So, if you’re talking about puberty blockers and gender-affirming hormone treatment, then that is something that even as a psychotherapist, you would be working in conjunction with an endocrinologist or pediatrician, likely a social worker. There are various members of the team.
The main way the gender affirmative model works with children and teens is the way that the therapists themselves are holding the space for a child to be able to explore who they are and be who they are, as well as increase what we call gender literacy. In the most basic sense, gender literacy is increasing an understanding of the sociocultural norms of gender roles and stereotypes, and what potential consequences there are if you step outside of those boxes.
We want children to be able to be themselves and explore who they are while also—in age-appropriate ways—making sure that they understand the world that they live in and that not everyone necessarily understands gender diversity.
But when a child enters puberty, and there is the question or desire for puberty blockers or later for gender-affirming hormone treatment, the gender centers require an assessment from a mental health provider, which they take into consideration. It’s one piece of the whole picture of whether this is the right thing for the child. The psychotherapist’s job in those instances is to share your thoughts about whether, in your professional opinion, that is the best next step for this child and family.
So, we’re looking at all aspects of their history. We’re looking at how parents feel about it because it’s important that if this goes forward, we have the parents’ full support.
There are various screeners and batteries, and things like that that some clinicians use to help them get a child’s gender into focus. I personally am not using those so much because I feel like I’m well-trained and I have a lot of experience, and that, through my conversations with children and their families, I get a very good picture and don't need those batteries.
I will say, though, that I am an advocate for more research in that area. I think there are some people that are working on a more standardized evaluation process, of course. But I have not found that useful in my own work.
I think now we’re seeing more and more kids come out later, in which case, when we’re looking at their history, we’re not necessarily looking for stereotypes, such as they played with stereotypical toys of the other gender, or they wore clothes of the other gender—although we do gather that information, but it’s not a required piece of their history.
If we’re going to introduce gender-affirming medical care, we’re looking for some sort of sense that this has been a consistent and persistent identity, especially once we’re talking about gender-affirming hormones. Because puberty blockers have not been shown to have long term adverse effects once they’re stopped, that could happen potentially more quickly if a child is in a lot of distress and puberty is right then and there. But that doesn’t mean then that that child would necessarily go on to gender-affirming hormones.
We are looking for some sort of consistency in their identities. We’re developing this pathway in conjunction with medical providers, which requires that the child is, at the same time, learning about the risks and benefits in a developmentally appropriate way. In some ways this is asking them to take on something we don’t typically ask of cisgender kids in terms of their medical care, but it does mean that a lot of times these kids know a lot.
I think another myth, which is part of our bigger culture, and we all hold it and have to work on it, is that being transgender or gender diverse in some way is less ideal than being cisgender. And that’s a big shift in thinking. That’s something that I am monitoring within myself. Oh, and then there’s the myths of the gender affirmative model, that it’s just a fad or a kid might say they’re transgender because they're trying to fit in with peers, or that being a gender-affirming therapist means that if a kid says they’re transgender, the therapist is going to immediately write a letter and say yes, puberty blockers. Yes, hormones. In reality, these are decisions that are very carefully sorted through and that take time.
You don’t have to be gender dysphoric to experience gender stress. You could feel very comfortable with your gender identity and your body and all of that, but on a regular basis, encounter situations based on your gender that cause stress. For example, if you’re a trans girl, and have to choose between men’s or women’s bathroom, the very process of going to the bathroom can become stressful. That would be gender stress even if you’re okay with who you are, and your body, and everything.
These were little kids that usually ranged in age from 3 to 6. But sometimes they were older, but almost always they were quite young. Early on in this work, I didn’t really ever have a parent bring a child who was designated female at birth when they were little. The way I understood this was that the girl box, so to speak, is a lot bigger than the boy box. It was, and maybe still is okay for little girls to cut their hair short and play with the boys and be good at sports. But it was not seen as okay for a little boy to wear a dress.
Over time, this has shifted. And as I touched on a little bit earlier, while we still see those young kids, they’re not coming to our offices as frequently. I think because parents have more awareness out there and perhaps parents aren’t as worried when the kids are little and they’re going to kind of see what happens and support their kid in the meantime. Parents might only bring their kids into therapy when that kid is nearing puberty and they’re starting to sense stress in the child about a changing body.
The other difference that we’re seeing is that kids come out later. I have many families that bring a teenager to me who has come out as transgender, post puberty. We never used to see that, and now we’re seeing it more and more. I see that pretty equally among “designated male” at birth or “designated female” at birth. But when we start to talk about who is showing up for medical treatment, there is a greater number of designated female teens showing up for hormones than there are designated male teens.
So, in that way, it’s not that big of a leap to think about it as you’re starting with the family. And somebody doesn’t have to be out there being super politically active if that’s not what they want to do. But the way that they are holding gender in mind and interacting in the community, in their own communities, for example, and raising awareness, I think is huge.
If the family doesn't want to bring in an educational specialist, I know about creating a gender and educational gender plan. I can offer information to the family if they feel like they can address the school themselves.
That’s basically about having a discussion with administrators about whether there is a safe person for this child to go to if something were to happen. What bathroom is this child going to use? Do they have access to one that feels safe and comfortable to them? Whether teachers are informed or not, whether the kid is out to peers or not, those sorts of things are talked about amongst the adults to create a plan to support the child at school, for example.
There are many, many young people who identify as gender queer, non-binary, or even as a trans girl or a trans boy who have no desire for medical intervention. They love their bodies the way that they are. And so, there’s that piece, and then in terms of the journey piece like we talked about in the book, is that gender journeys are something we’re all on throughout our life, right!?
Even as a cisgender woman—and being a woman has been an important identity of mine—but how I experienced being a woman, and thought about being a woman, and expressed my femininity or lack thereof at 20 years old is very different than how I do it now in my 40s. So, there can be shifts in how we express gender, experience it, and then there can also be shifts in identities.
That happens over time, and so we don’t think of there ever necessarily being an end point in terms of a gender journey, although there may of course be an end point in therapy when kids are doing well, and they’re not needing that level of support.
However, I think parents struggle more than siblings do, partly because we’re finding that young people just tend to have more flexible minds around gender than us adults. One particularly difficult thing is that every parent has dreams for their children and ideas about who their child is, who their child is going to become. When they realize that there’s an aspect of their child where their gender is something different than they’ve imagined, there has to be a reworking of those dreams and expectations. Oftentimes, there has to be a lot of grieving and mourning for what they thought that they would experience with their child, or what their child would experience in life.
There’s often anxiety for parents about how the world is going to accept their child. They may ask, “Is my child going to be hurt in this world because of who they are?” Then there’s the stress of extended family. I’ve worked with families where things are going really well within the nuclear family, but the thought of telling grandparents feels really dicey out of fear that the grandparents aren’t going to understand.
Or I’ve worked with families who are religious, and their particular church or synagogue is not supportive of gender diversity. This is a community that the family loves and relies on, and they’re having to face the harsh reality that they may need to move out of or disconnect from this community in order to support their children. Or they wonder if there is a way for them to bring education to those communities and to help them to grow and expand to accept their children for who they are. So, it's a lot of pieces that parents are holding.
I would say that we see less of this within the younger members of the LGBT community, like adolescents and young adults. I think there’s still some cases
Integrating Generative AI and Digital Play Therapy into Clinical Practice
The Chicken Lady
When my now almost 30-year-old son and his brother were in elementary school, I took on a new role—the Chicken Lady. I didn’t intend to achieve that title, but it is one I hope I always remember because it symbolizes a pivotal moment in my time as a mother and a therapist. May we all have our own Chicken Lady experiences.
The Chicken Lady was born soon after I realized my children were speaking a language I didn’t understand in the backseat of the car on the way home from school. They were having a very in-depth conversation about a game they had recently started to play—RuneScape, which is classified as an MMORPG (Massively Multiplayer Online Role-Playing Game). It is essentially an expansive fantasy world where players can engage in interactions, quests, combat, and skill-building activities.
RuneScape emphasizes problem-solving and social interaction within a richly detailed environment. Typically, we would all chat together on the way home from school, discussing things that had happened during the day, what we would be doing over the weekend, and other such family-type things. When I began noticing that the conversations had shifted and I no longer understood the content, I felt a bit of sadness. To be clear, I am quite aware that kids will have their own interests and conversations. Individuation is an important developmental process.
In that moment, I thought about whether or not I would just leave this to them as their brotherly bond. I asked them questions about the game and one of them said, “You should just play it, mom.” And so, I did. This was the birth of my exploration into discovering the therapeutic value within all things digital. I witnessed the connection, the interaction, the executive function engagement (and more) within the play for my children, and I knew there had to be value within my work as a therapist as well.
Artificial Intelligence: A Brief Overview
Artificial intelligence (AI) is a very broad field of computer science focused on creating systems capable of performing tasks that typically require human intelligence, such as learning, reasoning, organizing, problem-solving, and understanding language. The term is attributed to John McCarthy and the Dartmouth Summer Research Project in 1956. As an aside, many people disagree with the term “artificial intelligence,” as they feel it does not accurately describe what this tool and process is. It is unfortunate because the connotation of intelligence that can mimic human processes often diverts conversations in ways that can be distracting. Science fiction writer Ted Chiang offers Applied Statistics as a very viable alternative. I am inclined to agree with him and his proposal of the term.Generative AI
Generative AI refers to a type of artificial intelligence designed to create new content such as text, images, stories, and more—to generate content through programs such as ChatGPT. Unlike traditional AI systems that follow predetermined rules, generative AI uses complex algorithms, often based on neural networks, to learn patterns from large datasets. This allows it to generate original and unique outputs that can mimic creativity and problem-solving skills.
It can be used for numerous day-to-day administrative (letters, session notes, treatment plans) and training tasks (learning objectives, quiz questions, slide decks, presentations) to create personalized therapeutic content (images, storytelling) and a variety of interventions and exercises. By integrating generative AI into therapeutic practices, therapists can offer more tailored and personalized experiences for their clients. In this regard, I offer the following table.
| Aspect | Description | Therapeutic Application |
| AI Learning Process | AI learns from large datasets including therapy concepts, psychology texts, articles, and more | Reading and collating large volumes of data |
| Text Generation | AI creates written content for therapeutic use | Writing personalized stories about overcoming anxiety |
| Image Creation | AI produces images based on descriptions | Visualizing a client’s experience |
| Language Understanding | AI analyzes and interprets context in communication | Grasping underlying emotions in client responses |
| Customization for Therapy | Adapting AI for specific mental health applications | Training on therapy techniques, adjusting vocabulary |
| Prompt Creation | Therapists and clients learn to craft effective questions for AI | Components and iterations inform the client’s conceptualizations |
| Continuous Improvement | AI refines outputs based on feedback over time | Learning over time provides improved responses |
| Multimodal Integration | Advanced AI systems work with text, images, and audio | Combining written responses with generated images |
| Ethical Considerations | Prioritizing client privacy and data protection | Ensuring the use incorporates confidentiality, secure data storage, and client protections |
Administrative Uses
AI provides a way to complete administrative tasks quickly in therapeutic practices, streamlining processes such as letter writing, case notes, treatment planning, and business analyses. For instance, AI-powered tools can draft and format professional letters, saving therapists valuable time while ensuring consistency and accuracy, or even help finding a synonym as I have done in this paper from time to time using ChatGPT. APA has even addressed how to cite the use of ChatGPT.
AI can transcribe session case notes, summarize key points, and organize information, allowing therapists to focus more on their clients and less on paperwork. This can also assist in treatment planning, creating templates and formatting documents as desired. Additionally, AI can assist in creating personalized, evidence-based, formatted plans by analyzing sanitized client aspects and suggesting potential interventions.
For therapists who provide trainings, AI can assist in the creation of required proposal content. If the trainer inputs a description of the training, the slide deck, or any other details, AI can generate elements such as training descriptions of specific lengths, trainer bios, learning objectives, quiz questions, and more. By providing the desired format (APA, multiple choice, true/false), prompts can guide AI to provide the information in ways that will minimize necessary alterations. All material should be evaluated and edited for accuracy. This is an area where the therapist’s expertise is critical to alter, amend, and/or add information. AI is here to format and collate information for the user, not to replace the therapist’s experience, expertise, or knowledge.
The Many Uses of AI in Therapy
Generative AI is transforming therapeutic practices by enabling the creation of personalized and vivid representations of a client’s experiences, narratives, hopes, dreams, fears, and visions. Generative AI can turn descriptive narratives (prompts) into detailed creations, providing a tangible representation of a client’s inner world. These aids are incredibly beneficial in therapy, helping clients articulate and explore complex emotions and thoughts that might be difficult to express verbally. By depicting their personalized experiences, clients can gain new insights and perspectives, facilitating deeper self-understanding and emotional processing.Images
Visual representations can both represent and communicate important components of a client’s life. AI image generation allows for the creation of personalized images based on descriptive prompts provided by the client or therapist. These images can depict complex emotions, significant life events, or abstract concepts that might be difficult to express verbally. For instance, a client might struggle to articulate feelings of isolation, but an AI-generated image can visually convey their personalized essence of this experience.
By providing a tangible representation of a client’s inner world, these images serve as powerful therapeutic tools. They facilitate deeper emotional exploration and understanding, enabling clients to gain new insights and perspectives. This visual aid not only enhances the therapeutic process but also empowers clients by giving them a new medium to express and process their emotions.
Stories
AI can create powerful therapeutic stories; it can craft personalized narratives based on a client’s experiences, dreams, or visions, creating rich and immersive stories that resonate deeply. These AI-generated stories can serve as powerful therapeutic tools, allowing clients to see their personalized situations from different angles, have a more objective view of representation, identify patterns in their behavior, and/or explore alternative outcomes. Narrating their experiences through AI-generated stories helps clients externalize and reframe their thoughts, leading to potentially greater clarity and emotional relief.
Interventions
Generative AI can be invaluable in discovering interventions tailored to individual clients. By analyzing a client’s unique experiences and responses, AI can suggest personalized therapeutic strategies and interventions. These AI-driven recommendations might include specific therapeutic exercises, coping mechanisms, or behavioral techniques that align with the client’s needs and preferences and the therapist’s theoretical foundation. This tailored approach ensures interventions are highly relevant, enhancing the overall therapeutic experience and outcome. Integrating generative AI into therapy not only personalizes the treatment process but also empowers clients by providing them with tools and insights uniquely suited to their personal journey.
