Diverse Children, Adolescents, and Young Adults. Columbia University Press. Nealy, E. (2017). Transgender Children and Youth:Cultivating Pride and Joy with Families in Transition. Norton. Nichols, M. and Sasso, S. (2019). Transforming the identity of parents of transgender and gender nonconforming children. In A. I. Lev and A. R. Gottlieb (eds.), Families in Transition:  Parenting Gender Diverse Children, Adolescents, and Young Adults. Columbia University Press. Olson, K. R., Durwood, L., DeMeules, M., and McLaughlin, K. A. (2016). Mental health of transgender children who are supported in their identities. Pediatrics, 137(3). Olson, K. R., Key, A. C., and Eaton, N. R. (2015). Gender cognition in transgender children. Psychological Science, 26(4), 467–​474. Pepper, R. (ed.). (2012). Transitions of the Heart: Stories of Love, Struggle and Acceptance by Mothers of Transgender and Gender Variant Children. Cleis Press. Rekers, G. A. (2009). Treatment of gender identity confusion in children: Research findings and theoretical implications for preventing sexual identity confusion and unwanted homosexual attractions in teenagers and adults. Treating GID in Children,  1–​31. Teich, N. M. (2012). Transgender 101:  A Simple Guide to a Complex Issue. Columbia University Press. Winter, K. (2019). The ‘80% desistance’ dictum:  Is it science? In A. I. Lev and A. R. Gottlieb (eds.), Families in Transition: Parenting Gender Diverse Children, Adolescents, and Young Adults. Columbia University Press.



am identifies as nonbinary and uses ‘they/​ them’ pronouns. Sam, assigned female at birth (AFAB), doesn’t feel they fit into either a ‘male’ or ‘female’ category. They want a more androgynous appearance than they have now, and are planning breast reduction surgery. Sam doesn’t want a double mastectomy, but enough reduction so their breasts are not noticeable even without ‘binding,’ the practice of tightly wrapping one’s upper body in confining material to suppress the visibility of breasts. They aren’t interested in any other medical interventions at the moment. Austin, assigned male at birth (AMAB), identifies as ‘gender fluid.’ Austin is asking for female cross-​ gender hormones because they belief it will ‘soften’ their features and make their gender presentation more ambiguous. Austin says, ‘Some days I  feel more female, and I might wear a skirt and some make-​up, other days I feel more male and dress more “butch.” And some days I just feel in between.’ Pat was assigned female at birth and given the name ‘Patricia.’ They use ‘Pat’ now because it is androgynous and fits their identity, which they term ‘agender.’ Pat is considering medical interventions: As someone who is non-​binary and considering surgery, it’s more that my body is now in line with how society sees women. So even though I know I’m agender, the world treats me like I’m a woman. So surgery would make me feel better, and hopefully begin to help others see me as I see myself. Pat echoes a common complaint of nonbinary people –​invisibility. When I  do training sessions for therapists on transgender issues, they have the most difficulty with the concept of a ‘nonbinary’ gender identity.

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In modern Western countries, the idea that gender is binary is so firmly entrenched that any other formulation of gender seems incomprehensible. A New York Times Magazine article on nonbinary people, that appeared in June 2019, garnered 1,040 comments –​nearly all negative (Bergner, 2019). The pushback appears to be related to the idea that gender could be a continuum and that there might be people who identify as something other than one of the two polar opposites. Transgender people who are not nonbinary are less of a threat because they do not challenge this two-​gender system. They can be thought of as people who were ‘born into the wrong body,’ and medical interventions help them jump from the ‘wrong’ box of birth-​assigned gender to the ‘right’ gender box of what is in their brain. Interestingly, outside of modern Western societies the concept of being ‘in between’ is much more widely accepted. The hjiras of India, two-​spirit Native American people, muxes of Mexico, the ‘sworn virgins’ of the Balkans, and kathoeys of Thailand are all examples of people who are considered by their cultures to be in-​between males and females. Two-​spirited people were recognized by at least 155 tribes of North America, and were believed to have both the spirit of a man and the spirit of a woman. This category encompassed many identities and gender presentations. In Western society, the precursor to ‘nonbinary’ was the concept of ‘psychological androgyny,’ which was a popular topic for study by social psychologists in the 1970s. Sandra Bem developed a sex-​role inventory that classified people into four groups: those who were high in feminine traits, high in masculine traits, high in both feminine and masculine traits, and low in both (Bem, 1974). The latter two groups would correspond to nonbinary and agender identities in the twenty-​first century. In the 1990s, when the word ‘transgender’ began to replace and expand the meaning of ‘transsexual,’ the trans activist Riki Wilchins used the term ‘genderqueer’ in her book Read My Lips: Sexual Subversion and the End of Gender (Wilchins and Serano,1997). While she used it to refer to transgender people not planning to undergo surgery, it more generally signified those who feel their gender lies outside the binary. ‘Nonbinary’ is a much more recent term. Richards and Barker were among the first to use the term in print in a 2015 book on the psychology of sex and gender (Barker and Richards, 2015). They defined nonbinary as 1) between ‘male’ and ‘female’; 2) closer to one gender than another, but not entirely ‘male’ or ‘female’; or 3) outside of the binary system altogether. While other terms have been and to an extent are still used  –​for example, genderqueer, gender non-​ conforming, genderfluid, agender, androgyne, neutrois –​nonbinary, or ‘enby,’ is now the most commonly used descriptor and will be used throughout this chapter. A significant portion of people who identify as transgender also identify as nonbinary. The NCTE 2015 Transgender Survey found 35% of transgender respondents also defined themselves as nonbinary. Younger people

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use the term more than older people, and nonbinary people are more visible to younger generations. A Pew Survey from 2018 showed that 35% of Gen Z (those born in 1997 or later) know someone who is nonbinary, as compared to 12% of Baby Boomers (Parker, Graf, and Igielnik, 2019). If this trend continues, we can expect that the percentage of those who identify as nonbinary will increase. A number of US jurisdictions have begun to allow people to change the gender marker on their birth certificate to ‘X’ and as of 2019 nine states plus Washington, DC allow gender X on driver’s licenses. Why do people identify as ‘nonbinary’? Many people who identify that way report that, as a child, they knew they were not the gender they were assigned, but also didn’t want to be the ‘other’ gender. For these individuals, identifying as nonbinary is liberating: they no longer feel a need to live up to any gender norms or stereotypes. And it is authentic:  it expresses their gender more accurately than any other word or term. So when nonbinary people ‘come out’ to themselves and others, it often feels as though they are genuinely authentic and fully visible as themselves for the first time. Sawyer, a 22-​year-​old nonbinary person who uses they/​them pronouns, said: Most people, when they look inside, have a clear and strong feeling of ‘I’m a woman’ or ‘I’m a man.’ Even most trangender people feel that way, although they may think they are in the wrong body. But when I  do that –​I don’t have a feeling of ‘I’m a man’ or ‘I’m a woman,’ I feel ‘I’m both’ or sometimes ‘I’m neither.’ And when people see me as male –​or even if they see me as female –​I feel misgendered, and it’s really upsetting, because it’s not who I am. I want others to see me as I see myself, and that’s why it’s really important that I identify openly as non-​binary. Ari, a college student in New York, put it more simply: ‘I identify as nonbinary because I don’t identify with either male or female.’ Nonbinary vs. Intersex Some people have argued that intersex people are ‘naturally’ nonbinary. While it is beyond the scope of this book to fully explore the psychotherapy needs of intersex people, it is useful to understand who they are. The Intersex Society of North America defines intersex as: a general term used for a variety of conditions in which a person is born with a reproductive or sexual anatomy that doesn’t seem to fit the typical definitions of female or male. ISNA goes on to state that ‘intersex’ is a socially defined category. To understand what this means, we need to return to what I  touched upon

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in Chapter  16, the fact that gender isn’t binary. Anne Fausto-​Sterling, the noted biologist, has delineated at least five ‘levels’ of biological sex (2000): 1) chromosomal sex, 2) undifferentiated fetal sex, 3) differentiated fetal gonadal sex, 4)  fetal hormonal sex, which in turn influences fetal internal reproductive sex, genital sex, and brain sex, and 5) pubertal hormonal sex, which influences pubertal erotic sex, pubertal morphological sex, and ultimately adult gender identity. At each of these levels, there are opportunities for variation, meaning there is an almost infinite number of possible variations in human ‘sex.’ Where ‘normal’ male/​female sex ends and ‘intersex’ begins is determined by humans, mainly doctors. And doctors vary considerably even on what is considered ‘intersex.’ Many only categorize a child as intersex if they have ambiguous genitalia. But most of the variations do not result in ambiguous genitalia. For example, men with Klinefelter Syndrome, a fairly common (1 in 1,000) variation where males have XXY chromosomes instead of XY chromosomes, usually have no visible genital differences at birth, and may go a lifetime without diagnosis. On the other hand, children born with any of a number of conditions resulting in gonadal dysgenesis, defective development of the gonads, may be identifiable at birth because of the appearance of their genitals. Some professionals would not consider Klinefelter Syndrome an intersex condition (formally labeled ‘DSD’ –​ Disorders of Sexual Development). Both of these conditions are variations from the strict XX=female, XY=male definition of sex/​gender many of us were taught in school. In fact, if one considers all intersex conditions, both those resulting in ambiguous genitalia and those that do not, 1 in 100 children are born with bodies that differ from the ‘standard’ male or female. Technically, one could consider all these people ‘nonbinary,’ but in fact most develop with male or female gender identities, and do not consider themselves transgender or nonbinary. And most people who consider themselves nonbinary are not intersex. Intersex people have been misunderstood and mistreated by the medical profession for a long time. In the 1950s, medical specialists at Johns Hopkins University, under the theoretical leadership of John Money, developed an approach to intersex children called ‘optimum gender of rearing.’ Since Money believed that gender identity was all about nurture, and not nature, he recommended that intersex children be raised in the gender that most matched their external genitalia, regardless of other biological aspects of sex/​ gender. Infants were subjected to surgeries meant to ‘correct’ genitalia: an XY child born with a micro penis would be castrated and raised as a girl, an XX child with an an enlarged clitoris might be raised as a boy –​or might have the clitoris reduced in size to conform to ‘normal’ female genitalia. Parents were advised to keep the child’s condition a secret, and doctors were actually trained in how to lie to their intersex patients.

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Not surprisingly, a number of intersex people grew up to ultimately learn about their conditions, and to decry the treatment they received. In the 1990s a movement rose up to change the approach to intersex children. Summarized in a fact sheet called ‘Shifting the Paradigm of Intersex Treatment’ (Dreger, 2004), the new approach recommended by intersex activists and some professionals involves regarding intersex as a human variation, not a ‘disease,’ avoiding surgeries, unless medically necessary, until the child is old enough to consent, providing support and information for parents, determining the gender in which the child will be reared after considering many factors, disclosing information to the child as soon as they are old enough to understand, and understanding that the intersex individual may decide upon a gender identity change and/​or surgeries when they are old enough to consent. Intersex people have a significantly higher likelihood of gender transition than the general population (Kreukels et al., 2018), and this should be expected by caregivers. Health and Mental Health of Nonbinary Clients A 2019 paper (Scandurra et  al.) reviewing research on the health/​mental health issues of nonbinary people found only 11 such studies, none published before 2016; we know next to nothing about this population. The studies compared the health and mental health of nonbinary people to that of cisgender people and also to binary transgender people. Nonbinary study subjects were almost uniformly in their teens and 20s, reflecting the youthful nature of this population. The overall results of this research showed a mixed picture comparing binary and nonbinary transgender people: some showed nonbinary subjects with poorer health, and others showed binary transgender subjects with poorer health. All but one study, however, found that nonbinary subjects suffered poorer health and mental health than their cisgender peers. The nonbinary subjects reported more victimization and less support from peers, parents, and health care providers than either binary transgender or cisgender subjects, and more self-​harming behaviors, including drug abuse. The most prominent finding was that nonbinary people experienced unique challenges:  difficulty of others understanding the concept of nonbinary identity, feeling invalidated and ‘erased’ by others, including health care professionals, lack of information, and pressure from both cisgender and binary transgender people to ‘pick a side.’ Contrary to what many people assume, many nonbinary people want some form of medical intervention to change their bodies. Moreover, what they want may be ‘non-​traditional,’ meaning not conforming to the usual procedures desired by binary transgender people. For example, many self-​ identified transgender men, assigned female at birth, desire nonbinary bodies, and may have chest reconstruction and take testosterone but never

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get ‘bottom’ surgery, that is, phalloplasty or metoidoplasty. Others undergo phalloplasty but retain a functional vagina. Trans or nonbinary people assigned male at birth may eschew bottom surgery. Alternatively they may undergo new procedures such as ‘zero-​depth’ vaginoplasty, where labia are constructed but there is no vagina, only a ‘dimple’ meant to resemble the vaginal opening; or penile preservation vaginoplasty, a surgery where the skin used to construct a vagina is taken from other parts of the body so that the person retains a penis as well as a vagina. Perhaps more common are nonbinary people who want ‘micro-​dosing’ of hormones. These people want to masculinize or feminize their bodies somewhat, but they don’t want full development of the secondary sex characteristics of the sex opposite to what they were assigned at birth. An AMAB nonbinary person may merely want to reduce the amount of testosterone in their system, and therefore only want testosterone blockers; or they may want testosterone blockers and small amounts of estrogen, enough to soften their features and round their bodies slightly. An AFAB nonbinary person may want micro-​doses of testosterone. Here is what one AFAB nonbinary person said about micro-​dosing (Enriquez, 2019): The last time I took testosterone was about a year ago. My dosage was 20 mg every two weeks –​far lower than the typical dosage for someone looking to fully transition from female to male, which is anywhere from 50 mg–​100 mg every week. I’m nonbinary, and I’m not interested in presenting to the world as a ‘man’ based on whatever antiquated physical criteria that might invite that assumption. When I took the small amount of T that I did, the resulting physical changes were subtle. Over the course of months, my body fat redistributed, my shoulders broadened, and my face changed from soft to harder as my jawline squared off. The starkest change was feeling much more at home within my body. Nonbinary people often face resistance from medical professionals and psychotherapists who are locked into a two-​gender model. It seems easier to understand someone who wants to jump from one gender ‘box’ to another, opposite, ‘box’ than to comprehend someone who feels most comfortable in between –​or outside boxes altogether. This limits access to needed medical care for nonbinary people. Case Vignette Cameron, a 19-​year-​old Rutgers University student, listed ‘questioning gender identity’ as their primary reason for seeking therapy, but at the first session –​ when Cameron requested ‘they/​them’ pronouns –​it was clear to the therapist that they were not so much ‘questioning their gender identity’ as they wanted

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to know how to manage a nonbinary identity. Cameron was immediately and visibly relieved when their therapist, a psychology intern I supervised, asked, ‘Do you consider yourself nonbinary? I’ve seen a lot of people around your age who identify as enbys.’ Cameron smiled and vigorously nodded yes, and then recounted a fairly familiar story. They had ‘come out’ as lesbian at age 15, both to themselves and their parents. Cameron’s parents were divorced; Dad didn’t have much of a reaction, but Cameron’s mother, after some hand-​wringing, grudgingly accepted this news. But Cameron was never entirely happy with this identification. They knew they were attracted to girls, but they didn’t really feel like a girl themselves. On the other hand, they didn’t want to be a boy. At Rutgers, a progressive school with a large LGBTQ+ student population, Cameron encountered a lot of transgender people, and felt much in common with them, especially the trans men. But transitioning to male didn’t quite feel right. When Cameron found the website, which documents the ongoing story of a nonbinary person named Micah, they felt their heart lift up in recognition. But Cameron was hesitant to identify as nonbinary. They didn’t know any nonbinary people in real life, and the transgender students they found at Rutgers made jokes about enbys. ‘It’s just a stage –​they all transition eventually,’ Cameron was told. Cameron’s mother had a similar, disbelieving attitude. She laughed when Cameron came out as nonbinary. ‘What the hell is that?’ she asked. ‘Some new thing they thought up at that school you go to?’ Cameron’s girlfriend, a young bisexual woman Cameron had met at one of the school’s many LGBTQ+ events, was the only one who supported Cameron. Cameron’s therapist began by not only validating Cameron’s nonbinary identity, but by corroborating their experience of ‘dual discrimination’ from both cis and trans people alike. Cameron’s experience with the transgender community was particularly disturbing because they would need this community, going forward, to sustain and support them. The therapist pointed out that if Cameron could get to New  York, which is not far from where Rutgers is located, they would be able to attend a support group at New  York’s gay center that was exclusively for nonbinary people. Just knowing this existed eased Cameron’s sense of isolation. The therapist also challenged Cameron’s view that ‘no one’ at any of the Rutgers many LGBTQ+ groups and events understood being nonbinary, and urged Cameron to give these groups another chance. A more pressing problem was the negativity Cameron experienced from their mother. Cameron convinced their mother to attend a parent’s support group at IPG, but after one meeting she dismissed the group as ‘full of whining people who are too permissive with their kids’ and refused to go back. Therapy then focused on helping Cameron realize that, at least for now, they could not rely on their family of origin for support and that the visits home were toxic. Cameron started to limit the time they spent at home and concentrated on finding understanding people at school. The bond with the therapist was crucial to Cameron’s wellbeing; over several months, their sadness and depression lifted and they began

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to be bolder about changing their gender expression to appear more male. As of now, Cameron is not interested in any medical interventions, but does not rule that out for the future. Clinical Issues of Nonbinary People While some of the issues nonbinary people face are the same as those of their binary transgender peers, some are unique. To begin with, most nonbinary people are young, which means working with parents and family is even more crucial for them –​and often more difficult. For example, while most parents struggle upon learning they have a child who is transgender, parents of nonbinary kids often deny the existence of the gender continuum. It is not uncommon to see parents pushing their children to become ‘fully’ transgender rather than maintain a nonbinary identity. This is because, as we have noted before, the concept that gender is not only ‘male’ versus ‘female,’ two ‘opposite’ sexes, is one that is only now beginning to enter public consciousness. Many parents have a hard time tolerating what they see as the ambiguity of a nonbinary identity; a binary transgender identity is easier to understand! This means that when therapists work with parents of nonbinary kids, they need to do a great deal of psycho-​education around basic concepts like the difference between sex assigned at birth, gender expression, and gender identity. Ultimately, parents need to know that even if they don’t fully ‘get it’ about gender being on a continuum, they need to ‘get’ that their kid needs their support. And nonbinary young people whose parents are unable to be supportive need help to recognize that their family, whom they have been taught is their most reliable ‘safe haven’ in a sometimes hostile world, may actually turn out to be unsafe and toxic, at least for the time being. Nonbinary people also need help dealing with rejection from both cis and trans people. The rejection is a bit different. While cisgender people often simply deny the existence of a gender continuum, transgender people are more likely to see ‘nonbinary’ as a stage, a stepping stone to full transition. Cis people are saying, ‘You aren’t trans,’ while transgender people are often saying, ‘You aren’t trans enough.’ Validating this difficulty helps, as is directing nonbinary people to online and real-​life resources. Rejection is often channeled into arguments about ‘they/​them’ being used as singular pronouns. Suddenly, when discussing nonbinary people, grammar becomes a paramount concern. Related to the issue of dual rejection is the issue of invisibility. Nonbinary people are invisible in two ways. First, they are culturally invisible. Asia Kate Dillon made history as a nonbinary actor playing a nonbinary character in the TV show ‘Billions,’ but Asia is nearly alone in this regard. Second, nonbinary people are misgendered. Binary transgender people are often called by the wrong pronoun or honorific; this happens constantly to nonbinary people.

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The average person automatically ‘sorts’ people into male or female ‘boxes.’ So someone who fits neither box will almost never be perceived the way they want to be perceived. Because of our tendency to gender-​sort automatically, nonbinary people are used to being addressed as ‘m’am’ or ‘sir,’ ‘he,’ or ‘she,’ but that doesn’t mean it is comfortable to be addressed in that way, or to be constantly assigned a gender that doesn’t fit. As one nonbinary person described it: ‘I feel pretty socially anxious in situations where people use gendered terms to describe me without asking my pronouns,’ Mel says, and I  battle with dysphoria and frustration with myself for being so sensitive when so many people are completely unaware and don’t know how hurtful that kind of language can be. I can’t expect people to mind-​ read and know how I  identify, but being called ‘miss’ or ‘ma’am’ can shake me up depending on what kind of day I’m having. Nonbinary people, by virtue of their youth, are more likely to be facing age-​ related issues such as navigating the college experience, entering the work force, and learning about intimate relationships and sexuality. All of these are more complicated for those with a nonbinary identity. Therapists must be able to help nonbinary clients with these life-​stage developmental milestones as well as with issues directly related to being nonbinary. Nonbinary people may not want medical interventions, but many do, and this creates problems which the therapist must help navigate. I am on a number of listservs that are trans mental health related, and one of the most common problems I  see discussed on these listservs is that of nonbinary people who want ‘non-​traditional’ medical interventions not specified in the WPATH SOC 7, such as the examples I have given in this chapter: a client who wants micro-​dosing of testosterone or estrogen, or one who wants ‘top’ surgery without taking hormones at all. While the WPATH Standards allow for flexibility, many medical practicioners use them rigidly, and often health insurance will not cover a ‘non-​traditional’ use of a medical intervention. Therapists have to develop special resources within the medical community for their nonbinary clients. Finally, therapists working with nonbinary clients must be able to deal with counter-​transferential feelings about unusual body modifications so that they can help their clients explore their need for medical interventions such as micro-​dosing and non-​traditional surgeries. Takeaways for the Clinician If you are working with nonbinary clients, you are almost certainly working with young people. In some ways the needs of your nonbinary clients will be similar to those of your binary transgender clients. However, your nonbinary

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clients are more likely to need your validation and affirmation, as they often will be encountering ‘erasure’ by both cisgender and transgender people alike. Their parents may have more trouble accepting them as nonbinary than binary transgender, and may actually be pushing them to ‘pick a side.’ And when they want medical interventions, there is a high probability that they will want non-​traditional or altered interventions, such as hormone microdosing, and they will need your help to navigate the medical and insurance establishments. References Barker, M. J. and Richards, C. (2015). Further genders. In C. Richards and M. J. Barker (eds.), The Palgrave Handbook of the Psychology of Sexuality and Gender. Palgrave Macmillan, pp. 166–​182. Bem, S. L. (1974). The measurement of psychological androgyny. Journal of Consulting and Clinical Psychology, 42(2), 155. Bergner, D. (2019). The struggles of rejecting the gender binary. New York Times Magazine, June 4, 2019. Dreger, A. (2004). Shifting the paradigm of intersex treatment. Position paper written for Intersex Society of North America. https://​​compare/​ Enriques, A. (2019). How microdosing testosterone changed my life.​en_​ us/​article/​xwnzjz/​microdosing-​testosterone-​hormones-​non-​binary-​transition Fausto-​Sterling, A. (2000). The five sexes, revisited. The Sciences 40(4),  17–​23. Kreukels, B. P., Köhler, B., Nordenström, A., Roehle, R., Thyen, U., Bouvattier, C., … and Arlt, W. (2018). Gender dysphoria and gender change in disorders of sex development/​intersex conditions: Results from the dsd-​LIFE study. The Journal of Sexual Medicine, 15(5), 777–​785. NCTE. (2016). ‘The Report of the 2015 US Transgender Survey’ (PDF). National Center for Transgender Equality. Parker, K., Graf, N., and Igielnik, R. (2019). Generation Z looks a lot like millennials on key social and political issues. Pew Research Center, January 17. www.pewsocialtrends. org/ ​ 2 019/ ​ 0 1/ ​ 1 7/ ​ generation- ​ z - ​ l ooks- ​ a - ​ l ot- ​ l ike- ​ m illennials-on- ​ key-social- ​ andpolitical-​issues/​ Scandurra, C., Mezza, F., Maldonato, N. M., Bottone, M., Bochicchio, V., Valerio, P., and Vitelli, R. (2019). Health of non-​binary and genderqueer people: A systematic review. Frontiers in Psychology, 10. Wilchins, R. A. and Serano, J. (1997). Read My Lips:  Sexual Subversion and the End of Gender. Firebrand Books.



y earliest memories of being sexually aroused date from before I was ten years old, and the arousal was to fantasies of my being tied up, enslaved, humiliated, and degraded. Kink is more fundamental to my sexuality than the gender of my partners. And yet it was the last thing about my sexuality I came to terms with, and not until my late 30s. Even as an adult, long after I had come to terms with my same-​sex attractions, I still felt shame about these sexual fantasies I tried to repress, or at least suppress, because they seemed so clearly ‘pathological.’ Back in Chapter 1, I wrote about how Richard Krafft-​Ebing, the nineteenth-​ century psychiatrist considered the ‘Father of Sexology,’ wrote about same-​ sex desires in the first sexology textbook, Psychopathia Sexualis. Krafft-​Ebing helped convert sexual behaviors that were deemed bad –​immoral, sinful –​ into ones deemed mad –​symptomatic of a psychiatrically deranged mind. While this was arguably an improvement, in some ways it merely changed the rationale for stigmatizing and marginalizing people who were sex and gender outlaws. Like many others of his day, Krafft-​Ebing viewed procreation as the sole purpose of sex, and therefore any sexual acts that did not or could not result in reproduction were abnormal. Krafft-​Ebing’s views on sadism and masochism, that is, that they were ‘perversions’ of normal sexual desires, persisted well into the twentieth century and to an extent are still enshrined in the DSM. The first two editions of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) included a category for sexual deviations, which included homosexuality as well as other sexual behaviors like pedophilia, fetishism, and sexual sadism. In 1980, DSM-​III introduced a category of ‘psychosexual disorders.’ The paraphilia diagnosis was part of this category, and it applied to sexual behaviors that included

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non-​human objects, suffering and humiliation of oneself or one’s partners, sexuality directed toward children, and non-​consenting partners. Notice that from the beginning of this diagnostic category, no distinction was made between consensual and non-​consensual acts, a problem that has persisted to this day. Paraphilic disorders included such widely disparate acts as violent, sadistic rape and getting tied up for sexual pleasure. Just as the homosexuality diagnosis was challenged by gay activists, and transgender activists disputed the gender identity disorder, BDSM allies and advocates have attempted to change the paraphilia category. Charles Moser and Peggy Kleinplatz (2020, 2006) examined the paraphilia diagnostic category for logic and consistency and for the veracity of the evidence cited and concluded that ‘the Paraphilia section is so severely flawed that its removal from the DSM is advocated’ (2006, p. 91). While this has not happened, DSM 5, issued in 2013, does make a distinction between paraphilias and paraphilic disorders, concluding that paraphilic interests are not themselves psychiatric illnesses, but are considered disorders when they produce distress, impairment, or harm to self or others. In other words  –​it’s ok to be kinky as long as you aren’t upset by it and you don’t damage yourself or another person. This is analogous to changes made to the gender identity category, and to the original change made to the homosexuality diagnosis, when ‘ego-​dystonic’ homosexuality could still be considered a psychiatric illness. Although critics still maintain that the category should be entirely removed from DSM, within months of the release of the DSM-​5, the National Coalition for Sexual Freedom, an advocacy group for people in the BDSM and polyamory communities, reported better legal outcomes for kinky people fighting custody or visitation battles (Wright, 2014). Outside of psychiatric circles, most people define kink or BDSM differently than the DSM. The term ‘BDSM’ is an Internet acronym signifying bondage and discipline, dominance and submission, and sadism and masochism. Included in the general category of BDSM, aka ‘kinky,’ are non-​standard sex acts that fit into those categories as well as what are usually called ‘fetishes.’ Fetishes are sexual attractions to unusual materials or body parts, such as feet, or leather. Importantly, the categories of kink/​BDSM do NOT include nonconsensual sexual acts or those involving minors. Thus pedophilia, nonconsensual voyeurism, and sadistic rape, all considered paraphilias in the DSM, are not considered to be BDSM activities. In fact, the organized BDSM community is quite vocal about consent; people known to violate consent are often excluded from BDSM spaces, organizations, and events. In general, kinky sexual activities include one or more of the following characteristics: •

A hierarchical power structure, that is, by mutual agreement, one person dominates and the other(s) submits. It is important to note that these

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roles are negotiated for sexual play, for the duration of a sexual ‘scene,’ in much the same way that kids agree on the roles of ‘cops and robbers’ for the duration of that game; • Intense stimulation usually associated with physical or emotional discomfort or pain, for example, slapping, humiliation; • Forms of sexual stimulation involving mild sensory deprivation or sensory confusion (similar to that experienced on some amusement park rides) and/​or the use of restraints, for example, bondage, use of blindfolds; • Role-​playing of fantasy sexual scenarios, for example, doctor-​patient roles, abduction fantasies. The roles usually incorporate a dominant/​ subordinate theme, often mirroring roles commonly found in life such as teacher-​student and boss-​worker; • Use of certain preferred objects and materials as sexual enhancers, for example, leather, latex, stiletto heels; • Other unusual sexual objects or practices often classified as a fetish, for example, fixation with feet. BDSM sexual activities share certain characteristics. First, they are statistically non-​normative, that is, they seem unusual to those who do not share BDSM proclivities. Second, during a sexual experience, called a ‘scene,’ the roles appear very polarized (top/​ bottom, dominant/​ submissive). Third, BDSM players experiment with physical stimuli and emotions  –​like fear, humiliation, or pain –​that have a paradoxical relationship to the pleasure of sex. BDSM activities are the ‘extreme sports’ of sexuality. These sexual activities share much in common with activities like ‘Iron Man’ competitions, a penchant for sky-​diving, and a love of horror movies. The combination of pleasure with negative sensations is the hallmark of BDSM. It is the source of what is often called a ‘peak experience,’ which many believe are an essential quest of humans once basic needs have been met. Peak experiences can be experienced as spiritual, revelatory, and healing. A woman with a sexual abuse history who role plays a little girl with a partner who is sensitive and attentive to her history may enact a BDSM scene and may achieve intense sexual satisfaction, a sense of spiritual connection, and a healing of childhood wounds all at the same time. In fact, Kleinplatz has called BDSM practitioners ‘extraordinary lovers’ who can teach the rest of us a great deal about romance, creativity, sexual bonding, and healing, as well as about keeping sex vibrant and authentic in long-​term relationships (Kleinplatz, 2006). There has been some debate about whether to consider BDSM a ‘sexual orientation.’ Many in the kink community do consider it an orientation, by which they mean that they feel it is an essential part of their make-​up that was ingrained from birth. Some scientists agree with this appraisal. They argue that kink attractions are strong, persistent, immutable, not under

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conscious control, and that the attractions develop early, in adolescence or early adulthood. Others consider kink a specialized interest, like a hobby. Myths and Misconceptions Because BDSM practices have long been considered a taboo expression of sexuality and/​or identity, the kink community has existed in the shadows, and many myths and misconceptions have developed. Here are some of the most common of them. Myth #1: BDSM is Abuse In any community, mainstream or kinky, there will be some individuals who use sex abusively or engage in violence. But BDSM is not abusive per se, and there are many differences between kinky sexual practices and abuse. The motto of the kink community is ‘safe, sane, and consensual,’ and the website Kinkly defines the motto in this way: Safe means that the risk of activities should be understood by all participants and either eliminated or reduced as much as possible. Sane refers to the need to approach activities in a sensible and realistic frame of mind, and with an understanding of the difference between fantasy and reality. Consensual means that all participants have freely consented to the activity and were in a state of mind to do so. For any type of BDSM encounter to occur, both parties must be consenting individuals, where limits to the interaction are clearly discussed and agreed upon. Although some aspects of BDSM play might carry an element of risk (e.g., ‘breathplay,’ in which partners temporarily cut off or limit the other person’s oxygen supply), both parties must communicate how personal safety will be maximized. This usually entails the use of a ‘safe word’ for one partner to indicate to the other that a limit is being reached. Although it might be assumed that this is done solely to protect the partner who is in a more submissive role, it can equally apply to concerns that the dominant partner may have. For example, a dominant might invoke the usage of a safe word if discomfort in exercising control over the submissive is being experienced. Setting limits is a crucial element of BDSM practice. Partners in ‘vanilla’ sex (the term used in the kink community to denote sex that is not BDSM) frequently have little or no discussion about likes and dislikes before having sex. By contrast, BDSM partners typically communicate explicitly, verbally, and in great detail about what they like, what they are willing to try, and what is a hard ‘no.’ This communication is a big part of establishing safety.