Prompt Creation with AI
Creating effective prompts is arguably the most crucial aspect of integrating generative AI into therapeutic practices, particularly when exploring a client’s experiences, emotions, self-concept, identification, and representation. In the context of generative AI, a prompt is a carefully crafted input or question that guides the AI to produce relevant and meaningful output/responses. These prompts serve as catalysts for AI to generate content that mirrors the client’s inner world, whether through prompt creation, image generation, or narratives.A prompt can capture the essence of a client’s priorities, experiences, perceptions, thoughts, and feelings. Depending on the client and the therapeutic needs, the client or the therapist could create the initial prompt with iterations and changes guided by the client. Prompts act as powerful projective tools, revealing underlying therapeutic material. As the process unfolds, subsequent iterations allow for deeper understanding for the client and therapist. By refining the initial prompt to more accurately represent their internal landscape, clients engage in a valuable process of self-discovery and expression.
The iterative nature of prompt creation significantly enhances its therapeutic value. Each refinement can unveil new facets of a client’s self-representation, offering a fluid, dynamic, and evolving view of their inner world. As clients fine-tune their prompts, they embark on a journey of self-reflection, identifying and articulating aspects of their experiences that may have previously been unconscious or difficult to express. This process not only helps clients gain clarity but also allows therapists to track changes in the client’s self-perception and emotional state over time. By engaging with the AI-generated output—accepting, modifying, or rejecting it—clients further refine their self-understanding, benefiting both themselves and the therapeutic process.
The therapist or client, or a combination of both, can lead the prompt generation process. For example, to help a client visualize a calming environment, a therapist may ask the client to “describe a place that feels safe.” This can include colors, items, people, animals, weather, and many other aspects. A client-driven image may include a request for something which depicts “a sad little boy with brown hair, brown skin, and brown eyes who is all alone in a storm.” Aspects which do not fit the criteria can then be changed through iterations, thereby revealing the client’s experience or desired depiction.
Prompt creation can serve as a projective exercise along with the desired creation. Each version of the creation, whether initial or refined, holds valuable insights. The evolving nature of prompts encourages ongoing dialogue between client and therapist, fostering a collaborative and exploratory therapeutic environment. When used skillfully and ethically, it can significantly enhance the therapeutic process, providing both clients and therapists with tools to advance the treatment plan forward.
The Ethics of Using AI in Therapy
The integration of generative AI in therapy presents significant ethical considerations, particularly regarding the protection of personal health information (PHI) and maintaining client confidentiality. Therapists must ensure that any data input into AI systems omits identifiable information as a safeguard of a clients’ privacy. This involves adhering to strict guidelines for data anonymization and being vigilant about the types of information shared with AI tools. Ensuring that all generated content complies with privacy regulations, such as HIPAA in the United States or GDPR in the United Kingdom, is essential to maintaining trust and ethical standards in therapeutic practice.As mentioned earlier, of key importance is the therapist’s expertise, experience, and training. While AI can provide valuable insights and tools, the therapist must have the final say in what is included and presented to the AI tool, and the decision regarding what type of output is generated within the therapeutic interaction. Therapists need to explore programs in advance and critically evaluate AI-generating programs, ensuring they align with therapeutic goals. This requires an understanding of both the technology and the therapeutic context, emphasizing the importance of ongoing education and supervision regarding the use of AI applications within therapy.
Case Example
Emily is a 16-year-old transgender girl who presented for play therapy treatment during the transitional process of altering her gender identification and representation. She utilized generative AI to explore and articulate her experiences through image and story generation. Emily was assigned male at birth but discovered her identification as female. Among other approaches and interventions, her therapeutic process was enriched by the use of generative AI. She was able to visualize and narrate her journey of self-discovery, family acceptance, and social representation.Emily began her therapeutic gen AI journey by creating representative therapeutic images. She crafted complex prompts and many iterations that helped her create images which depicted her true identity as a female. Despite being born with male anatomy, these images allowed Emily to see herself in a way that felt authentic and congruent with her internal sense of self. The visual representations were a powerful tool in helping her recognize and affirm her identity, providing a sense of validation and clarity.
(Created with Photoleap, numerous prompt iterations -representations of Emily’s Work)
Therapeutic Outcomes
Through the use of image and story generation, Emily achieved several therapeutic outcomes:
1. Self-Representation: She was able to see a visual representation of herself that was congruent and customized to her experience.
2. Narrative Creation: Emily created a narrative that represented her journey, helping her process and make sense of her experiences.
3. Sharing with Others: She produced content that could be shared with others, both known and unknown, fostering understanding and support.
4. Prompt Iteration: Emily learned to determine the important components of her experience and represent them accurately through prompt creation and iterations.
A Beginner’s Guide to Generative Artificial Intelligence
Generative AI is a type of artificial intelligence that creates new content, like text and images, based on patterns it has learned from data. Unlike traditional AI, which follows set rules, generative AI uses complex methods to generate original outputs.Key Concepts of Generative AI:
1. Neural Networks:
- Think of neural networks as layers of connected “nodes” that process data, similar to how our brain works.
- They help the AI learn patterns in data, enabling it to create new content.
2. Training Process:
- AI learns from large amounts of data, such as texts and images.
- AI goes through the data multiple times, adjusting its internal settings to improve accuracy.
3. Generative AI in Action:
- Text Generation: AI models like GPT can write coherent text based on a given prompt. They are used in chatbots and content creation.
- Image Generation: AI tools can create images from descriptions, helping visualize concepts.
4. Applications in Therapy:
- AI can create personalized narrative content, like personalized storytelling.
- AI-generated images can help clients visualize their emotions and experiences.
Important Considerations:
5. Data Quality: The AI’s performance depends on the quality of the data it learns from.
6. Privacy: It’s crucial to keep client information private and secure.
7. Understanding Limitations: While powerful, these AI models have limitations and can sometimes produce biased and incorrect results.
Concluding Thoughts
Integrating generative AI into Digital Play Therapy™ marks a significant evolution in the field of mental health care. Through blending advanced technology with psychotherapeutic expertise, therapists can enhance their practice in multiple ways—from creating personalized therapeutic content to streamlining administrative tasks and discovering tailored interventions that resonate with each client’s unique experiences.
Just as I embraced the world of Rune Scape to connect with my children, therapists today can embrace digital tools, including generative AI, to form deeper connections with their clients. This technology offers unparalleled opportunities for creating vivid visual representations, crafting personalized narratives, and developing customized therapeutic strategies that cater to individual needs.
However, the integration of AI into therapy must be approached with careful consideration of ethical responsibilities. Ensuring client confidentiality, maintaining rigorous training standards, and critically evaluating AI-generative programs are essential practices that uphold the integrity of therapeutic work. Therapists must balance innovation with ethical responsibility to protect clients' privacy.
Thoughtful and ethical use of AI can allow therapists to enhance their practices by offering clients more options for engaging, insightful, and effective therapeutic experiences. The future of therapy is bright with the possibilities that generative AI brings. As we continue to learn and adapt, we can utilize these technologies to transform the therapeutic process in profoundly positive ways.
Rick Miller on the Clinical Challenges of Working with Gay Sons, Mothers, and Families
Gay Sons and Their Mothers
Lawrence Rubin (LR): You may be known to our readers as the founder of Gay Sons and Mothers. But they may not be familiar with how extensively you’ve been trained and how long you've been practicing as a psychotherapist with a personal interest in working with gay men and their mothers.
Rick Miller (RM): I'm a gay man who grew up really appreciating the bond and love of my mother. And, in hindsight, as an adult, what it meant for me was that I got to be myself. She didn't necessarily know that I was gay, or maybe she did, but she never forced me to do anything differently than what I did.
And growing up in a world in the 1960s where it was prescribed, this is what boys do, having a mom who let me be me — and we did a lot of things together — was pretty miraculous. I hear so many stories about people growing up whose parents abused them or forced them to do things differently.
I wrote a book several years ago for clinicians about doing hypnosis with gay men. I thought it would be relevant to do the research or to seek out research about gay men and their mothers. I looked at the literature about gay men and their mothers to include in the book. You'd think this a cliché topic and that there would be way too much information to use. I couldn't find anything! I thought, I’ll write an article about this, and it ended up turning into video interviews. And from there, I started a nonprofit called Gay Sons and Mothers.
We are educating the public about the special bond between mothers and their gay sons and how she contributes to his sense of well-being in the world. It's a multicultural story that looks at strength, at disappointment, and is a very emotional topic.
LR: So, even before you and your mother had a conversation about being gay and you knew, you had no particular concern over sharing it with your mom. You didn’t worry how she would take it, how you'd be perceived, how you'd be treated. You were just free from the start to be you.
RM: Well, I was free to be me, but I didn't come out to them — meaning my parents, my mother and my father — until I was 21. So, it was interesting that I had the freedom to be me, but I didn't feel 100 percent free to be me because I waited longer to come out than I probably needed to in hindsight. Today, many kids are coming out at a much younger age to their parents. Of course, the world is very different.
LR: If you intuitively felt accepted by your mom and weren’t censored or limited in any way from being you — you haven't talked about your dad — why do you think it took you as long as it did to become public about it?
RM: Well, so, it was the early 80s. So, AIDS was hitting the press big time, and I suppose on one level, I was protecting her or them from thinking that something would happen to me, which, knock on wood, did not happen. I was afraid that I'd be rejected, and, not to sound callous, they were paying for my graduate school education, and I just made a mental note in my mind I was going to wait until I finished school to come out, which is so stupid.
Knowing my parents, of course, they wouldn't have done anything differently. It took them a while to come around, a month or so, which I thought was horrible at the time. But I look back and I think that my parents had to go through their own grieving when I came out to them. Of course, they knew I was gay long before I came out, but hearing it was definitive. And it took them a short time to acclimate and appreciate it. I was incensed at the time. And, often, I say to children and to parents, it's okay to grieve.
LR: Incensed about?
RM: They were not 100 percent supportive the second I came out to them. And the first thing my father did when I came out was to become a little weepy saying, “the world is unfair, and I'm worried about what that will mean for you.” I took it as supportive, for sure. And then he kind of changed the tune for a bit, and that is when things turned ugly, and again that lasted a few weeks and then everything turned around.
LR: Smooth sailing with your parents and especially your mom ever since.
RM: Yep. And I had a partner that I was moving in with at the time. So, what I did, which I shouldn't have done, was when I came out to them, I told them that I was moving in with the person they knew as my friend all at once, so that threw them a little bit.
LR: Overload! Going back to the second part of the earlier question about your foundation; how do you think clinicians can benefit from awareness of it?
RM: There's so much inherent in the videos that we share through Gay Sons and Mothers. It's not only about the relationship between a mother and a son, but that part in and of itself is so affirming. Clinicians can watch stories of sons and their mothers and appreciate what it is being gay. And it's not only mother in these interviews. Families are talked about. Extended families are talked about. Culture and religion are addressed in these videos.
So, there's a lot there, and, when mothers are struggling with their kids, I send them videos from Gay Sons and Mothers. On our website, there's a link to our Instagram page. We have a YouTube page. Sons watch. Most people — therapists included — watch these videos and have a deep emotional resonance around the issue of being included, being loved, being supported, being rejected. It's hard not to feel something when you're watching videos pertaining to these themes.
LR: A connection. How would you respond to a therapist or to a non-therapist who’s visited your site and says, “Yeah, well, what about gay sons and their fathers?”
RM: There's way more information in the literature about gay sons and their fathers than there is about gay sons and their mothers. And if there hadn't been any with fathers, I would have pursued that, as well. I grew up with a great relationship with my mother. I had the fame of saying to my siblings, “Mommy likes me best.” It carried me through. So, it seems completely perfect that that would be the focus of my work.
Historically, mothers in the 1970s — or even earlier in the psychiatric and the medical field — mothers were blamed for making their sons gay. And, so, with the lack of literature out there, what's missing is that mothers have the power to raise sons who are mentally healthy, just from being a good enough mother. And, so, that premise is so important to me that I've focused exclusively on mothers and sons.
The issue of fathers and extended family is embedded in the work anyway. So, this project, Gay Sons and Mothers, is inclusive of the entire family. And we're also expanding beyond just gay sons and mothers. We're talking about trans children and all sorts of things.
Intersecting Identities
LR: How has your advocacy and clinical work been informed by your own personal evolution?
RM: Oh, gosh, that's such a big question, but I think I can get there. I came out in 1983 — I was already a clinical social worker. In the 1980s, AIDS was emerging, and gay men were dying in big cities, and people were afraid. Homophobia was on the rise because people were afraid of catching AIDS. I was working in the AIDS field, doing volunteer work at this time, and I started working with the gay community from the start.
Boston, where I lived, was a progressive place. So, I was known in Boston as being an out gay male therapist. I mean, there was no web at that time, but anyone who knew me would know that I was gay. But I was also practicing in a very conservative place, Boston, Massachusetts, very hierarchical, very psychodynamic. So, in the professional world that wasn't the world of AIDS, I worked in a hospital. I kept a very low profile, and I felt like I didn't fit in the hierarchy of psychiatrists, psychologists, social workers.
I'm a social worker, and looking back at my evolution and my history, I wish I had put myself out there more because the contributions that I'm now making to the field in the last ten years as a writer, as a teacher, as someone who's done Gay Sons and Mothers, if I had the confidence to do some of this earlier, I would have done more research focusing on gay men, on gay men and their mothers, gay families. And I think I could have made a bigger contribution to the field.
What happened for me is I started my private practice in the mid 80s, and I switched to full-time private practice. So, I left the hospital. I left the agency where I was doing AIDS work, and basically, I hid in my office with the door closed for decades. And I was very successful in private practice, in part because of my clinical skills, in part because of my personality, and I got to hide.
Once I wrote my first book and I started teaching about working with gay men, I could no longer hide. And, at the time, I was probably 52 years old — 10 years ago. And I'm really glad it happened, but it forced me beyond a comfort level that was really important and good for me, and I wish I did that sooner.
LR: So, you came out of the closet before you came out of the office. I can see that your personal story could be used as an exemplar, not only for gay therapists, but for gay men, whether still not out or out. I would imagine that you don't impose your story on others. But by living it and being genuine, as you've always struck me, you are an unintended role model.
RM: Well, thank you for saying that, and it served me very well in my practice. I grew up in an upper-middle-class family with well-being and mental health and good physical health. And, to me, that's how everyone lived in the world, and that is so not the case. And so, as a gay man who had a sense of self, who worked with gay men, I served as a role model to other gay men, to all my clients really but specifically to other gay men who didn't have the good fortune that I did or didn't have the personality that I did.
So, my being outgoing was a very good clinical skill, and, fortunately, in my early 20s, I was in therapy with a therapist who was gay, who had a very good sense of himself, who had a great sense of humor, and who allowed me in the process of therapy to love myself. If I had chosen one of those uptight, analytical therapists in Boston instead, I don't know where I would be right now.
When I was looking for a therapist, I was given the name of eight different people. Back in 1983, I was calling their answering machines. On some, I was hanging up because I was frightened by them. Others shamed me through their tone, and thank God, I didn't work with them.
Clinical Challenges of Working with Gay Men (and their Mothers)
LR: What are some of the clinical challenges you've found in working with gay sons and their mothers?
RM: Long before I ever knew I'd be working with gay men and their mothers, I had a gay male client who was really struggling with confidence. He grew up in the projects outside of Boston, and his father left the family, and deprivation was a big part of his upbringing. So, one day, for whatever reason, I had his mother join him in a session and it was like the heavens opened up.
I understood him so much more, and the bond and the strength of their relationship was amazing. It helped so much in the clinical work. He was a catalyst that led to this project, Gay Sons and Mothers. Every now and then, I'd have another mother and son together, but it wasn't why they were in therapy. Once I started working on this project, various people consulted with me, families for help with their families. For some, in the field of psychotherapy, for others, through the nonprofit where, for free, I just consult with people and help them along.
What's been interesting is one mother and son that I'm working with right now in therapy are enmeshed with each other, and they're seeing me every two weeks. On certain days, it feels like couples therapy and I really have to work with them to detangle and let go of their expectations with each other. And, so, this is a divorced mom with an only child who's gay, and they expect each other to meet needs that goes well beyond what they should be for a mother and a son.
This isn't the case in all circumstances, but I think it's a great example of how it can be a bit of a burden on both ends to have this close bond that goes kind of way too far on both ends.
LR: So, enmeshment is one of the challenges. I imagine acceptance is another.
RM: So many gay men are way too careful, and they're not coming out to their families as soon as they might, or they give absolutely no details about their private lives to their families who really want more from them. So, that is another challenge, that in being careful, even once they come out, being careful continues to be their MO, even when they don't need to be, and people want more from them. They want to hear more details about their day-to-day lives or what they struggle with, or are they in a relationship with someone?
LR: And I wonder if these particular men are so cautious and close to the chest with their families, if they're even more so outside of the home.
RM: Correct. I'm working with a bunch of men in their 50s, let's say in their 60s, who came out in an era where it wasn't okay to be gay. And even though it's fine now and they have jobs where they are out, they, without even realizing it, are kind of slipping into modes of privacy and protecting themselves because it's a habit that's been with them through their life.
LR: I was going to ask you a little bit later about working with elderly gay men. But this seems like a good point to interject the question of, “what are some of the clinical challenges in working with elderly gay men whose mothers, I imagine, have long passed?”
RM: The most significant challenge is that they grew up in an era where they couldn't be out, where it wasn't safe, and many older men were kind of forced indirectly or even directly to live conventional lives and got married and had children without even questioning the freedom of living life as a gay man.
I had a great-uncle who was gay, and he never came out to my family. When I came out to my parents, they said, “Well, Paul has lived a good life. So, we know that you'll live a good life, too.” But this great-uncle, my grandmother's brother, was in his 80s when I came out. And he said to me, “I really appreciate that you have freedom that I didn't have, and I hope that you will keep my secret from your family because I just don't feel comfortable being out there.”
LR: Well, I wonder if that fear of abandonment, being cast out by remaining family is that much greater to an elderly man?
RM: He had an incredible social network. He lived in Washington and was cryptographer for the CIA because keeping secrets was something that they did well. So, he had the love of a community of people, and my mother, his niece, and us, meaning my mother's children who were generations below him. And he was still worried about our knowing. It was just a pattern that was ingrained for the time with which he was raised. It's that simple.
LR: Can you imagine taking homosexuality, or any significant part of your identity, to the grave?
RM: When he died, my mother and I went to Washington to clean out his house — he saved everything. There was a pile of letters that his gay friends wrote to him in the 1950s and the 1960s about falling in love with men that they met in cruising areas in parks, and how they couldn't tell their spouses and how tortured they were.
We were cleaning out his house with three of his close friends. My mother came to me, without saying anything, handed me the pile of letters, and I read them. And I thought poor Uncle Paul would die if I kept these letters, so I shredded them and threw them out. And it is my biggest regret because in these letters was the reality of gay history lived by all these men.
But, in my desire to be loyal to my great-uncle, I threw them out. And this was maybe three or four years after I had come out. I was still living in a careful way and more worried about loyalties. If I had these letters now, what they would mean? Oh my God.
LR: What clinical challenges have you experienced working with gay sons of mothers from other cultures, the Caribbean culture, the Asian, the Southeast Asian, or even African, where homosexuality is shunned and punished, sometimes even fatally?
RM: In these cultures, homophobia is rampant and masculinity and norms around masculinity are such that fathers are not accepting of their gay kids. Religious norms are such that being gay is a sin and these are beliefs that communities buy into without questioning. So, fathers are often emotionally and physically abusive to their sons. Mothers are forced to choose between their husband or their child.
Some mothers choose their husband over their child. I had a guy that I interviewed who was Latino, and his mother said to him, “First comes God, then comes your father, and then comes you.” So, when he came out, they sent him to an aunt's house far away to Texas where he would somehow have a different life for himself. He ended up responding to a personal ad from someone who he didn't know at the time was a human sex trafficker, and he became a victim of human sex trafficking. It's a tragic story, and he's now an advocate for all of this. But his parents kicked him to the curb and still don't accept him.
LR: Have you worked with men and mothers and their parents from other cultures, where the parents themselves were afraid of being sanctioned, punished, or harmed?
RM: You're saying that with a great degree of sensitivity and attunement. Most situations, that is exactly what the parents are feeling, but they don't recognize that in themselves. What they recognize is what they're supposed to believe, and that's what they've gone along with. I've worked with Mormon families who have rejected their children. I've interviewed a Latino Mormon man whose mother read his journal and packed up his bedroom one night and put all his belongings in the garage and said, “You're not going to live here anymore. What you're doing is a sin.”
Eventually, they came around and made up years later. These horror stories unfortunately exist. Some families that are less severe than the examples I gave don't let their kids come to family holidays. They insist that they not come out to extended family that there’s all these conditions. There's a woman named Caitlin Ryan who’s done a lot of research through her organization called the Family Acceptance Project. Her work shows that LGBTQ family members can gain acceptance with their children or their siblings through being exposed to other people that give a message that it's okay.
And that's essentially what we're doing through Gay Sons and Mothers. We're sharing stories saying, “Look, we're out in the world and everything is fine.” And as family members realize that it's okay, they are far more accepting of their gay children. So, that's the message that we need to get out into the Latino, the Asian, the Black communities, and the best way that they're going to accept it is by hearing stories through people like themselves.
If they're hearing from a gay social worker who's White that it's okay, maybe some percentage of people will listen to me and be comforted, but they're going to hear it most from another father who's found through his own experiences that it's better to have a relationship with their child than to reject them.
And that's essentially what we're doing through Gay Sons and Mothers. We're sharing stories saying, “Look, we're out in the world and everything is fine.” And as family members realize that it's okay, they are far more accepting of their gay children. So, that's the message that we need to get out into the Latino, the Asian, the Black communities, and the best way that they're going to accept it is by hearing stories through people like themselves.
If they're hearing from a gay social worker who's White that it's okay, maybe some percentage of people will listen to me and be comforted, but they're going to hear it most from another father who's found through his own experiences that it's better to have a relationship with their child than to reject them.
LR: I imagine there’s a significant number of these families that don’t make it successfully through therapy with you. This young man is left feeling just as isolated and rejected as before.
RM: Right. Or the young man will stay in therapy and build his own community, but, unfortunately, not with his family, outside of the family and elsewhere. That said, I am a family therapist. I’m a couples therapist. I'm totally optimistic. I never give up on families reuniting. And, last year, I worked with a fundamentalist gay man in his 30s, really successful in his career and in his life. But he didn't come out until his 30s to please his parents. I had three joint sessions with him and his mother, with the hopes of bringing them together. He never thought it would happen.
I met with her alone first, and she was talking about the Bible and blah, blah, blah, blah. They didn't stick with the sessions, and eventually started talking to each other. A couple of months ago, she was potentially diagnosed with cancer, and that's what brought them together more than anything else. And I wish it could have been sooner.
LR: How would you advise straight therapists working with gay men, beyond the standard of “unconditional acceptance?”
RM: You raise a very important issue about unconditional acceptance, and many well-intentioned straight therapists try way too hard with their gay clients. In my life, socially, I'll go to a party, and they'll say, “Oh, do you live where all the gay people live? And do you know so and so, and so and so, and so, and so?”
LR: Gay Jewish geography.
RM: Exactly, and often I do. But therapists who try to promote unconditional acceptance and convince their clients that they're gay-affirming and then offer, “Oh, I have a neighbor who's gay,” which actually may induce a lack of trust. The best way to promote unconditional acceptance is to simply say, “I’m straight. Are you comfortable working with me? I am accepting, and I've worked with other gay clients. But, please, if you feel any bit of discomfort, let me know. Let's talk about it.” To me, that's unconditional acceptance, and that's more welcoming than doing a sales pitch that ends up sounding like a microaggression more than anything else.
So, my mentor, Jeff Zeig, accepted me for who I was, and he’s a straight man. There was something so profound in that experience for me. Was he the first straight man that accepted me? No, but it was wonderful to have a mentor who didn't care if I was gay, didn't pathologize me, and said, “Write a book about working with gay men, the field is lacking this information.” It was so validating. And so, what he did for me, which all therapists ideally do for their clients, is embrace, love, support, and send me out into the world to be successful.
That is unconditional love, and that is what straight therapists can do for their gay clients. And what I say in the work that I do is you're giving your clients a bigger gift of healing than you would even recognize because your clients are coming into your office with their presenting problem, whatever that happens to be. It may have nothing to do with being gay. And, through the love and the acceptance and the respect that you're showing to them, they're getting additional healing from the experience of being in your office.
So, frequently, when people want a referral to a therapist who's a gay client, frequently I'll say, “Why don't you work with a non-gay therapist? Because there is extra work that you can have done, as a result.” Some people will do that, some people won't.
LR: I used to think it important to be colorblind, but we must see color to validate the experience of the “other.” that idea. Similarly, one can’t be gay blind, because being blind to that does not suggest acceptance. It suggests walling off and not affirming that person, not accepting that person. So, I imagine that a clinician working with a gay person has to be very cognizant of the stories, the history that this person brings into therapy.
RM: Yes. The words that are coming to my mind are cultural competence. And that's what we need in the field these days. And I, too, did the same that you just described. I worked with an Asian gay man and a Black gay man, and I cringe when I think to myself or I even probably said things aloud that it's not as bad as you perceive it to be, which is absolutely not true.
LR: It’s not affirming.
RM: Right. The best thing that we can do is to hear the experiences that our clients are bringing to our offices and trust that to be true. The other best thing that we can do to become culturally competent is to go to workshops or watch videos like this or read a few books or speak to your gay friends and family members about their experiences to get educated. It's not hard to do. I find that in our field of mental health there are many people who are well-educated and liberal in their thinking, so that they feel like they have all that they need to know.
But their gay clients are testing them indirectly and don't feel safe because they're presenting a norm that may be uncomfortable. The other thing that I found, and I've mentioned this to you before, is that the field in general, of course, is run by metrics and numbers. And the most successful clinicians and teachers in the field have large numbers of followers and huge turnouts to their conferences. When I teach, sometimes I get 20-25, maybe 40 attendees, if I'm lucky, at a big mental health conference. Well, that's not good for the conference.
So, I'm not advancing as I'm teaching about working with LGBTQ people. And there are very few courses offered at huge conferences, which is unfortunate. So, my advice to people who are organizing conferences is to put us in panels with other people, and that way we can kind of gain exposure and educate people.
LR: So, the idea of a gay-affirming therapist is more cliché than anything else I would think because if you're not a person-affirming therapist, you're not going to be a gay-affirming therapist. Am I getting it, right?
RM: Yeah, yeah. And I mean, interesting. A clinician that's worked a lot with the gay man or the LGBTQ population by nature is gay-affirming. I know through conversations with a person who has worked a lot with the LGBTQ population is gay-affirming, and they've cultivated acceptance and skills that are affirming and comfortable. As a person, are you a gay-affirming person? I'm not asking you that. I know that you are, but I'm asking people who are listening to this. Do you understand what it's like living life as an LGBTQ person in today's world?
And if you're honest with yourself, maybe there are things you don't understand, and there's ways of getting information. If you pretend that you are, you're fooling yourself. People are going to see beyond that.
LR: They’re going to catch up.
RM: So, when you go to therapy, you should be talking about your sexual life. Many gay clients, out of shame, won't even broach the idea of sex with their therapists. Or, when they talk about sex, their therapist winced because they don't believe in open relationships, or they think that gay men are too sexual, and their biases are coming forward. I h
Strengthening the Therapy Relationship with Gay Men
In general, gay men have grown up feeling diminished in their families and beyond. The way in which they interact in the world is shaped by these experiences and so the stakes are high when they come see you. Comfort and compassion are essential components in successful treatment with gay men, and the immediate goal is to create a positive alliance. Growth takes root in this alliance, regardless of which therapeutic models or specialties you offer.
Because connection takes precedence in this moment, the paperwork that comes with this professional interaction can be put aside in favor of establishing rapport. Paperwork can wait, connection cannot.
When the client shows up to your office for psychotherapy, he will already be in a vulnerable state. His presenting issue, which is often a source of failure or shame, is accompanied by the internalized feeling that being gay is to blame. Thus, the association formed by the two of you must serve as a foundation of ongoing trust in order to explore what inherently feels dangerous to explore.