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The Lesbian Sex Mafia, an organization of gay and bisexual women interested in kinky sex, makes a number of distinctions between BDSM and abuse: 1) a BDSM ‘scene’ (the term used for a session of kinky sex) is a controlled situation, whereas abuse is an out-​of-​control situation; 2) negotiation occurs before a BDSM scene to determine what will and will not happen in that scene, whereas in abuse one person determines what will happen; 3) BDSM involves knowledgeable consent to participate in the scene expressed by all parties whereas abuse involves the absence of consent; 4) BDSM participants employ a safeword that will allow for a discontinuation of the scene at any time for physical or emotional reasons, whereas an abused person cannot stop what is happening; 5) everyone in the BDSM scene is concerned about the needs, desires, and limits of others, whereas abuse is the lack of concern for the needs, desires, and limits of the abused person; 6) the people involved in an BDSM scene are careful to be sure that they are not impaired by alcohol or drug use during the scene whereas alcohol or drugs are often used before an episode of abuse; and 7) after a BDSM scene, the people involved feel good whereas after an episode of abuse, the person abused feels bad. Myth #2: People Who Like BDSM Were Abused as Children Many people believe that those who engage in BDSM must have a history of being abused when young, and that this abuse has shaped their ‘sick’ sexual desires. In fact, there is no evidence of greater incidence of child abuse among the BDSM population in comparison to those who engage in vanilla sexual behaviors (Sandnabba, Santtila, and Nordling, 2002; Richters et  al., 2008). Additionally, there appears to be no difference in childhood attachment styles between kink and non-​kink individuals (Nordling et al., 2006). Some therapists assume that ‘bottoms,’ also called ‘submissives,’ must be self-​destructive and that those who play the dominant role must be violent or angry, but there is no evidence for these assumptions either. Myth #3: BDSM is Addictive Observing the intense stimulation involved in BDSM practices, like flogging, some people fear that those who try them will become ‘addicted.’ They believe that practitioners habituate to the stimuli and require increasing amounts of, say, pain in order to reach the same ‘high.’ From this perspective, even experimenting with kink is viewed as dangerous, as experimentation can become a ‘slippery slope’ that will result in people requiring more extreme or intense experiences. There is no evidence for this, nor is there evidence for the related belief that people who like kink only engage in kink or that ‘kinksters’ gradually spread their interests to nonconsensual paraphilias, like pedophilia or sadistic rape. In fact, most BDSM practitioners also enjoy non-​kinky

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‘vanilla’ sex, and while they may experiment with new forms of consensual BDSM, they are no more likely to be interested in non-​consensual activities than are people who like heterosexual intercourse likely to be interested in rape (Richters et al., 2008). Although there is no evidence that kinky individuals escalate over time in terms of their need for intensity or in terms of the harmfulness of their behavior, it is the case that most kinky people have a wider repertoire of sexual acts than vanilla people and rarely confine their sexual interests to one activity (Nordling et al., 2006). Myth #4: BDSM Is All about Pain Many people associate BDSM with pain. Although the exchange of pain may be an occasional part of BDSM practices, it is incorrect to assume that activities like flogging or spanking are practiced by all kinky people, or that pain is the only or primary sensation that is experienced during a BDSM interaction. BDSM is an exchange of heightened emotional or physical stimulation, and much of the stimulation takes place during periods of very high levels of sexual arousal when the body is less susceptible to feelings of pain. So the experience elicited, say, during a spanking, is not pain as most vanilla people think of it. When trying to conceptualize the type of pain experienced during kinky sex, it is much more useful to think of the pain that comes from being bitten by your lover in a moment of sexual abandon than to imagine the pain of a root canal. Power dynamics in BDSM are usually more significant than the giving or receiving or pain, per se. For example, a person who enjoys being slapped by his partner may be receiving just as much, or even more, stimulation from the act of being submissive to the partner than from the slapping itself. In fact, if one had to isolate one preeminent dynamic that characterizes BDSM, it would not be giving or receiving pain, it would be dominance and submission. There are many kink activities that involve a dominant/​submissive dynamic but do not incorporate pain, such as bondage or role play. And the sources of pleasure in BDSM are complex. As a client of mine once expressed: ‘My partner does not allow me to masturbate, sometimes for days or weeks. Of course it’s hard for me to control that. But being obedient to him ultimately gives me a rush that no amount of masturbation could ever achieve.’ Modern History of BDSM BDSM has been part of human sexuality since the earliest times. In Mesopotamia, ritual ceremonies for the goddess Inanna included dances where participants were whipped and then had sexual intercourse. Ritual

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flagellation was a custom in ancient Sparta, and BDSM sex acts were depicted in the Indian Kamasutra. In the eighteenth century the Marquis de Sade published erotic literature centered on kinky sexual practices. More recently, BDSM flourished in Germany between the two world wars, and a heterosexual kink culture developed in the United States during the Great Depression. But kink really began to be visible in the US after World War II in the form of biker’s clubs, which proliferated in the late 1940s and the 1950s. While most of these were comprised of heterosexual men, some were organized by gay men looking for ways to connect with other gays. The most well known of these gay motorcycle clubs was the Satyrs, founded in 1954. Because of these clubs, leather became fetishized and associated with gay masculinity. Sex magazines also proliferated in the 1950s  –​Playboy was founded in 1953  –​and some of these catered to kinky tastes. Irving Klaw, a photographer nicknamed the ‘Pin-​up King,’ produced fetish magazines, many using the pin-​up girl Bettie Page, who posed for bondage and BDSM photographs as well as the more well-​known ‘girlie’ pictures. The Eulenspiegel Society, now abbreviated simply to ‘TES,’ was founded in 1971 and was one of the earliest BDSM organizations in the United States. TES lists itself as a ‘pansexual’ organization, catering primarily to heterosexual, bisexual, and pansexual people. The 1970s also saw the blossoming of the gay male ‘leather community,’ with organizations like GMSMA (Gay Male S/​M Activists) and the opening of gay male ‘leather bars,’ later the proliferation of events/​parties like the International Mr. Leather contest, Folsom Street Fair, and New York’s Black Party. Lesbians developed their own BDSM organizations, such as Samois in 1978 and LSM (Lesbian Sex Mafia) in 1981. Historically, in the United States there is a great deal of cooperation between different BDSM organizations. For example, the long-​running but now defunct Leather Pride Night fundraiser in New York included TES as well as gay male and lesbian kink organizations. In 1997, a coalition of national leather groups representing all sexual orientations formed the National Coalition for Sexual Freedom (NCSF), an advocacy group formed ‘to advance the rights of, and advocate for consenting adults in the BDSM-​ Leather-​Fetish, Swing, and Polyamory Communities’ ( NCSF, along with some mental health advocates such as Charles Moser, were instrumental in lobbying the American Psychiatric Association to change the paraphilia diagnosis in a way that acknowledged that kinky sexual interests were not inherently pathological. However, the event that has arguably done the most to bring BDSM out of the shadows and into the mainstream is the publication of the book Fifty Shades of Grey, an erotic romance novel by the British author E. L. James in 2011 (James and Battoe, 2012). In fact, Susan Wright, the Director of NCSF, has dubbed this book ‘the Stonewall of the kink community.’ Originally self-​published, the book has set

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many sales records and topped best-​seller charts. Fifty Shades is the first book of a trilogy of novels featuring explicitly erotic BDSM sex scenes between a young woman, Anastasia Steele, and a business magnate, Christian Grey. The book has been translated into over 50 languages, and spawned a similarly popular film version and a hugely popular line of sex toys. For many people who read the book and found it sexually arousing, it was their first introduction to kink. A substantial portion of readers bought kinky sex toys; the sex toy industry experienced a 400% boost in sales in 2012, and then again after the Valentine’s Day release of the movie in 2015. Sex therapists have reported a substantial uptick of couples who want guidance introducing kinky sex into their relationships. BDSM has been part of the LGBT community for decades; in the last few years, it has become part of the mainstream culture. How Many Kinky People Are There? Various research studies have shown that the prevalence of BDSM interests and even behaviors in the general population of adults is very high. For example, Joyal and Carpentier (2017) surveyed a representative sample of 1,040 adult Canadians on paraphilic interests and experiences, using the DSM paraphilia categories, for example, fetishism, sadism, masochism, and so on. Nearly half the sample acknowledged a desire for at least one paraphilic act, and one-​third had engaged in at least one of these acts in their lifetime. Herbenik et al. (2010) surveyed 2,021 US adults and found, similarly, that large numbers had experienced ‘kinky’ sexual behaviors: 43% had participated in public sex, 30% had participated in spanking, 22% had done sexual role playing, and 20% had done experienced bondage. In Herbenick et al.’s sample, even larger numbers than this had fantasized about but not participated in these acts. Thus, despite the stigma attached to BDSM, kinky sexual acts are desired and experienced by substantial numbers of people in the general population. A study by Coppens et al. (2019) reveals the differences between public and private BDSM participants. Researchers surveyed people who participate in BDSM in community settings like clubs or events, people who practiced BDSM only privately and people who only fantasized about BDSM activities. Eighty percent of the people who only had kinky sex at home denied having a personal identity as a BDSM practitioner. People who experience kinky sex privately are able to avoid stigma because their behavior is private and because they do not interpret their sexual behavior as BDSM. These people are underrepresented in much research on BDSM, because BDSM research tends to recruit people who embrace a kink identity. As the Coppens study indicates, there are a number of ‘levels’ of involvement in BDSM. There are those who fantasize without ever actualizing their fantasies. As studies like those done by Joyal and Herbenick suggest, many,

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perhaps a majority, of people have at least occasionally expressed fantasy interest in kink. Many others incorporate some aspects of BDSM sexual behaviors into their sex lives, but usually do not consider themselves kinky. An unknown but much smaller percentage are part of the ‘kink community,’ as we have described it, a loose network of advocacy and support groups, spaces, and events. The Internet has allowed people interested in BDSM to find each other much more easily. The foremost social networking site for kinky people is, which is similar to Facebook and began in 2008. As of 2019 Fetlife had 7.5 million members internationally. Characteristics of Kinky People Most of the research on BDSM practitioners has used samples derived from kink community organizations and events. Thus, we have little information about the large pool of people who practice kink in their own bedrooms but have no public affiliation with BDSM. Existing research indicates that kink-​ identified people are a small subgroup of the general population; about 2% in Richters et al. study (2008). Overall, they tend to have more education and a higher income than the general population. Male BDSM practitioners are somewhat more likely to be single and to have fewer children, but this is in part because of an overrepresentation of gay men in BDSM studies. They are no more likely than non-​BDSM practitioners to have been sexually abused as children, and no more likely to suffer from anxiety and depression. They are just as likely to have been raised in two-​parent households (Sandnabba, Santtila, and Nordling, 2002; Nordling et  al., 2006). Psychologically, they appear to be mentally and emotionally well-​adjusted. Wismeijer and Van Assen (2013) assessed the personality traits of BDSM practitioners using the ‘Big Five’ model of personality traits, that is, openness, conscientiousness, extraversion, agreeableness, and neuroticism. Their study indicated that kinksters rank higher than average on openness to new experiences, which makes sense if one conceives of kink the way some researchers have, as an ‘adventurous hobby.’ Kinky people tend to have recognized their attractions to BDSM in adolescence, although some, like me, were aware at a much younger age. People involved in BDSM practices have long talked about altered states of consciousness attained during kinky play, which are dubbed ‘sub space’ (submissive) and ‘dom space’ (dominant). A 2017 study (Ambler et al.) looked at BDSM practitioners before and after a BDSM ‘scene’ using psychological measures and Stroop tests and found that those who were dominant in the scene evidenced signs that they had been in a state characterized as ‘flow,’ which involves heightened concentration, a loss of self-​consciousness, and is subjectively highly rewarding. Those who were submissive experienced a state of transient hypofrontality, which involves diminished activity in the

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frontal and prefrontal areas of the brain, with increased feelings of peacefulness, floating, and living in the here and now. These altered states contribute to the appeal of BDSM and may also explain why some BDSM practitioners consider kink an expression of spirituality (Easton and Hardy, 2011; Hammers, 2019). Stigma and the BDSM Community People who practice BDSM do not constitute a ‘protected class’ under any laws. Not only do laws not protect kinky people, they often victimize them. For example, BDSM is frequently considered criminal assault under the law. This means that ‘consent’ is not a defense. In many jurisdictions, if a law enforcement officer is called to the scene of a situation involving BDSM sex –​ for example, a neighbor complains of noise –​and observes marks, bruises, or other signs of ‘violence,’ the ‘perpetrator’ can be charged with a assault no matter if the ‘victim’ insists that the activities are consensual. Someone who practices BDSM can legally be fired from a job or evicted from their home if their sexuality is discovered. And BDSM can be used in custody cases to charge that a parent is unfit. In 2019, for example, the National Coalition for Sexual Freedom received 183 requests for help from BDSM practitioners. Thirty-​nine of these involved criminal charges, 16 requests were for help with divorce or child custody, 21 involved civil issues such as being fired from a job, and 75 were from groups, including groups which had had an event cancelled because it was a BDSM event (Wright, 2020). Thus there are real risks for people in the BDSM community that make it difficult for them to be open about their identity and activities. In part because of the stigma that regards BDSM as violence, the kink community has been extremely scrupulous about constructing and enforcing standards to prevent abuse or violations of consent. As I  said earlier, the motto of the community is ‘Safe, Sane, and Consensual’: kinky behaviors should be non-​life threatening, practiced by rational people not unduly influenced by alcohol or drugs, and explicitly consented to by both parties. Those who do not follow these rules, if discovered, are shunned and even banned from BDSM events. Because the community takes this so seriously, BDSM spaces are often among the safest places for single women. When I was exploring kink on my own, I could go to a BDSM club without anxiety because I knew that anyone who attempted to violate my boundaries would in all likelihood be removed by club monitors, and I would even be warned in advance about men considered ‘sketchy.’ Of interest to clinicians is the discrimination BDSM practitioners face from the mental health community (Dunkley and Brotto, 2018). The available research suggests that many therapists have inadequate or inaccurate information on BDSM practices, are uncomfortable working with BDSM

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clients, use unhelpful or even unethical practices with BDSM clients, and inappropriately pathologize BDSM practices. For example, some participants reported that their therapists went as far as requiring them to give up their involvement with BDSM as a condition of continuing therapy … BDSM practicioners have lost jobs, housing, and custody of their children based on the legal testimony of psychiatric consultants’ pathologization of BDSM. (p. 2) The NCSF maintains a list of ‘Kink Aware Therapists’ because many in the BDSM community are afraid to seek therapy or, if they do, afraid to tell their therapist about their lifestyle. As a therapist, it can be very rewarding to work with this population because they have so few resources and it makes such a vast difference for them to see a therapist who will affirm rather than pathologize them for their sexual preferences. Takeaways for the Clinician In the next chapter I  will write about specific issues you may be asked to address when treating someone who is, or wants to be, involved in BDSM sexual practices. But the facts and research I  have discussed here should make it clear that: 1) BDSM encompasses a wide range of practices –​and people; 2) BDSM interests are not in themselves pathological; 3) people who practice BDSM are not disproportionately suffering from mental disorders or past abuse issues; and 4) your job as a therapist begins with affirming and validating your client’s sexuality. References Ambler, J. K., Lee, E. M., Klement, K. R., Loewald, T., Comber, E. M., Hanson, S.A., Cutler, B., Cutler, N., and Sagarin, B. J. (2017). Consensual BDSM facilitates role-​specific altered states of consciousness:  A preliminary study. Psychology of Consciousness:  Theory, Research, and Practice, 4(1),  75–​91. Coppens, V., Ten Brink, S., Huys, W., Fransen, E., and Morrens, M. (2020). A Survey on BDSM-​related activities:  BDSM experience correlates with age of first exposure, interest profile, and role identity. The Journal of Sex Research, 57(1), 129–​136. Dunkley, C. R. and Brotto, L. A. (2018). Clinical considerations in treating BDSM practitioners: A review. Journal of Sex & Marital Therapy, 44(7), 701–​712. Easton, D. and Hardy, J. W. (2011). Radical Ecstasy: S/​M Journeys in Transcendence. SCB Distributors. Hammers, C. (2019). Reworking Trauma through BDSM. Signs:  Journal of Women in Culture and Society, 44(2), 491–​514.

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Hébert, A. and Weaver, A. (2015). Perks, problems, and the people who play: A qualitative exploration of dominant and submissive BDSM roles. The Canadian Journal of Human Sexuality, 24(1),  49–​62. Herbenick, D., Reece, M., Schick, V., Sanders, S. A., Dodge, B., and Fortenberry, J. D. (2010). Sexual behavior in the United States:  Results from a national probability sample of men and women ages 14–​94. The Journal of Sexual Medicine, 7, 255–​265. James, E. L. and Battoe, B. (2012). Fifty Shades of Grey (Vol. 524). Vintage Books. Joyal, C. C. and Carpentier, J. (2017). The prevalence of paraphilic interests and behaviors in the general population:  A provincial survey. The Journal of Sex Research, 54(2), 161–​171. Kinkly.​definition/​312/​safe-​sane-​consensual-​ssc Kleinplatz, P. (2006). Learning from extraordinary lovers: Lessons from the edge. In in P. Kleinplatz and C. Moser (eds.), S/​M: Powerful Pleasures. Haworth, pp. 325–​348. Lesbian Sex Mafia http://​​bdsm/​ Moser, C. and Kleinplatz, P. J. (2020). Conceptualization, history, and future of the paraphilias. Annual Review of Clinical Psychology, 16, 8.1–​8.21. Moser, C. and Kleinplatz, P. J. (2006). DSM-​IV-​TR and the paraphilias: An argument for removal. Journal of Psychology & Human Sexuality, 17(3–​4), 91–​109. Nordling, N., Sandabba, N. K., Santilla, P., and Alison, L. (2006). Differences and similarities between gay and straight individuals involved in the sadomasochistic subculture. In P. Kleinplatz and C. Moser (eds.), S/​M: Powerful Pleasures. Haworth, pp. 325–​348. Richters, J., de Visser, R., Risset, C., Grulich, A., and Smith, A. (2008). Demographic and psychosocial features of participants in bondage and discipline, ‘sadomasochism’ or dominance and submission (BDSM): Data from a national survey. Journal of Sexual Medicine, 5, 1660–​1668. Sandnabba, N., Santtila, L., and Nordling, N. (2002). Demographics, sexual behavior, family background and abuse experiences of practitioners of sadomasochistic sex: A review of recent research. Sexual and Relationship Therapy, 17,  39–​55. Wismeijer, A. A. and Van Assen, M. A. (2013). Psychological characteristics of BDSM practitioners. The Journal of Sexual Medicine, 10(8), 1943–​1952. Wright, S. (2014). Kinky parents and child custody: The effect of the DSM-​5 differentiation between the paraphilias and paraphilic disorders. Archives of Sexual Behavior, 7, 1257–​1258. Wright, S. (2020). 2019 incident reporting and response report. https://​​ 2020/​02/​03/​2019-​incident-​reporting-​response-​report/​



ne day a few years ago, there was a man in my waiting room nervously tapping his foot and glancing around warily, as though unsure whether he wanted to be here. Luis was a 40-​year-​old man who was seeking therapy for increasing feelings of depression and anxiety. He was very familiar with the therapy process; his hesitation in the waiting room hadn’t been because he was a therapy ‘newbie.’ Once he got settled in my office, he was forthright about his concerns. For ten years he had been in a relationship with a woman, Avery, that he described as very satisfying. The couple had no children, but shared many interests and, according to Luis, got along well. Luis stated that he had seen countless therapists throughout his life but that most of them were only for a few sessions. He felt he had never ‘clicked’ with a therapist and had never been completely open with any of them. I probed this a bit further, asking Luis if there was a particular issue that he felt uncomfortable discussing in previous therapy. Here, Luis held back a bit. I said, ‘Look, Luis, I’ve been doing this a long time. I’m a sex therapist, not just a regular therapist, and I can assure you there is nothing I haven’t heard. And it takes a lot for me to be judgmental.’ At this, Luis began to talk, at first hesitatingly, then more rapidly when he saw the encouraging, accepting look on my nodding face. Luis stated that there were certain kinky elements to his relationship with Avery that previous therapists sought to ‘cure.’ At this, I stopped him and said, ‘Let me be upfront about where I am on kink. I consider myself kink-​affirming and kink-​knowledgeable, I’m very much against BDSM being labeled a mental illness and I  think it’s unethical to try to cure people of their kinks.’ Finally, Luis sighed in relief and his body lost a lot of its tension. I talked with Luis about his sexuality enough

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to get his confirmation that his BDSM play with Avery was ‘safe, sane, and consensual.’ I asked a few more questions, all the time normalizing the range of kinky relationships, using certain terms such as ‘master/​slave’ and ‘dominant/​submissive,’ terms that are well known to people who engage in kink and that served to reveal my understanding and acceptance of the subculture. Luis’ body language and facial expression immediately became more open, and he said with some surprise, ‘I’ve never had a therapist who spoke my language!’ Luis explained that he was the ‘dom’ to Avery’s ‘sub,’ a relationship that only sometimes involved sexual intercourse. I validated this dynamic by addressing how kink relationships can sometimes be more about a particular state of consciousness than about sexual expression. From there, Luis began to talk about the real problem, the real reason for coming to therapy, and we stopped talking about his sexuality. He spoke of his deepening feelings of depression and anxiety, which were largely related to transitions and stress at his place of employment. After exploring the recent changes at his job, and talking briefly about using therapy to develop coping mechanisms, the session concluded with Luis thanking me for focusing the therapy on the issues that were problematic for him. In the past, on the couple of occasions when he revealed his kinky lifestyle in therapy, his therapists had focused on his kink interests, ignored the non-​kink related issues that concerned him, and made him feel judged for having BDSM interests. Luis never felt truly safe in therapy. Moreover, he never got to tackle the problems that brought him for help. At the end of the session, Luis stated, ‘I have told you 90% more in one session than I have ever told a previous therapist. Thanks for not making me feel like a freak.’ If this last statement from Luis sounds a bit dramatic, consider these facts, as reported in Dunkley and Brotto’s review of research on clinical issues involving BDSM practitioners (2018): •

In a study of 175 BDSM practitioners, respondents reported 118 distinct instances of therapists providing poor care to BDSM clients; • Another study found 32% of BDSM practitioners reported that the counselor was insensitive to their sexual identity; • In a study of 115 BDSM practitioners, fewer than half were ‘out’ to their health care providers; • A study of therapists’ attitudes toward BDSM found that 76% of clinicians had treated at least one client involved in BDSM –​while only 48% considered themselves clinically competent in this area! Given this data, if you are a therapist reading this, you are already better educated than half of clinicians practicing, just because you are reading about contemporary perspectives and current research. In the rest of this

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chapter, I describe some of the most common issues you will encounter as a kink-​friendly counselor. Let’s start with a point illustrated with Luis’ case: most BDSM practitioners engage in psychotherapy for reasons that have nothing to do with their sexuality. The study above that surveyed 175  ‘kinksters’ found that nearly 75% of them went to therapy for non-​kink-​related issues. This has also been my experience as therapist. Most of the time, your training and work on yourself to be kink-​knowledgeable and affirming will be important in order to secure the trust of your kinky client, not because you will be asked to handle a BDSM-​related problem. Best Practices/​Guidelines for Clinicians Working with Kinky Clients Because the ignorance of BDSM among psychotherapists is so widespread and profound, some clinicians who have been working with this population for years have developed training and education programs to train therapists and, more recently, a group of them, including me, have produced a best practices document. Found at and reproduced in the Appendices of this book, the 23 ‘Clinical Practice Guidelines for Working with People with Kink Interests,’ is a comprehensive list of principles, facts, and recommendations, complete with bibliography, that can provide you with a wealth of information and resources. The guidelines include principles such as these: Guideline 3:  Clinicians understand that kink fantasies, interests, behaviors, relationships and/​or identities, by themselves, do not indicate the presence of psychopathology, a mental disorder or the inability of individuals to control their behavior. and Guideline 4: Clinicians understand that kink is not necessarily a response to trauma, including abuse. Of particular importance to a clinician attempting to develop competence in this area is Guideline 17:  Clinicians should evaluate their own biases, values, attitudes, and feelings about kink and address how those can affect their interactions with clients on an ongoing basis. Let’s take a closer look at Guideline 17.