Sizing You Up
Gay male clients will be sensitive to certain aspects of interaction and particular qualities in you. Gay men are well versed in detecting safety concerns.
Do you understand him?
Are you reassuring?
Do you accept him being gay?
If you do, are you conveying it in a way that feels accepting and loving? (If he is coming to therapy based on issues pertaining to sex, intimate relationships, or compulsive behaviors, this will be especially salient).
If you are gay, do you share enough similar viewpoints for the relationship to feel safe and satisfying?
Is there a way in which the fact that you are gay actually evokes a sense of competition him?
Are you the kind of gay man he feels comfortable with — a therapist who understands his values within the community?
Is your style something he judges you for or reacts to?
If you are not gay, what are your biases, and how or when will they show up?
Are you open enough?
Whatever your orientation, do you offer the right balance of familiarity, professionalism and freshness?
As I said, the first goal at the start of new treatment is to make the connection. Remember the gay male’s history. Your client’s needs may have him looking outside of himself for acceptance, and your job at the beginning is a tough one. It is easy to fool ourselves into thinking we are doing what is right in order to make a connection, but paying attention to subtle interactional qualities is a crucial aspect of creating that necessary sense of trust. Dr. Zeig asks clinicians to imagine themselves in the consulting room: “What postures do you habitually assume? Are you unnecessarily rigid? What flexible postures can you adopt that can enhance your effectiveness?” (1)
If the client has been in therapy before, his explanation, “I wanted something new,” may warrant some exploration. Did he have a sense that his previous therapist disapproved of aspects related to him being gay? Did he come to some kind of therapy impasse? Was he having trouble translating insight into action? Whatever the reason for his having left the previous context, you’re it now, and in order to meet him where he is, you will need to appreciate his dilemma, figure out his relational style and provide the right amount of what he needs.
Keep in mind that most gay men are used to sitting on the sidelines. Showing sincere enthusiasm is inspiring, though it may take some time for him to adjust to the attention. Most clients come to therapy wanting to resolve a problem. Some are clear that it is crucial to have a good connection with the therapist in order to accomplish this, but others may not be aware of how important this aspect of therapy is.
Most gay men have grown up in unempathic environments. Thus, empathic resonance and responsiveness from the therapist are of particular importance. At the same time, the therapist’s empathic responses may fall on deaf ears as the client questions the genuineness of the interaction (2). Gay males suffering from low self-esteem are accustomed to deflecting energy from themselves and may have a knack for not accepting positive feedback. I also attribute the reaction to internalized homophobia. People with low self-esteem are more comfortable with critical feedback than praise, and they elicit values that confirm their negative self-view (3).
A quick story: A client who is not new to therapy but has just joined a group I lead reveals the tenaciousness of his low self-esteem even as he is receiving very positive feedback. This man is upbeat, attractive, articulate, and warm. When it is pointed out by the group that he exhibits these traits, his face becomes flushed, he breaks eye contact, looks down, and his posture transforms into that of a vulnerable child. Exploration of this response only brings out more embarrassment and shame. This is a man who is successful in business and to whom others respond with interest. His mysteriousness — a façade developed to hide behind — only evokes greater interest. In this moment, the uncertainty that lurks just beneath the surface is glaring.
Attunement
As therapists, we always appreciate the significance of the therapeutic relationship or we wouldn’t be working in this field. The topic is endlessly captivating. “The therapy relationship is more than a staging ground for technique, it is the primary factor in successful psychotherapy” (3).Our chief goal is to provide a meaningful experience with our clients. It is that simple. For gay men, this meaningful experience provides the greatest opportunities for change. Remember, using body awareness through experiential work, focusing on clients’ resources, and using the strength of the therapy relationship creates optimal change.
You and your client will simultaneously enjoy the rewards of using this three-prong approach. Attunement refers, in part, to this palpable shared experience. The term attunement has become popularized largely based on remarkable neuroscientific findings. Mutual physiological changes take place when people are attached to, and are in sync with, each other (4).
Your Natural Self
Whether it be your areas of expertise or your reputation that brought a client to you, being appreciative of the dynamic of the relationship is crucial. How you exhibit warmth and interest in him makes a difference. It is your natural strengths that create the greatest comfort and promote closeness. How you interact is far more important than the exact words you use. Techniques that you learn are helpful but perfecting them might be more significant for you than for your client. Your stance is that of a healer, respectful and sacred in your intentions. You are an important figure to your client, perhaps in ways he has never had in his life before.
Literature delights in affirming the significance of this relatedness. Successful therapy depends much more on the connection, empathy, and mutual fondness that develop between a gay client and therapist than any other attribute of the therapist. “What is healing as the client experiences being at one with the therapist.” (5). It is more important that the therapist direct efforts towards appreciating the client’s experience than focusing on what really happened. This perspective centers on the client’s affective experience.
Now, in current work with gay men, we can explore sensory experiences too. This opens up a treasure chest of possibilities because somewhere inside are his resources. Perhaps they have been dormant for years, but with caring guidance they can be elicited from deep inside. Research indicates that within the context of healthy relationships, individuals are able to gain experience of identity, meaning, choice, and love. The combination of these produces hope and resiliency. We discover our value, stretch our limits, gain new abilities, and collaboratively create a meaning for our existence (Short, 2010, pp. 301, 302). Authenticity opens to creativity and collaboration; the powerful mixture leads to success in the therapy.
Attunement in Action:
Create an inviting, informal atmosphere.
Use your eyes to make contact with your clients.
Be aware of your body language and show yourself to be open and welcoming.
Use your intuition to create a relational match by joining the client in his ways of perceiving things and living life.
Trust the unique ways in which information comes to you as you sit with your client. Utilize them.
Use humor with purpose in order to promote closeness or emphasize a point.
Strive to make a powerful connection that is profoundly experienced by both of you.
Focus on experience rather than technique.
Authority Figures
For gay men, positive experiences with authority figures are few and far between. Most gay men have concealed their identity or behaviors, recognizing that there was always the danger that people in positions of authority would be disapproving. I still find that many clients don’t tell their physicians they are gay, despite being sexually active. They are afraid their physician will react negatively, and the need for interpersonal harmony surpasses anything else. Of course, it is of the utmost importance to maintain good physical health, get regular HIV tests and immunizations for hepatitis, and to have safe-sex discussions. If a physician or therapist is perceived as being disapproving, the option of another provider is always a good one, yet secrecy is the default mode for many men. They forget that they have other options. This scenario happens just as often in psychotherapy, especially where sex and use of substances are concerned.
What Does it Mean to be Gay Affirmative?
I have highlighted that gay male clients flourish through your ability to notice and utilize their resources. This is the magic you can easily provide. Although it isn’t difficult, it often is forgotten amidst the therapy protocols and the current emphasis on identifying treatment goals. Clients are the best at self-pathologizing. Gay liberation itself is still fairly young (early 1970s); affirmative therapy for gay males is even younger.
Before 1990, there was ample literature to support the idea that conversion from homosexual to heterosexual was a preferred intervention. Some therapists believed it was in the best interest of their clients to change their sexual orientation, given that it is impossible for a gay man to live a happy life or have a stable relationship (6). There is still conservative religious literature that supports this perspective, but it is less common than before.
There is now consensus that it is damaging to a person to attempt reparative or conversion therapy with him. I am surprised at how often I get referrals of men who were treated with conversion as the goal. However, more common these days than outright suggestions for conversion is the perception of disapproving attitudes from psychotherapists that negatively reinforce a client’s feeling about being gay. Often these therapists are seen as rejecting and uncaring, though I would guess that many of them are actually just unaware of how they are coming across to their clients.
People who grow up with healthy authorities may not recognize that a gay man has tended to the needs of the authority figures (including parents) in his life by keeping quiet and hiding his secrets. Therefore, a client may recreate in therapy a dynamic he had with his parents by remaining hidden. The need to be compliant or good prevails. Therapists need to be on the lookout for such a dynamic and create a tone that implies mutual openness and acceptance.
The bottom line is that accepting your client for being gay is essential. A wonderful description of gay-affirmative therapy states: “Psychotherapy can result in change, although this is the secondary goal to creating an experience of empathic contact for the patient, whether or not change takes place” (2). Right on. Making this connection will be as useful as anything else.
Perhaps the best way to provide affirming therapy is to accept and affirm that you care for your client. Then you find a way to join him in his views and sensibilities. The therapist’s ability to be reliable provides a milieu that aids the patient in experiencing “twinship.” Sensitivity and empathy affirm that patient’s sense of self (2). Internalization of these interactions can lead to significant internal structural expansion and cohesion.
A Gay Affirmative Perspective in Action
You want your client to feel comfortable, valuable, proud about being gay, and for him to know that you are in accord with his true self. You can do this by finding avenues of connection with him, as a person, not just as a client.
Allow yourself to appreciate how you respect him, where your commonalities intersect, and how your differences are intriguing to each other. This way of relating is not didactic, but rather it is intuitive and emotional. Either you both will feel it, or you won’t. There is no need to try too hard to win him over, the way that you effortlessly relate is the win.
Script: Seeing and Knowing You
This script was inspired by a client sharing his difficult experiences of coming out in college. Because these struggles were having an effect on his coursework, his professor asked to meet to offer him support. His memory of receiving nurturance all those years ago was so profound that he describes it as a turning point in his life. Ironically, he remembers nothing about what was said. Instead, he vividly recalls the feeling of being cared for in this special relationship. The lamp that was shining on his professor’s desk figures prominently in his memory. The visual representation of this lamp still captivates him and represents the richness of this experience, even 30 years later.
I am struck by how other clients report similar types of childhood or young adult memories, often with neighbors, grandparents, aunts, uncles, or other people who shared their love.
This script can be used as a reminder that there were people in the past whose nurturance made a lifetime of difference. In addition, I use this script at conferences and with therapists to remind them about having had significant moments like this in their own past.
For traumatized clients who cannot conjure up anybody who provided this type of experience, a family pet or a childhood toy can be used.
“Allow a time in your past to come to you when you may have felt awkward, just a little bit different from others, or perhaps you felt alone. It might have been as a child or as a teenager, and you can look back and appreciate what it was like for you then, remembering the ways that you may have held yourself back, or constrained yourself. You can even assume that position in your body right now.
You can also appreciate how time has shifted for you now, since you are no longer at that place anymore.
Now, remember a person back then who could see you and know you for who you really were, and for what you needed at that moment in time. You can appreciate how it feels that you knew that he or she cared about you, how lucky you were and are to know that he or she cared. This caring person may not have even verbalized the ways that he or she could appreciate you, or the ways that you mattered, but you just knew this was so. You simply knew this by the way the person looked at you, spoke to you, or did something special, just for you. Appreciate the way it feels inside.
It may have been a teacher, a doctor, an aunt or uncle, or perhaps a neighbor who noticed you and took care of you in just the right ways. In your mind, you can see what this person looks like, where you were back then, and what the surroundings looked like back then. You might even remember the sounds or smells back then. That is right.
This person could see you for who you really were and really are, and was able to offer you love and support, and it felt so very special. It was just what you needed. Appreciate how it feels now and assume that position in your body. That is right.”
“If I Can, So Can You”
I provide experiences that help my clients feel alive through my own interactive stance. Near the start of treatment I say: “What you see is what you get.” In addition, I am mindful of my posture, movements, tone of voice and use of eye contact, all to imply an available informal stance that encourages the same of them. This mindset provides gay men with new opportunities. It is met with great relief, especially for clients who have had more aloof therapists in the past.
Clients are grateful to experience this positive energy and it elicits a new way of being: My informal use of self serves as a role model with its intrinsic message of acceptance of being gay. Just being myself has proven to be the most successful therapeutic tool in the room. Again, behind the curtain of any therapy technique should be authenticity: this is what allows for the power of any given technique to come through.
A quick story about my client Thomas: He was raised Mormon and says he envies the confidence of his Jewish friends. Turns out, his therapist, me, is Jewish and gay. I was excited from the start that he was willing to use the energy between us as a part of therapy; it is just how I love to work.
While exploring career stagnation, he describes a scene in hypnosis that suggests a dynamic between us. It hadn’t occurred to me until months later when I re-read my notes that the person he described might be me. It reflects how powerfully the relationship in therapy is experienced, even when it isn’t in full conscious awareness.
“There is a man in the foreground, standing in water. It is some kind of a pond or a lake. There is a reflection of a forest behind him, and the background is green and black. The sun is focused on this man. He is smiling with his head tilted, looking friendly, but strong and inviting.”
Perhaps the sun that focuses on me symbolizes the success he perceives in me, or me in him. I often am inviting him to leap into the depths of the water, either with me, or for himself.
The next excerpt brings Brad back. Here you get a glimpse of what the weave of therapeutic alliance, experiential work, and calling forth the client’s resources looks like in session.
Brad
Thinking about his growth in therapy, Brad is very clear: “Love is wanting someone who truly wants me, rather than my settling for his approval of me. I have been waiting too much for permission from men. I deserve to have a man offer me what it is that I want, and it is exciting that I am beginning to be self- directed now. I am going against the old voices I have lived with for years.”
In exploring ongoing themes, he describes, “When I am faggy, I am faggy by choice, no more editing of myself!”
Knowing how much he enjoys being creative in hypnosis, I decide to embrace his “faggy” stance in a way that symbolizes resourcefulness. I ask him to describe a memory when feeling this way was wonderful. (This was all with his eyes closed, in hypnosis, where he could let himself go more than usual.) He recalls going to the disco in the late 1970s: “Everybody was happy, celebrating their gayness and having a ball on the dance floor, uninhibited and free.”
When I ask which “faggy” song was playing — reflecting back his use of the word “faggy” in a light and easy way — he answers: “‘I Feel Love’ by Donna Summer.” Since we grew up in the same era, we spend a few moments mutually sharing our enjoyment of these times. I continue with this theme.
I ask him to bring this feeling of being free to a time in his past when he would have liked or needed more of it.
“I am in the way back of my parents’ station wagon. This was a place where I would go to in order to escape from them and try my best to feel free from them.” Knowing that he is a wonderful singer, and assuming that his singing will be a powerful experiential moment, I then ask him to sing the song out loud. I am right. It is a powerful and intimate moment. I push him to push himself further than he usually does, and I also participate in enjoying the depths of this intimate moment, one of the more intimate moments in my career.
He begins meekly:
“Ooh
It's so good, it's so good It's so good, it's so good It's so good
Ooh
You and me, you and me
You and me, you and me You and me
Ooh
It's so good, it's so good It's so good, it's so good It's so good
I feel love, love, love, love, I feel love.”
He is very self-conscious, but he continues. It is incredible. I ask him to describe what happens next. “You are driving the car, the music is blaring, I am in the way back and the lights are blinking, like the lights in the disco. We are now at a red light, where the people in other cars watch us.”
He is emphatic: “Turn up the volume, Rick!”
I had turned up the volume by asking him to sing, and gladly turn up the volume again in this important moment.
With tears, he says, “This is so incredibly hard. I want to be somewhere where all of this is okay, and it is right here.”
Experiences Unite
The success you achieve with your clients comes from your ability to join your client in his world. This often feels like a trance state or state of flow where everything else goes away and it is just the two of you. This ability to join involves the challenging task of putting your own perceptions and experiences aside.
However, in a trance state it can feel effortless. Martha Stark describes the tension between decentering in order to lose herself in the client’s experience, while recentering in order to give her authentic self to her client. Though she does not do hypnosis, it certainly is hypnotic.
A client sitting with his eyes closed and allowing the therapist to guide his experience is in a vulnerable position. In these moments, the client is no longer able to reference the therapist’s facial expressions to judge how the emotional interaction is proceeding. Trust is paramount and should be well established before embarking on this type of work, and one should only proceed with the client’s full permission.
The payoff for those who can establish comfort with vulnerability is that therapist and client together have greater access to the richness of the client’s internal world. This happens through joint exploration and joint experience. Clinician and client follow each other’s leads, and at the same time, each takes the lead.
The experience is mutual: a deep state that is creatively assembled and experienced with and for each other. This is interpersonal trance. The therapist’s unconscious mind tunes into the client’s unconscious messages, feelings, and needs. The therapist involved in this trance activity is better able to resonate empathetically with the client, and to meet his unconscious needs. As both experience a receptive trance, the client is also experiencing an interactive, interpersonal state of high resonance. The internal resources of therapist become available to him.
Even though this is done experientially, the experience is processed consciously, and the client not only has the benefit of what came up while doing this work, but also has the benefit of expanding on the respectful and loving experiences within him.
Often, while doing hypnosis, I am aware that I am talking to the child, and that he is responding to me both as child and as adult. Thus, I exaggerate the softness or the kindness in my voice during these moments. The client is often nodding his head, receiving my voice — its cadence and tone — as though listening to a lullaby. Inevitably the experience of being understood and appreciated moves clients to tears. Milton Erickson believed the therapist’s role to be a surrogate parent, and I concur.
The brief excerpt that follows provides a snippet from a much longer hypnosis in which I placed emphasis on being relational and tailoring the session to build on the solidity of my connection with the client.
Bud
Bud was having difficulty moving out of his parents’ home and establishing an independent life. Together we go on a journey, traveling by car.
Me: “And even though I am driving the car, I wouldn’t know where to go unless you gave me directions, because you are the navigator and all I am doing is following your directions.”
Bud: “We are still in the car; you are continuing to drive me past all the dark places. And you know exactly where to go, you know where to take me, I can’t do this alone. Please don’t leave.”
Me: “And you can trust, Bud, that I am here for you, that I am not going to drive away. And I wonder if you can appreciate moments when you sit here with me during a session, and moments when you leave a session, and I am not with you anymore, and yet I am with you at the same time.”
Bud: (Nodding his head) “That feels very manageable, very reassuring. Not so scary. Manageable. It doesn’t feel as scary, or lonely. I can hear you in the back of my mind telling me I can do this; I can manage this. It feels good. It makes me feel like I can do this. I can hear you saying, ‘You can do this; you can get through this.’”
“I Am Here for You”
Earlier I talked about the significance of maintaining a “You can” position for our clients. Another important stance is “I am here for you.”
I say or imply this often, and with great sincerity. It cuts through many protective layers when offered at the right moments. Sometimes I directly say this in hypnosis. If a client is struggling with pain, I want him to know that he doesn’t have to hold it by himself. This is a hard allowance for men who have been denied and have denied themselves the availability of others and of love.
Jason
Jason is a client with a painful history of sexual abuse, alcoholism, physical abuse and emotional neglect. He has learned to quietly excel in his own private world. Although it appears that he is successful and gregarious, and has many close friends, he is actually a loner and keeps himself well hidden from others.
Over the course of his sessions, it is clear that he is doing with me what he does with others, deflecting and hiding. One day I decide to take a big risk.
I ask him if he knows that I am really there for him. Tears come to his eyes. “I am here for you, Jason. And I will continue to be here for you.” These words are magic to him. He continues to weep, relieved and moved.
Later he expressed many times that this was a pivotal moment in his life. “It was the first time I could believe the truth of this: Rick is and was there for me.”
Going Deeper into the Relationship: Dealing with Conflict
When you sense that your client is having a struggle with you, do you encourage him to speak about it?
Do you ask him to describe what he needs from you?
Are there times that you avoid these kinds of conversations?
Do you find yourself giving in to your fear about pushing your client?
How many times has your client had struggles with an authority figure and not been able to discuss it?
Many of us simply prefer to avoid these kinds of discussions and instead stay focused solely on the client’s symptoms and presenting problems. In doing this, we miss out on rich moments. We hope that the connections with our clients provide lasting changes, and that our relationship provides the love of a parental figure. It does, and yet there needs to be more: working through the resolution of conflict is a crucial piece. It adds richness to the therapeutic experience, particularly with clients who stay for longer treatment.
Dealing and working through conflict in the context of the therapy relationship is a must because a gay client’s history with conflict may simply consist of avoidance. But in life conflict is inevitable; now is his chance to move through it in a different way. The question is, will you meet him there?
Whose Fault Is This Anyway?
Apologies and countertransference disclosers are crucial to successful therapy with gay men. The shame that gay clients feel is often manifested in accepting responsibility for painful experiences that are externally prompted. An empathic lapse by the therapist often becomes a source of self-criticism for the client.
I recall once in a group I was leading that I made a joke that turned out to be at one of the participant’s expense. As soon as I blurted out the joke, the group came to Todd’s rescue making clear that my comment was too gruff. It would have been tempting to rush to my own defense, “explaining” what I really meant, in order to save face. Of course, this would have also further isolated the participant and put the group in a dilemma.
Instead, I contacted him immediately following the meeting and apologized. And in the next meeting I took responsibility by reiterating to the group what Todd and I had talked about. It was important for the group, and Todd verified how important it was for him to have me apologize.
Martha Stark discusses “The New Good –The Old Bad;” The unconscious wish on the client’s part to engage the therapist in a reenactment of his internal dramas, with the therapist assigned the position of the powerful parent, and at times the po
Should Transgender Youth Care be Guided by Beliefs or Science?
Introduction
The current American approach to transgender-identified youth and adults is strongly affirmative. Many professional organizations in the United States have endorsed the safety and efficacy of social transition, puberty-blocking hormones, cross-sex hormones, and breast, genital, and facial surgeries as the ideal treatment of gender dysphoria.
These prestigious decade-old endorsements have led to the development of gender specialists in over 70 US clinics where children, adolescents, and younger and older adults are seen. It also has led to affirmative care being taught in medical schools, residency training programs, and various mental health continuing educational programs. For half a century, WPATH has been the key nongovernmental organization that has gathered specialists, provided courses that promulgate clinical principles, and published standards of care. WPATH represents itself as an advocacy, policy, and scientific organization.
Its membership recognizes a great need for social change as discrimination in housing, employment, health care, intrafamilial and peer relationships, and incarceration are significant cultural sources of stress for the transgendered. WPATH considers its recommendations to be scientific, even though its author-committees recognize a need for improved scrutiny of outcomes of social, medical, and surgical interventions. While it recognizes that the quality of supportive evidence is objectively low, nonetheless, it treats affirmative care as a settled scientific matter. DSM-5-TR and ICD-11 diagnostic criteria exist, elective treatment sequences have been defined, and many clinicians and patients consider affirmative care to be life-enhancing and sometimes lifesaving.
Affirmative care, however, is not a scientifically settled matter. There is much justifiable ferment. Affirmative care is far more fraught and uncertain than WPATH and professional associations have suggested. (1-3) It is a paradox for WPATH to portray itself as a trustworthy authoritative advocacy, policy, and scientific organization in the face of uncertainties about long-term treatment outcomes, the unexplained dramatic explosive incidence of new gender identities, and the increasing recognition of de-transition.
There is an ongoing culture war within the US about the treatment of transgender youth who are uncomfortable with their bodies. (4) The political aspect of this culture war addresses transgender treatments as a conflict between those who support and those who oppose the civil rights of LGBTQI+ individuals. Those who question the wisdom of affirmative care are described as “anti-trans.” A medical perspective begins with a different question: Is the scientific basis for affirmative care sufficiently established? If the answers are either no or uncertain, three other questions follow.
- Can gender specialists separate their beliefs from what is scientifically known about etiology, incidence, psychopathology, and the long-term benefits and harms of affirmative interventions?
- Can these specialists provide parents and patients with the legal and ethical requirements for informed consent? (5)
- Can high-quality research be designed and funded to answer the current relevant clinical uncertainties?
Usually when health is the topic the medical profession leads the way, relying first on rigorous science, and second on the values of individual patients and their families. In the arena of trans care, however, values have historically played a more important role than science. This may be summarized as eminence-based or fashion-based medicine dominating over evidence-based medicine. As has been seen with the COVID vaccine, mask mandates, the opioid epidemic, and the FDA approval of a drug for Alzheimer’s disease, trust in the medical profession is far from universal. Consequently, what individual doctors, gender care clinics, professional societies, and mental health professionals may have to say about the ideal care of trans persons may not be the most powerful force governing social policy.
Forces Shaping Attitudes About Transgender Care
Transgender phenomena elicit intense feelings among laypersons and professionals. Such passion, which is destructive to objective scientific appraisal, derives from many personal sources. While numerous factors influence attitudes toward transgender care, their confluence makes it difficult to judge their relative contributions to how individuals and institutions regard trans healthcare.
There are five universal potential influences.
1. Fascination with sex change. The intriguing question, “Can sex be changed?” has long been explored in the arts, where men and women have for centuries been presented as the opposite sex in humor, drama, dance, opera, drag, and popular music. Today, it is better understood that in a basic biological sense, sex cannot be changed, but gender presentation can, with or without medical assistance.
2. Political sensibilities. The Left may consider transgenderism the courageous pursuit of self-expression, a civil right, a movement to improve diversity in all walks of life, and a praiseworthy social movement to eliminate discrimination. Their political values lead them to view studies and clinical services with trust. The Right, on the other hand, may consider transgenderism morally wrong, threatening to societal health, and dangerous to the health and well-being of individuals and families. These assumptions lead to a skeptical approach to studies and clinical services.
3. Religious sensibilities. These value-laden thought patterns derive from theological assumptions. They may resemble the Right or the Left. In the United States, the most vocal religious institutions on this topic lean to the political Right.
4. Sexual orientation sensibilities. Membership in the heteronormative or sexual minority communities often generates opposite responses — the former may have initial unease with, and the latter, initial comfort with trans phenomena. One’s sexual orientation, per se, does not guarantee a particular attitude any more than one’s political or religious affiliations do. However, many of the leaders who advocate trans care identify as a sexual minority.
5. Intuitive age-related sensibilities. Intuitive sensibilities are best reflected through age. Younger and older generations have different life experiences with which to be intuitive regarding attitudes toward the transgender experience. The very existence of sexual minority communities and their entitlement to civil rights are far more visible today than was the case when older persons were growing up. These generational differences reach into each group’s system of values.
There are four influences that are unique to professionals.
6.Personal clinical experience. The 7th edition of WPATH’s Standards of Care (SOC) downgraded the importance of a comprehensive assessment of psychiatric co-morbidities in determining the next step. 6 The process of evaluation was then pejoratively referred to as gatekeeping. Prior to 2012, adults who immediately wanted hormones or surgery were often impatient, demanding, rude or dishonest about their histories. With the 2012 guidance, adults and older adolescents were assumed to know best what should be done. Respect for Patient Autonomy became the primary ethical principle to follow. The frequency of unpleasant clinical experiences dramatically diminished. When professionals experience unpleasant patients, those with conspicuous emotional impairments, or those who deteriorate with hormonal treatment, they are more likely to be avoidant of future encounters. Positive experiences with appreciative patients and families yield more willingness to engage.
7. Knowledge of clinical reports from clinical innovators. Positive outcome studies of transgender treatments typically consist of retrospective case series without control groups and without predetermined measurement instruments. Such outcome reports are numerous for each intervention. Positive results tend to be more often published than negative or uncertain outcomes. The most influential studies for minors were published in 2011 and 2014, and while they too lacked a control group, they were interpreted as establishing the concept that selected prepubertal cross-gender identified children could benefit from affirmative social, endocrine, and surgical care. (7),8
Clinicians cannot be expected to keep up with the burgeoning literature; they trust what they read, heard about, or were taught. Such learning reflects a chain of trust that is basic to all medical education. It has become apparent that the chain of trust is not necessarily trustworthy, as positive studies are published in peer-reviewed journals only to have their conclusions criticized by knowledgeable academics. Once clinicians begin to facilitate patients’ transitions based on the studies they have seen, they believe they are facilitating happy, successful, productive lives even without having the reassuring follow-up information to verify their beliefs.
8. Scientific studies. Groups of studies demonstrate patterns that individual studies do not. Scientific data are widely assumed to dominate institutional policy. This is not necessarily so, however. For example, high desistance rates in trans children have been demonstrated in 11 of 11 studies, (9) but a committee of pediatricians created a policy of supporting the transition of grade school children. (10) As a result of these often-conflicting processes and sources of data, comprehensive evaluation and psychotherapy rather than affirmative care are increasingly being recommended
9. Source of income. With 70+ clinics in the United States, with many individuals in private practice who practice affirmative therapies, and with special units within prisons to support trans inmates, the attitudes of new-to-this-arena clinicians may be quickly determined by their work environment. In these settings, disapproval of affirmative care, which may grow with experience, as it did for many psychologists at the Tavistock Clinic, means resignation or job loss.