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Countertransference: ‘If It Isn’t Sick, Why Do I Feel Disgust?’ For many clinicians, negative countertransference is the greatest impediment to working with kinky clients. Some find it difficult to see BDSM as ‘normal’ because some of the sexual behaviors seem strange, frightening, and inexplicable to an outsider. Because of the difficulty in imagining how a particular activity can be genuinely pleasurable, the tendency is to judge its appeal as ‘sick.’ It is therefore helpful for therapists to try to gain a personal understanding of the appeal of BDSM. Many people can find something in their own personal experience that helps them understand BDSM practices. Those who have ever had sex someplace where it isn’t ‘supposed’ to take place  –​the in-​laws’ bathroom or the kitchen table  –​or fantasized having sex with someone ‘off limits’ will understand the appeal of transgressive sex. People who have liked ‘dirty talk’ where their partner calls them a ‘bad girl’ or a ‘bad boy’ may understand how erotic a little bit of humiliation can be. Those who have experienced a hickey as erotic, enjoyed a love bite or love scratch, or liked having their hair pulled, have a glimpse of dominance and submission, sensory distortion, and sado-​masochism. If you’ve ever felt aroused by, for example, the sight and feel of sexy underwear or the smoothness of silk stockings, you know what a fetish is. Even if none of these experiences appeals to you, consider other activities where positive affect seems, at first blush, counterintuitive: horror movies, amusement park rides, extreme sports, car racing, zip gliding, boxing. These common experiences illustrate the fact that pleasure can come from many seemingly contradictory sources, even fear. In working with people in the kink community, it is helpful to try to extend one’s own experiences to find common ground. But sometimes this is difficult; there are times when a certain activity seems bizarre or repugnant, and it might be hard to not pathologize those who participate. People in the BDSM community have a word for this: it is called being ‘squicked.’ ‘Squicked’ is an invented word meant to connote an uncontrollable physical revulsion that includes no moral judgment. If you are strongly turned off to an activity and therefore decide that those who participate are ‘sick,’ you are exhibiting judgment. But if you are ‘squicked,’ you may feel repulsed but remain nonjudgmental. When members of the BDSM community face this visceral reaction they assume it might come from ignorance, or be a reaction formation to their own arousal, or simply express an idiosyncratic distaste. When a clinician is ‘squicked,’ it is neither cause for alarm nor a reason to judge the client, but rather an opportunity to examine our own countertransferential feelings, perhaps with a colleague or supervisor sensitive to BDSM issues. Clinicians who are troubled by their own reactions may also benefit from more information. This can be found in books explaining and describing

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BDSM practices, such as those by Patrick Califia (1993), Morpheus (2013), Easton and Hardy (2011a, b), or Wiseman(2011). You can also watch videos on, like ‘Edging,’ ‘Rope Suspension,’ or ‘How to Clean Your Sex Toys.’ This can be helpful because sometimes understanding how a practice produces pleasurable sensations helps quell the ‘squicked’ feeling. Steel nipple clamps can look frightening. But they make more sense when one understands that, once the clamps are removed, the nipple is left exquisitely sensitive. Spanking and flogging make sense as well in the context of the physiological phenomena induced by extremes of sensation. The flow of blood to the surface of the skin, the rush of endorphins and other chemicals create an experience known to BDSM practitioners as ‘sub space’ (i.e., a psychological submissive space), an experience often described as an out of body altered state like flying or floating weightless. This experience can be deeply fulfilling on levels beyond sexual (Ambler et  al., 2017; Easton and Hardy, 2011c). Pathologizing by Looking for ‘Reasons’ Inexperienced clinicians working with kinky clients often perceive a need to explain the origin of the behavior. ‘Why would someone want to (fill in the blank: be a bottom, flog their partner, get tied up, etc.)?’ The question itself is a subtle way of pathologizing behavior. Just as people want to know the origins of homosexuality but do not question how heterosexuality develops, we often assume a psychodynamic reason for nonstandard sexual practices but don’t think about standard ones. Therapists want to know why someone likes spankings but not why they like oral sex; they may question why a man would want to urinate on a partner’s body but not why he wants to ejaculate on her. Before pursuing psychodynamic explanations for unusual sexual behavior, a therapist might ask herself whether she would do the same for more mundane sexuality. And in fact, the ‘reasons’ are irrelevant, unless you are somehow assuming that the kinky desire is an expression of psychopathology. Since one of the premises of this book is that sexual acts are innocent until proven guilty, it follows that I  recommend you avoid exploring the ‘origins’ of a kinky desire. Your client may tell you he came to fetishize diapers because he has memories of feeling warm and comfortable in a wet diaper as an infant or toddler. This may or may not be true: humans are not necessarily the most knowledgeable about the sources of their own behavior. It may be important to your client because he feels it fits into a coherent narrative of his life. Other than that, it’s pretty irrelevant. If you are not well known in the BDSM community, you are less likely to have clients who are intensely involved in the community and/​or who have complicated BDSM-​related issues. Experienced kinksters also know most therapists are biased, and will tend to seek out clinicians listed on the

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Kink Aware Professionals (KAP) list, found on the website of the National Coalition for Sexual Freedom ( And, as we noted earlier, most kinky people who go to therapy want help for problems unrelated to BDSM. I will not tackle most BDSM issues in this book. Therapists can read more about these clinical situations in Ortmann and Sprott (2012) and Shahbaz and Chirinos (2016). ‘Coming Out’ –​and ‘Cure Me’ There is one type of kink-​involved client that is likely to seek treatment because of their sexual preferences and is unlikely to even know about the KAP list: clients who are hiding their kink, from others and possibly themselves, and/​or who are distressed about their BDSM interests. The clinical issues and cases below involve clients like this. I used to speak frequently at meetings of BDSM organizations like TES in New  York. Generally, the talk was about how, despite the historically pathologizing stance of psychiatry and mental health, there is nothing ‘sick’ or ‘mentally ill’ about being kinky. These talks were useful community-​based interventions because most people in the audience were greatly relieved and helped to be validated by a bona fide mental health ‘Doctor.’ Often, there was at least one person who rebutted me, insisting that ‘Even though I’m kinky, I don’t like it and I know it’s sick. You shouldn’t be saying this! I hope someday someone discovers a cure!’ If I encountered people with what I would call ‘internalized kinkphobia’ or in the midst of BDSM organizations, you, as, a clinician working with people in hiding from or confused about their desires, are even more likely to experience clients with deep feelings of shame and self-​hatred about their sexuality. These are also the clients most likely to hide their BDSM interests from you in therapy. If you are a sex therapist or a clinician who routinely asks about sex life in their initial assessments, you can increase the odds of disclosure by using a questionnaire that ask specific sexual questions that include kink activities. For example, I use a ‘Sexual Concerns Questionnaire’ that includes a checklist of sexual acts with the option to check if you have tried it, want to, or don’t want to. My checklist includes things like bondage, spanking, use of blindfolds, use of costumes, role play, and so on. If nothing else, this kind of instrument signals to your client that you are open to diverse sexual expression. If and when your client reveals a kinky orientation or experience in treatment, your response as a therapist is important. A  client who has been hiding their sexuality from you is also very possibly struggling within themselves. People with BDSM interests often go through an identity evolution process similar to that described by Vivenne Cass in her stage theory of coming out as gay or lesbian, described in Chapter 7.

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It is not unusual for feelings of guilt or shame to exist during the time a person is coming out as kinky, and for that to take the form of a desire to be cured. It is important for you as the therapist to avoid perpetuating clients’ guilt and shame by urging your clients to stop their sexual practices. Moreover, should the topic of ‘cure’ come up, it is critical that you educate your client about the reality that, to date, no one has discovered a way to eradicate unwanted sexual desires, kinky or otherwise. Your job as a clinician is to help your client come to accept their own sexuality, regardless of whether they choose to act from their sexual impulses. Clients just beginning to explore their kinky sexuality need their therapist to provide an affirming alternative to the negative attitudes of the mainstream culture. Some clients may not know that they are ‘allowed’ to entertain kinky thoughts, and may be seeking ‘permission’ from their therapist –​and needing it –​to even verbalize these thoughts. Often, a therapist is in a position to create a safe space for the client to first begin to express these desires. Clients in the coming-​out process also may feel compelled to search for the reasons ‘why’ they identify with some aspect of BDSM. If this happens, you need to caution against the belief that understanding will lead to eradiction of the desire. As long as it is clear that you are not aiming to cure their kinky inclinations, exploring a client’s beliefs as to what ‘caused’ their connection to BDSM might allow valuable insight into the client’s sexual history and value system. You as an accepting, supportive clinician can make a critical difference for a client who is first coming out to themselves and discussing it with a professional, probably for the first time in their life. You are allowing a safe place for the client to express any concerns, beliefs, or opinions related to BDSM, and in this supportive space self-​hatred can often evolve into not simply acceptance, but even identity pride. In the process of working with a client with this kind of internalized shame, in the early stages of self-​ discovery, it is important that you be able to offer resources: books, websites, and information about local groups, organizations, or events. But My Wife Will Leave Unfortunately, some of the clients you see who are just beginning to come to terms with their BDSM interests will be married to a spouse who has no idea about their spouse’s sexuality. Others may be ‘out’ to themselves but not know how reveal this information to their wives, for fear that the disclosure will turn their lives upside down –​which it might. Those whose sexuality is hidden from spouses often are the most distressed, particularly if they believe the spouse will be disapproving and they want to preserve the marriage. They are reluctant to tell their partners and, once they are convinced that they cannot be cured, likely to either attempt to repress their behavior or to maintain a secret second life.

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The fact is, this is not a wholly unrealistic fear, and when you work with a husband who decides to disclose his kink to his wife, it is highly desirable for you or a colleague to work with them as a couple. There is a higher than average chance that this couple will split up. Just as when a spouse is secretly gay, or transgender, the partner of a kinky spouse may consider the revealed truth about a man who she now realizes she knew incompletely, to be too life-​ changing, too shattering, to accommodate. On a practical level, the spouse of a kinky man, even if she is not judgmental or condemning about his particular desires, may be repelled by the content of those desires. Some kinks are harder for the average person to accept than others. It is harder to work with a couple where, for example, the husband’s kink involves poop, than it is when the husband’s desires are to be a dominant and tie her up. However, even the mildest whiff of kinkiness is repellant to some people. Alternatively, the wife may simply be a very nonsexual person who has no interest in pursuing anything out of the ordinary. Kink involves centering sex more than some people want in their relationship. When you are working with a man who is considering ‘coming out’ to his wife about his kink, it is wise to advise him of the strong possibility of negative outcomes and to help him come to a decision carefully and slowly. Here are three examples, cases I’ve described in other writings, that illustrate a variety of end results of such disclosure. By the way, the fact that all these cases involve men is not an accident or sexism on my part. Most of these mis-​matched sexual script couples involve a kinky husband and non-​kinky wife. It is not known whether this is because there are far fewer kinky women than men, because women are less likely to express their sexual desires, or because husbands are more accepting of their wives’ desires. Case Vignette George’s ‘presenting problem’ was erectile dysfunction, but it was soon apparent that the real problem was his lack of arousal during sex with Evelyn, his wife of several years. It didn’t take George that long before he trusted me enough to tell me that, in fact, he had intense interests in bondage which had been present since early childhood and which he had always suppressed. No one knew about his kink, and he had never enacted it with a partner. The sex he had attempted to have with Evelyn was purely conventional. However traditional their sex might be, however, George and Evelyn were both themselves pretty non-​ traditional. They were educated, technologically minded people, who ran a social media business together, knew many gay people, and were liberal and open-​minded. George eagerly embraced the idea that his sexual desires were normal after only a handful of sessions and worked to reduce his shame and increase his self-​acceptance. Eventually, after considering the pros and cons of disclosure, George decided that he wanted to

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tell Evelyn, and so eventually, he brought her to sessions so he could come out to her in the safety of the therapy room. Evelyn was surprised and distressed, but not because she thought George was sick. Initially, Evelyn was upset that George had kept this from her, and it caused her to question her perception of their intimacy. This is a common reaction of wives who discover a hidden aspect of a partner; in a short period of time, Evelyn worked through her distress enough to participate in a few couples sessions to explore the issue in more depth. Evelyn’s second source of distress was that George’s interest in bondage was as a ‘bottom’: he wanted Evelyn to tie him up and dominate him. But Evelyn could not imagine herself in that role. She had been physically abused by her father as a child and equated dominance with cruelty. But Evelyn and George had a close, loving, stable relationship and they were both very committed to finding a way to stay together. Evelyn did some individual work, including therapy for her childhood trauma, in order to try to overcome her reticence. Once Evelyn was ready to experiment with George she discovered, to her surprise, that she enjoyed the experience. She found that being in a dominant sexual role was exhilarating and healing. Moreover, it felt like a ritualized re-​enacting of her childhood abuse, but in a way she experienced as corrective. For me, Evelyn’s experience illustrated not only a highly successful outcome for a couple with a difficult issue, but an example of the potential BDSM has for psychological healing. Case Vignette Al was not a typical client for my practice. A blue-​collar construction worker in his mid-​30s, Al was the kind of man who considers going to therapy a weakness. But he was desperate. He had strong BDSM desires, which he had fought for years, acting on them intermittently with women he met online. Al liked to dominate women, put them in bondage, and sometimes spank or flog them. But Al never acted out, or even disclosed, his sexual interests to women he considered ‘marriage material.’ With those women, sex remained conventional, and his kink could be compartmentalized. But Al was now engaged to be married, and his fiancée was pregnant with their first child. He could not imagine telling his fiancée of his sexual tastes, but he also could not imagine living his life without kink. He realized it would be harder to pursue outside sexual liaisons while living with a wife and baby, and he also felt guilt about infidelity. Al initially came to me begging for a cure. He stayed in treatment even after I told him that wasn’t possible, because he hoped I could help him come to some resolution that would allow him to happily marry his fiancée. Over time, Al was convinced his desires were not ‘sick,’ but he rejected the idea of telling his fiancée about his sexuality. As Al became more self-​accepting he was encouraged to allow himself to fantasize privately about kink while making love with his partner, as I assured him fantasizing about other partners was commonplace and ‘normal.’

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When Al incorporated fantasy into his lovemaking with his fiancée, it had the effect of making him enjoy intercourse and oral sex more, which in turn, reduced his anxiety and distress. It was clear that Al’s reticence to divulge anything of his sexuality to his wife came from two sources: first, he still retained shame himself, and doubts about whether his desires were ‘sick’; and second, the pedestal he put his wife on didn’t allow him to imagine she might enjoy any non-​traditional sexual acts herself. Months of therapy, and visiting websites like the one maintained by TES, which normalize kink without sensationalizing it, helped Al gradually accept his sexuality. I  repeatedly confronted his belief that his wife was not sexual, and normalized lusty sexual interests for women. Eventually, Al broached the idea of light bondage to his partner, and to his surprise, she showed genuine interest. Once Al realized that his ability to be faithful to his about-​to-​be wife would be strengthened by making sex with her more enjoyable to him, he incorporated a little kink into his sex life, without ever disclosing the extent of his BDSM interests to his partner. He felt satisfied with this outcome and left treatment. Case Vignette Larry was another man who came to treatment asking to be cured of his BDSM desires. A successful, middle-​aged businessman, Larry lived in a rich New Jersey suburb with his wife and two college-​age children. He had been married for over 20 years to a woman who never enjoyed sex and who over the years had gradually ceased to be sexual with him at all. During the early years of his marriage, Larry had managed his kinky interests through fantasy during masturbation and during sex with his wife, but as his wife became less sexual, Larry’s drive to act out his kinky fantasies increased. He came to me asking for a cure, but readily accepted the concept that his desires were normal; he was highly educated and devoured all the informational literature I could recommend. As sometimes happens, however, as Larry became more self-​accepting of his own sexuality, his kinky desires increased. He began to feel he could not live the rest of his life without actualizing his BDSM interests. But Larry refused to tell his wife about his sexual interests or to bring her into therapy. He reasoned, quite rationally, that a woman who hated even tame, conventional sex wasn’t going to be interested in kink. He knew that the two had not been terribly emotionally intimate for years, and feared that disclosing his BDSM to his wife would trigger her to demand a divorce, and to poison his children’s minds against him. So Larry instead constructed a secret life for himself while attempting to maintain the image of a perfect suburban husband. He had regular online partners with whom he had video sex, and eventually he found a woman in New Jersey who enjoyed the kinky sex scenes they had together. After a couple of years, however, his wife discovered his activity and the marriage did, as he had predicted, dissolve. Despite a difficult and costly divorce, and a period of time

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during which his children were distant, Larry feels he is better off now. He is able to pursue BDSM relationships, which he finds rewarding personally and sexually. And he is relieved of the burden of a secret life. Working with Partners and Families As many of the above cases illustrate, it is very difficult to work with couples where one partner is disclosing formerly hidden sexual desires. It is often better for a different therapist to work with the wife, or with the couple. The partner needs a therapist who can fully emphathize with her situation, and it may be hard for her to trust a therapist who has been helping her husband ‘come out’ as kinky. A couples counselor needs to be able to fully support her pain and anguish, even while her husband may be beginning a time of joyous exploration in his life. It is ideal for the therapist working with such a couple to have sex therapy experience, because at times the issues between the partners have to do with a sexual mismatch that might be reconcilable, as in the case of George and Evelyn described earlier. When working with kinky clients, it is important to be mindful that those who are strongly involved with the kink community, as opposed to practicing BDSM purely in private, may be involved in consensually nonmonogamous relationships. There are many so-​called ‘leather families’ or ‘BDSM families’ in the community, with sometimes complicated roles and relationships. For example, a well-​known BDSM activist in New York has a wife with whom he lives in a full-​time dominant/​submissive relationship, he plays the role of ‘Daddy’ to two other women who are his ‘girls’ and who sometimes live with him and his wife, and his wife has a long-​term male partner who is submissive to her but lives apart. They all consider themselves to be part of an extended family. Typically, people involved in BDSM do not share these sexual preferences with their children, so kink is rarely the same kind of issue it is, for example, with gay households. However, kink is frequently used as a weapon in child custody cases. This is a factor to consider, and to discuss in therapy, when you are counseling clients who are married with kids and who have not ‘come out’ to their wives. Clients who anticipate a hostile response might consider whether and how to disclose, and should be advised to consult with a knowledgeable attorney before revealing anything. You may be able to play a helpful role with wives of kinky husbands when the couple has children. You could, for example, reassure a wife who has just recently learned her partner is kinky that there will be no harmful impact on the children. If children have been told negative things about the kinky parent, and you are able to have sessions with them, you can educate them to reassure them that their father isn’t a ‘sex pervert.’ Similarly to situations where you are counseling a couple where one member’s homosexuality has just been revealed, or when one member is

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transitioning to another gender, your goal is not necessarily for the relationship to stay together, but rather to help them discover what best suits both their needs, and if they separate, to do so with a minimum of rancor and blame. But What If It Really Is Abuse? One of the problems that confronts kinky people is that neighbors  –​and police  –​can mistake consensual BDSM activities for domestic violence. Sometimes, of course, domestic violence exists alongside kinky sex, and it is important to know the difference. In addition, some BDSM activities may seem so extreme or unsafe that it is hard to assess whether or not the person is being self-​destructive. This problem may arise more often for clinicians less experienced in working with BDSM practitioners. The clinician may not automatically know if a behavior is safe or sane, two of the three criteria for appropriate BDSM activity. Many of us harbor unconscious biases regarding sexual risks as compared to other more common risks. We often tend to accept common risks more than uncommon ones, for example, the risk of allowing a child to play football. But most clinicians, at least those who have training in domestic violence, will have more ability to assess a third and critical component, consensuality. One of its key aspects is mutual enjoyment: the difference between a violent sexual sadist and a sadist in the BDSM community is that the former has no interest in the needs or well-​being of their partner, while sadists in the BDSM world usually pride themselves on how well they take care of their ‘bottoms,’ not just sexually but emotionally as well. Mutually arousing and agreed-​upon sexual activities are consensual. Non-​consensual BDSM relationships are a particular form of partner/​spousal abuse, and this abuse is marked by the lack of pleasure and the presence of real fear on the part of the submissive partner, a fear that is not confined to the sexual encounter but pervades the relationship. When consensuality is not obvious, the therapist can assess the couple for domestic violence. It is also important to recognize that domestic abuse can also occur toward the more dominant partner, from the one who is more submissive. The therapist should interview the partners separately to assess safety and look for non-​sexual violence and evidence of rage and/​or contempt for his or her partner. The therapist can assess for signs of fear and intimidation, incidence of non-​sexual abuse, and a sense of being trapped in the relationship. Case Vignette It can be more difficult to assess when a client is using BDSM in a self-​destructive way. Lois and Lila were a lesbian couple, both in their early 30s, living together

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in what is sometimes called a ‘24/​7’ BDSM relationship. In other words, Lois was dominant, Lila submissive, and the two women kept this dynamic in every aspect of the relationship. Lois handled all the money and handled every detail of Lila’s life, including what friends she could talk to and when. 24/​7 ‘lifestyle,’ or TPE (Total Power Exchange) relationships are a type of BDSM relationship that is controversial even within the kink world. In these relationships, the submissive hands over complete control of their life and finances to their dominant. Often there is a written contract, specifying the rules and obligations of each partner. Lois and Lila did not have such a contract. They came to see me because Lois insisted they come. Ironically, Lois felt Lila was getting too dependent upon her. And she was right. Over time, Lila was losing the ability to make any decisions at all. If Lois told her to get dressed, she couldn’t do it unless Lois picked out every garment. Lila was finding it harder and harder to function at work and was at risk of being fired. In this case, it was clear that Lila was a deeply disturbed young woman using the 24/​7 relationship to abdicate any responsibility for her life. While Lois enjoyed some aspects of the TPE arrangement, she found she had no desire to parent a grown woman as if she were a small child. Lois became convinced that the 24/​7 lifestyle was not working for her, or for Lila, and she used her dominant role to insist that Lila get intensive individual treatment. Lila entered treatment with a kink-​knowledgeable therapist who could separate Lila’s pathological dependency from her submissive role and help Lila individuate from Lois. With the help of this therapist, the couple suspended the TPE lifestyle and modified their relationship to confine the dom/​sub roles to specified, time-​limited ‘scenes,’ rather than every aspect of their lives. It should be noted that neither Lois nor Lila would have accepted this direction from therapists who they did not perceive to be kink-​aware and kink-​affirmative. People Who Want to Explore BDSM Since the publication of Fifty Shades of Grey, therapists at IPG  –​and sex therapists everywhere –​have received requests from individuals or couples who want to incorporate kinky sexual practices into their sexual repertoire. When I get clients like this, I refer them to some of the sex manuals mentioned in Chapter 21 or to websites like, a site containing both free and paid instructional videos teaching BDSM techniques. It may be useful to hire a sex coach, or even a professional dominatrix. If you are near a BDSM organization like TES in New  York, there may be meetings and demonstrations for beginners to teach some BDSM basics. The point here is that BDSM involves techniques, and many BDSM practices are dangerous if not done properly. As a therapist, you cannot teach these techniques yourself, but you can refer your clients to good sources of education.

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What Kinky People Can Teach Us All Much of the research on BDSM has focused on establishing that kinky people are not psychologically disturbed or the victims of past abuse. But more recently, some writers instead have described the ways in which those in the kink community have developed behaviors that enhance sexuality in general and that strengthen couple relationships. Those familiar with the BDSM community are impressed by the level of sexual satisfaction attained by kinksters and the way in which sex has stayed hot for decades in many long-​term kinky relationships. Here are some lessons from BDSM practicioners: Communication and Negotiation For a BDSM encounter to be successful, the dominant person, the person in charge, must know a great deal about his or her submissive, and both partners must reach a mutual understanding about the general parameters of what will take place between them. Questionnaires listing the kind of information a ‘dom’ often obtains from the ‘sub’ can be found online at sites such as https://​bdsm-​​ or https://​​contact, as well as in SM manuals such as the ones listed in the last chapter. Most of these inventories list upwards of 100 different sexual activities and require the submissive to rate their desire for each activity on scales ranging from ‘Never’ to ‘Essential.’ This is remarkable because the average non-​kinky person could not even list 100 or more sex acts, much less readily identify his or her level of interest in each. BDSM forces people to know their own sexuality intimately and in great detail, to acknowledge their deepest sexual fears, desires, and fantasies; and to communicate those things to a partner. At the same time, participants in an SM scene agree upon rules and procedures, including safe words, and ways to communicate discomfort and lack of consent clearly during the sex act itself. BDSM scenes also require sexual negotiation. Participants often must push their boundaries, restrain their desires, or compromise a bit on what they want in order to create a joint pleasurable experience. Sexual giving and generosity are emphasized, and participants are forced to clarify their boundaries within themselves and with their partner in order to determine where they are and are not willing to compromise. Objectivity and Nonjudgmentalism about Sex After working with people in the kink community, who go out of their way to be nonjudgmental of any consensual adult sexual practices, one is struck by

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the sexual judgmentalism of the mainstream culture and of many mainstream couples. In the mainstream world, sexual inhibitions often are related to fear of judgment, and sadly that fear is sometimes realistic. BDSM practitioners may not share one another’s desires but they do not condemn each other for these desires. The rest of us can learn a great deal from this accepting stance. Sexual Variety Surveys of people who identify as kinky invariably find that BDSM practitioners are not only not focused just on one type of kink, they incorporate a far greater variety of sex acts than their ‘vanilla’ (non-​kinky) counterparts. Kinksters are sexual adventurers whose tastes range far and wide, rather than being narrowly focused. No matter how mundane their everyday relationship may be, no matter how familiar they become with their partner, they can always explore new and slightly risky, edgy sexual fantasies together. Over time, the variety results not just in a breadth of activities, but in psychological and emotional depth in the form of trust and intimacy. Planning vs. Spontaneity Sex therapists often struggle to get couples to accept the fact that they must plan for sex. The myth of spontaneity is firmly ingrained as a sexual value for most of our culture, except in the kink community. By necessity, BDSM sex must be planned ahead at some point: equipment prepared, scenes negotiated, costumes assembled. Not only does this not detract from the enjoyment of the sexual encounter, it facilitates ‘simmering.’ ‘Simmering’ is the anticipation of pleasure that will come at a later time, and it tends to increase arousal and heightens and extends the entire erotic experience. Technical Skill Too often sex therapists downplay the importance of sexual technique. BDSM practitioners pride themselves on being highly practiced and technically competent in, say, the use of particular floggers or a type of bondage. Among kinky people, there is an expectation that sexual skill is learned through practice, and that responsible players learn and perfect their skills before trying them out on a partner. Non-​kinky people, however, often maintain the myth that sex should come ‘naturally’ and that skills are irrelevant. For many people it is insulting or shame-​inducing simply to suggest that their sexual technique needs improvement. In reality, though, sexual skills, like all skills, are learned. The kink attitude toward sex embodies what sex advice columnist Dan Savage has called ‘The Three G’s: Good, Giving, and Game.’ ‘Good’ refers to technical skill, ‘giving’ refers to consideration for

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one’s partners’ needs, and ‘game’ means an openness to new experience and willing to try new sexual activities. Sex as a Form of Healing Recent investigations of kink have also explored how kinky people enact ‘sexual healing.’ ‘One key narrative, which has emerged recently in accounts of BDSM experience, is that of BDSM play as a safe space to explore issues that might traditionally have been brought to contexts such as counseling and psychotherapy’ (Barker, Gupta, and Iantaffa, 2007, p.  203). Peggy Kleinplatz movingly describes therapy with a lesbian couple who used BDSM to explore, reenact, and resolve trauma induced by one partner’s childhood abuse (Kleinplatz, 2006). Although people with BDSM desires are no more likely than others to have endured such childhood trauma, for those who have, kink can be a pathway to sexual healing. Dossie Easton has labeled this ‘shadowplay,’ after the Jungian concept of the shadow side of one’s personality, the part that holds darkness and negative emotions but also tremendous capacity for creativity (Easton, 2007). Shadowplay, as Easton describes, is a way of using BDSM for therapeutic purposes. It is not always about childhood issues or psychological problems; it can be about current stressors as well. Easton has described a woman who constructed a BDSM scene in which she was ‘abused’ by four gay male friends and, while she was restrained in bondage, she could safely vent some of the rage she felt about living in a sexist society and dealing with patriarchal abuse every day. Easton and Hardy (2011c) have also described such an experience, in which one of the participants used the BDSM scene to come to terms with a feared part of herself, a part she named the ‘hostile horny nasty teenage boy.’ There are many ways to resolve trauma and negative feelings; resolving trauma through sexual healing is not pathological. If one acknowledges that intimate relationships can heal old psychic wounds, BDSM can sometimes be the ideal crucible in which to re-​enact and resolve trauma and fears. Shadowplay, the practice of using BDSM to re-​enact and resolve trauma or stressors, is not recommended for BDSM beginners, but it can accomplish healing when done thoughtfully between experienced, trusted partners. It could be thought of as a form of erotic bodywork. Sex as Spirituality BDSM play takes much longer than more standard sexual encounters, requires more planning, and often is much more emotionally and physically intense. BDSM participants often experience altered states of consciousness referred to within the kink subculture as ‘sub space’ or ‘dom space.’ Many

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kinky people are open about considering these sexual practices sacred, a path to spirituality. Just as those who practice tantric sex experience not only more intense sexual experiences but also a sense of spiritual connection, so do some kinksters. Easton and Hardy (2011c) describe this: When I am dancing in the storm of a flogging, to the song of the whip; when I am writhing in the throes of orgasm; when Kundalini the great snake is awake all through my body and beyond and I am thrashing and bellowing on my meditation mat, I know that the divine is real. (p. 57) Takeaways for the Therapist Working with clients who engage in BDSM requires a therapist to confront feelings and biases about sexuality which may have been deeply held and unconscious. Kinky sex itself has been called an orientation –​or a very intense hobby. People who engage in BDSM sex are no more likely than others to be psychologically disturbed or to be suffering from childhood trauma, but they are more open to new experiences. However, many clients who practice BDSM suffer from internalized shame and ‘erotophobia’ or ‘kinkphobia.’ BDSM desires can be suppressed but not eliminated, and so part of the task of the therapist is to help the client come to accept and hopefully enjoy their sexuality. Kinky clients usually come to treatment for reasons unrelated to their sexuality, similar to other clients: for example, depression, anxiety, stress, the breakup of a relationship, coping with a major life change. You will, however, sometimes get kinky clients who are in the beginning stages of exploring their sexuality, or who are contemplating ‘coming out’ to others. You will be asked to ‘cure’ kinky desires, and you will need to help clients who ask for a ‘cure’ to understand that they cannot eradicate these desires. Sometimes you will need to do couples work when one member of the relationship is just learning that they are involved with a kinky partner. The reward of working with kinky clients is great, not only because you are providing essential services to a vastly underserved population, but also because in working with these clients, you will yourself learn about some of the ways in which many kinky people have mastered the art of having exceptional sex, with the same partner, over a lifetime. References Ambler, J. K., Lee, E. M., Klement, K. R., Loewald, T., Comber, E. M., Hanson, S.A., Cutler, B., Cutler, N., and Sagarin, B. J. (2017). Consensual BDSM facilitates role-​specific altered

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states of consciousness:  A preliminary study. Psychology of Consciousness:  Theory, Research, and Practice, 4(1),  75–​91. Barker, M., Gupta, C., and Iantaffi, A. (2007). The Power of Play: The Potentials and Pitfalls in Healing Narratives of BDSM. Palgrave Macmillan. Califia, P. (1993). Sensuous Magic: A Guide for Adventurous Lovers. Masquerade Books. Dunkley, C. R. and Brotto, L. A. (2018). Clinical considerations in treating BDSM practitioners: A review. Journal of Sex & Marital Therapy, 44(7), 701–​712. Easton, D. (2007). Shadowplay: S/​M journeys to our selves. In D. Langridge, M. Barker, and C. Richards (eds.), Safe, Sane and Consensual:  Contemporary Perspectives on Sadomasochism. Palgrave Mcmillan, pp. 217–​228. Easton, D. and Hardy, J. W. (2011a). The New Topping Book. SCB Distributors. Easton, D. and Hardy, J. W. (2011b). The New Bottoming Book. SCB Distributors. Easton, D. and Hardy, J. W. (2011c). Radical Ecstasy: S/​M Journeys in Transcendence. SCB Distributors. Kleinplatz, P. J. (2006). Learning from extraordinary lovers:  Lessons from the edge. Journal of Homosexuality, 50(2–​3), 325–​348. Morpheous. (2013). How to Be Kinky: A Beginner’s Guide to BDSM. Green Candy Press. Ortmann, D. M. and Sprott, R. A. (2012). Sexual Outsiders:  Understanding BDSM Sexualities and Communities. Rowman & Littlefield Publishers. Shahbaz, C. and Chirinos, P. (2016). Becoming a Kink Aware Therapist. Routledge. Wiseman, J. (2011). Sm 101: A Realistic Introductoin. SCB Distributors.



had been seeing the couple sitting across from me for a little more than six months. They’ve had a sexless marriage for many years, and Joyce, the wife, was at the end of her rope. Her husband, Alex, had little or no sex drive. There’s no medical reason for this; he’s just never really been interested in sex. After years of feeling neglected, Joyce recently had an affair, with Alex’s blessing. At first, Alex’s casual attitude about the affair hurt Joyce, but she didn’t let that stop her. The experience she had with this partner convinced her that she could no longer live without sex, so when the affair ended, her marriage was in crisis. ‘I love Alex,’ Joyce said, ‘but now that I know what it’s like to be desired by someone, not to mention how good sex is, I’m not willing to give it up for the rest of my life.’ Divorce would’ve been the straightforward solution, except that, aside from the issue of sex, they both agreed their life together as coparents, best friends, and members of a large community of friends and neighbors was satisfying and meaningful. They wanted to stay together, but after six months of failed therapeutic interventions, including sensate-​focus exercises and Gottman-​method interventions to break perpetual-​problem gridlock, they were at the point of separating. As their therapist, I had several choices. I could: • Help them ‘consciously uncouple’; • Refer them to an EFT (Emotionally Focused Treatment) therapist to help them further explore their attachment issues; • Advise a temporary separation, reasoning that with some space apart they can work on their sexual problems; • Suggest they consider polyamory and help them accept Alex’s asexuality.

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I would have helped Joyce and Alex ‘consciously uncouple’ if there were no alternatives, but they didn’t want to separate. Referring them to an EFT therapist would’ve implied that I thought their sexual issues were rooted in relationship problems, which I did not. As a sex therapist, I know that sexual problems can exist in wonderful relationships, as well as in bad ones, and only sometimes are sexual problems related to the quality of the relationship. Suggesting a temporary separation seemed like a stalling tactic. So, instead, I  recommended they consider polyamory, a form of consensual nonmonogamy. I pointed out that Alex didn’t seem to have a jealous bone in his body and that Joyce seemed capable of loving more than one person at a time. Neither of them was familiar with polyamory, but they were open, psychologically curious people and promptly began to research it. Eventually, they got involved with a local polyamory group they found online. Twelve years later, they’re still together and have an even larger community of friends which include deep, nonsexual friendships for Alex and an ongoing lover for Joyce. Here’s another therapy dilemma I  faced. Nate, my client, and his wife Tina are caring together for their adult son who is autistic. After 30  years of marriage, Tina no longer even feigns interest in sex, and it’s been over a decade since they’ve shared sexual contact of any sort. In treatment, Nate confides that he now has a girlfriend on the side. He wants me to understand that divorce is neither desirable nor practical (not enough money to support two households, and a son who requires care from both parents). He wants to be able to talk about issues he has with his girlfriend without my judgment, and he wants my support in eventually suggesting to Tina that he can love her while maintaining a relationship with someone else. If Nate were your client, would you do it? I did, and I even helped him mitigate his guilt by validating the impossibility of his current situation. From my perspective, Nate was trapped in an outmoded relationship model. When he and Tina made a commitment to monogamous marriage, he had no idea that someday his wife would become entirely indifferent to sex. Like most people who enter into monogamous agreements, he assumed that sex would continue to be a significant element of the relationship, as it had been in the beginning. When that turned out not to be true, he was left with a few alternatives. He could’ve behaved as husbands did up until recently and simply demanded sex from a reluctant partner, but he didn’t want to do that, nor did he want her to have ‘pity sex’ with him, as he called it. He could’ve asked Tina for a divorce, but he wanted to continue living with her and help her care for their son. He could’ve given up having sex with a partner altogether, but that option seemed completely undesirable –​and unreasonable –​to him. So he opted for an age-​old solution: a clandestine affair. Both Joyce and Nate, in their respective relationships, were struggling with the same problem:  how to keep a marriage going when one partner

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doesn’t want sex. Until recently, psychotherapists, including sex therapists like me, have considered a very limited set of options, and they almost all involved the partner or partners living a life devoid of truly good, high-​ quality sex. Now we have alternative interventions, at least for some couples. Although there’s surprisingly little research on this topic, sexless marriages are far from rare. In fact, in 2018, psychologist Justin Lehmiller, in his blog, ‘Sex and Psychology,’ summarized existing studies and estimated that one in seven adults are in sexless marriages or relationships. Most report it as a major problem, but more than half stay in their relationships nonetheless, and approximately 40% have affairs or resort to cybersex. But sexless marriages aren’t the only kind of relationships with sexual incompatibilities. In our practice at IPG, we work with couples where one partner is kinky and the other isn’t, or one is bisexual and the other isn’t, and with couples who just have vastly different sexual scripts and preferences. One way a sexual script can differ is if one person feels an intense need to have sex with more than one partner. In past decades, the only alternatives to involuntary celibacy in a relationship, or to sexual mismatches, were affairs or divorce. But, increasingly, people, including therapists, are recognizing there’s another option:  consensual nonmonogamy (CNM), an arrangement where both partners freely agree that they can have sexual partners outside the marriage/​relationship. This option can work for couples who have various sexual incompatibilities, for couples who simply don’t believe that fidelity –​faithful commitment to a partner –​is the same as monogamy, and for those people who believe that having multiple sexual and/​or romantic partners at the same time enriches their lives and the quality of their primary relationships. A Brief History of CNM The idea of consensual nonmonogamy (CNM) isn’t new. Christopher Ryan and Cecildá Jethá, authors of Sex at Dawn (2010), hypothesize that primitive humans were by nature nonmonogamous, and that monogamy was instituted around the time of the agricultural revolution as a way for men to establish patrilineality and hand down material wealth to their offspring. Despite the ubiquity of monogamy in contemporary Western culture, it is by no means universal. Throughout history, cultures around the world have supported polygamy  –​one husband with multiple wives  –​and, to a lesser extent, polyandry –​one wife with more than one husband. Even the United States has a rich history of ideologically driven nonmonogamous experiments, beginning with the transcendentalism movement in the mid-​ nineteenth century. The most famous of these attempts was the Oneida community (yes, the same Oneida that made your grandmother’s silverware). John Humphrey Noyes established Oneida in 1848 as a utopian religious

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community with a system of ‘complex marriage,’ which involved all males married to all females and the communal rearing of all children. By 1879, hostility from surrounding communities forced the community to abandon this arrangement and Noyes to flee to Canada. The next organized experiments in nonmonogamy in the United States began in the beatnik world of the 1950s with Kerista, a commune that originated as a spiritual movement in Harlem and continued for 20  years, from 1971 to 1991, in Haight-​Ashbury, San Francisco. Kerista, considered the most influential commune of this second wave of intentional nonmonogamy, popularized terms like polyfidelity (sexual fidelity among members of a polyamorous group) and compersion (the feeling of joy seeing a loved one love another –​the opposite of jealousy). The 1970s saw the development of more forms of CNM in American culture. So-​called ‘free-​love communes’ proliferated among those who called themselves hippies. George and Nena O’Neill’s book Open Marriage (1972) sold 1.5 million copies when it came out (more than 35 million worldwide to date). Swinging emerged as a more conservative alternative to the communal forms of sexual freedom. Initially, swinging followed strict rules of ‘wife-​swapping’ with no emotional involvement beyond sex, although it has evolved beyond that in recent years. Also, lesbians and gay men used their newfound social freedom to develop their own forms of nonmonogamy. Gay male communities in urban areas formed around the concept of what writer Erica Jong (1973) famously called the ‘zipless fuck’: sex, often anonymous, without commitment. Some lesbian feminists considered monogamy a patriarchal plot and developed nonmonogamous styles similar to the earlier free-​ love communes. While for many lesbians nonmonogamy was more a theory than a practice, by the end of the 1970s gay men had made nonmonogamy the norm. In fact, when Dave McWhirter and Andrew Mattison published their landmark book The Male Couple (1984), a study of long-​term gay couples, they found that 100% of their sample had nonmonogamous arrangements. And then the AIDS epidemic hit, forcing the entire gay male culture to take a step back from sexual liberation. Openness about sexual adventurism and nonmonogamous relationships had to wait for the Internet era to really expand –​and it has. A 2017 study published in the Journal of Sex and Marital Therapy used census data to determine that more than 21% of single American adults have engaged in CNM at some point in their lives (Haupert et al., 2017). Data from the 2012 National Survey of Sexual Health and Behavior indicate that 4% of respondents over the age of 14 in relationships are currently living in a CNM relationship. (Levine et al., 2018). A similar study of Canadians also found 4% currently in consensually nonmonogamous relationships, one-​ fifth reporting that they had ‘ever’ been in a CNM relationship, and 12% reporting CNM as their ideal relationship type. Younger people are more accepting of

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consensual nonmonogamy. A 2016 YouGov survey of adults over 18 showed that 11% of their sample reported sexual contact outside of their relationship with the consent of their partner, but 17% of those under 45 have had CNM relationships, and approximately one-​third say they would be okay if their partner had an outside sexual relationship (Moore, 2016). Monogamy is hardly dead, but it’s getting some healthy competition. And not just from the queer community: CNM has been sufficiently destigmatized that celebrities like Will Smith, Mo’Nique, Alan Cummings, Emma Thompson, and Dolly Parton have all talked publicly about being nonmonogamous. Marriage Counseling, Anyone? With some notable exceptions like Tammy Nelson and Esther Perel, most psychotherapists are conservative on the issue of monogamy. As polyamory expert Elisabeth Sheff wrote (2016), Monogamy remains one of the last unquestioned bastions of relational legitimacy –​at least in the minds of many couples and marriage therapists. Pro-​monogamy bias in therapists is not an accident –​in the majority of conventional counseling programs, therapists-​in-​training are taught that monogamy is important and should be protected. Conversely, nonmonogamy is cast as a sign of a problem, something that should be solved instead of celebrated or explored. If this is the mainstream view of monogamy, it’s no wonder that people involved in nonmonogamous relationships, and those who are considering opening their relationships, avoid seeking therapy to help them. There is a great need for couples therapists to confront their prejudices and to become knowledgeable about types of consensual nonmonogamy. Ask yourself questions like: •​ Do I  believe that people can choose nonmonogamy for healthy reasons? •​ Can someone want a nonmonogamous relationship even if their primary relationship is functioning well? •​ Can someone in a relationship have outside partners without it hurting their primary relationship? If your instinctive response to any of these questions is ‘No,’ then you need to educate yourself more before you work with people who engage in CNM.

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Another Way In the early 1970s, I lived for a time in a free-​love commune. It was wonderful, caring, and nurturing –​until it wasn’t. The half-​dozen or so of us experimenting with group love were young, naïve, and dealing with a cauldron of poorly explored personal issues, including emerging alternative sexual orientations, complex emotional states, and alcohol abuse. When the commune broke up, at about the time I  came out as lesbian, I  was heartbroken. On a personal level, it felt like I was losing my family, a family that had been far more nurturing than my family of origin. On a political level, it collided with my youthful ideals. Although my radical feminist mind subscribed to the rhetoric that monogamy is a tool of patriarchal oppression, as soon as I met my partner, Nancy, we fell into reflexive monogamy. So when in 1986 I came out as bisexual and found myself attracted to a gay male friend, neither Nancy or I was prepared in the slightest. We attempted to open up the relationship and I  became sexually and romantically involved with my friend, but I wish that I’d had someone back then who could’ve explained ‘new relationship energy’ (NRE) and its implications to me. Long before psychologists studied limerance, or obsessive love, people experienced in polyamory recognized that there’s an infatuation phenomenon called NRE in poly circles that never lasts and shouldn’t be taken that seriously. I took it far too seriously, and ended my relationship with Nancy because of it. Our couples therapist at the time was just as clueless. He was a gay man who understood casual, recreational, and anonymous extradyadic sex, but couldn’t fathom my type of nonmonogamy. I  always felt he judged me negatively and offered Nancy and me no help in maintaining our relationship in the face of my affair. Nancy and I  still communicated because of our son, and after years apart we have ended up once more as life partners. But I wonder what would’ve happened if we’d had a competent therapist to help us navigate the uncharted waters of an open relationship and guide us in the ways of polyamory. I would’ve preferred to find a way to stay in that relationship with the mother of our son, especially while he was growing up. Maybe that’s one reason I’m so determined to help my nonmonogamous and polyamorous clients now. I  know in my bones that I’m not ‘wired for monogamy’ –​quite the opposite. The number of sex partners and the variety of sexual experiences I’ve had make me an outlier from most women of my generation, but they’ve opened up parts of myself that I’m grateful to have accessed. Many of my interests in politics, poetry, psychedelic experiences, history, world travel, opera, and other things were enhanced and developed in intense, nonmonogamous relationships. One of my most spiritual –​and erotic –​moments happened while I was bound and enveloped in a black leather bag in the middle of a scene orchestrated by a gay male bondage ‘top’ who

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never touched my skin or genitals. Could these experiences have happened another way? Theoretically, yes, but for me, sexual intimacy has always been the hand that unlocks doors in my mind I didn’t even know were there. And sex has always felt like a life-​affirming act to me. So when a friend described her long-​term, monogamous, loving marriage as a room devoid of oxygen, I understood and supported her foray into polyamory. And when gay men describe sexual experiences with strangers as spiritual, I get that, too. I’m not saying most people view sex in this way, but for those who do, committing to having sex with only one person for decades of your life is like committing to being in prison: a deal breaker. CNM can be a solution for sexually incompatible marriages, but it can also be an avenue for self-​actualization and deep exploration of self in relationships. What Does CNM Look Like? There are many types of consensual nonmonogamy, but they can be roughly divided into three groups: •​ Swinging:  a type of CNM that might involve ongoing sex with the same outside partner or partners, but stops short of romantic or love relationships; •​ Polyamory (literally ‘many loves’):  CNM where participants have relationships that are both romantic and sexual, and may evolve into multiple marriages and/​or joint living arrangements; •​ Open relationships: a catch-​all term that includes any type of CNM that is neither swinging nor polyamory. For example, one couple might allow partners to have sex outside the relationship that is a one-​off with that particular partner; another might have a ‘don’t ask, don’t tell’ policy; a third might be comfortable with ongoing sexual relationships that include no contact outside of the sexual encounters. Case Vignette Mickey and Ethan were married for eight years. Two years before seeking therapy, they’d opened up the relationship and at first their forays into extramarital sex were fun and improved their sex life with each other. Both were ‘bottoms’ –​meaning they both liked to be on the receiving end of anal sex –​ and with those urges satisfied outside the relationship, their sex together was conflict-​free and better. Then one night, Ethan didn’t come home. Mickey was enraged and insisted the two enter couples counseling. In the first session, Mickey announced, ‘That’s it. I’m never going through that again. I was terrified he wasn’t okay, and then furious when I found out he’d just passed out after sex. We have to close the relationship.’ At this point, the average couples therapist

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would have agreed. But Mickey and Ethan saw an IPG therapist, Mike Moran, who was well versed in the issues of nonmonogamy. He suggested they close the relationship for a time to process what had happened. In fact, when they discussed their experiences with him, they realized that they’d never explicitly set boundaries for their outside sexual experiences –​boundaries like ‘don’t stay overnight’ –​and that Ethan’s experiences had often involved excessive amounts of alcohol. Over time, Mickey regained trust, and they began exploring nonmonogamy again. They found that what worked for them was sex with a third person or sex with another couple in the room: in other words, experiences that both shared together. Gay men are likelier to have nonmonogamous arrangements than heterosexual men and women and lesbians, and they do CNM a little differently. Typically, a male couple will bring in a third partner for group sexual experiences, an arrangement Dan Savage has called ‘monogamish.’ This type of activity is so common, in fact, that Michael LaSala (2004a, b) who does research on gay male sexuality, has pointed out that some gay couples describe themselves as monogamous even if they engage in the occasional three-​way. In general, gay male extradyadic sex tends not to involve romantic connection, and this reduces the tendency to be jealous. There are exceptions, however, that look more like what we’d call polyamory relationships with both a sexual and love connection. Besides monogamish relationships, gay men often structure nonmonogamy around rules that prevent emotional attachment. One example might be that outside sexual partners are to be seen only for sex; in such an arrangement, going out to dinner with an outside partner would constitute a rule violation. Structure and rules are operative words here: most gay male couples discuss and agree upon the parameters for outside contacts. The reason for this is to preserve the couple’s integrity and sense of security, and each couple has different conditions that symbolize integrity and security. Boundaries are idiosyncratic and not always obvious. For example, for some couples, the line between what is acceptable and what is not might be nonsexual contact or kissing, which many people of all orientations see as more intimate than sex. Ethan and Mickey had attempted their nonmonogamous lifestyle without exploring what each of them needed to feel safe. With help, they at first took a break, and then restructured their CNM activity. Among heterosexuals, swinging is probably the closest equivalent to the type of CNM practiced by gay men. Typically, couples ‘in the lifestyle,’ as swinging is called, have sexual relationships with other couples or sometimes single people. But they tend not to have romantic relationships with them, and they certainly don’t attempt to live together and form nontraditional family units. That said, swingers often have sex over and over with the same people and form enduring friendships that can last for decades. Swingers meet each other online, at private parties, at swing clubs, or swing resorts. In

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recent years, the line between swinging (casual, recreational sex) and polyamory has blurred to the extent there’s now a noun for this, the blend of the two types: swoly. My clients, Janice and John, were middle-​aged doctors who’d been active in the swing community for 10  years when they met Samantha and Bill. Their swinging partnership gradually evolved in time to more of a ‘swoly’ relationship, but Samantha’s feelings about John became particularly intense, and their partners felt threatened. I helped them construct boundaries to contain the relationships and reestablish the primacy of the two couples. But ultimately, Samantha violated the rules:  she sent a love letter to John criticizing his relationship with his wife. Janice and John ended the quad relationship and, after a brief period of monogamy, returned to swinging, which they considered a safer alternative. No matter what type of CNM a couple practices, a critical feature is to maintain a sense of trust and security in the primary couple. Arguably, this is easiest when the extra-​relationship activities are purely sexual in nature and harder when it comes to polyamory, which is most favored by women of all sexual orientations, as well as many men. Polyamory has many subtypes: •​

In hierarchal poly, the primary relationship is held to be more important than other relationships. •​ In nonhierarchal poly, all the relationships are equal. •​ Some polyamorous arrangements are triads or quads or even more people who live together as well as have romantic and sexual relationships. •​ Other poly configurations may involve people who don’t live together but maintain group identities. •​ ‘Fluid-​bonded’ relationships involve practicing polyfidelity as a group, i.e., members of the group can have condomless sex with each other, but not with anyone outside the group. •​ ‘Polycules’ are complex interrelated groups involving ‘primary’ partners and ‘secondary’ partners. •​ Poly ‘free agents’ may have sexual and romantic partners who don’t even know each other. Poly people of all types meet each other at conferences, munches (casual social gatherings at restaurants or pubs), or on dating apps, including mainstream ones like OkCupid. Unlike swinging, which is more or less restricted to couples, uncoupled people are welcomed in poly circles. Case Vignette Nikayla and Lennie tried swinging before they took the polyamory leap. They met at college in Chicago and now live with their two children in a nearby suburb. Lennie manages a nonprofit, while Nikayla stays home with the kids

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and has a small crafting business. ‘A few years into dating, we started going on dates with other couples and occasionally to a swingers club. We found it was a great way to keep our sex interesting, and it brought us closer together,’ remarks Lennie. The couple took a break from swinging while they had two children just 18 months apart. When the kids became toddlers, they revisited CNM, this time opening up their relationship so they could be involved with others separately. ‘We felt that sharing intimacy with others wouldn’t take away from our relationship,’ says Nikayla. ‘And we needed a chance to get out.’ The couple read books, talked to others in the poly community, and discussed rules and guidelines. ‘It wasn’t always easy and we experienced challenges.’ Nikayla says. ‘There were tears and hurt feelings, jealousy and insecurities, but we were always able to communicate and work through them, often using it as a learning experience. Overall, being in a nonmonogamous relationship has helped us be a strong couple. It’s strengthened our ability to communicate and work through disagreements as well as keep things interesting and fun.’ What about the Problems? As Nikayla intimated, CNM, especially polyamory, isn’t easy. It necessitates near constant communication and processing. It is common for couples to make adjustments to the initial agreements, form new rules, shift from one form of CNM to another, or take a monogamous break from time to time. As Sherill Cantrell-​Brown, a therapist at IPG who’s worked with many couples in open and polyamorous relationships, points out, ‘The issues that crop up with CNM couples are the same as with monogamous couples –​differences in sex drives, poor communication skills, and fear of being left out.’ But there are some additional challenges. Even the best communication skills can be strained when it’s necessary to deal with multiple partners and complicated interrelationships. Many people are titillated when they first hear about polyamory, but a common joke in poly circles is that CNM people spend far more time talking to partners and discussing issues than actually having sex. Another challenge is simply finding the time to maintain two or more intimate relationships amid work schedules and other activities. And having multiple partners complicates some tasks of daily living. How do I  make dinner for my paleo-​diet lover and my vegan partner? Who used this sex toy last? If Susan has to change our date night from Friday to Saturday, what will I do about Alan, who’s available only on weekends, and my kids, who need me to ferry them to soccer and dance? And of course, there’s jealousy, which in a monogamous relationship can often just be handled with a simple reassurance that your partner is ‘the only one,’ an assertion not possible in an open relationship. Fortunately, people in CNM relationships don’t seem to experience jealousy as much as monogamous people; it is undoubtedly a factor in making

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the decision to try CNM. Nevertheless, it’s still an issue that often needs to be discussed. For example, a colleague at IPG worked with one couple, a 20-​something teacher and her lawyer husband, who’d been married five years and expressed the desire to have other partners. The couple, Sara and Carlton, initially showed the same enthusiasm for polyamory. They’d read the research and come to treatment with a list of local poly groups. However, their reactions to the first months of their exploration varied dramatically. ‘Sara described feeling as if she’d finally been let out of a cage and was feeling euphoric,’ says their therapist. Carlton, on the other hand, found himself struggling with more intense feelings of jealousy than he’d anticipated. This is the point where a more traditional therapist might have pronounced their CNM experiment a failure. Instead, their IPG therapist normalized these feelings and helped Carlton deconstruct them. As is sometimes the case, his jealousy turned out to be more of a fear of missing out: Sara had had more initial success in meeting partners, and Carlton was nursing feelings of rejection and fear that he’d always be alone while Sara ‘had all the fun.’ Because his feelings were in direct conflict with both his desire to please his wife and his wish to experience other relationships, he persevered, and when he too found an outside partner with whom he connected strongly, the jealousy dissipated. Jealousy can arise when one partner has a relationship with someone who has little or no contact with the primary partner, as the unknown can understandably trigger feelings of insecurity or inadequacy. In another case, when they first opened up their marriage, Marcie discovered that when Ann left to meet her new partner, she was crippled with a sadness and despair she hadn’t felt since childhood. Unwilling to give up CNM because of this, however, she worked on understanding her feelings and traced the despair back to feeling abandoned by a depressed mother. Knowing that helped. In addition, the two of them brainstormed ways to make Marcie more comfortable, and found that if Ann sent just one short loving text to Marcie while with her outside partner, it did the trick. What about the Children? Like the people who worried that having two same-​sex parents would negatively impact children, people who are skeptical of CNM often make the ‘it’s bad for the kids’ argument. But Elisabeth Sheff, who studied polyamorous families for 15  years and published results in The Polyamorists Next Door, her first book on the subject, found the children of nonmonogamous parents to be articulate, thoughtful, and securely attached to parent figures (Sheff, 2013). Younger children weren’t really aware of the differentness of their families, or the stigma. Older kids were aware of the stigma but tended to manage it well, and although losing adults when relationships broke up was an issue, the children didn’t see it as a major concern.

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Case Vignette Gabriella and Lena were active in lesbian poly circles for years, but each practiced different forms of CNM. Lena dated one person at a time and finally settled into one outside relationship that had lasted for five years. Gabriella, in contrast, seemed to be addicted to ‘new relationship energy’ and often chose lovers of questionable mental stability. Lena tolerated the drama of Gabriella’s passionate but conflict-​ridden partnerships, but started spending more and more time with her outside partner, and the intimacy of the primary relationship deteriorated. During this period, their 10-​year-​old son Joey started to exhibit angry and oppositional behavior. The women brought Joey to IPG because they knew our therapists were familiar with poly, and they wanted him to be able to talk honestly about their household without fear that the therapist would react negatively. In treatment, Joey revealed how angry he was about the situation at home, not at the fact that they had a polyamorous household, but at the chaos and the revolving door of Gabriella’s partners. In a family session, he yelled, ‘You expect me to be close to them, but then you two have a terrible fight and they leave. It’s easier not to get involved!’ Gabriella and Lena were stricken to learn that their CNM activities might have harmed their child. So for the next couple of years they closed their relationship to calm things down. Now they’re involved in what seems to be a stable poly quad, and Joey seems to have found his way to feel at home with this arrangement. Although CNM can create problems for some kids, primarily around issues of stigma and partners leaving, the benefits usually outweigh the costs. Joyce and Alex are part of a big extended family that includes both poly and nonpoly members, and they have four children. The norm in their poly family is for partners to stay close, even when the romantic or sexual part of the relationship ends, especially when children are involved, and to continue to share parenting responsibilities. Joyce and Alex’s children have benefited enormously from the attention. It’s particularly useful now, Joyce says, because she has a new job, which means a lot of time away from home, and Isak, her long-​time partner, is doing extra parental duty when Alex can’t. What Does It Mean? CNM is threatening to a lot of therapists for the same reason it’s threatening to most people:  we instinctively want to believe that these unconventional relationships are flawed, that they won’t/​don’t/​can’t last, that they’re retreats from intimacy, or signs of problems in the primary relationship. Nonmonogamy speaks to our deepest fears:  that we’re not enough for our primary partners, that, if let out of the cage of monogamy, they’ll fly away. Although consensual nonmonogamy is coming out of the shadows,

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I doubt it’ll ever be the choice of the majority of people. Many people are content with monogamy and have no desire to tamper with a relationship that is working. And for most people, the disadvantages of CNM outweigh the advantages: dealing with jealousy, worrying that your partner will leave for someone new, finding enough time for multiple partners and the energy to work out conflicts within the primary dyad, suffering through the social stigma. But for other people, particularly those who are sexually mismatched with a partner but compatible in other ways, those with high sex drives and high need for novelty and adventure, and those who actualize themselves through intimate relationships, CNM is the breath of life. What We –​as Therapists and Humans –​Can Learn from CNM In her book Straight: The Surprisingly Short History of Heterosexuality (2012), Hanne Blank introduces the concept of the doxa, cultural beliefs that are so baked in that we aren’t usually aware of them and don’t even recognize them as beliefs. Often the doxa is revealed only by contrast. For example, part of the doxa is that gender is binary. That doxa is revealed for many of us only when we first meet a nonbinary person. In a similar way, CNM reveals our doxa about relationships, even if we never practice CNM or suggest it to a client. Most of the time, the couples I  work with aren’t considering opening their relationship, nor would I suggest it for them. But because of my personal and professional experiences with CNM, my very idea of what can constitute a successful relationship has changed, and this affects my work. I validate single lifestyles more than I ever did before. I question jealousy and invite my clients to analyze its origins as a way to learn more about themselves. When a couple separates, I see this as an evolution of their relationship to another form, and encourage maintaining ties with past partners. I’m a champion of the idea that we make our own rules for our relationships, rather than accepting the doxa. You can be life partners and not live together or share finances or even be sexual with each other. You can break up as romantic partners yet still choose to live under the same roof. You can parent with people you aren’t in love with. Consensual nonmonogamy isn’t just about sex and marriage: it’s about expanding our concepts of relationships so that individuals, couples, and families can set rules of engagement that fit their situations and can be adapted as their circumstances change. Consensual nonmonogamy challenges us to see a world that’s more flexible and understanding of individuals’ different needs and how they change over a lifetime, a world that permits many combinations and permutations of sexual and romantic relationships while still prioritizing human connection as our most basic human need.

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References Blank, H. (2012). Straight:  The Surprisingly Short History of Homosexuality. Beacon Press. Fairbrother, N. , Hart, T. A., and Fairbrother, M. (2019). Open relationship prevalence, characteristics, and correlates in a nationally representative sample of Canadian adults. The Journal of Sex Research, 56(6), 695–​704. Haupert, M. L., Gesselman, A. N., Moors, A. C., Fisher, H. E., and Garcia, J. R. (2017). Prevalence of experiences with consensual nonmonogamous relationships: Findings from two national samples of single Americans. Journal of Sex & Marital Therapy, 43(5), 424–​440. Jong, E. (1973). Fear of Flying: A Novel. Macmillan. LaSala, M. C. (2004a). Extradyadic sex and gay male couples: Comparing monogamous and nonmonogamous relationships. Families in Society, 85(3), 405–​412. LaSala, M. C. (2004b). Monogamy of the heart: Extradyadic sex and gay male couples. Journal of Gay & Lesbian Social Services, 17(3),  1–​24. Lehmiller, J. (2018). Sexless marriages: how common are they and how do people cope with them? Psychology Today Magazine, October 22, 2018.​blog/​ 2018/​10/​22/​sexless-​marriages Levine, E. C., Herbenick, D., Martinez, O., Fu, T. C., and Dodge, B. (2018). Open relationships, nonconsensual nonmonogamy, and monogamy among US adults: Findings from the 2012 National Survey of Sexual Health and Behavior. Archives of Sexual Behavior, 47(5), 1439–​1450. McWhirter, D. P. and Mattison, A. M (1984). The Male Couple: How Relationships Develop. Prentice-​Hall. Moore, P. (2016). Young Americans Are Less Wedded to Monogamy than Their Elders. Yougov. O’Neill, N. and O’Neill, G. (1972). Open Marriage: A New Life Style for Couples. M. Evans & Company. Ryan, C. and Jethá, C. (2010). Sex at Dawn: The Prehistoric Origins of Modern Sexuality. Harper. Sheff, E. (2013). The Polyamorists Next Door:  Inside Multiple-​partner Relationships and Families. Rowman & Littlefield. Sheff, E. (2016). Therapeutic bias against consensual non-​monogamy. Psychology Today, March 3, 2016.​us/​blog/​the-​polyamorists-​next-​door/​ 201603/​therapeutic-​bias-​against-​consensual-​non-​monogamy



onica, aged 40 and married to Chris for 15 years, came to therapy asking for help to ‘open up her relationship.’ I noted, for starters, that she was alone. Her husband, Chris, was not with her and had no clue about her wishes. Monica explained to me that she had lost all feelings of sexual or romantic attraction for Chris, and the occasional sex they had was a perfunctory performance for her. But she didn’t want to divorce him. ‘Chris is a good provider and loves our kids,’ she said. ‘I don’t want to be on my own –​I just don’t want to give up sex and romance forever.’ As Monica talked about her marriage, it became clear that the couple had been emotionally distant for some time, and their communication with each other was almost entirely about ‘business’ issues –​money, household arrangements, and so on –​and the children. When I asked Monica how she expected Chris to react to her proposal, she said, ‘I think he’ll be upset –​ that’s why I’m coming to you. I’m hoping you can convince him that open relationships are normal.’ Monica and Chris’ marriage is an almost stereotypical example of when not to open up a relationship. Elisabeth Sheff, a prominent expert on polyamory, in a 2019 Psychology Today blog titled ‘Relationship Broken, Add More People?’ cautions against the folly of opening up a relationship to solve problems. In most cases, it makes things worse, with one caveat:  if the relationship problem is a sexual mismatch and both partners consent to nonmonogamy, opening up can be a boon, just as it was for Joyce and Alex, the clients I described in the previous chapter. In this chapter I’ll write about how to open a relationship responsibly, and how to deal with problems that may arise in CNM arrangements.