Sources of Controversy about Affirmative Care
1. Morality — Conservative citizens, religious denominations, politicians at local, state, and federal levels, and some gay, lesbian, and feminist groups view affirmative care as dangerous. They ask, “What are we doing to these young people? What will be the outcome for them and their families? Do doctors really know what is best for my son or daughter? Why is it acceptable to sterilize young people? Why is the suicide rate high after completion of medical and surgical interventions?” Such questions burrow down into moral values.
Some religious groups assert that since God made male and female, this provides fundamental guidance to decision-making. However, because these groups have historically been similarly against homosexual lives, the power of this theological assumption is politically diminished for many others.
Some gay and lesbian organizations see affirmative care of feminine boys and tomboys as an attempt to eliminate gay and lesbian people. Almost all groups recognize that cross-gender identification is nothing new. What is new is its dramatically increased incidence and Medicine’s response to it.
2. Questions Emanating from Medical Ethical Concerns
- Are children and adolescent patients experienced enough, cognitively mature enough, to make life-altering decisions that will predispose them to known challenges such as sterility, sexual dysfunction, decades-long medical care, discrimination, and loneliness (11, 12)
- Do their frequent co-existing psychiatric diagnoses further impair their ability to thoughtfully consider the consequences of each of the steps of affirmative care?
- Are affirmative professionals knowledgeable about the limitations of their recommendations?
- Do they know the inadequacies of the outcome data supporting the policies of socialization of children and endocrine and surgical interventions with adolescents?
- Do they know the fate of most patients given hormones a few years after they age out of pediatric endocrinology?
- Are they aware of the rates of complications, physiological consequences, long term unhappiness after the surgical procedures that they recommend?
- Are parents sufficiently informed about the limitations of outcome data?
- Are they told of Sweden’s, Finland’s, UK’s, and France’s shifts towards psychotherapeutic-first interventions?
- Are they informed about the social, economic, vocational, physical, and mental health problems of transgendered adults?
- Are they told about detransition following hormonal and surgical treatments?
- Are they told about the elevated suicide rates after surgical treatment of adults?
3. Confirmation bias — When defending a particular position, authors tend to quote studies supporting their position and ignore contrary findings or glibly dismiss them as methodologically unsound. This confirmation bias creates important scientific concerns on both sides of the debate. Science advances by defining controversy and designing a study that may better answer a specific question. Independent reviews have concluded that the evidence is not convincing that puberty blockers and cross-sex hormone administration lastingly improve mental health, decrease suicidal ideation, or eliminate gender dysphoria. (13)
The Endocrine Society acknowledges a low level or very low level of supportive evidence. Advocates, however, portray certainty that science has already demonstrated these lasting benefits without significant harm. When they list supportive studies there is no mention of the published criticisms of them. A scientific review is characterized by balance; it is not performed only by those who deliver the treatment. (14,15) Trustworthy reviews point out the limitations of studies and ideally suggest a study design to answer the specific question.
4. Political — Nowhere in Medicine has free speech been as limited as it has been in the trans arena. Skeptics are being institutionally suppressed. Critical letters to the editor in journals that published affirmative data are refused publication, symposia submitted for presentation at national meetings are rejected, scheduled lectures are canceled, and pressure has been exerted to get respected academics fired. A notable exception to this pattern occurred when a paper investigating the long-term mental health outcomes of trans adults (a basic unanswered question) was published in the American Journal of Psychiatry.
It, of course, had undergone a peer review process by experts in gender care. When the authors asserted in their online publication that their data supported increased access to surgeries, the editor received seven critical letters. In response, Dr. Kalin had two independent statisticians review the work. They agreed with the twelve authors of these letters to the editor that the data did not demonstrate improvement in mental health. The editor published the original article, the seven letters, and the authors’ response. The authors retracted their conclusions. (15,16) When critical letters have been sent to other journals, they have been rejected. As a result, they are published in separate journals.
This makes it more difficult for clinician readers of the original journal to know about the critique. Unless published with open access, the original flawed article’s limitations are difficult to access in another journal. A significant paywall is often encountered to obtain articles in journals to which the professional does not subscribe. Given the well-known attacks on those who question the prevailing wisdom of affirmative care, it is not surprising that many mental health professionals avoid working with these individuals and their families for fear of being labeled as anti-trans, transphobic, or conversion therapists.
5. Familial — The parents, siblings, and extended family members, each of whom have different relationships and responsibilities for the trans-declared person, typically have intense feelings about their relative’s gender change. Family members’ affects, attitudes, and behaviors derive from one or more of the five sources discussed above but take on a new poignancy. While parents are the only ones that professionals deal with, the intrafamilial ramifications affect everyone.
Parents have realistic, reasonable concerns. What will gender change mean for my child’s developmental future physical, social, and mental health? Their assumptions that the outcome will be negative often create an acute depression. This intensifies when their expectation of informing the mental health professional (MHP) about the child’s development, personality, and previous challenges.
Many parents are distressed when the MHP seems far more interested in making the diagnosis and declaring their belief in affirmative care. Parents who have not previously seen behavioral evidence or heard expressions of cross-gender identifications prior to puberty want this new identity to be taken away. Other concerns emerge over time. How will the gender change impact siblings and grandparents? How to discuss it with others? How to ensure we don’t lose our relationship? What to do with one’s anger at the child and one’s guilt of not seeing this earlier? How to find an MHP who will not quickly affirm but is willing to spend time understanding the family situation?
Parents who are not supportive are often described as transphobic by their child. They often learn this accusation on the Internet. A more accurate and kinder description of these parents might be trans-wary or trans-opposed. When transphobic is used, it induces some adolescent patients to behave hatefully toward their parents. While the medical profession focuses on the patient, parents are immersed in a dramatic conflict within the home. Gender specialists only gradually become aware of this when they follow the family. This is one of the reasons for an extended evaluation process. (8, 17)
Problems Facing Transgendered Persons
There is agreement about the challenges that transgender adults as a group are facing. The medical profession has been repeatedly told that the explanations for the poor state of physical and mental health and the diverse health disparities are minority stress, discrimination, and barriers to health care. (18) There is no mention in such discussions of the possibility that the mental health of a trans person may be intrinsically compromised even though many studies have shown the poor mental health of children before the diagnosis of gender dysphoria is made. (19)
Rather, discrimination experienced by some in healthcare settings and fear of mistreatment in health facilities by others are emphasized. Higher rates of cardiovascular diseases, obesity, cancer, sexually transmitted diseases including HIV, syphilis, hepatitis C, and papillomavirus, and shorter life spans have been noted. Higher rates of depression, anxiety, substance abuse, suicide attempts, and suicide, (20) as well as seeking psychiatric services have been documented. 21 Gender minorities are more likely to live in poverty, be unemployed, be victimized by domestic partners, be homeless at some time, and be on disability. (20)
Nowhere in these well-documented patterns is the suggestion that what is known about adult trans populations should create more caution about affirmative care for minors. Rather, many articles urge better medical education to promote affirmative care for young persons, (20, 22) or for medical institutions to fight against the legislative forces that are attempting to limit affirmative care to minors. (23, 24) These authors ignore the more cautious approaches developing in Europe.
Affirmative Care Assumptions
The following concepts, sometimes articulated as principles of care, (6) enable the conviction that more, rather than less, affirmative care is indicated. When these ideas are presented as unproven, those who practice or support affirmative care of youth
The Existential Importance of the Penis: A Guide to Understanding Male Sexuality – Daniel N. Watter, EdD
Existential Sex Therapy in Practice
The practice of sex therapy and psychotherapy can be done utilizing many different modes and theoretical orientations. Yalom reminds us that existential psychotherapy does not represent a standard set of techniques, styles, or protocols. The concepts of existential therapy can be best understood as a lens or guide by which psychotherapy is practiced. Practitioners of all theoretical philosophies can bring an existential perspective to their treatment process.
When I treat my male sex therapy patients, I follow a similar pattern with all as a starting point. Whether I am treating an individual male or a couple, I like to begin by asking about what brings them in to see me and allow the story to unfold in whatever manner they choose. I am particularly interested in the description of the problem, the conditions under which the problem manifests itself, and the timeline regarding when the symptom first presented. My goal is to begin to get an understanding of the meaning and protective/adaptive purpose the sexual difficulty may represent. Typically, men will present with little to no insight as to the reason for their sexual shutdown. They often describe a generally satisfying relationship with a partner they find attractive. Most of the men I treat, especially those experiencing erectile difficulties, will report relative ease at attaining penile tumescence, and engorgement will be maintained through extended periods of sexual foreplay. But the erection fades as intercourse approaches or shortly after penetration occurs. Typically, these men reveal a current history of satisfying and frequent masturbation. They will often express a vague notion of being anxious about sexual function and a firm belief that their penile difficulties have some medical basis. However, they are at a loss to explain how a physical or medical issue allows for erections that are fully functional during masturbation but not penetrative sex. Their partners are similarly stymied.
Following the initial consultation, I will focus on family and developmental history. If I’m treating a couple, I will ask to do three individual sessions with each before resuming couples’ work. It is important to me to develop a good understanding of each person’s experience in his or her family of origin and to identify any patterns of trauma that might be getting triggered in the current relationship. I want to learn about the personalities of family members, their relationship with each of them, and their relationship with each other. I want to know if this was a family that was able to communicate about and/or demonstrate emotions, or if theirs was a family of secrets and repressed suffering. I want to know if there was any presence of substance abuse or domestic violence and/or parental neglect/over-involvement. In essence, I am looking to gain an appreciation for any family dynamic that may have felt threatening that could be reenacting itself in the current relationship and, thereby, creating a threat to the man’s existence and well-being.
Many highly regarded sex therapists will spend a great deal of time taking an in-depth sexual history. I do not, as I find much of the information in a standard sex history to be irrelevant, particularly in those men who have had a prior history of good sexual functioning. Through an existential lens, the sexual “problem” is often not about how the man feels about sex per se. The sexual problem is more typically understood as an attempt for the man’s penis to communicate some deep anxiety, concern, and existential threat to his existence. Therefore, to more fully comprehend the message the penis is sending, a comprehensive developmental/family-of-origin/ relational history will be of greater value. Let’s consider the case of Russ from the perspective of an existentially oriented sex therapist.
The Case of Russ
Fifty-one-year-old Russ came to see me shortly after his wedding to Sarah. This was a first marriage for Russ and the second for Sarah. Both had come from traumatic families of origin, and Sarah’s first marriage was to a man who regularly abused her. Russ’s primary complaint was a lifelong inability to ejaculate. I began by asking Russ for a timeline regarding his ejaculatory difficulties. I have found that the time of onset of problematic sexual symptoms is often of great significance in understanding what may be triggering the current inhibition. While most men presenting with this complaint have their ejaculatory difficulty limited to their time with a partner and have little to no difficulty ejaculating during masturbation, Russ reported that Sarah was his first sexual partner, and ejaculation during masturbation was problematic as well, although it would occur on occasion. Given the unusualness of this situation, I asked if Russ had consulted a urologist or other physician, and he indicated that it was his urologist who provided him the referral to me. His urologist did not detect any medical explanation for Russ’s ejaculation problem.
We next began to talk about Russ’s upbringing and family of origin. Russ came from a family with two professionally educated parents, both of whom enjoyed great professional success and respect. They also were rather puritanical and punitive. Russ was the oldest of four children, and the siblings all have minimal interaction with each other. Despite the fine professional reputation his parents possessed, Russ recalls them as constantly fighting, explosively angry, sleeping in separate rooms, engaging in multiple infidelities, and hardly being civil to each other. Neither had much to do with the children, his father due to excessive alcohol use and his mother using her work to avoid being at home. He recalls his mother telling him in a fit of rage that she never wanted to be a mother and blamed his father for forcing parenthood on her.
Russ also reported that laughter, enjoyment, and pleasure were not only absent in his home but were considered sinful and to be averted at all costs. Any expressions of joy were severely reprimanded and punished. As a result, Russ learned as a young boy to repress any feelings or demonstrations of delight, joyfulness, and pleasure. He recalled that to the present day, if he is enjoying a television show or a musical piece, he will turn it off. He does not enjoy comedians or most other forms of entertainment. His free time is spent reading serious, nonfiction books and tinkering with electronic devices. Regarding the specifics of sex, he reports a strong libido and easy arousal, but he begins to panic as he approaches ejaculation and, thus, ceases all stimulation. In addition to shutting down all sensations of pleasure, Russ reports learning to be exquisitely attuned to the displeasure of his parents. He was constantly scanning the home environment to head off any actions or commotions that would rouse the ire of his chronically unhappy and volatile parents. Russ grew up a very lonely child. Despite having three siblings, the home was minimally interactive, and Russ did all he could to avoid other family members. He spent a great deal of time alone in his bedroom or in the local branch library. He recalls few friendships with schoolmates, as his parents discouraged such contacts. His activities were primarily solo, and this pattern continued through college and his career. In high school, Russ discovered a love of the sciences, and he decided to pursue a career in medicine. While he enjoyed his studies, he found his clinical rotations to be laborious. For a time, Russ thought he had made a poor career choice until he discovered the field of pathology. Pathology afforded him the solitude he found comforting as well as the opportunity to pursue his interest in lab sciences. In addition, being a pathologist required minimal interaction with colleagues, offered steady, predictable hours, and relieved Russ of the burden of having to deal directly with patients. He had a reputation at work as a hardworking and dependable physician but also as a loner who showed little interest in the lives of his co-workers. Oddly, his workplace was where he met the person who would dramatically alter his life’s course, Sarah.
Sarah was a pathologist in the same lab as Russ. She was also a serious- minded and reserved person, but she was more social and outgoing than was Russ. She found Russ to be appealing for several reasons. She liked that he was smart, hardworking, and seemingly uninterested in office gossip and politics. She also discovered Russ’s dry, witty sense of humor as being particularly self-effacing and clever. She decided to ask him to join her for dinner one evening, and Russ, to his surprise, accepted.