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Who Is Nonmonogamous –​and How? Let’s recap what we know about the prevalence of consensual nonmonogamy. Studies based on US Census samples determined that more than one in five Americans report being in a CNM relationship at some point in their lives (Haupert et al., 2017) and others have shown that at any given time, approximately 4–​5% are currently in a CNM relationship (Rubin, 2014). While earlier research suggested that people who practiced consensual nonmonogamy were richer, more highly educated and whiter than the general public, these more recent studies have shown no demographic differences except that men and sexual minorities are more likely to be CNM participants. A  number of surveys have found bi/​pansexually identified people to be most likely to espouse nonmonogamy, and younger people –​Millennials and Gen Z –​are more interested in and accepting of CNM. There are a number of different forms of CNM, and they tend to attract slightly different types of participants. Let’s review them again: Monogamish couples (the term was coined by author and LGBTQ activist Dan Savage) agree to occasionally bring a third person into their sex lives, with both members of the couple present and actively involved. While, in general, research on CNM did not ask participants to specify the type of nonmonogamy they practiced, one less scientific survey –​the Stranger sex survey (Strange staff, 2018) –​surveyed 8,776 readers and asked for preferences for monogamy vs nonmonogamy. They found that 45% of participants preferred ‘monogamish’ relationships, 43% wanted monogamous, and 12% other forms of consensual nonmonogamy. The Stranger survey also revealed that while men overall had lower preferences for monogamy than women, gay men were the most nonmonogamous of any group and lesbians were more nonmonogamous than heterosexual women. ‘Monogamish’ relationships are the easiest kinds of open relationships to navigate, and often the best choice for those just venturing into CNM territory. Swinging is a form of consensual nonmonogamy practiced primarily by couples, secondarily by single women and men. Swingers engage in sexual activities with other couples and sometimes singles, often in the presence of their primary partner. Generally speaking, swingers do not have emotional or romantic relationships with their partners. Swingers tend to be mostly heterosexual; bisexual women are welcomed in the swing community, but bi men and gay men and women are much less common. There are swingers’ clubs and conventions, but much swinging is private. Swinging has been around since the 1970s. There are no accurate figures as to the number of swingers, but some authors (Vaillancourt, 2014) estimate as many as 15% of couples have tried it at some point. As a group, swingers tend to be more conservative than, for example, those who practice polyamory. Swinging is a less

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complicated nonmonogamous lifestyle than polyamory, primarily because romantic relationships are not part of the arrangement. Polyamory is unique among types of CNM because polyamorous people are looking for multiple romantic relationships, not simply sexual diversity or experimentation. It is not known how many CNM people practice polyamory as opposed to other forms of consensual nonmonogamy, but from anecdotal evidence and experience, poly people seem to be less mainstream and conservative than swingers. They are mainly heterosexual or bisexual, some lesbians, not so many gay men. There is a vibrant, extensive ‘poly community’ made of many groups and events geographically dispersed across the United States. Polyamory is more complex than any other form of CNM, with many sub-​types. Some polyamorists have a hierarchical view of their relationships, that is, each person has one primary partner, to which their commitment is strongest; other relationships are secondary. Couples with long-​established relationships who venture into consensual nonmonogamy usually prefer hierarchical polyamory, and the agreement between the primary couple may include a provision that secondary relationships end if the primary partnership is threatened. Partners in these arrangement may have ‘veto power’ to prevent the formation of a secondary relationship: ‘No, you can’t date Alyssa, her son is friends with our child, it feels too close to home.’ Other polyamorists espouse an anarchic form of poly, where no partner is privileged over another. Some form stable multiple relationships, such as poly triads –​threesomes, or throuples, where usually all three people are sexually and romantically involved with each –​or poly quads, a similar group but with four people. All of these re types of ‘polycules’: the group of all people linked through their romantic and sexual relationships to one or more member of a polyamorous group. Some polycules are fluid-​bonded –​within the network, sex is practiced without use of condoms, preferably after everyone has been tested for sexually transmitted diseases. Some practice polyfidelity –​while members are sexual with each other, they are not sexual with anyone outside the polycule. There are poly singles as well as couples. Single bisexual women who are willing to partner with a mixed-​sex couple are sometimes called ‘unicorns’ (because they are so rare) and couples looking for them are ‘unicorn hunters.’ Poly people are usually friendly in a non-​sexual way with their partner’s partners, who are called ‘metamours.’ Most importantly, polyamory is only somewhat about sexuality, and mostly about having multiple love relationships, including building complex family structures from these relationships. The polyamorous people I know are mostly part of larger poly communities. They spend more time supporting and helping each other, participating in each other’s families and sharing interests, working together and just hanging out together than they spend having sex. It’s important to realize this about polyamory. Poly relationships are often like good friendships. One person said to me:

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I have someone to go to the opera with now, another who likes to cook with me, and a third I can go on hikes with. My spouse doesn’t like any of those things, but it doesn’t matter because I can get them in my poly community. Other Open Arrangements:  there are a host of other open relationship agreements that couples employ that do not easily fit into any of the categories above. For example, some have an understanding that if one person is out of town, they may engage in a brief, time-​limited sexual relationship with another person. Others employ a ‘don’t ask, don’t tell’ policy about occasional casual trysts. Gay men tend to craft arrangements that do not involve romantic involvements. In part, this reflects the ease with which many gay men are able to find partners willing to have one-​off or very short-​term sexual relationships that involve no other intimate contact. As a clinician, it is important you know the differences between these types of consensual nonmonogamy, and to understand the pros and cons of each lifestyle. In addition to helping you understand your nonmonogamous clients better, it will equip you to advise couples who want to open their relationship up. For example, for some couples, designing a monogamish relationship will be ideal. It may be the least threatening way to begin. Other clients would prefer not to watch their partner with anyone else. And still others are seeking more independence from their primary partner as part of their drive to try CNM. Case Vignette Not only are there a multitude of different kinds of CNM, it is not at all unusual for people to change the form of their open relationship with time and experience. Cindy Caneja, a therapist at IPG, describes a couple she saw a few years ago. Franklin and Tamara had been married for 11 years, with no children. Both identified as bisexual, but neither had ever explored same-​sex relationships. Now, as he approached 40, Franklin yearned to actualize this part of himself that had always been suppressed. Tamara did not feel the same urgency, but she too was interested in opening up the relationship, and both were interested in BDSM as well. Cindy directed them to the Poly Living conference in Philadelphia, organized every year by Loving More, an organization supporting polyamory since 1985. As ‘newbies,’ they found the staff and attendees of Poly Living to be welcoming, supportive, and informative. They attended workshops on communication, on ‘coming out’ as poly, and on managing jealousy, and Tamara met a potential new partner, a man who lived within driving distance of the couple. Because both Tamara and Franklin had expected their first new partners would be same sex, Franklin was initially a little shaken by Tamara’s choice. He handled his insecurity by negotiating an

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agreement with Tamara that she would not share any details of the new relationship with him other than the time and place of the meetings. After a few months Franklin felt secure enough to meet Tamara’s partner, and discovered that knowing her partner actually made him less jealous, not more. Moreover, Franklin and Tamara felt closer and more intimate than ever, and their sex with each other was better. Later, Tamara and Franklin joined the Kink Aware Collective (KAC), an area meet-​up group that sponsored get-​togethers and parties for both kinky and nonmonogamous people. Franklin met a man at KAC with whom he became romantically and sexually involved, and finally felt he was able to express this hidden side of himself. Franklin’s partner turned out to be bisexual himself, and eventually became involved with Tamara as well, and the three became a ‘throuple.’ When CNM Strengthens a Relationship Consensual nonmonogamy cannot fix a broken relationship, and its success requires a degree of close and skillful communication rarely found in deeply troubled couples. Moreover, CNM cannot work when one partner feels ‘blackmailed’ or coerced into opening the marriage. This is not to say that both parties have equal enthusiasm; it is very common for one partner to initiate discussions about opening up with a less interested mate. But if the more hesitant partner feels they are being threatened with abandonment if they don’t comply, the CNM is doomed from the start. While some people incorporate CNM in all their relationships right from the beginning, other CNM arrangements begin after the partners have been together monogamously for a time and they both make a decision to ‘open up.’ The latter is probably more common. Relationships stand the best chance of success with CNM if the partners are functioning well as a couple, have excellent communication skills, and are both enthusiastic about trying nonmonogamy. It also helps if they are not highly jealous by nature. However, consensual nonmonogamy can actually strengthen some relationships, particularly those in which partners are sexually mismatched but otherwise very compatible. Lori Sequiera, an IPG therapist who is also an AASECT certified sex therapist, worked with such a couple. Case Vignette After 25  years of marriage and two grown children, Brian and Marian sought help from Lori Sequeira at IPG after Marian disclosed her attractions to women. The two had been in a sexless marriage for half a dozen years; when Marian finally revealed her same-​sex attractions she admitted that she had never been very sexually attracted to men. Despite the lack of sex in his marriage, Brian was not interested in nonmonogamy for himself, but he wanted to make Marian happy, and neither of them wanted to dissolve the

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marriage. Marian did ultimately begin to date a woman, and Lori worked with Marian and Brian to negotiate boundaries to protect Brian from feelings of insecurity. For example, Marian agreed to eschew communication with her new lover when she and Brian were together, to limit her in-​person contact with the woman to once or twice a week, to not push Brian to meet her lover. The boundaries that Brian and Marian set created some problems with Marian’s new partner, who wanted to be a more ongoing part of Marian’s life. Lori held a couple of individual sessions with Marian to help her navigate this new relationship. If it had seemed productive, Lori would have had sessions with Marian and the female partner as well, but this turned out to not be necessary. Marian’s new partner agreed to be patient with the limits on their relationship. It also appeared possible that, at some point in the future, Brian might agree to allow the lover to play a somewhat larger role in Marian’s life –​and in his. In this example of Marian and Brian, opening their marriage helped to save it by allowing Marian to actualize her same-​sex attractions without leaving her husband. CNM can serve to offset or balance other types of sexual mismatches: when one partner has lost interest in sex, or when one partner is kinky, for example. Curt and Lou seemed a perfect couple: they shared many interests, both enjoyed outdoor activities, and both were totally devoted to the two children they adopted. However, both men were also ‘tops’ –​they preferred the active, or insertor, role in anal and oral sex. Most of the time, they compromised and accommodated each other’s preferences. But they also had sexual encounters outside the relationship in which they didn’t need to compromise, and it helped complete their sex lives in a way that did not harm the primary relationship. Helping Couples Open Up Most of the couples you work with as a therapist will not be willing to consider an open marriage, and would even be offended if you suggest it. However, some will introduce the topic themselves in couples counseling, and a few others will be receptive if you bring it up. If you have a couple hopelessly deadlocked around a sexual issue that might be resolved by CNM, if they feel they have run out of potential solutions, and if they are open-​minded about sexual diversity, you might bring it up casually. ‘This may sound crazy to you,’ I might say, ‘but I had the thought that an open relationship might work for you two –​sound nuts? Or should we talk about it?’ For couples who are interested in CNM, it is helpful to guide them to open their relationship in a way that is optimized for success. You can start by exploring the issue of consent: while one person may be more enthusiastic than the other about CNM, neither should feel coerced, or consensual nonmonogamy won’t work. Assuming both partners are willing, your next

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task is psychoeducation. I  usually begin by describing the different types of CNM, and I  help the couple answer questions that might direct them to the form of CNM that will work for them. I  recommend reading. The books The Ethical Slut (Easton et al., 1997), Opening Up (Taormino, 2008), and Designer Relationships (Michaels, 2015) all cover the range of consensually nonmonogamous relationships. More Than Two (Vaux, Hardy, and Gill, 2014), and The Polyamorist Next Door (Sheff, 2013) are specific to polyamory. The members of the couple need to explore questions such as: do we want only sexual openess, or are romantic relationships ok as well? How much do we want to share with each other, and how much do we want to keep private? Are we comfortable with outside partners coming to the house? Using our bed? Will we have any non-​sexual contact with outside partners at all? It is best for couples to confront all these possibilities ahead of time, while at the same time realizing there will be situations you cannot predict in advance. I  point out to the couple that for people venturing into these waters for the first time, a monogamish structure may be the gentlest entry. Alternatively, swing clubs and swinger groups offer an opportunity to explore nonmonogamy on a casual or occasional basis. CNM tends to be different for gay men, and you may not need as much education for them. Most gay men know about hook-​up apps like Grindr and Scruff, and those who live in or near urban centers may also know of bars and clubs where men can meet for casual sex. For clients who are hetero/​bi/​lesbian, there are numerous websites that function to inform and connect swingers (e.g.,, People interested in polyamory also use swing websites but can meet people on more ‘mainstream’ sites like and, or the poly-​specific There are a multitude of groups, events, and organizations where polyamorous people can meet in real life. lists 409 polyamory meetups worldwide, and there are poly conferences ever year all over the US, such as PolyLiving in Philadelphia, Polytopia in Portland Oregon, Atlanta Poly Weekend in Atlanta, Giorgia, and even The Village of PolyParadise, held each year at Burning Man. Once a couple has decided what they would like to try, it is time to discuss rules. Rules include sexual limits and boundaries such as: how many partners can we have; where will we find these partners (e.g., are people we know out of bounds?); how often can we see them and where; are there sex acts that are out of bounds; how will we insure that we do not get STIs? Rules can get very specific: you can see the same person two or three times, not more; you can contact them in between liaisons, but only to set up dates and times; you can only have sex with someone out of town, away from where we live; you can have vaginal intercourse but not anal. It is also helpful to try to anticipate what might go wrong and how you will deal with it, answering questions like:

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• • • • • •

What if one of us changes our mind about having an open relationship? What if someone doesn’t respect the boundaries? What if we develop intense romantic feelings for another person? What if one of us sees the other one being intimate with a new person? What if one of us gets a sexually transmitted infection? What if it starts feeling like our relationship is being neglected, or we don’t have enough time for each other?

Answering these questions and considering these possibilities takes some time, but it is well worth it to avoid future problems. Moreover, it accurately mirrors the kinds of conversations between the couple and the effort it will take to maintain a nonmonogamous relationship. I  advise couples to expect that there will be at least one situation that arises where rules are broken, or thought to have been broken, or where one partner feels much more threatened than they expected to feel. I  recommend that they discuss an exit strategy:  under what circumstances do they grant their mate veto power over a partner or potential partner, who and in what situations can someone pull the plug completely? For couples venturing into polyamory, in particular, I  describe what poly folk call ‘NRE’ –​new relationship energy, commonly called ‘infatuation.’ People who aren’t expecting to experience NRE themselves, or to see their spouse excited by NRE, can be very confused by the phenomenon; it can cause some to question their love for their primary partner. In describing this to the couple, I contrast NRE with ‘ORE’  –​old relationship energy  –​the secure, comfortable love you have for a trusted, long-​term partner  –​and reflect on the fact that while NRE inevitably fades, deeper feelings of love tend to endure, and ultimately have more value. Lastly, I suggest that couples remain in counseling, at least on an occasional basis, for some period of time after they initiate a nonmonogamous arrangement. Jealousy and Compersion We are raised to believe that jealousy is a ‘natural’ and unchangeable emotion. The truth is that people vary widely in their tendency to experience jealousy, and jealousy is often a signal of something else. Emma was miserable every Friday night when her wife, Blaire, went out with her girlfriend. But after discussing her feelings with some friends in the poly community, she realized that what she was actually experiencing was mostly FOMO –​fear of missing out. What she was ‘jealous’ of was not so much Blaire’s time with someone else, but that Blaire was out having a good time while she remained at home. This problem was easily remedied, and Emma found that when she was out herself, whether with a lover or just friends, she didn’t think much about what Blaire was doing. Miles was bothered every time his wife Jillian spent

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the afternoon with her girlfriend, but soon realized he was upset because they met at Miles’ and Jillian’s house. When they agreed to meet at the girlfriend’s apartment, Miles’ jealousy was alleviated. Compersion is a term used in the poly community to signify the positive feeling you get by realizing your partner is experiencing happiness in their relationship with someone else. It is the opposite of jealousy. Not everyone experiences compersion; for some, it is all they can do to manage jealous feelings. But people who have been practicing CNM for a long time often believe that their security in their primary relationship increases because of the openness, and they are likely to have magnanimous feelings about their partner’s partners. Other Common Issues Some of the other questions or issues that come up with couples who practice CNM are: •​




Time management –​it sounds obvious, but is often overlooked. CNM is time-​consuming, not only because the nonmonogamous person is balancing time with multiple partners as well as work, home life, children, etc., but also because CNM requires lots of communication, which requires time. Think of the time and communication needed to keep one relationship functioning well, and then multiply that exponentially. Contact with ‘metamours,’ i.e., your partner’s partner. Depending upon the CNM arrangement a couple makes, contact, even friendship, with a metamour can be required, or off the table completely. This is best established ahead of time, and whatever arrangement exists needs to be conveyed to potential extramarital partners. If your husband wants to meet all your playmates, but the guy you just met has no desire to meet your husband, that can create problems that are best resolved before you get involved. Vetoing a relationship –​although most CNM arrangements have some rules about an exit strategy built in, actually exercising veto power can be problematic, especially if the relationship you want to veto has been ongoing. Mallory’s husband, Paolo, had a partner he had been close with for several years. When Rachel, Paolo’s long-​term girlfriend, found herself without a primary partner of her own, she began to want more from Paolo, which in turn threatened Mallory, who asked him to sever ties with Rachel. The emotional turmoil this caused in the marriage sent both Mallory and Paolo into relationship counseling for several months. Children –​most couples who practice most forms of CNM keep the full nature of their relationships private from their minor children. That couple that Mommy and Daddy spend so much time with are simply

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their close friends. But polyamorous relationships tend to be more difficult to conceal, and children who are old enough to understand are often told about it. In my experience, polyamorous relationships tend to benefit a child because there are more adults around and more attention paid to the children. Zoe and Matthew were married, but Harry was Zoe’s long-​term CNM partner and an ‘uncle’ to Zoe and Matthew’s daughter. He often stepped in to do childcare when Zoe and Matthew both had to work late, and the child often talked to Harry about things she was not comfortable discussing with her parents. Because CNM is ‘invisible’ to outsiders, children do not have to contend with the social stigma that might be attached to these arrangements if they were public. Elisabeth Sheff (2013) has researched polyamorous families and concluded that the impact on children is neutral to positive. Solo Nonmonogamists and Poly-​Mono Relationships Polyamory is not just practiced by couples. Many single people find it is a lifestyle that works well for them, especially those who are not interested in pairing with one partner. McKenzie was a political activist who moved around the country every year or so to do community organizing. For McKenzie, polyamorous relationships were ideal. He had partners in many locations without feeling the pressure to ‘settle down’ with one person, and without having to conceal these relationships from other partners. As I’ve mentioned before, there are also couples that successfully manage an arrangement where only one partner has outside romantic/​ sexual liaisons. Some of the case examples given in these chapters illustrated what these ‘poly-​mono couples’ are like, such as Lori Sequeira’s clients Brian and Marian in this chapter and my clients Alex and Joyce in Chapter 23. Poly-​ mono couples are often successfully integrated into the larger polyamorous community. Edgar, for example, had no interest himself in nonmonogamy, but he accompanied his wife Idania to poly conferences and events and built a strong friendship network among the people he met there. Relationship Counseling with More than Two If you work with people who practice forms of nonmonogamy that are not purely casual/​sexual, you may be called upon to help work out relationship problems among three, four, or even more people. Case Vignette Bob and Carly were married and in a polycule with another married couple, Agnes and Tim. They considered themselves in a polyamorous arrangement,

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even though the men did not have sex together at all and the women only occasionally had sex with each other. Nevertheless, in many ways they were like a family. At one point, friction between the two men threatened to disrupt the foursome, and so they came to me for help. Initially, I held a session with all four people to let them all air their perspectives and grievances. Bob, who was a blue-​collar worker with a high school education, felt put down by comments that the highly educated Tim made when they were together. He also felt that Carly was ‘dazzled’ by Tim’s intelligence; this made him feel threatened, and he blamed Tim for this. Tim couldn’t understand Bob’s jealousy, because Tim felt Bob exemplified a masculine physical ideal that Tim could never match. Carly tried to ignore her husband and Tim’s antagonism. Agnes felt that as Bob’s anger at Tim increased, Bob was paying less attention to her. After a couple of sessions with all four of them together, I began to do sessions with different elements of the polycule: several sessions with Tim and Bob, a session with Agnes and Bob, and one with Carly and Bob with the focus on reassuring Bob that Carly did not find him less appealing than Tim. When I brought the four back together again, the anger, jealousy, and resentment had dissipated. Tim asked for an individual session to talk about the way Bob’s masculinity had triggered his own feelings of inferiority. But the polycule was running in a smooth, cooperative way again, and I  reminded them that they could always come back for ‘tune ups’ if problems emerged in the future. Takeaways for the Clinician If you are working with couples involved in consensually nonmonogamous relationships, you need to know about the different kinds of CNM and how they operate. You need to be willing to help clients deconstruct and work through jealousy, instead of just taking it for granted as a ‘natural’ human reaction. You need to facilitate communication between all participants in the CNM, and this may at times mean doing relationship counseling with three, four, or more clients in the room. In helping couples who are interested in opening up their relationships, it is even more critical that you know the pros and cons and the challenges of different forms of CNM. In addition, you must be able to direct clients to resources to increase their knowledge and understanding: books, websites, and groups. You should assess the extent to which both partners are fully consenting to opening up the marriage, and whether there are serious underlying problems that are being avoided, that may worsen after CNM is attempted. Most of all, you need to examine and eradicate your biases about monogamy. Monogamy is so deeply ingrained in our culture that it is often difficult for therapists to put aside these biases and treat people involved in consensually nonmonogamous relationships objectively. But contact with this

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community broadens our understanding of relationships. We see how individuals communicate with each other deeply about emotion-​laden topics, how they handle potentially explosive feelings like jealousy and sexual desire, and how they benefit from broadening their sexual and relationship options. We see how people can get needs met by others that they can’t get from their primary partners, and how they expand their horizons with people different from their spouse. For some people, expansive sexuality is an essential need; for others, intimate relationships are how they actualize hidden parts of themselves. Working with people in consensually nonmonogamous relationships can enlarge the world view of the therapist as well, and increase one’s understanding of human love and sexuality. References Easton, D. and Hardy, J. (1997). The Ethical Slut. A Practical Guide to Polyamory, Open Relationships and Other Adventures. Greenery Press. Haupert, M. L., Gesselman, A. N., Moors, A. C., Fisher, H. E., and Garcia, J. R. (2017). Prevalence of experiences with consensual nonmonogamous relationships: Findings from two national samples of single Americans. Journal of Sex & Marital Therapy, 43(5), 424–​440. Michaels, M. (2015). Designer Relationships:  A Guide to Happy Monogamy, Positive Polyamory, and Optimistic Open Relationships. Cleis Press Start. Rubin, J. D., Moors, A. C., Matsick, J. L., Ziegler, A., and Conley, T. D. (2014). On the margins: Considering diversity among consensually non-​monogamous relationships [Special Issue on Polyamory]. Journal für Psychologie, 22(1),  19–​37. Sheff, E. (2013). The Polyamorists Next Door:  Inside Multiple-​partner Relationships and Families. Rowman & Littlefield. Sheff, E. (2019). Psychology 11/​18/​19 Relationship broken, add more people?​us/​blog/​the-​polyamorists-​next-​door/​201911/​relationshipbroken-​add-​more-​people Strange staff:​features/​2018/​07/​04/​28635069/​the-​results-​of-​thestrangers-​2018-​sex-​survey Taormino, T. (2008). Opening Up: A Guide to Creating and Sustaining Open Relationships. Cleis Press. Vaillancourt, K. T. and Few-​ Demo, A. L. (2014). Relational dynamics of swinging relationships: An exploratory study. The Family Journal, 22(3), 311–​320. Veaux, F., Hardy, J., and Gill, T. (2014). More than Two:  A Practical Guide to Ethical Polyamory. Thorntree Press, LLC.

CONCLUSION The Tangled Path Forward


n February 2020 I arrived at my recently acquired vacation home in Tucson, Arizona, to find a copy of the newspaper Tucson Weekly, left by my partner Nancy, who lives there year-​round. The sympathetic cover story featured a local transgender man, pregnant with his first child. A few days later I attended a meeting of a regional anti-​gun violence group and heard a different young man speak about nearly ending his life with a gun. He described being gay and ostracized and rejected by his family, church, and his school, which refused to protect him against being bullied by his peers. Arizona is a ‘red state,’ arguably purple-​ish now, with some of the least restrictive gun laws in the nation. Its highways are dotted with billboards that say things like ‘Jesus Christ is Lord’ and ‘Our Spirit Will Move You.’ It’s quite a culture shock for someone like me who has lived all my life in East Coast urban centers. But Arizona is emblematic of much of the United States, and of many Western developed countries, in its clash between modern and conservative values. While I  have been writing this book, several states, including my home state of New Jersey, have passed laws requiring that LGBT history be taught in schools. Meanwhile, South Dakota passed a law in 2020 mandating prison time for medical professionals who prescribe puberty blockers to minors, and seven more states are considering such laws. Sex and gender-​affirmative therapy has never been more politicized than it is now. As a clinician, simply practicing in this way is an act of advocacy for LGBTQ+ people. How Did We Get Here? In the first few chapters of this book, I  described how the convergence of several late twentieth-​century trends combined to produce the LGBTQ+

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community of today:  the rise of liberation movements, including sexual liberation; the emergency of identity politics, fueled by thymos, the need for recognition and the demand for dignity; the breakdown of traditional communities formed by kinship ties, geography, and religious beliefs; the need to affiliate with communities of peers who share horizontal identities, as opposed to family-​based vertical identities; the advent of the Internet, making it possible to connect with others who are like you despite physical distance; the tendency to re-​label characteristics previously seen as ‘defects’ –​ for example, deafness –​as simply ‘differences.’ I also explained that sex and gender diversity are universal across human cultures throughout time, and ubiquitous in the animal kingdom. Although this diversity takes a multitude of different forms, and has been variously tolerated, despised, accepted, and revered in different societies and historical periods, it is a constant feature of human existence. There have always been humans who loved those of the same sex, humans who enjoy non-​standard sexual practices, and humans who don’t fit into a male/​female binary system. What has changed is that we do seem to be in the midst of accepting all of this diversity in a way that is rare in the historical record. In part, this is because of another late twentieth-​century trend:  that of questioning the role of psychiatry in the oppression of women, minorities, and sex-​and gender-​diverse people. Beginning with Thomas Szasz in the 1960s, many have viewed the mental health establishment as enforcers of traditional social values, joining religion and the law as upholders of traditional principles. In many ways, the antipsychiatry movement founded by Szasz gave birth to the sex and gender-​affirmative treatment described in this book. What Are Principles of Sex and Gender-Affirmative Treatment About? I listed some of the basic principles of sex and gender-​affirmative treatment in the Introduction, but I expand on them here. First, I want to acknowledge that the principles I describe below draw heavily from two already published works: Appendix: Best Practices for the Care of Transgender Youth (Lev and Gottlieb, 2019); and Good Practices Across the Counselling Professions: Gender, Sexual and Relationship Diversity (Barker, 2019). Moreover, many professional organizations are issuing their own sets of guidelines and best practices for LGBT+ clients, especially transgender clients. For example, the National LGBT Health Education Center publishes ‘Affirmative Care for Transgender and Gender Non-​Conforming People: Best Practices for Front-​Line Health Care Staff ’ on the website​ wp-​ content/​ uploads/​2016/​12/​Affirmative-​C are-​for-​Transgender-​and-​G ender-​Non-​ conforming-​People-​B est-​Practices-​for-​Front-​line-​Health-​Care-​Staff.pdf. This document describes specifics such as how to handle record-​keeping

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issues involving gender and names. The reader is urged to look into their own professional organizations to see whether they have published guidelines/​ best practices documents for their membership. The title of the Barker ‘Good Practice’ guidelines implies a new way of looking at the LGBT+ community. Barker uses the term ‘Gender, sexual, and relationship diversity (GSRD)’ to group together all the types of diversity I have described in this book. ‘Gender-​diverse’ people include all variations on gender identity as well as intersex people. ‘Sexually diverse’ people include those with same-​sex, bisexual, pansexual, and asexual attraction, as well as those with uncommon sexual practices, that is, BDSM. And the ‘relationship-​diverse’ universe includes those who are aromantic or single by intention as well as those interested in consensual nonmonogamy, and sex workers. Barker argues that these three types of diversity are intertwined, and suggests that one way they are related is that in all three categories, people whose identities and/​or lifestyles do not fit the social norm are stigmatized and marginalized. I find myself in agreement with Barker, and see a trend among US academics to use ‘GSD’ –​gender and sexual diversity –​instead of LGBTQ+. By including relationship diversity, Barker has made the category more descriptive and more inclusive. Moreover, this model mirrors the trends in the queer community. At any Gay Pride march in the US, you will see people marching under banners for asexuality, kink, and polyamory alongside banners for gay, lesbian, bisexual, or transgender groups. If one thing these groups all have in common is that they are marginalized by the larger culture, another is the negative mental health consequences that come from being stigmatized, discriminated against, and ostracized by mainstream society. This is why there are certain general principles of affirmative therapy for gender, sexuality, and relationship-​diverse people that apply to all. Principles of Affirmative Psychotherapy Care for Gender, Sexuality, and Relationship-​diverse Clients (GSRD) 1) Engage in self-​education so that you are up to date on information regarding LGBTQ+/​GSRD clients. 2) Engage in self-​ examination of your own prejudices and biases. Understand how these reflect attitudes of your larger culture. 3) Be aware of the impact of stigma and discrimination on your client’s lives, especially the way your/​our profession of psychotherapy has contributed to their oppression. 4) Be aware of your own position of privilege, both the privilege inherent in the structural inequality of the therapy relationship as well as privilege you may have by virtue of not being gender, sex, or relationship diverse yourself, if you are not.

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5) If it is appropriate and possible for you to self-​disclose your own GSRD status to your clients, do so. 6) Make sure the environment in which you practice is welcoming to sex, gender, and relationship-​ diverse people. See that the waiting room contains magazines, books, posters that reflect diversity, ensure that your website reflects your diversity-​affirming stance. Make sure forms for clients reflect diversity:  allow multiple genders, not just ‘male’ and ‘female,’ ask for legal as well as preferred name, make sure questions about sexuality and relationships do not assume heteronormative monogamous experience or orientation. Insist that office staff are trained in diversity and use names, pronouns, and so on respectfully. 7) Be aware of the limits of your expertise, and refer to other professionals when necessary. 8) Do not attempt to ‘cure’ your client of their diversity –​even if they ask for it. There is no reliable evidence that gender or sexually diverse desires or feelings can be eradicated throughout psychotherapy, and most professional organizations consider attempts to change diverse expressions unethical. 9) Do not assume your client’s diversity is relevant to their presenting problems unless the client brings it up. 10) Do not count on your clients to educate you; it is not their job. If you are taking on a new type of client, educate yourself before treatment begins. 11) Understand that an important part of your role may be to validate and support your client’s identity. 12) Authenticity is important to all people, and that may mean that part of your role will be to help your client ‘come out’ to others about their diversity. However, understand that disclosure is complicated and not advisable for all clients in all situations. 13) Be knowledgeable about resources for your clients, not only resources in the community but also books and websites that can support and inform them. 14) Many sex, gender, and relationship-​diverse people are not supported by their own families. You need to be able to do therapy with parents and spouses/​partners, or have reliable colleagues who can do this. Obviously, it is most critical when your clients are children or adolescents. 15) You need to help clients access other services. This is particularly important for transgender clients, who may need referrals for medical interventions. 16) Be prepared to be an advocate for your clients, especially younger ones who may need help navigating unsupportive school systems, but also with insurance companies, medical providers, community groups, and others. 17) When you can, educate others in your professional community about GSRD.

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Where Are We Going? I am possibly a foolish optimist, but it does seem to me that, politically, although we periodically suffer backlash and setbacks –​in the United States, we are going through a pretty intense backlash period as I write this book in 2020 –​in the end, as Martin Luther King, Jr., said, the moral arc of the universe bends toward justice. I  am confident that LGBTQ+ people, sex-​, relationship-​, and gender-​diverse people, will become increasingly accepted in the future. I’m curious about how the current proliferation of people who identify as nonbinary will impact our view of gendered bodies. Nonbinary people often want unconventional medical interventions, and this changes our concept of what male and female bodies are like. For example, the transgender man described in the beginning of this chapter got pregnant with his trans woman partner. He still has a vagina and intact uterus and ovaries; she still has a functioning penis and testes. Will we start to de-​couple genitals from gender? Will more and more people choose to have bodies that blend what we traditionally think of as ‘male’ and ‘female’? I am not sure about where the explosion of new sex, gender, and relationship-​ diverse identities will end. Will ‘girlfags’ and ‘guydykes’  –​ mentioned in Chapter 3 –​become a ‘thing,’ will we see them included in the transgender community? Will identities proliferate to the point of the ridiculous, the point at which every human being has a unique identity? We may already be seeing identities spring up that are, well, not very useful. Although I know that, technically, a skoliosexual is someone attracted to transgender, nonbinary, and genderqueer people, I don’t actually know anyone who claims that term as an identity. Let’s look at why people claim any LGBTQ+ identity. The fact is, all of us have multiple ‘identities’ we could use to describe ourselves. I  can say I’m queer, but I could also describe myself as a woman, a mother, a psychologist, a US citizen, or any number of other things. I ‘identify’ as queer because my sexual identity is and has been a central feature of my life. And why has it been a central feature? To a large extent, because society has stigmatized the identity, and to overcome the shame and stigma I must claim it and make it important in how I  choose friends and acquaintances, my career, even where I live. This implies that, as stigma decreases, so does the importance of stigmatized identities. I remember that the idealistic lesbian feminist theory I embraced in the 1970s often maintained that the goal of the gay rights movement was to erase sexual orientation identity labels, to create a future in which the gender of person to whom you are attracted is so unimportant that it is not necessary to claim an identity based on it. We can imagine that being true of gender and relationship orientation as well: a future where it is assumed that gender

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is nonbinary, that all gender variations are socially acceptable, and where no one cares whether you are monogamous or non, relationship-​oriented or single. In such a culture, your sexual orientation identity, or your idiosyncratic gender expression, would be no more important than the color of your hair. In such a culture, you might still be a social justice warrior, but the issues would not be LGBTQ+ related. There are small signs of that. Younger, post-​Millennials tend both to know a broader diversity of people (remember, over a third of Generation Z knows someone who is nonbinary) and to eschew identity labels as too confining. It’s possible that my now six-​year-​old granddaughter may grow up to wonder why being queer was such a big deal to my generation. In 2018, on the occasion of the revival of the 1960s play ‘The Boys in the Band,’ New  York Times columnist Frank Bruni wrote a piece called ‘The Extinction of Gay Identity.’ Bruni, in conversation with Mart Crowley, the author of the play, mused about the disappearance of gay bars, bookstores, and community organizations, the general dispersion of gay culture, and the assimilation of gays into mainstream society. They agreed that in part this trend has happened because of increased tolerance of LGBT+ diversity. If the mainstream embraces you, you have less need of your own ‘tribe.’ In a 2005 article in the New Republic magazine, the gay conservative writer Andrew Sullivan predicted the total assimilation of gay culture into the larger society. Will this happen? Will there come a day when no one remembers that it used to be mostly queer people that performed in drag shows? Or will drag disappear? In places like New York, acceptance of gays may have grown so strong that assimilation has begun to occur. There is less need to live in a ‘gay ghetto’ if your non-​gay neighbors aren’t hostile to you. You may still belong to a ‘tribe,’ but the defining characteristics of that tribe might have nothing to do with sex, gender, or relationship orientation. But in most of the US, and most of the world, that is not the case. I don’t think that is the experience of the young man who spoke at the Tucson anti-​ gun violence meeting whom I described at the beginning of this chapter. His gay identity is anything but irrelevant, and he has been rejected from, not assimilated into, the straight community around him. It is a lovely dream to think about a world where tolerance prevails so much that diverse identities are not necessary. In such a world, a book like this would be unnecessary. But, as a planet, we are far from that. Same-​sex sexual activity is a crime in 70 countries, and in 13 of them, it is a crime punishable by death. In the United States, there is still no federal law protecting LGBT+ people from discrimination in housing, employment, or education. Some states have their own anti-​discrimination laws, but 26 states have no protection for LGBT+ citizens. Conversion therapy is still legal in 31 states. Numerous states have enacted or are trying to enact laws to prevent gay

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people from adopting, and as I mentioned earlier, several states are trying to prohibit medical practitioners from treating transgender minors. As long as this situation exists –​discrimination against people with diverse sexualities, genders, and relationships, often allowed by law –​mental health professionals will be tasked with helping GSRD minority clients heal from and buffer themselves against marginalization and hate. And you will need this book, and others like it. References Barker, M. (2019). Good Practice Across the Counselling Professions: Gender, Sexual, and Relationship Diversity (GRSD). BACP House. Bruni, F. (2018). The extinction of gay identity. New York Times, Sunday Review, April 28. Lev, A. I. and Gottlieb, A. R. (eds.). (2019). Families in Transition:  Parenting Gender Diverse Children, Adolescents, and Young Adults. Columbia University Press. Sullivan, A. (2005). The end of gay culture. New Republic Magazine, October 24, 2005.


Ace Affirmed Female Affirmed Male Agender Androgynous

Aro Aromantic Asexual

Assigned Female at Birth/​AFAB Assigned Male at Birth/​AMAB

Term asexual people use to describe themselves. Someone whose affirmed (as opposed to ‘assigned’) gender identity is female. Someone whose affirmed (as opposed to ‘assigned’) gender identity is male. A person who identifies as having no gender. Term used to describe an individual whose gender expression and/​or identity may be neither distinctly ‘female’ nor ‘male,’ usually based on appearance. Term used by people who identify as aromantic. Someone who does not experience romantic feelings toward anyone, although they may experience sexual feelings. A  sexual orientation generally characterized by not feeling sexual attraction or desire for partnered sexuality. Asexuality is distinct from celibacy, which is the deliberate abstention from sexual activity. Some asexual people do have sex. There are many diverse ways of being asexual. Used instead of ‘biological sex’ or ‘birth gender;’ someone who was declared/​ assigned female at birth usually on the basis of genital appearance. Used instead of ‘biological sex’ or ‘birth gender;’ someone who was declared/​ assigned male at birth, usually on the basis of genital appearance.

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Bigender Binding Bisexual, Bi

Boi Bottom surgery Chemsex

Cisgender Compersion

Consensual Nonmonogamy Cross-​dresser

An Internet-​ generated acronym standing for ‘bondage and discipline/​ dominance and submission/​sadism and masochism.’ Term used to describe a wide range of non-​ standard sexual practices. Someone whose gender identity is a combination of two genders. Practice used by some AFAB, affirmed male and nonbinary people who want to conceal or minimize the appearance of breasts. An individual who is physically, romantically and/​or emotionally attracted to men and women. Bisexuals need not have had sexual experience with both men and women; in fact, they need not have had any sexual experience at all to identify as bisexual. Term for a butch lesbian or; term for male submissive in BDSM play. Gender-​ affirming genital surgery, e.g., vaginoplasty, phalloplasty. When two or more people take drugs with the intended purpose of increasing the pleasure of sex. Chemsex most commonly includes methamphetamine, mephedrone, or GHB (gamma hydroxybutyrate). A term used to describe people who, for the most part, identify as the gender they were assigned at birth. The feeling of happiness you get when you see your intimate partner enjoying a relationship with another partner; term in the polyamory community –​the opposite of jealousy. A  term referring to a number of different relationship arrangements that involve partners agreeing  –​consenting ‒ to some form of nonmonogamy. An infrequently used term for men (mostly heterosexual) who want to dress and present as women sometimes, but not always. Some cross-​ dressers have a female persona when dressed and may have a female name for this persona. Few younger people identify as cross-​dressers.

Glossary of Terms  311

Demisexual Dominant/​’Top’ Drag Queen/ Drag King

Enby Fetish Fluid Bonding


Genderconfirmation Surgery Gender Expression

Someone who does not experience sexual attraction unless they form a strong, emotional bond with someone. In BDSM, the person who the partners agree will be in a dominant, or controlling role. Also called a Master or Mistress. Used by people who present socially in clothing, name, and/​ or pronouns that differ from their everyday gender, usually for enjoyment, entertainment, and/​ or self-​ expression. Drag queens typically have everyday lives as men. Drag kings typically live as women and/​or butches when not performing. Drag shows are popular in some gay, lesbian, and bisexual environments. Unless they are drag performers, most transgender people would be offended by being confused with drag queens or drag kings. A term used to denote someone who is nonbinary, often used by nonbinary people themselves. A sexual attraction to particular objects, articles of clothing, or parts of the body, e.g., leather fetish, shoe fetish, foot fetish. When two or more people agree that they will have non-​barrier protected (i.e., condomless) sex with the others in the fluid bonded group, but will have barrier protected sex with anyone outside the group. The adjective used to describe people whose enduring physical, romantic, and/​ or emotional attractions are to people of the same sex (e.g., gay man, gay people). In contemporary contexts, lesbian (n. or adj.) is often a preferred term for women. Avoid identifying gay people as ‘homosexuals,’ an outdated term considered derogatory and offensive to many lesbian and gay people. Refers to a surgical procedure to transition a transgender person from one biological sex to another. This is often paired with hormone treatment and psychological assistance. Refers to how an individual expresses their socially constructed gender. This may refer to how an individual dresses, their general appearance, the way they speak, and/​or the way they carry themselves.

312  Glossary of Terms

Gender Fluid Gender Identity

Gender Neutral


Girlfag GNC/​ Gender nonconforming Gender Role



Gender expression is not always correlated to an individuals’ gender identity or gender role. An identity that denotes that the person feels their gender can change from one time period to another. An individual’s internal self-​perception of their gender, which may be different or the same as the gender assigned them at birth. Gender identity is an internalized realization of one’s gender and may or may not be manifested in their outward appearance (gender expression) or their place in society (gender role). This term is used to describe facilities that any individual can use regardless of their gender (e.g. gender neutral bathrooms). This term can also be used to describe an individual who does not subscribe to any socially constructed gender (sometimes referred to as ‘Gender Queer’). A  person who does not subscribe to conventional gender distinctions but identifies with neither, both, or a combination of male and female genders. A  person assigned female at birth who identifies with gay male culture and/​or is attracted to gay men. Someone whose gender expression and/​or gender role do not conform to the stereotypes of the gender assigned them at birth –​or any gender. A societal expectation of how an individual should act, think, and/​or feel based upon an assigned gender in relation to society’s binary biological sex system. Gender and sexual diversity, a term many use to replace the ‘LGBTQ+’ designation. Gender, sexuality, and relationship diversity, a term used to replace the ‘LGBTQ+’ but also to be inclusive of other sexual diversity, e.g., BDSM, and non-​standard relationship forms, e.g., consensual nonmonogamy. A  male who is sexually attracted to lesbians and bisexual women and identifies with lesbian/​ bisexual women.

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The assumption that everyone is heterosexual. And that heterosexuality is superior to all other sexualities. Heterosexual An adjective used to describe people whose enduring physical, romantic and/​ or emotional attraction is to people of the opposite sex. Also straight. Homophobia Fear of lesbians and gay men. Prejudice is usually a more accurate description of hatred or antipathy toward LGBT people. Homosexual (see Offensive Terms to Avoid) Outdated clinical term considered derogatory and offensive by many gay and lesbian people. The Associated Press, New  York Times, and Washington Post restrict usage of the term. Gay and/​or lesbian accurately describe those who are attracted to people of the same sex. Intersectionality Intersectional theory asserts that people are often disadvantaged by multiple sources of oppression:  their race, class, gender identity, sexual orientation, religion, and other identity markers. These multiple sources of oppression interact with each other, the impact is not merely additive. Intersex People who naturally (that is, without any medical interventions) develop primary and/​or secondary sex characteristics that do not fit neatly into society’s definitions of male or female. Intersex people are relatively common, although society’s denial of their existence has allowed very little room for intersex issues to be discussed publicly. Has replaced ‘hermaphrodite,’ which is inaccurate, outdated, problematic, and generally offensive. Medical term: Disorders of Sexual Development. Kink Another term for BDSM. Kinksters People who practice BDSM. Kinsey Scale Alfred Kinsey, a renowned sociologist, described a spectrum on a scale of 0 6 to describe the type of sexual desire within an individual. 0 Completely Heterosexual –​6: Completely Homosexual. Leather Gay term, mostly male, for BDSM. Lesbian A  woman whose enduring physical, romantic and/​or emotional attraction is to other women.

314  Glossary of Terms

Some lesbians may prefer to identify as gay (adj.) or as gay women. LGBTQQIA An acronym used to refer to all sexual minorities: ‘Lesbian, Gay/​ Gender Neutral/​ Gender Queer, Bisexual/​Bigender, Transgender/​Transvestite/​ Transsexual, Questioning/​ Queer, Intersex, and Allies/​Androgynous/​Asexual.’ Microaggression A subtle but offensive comment or action directed at a minority or other nondominant group that is often unintentional or unconscious. Minority Stress The scientifically proven physical and emotional stress that comes from being a member of a stigmatized minority. It has been shown to be related to impaired physical and mental health. Monogamish A term coined by columnist Dan Savage to refer to an arrangement where a primary couple occasionally bring in a third person for sexual encounters. Mostly Straight A  category Ritch Savin-​ Williams added to questions about sexual orientation identity; apparently the largest non-​heterosexual group. (NRE): A  term within the polyamory commuNew Relationship nity that refers to the overwhelming feelings of Energy infatuation experienced in the beginning of love relationships. Nonbinary A gender identity indicating that the person is ‘in between’ the binary poles of gender, of a blend of male and female. Nonbinary people may also identify as gender queer, agender, or gender neutral. Pansexual Not limited in sexual choice with regard to biological sex, gender, or gender identity. Pansexuals differentiate themselves from bisexual because they say gender doesn’t matter, rather than they are attracted to ‘both’ genders. Paraphilia An outdated term applied to non-​standard sexual practices that we would call BDSM or kink/​ fetish, as well as nonconsensual sexual behaviors like pedophilia. It still exists as a category in the DSM 5. Party and Play The consumption of drugs to facilitate or enhance sexual activity, also called ‘chemsex.’ Polyamory A  form of consensual nonmonogamy in which partners agree to have extra-​dyadic romantic and sexual relationships with other people. There are many subtypes of polyamory.

Glossary of Terms  315

Polycule Polyfidelity Queer

Questioning Seroconversion Sexual Fluidity Sexual Minority

Sexual Orientation

Skoliosexual Submissive/ ‘Bottom’ Swinging, Swingers

A group of people who are related to at least one other person in the group in a romantic and sexual relationship. When a group of three or more people agree to only have sexual relationships with each other, and no one outside the group. Traditionally a pejorative term, queer has been appropriated by some LGBT people to describe themselves. However, it is not universally accepted even within the LGBT community and should be avoided unless someone self-​identifies that way. The process of considering or exploring one’s sexual orientation and/​or gender identity. When an HIV negative person becomes HIV positive, i.e., infected with the HIV virus. A  way of conceptualizing pan or bisexuality; someone whose sexual orientation is context dependent and can change. An all inclusive, politically oriented term referring to individuals who identify with a minority sexual orientation, sex identity, or gender expression/​ gender identity. The term commonly used to describe an individual’s enduring physical, romantic, and/​or emotional attraction to members of the same and/​ or opposite sex, including lesbian, gay, bisexual, and heterosexual (straight) orientations. However, others are using ‘sexual orientation’ to mean a deeply ingrained sexual preference, e.g., for BDSM of consensual nonmonogamy. Someone attracted to transgender people. In BDSM, the person who the partners agree will be submissive to and dominated by the dominant or top. Also called slave. A  form of consensual nonmonogamy usually engaged in by heterosexual couples wherein partners have sexual encounters with other singles and couples with no romantic involvement. Swingers may have regular sexual partners, but the relationships with extramarital partners are expected to stay non-​romantic. There are swing clubs/​venues, organizations, and websites.

316  Glossary of Terms

Top Surgery Transgender


Transgender Man/ Trans Man Transgender Women/ Trans Woman Transsexual


Zie and Hir

Gender-​affirming surgeries on the chest. An umbrella term (adj.) for people whose gender identity and/​ or gender expression differs from the sex they were assigned at birth. The term may include but is not limited to:  transsexuals, cross-​dressers and other gender-​variant people. Transgender people may or may not decide to alter their bodies hormonally and/​or surgically. The process of changing from one gender to another. There are two types of transition, social transition and medical transition. Social transition includes publicly, socially, presenting as one’s affirmed gender and may also involve changing personal documents, ‘coming out’ to family, friends, co-​workers, etc. Medical transition can include hormone therapy and a variety of surgeries. Someone assigned female at birth with a male gender identity. Someone assigned male at with a female gender identity. (also Transexual): An older term which originated in the medical and psychological communities. While some transsexual people still prefer to use the term to describe themselves, many transgender people prefer the term transgender to transsexual. Unlike transgender, transsexual is not an umbrella term, as many transgender people do not identify as transsexual. It is best to ask which term an individual prefers. A  modern, pan-​Indian, umbrella term used by some Indigenous North Americans to describe Native people in their communities who fulfill a traditional third-​gender (or other gender-​variant) ceremonial role in their cultures. Infrequently used, gender neutral pronouns used in lieu of the singular they. Zie is subjective (replaces he or she) and Hir is possessive and objective (replaces his or her).

APPENDIX A Sample Letters for Transgender Clients

Sample Letter for Hormone Treatment, Minor DATE Dear Dr.: Re:                           BN/​birth name ……… I am a New Jersey licensed clinical social worker, a member of NASW and AASECT, and employed by the Institute for Personal Growth (IPG) in New Jersey, where I have worked with transgender clients since 2011. I am currently under the supervision of certified sex therapists and licensed psychologists who supervise and consult with me regarding my clients on a regular basis. Prior to being employed by IPG, I worked with gender-​variant youth in an outpatient community mental health clinic. This letter is in support of hormone therapy for (affirmed name) who presented to me in DATE, requesting support and direction in their decision to embark on transitioning from their biological female gender to a male gender. B is a _​_​-​year-​old assigned female who has struggled with gender dysphoria since childhood. B has reported that when their body began to change in adolescence it was ‘unacceptable.’ By freshman year in high school B began to identify as transgender. B is a rising senior in high school and is eager to transition before the start of college next year. B has the support of their parents, who are divorced from each other. They have all been coming into counseling to assist B and themselves in the understanding of this process. They will continue to support B. both

318  Appendix A

financially and emotionally, as B. undergoes a name change and masculinizing hormone therapy. B and B.’s parents will continue to check in with me on a monthly basis once hormones have begun. B has a history of dysphoria and an eating disorder. As self-​reported, and described by the mother, there was one episode of anorexia, restrictive type, due to B’s thinking that the weight loss would enable them to appear more male. B.’s parents put B. in counseling and B. has made a good recovery. B eats healthily and goes to the gym and their mood, since starting therapy at IPG, is good. B has a history of fibromyalgia and is being treated for that by a physician. B is a very good student and quite articulate in their ability to explain who they are and what they need. Although an introvert by nature, they engage in subjects that interest them. B. is fiercely independent yet respectful and appreciative of their family. B has begun to come out as B at school and is finding acceptance. B is mentally stable and committed to this transition, thoughtful in their approach, as well as enthusiastic and eager to begin the transition to masculinizing hormones. With the support offered by family, I  am confident that any obstacles B. may face will be dealt with thoughtfully and responsibly. BN, and their parents, have reviewed this letter and all fully consent to my submission of this letter for hormone therapy. I am available to discuss or provide additional information regarding this request for treatment. I can be reached at ……….. Sincerely, (your name, credentials, license number, contact info) Sample Letter for Hormone Treatment, Adult January 29, 2015 Dr. xxxxxxx Re: NAME DOB: XXXXX SSN: XXXXX Dear Dr.


Jane H. Doe (Legal name John H. Doe, Date of Birth XXXXX, Social Security Number XXXXX) has been receiving individual psychotherapy with me

Appendix A  319

since XXXXX for treatment related to gender dysphoria. This letter is to state my judgment that cross gender hormone therapy is appropriate for Ms. Doe at this time. Ms. Doe is a 50 year old natal male, Caucasian, of average stature. Though assigned male at birth Jane has expressed an inner sense of self as female. She attends sessions approximately every other week; she participates freely, demonstrates no cognitive impairments and is fully oriented. Ms. Doe is currently diagnosed with 296.32 Major Depressive Disorder, Moderate, as well as 300.02, Generalized Anxiety Disorder. In sessions with me, Ms. Doe has demonstrated maturity and the ability to make informed decisions regarding her gender and healthcare, and the ability to respond constructively to issues of gender transition and ongoing life stressors. Ms, Doe demonstrates stability around school and consistent attendance, good grades,and she has parental support from both parents. PARAGRAPH ON ANY OTHER COMPLICATING FACTORS Ms, Doe demonstrates all the characteristics of Gender Dysphoria as per the DSM-5 diagnosis including strong, persistent identification as female, discomfort with their natal gender as male, and both primary and secondary sex characteristics. There is no indication of an intersex condition, and the dysphoria causes significant distress and impairment in social and educational settings. I am an experienced professional well versed in issues of gender and sexuality. Attached find a release form. If you have any additional questions, please feel free to contact me. XXXXXXX LCSW Psychotherapist NYS License: NJ License: contact info

320  Appendix A

Sample Letter for Top Surgery Date Dear Dr.: Mr. XXXX (client’s preferred name), D/​O/​B, has been receiving individual psychotherapy with me since (date) for treatment related to his gender reassignment. This letter is to state my judgment that mastectomy and chest reconstruction are medically necessary and appropriate for Mr. XXXX at this time. Mr. XXXX is a 19-​year-​old of European descent, with dark hair, short but with otherwise average build. Though born female and originally named YYYYYY, he has legally changed his name and has been undergoing treatment to transition from female to male. Mr. XXXX attends sessions approximately every other week; he is consistent in his attendance and participates freely. He demonstrates no cognitive impairments and is fully oriented. In addition, Mr. XXXX demonstrates maturity and the capacity to make informed decisions and consent to treatment regarding his own gender and healthcare, as well as ongoing mental and emotional stability and the ability to respond constructively to ongoing life stressors. Mr. XXXX demonstrates all the characteristics of Gender Dysphoria as per the DSM-​V diagnostic criteria, including strong, persistent identification as male, discomfort with his natal gender as female and discomfort with both primary and secondary sex characteristics. Mr. XXXX presents as male in all situations. There is no indication of an intersex condition, and the disturbance causes significant distress and impairment in social, occupational, and educational settings. Mr. XXXXX began hormonal treatments with endocrinologist Dr………… on (date). He fully meets the criteria for surgery as outlined in the WPATH Standards of Care Version 7. He has a strong support system in his family and several people who are prepared to assist him with aftercare. I am an experienced professional well versed in issues of gender and sexuality. I  have been working with transgender clients since …………. Both mastectomy and chest reconstruction are medically necessary procedures for Mr. XXXXX If you have any additional questions, please feel free to contact me. Sincerely, (your name, credentials, license number, contact info)

Appendix A  321

Sample Letter for Gender-​confirmation Surgery DATE RE: JR (AFFIRMED NAME) Dear Dr.: Please accept this mental health letter for (AFFIRMED NAME), formerly (BIRTH NAME) in preparation for her gender reassignment surgery. I am a N.J. Licensed clinical social worker with 30 years of experience providing therapy to GLBTQ clients. Currently I am working at the Institute for Personal Growth in Highland Park, NJ, under the supervision of Dr. Margaret Nichols. The services I provide are in complete compliance with WPATH Standards. 1) JR, DOB 8/​23/​86, is a 30-​year-​old client transitioning from male to female. 2) JR’s diagnoses are gender dysphoria (GD) and major depressive disorder (MDD), moderate. JR is currently prescribed Pristique, 100 mg.; and Abilify, 2 mg. by her psychiatrist, Dr. in Somerset, NJ. (phone number). 3) JR is currently receiving hormone treatment from the Mazzoni Center in Philadelphia, PA. She is taking Estriadol and Spironolactone. 4) JR began regular psychotherapy sessions with me in ……… 5) JR’s gender dysphoria began during her pre-​school years when she wanted to wear female attire to day care. 6) This desire continued throughout her life; at age 11 or 12 she remembers borrowing and wearing her mother’s clothing in private. By the age of 15, she began buying her own female clothing and dressing privately. 7) In May of …….., JR began to regularly attend a Transgender Support Group at the Pride Center in New Brunswick, NJ. 8) Soon after beginning therapy, JR began her social transition. She came out to her family of origin, who are very supportive. 9) She came out in her workplace and began presenting herself as female in March of.…. 10) JR legally changed her name from (birth name) to (affirmed name) in January of.…. She also changed her gender status to female on her medical insurance policy. 11) JR has a lot of support for her transition, consisting of her fiancé, Sam, with whom she lives, her family of origin, her friends, and her co-​workers. Sam, and JR’s mother, will be available to provide post-​operative  care. 12) JR is an extremely intelligent and resourceful person. She attends in-​ person and online support groups, and she has thoroughly researched what to expect from gender reassignment surgery.