Russ did not date and reports no prior relationships before meeting Sarah. He was quite taken aback when Sarah invited him to dinner, as no other women had ever pursued him. He liked Sarah, thought she was beautiful, and found her laugh to be quite charming. She always seemed to genuinely enjoy her conversations with him, and this was a most unfamiliar experience. Russ recalls being nervous before the date but also excited to go. He reported they had a surprisingly nice evening, and he felt a lightness that was both strange and pleasing. He very much wanted to continue dating Sarah. Fortunately, Sarah, too, recalled enjoying her evening with Russ, and the two began to spend a considerable amount of nonworking time together. Sex proceeded slowly, which was fine for them both. Russ was unable to ejaculate during intercourse and soon began to develop erectile difficulties. Russ found erections fairly easy to achieve and maintain until it was time for vaginal penetration. Russ would then begin to lose tumescence. Sarah was unflustered and patient, but Russ was frustrated. He wanted to be able to fully experience sex with Sarah, mostly because he did not want her to feel bad or worry that he wasn’t attracted to/interested in her.
It seemed readily apparent to me that Russ’s traumatic upbringing was affecting his sexual functioning. His penis was speaking to him and cautioning him against allowing himself to be vulnerable to others. We spent a good deal of time discussing his family of origin and how his penis might be trying to send him a message of prudence. Existentially, Russ suffered from fears of mortality and isolation. Specifically, Russ found his existence threatened by his feelings of vulnerability with Sarah. His past relationships with family left him vigilant against allowing others to get close and potentially harm him. He had spent most of his life as a loner, and this allowed him to feel protected and safe. However, meeting Sarah made him aware of the depth of his loneliness, and he longed for companionship and love. While his conscious mind was telling him how wonderful life with Sarah would be, his protective unconscious was alerting him to the peril and fragility of his existence should he allow himself to be exposed and laid bare to another. The threat of hurt, rejection, and grief was palpable as Russ continued to deepen his affection and connection to Sarah.
In addition to the threat of annihilation, Russ also was becoming increasingly aware of his isolation from self. His perpetual scanning of his childhood home environment and vigilance for any signs of upset from his parents made him unaware of what his own needs were. That, combined with the family’s disdain for anything pleasurable, left Russ in a constant state of anxiety during partnered sex. When in sexual situations with Sarah, Russ was so preoccupied with whether Sarah was responding positively that he was oblivious to his own sense of sexual arousal. Psychotherapy focused on Russ allowing himself to become comfortable with experiencing nonsexual pleasure and then moving to sexual pleasure during solo masturbation. A combination of dealing with the trauma of his childhood environment along with some directed behavioral suggestions allowed this to be accomplished over a period of several months.
Allowing himself to ejaculate during his time with Sarah proved more challenging, and improvements came about in small, inconsistent increments. Russ’s ability to fully let go when in the presence of another was (not surprisingly) difficult to overcome. Russ’s childhood home taught him to self-protectively be on guard against the ire of his warring parents. Hypervigilance in the presence of others became his lifelong strategy for survival. Overcoming the trauma of his childhood took considerable work in psychotherapy, but eventually, Russ was able to ejaculate in Sarah’s presence. First, he was able to ejaculate in her presence via solo masturbation. This then progressed to Sarah being able to bring Russ to ejaculation using her hand, and eventually, Russ was able to ejaculate during sexual intercourse. Each of these successive advances occurred inconsistently for quite some time but gradually became easier and easier to achieve. During times of emotional stress/dysregulation on either of their parts, Russ will regress, but such regressions are temporary and typically resolve in a matter of days to weeks. Both Russ and Sarah are pleased with their movement, and treatment is ongoing.
Russ and Sarah’s story illustrates many of the seminal points in existential sex therapy. Note the existential concerns of a threatened existence and the penis speaking through a self-protective shutdown of sexual functioning. Russ feared his existence would be snuffed out if he allowed himself to be emotionally close to Sarah or allow himself to feel joy/ pleasure. In addition, Russ became increasingly aware of his isolation from himself. When with Sarah, he was so consumed with scanning her reactions that he completely lost sight of his own desires. Russ’s anxiety about displeasing another meant that the only time he felt sexually comfortable was during solo sexual activity, when he could focus exclusively on himself with no distraction.
Russ was a man who was deeply untrusting of others, and this, along with his isolation from self, negatively affected his budding relationship with Sarah. While what makes psychotherapy work is always somewhat mysterious, it seems clear to me that a significant aspect of Russ’s improvement was the quality of the therapeutic relationship built between the two of us. Over time, Russ came to trust that my interest in him and his well-being was genuine. As his comfort with me increased, Russ was able to take more risks in therapy and reveal more and more of himself. In addition, he was able to venture into unexplored territory as he began to learn more about himself, his feelings, his fears, and his desires. Existential sex therapy, like existential psychotherapy, is rooted in the depth of the therapeutic relationship. The elements of connection, genuineness, compassion, and safety are the most potent tools available to the practicing sex therapist.
I am often asked if behavioral sex therapy exercises have a place in existential sex therapy. While I tend to use them sparingly, they certainly have an important place in providing some immediate relief of symptoms and encouraging patients to take risks and move forward. However, I believe that a therapy that was primarily based in behavioral exercises would have been ultimately ineffective for Russ. Russ had suffered so much damage from his family of origin that without doing deep trauma work with an existential lens, he would not have allowed himself to move toward tolerating the experience of pleasure. In addition, exercises that focused directly on the functioning of his penis would have been of little value until Russ better understood the messages of anxiety and trauma being communicated to him through his penis. Frankl’s process of dereflection allowed Russ to focus on triggering of childhood trauma and allow his protective unconscious to loosen its grip. Still, behavioral suggestions clearly had a place in Russ’s treatment, as merely working through the trauma of childhood would not have given him the sexual skills he required. I am often reminded of one of Yalom’s most important axioms: “Insight without action is merely interesting.” All good therapy needs to move the patient beyond the point of insight to take the necessary emotional risks to make use of such insights and awarenesses. As a result, even though the bulk of my therapy focuses on deep reflection and insight to assist the man in better understanding the message his penis is sending him, I often find behavioral exercises or suggestions to be of great value.
Let’s examine another case that illustrates the principles and process of existential sex therapy.
The Case of Ascher
Ascher was a 44-year-old man who had been married for 21 years to Marcie. Both reported a generally satisfying relationship that had recently become distressed due to Marcie’s discovery of Asher’s many infidelities. Ascher admitted to frequent use of pornography, chatrooms, and sex workers. Marcie discovered Ascher’s transgressions after being diagnosed with a sexually transmitted infection at a routine GYN exam.
Both Ascher and Marcie were religiously observant, and sexual intercourse was not attempted until after marriage. Sex seemed to proceed smoothly with little complication for the first 12 to 24 months of marriage. Both reported a high level of sexual satisfaction during this time. However, Ascher began to pull away from Marcie sexually, and their sexual frequency quickly diminished. When Marcie questioned Ascher about his apparent sexual avoidance, he offered some vague explanations and vowed to increase the frequency of his sexual initiations. Ascher did begin to initiate sex more often, but then he often would experience erectile loss just prior to vaginal penetration. Both Ascher and Marcie found this distressing, but Ascher was reluctant to consult his physician and instead just drifted further away from Marcie sexually. Marcie was troubled by Ascher’s lack of interest in pursuing an answer to this conundrum, and the two began to fight repeatedly. It was later discovered that Ascher’s reluctance to consult his physician was due to his awareness that his erectile difficulties did not occur during solo masturbation or inter- actions with sex workers. Had Marcie not been diagnosed with an STI, this cycle of sexual avoidance may have continued indefinitely, as divorce was not a consideration for either of them.
Ascher agreed to begin psychotherapy and consulted a “sex addiction specialist.” Sex addiction therapy proceeded for about a year, but improvement was minimal. Therapy focused primarily on behavioral interventions designed to control Ascher’s urges to sexually “act out,” as well as regular attendance at a 12-step sex addiction group. Ascher reported enjoying both the individual therapy and the group meetings and found the support he received from both to be very meaningful. However, Ascher felt that his issues were not being adequately identified and addressed, and change was negligible. Both Ascher and Marcie were frustrated by the lack of progress, and they were referred to me for an alternative approach to the problem.
My initial meeting was with both Ascher and Marcie, but their wish was for Ascher to receive individual psychotherapy. Marcie attended the session to be supportive and offer to be helpful in any way she was needed. However, Ascher felt he needed to “confront his inner demons” and wanted to do this via individual treatment. I agreed, as I thought Ascher’s difficulties preceded and were separate from his relationship with Marcie, and we agreed to begin individual therapy with the idea of bringing Marcie into the therapy at a later point if necessary.
Ascher and I began by discussing the onset of his problematic behavior. He reported that he had never felt sexually conflicted or compulsive prior to his marriage to Marcie. He reported loving Marcie and thought she was an outstanding wife, mother, and friend. He found his behavior puzzling, as he found her sexually attractive and enjoyed sex with her greatly. We also discussed his prior psychotherapy and what he found helpful and not helpful about it. Ascher recalled liking his therapist and felt great relief at being able to discuss what he had been keeping hidden for so long. He also enjoyed the support and camaraderie of the 12-step group but had a nagging sense that as inconceivable as it was to him, his problem was not really about sex, which was the sole focus of his prior therapy and the 12-step group. I asked him if his problem was not about sex, what did he think it was about, but he had no answer and found his situation to be quite puzzling.
We next began to talk about Ascher’s family of origin and childhood memories. Ascher was the oldest of five boys born to a religiously observant mother and father. He reports a generally happy home environment in which the laws and rituals of Judaism were practiced, celebrated, and enforced. Ascher was educated in Jewish day schools, where he received both secular and nonsecular education. He recalls enjoying school and being a very good and popular student. Ascher was very much committed to his religious teachings and practices but recollects always fighting a desire to rebel. He didn’t mind or object to any of his religious obligations but always felt an objection to being “controlled.” Ascher described himself as being an intensely curious youngster who frequently questioned the absoluteness of rabbinic authority and wanted to know what the “forbidden” experiences would be like. He had questions about the laws of kashrut (the requirement to keep a kosher diet) and often felt a strong urge to sample non-kosher food and, on occasion, did secretly indulge. As an adolescent, Ascher experienced the expected sexual urges and desires and would occasionally allow himself to masturbate. These transgressions left him feeling guilty but pleased by his displays of autonomy and independence. Again, it was not that Ascher felt forced into a life of religious observance that he did not want, but Ascher abjured feeling controlled, stifled, and limited.
Ascher reported that while he was eager to marry Marcie, he felt rather quickly like marriage was “suffocating.” This feeling was quite surprising to him, since he believed he enjoyed being with Marcie a great deal. Nevertheless, marriage quickly felt confining, limiting, and controlling. Since Ascher did not engage in premarital sex, he did not know how he would have behaved sexually in another relationship with someone besides Marcie, but he suspects he may have felt suffocated in any relationship that removed his ability to feel as if he had choices.
It was becoming increasingly clear that Ascher was reacting to feelings of being controlled (losing his autonomy) and suffocated. Existentially, this would correspond to Yalom’s dilemmas of freedom and mortality. Ascher’s problematic sexual behavior was likely his response to these internal and unacknowledged conflicts, much like his desire to sneak non-kosher foods when a young boy.
When I mentioned this to Ascher, he responded immediately and enthusiastically that this conceptualization resonated strongly. Ascher then described the strong obligation he felt to not disappoint his parents or to be a poor role model for his brothers. Throughout his life, he felt both proud of and burdened with these responsibilities. The combination of family and religious obligation often made Ascher feel as if his life was not his own, and he struggled with his desires for freedom and autonomy against the perceived constraints imbedded in so much of his life. He reported never having expressed these feelings to anyone before, and this was never explored in his prior therapy. As our discussion continued over the weeks and months, it became increasingly clear to Ascher why he was behaving as he was, and he felt that now that he had a substantially greater insight into the meaning behind his actions, he would have an easier time dealing with them. It was now time to ask Marcie to rejoin the therapy.
Marcie was pleased to participate in the therapy, and she had been doing important work on herself in individual therapy. She reported being pleased with Ascher’s new understandings and insights but found herself struggling with issues of trust. Her existence now also felt threatened, as she saw Ascher as not only someone she loved but also as someone who had the ability to do her great harm and destroy the life that she loved. It was determined that they would be best served by another psychotherapist for couples’ therapy, since Ascher wished to continue his individual therapy and growth with me. Both Ascher and Marcie agreed that this was the best way to go, and I referred them to one of my colleagues who did couples’ work. At the time of this writing, Ascher continues a productive individual psychotherapy with me, and the two of them are doing well in couples’ therapy, having recently begun resuming their sexual relationship.
The case of Ascher again highlights how the penis speaks for distressed men. Ascher shut down sexually when he began feeling suffocated and constrained. First, he pulled away sexually from Marcie. This was of great concern for her, and she began to push Ascher for an explanation. Since Ascher felt unable to express his feelings for fear of acknowledging his “less than pure” urges, he subordinated his emotions and tried to bypass them. He then tried to accede to Marcie’s wishes and continue to interact sexually with her, but his protective unconscious would not let his penis function, and the sexual shutdown took a much harder-to-explain path. All of this was further complicated by Ascher’s frequent use of pornography and sex workers. These outlets, while making Ascher feel extremely guilty, also provided him with the “reassurance” that he was not being controlled and still possessed the autonomy to rebel against expectations. Given the internal conflicts Ascher was battling, it is little wonder that a therapy primarily focused on behavioral exercises designed to increase sexual interest and improve erectile functioning fell short. Ascher’s protective unconscious would thwart all efforts to move into territory that created an existential threat to him. Until those unacknowledged and unexpressed conflicts had been exposed, Ascher was unable to understand, and therefore change, any of his problematic behaviors.
Oftentimes, behavioral sex therapy’s treatment failures alert us to the possibility that something else is going on, and it is in these cases that an exploration of existential issues may be most helpful. In the case of Ascher and Marcie, we see that once again, the penis speaks and, according to well-known psychologist and sex therapist Kathryn S.K. Hall [with whom I had personal communication, sometimes it yells!
***
In this chapter, we have explored many of the most salient features of existential sex therapy and how sex therapy with an existential lens differs from most traditional forms of sex therapy. Ascher’s case provides us with an excellent transition to our next chapter, hypersexuality, or what is often referred to as sex addiction. Many of the patients we see in sex therapy practice are not suffering from a sexual shutdown but what appears to be quite the opposite — a pattern of sexual behavior that they find difficult to control and manage. The existential issues in cases of hypersexuality are often most closely aligned with fears of death and mortality. Let&
Stefani Goerlich on Becoming a Kink-Affirming Therapist
But pain is a very subjective term and varies widely based on the individual. When I’m training other professionals, I talk about sadism and masochism as the exchange of intense sensation. So, within kink relationships, we’ll have one or more of those three—an exchange of control, an exchange of authority, or an exchange of sensation.