322  Appendix A

13) In order to pay for surgery, JR is using her own savings, and her mother is willing to contribute to the cost. She is also working with her benefits coordinator at work to attain reimbursement from her insurance company. 14) If you have any questions or concerns please do not hesitate to call me at …….. Sincerely, (your name, credentials, license number, contact info) Sample Second Letter for Gender Confirmation Surgery DATE Re: (affirmed name) formerly (birth name) Dear Dr.: This is a second letter in support of gender reassignment (vaginoplasty) surgery for (affirmed name). (Affirmed name) is a 32-​ year-​ old transgender woman who consulted with me on March 15, 2018 for the purpose of obtaining another letter to complement the letter she already has from Mazzoni Center in Philadelphia Pa. Up until now, Mazzoni Center has provided multidisciplinary care for (affirmed name) that has included hormone therapy and counseling as needed. Ms. (affirmed name) consulted with me for a second letter of recommendation for surgery on ……………. I have seen her times for this purpose. I have personally worked with transgender people since, and have been trained in this work and in the requirements of the WPATH Standards of Care. Ms. (affirmed name) has a history typical for a transgender person assigned male at birth. She reports feeling she was a girl from an early age, but she also understood that her family and community would not accept her as a transgender person. Consequently, like many transgender people, Ms. (affirmed name) hid her true identity for many years, only feeling she could ‘come out’ at age 28. She became a patient at Mazzoni shortly thereafter, and has been taking cross-​gender hormones and living full time as a female for four years. Ms. (affirmed name) has no mental health history, and no psychiatric diagnoses other than gender dysphoria. My interview and questioning of her, and her results on two brief measures of mood volatility, indicate that she is stable and free from mental illness. She is fully aware of what is involved in her surgery and all the possible complications, and she is cognizant of the aftercare that will be involved. Ms. (affirmed name) has an excellent support system,

Appendix A  323

in the form of a girlfriend who lives with her and will help with aftercare, and several friends who are also available for support and concrete assistance. Ms. (affirmed name) fully meets the DSM requirements for Gender Dysphoria, and she has met both the eligibility and readiness guidelines set by the World Professional Association for Transgender Health as requirements for this surgery. She understands the risks and benefits of the procedure, she is mentally stable, and she is well supported. In short, in my opinion Ms. (affirmed name) is an excellent candidate for this surgery. Please feel free to contact me if you require further information. Sincerely, (your name, credentials, license number, contact info)

APPENDIX B Clinical Practice Guidelines for Working with People with Kink Interests

Note: the full 62-​page document, which contains research findings, explanation of, and justification for each guideline, can be found at:​the-​guidelines Guideline 1:  Clinicians understand that kink is used as an umbrella term for a wide range of consensual erotic or intimate behaviors, fantasies, relationships, and identities. Guideline 2: Clinicians will be aware of their professional competence and scope of practice when working with clients who are exploring kink or who are kink-​identified, and will consult, obtain supervision, and/​or refer as appropriate to best serve their clients. Guideline 3: Clinicians understand that kink fantasies, interests, behaviors, relationships, and/​or identities, by themselves, do not indicate the presence of psychopathology, a mental disorder or the inability of individuals to control their behavior. Guideline 4: Clinicians understand that kink is not necessarily a response to trauma, including abuse. Guideline 5: Clinicians recognize that kink intersects with other identities in ways that may shape how kink is expressed and experienced. Guideline 6:  Clinicians understand that kink may sometimes facilitate the exploration and expression of a range of gender, relationship, and sexuality interests and identities. Guideline 7:  Clinicians recognize how stigma, discrimination, and violence directed at people involved in kink can affect their health and well-​being.

Appendix B  325

Guideline 8:  Clinicians understand the centrality of consent and how it is managed in kink interactions and power-​exchange relationships. Guideline 9: Clinicians understand that kink experiences can lead to healing, personal growth, and empowerment. Guideline 10: Clinicians consider how generational differences can influence kink behaviors and identities. Guideline 11: Clinicians understand that kink interests may be recognized at any age. Guideline 12:  Clinicians understand that there is a wide variety of family structures among kink-​identified individuals. Guideline 13: Clinicians do not assume that kink involvement has a negative effect on parenting. Guideline 14: Clinicians do not assume that any concern arising in therapy is caused by kink. Guideline 15: Clinicians understand that reparative or conversion therapies are unethical. Similarly, clinicians avoid attempts to eradicate consensual kink behaviors and identities. Guideline 16:  Clinicians understand that distress about kink may reflect internalized stigma, oppression, and negativity rather than evidence of a disorder. Guideline 17: Clinicians should evaluate their own biases, values, attitudes, and feelings about kink and address how those can affect their interactions with clients on an ongoing basis. Guideline 18:  Clinicians understand that societal stereotypes about kink may affect the client’s presentation in treatment and the process of therapy. Guideline 19: Clinicians understand that intimate partner violence/​domestic violence (IPV/​ DV) can co-​ exist with kink activities or relationships. Clinicians should ensure their assessments for IPV/​DV are kink-​informed. Guideline 20:  Clinicians strive to remain informed about the current scientific literature about kink and avoid misuse or misrepresentation of findings and methods. Guideline 21: Clinicians support the development of professional education and training on kink-​related issues. Guideline 22:  Clinicians make reasonable efforts to familiarize themselves with health, educational, and community resources relevant to clients who are exploring kink or who have a kink identity. Guideline 23: Clinicians support social change to reduce stigma regarding kink. The Kink Guidelines Authors:  Charles Moser, M.D., Richard Sprott, Ph.D., Ruby Johnson, LCSW, Anna Randall, DHS, LCSW, MPH, Aida Manduley,

326  Appendix B

LCSW, Shan’a Thomas, LICSW, M.Ed., Carrie Jameson, LCPC, Braden Berkey, Psy.D., Caroline Shahbaz, Susan Wright, Shadeen Francis, LMFT, DJ Williams, Peter Chirinos, Emily Prior, MA, Peggy Kleinplatz, Ph.D., Lori Michels, LMFT, CST, Audriannah Levine-​Ward, Psy.D., Margaret Nichols, Ph.D., Patrick Grant, MPH, Laura Jacobs, LCSW-​R, Russell Stambaugh, Ph.D., DST.


24/​7 BDSM relationships 270 abortion, legalization of 39 abuse, and BDSM 250–​251, 269–​270 ‘aces’ see asexuality/​asexual  people Achermann, John 185 acronyms 35 addiction: and BDSM 250–​251; see also substance abuse adolescence, and identity formation 160 adolescents see transgender adolescents adoption 132, 308 advocacy role of therapists 6, 302, 305 AFAB (assigned female at birth) 190; nonbinary people 241; trans boys 215 ‘Affirmative Care for Transgender and Gender Non-​Conforming People: Best Practices for Front-​Line Health Care Staff ’ (National LGBT Health Education Center) 303–​304 affirmative psychotherapy care for gender, sexuality, and relationship-​diverse clients (GSRD), principles of 304–​305 affirmative therapy 4, 5–​7, 20, 302–​303 African Americans: HIV infection rates among gay/​bi men 96; lesbians 121, 122; minority stress 80; population surveys of sexuality 58; recognition of equality 38

AfterEllen 123 agender people 177, 237 age-​structured homosexuality  12 AIDS 41–​42; see also HIV AIDS Project Los Angeles 41 Ainsworth, Claire 185 Aldrich, R. 11 Al-​Fatiha Foundation  74 Allport, Gordon 80 altered states of consciousness, and BDSM 254–​255, 273–​274 AMAB (assigned male at birth) 190, 236; nonbinary people 241 ambiguous genitals 239; see also intersexuality/​intersex  people American Association of Sex Educators, Counselors, and Therapists 225 American Couples: Money, Work, Sex (Blumstein and Schwartz) 103–​104 American Institute of Bisexuality 59 American Psychiatric Association 4, 15, 17–​18, 20, 31, 74, 92–​93, 119, 121, 225, 252; definition of identity 160; see also DSM (Diagnostic and Statistical Manual of Mental Disorders) American Psychological Association 225 anal sex: condomless (barebacking) 96, 98–​99, 109; see also sodomy laws Ancient Greece 12, 13, 46, 117

328 Index

And the Band Played On (Shilts) 95 Anderson, Mary (Murray Hall) 27 androgyny 237 animals: asexuality in 161; sex and gender diversity in 5, 6–​7, 11, 26, 45–​46, 47, 49, 184, 303 anti-​gay discrimination  5 antipsychiatry movement 303 antiretroviral treatments 96 Appendix: Best Practices for the Care of Transgender Youth (Lev and Gottlieb) 303 apple children 226–​227, 232 Archives of Sexual Behavior 18 aromantics (‘aros’) 159, 163, 166, 304 Asexual Visibility and Education Network (AVEN) 37, 161, 162, 163, 165 asexuality/​asexual people 35, 36, 37, 43, 60, 159, 304; asexual identity 161–​163; attitudes and beliefs about 162, 163–​164; client paperwork issues 164; clinical work with 164–​166; statistics 1 assault, risk of for transgender people 202 assigned female at birth see AFAB (assigned female at birth) assigned male at birth see AMAB (assigned male at birth) assimilation, of gay culture into wider society 307 Atkinson, Ti-​Grace  118 Atlanta Poly Weekend 296 authenticity 6, 160, 197, 305 author: positionality of 2–​3 autism: as an identity 39; autism spectrum disorder, and transgender adolescents 213 ‘autogynephilic transsexuals’ 195–​196 Autostraddle 121, 123, 134 AVEN (Asexual Visibility and Education Network) 37, 161, 162, 163, 165 aversive electric shock treatment 53 Baby Boomers 61, 238 back rooms 95–​96 ‘bad’ classification 9 Baghemihl, Bruce 6, 11, 46, 47 Bailey, J. Michael 143 Baldwin, J. 57

Baldwin, Tammy 120 barebacking (condomless anal sex) 96, 98–​99, 109 Barker, M. J. 237, 303, 304 Barnard Conference on Sexuality 120 Barnes, Djuna 118 bath houses 95–​96 ‘bathroom bills’ 32 Bayer, R. 15, 16, 17 BDSM (Bondage and Discipline, Dominance and Submission, Sadism and Masochism) 36, 42, 246–​249, 256, 304; and abuse 250–​251, 269–​270; and addiction 250–​251; and bisexual people 146; categorisation of as ‘paraphiliacs’ 5; characteristics of 247–​248; characteristics of kinky people 254–​255; demography of 253–​254; and lesbians 125, 130, 131, 134, 136, 252; modern history of 251–​253; myths and misconceptions about 249–​251; and pain 251; people who want to explore 270; as a sexual orientation 248–​249; statistics 1; and stigma 255–​256; working with kinky clients 255–​274; see also kinky people Beach, Frank 15 Beemyn, G. 30, 185 Believe Out Loud 74 Bell, A. P. 52, 71 Ben, Sandra 237 Benjamin, Harry 27, 28, 29 Berland, Susan Hope 86 Berzon, Betty 20, 68 bibliotherapy 74 Bieber, Irving 14 ‘Big Tent,’ creation of 41–​44 bikers’ clubs 252 Biological Exuberance (Baghamihl) 6, 11, 46, 47 biological sex: five ‘levels’ of 239; see also AFAB (assigned female at birth); AMAB (assigned male at birth) Birkett, M. 79 biromantic 163 birth control: birth control pill 39; transgender people 199 birth gender 182

Index  329

bisexual activism 22 Bisexual Forum 22, 59 Bisexual Option, The (Klein) 143 bisexual women 22, 23 bisexuality/​bisexual people 12, 21–​23, 42, 59, 141–​143, 159, 168–​169, 183, 304; attitudes towards 141–​142; clients’ personal definitions of 150; clinical issues 147–​148, 150–​158; current attitudes 144–​145; definition 141; demographics of 145–​146; Freud on 14, 21; invisibility and stigmatization of 22–​23, 151–​152, 154–​155, 172; and mental health 146, 151; minority stress 151–​152; mixed-​orientation couples 154–​158; population surveys of sexuality 1, 58; reinforcement of gender binary 173–​174; sexual fluidity 62, 168–​169, 170; single bisexual women (‘unicorns’) 292; substance abuse 152–​153 black lesbians 119–​120, 122 Black Party, New York 252 Blair, K. L. 170 Blanchard, Ray 195–​196 Blank, Hanne 288 Blaszczynski, A. 174 ‘Blues Women’ of Harlem 118 Blumstein, P. 103–​104, 106, 129 Bogaert, Anthony 161, 162 Bolland, K. S. 204 bondage 247; see also BDSM (Bondage and Discipline, Dominance and Submission, Sadism and Masochism) bone development, impact of puberty blockers on 231, 232 bonobo monkeys 47 ‘Boston marriages’ 118 ‘bottom’ surgery 199–​200, 205, 218, 221, 241 Bowman, Karl 28 Boy Erased 91 boys: effeminacy in 224–​225; see also children; gay men and boys; transgender children ‘Boys in the Band, The’ 307 brain, the: and sexual orientation 49–​50, 54; and transgender women 52, 54

Briggs Initiative, California 119 Brooklyn Boi Hood 134 Brotto, Lori A. 161, 255–​256, 259 Brown, Rita Mae 119 Bruni, Frank 307 ‘bud sex’ 172 Buddhism 7, 74 Buford, Harry (Loreta Janeta Velazquez) 27 bullying 70; transgender children and adolescents 214, 216; young LGBTQ+ people 79, 81, 92 Bunch, Charlotte 119 ‘butch lesbians’ 180 butch/​femme  186 Buxton, Amity Pearce 112, 155–​156 CAH (congenital adrenal hyperplasia) 50 Califia, Patrick 262 CAMH (Center for Addictions and Mental Health) 225 Cantrell-​Brown, Sherill  285 Carey, B. 143 Carpentier, J. 253 Cass, Vivenne 81–​82, 263 CDC (Centers for Disease Control) 95–​97, 96 Center for Addictions and Mental Health (CAMH) 225 Chambers, Alan 75 Chandra, A. 142–​143 changes of mind in transgender children 229–​230 chapstick lesbians 121 chemical castration 53 chemsex 93, 96 child abuse 283; and BDSM 250 child custody decisions, and BDSM 255, 268 children: and consensual nonmonogamy 286–​287, 298–​299; gender nonconformity in 71–​72, 81, 86, 92, 181–​182, 215, 227–​228; see also gender-​expansive children; transgender children chosen/​created families 87–​88, 133 Christianity 13, 18, 53, 68, 74, 86, 117, 179, 218

330 Index

chromosomal sex 239 Church and the Homosexual, The (McNeill) 68, 74 circuit parties 93 cisgender 183 civil rights 18; transgender people 32 Clark, Don 20, 68 client paperwork/​record-​keeping issues 150, 164, 303–​304, 305 ‘Clinical Practice Guidelines for Working with People with Kink Interests’ 260 CNM (consensual nonmonogamy) see consensual nonmonogamy (CNM) Code of Hammurabi 117 Collette 118 coming out 60, 82–​85; and gay-​affirmative therapy 21; and kinky clients 263–​264, 265; young LGBTQ+ people 81 Coming Out, Coming Home (LaSala) 86 communication, and kinky people 271 community resources, directing of clients to 6 compersion, and consensual nonmonogamy 279, 298 condom use 95, 96 condomless anal sex (barebacking) 96, 98–​99, 109 congenital adrenal hyperplasia (CAH) 50 Conley, Garrard 91 conscious uncoupling 276, 277 consensual nonmonogamy (CNM) 22, 36, 107, 276–​278, 281–​282, 300–​301, 304; and bisexual people 146; brief history of 278–​280; and children 286–​287, 298–​299; and compersion 279, 298; gay men 283; helping couples open up 295–​297; and jealousy 285–​286, 297–​298; kinky people 268; and lesbians 22, 131, 136; lessons from 288; meaning of 287–​288; mixed-​ orientation couples 156; prevalence and patterns of 291–​294; problems with 285–​286; relationship counseling with more than two 299–​300; and relationship strengthening 294–​295; solo nonmonogamists and poly-​mono relationships 299; statistics 1; therapists’ bias against 280; and time management

298; types of 282–​285; vetoing a relationship 298; working with clients 290–​301; see also polyamory/​ polyamorous people consent: and BDSM 247; see also informed consent context-​specific sexual orientation 168, 170 contraception: contraceptive pill 39; transgender people 199 conversion therapies 14, 53, 74, 91; legal prohibition of 53, 75, 225; legality of in some states 307; and transgender children 234 Coppens, V. 253 Cotrell, Susan 86 countertransference: kinky clients 261–​262; lesbian couples 133; nonbinary people 191; transgender people 191, 233 ‘courtesy stigma’ 87, 154 Cpen, C. E. 142–​143 Crenshaw, Kimberlé 42, 88 cross-​dressing 28, 186, 193–​195; laws against 16, 26–​27 cross-​gender hormones see hormones Crowley, Mart 307 cultural feminists 120 Cummings, Alan 280 Cunningham, Sara 74 cure, desire for by kinky clients 263–​264 Daniel, Harold 92 Dar-​Nimrod,  I.  174 D’Augell, A. R. 82 Daughters of Bilitis 15, 21, 118 deafness, as an identity 39 Defense of Marriage Act (DOMA) 120 DeGeneres, Ellen 61, 78, 120 demisexuality 159, 162 Denmark 29 Designer Relationships (Michaels) 296 detransition, of transgender adults 203–​204 Diagnostic and Statistical Manual of Mental Disorders see DSM (Diagnostic and Statistical Manual of Mental Disorders)

Index  331

Diamond, Lisa 57, 61, 62, 144, 168–​169, 170, 171 Dickenson, J. A. 170 differentiated fetal gonadal sex 239 digit length ratios 50, 52 Dignity 68, 74 Dinah 123 disabilities, as identities 39 disabled people, civil rights of 38 discipline 247; see also BDSM (Bondage and Discipline, Dominance and Submission, Sadism and Masochism) discrimination: anti-​gay 5; dual discrimination of nonbinary people 242, 243; employment discrimination of transgender people 201; and gay-​affirmative therapy 21; against LGBTQ+ community 307; see also marginalization; stigmatization ‘Disorders of Sexual Development’ (DSD) 239 diversity see sex and gender diversity ‘dom space’ 254, 273 DOMA (Defense of Marriage Act) 120 domestic violence 107; see also intimate partner violence dominance 247; see also BDSM (Bondage and Discipline, Dominance and Submission, Sadism and Masochism) doxa 288 ‘drag ball’ culture 27, 30 drag queens 27, 31, 179, 186 Dreger, A. 240 Drescher, Jack 18 DSD (‘Disorders of Sexual Development’) 239 DSM (Diagnostic and Statistical Manual of Mental Disorders): DSM-​I classification of homosexuality as a ‘sociopathic personality disturbance’ 15; DSM-​III and ‘gender identity disorder of childhood’ 224; DSM-​III and ‘psychosexual disorders’ 246–​247; DSM-​V 31, 33, 178, 247; and ‘gender identity disorder’ 32–​33, 178; illness model of gender variance in, 1980 31; removal of homosexuality from,

1973 4, 17–​18, 39, 74, 119; and sexual deviations 246; ‘transvestic disorder’ 33 dual discrimination, of nonbinary people 242, 243 Dunkley, C. R. 255–​256, 259 Duron, Lori 86 dwarfism, as an identity 39 dysphoria 30 Easton, Dossie 262, 274, 283, 296 eating disorders 93 EFT (Emotionally Focused Treatment) 276, 277 Ehrensaft, Diane 226, 229, 232 Eisenberg, M. E. 78 Elbe, Lili 26 electric shock treatment 53 Ellis, Havelock 14 embryo cryopreservation 221 EMDR (Eye Movement Desensitization and Reprocessing) 69, 97 ‘emotional affairs’ 132 Emotionally Focused Treatment (EFT) 276, 277 employment discrimination, against transgender people 201 Employment Non-​Discrimination Act 43 enby see nonbinary people environmental factors, lack of influence on sexual orientation 49, 51, 52 Erickson Educational Foundation 29 Erickson, Erik 160 Erickson, Reed 29 estrogen 199, 221, 241 Ethical Slut, The (Easton) 296 etiology research 48–​53 Etruscan Tomb of Whipping 46 Eulenspiegel Society (TES) 36, 252, 267, 270 Evolution’s Rainbow (Roughgarden) 6–​7, 45 exclusion, and gay-​affirmative therapy 21 Exodus International 74, 75 ‘Extinction of Gay Identity, The’ (Bruni) 307 Eye Movement Desensitization and Reprocessing (EMDR) 69, 97

332 Index

Faderman, Lillian 118 fa’fafine (Samoa) 51 Fairchild, B. 86 Families in Transition (Lev and Gottlieb) 226, 233 Family Acceptance Project 233 family relationships: bisexual people 152–​153; created vs. families of origin 87–​88; and homosexuality 14; rejection of LGBTQ+ family members 91–​92; young LGBTQ+ people 79; see also parent-​child relationships Far From the Tree (Solomon) 3, 39 father-​son relationships 52–​53, 97 Fausto-​Sterling, Ann 7, 185, 239 Febo-​Vasquez, I. 142–​143 Feinberg, Leslie 31 feminism: and gay men and boys 96; lesbian feminism 118–​119, 178–​179, 306; radical feminists 120, 178–​179; second-​wave 39, 179; third-​wave 120; Trans Exclusionary Radical Feminists (‘TERFS’) 31, 179 fertility: impact of puberty blockers on 231–​232; transgender adolescents 221; transgender people 199 festivals 122–​123 fetal hormonal sex 239 fetal hormone exposure 49–​50 fetishes/​fetishists 196, 247, 248 Fifty Shades of Grey (James) 252–​253, 270 finger length ratios 50, 52 Folsom Street Fair 252 Ford, Cleland 15 fraternal-​birth-​order effect  51 ‘free love communes’ 279, 281 86 Freud, S. 14, 21, 169, 173 fruit salad children 226, 227, 232 Fryer, John 20 ‘FtM’ see trans men Fukuyama, Francis 4, 7, 38 gay activism 38, 41; and transgender people 25–​26, 31; see also homosexual activism Gay Activist Alliance 21, 31

Gay and Lesbian Alliance Against Defamation (GLAAD) 92 ‘gay,’ as an identity 12 ‘gay caveman’ 11, 26, 45 ‘gay gene’ 9, 49 Gay Liberation Front 21 Gay Life and Culture: A World History (Aldrich) 11 gay male couples 103; clinical work with 107–​114; demographic characteristics 104; issues in common with lesbian couples 106–​107; longevity of relationships 106; mixed-​orientation couples 112–​113; nonmonogamy 95, 98, 107, 110, 279, 283; and parenting 104, 108–​109, 110–112; relationship quality and style 105; research on same-​sex vs mixed sex couples 103–​106; sex after seroconversion 109–​110; see also gay men and boys; gay people; LGBTQ+ community Gay Male S/​M Activists (GMSMA) 36, 252 gay men and boys 91–​93; animosity towards lesbians 41; clinical work with 97–​101; consensual nonmonogamy 22; cross-​dressing by 27; fraternal-​ birth-​order effect 51; in heterosexual marriages 112; and HIV 95–​97; maternal relationships 53; mental health issues 92–​94, 97–​98; prejudice against bisexual people 144; role of sex in gay male culture 94–​95; see also gay male couples; gay people; homosexual men; homosexuality/​homosexual people; LGBTQ+ community Gay Men’s Health Crisis (GMHC) 41, 95 gay people 56–​57, 63–​64; assimilation into wider society 307; childhood gender nonconformity 71–​72; contemporary clients 77–​89; and hate crimes 70; identity, and gay-​affirmative therapy 21; mental health issues 80–​81; population surveys of sexuality 1, 58; twentieth-​ century clients 66–​76; see also gay male couples; gay men and boys; homosexuality/​homosexual people; lesbian couples; lesbians; LGBTQ+

Index  333

community; same-​sex attraction/​ behavior ‘gay rams’ 49 Gay Straight Alliance (GSA) 77, 100, 212, 230 gay-​affirmative therapy 4, 20–​21; see also affirmative therapy ‘gayborhoods’ 16, 133 Gen Z 60–​61, 89, 307; acceptance of gender variance 189–​190; and consensual nonmonogamy 291; lesbians 121–​122; and multisexuality 172–​173; and nonbinary people 238 gender: components of 182–​183; as a continuum 185, 186; evidence to contradict 7 ‘gender affirmation surgeries’ 199 ‘gender and sexual diversity’ (‘GSD’) 304 gender binary: bisexuality as reinforcement of 173–​174; breakdown of 60 ‘gender blind’ attractions 173 gender clinics 29–​30; restrictive criteria of 29–​31 gender continuum 185, 186 gender diversity see sex and gender diversity gender dysphoria 178, 187, 196; and DSM V 33; resolution of 185; ROGD (Rapid Onset Gender Dysphoria) 218–​219, 225 Gender Dysphoria Affirmative Working Group 219 gender expression 182 gender fluidity 126, 186, 236, 237 gender identity 182; anti-​discrimination legislation 32; client paperwork issues 150; ‘hard-​wired’ nature of 54 ‘gender identity disorder’ 32–​33, 178, 196 ‘gender identity disorder of childhood’ (DSM III) 224 ‘gender incongruence’ 33 gender nonconformity in childhood 71–​72, 81, 86, 92, 181–​182, 215, 227–​228 gender roles 182 ‘Gender, sexual and relationship diversity’ (‘GSRD’) 303, 304; principles of affirmative psychotherapy care for gender, sexuality, and

relationship-​diverse clients (GSRD) 304–​305 gender spectrum 185, 186 gender web 186 ‘gender-​confirmation surgeries’  199 gender-​expansive children 223–​224, 232–​233; 80% desistance myth 226–​227; mental health issues 232–​233; and puberty blockers 231–​232; recent history of treatment of 224–​226; therapists and gender-​ affirmative treatment 228–​230; treatment for 227–​228; see also transgender children gender-​neutral pronouns 174, 177, 185, 236, 238, 241 GenderPac 32 genderqueer people 60–​61, 181, 195, 237 gender-​transformed homosexuality  12 genetics: etiology research on sexual orientation 49–​50, 51, 52, 54 Genial Gene, The (Roughgarden) 6–​7 Germany 13, 26, 28 Gill, T. 296 Girl Splash 123 ‘girldicks’ 203 ‘girlfags’ 43, 306 girls: gender nonconformity in childhood 71–​72; ‘tomboys’ 215, 225; see also children; transgender children GLAAD (Gay and Lesbian Alliance Against Defamation) 92 GMHC (Gay Men’s Health Crisis) 41, 95 GMSMA (Gay Male S/​M Activists) 36, 252 ‘go stealth’ 211 God and the Gay Christian (Vines) 74 God vs. Gay (Michaelson) 74 Goffman, Erving 80 gonadal development, impact of puberty blockers on 231 gonadal dysgenesis 239 Good Practices Across the Counselling Professions: Gender, Sexual and Relationship Diversity (Barker) 303, 304 Gottlieb, A. R. 233, 303 Gottman, John 105–​106, 107 gray-​asexuals (gray-​As)  163

334 Index

Green, Richard 71, 224 Greer, Germaine 179 Grindr 97, 296 growing up gay 70–​71; impact of 71–​73; stress of 80–81 GSA (Gay Straight Alliance) 77, 100, 212, 230 ‘GSD’ (‘gender and sexual diversity’) 304 ‘GSRD’ (‘Gender, sexual and relationship diversity’) 303, 304; principles of affirmative psychotherapy care for gender, sexuality, and relationship-​ diverse clients (GSRD) 304–​305 ‘guydykes’ 43, 306 Haggard, Ted 75 Hall, Murray (Mary Anderson) 27 Hamer, Dean 50 Hammersmith, S. K. 52 ‘hard-​wired’ nature of sexual orientation and gender identity 54 Hardy, J. W. 262, 273, 274, 296 Harry Benjamin Society 33 Hasbians 22, 42 hate crimes 70 ‘Haven for Human Amoeba’ group 37 healing, sex as a form of 273 Heche, Ann 61 Hellman, Lillian 77 Herbenik, D. 253 Herdt, G. H. 11–​12, 47, 48, 134 Herek, G. M. 141 heteroromantic 163 ‘heterosexual panic’ 63 heterosexual transvestites 28; see also cross-​dressing hierarchy of needs 37–​38 Hinge 134 ‘hir’ pronouns 185 Hirschfeld, Magnus 14, 26, 28 HIV 57, 93; antiretroviral treatments 96; gay male couples 107; and gay male sexuality 95–​97; service programs 3; sex after seroconversion 109–​110; see also AIDS homelessness 201–​202 homophile groups 15–​16, 17, 21, 41 homoromantic 163

homosexual activism 21; homophile groups 15–​16, 17, 21, 41; transgender people in 25–​26 homosexual men: brains characteristics of 49, 50; fraternal-​birth-​order effect 51; see also gay men and boys homosexuality/​homosexual people: active partners 12, 13; age-​structured 12; as an identity 12–​13; in ancient cultures 12, 13, 46–​47; criminalization of in US 16–​17; decriminalization of in US 17, 18; DSM I classification of as a ‘sociopathic personality disturbance’ 15; exclusive 12, 13; gender-​transformed 12; ‘homosexual panic’ 63; ‘homosexual transsexuals’ 195; homosexual/​ s, as a term 13, 29; impact of de-​ pathologization of 18–​20; as mental illness 14–​15, 17; normality of 5, 6–​7, 15; normalization of 15–​18; as a psychiatric condition 14–​15; receptive/​ submissive partners 12, 13; removal from DSM (Diagnostic and Statistical Manual of Mental Disorders), 1973 4, 17–​18, 39, 74, 119; and transvestism 28; see also gay people; lesbians; LGBTQ+ community; same-​sex attraction/​ behavior Hooker, Evelyn 15, 16, 17 ‘horizontal identities’ 4, 39–​40, 88, 303 hormone treatment: for nonbinary people 241, 242; for transgender adolescents 209, 211, 213, 216–​218, 219, 220–​221; for transgender people 28, 33, 179, 183, 187, 197, 198–​199, 200 hormones: etiology research on sexual orientation 49–​50, 51, 54; etiology research on transgender people 52; see also puberty blockers ‘Houses’ 30 HSSD (hypoactive sexual desire disorder) 161, 164 Human Rights Campaign 201 Human Rights Campaign Youth Survey, 2017 81, 144 Human Rights Campaign Youth Survey, 2018 162 Hyacinth Foundation 3, 41, 120

Index  335

Hyde, J. S. 7 hypermasculinity, in gay male culture 94 hypoactive sexual desire disorder (HSSD) 161, 164 hysterectomy 200, 221 ‘identity politics’ 3, 37, 160, 303; definition 38–​39 Identity: The Demand for Dignity and the Politics of Resentment (Fukuyama) 4, 7 identity/​ies 7–​8; birth of new identities 37–​41; perception of conditions previously categorised as illnesses as 3–​4 Imago Relationship Therapy 111, 154 IML (International Mr. Leather) 36, 252 ‘impersonating the opposite sex,’ laws prohibiting 27 ‘in-​between’ gender identities 237; see also nonbinary people Indian hijiras 8, 237 infidelity 107; and lesbian couples 131–​132; see also consensual nonmonogamy (CNM) informed consent: and minors 219–​220; treatment for transgender people 33, 183 Institute for Personal Growth (IPG) 2, 3, 19, 20, 41, 68, 126, 155, 157, 204, 212, 230, 270, 278, 285, 286, 287, 293, 294 Institute for Sexual Science 26 institutional bias against transgender adults 201–​202, 206 institutionalization 67 insurance, and medical treatment for transgender people 32–​33 Integrity 74 ‘intentional couples dialogue’ 111 internalized homophobia 4, 20, 67, 69, 70, 71, 94, 97–​98; transgender people 179 internalized kinkphobia 263 International Mr. Leather (IML) 36, 252 Internet, the 303; and BDSM 254; and transgender people 32, 180–​181, 181–​182 interracial relationships 107; lesbians 123–​124, 131 intersectionality 42–​43, 81, 88, 122

Intersex Society of North America 185, 238 intersexuality/​intersex people 29, 185, 304; in animals 46; definition of 238; etiology research 49; nonbinary vs. intersex 238–​240 intimate partner violence: gay men and boys 93, 94; see also domestic violence invisibility, of nonbinary people 236, 243 IPG (Institute for Personal Growth) 2, 3, 19, 20, 41, 68, 126, 155, 157, 204, 212, 230, 270, 278, 285, 286, 287, 293, 294 Islam 74 isolation, felt by partners of transgender people 204 isothymia 38 J. O. Parties (jerk off) 96 James, E. L. 252–​253, 270 Jay, David 37, 161 jealousy, and consensual nonmonogamy 285–​286, 297–​298 Jeffreys, Sheila 179 Jenner, Caitlyn 187 Jennings, Jazz 178, 209, 215 Jethá, Cecildá 278 Jews 74, 223 Johns Hopkins University 224, 225, 239 Johnson, Marsha P. 26, 31 Johnson, Tae 92 Jong, Erica 279 Jorgensen, Christine 29, 224 Journal of Bisexuality 59 Journal of Sex and Marital Therapy 279 Joyal, C. C. 253 KAC (Kink Aware Collective) 294 Kama Sutra 46, 252 Kameny, Frank 17 KAP (Kink Aware Professionals) 263 kathoeys, Thailand 237 Kaufman, Benjamin 74 Kenny, C. 92 Kerista 279 Kertbeny, Karl 13 Keshet 74 Kilodavis, Cheryl 182 kin selection hypothesis 51

336 Index

Kink Aware Collective (KAC) 294 ‘Kink Aware Therapists’ 256 262, 270 kinky people 35, 42–​43, 60; ‘Clinical Practice Guidelines for Working with People with Kink Interests’ 260; clinical work with 255–​274; internalized self-​hatred 4; lessons from 271–​274; partners and families 264–​269; and shame 5; see also BDSM (Bondage and Discipline, Dominance and Submission, Sadism and Masochism) Kinsey, Alfred 15, 21–​22, 27, 59, 142, 161, 170 Kinsey Scale 59, 142, 143, 161 Klaw, Irving 252 Klein, Fritz 22, 59, 143 Klein Sexual Orientation Grid (KSOG) 59, 143 Kleinplatz, Peggy 247, 248, 283 Klinefelter Syndrome 239 Kraft-​Ebbing, Richard von 13–​14, 246 KSOG (Klein Sexual Orientation Grid) 59, 143 Kurdek, L. A. 105 Ladder, The 70, 118 Landers, Ann 144 Langley Porter Psychiatric Clinic, San Francisco 28 LaSala, Michael 73, 86, 283 Latinos: Latina lesbians 122; Latino gay/​ bi men 96; population surveys of sexuality 58 Lavendar Menace 118 Lawrence, Louise 28 Lawrence v. Texas, 2003 5, 18, 47 Le Vay, Simon 50 leather 252 ‘Leather’ 36 Leather Pride Night 36 Leiblum, Sandra 3 lesbian activism 31, 38, 118–​119 ‘lesbian bed death’ 129, 130 lesbian couples 129–​130; and bisexuality 131; clinical issues 130–​133, 134–​139; demographic characteristics 104; family relationships 135–​136; generational

issues 133–​134; issues in common with gay male couples 106–​107; lonevity of relationships 106; and parenting 104, 122, 127, 132–​133; relationship quality and style 105; research on same-​sex vs mixed sex couples 103–​106; trans women in 186; see also gay people; homosexuality/​homosexual people; lesbians; LGBTQ+ community lesbian feminism 118–​119, 178–​179, 306 Lesbian Psychologies (Nichols) 144 Lesbian Sex Mafia (LSM) 36, 250, 252 lesbian/​feminist sex wars 120 LesbianNews 123 lesbians 116; and the AIDS epidemic 41; animosity towards gay men 41; and BDSM 125, 130, 131, 134, 136, 252; and bisexual women 22, 23; childhood gender nonconformity 71–​72; and consensual nonmonogamy 22, 131, 136, 287; contemporary clients 77–​89, 120–​123; family relationships 125–​126; festivals 122–​123; and hate crimes 70; history of lesbianism 117–​120; issues of 123–​127; lesbians of color 119–​120, 122; motherhood status 124–​125; and parenting 122, 127, 132–​133; population surveys of sexuality 1, 58; prejudice against bisexual people 144; self-​identified 62; transgender 124; twentieth-​century clients 66–​76; younger 121–​122, 124, 127; see also gay people; homosexuality/​homosexual people; lesbian couples; LGBTQ+ community; same-​sex attraction/​ behavior Lev, Arlene 182, 209, 233, 303 LeVay, S. 57 LGBTQ+ community 302–​303, 306–​307; and asexuals 162; best practices and guidelines for care of 303; discrimination against 307; hostility towards transgender people 178–​179, 180; and identity politics 39; intersectionality in 122; mental health issues 5, 80–​81; and the queer revolution 186–​187; young people 78–​79; see also bisexuality/​bisexual

Index  337

people; gay male couples; gay men and boys; gay people; homosexuality/​ homosexual people; lesbian couples; lesbians; same-​sex attraction/​ behavior; transgender people; young LGBTQ+ people LGBTQ+ history 8–​9, 12–​13, 23; and bisexual people 21–​23; development of affirmative therapy 20; early scientific perspectives 13–​15; and intersectionality 35–​44; normalization of homosexuality 15–​20; teaching of in schools 302; and transgender people 25–​34 Ling, Martin Luther 306 lipstick lesbians 121, 186 Littman, Lisa 219 lobotomies 53 ‘Love in Action’ conversion therapy 91 Loving More 293 Loving Someone Gay (Clark) 20, 68 LSM (Lesbian Sex Mafia) 36, 250, 252 Lyon, Phyllis 70, 118, 120 macro aggressions 80 ‘mad’ classification 9 Maddow, Rachel 120 Male Couple, The (Mattison and McWhirter) 95, 279 Manford, Jeanne 86 ‘man-​holes’  203 March on Washington for Gay and Lesbian Rights 22 marginalization 4, 43, 304; partners of transgender people 204; see also discrimination; stigmatization Marquis de Sade 252 Martin, Del 70, 118, 120 Martin, James 94 Maslow, Abraham 37–​38 masochism 246, 247; see also BDSM (Bondage and Discipline, Dominance and Submission, Sadism and Masochism) Mattachine Society 15–​16, 17, 21, 118 Mattison, Andrew M. 95 McHugh, Paul 31 McKinnon, Kate 120

McNeill, John 68, 74 McWhirter, Dave P. 95, 279 medical transition of transgender people 30, 185–​187; banning of treatment for transgender children 225; transgender adults 197, 198–​200; see also hormone treatment; surgical treatment medical treatment of nonbinary people 240–​241, 244, 306 296 melting pot 38 men who have sex with men (MSM) 57 men who have sex with men and women (MSMW) 57 men who have sex with women (MSW) 57 mental health community: and BDSM 255–​256, 259; as enforcers of traditional social values 303 mental health issues 106–​107; LGBTQ+ community 5, 80–​81; young LGBTQ+ people 78–​79 mental illness: gender diversity as 31; homosexuality as 14–​15, 17; sexual fluidity 61–​62 Mesopotamia 251 ‘metamours’ 292, 298 metoidoplasty 200, 241 Meyer, I. H. 80 Meyer, John 30–​31 Michaels, M. 296 Michaelson, J. 74 Michigan Womyn’s Music Festival 32, 118 micro aggressions 80 micro-​dosing of hormones for nonbinary people 241, 242, 244 military service 16, 32 Millennials 61, 89, 307; acceptance of gender variance 189–​190; and consensual nonmonogamy 291; lesbians 121–​122; and multisexuality 172–​173 minority stress 80–​81, 123; bisexual people 151–​152; transgender people 189 misgendering 183, 243–​244 mixed-​orientation couples 112–​113, 154–​158 ‘Mommy blogs’ 86 Monae, Janelle 173, 181

338 Index

Money, John 29, 224 Mo’Nique 280 ‘monogamish’ 107, 110, 283, 291, 293, 296 monogamy 280, 288, 300 Moran, Mike 283 Morandini, J. S. 174 More Than Two (Vaux, Hardy and Gill) 296 Morgan, Robin 31 Morpheus 262 mosaic culture 38 Moser, Charles 247, 252 ‘mostly heterosexual men’ 58–​59, 61–​62, 63, 144, 170, 172 Mostly Straight (Savin-​Williams) 144–​145 MSM (men who have sex with men) 57 MSMW (men who have sex with men and women) 57 MSW (men who have sex with women) 57 ‘MtF’ see trans women multiculturalism 38 multisexuality/​multisexual people 159, 169, 171–​173 Musgrave, Nancy 119, 122, 132–​133, 181, 281, 302 Mustanski, B. 79 muxes, Mexico 237 My Princess Boy (Kilodavis) 182 ‘My Son is Gay’ (Berland) 86 Myth of Mental Illness, The (Szasz) 15 NARTH (National Association for Research and Therapy of Homosexuality) 14–​15, 74–​75 National Association of Gay and Lesbian Health Care Professionals 95–​97 National Center for Transgender Equality (NCTE) 202, 237 National Coalition for Sexual Freedom (NCSF) 36, 247, 252, 255, 256, 263 National Gay Task Force 21 National Lesbian conference, 1991 32 National LGBT Health Education Center 303–​304 National LGBTQ Task Force 21 National March on Washington for Lesbian and Gay Rights, 1979 119

National Organization for Women (NOW) 41, 66, 118, 119 National Survey of Family Growth 142–​143 National Survey of Sexual Health and Behavior, 2012 279 National Survey on Adolescent Health 169 National Transgender Advocacy Coalition 32 National Transgender Discrimination Survey 42 Native Americans: civil rights 38; two spirit people 8, 12, 26, 117, 237 natural diversity see sex and gender diversity ‘nature’ models of sexual orientation 49–​50 NCSF (National Coalition for Sexual Freedom) 36, 247, 252, 255, 256, 263 NCTE (National Center for Transgender Equality) 202 Nealy, E. 233 Near, Holly 61 negotiation, and kinky people 271 Nelson, Tammy 280 Nestle, John 120 neutrois 237 New Gay Teenager, The (Savin-​Williams) 79, 144–​145 New Jersey sunfish 47 ‘new relationship energy’ (NRE) 281, 287, 297 New York Area Bisexual Network (NYABN) 153 Newcomb, M. E. 79 Nichols, M. 144 Nicolosi, Joseph 14, 74 Noble, Elaine 119 nonbinary people 43, 60–​61, 130, 174–​175, 181, 189, 190, 195, 236–​238, 244–​245, 288, 306, 307; clinical issues 243–​244; generational aspects 237–​238; health and mental health 240–​243; medical treatment of 240–​241, 244, 306; nonbinary vs. intersex 238–​240; slow recognition of 26; statistics 1 nonconsensual voyeurism 247

Index  339

nonjudgmentalism about sex, and kinky people 271–​272 nonmonogamy: in ancient societies 46–​47; gay male couples 95, 98, 107, 110, 279; internalized self-​hatred 4–​5; lesbian couples 134; see also consensual nonmonogamy NOW (National Organization for Women) 41, 66, 118, 119 Now That You Know (Fairchild) 86 Noyes, John Humphrey 37, 278–​279 NRE (‘new relationship energy’) 281, 287, 297 ‘nurture,’ lack of influence on sexual orientation 49, 51 NYABN (New York Area Bisexual Network) 153 Obama, Barack/​Obama administration 13, 32 Obergefell decision, Supreme Court 104 objectivity, and kinky people 271–​272 134, 159, 284, 296 old relationship energy (ORE) 297 Olson, Kristina 227, 232–​233 Oneida community 37, 278–​279 O’Neill, George 279 O’Neill, Nena 279 oocyte cryopreservation 221 oophorectomy 200 Open Marriage (O’Neill and O’Neill) 279 open relationships 282, 293; see also consensual nonmonogamy Opening Up (Taormino) 296 ‘optimal gender of rearing’ 239 orange children 226, 227, 232 orchiectomy 200, 221 ORE (old relationship energy) 297 organizational hypothesis 49–​50 Orthodox Jewish communities 223–​224 pain, and BDSM 251 panromantic 163 pansexuality/​pansexual people 62, 134, 144, 159, 169, 172–​174, 177, 252, 304 paperwork/​record-​keeping issues 150, 164, 303–​304, 305

Papua New Guinea, homosexual initiation rites 12, 47, 48 paraphilia 5, 18, 246–​247, 252 parent-​child relationships: nonbinary people 242, 243; reaction to children’s sexual orientation 73; and sexual orientation 52–​53; therapists’ help to 85–​87; transgender children and adolescents 216, 219, 221–​222, 233–​234; transgender people 181–​182; young LGBTQ+ people 79; see also family relationships Parents and Friends of Lesbians and Gays (PFLAG) 32, 74, 78, 86, 212, 233 Parkhurst, Charlotte (Charlie Parkhurst) 27 partners: of kinky clients 264–​269; of transgender people 204–​205 Parton, Dolly 280 ‘Party and Play’ (PNP) 93, 96 ‘passing women’ 27, 30, 117–​118 patriarchy 96 ‘peak experiences,’ and BDSM 248 pedophilia 247 Pepper, R. 233 Perel, Esther 280 Persian Civilisation 26 Persistent Desire, The (Nestle) 120 PFLAG (Parents and Friends of Lesbians and Gays) 32, 74, 78, 86, 212, 233 phalloplasty 200, 202, 241 planning, and kinky people 272 Platt, L. F. 204 Pleasure and Danger (Vance) 120 296 PNP (‘Party and Play’) 93, 96 political correctness 119, 174 Poly Living 293, 296 Polyamorist Next Door, The (Sheff) 286, 296 296 polyamory/​polyamorous people 22, 35, 36, 37, 42–​43, 60, 277, 281, 282, 283, 284–​285, 292–​293; and asexuals 163; gay male couples 107; lesbians 130, 136; and multisexuality 171; subtypes of 284; see also consensual nonmonogamy polyandry 278

340 Index

polycules 292 polyfidelity 279, 292 polygamy 278 poly-​mono relationships  299 Polytopia 296 Positively Gay (Berzon) 20, 68 ‘post gay’ young LGBTQ+ people 79 post-​traumatic stress disorder (PTSD) 75, 97, 214 poverty, and transgender people 201 pre-​natal hormones  50, 52 PrEP (Pre Exposure Prophylaxis) 96–​97, 99 Presley, Elvis 39 Prince, Virginia 28–​29, 195 pronouns, gender-​neutral 174, 177, 185, 236, 238, 241 psychiatry, role of in oppression 303 ‘psychological androgyny’ 237 Psychopathia Sexualis (Kraft-​Ebbing) 13–​14, 246 ‘psychosexual disorders’ (DSM) 246–​247 PTSD (post-​traumatic stress disorder) 75, 97, 214 pubertal hormonal sex 239 puberty blockers 200, 209, 211, 213, 216–​217, 220–​221, 226, 228, 230; controversies around 231–​232; imprisonment of medical professionals who prescribe to minors 302, 308 public stigma 87 queer 35 Queer Dharma 74 queer revolution 186–​187 radical feminists 120; hostility towards transgender people 178–​179 Rado, Sandor 14 Rainey, Ma 118 ‘Raising my Rainbow’ (Duron) 86 Rankin, S. 185 Rapid Onset Gender Dysphoria (ROGD) 218–​219, 225 Raymond, Janice 31, 179 Read My Lips: Sexual Subversion and the End of Gender (Wilchins) 237 Reagan, Ronald/​Reagan administration 41

Reconciling ministries 74 Rekers, George 224 religion 9, 13, 14–​15, 49, 74 reparative therapy 15, 49, 53, 74; for ‘pre-​ homosexual boys’ 225; prohibition for gender identity issues 178, 182 resiliency, of young LGBTQ+ people 79, 81–​82 Resnick, M. D. 78 Richards, C. 237 Richards, Renée 30, 178, 179 Richter, Dorchen 28 Richters, J. 254 Rivera, Sylvia 26, 31 ROGD (Rapid Onset Gender Dysphoria) 218–​219, 225 Roman homosexuality 12, 13 Rosenthal, L. E. 143 Rothblum, E. D. 162, 164 Roughgarden, Joan 6–​7, 45, 47, 184 Rubin, Gayle 120 Rubyfruit Jungle (Brown) 119 Ryan, Christopher 92, 278 sadism 246, 247; see also BDSM (Bondage and Discipline, Dominance and Submission, Sadism and Masochism) sadistic rape 247 safe words 249, 250 safer sex 95–​96 Sambia, Papua New Guinea, homosexual initiation rites 12, 47, 48 same-​sex attraction/​behavior 304; in animals 46; etiology research 48–​53; history of (see LGBTQ+ history); illegality of in some countries 307; normality of 5, 6–​7, 15, 26; population surveys of sexuality 58; statistics 1; see also gay people; homosexuality/​ homosexual people; lesbians; LGBTQ+ community same-​sex marriage 104, 107, 120, 122 Samoa: transgender males (fa’fafine) 51 Samois 252 San Francisco Human Rights Commission 22 sapiosexuality/​sapiosexual people 43, 159, 173

Index  341

Sappho 117 Satyrs 252 Savage, Dan 107, 162, 272–​273, 283, 291 Savin-​Williams, Ritch 58–​59, 61–​62, 79, 82, 144–​145, 169, 170 Schwartz, P. 103–​104, 106, 129 scrotoplasty 200 Scruff 97, 296 SDN-​POA (sexually dimorphic nucleus of the preoptic area) 49, 50 second-​wave feminism 39, 179 Segobiono, Daniel 92 self-​identification of sexual orientation 57 separatism 119 Sequiera, Lori 294–​295, 299 serosorting 99 Seto, M. C. 60 sex: as a form of healing 273; in gay male culture 94–​95; and lesbian couples 129–​130; as spirituality 273–​274, 282 sex and gender diversity 9, 23, 184–​186, 303; function of 47–​48; normality of 5, 6–​7, 15, 26; proliferation of 159; research on etiology 48–​53 sex and gender-​diverse affirmative psychotherapy 5–​7; see also affirmative therapy Sex at Dawn (Ryan and Jethá) 278 sex magazines 252 sex work 201, 304 Sexing the Body (Fausto-​Sterling)  7, 185 sexless relationships 130–​131, 159, 166, 277–​278, 294–​295; see also asexuality/​ asexual people sex-​role inventory  237 sexual fantasies 59–​60 sexual fluidity 61–​62, 63–​64, 168–​171; bisexual people 62, 168–​169, 170; and heterosexual identity 172; implications for clients 171–​175; lesbians 122, 134, 144 sexual liberation movement 39, 303 sexual orientation 183; BDSM as a 248–​249; and the brain 49–​50, 54; characteristics of 60; client paperwork issues 150; complexity of 57–​63; context-​specific 168, 170; as a continuum 59, 142, 145, 170; etiology

research 48–​53; ‘hard-​wired’ nature of 54; and identity 7–​8; lack of research in women 52; population surveys of sexuality 58; self-​identification 57; and transgender people 202–​203, 204 sexual technique, and kinky people 272–​273 ‘sexual variants’ 26, 27 sexual variety, and kinky people 272 sexuality, and transgender people 202–​203 sexually antagonistic gene hypothesis 51 sexually dimorphic nucleus of the preoptic area (SDN-​POA)  49, 50 ‘shadowplay’ 273 shame 63, 81; helping clients to heal from 73–​75; kinky clients 263–​264 Sheff, Elisabeth 280, 286, 290, 296, 299 Shernoff, Michael 95, 98–​99 ‘Shifting the Paradigm of Intersex treatment’ (Dreger) 240 Shilts, Randy 95 Silva, T. 172 Silverstein, Charles 18 ‘simmering’ 272 single by intention 304 skoliosexual 43, 60, 145, 205, 306 Smith, Bessie 118 Smith, Jaden 181 Smith, Sam 181 Smith, WIll 280 SOC7 (7th Standards of Care), 2011 see WPATH (World Professional Association for Transgender Health) SOC7 (7th Standards of Care), 2011 Socarides, Charles 14, 74 ‘social contagion’ effect and transgender adolescents 218 social transitioning of transgender people 185, 186, 187, 198; transgender adolescents 209–​210, 220; transgender children 226, 228, 229 Society for Human Rights 118 Society for the Second Self, The (Tri-​Ess) 29, 195 Society of Janus 36 ‘sociopathic personality disturbance,’ DSM I classification of homosexuality as 15 sodomy laws 5, 13, 16, 18, 47

342 Index

soft butch lesbians 121 solo nonmonogamists 299 Solomon, Andrew 3, 4, 39 Southern Comfort 32 Spack, Norman 213–​214 Sparta 252 sperm banking and storage 19, 221 spirituality, sex as 273–​274, 282 sponteneity, and kinky people 272 ‘squicked’ feeling 261–​262 SSN (Straight Spouse Network) 112, 113, 157 Stein, Arlene 187 Stein, Gertrude 118 stem lesbians 121 stigmatization 4, 304; asexual people 164; and BDSM (Bondage and Discipline, Dominance and Submission, Sadism and Masochism) 255–​256; of bisexual people 22–​23; of identities 160; see also discrimination; marginalization Stollerm, Robert 224 ‘stone butch’ 66 Stone, Sandy 179 Stonewall rebellion 17, 25–​26, 31, 118 Storms, Michael 161 Straight Spouse Network (SSN) 112, 113, 157 straight spouses 112, 113, 155–​158 Straight: The Surprisingly Short History of Heterosexuality (Blank) 288 Stranger sex survey 291 stress response 80 Stryker, Susan 28, 29 ‘sub space’ 254, 262, 273 submission 247; see also BDSM (Bondage and Discipline, Dominance and Submission, Sadism and Masochism) substance abuse: bisexual people 152–​153; gay men and boys 93, 99–​101; lesbians 124–​125 suicidal ideation: gay men and boys 93; transgender people 183, 213, 216 Sullivan, Lou 29 surgical treatment: ‘bottom’ surgery 199–​200, 205, 218, 221, 241; intersex children 239–​240; ‘top’ surgery 199–​200, 214, 218, 244; transgender

adolescents 218, 221; transgender people 28, 30–​31, 33, 179, 187, 197, 198, 199–​200 Surpassing the Love of Men (Faderman) 118 swinging 279, 282, 283–​284, 291–​292, 296; see also consensual nonmonogamy Sworn Virgins of Albania 12, 48, 237 Szasz, Thomas 9, 15, 303 Tanner Staging 217 tantric sex 274 Taormino, T. 296 technical skill, and kinky people 272–​273 Teena, Brandon 32 Teich, N. M. 233 ‘TERFS’ (Trans Exclusionary Radical Feminists) 31, 179 TES (Eulenspiegel Society) 36, 252, 267, 270 testosterone 199, 221; pre-​natal exposure to 49, 50; testosterone blockers 241; and transgender people 187 Thai ‘ladyboys’ 8 Theron, Charlize 178 ‘they/​them’ gender neutral pronouns 174, 177, 185, 236, 238, 241 third gender 26, 184 third-​wave feminism  120 This Bridge Called My Back 119–​120 Thompson, Emma 280 thymos 4, 38, 303 time management, and consensual nonmonogamy 298 Tinder 122, 134 Tipton, Dorothy Lucille (Billy Lee Tipton) 27 Tom of Finland 94 ‘tomboys’ 215, 225 ‘top’ surgery 199–​200, 214, 218, 244 TPE (Total Power Exchange) relationships 270 trans boys 212, 215; see also transgender adolescents; transgender children; transgender men Trans Exclusionary Radical Feminists (‘TERFS’) 31, 179

Index  343

trans girls 212; see also transgender adolescents; transgender children; transgender women trans men 130, 188, 190; see also transgender adults; transgender men; transgender people trans women 130, 134, 190; in lesbian couples 186; post-​transition gender identity 188; see also transgender adults; transgender people; transgender women transcendentalism movement 278 Transexual Phenomenon, The (Benjamin) 29 transgender: as a term 31, 186 Transgender 101 (Teich) 233 transgender activism 28–​29, 31–​34, 38 transgender adolescents 208–​211; clinical work with 219–​222; co-​morbid conditions 212–​215; hormone treatments 200; imprisonment of medical professionals who prescribe puberty blockers to minors 302, 308; medical intervention 216–​218; mental health issues 213–​214; ROGD (Rapid Onset Gender Dysphoria) 218–​219; ‘social contagion’ effect 218; trans youth explosion 212; and trauma 216; two paths to trans identity 215; see also trans boys; trans girls; transgender children; transgender people transgender adults 193–​198, 205–​206; detransition 203–​204; generational differences 197–​198; institutional bias 201–​202, 203; issues facing 200–​202; medical transition 198–​200; sexuality 202–​203; working partners 204–​205; see also trans men; trans women; transgender men; transgender people; transgender women transgender children 178, 179, 188, 212; banning of medical treatment of 225; changes of mind in 229–​230; hormone treatment 217; imprisonment of medical professionals who prescribe puberty blockers to minors 302, 308; mental health issues 232–​233; treatment

for 227–​228; and trauma 216; ‘watchful waiting’ approach to 231; working with parents of 233–​234; see also gender-​expansive children; trans boys; trans girls; transgender adolescents; transgender people Transgender Children and Youth (Nealy) 233 Transgender Day of Remembrance 202 Transgender Emergence (Lev) 182, 209 transgender men 30, 179–​180; sexuality 202–​203; surgical treatment 200; see also trans men; transgender adults; transgender people transgender people 12, 21, 22, 25–​26, 60–​61, 177–​178; best practices and guidelines for care of 303–​304; civil rights 32; clinical work with 191; etiology research 52–​53; feelings of 182–​184; future trends 189–​190; in the gay activist movement 25–​26; ‘gender markers’ 201; harm caused by psychotherapy to 5; history of 178–​180; hostility of LGBTQ+ community towards 178–​179, 180; internalized self-​hatred 4; Internet as healer 180–​181; legal recognition of 26; medical treatment for 28, 29–​31, 32–​33; mental health issues 183; non-​binary nature of gender 183–​186; parental support 181–​182; ‘passing women’ 27, 30, 117–​118; poverty and employment discrimination 201; principles for working with 188–​189; and the queer revolution 186–​187; statistics 1; therapy path 187–​188; transgender lesbians 124; transgender males (fa’fafine) in Samoa 51; transitioning 177–​178, 185–​186; twentieth-​century developments 27–​31; in US history 26–​ 27; words and terminology 190; see also trans men; trans women; transgender adolescents; transgender adults; transgender children; transgender men; transgender women transgender students, rights of 210 transgender women: brain research 52, 54; hostility of LGBTQ+ community and

344 Index

radical feminists towards 178–​179; and lesbian activism 31; and lesbian couples 131; men who love 205; sexuality 202–​203; surgical treatment 200; see also trans women; transgender adults; transgender people Transitions of the Heart (Pepper) 233 Transsexual Empire, The; the Making of the She-​Male (Raymond) 31, 179 transsexualism/​transsexual people 28, 29, 178, 186, 190, 195–​196; transsexual women 30, 31–​32 Transvestia 29, 195 ‘transvestic disorder,’ DSM 33, 196 transvestism/​transvestites 28, 29, 186 trauma 70, 75, 92, 283; gay men and boys 97, 99–​101; helping clients to heal from 73–​75; transgender children and adolescents 216 Tri-​Ess (The Society for the Second Self) 29, 195 Trump, Donald/​Trump administration 13, 32, 70 Truvada 97 twinks 186 two spirit people (Native Americans) 8, 12, 26, 117, 237 Tyler, Robin 70 UCLA 224 U-​Hauling 123, 129 Ulrich, Karl 8, 13, 14, 30 Unbound (Stein) 187 undifferentiated fetal sex 239 ‘unicorns’ (single bisexual women) 292 vaginectomy 200 vaginoplasty 200; ‘zero-​depth’  241 Van Assen, M. A. 254 Vance, C. S. 120 Vaux, F. 296 Velazquez, Loreta Janeta (Harry Buford) 27 ‘vertical identities’ 4, 39, 303 vicarious stigma 87 Village of PolyParadise, The 296 Village People 94 Vines, M. 74 violence: domestic violence 107; intimate partner violence, gay men and boys

93, 94; against transgender people 202; see also abuse voyerism, nonconsensual 247 Vranglova, Z. 58–​59, 62, 144–​145 vulvoplasty 200; ‘zero-​depth’  203 WAP (Women Against Pornography) 120 ‘watchful waiting’ approach to transgender children 231 Weinberg, M. S. 52, 71 white non-​Hispanic lesbians 122 Whittle, Stephen 33 Wilchins, Riki 237 Windsor, Edie 120 Winters, Kelly 226 Wismeijer, A. A. 254 women: civil rights activism 38; lack of research into sexual orientation development 52; sexual fluidity 61 Women Against Pornography (WAP) 120 ‘woodworking’ 30, 179 work, coming out at 84 work stress 106 World Health Organization: International Classification of Diseases (ICD) 33 WPATH (World Professional Association for Transgender Health) SOC7 (7th Standards of Care), 2011 33, 178, 188, 196–​197, 198, 199, 209, 214, 217–​218, 219–​220, 225, 244 Wright, Susan 252–​253 young LGBTQ+ people 78–​79, 133–​134; bullying of 79, 81, 92; family rejection of 91–​92; mental health issues 80–​81; peer harassment of 92; ‘post gay’ 79; resiliency of 79, 81–​82; see also growing up gay; LGBTQ+ community younger people: and consensual nonmonogamy 279–​280, 291; population surveys of sexuality 58; see also Gen Z; Millennials ‘ze’ pronouns 185 Zell Ravenheart, Morning Glory 37 ‘zero-​depth’ vaginoplasty/​vulvoplasty 203, 241 ‘zipless fuck’ 279 Zucker, Kenneth 225