On one hand, E. L. James did a great job of bringing kink dynamics into the mainstream, where soccer moms, housewives, and school teachers were reading about this kind of relationship. It was no longer the secreted experience of buying the pulp novel from behind the counter at the adult bookstore. So from that perspective, it was fabulous.
Unfortunately, the actual relationship the 50 Shades books portray is incredibly abusive. It is not a healthy model of kink. And in fact, the only time I mention it in my intro talk is as a case example where I walk people through a case study and offer a few different scenarios. I then ask the participants to tell me if the various scenarios represent consensual kink or domestic violence. At the end, I ask them if they recognize my case study, which is 50 Shades. So, it’s done wonders for normalizing conversations about and knowledge of BDSM. But I think it’s done a lot of harm in terms of how people understand BDSM relationships to actually be.
When somebody who has struggled to form relationships because they have abusive patterns now decides, “Well, I’m a dominant and so the way I have a relationship with a partner who won’t leave me is to find a partner who likes being mistreated.” That sort of mindset misunderstands what it means to be submissive and also misunderstands what it means to be dominant.
In kink-affirming practice, we would look at the use of protocols and rituals to enhance the work that we’re doing with clients perhaps with a trauma history or with a rejection dysphoria. Working daily protocols with their partner into their treatment planning can be really positive for them. If we’re working with somebody with disordered eating, for example, working with their partner—their dominant partner—to help establish rules around that so that they have accountability in their relationship in a way that doesn’t feel focused on their eating but becomes an act of service to complete a meal, can be a really healthy reframing for them.
Another great example for a dominant partner would be—I had a client who struggled with their own med management, blood pressure medication in this case. But they were very busy, and because it wasn’t a huge priority for them, their health was compromised. So we actually worked together to make it an act of service for their partner to remind them of their meds. It became, “Sir, it’s 6:00. It’s time for you to take your medication.” In another context, or one that was not kink-affirming, this reminder could have felt bossy or nagging, controlling. But we played to the strengths of their dynamic and made it something that felt like service to them. Both of these examples reflect a DS context.
If they have a consenting partner who enjoys receiving the kind of aggressive sensation they want to be giving out, then, yay, we all win, and nobody’s consent is being violated. But we also need to recognize that there is such a thing as prosocial sadism—people who enjoy evoking these reactions in willing people who, in turn, enjoy receiving these sensations. We need to be mindful as clinicians to not assume deeper social or psychological implications here simply because our clients enjoy giving or receiving these intense sensations.
Another good chunk of my practice is people who are experiencing desire discrepancy between themselves and their partners, mismatched fetish interests, mismatched kink dynamic interests. I’m starting to look at those sorts of cases more as a mixed-orientation marriage than as a libido issue, because when we look at things as a desire-libido issue, we’re operating from the assumption that one person’s libido needs to be adjusted. When instead we look at it as a mixed-orientation relationship, neither person is wrong. Neither person needs to be fixed or corrected or medicated. We simply need to find the Venn-connection between their common erotic maps. So helping these couples through a mixed-orientation framework has become a big part of my practice.
And the last group is couples and individuals who are newly aware of or newly willing to discuss their interest in kink or polyamory. They’re coming to me for guidance and for a place to talk through and process these new ideas and new experiences as they start to enter into those initial sort of explorations and community engagements.
I think that one caveat I would add is we need to be willing to let clients teach us about their dynamic and the way that they do kink. I do not think we should be looking to our clients to educate us about kink in general. We need to be pursuing continuing education. We need to be reading books or watching documentaries or attending conferences written by members of the kink community. We need to be educating ourselves, and then asking our clients, “What does this look like for you?” I don’t think it’s fair to ask our clients to pay us to use their therapeutic hour to teach us what we need to know to do the work with them.
But for me, in terms of comfort, really diving into the details of somebody’s experience, where I’m able to sit and hold space for a given narrative, people who are zoophiles—that’s something that I personally struggle with.
Thankfully, I have colleagues I can refer out to. And I do. And again, I’m not necessarily putting a moral weight on that. It’s just I can’t be what they need. I work with people who struggle with pedophilic urges. And I’m comfortable doing that. I’m a member of the Association for the Treatment of Sexual Abusers. I’m comfortable working with non-offending pedophiles. I don’t work with actively offending pedophiles. But for the most part, those are the two big ones for me. I have people that engage in a lot of niche fetishes that some of my peers struggle with, like coprophilia. So, most things I am fully capable of holding space with. For me, really, just in terms of being able to sit and hear the stories and process and be present for, those are the two that I refer out for, personally.
And we have a huge population of young people who know that this is a part of how they form relationships, how they give and express affection. And yet they can’t attend kink conferences. They can’t go to BDSM events. And absolutely, we have to be aware of predators and of problematic situations. That’s because, when you’re talking about power exchange in young people, you want to make sure that they’re capable of consent. So, there are really no great answers. I think where I focus with parents is on recognizing that BDSM is a healthy relational expression, on normalizing BDSM as something that can be done in a safe, consensual way, on recontextualizing power exchange as not coercive and grooming behavior, but as a future relationship model their children may aspire to. Even though they’re not adequately able to enter into a dynamic like that now.
There was nothing I could say to that. You have to respect everybody’s process. But it broke my heart a little bit because they deserved to—whatever their identity was—be affirmed in that. Whether that was a heterosexual cis-man that just liked wearing dresses every so often, or whether that was a complete reshaping of their gender identity, I wanted them to be loved and accepted for who they were. And after having so many conversations about what it would be like if they could have that, to have them come in and say, “I just decided it’s not worth trying,” was really—it made me very sad for them.
I then asked her, “How much of this is okay, because not everything on here can be healthy. And sure, there are things on the Wheel of Power and Control that can be negotiated. Absolutely. Name-calling—absolutely. If that’s your thing, go for it. But there are some things like threatening to harm pets or children that are never a part of—and it seems sort of counterintuitive considering the conversation you and I have had.” Looking back on that powerful interchange, I was able to help somebody understand that they had been gaslighted by their partner into thinking that she was just a terrible submissive, and, if she was just a better submissive, they would have a great relationship. She understood at that moment that this was not kink, that this was a really abusive relationship—and that was very hard.
That was the start of about two years’ worth of work. She ended up moving out. He ended up making some threats to me. I had to have security walk me to and from my car for quite a while. And then she terminated. And I was worried about her. But last summer, out of nowhere, I got a text message saying that she had moved across the country and she had gotten her dream job and she had a new dog that she’d always wanted to have that he would never have let her have. It was a very lengthy text message. And she was just living her best life. And she told me that she would never have thought that she was capable of doing that if she hadn’t had me look at her and say, “This isn’t what kink looks like.”
Countertransference to Sexual and Developmental Trauma in the Psychoanalysis of a Disabled Patient
Our First Meeting
Referred to me by a colleague, Tanya was an elementary school principal who had polio as a child. When I initially asked my colleague how severely Tanya had been affected, she told me, “It isn’t too bad.” When I opened the door to my waiting room to greet my new client for the first time, I was shocked to see that Tanya had a deformed arm and leg. She struggled to get out of the chair and when she stood up, I was struck by the contrast between my colleague’s description and the reality before me. I wondered what made my esteemed colleague deny the severity of Tanya’s deformity.
Tanya settled into the chair in my office and was silent. Although she was in her late thirties and a successful professional, she was dressed like a pre-adolescent in short white socks and sneakers. When I asked what brought her for psychotherapy, she said she wanted to feel sexual.
“Everyone else has somebody,” she said. “They have a husband, they have children. I have nothing. I hate my life. I need something, help me, help me,” she cried. “I need something. I want someone to love me. I want to get married. I want a family."
In her third session, Tanya began talking about her deformity.
“Nobody can see it,” she said. “Nobody knows I had polio, that’s why nobody says anything about it. You can’t tell, can you? Can you?”
Shocked that she could be in such a state of denial, I hesitated a moment.
“Yes,” I said as softly as I could, “I can tell you had polio.”
“I’m sorry. How can you say that?” she yelled. “You’re horrible. I’m sorry. I’m not coming back.” She hugged her purse but did not leave.
Tanya’s pleading for me to deny her deformity and the repetition of “I’m sorry” continued for many months. It grated on me. I wanted to yell at her: “Stop it, I can’t stand it.” Session after session as the same scene unfolded over and over, I felt tortured by her, and I felt guilty for feeling tortured.
““I think my mother couldn’t stand me,” she said. “She wanted me to go away.””
Finally, to my great relief, I realized that this was an enactment of her experience with her mother.
When Tanya was ten, she complained that she had intense back and neck pain, but her mother told her “it was nothing” and to go to sleep. But Tanya could not sleep. Finally, when she was in such pain that she couldn’t walk, her parents took her to a doctor, who said she had polio and needed to be hospitalized immediately. Her parents did not explain it to her. The doctors explained it to her parents, but not to her. She did not understand that she would have to remain in the hospital for several weeks. Her parents did not visit every day because the hospital was far from their house, and when they did visit, they only stayed for an hour. Tanya was filled with anxiety and rage.
When she was finally released from the hospital, recuperating at home, Tanya often pleaded for her parents to tell her she would not have to go back to the hospital. Her parents said, “No, don’t worry.” They knew that was not true, but they could not bear her reaction to the truth. When she had to go back a second time, she was enraged that her parents had lied to her.
“Tanya felt betrayed and unprotected”. Her parents said they would visit and didn’t come; they said she would be fine, and she wasn’t. After a while she felt that she could not trust anything they said. Later, when she went through puberty and the curvature of her spine worsened, her mother assured her that no one could tell she had had polio.
I knew that telling Tanya that I could see her deformity would enrage her. But if I had tried to avoid it when she communicated “Don’t you dare say you can see it,” I would have communicated that I was unable to deal with the reality of her polio—just like her mother.
Nevertheless, I continued to feel I was between a rock and a hard place with Tanya. I did not want to lie to her as her mother had, but telling her the truth enraged her.
“Do you think I’ll get married?” she pleaded over and over.
I felt a wave of meanness. The lyrics to “Que Sera Sera” came into my head:
“When I was just a little girl
I asked my mother
What will I be
Will I be pretty
Will I be rich
Here's what she said to me.”
I knew any answer other than “yes” would result in her fury and threats to quit treatment.
“I cannot predict the future,” I said. “I don’t know if you will get married.”
“You’re horrible,” she yelled, picking up her purse from the floor and embracing it. “How can you say that to me? I’m sorry. What’s wrong with you? I’m sorry. I’m not going to come back anymore…”
“What would you like me to say to you?” I asked. My head throbbed.
“That I’m going to get married like everyone else. What’s wrong with you?” she yelled.
“Do you want to get married?” I asked.
“Of course, I want to get married. But who will want to marry me?” she cried.
“I could hear my heart thumping. What am I going to say to her?” She was right to feel her chances were diminished because of her disability.
“You’re right,” I said. “There are some men who will not be interested in you because you had polio. But there are some men who don’t have perfect bodies either or who are more interested in finding someone who they can feel close to than whether her body is perfect.”
She was quiet.
“You had polio, and it affected your arm and your leg,” I said. “That is part of who you are, but that is not all that you are.”
Tanya had not been able to accept that she had polio and tried to cope with it by joining in her mother’s denial that it was visible. I realized that my referring colleague had also been drawn into the denial.
Being a Sexual Person
As the treatment deepened, it became clear that Tanya’s overwhelming anxiety was not simply the result of her polio. One session was a turning point in our understanding Tanya’s level of anxiety and confusion. She began by talking about seeing her doctor for dizziness.
“I went to see Dr. Roberts, and he took my blood pressure,” she said. “It was lower than it has been since this whole thing began. But then he took it ten minutes later and it went up. But it still wasn't as high as it has been in the last few weeks.”
Tanya sat with her legs spread apart. Her crotch was in full view. She did this often when she was wearing a skirt. I was trying not to look at her crotch while she was talking to me, but I thought she was not wearing underpants. I thought to myself that perhaps she was just wearing dark underpants. At first, I questioned whether I was imagining things, but I knew what I was seeing. I started thinking about how to handle it. If I ignored that she seemed to be exposing herself to me, I would be denying the reality. On the other hand, I knew that however I said it to her, she would be mortified and furious at me if I brought it up. In the past I felt the mortification would be too much for her, but this time I felt I could not ignore it.
“Are you aware of how you're sitting?” I asked.
Tanya immediately put her knees together.
“What are you talking about? What are you saying? I'm sorry. You hate me. You think I'm bad. What are you saying? You want me to leave?”
“I don't hate you,” I said. “I don't want you to leave. You were sitting with your crotch exposed to me, and I think that has some meaning. Don’t you?”
“I'm sorry. I like you and I respect you. I don't know what you're saying,” she cried. “You think I'm bad. I'm sorry. You want me to leave.”
“I know you like me and respect me, and I don't want you to leave,” I said. I leaned forward in my chair. “I don't think you are bad. You don't need to apologize. I just think that sitting like that means you have some feelings about yourself and about me that we need to understand.”
“I'm sorry. Sitting like that doesn't mean anything. I just don't think it matters how I sit.”
“You mean it doesn't matter if your crotch is exposed or not?” I asked.
“”I just don't feel like a sexual person. I don't feel like a woman”. Look how I dress. Look how I take care of myself. I just don't feel like a sexual person; that's why it doesn't matter how I sit.”
“You mean you feel like there's nothing between your legs?”
“That's right. What's between my legs is dirty and smelly and bad and disgusting. You don't want to see it.”
“So you think that I am pointing out how you're sitting,” I said, “because I feel your vagina is bad and smelly and disgusting.”
“I offended you. I'm sorry. I won’t do it again. Don’t worry about it.”
“You didn't offend me. But I think exposing yourself is a way of telling me something.”
“You know, you're really inappropriate sometimes. I can't believe you said that to me. Who would say such a thing? I don't know anyone who would say such a thing.”
““You mean you would rather I act like your mother and make believe that there's nothing between your legs or that it's too disgusting to talk about?””
“Maybe it's like the polio. I don't want you to see that I have it. I want you to say you can't tell I have it. But I also don't think I have anything. I am completely out of touch with my body,” she said, crying. “I don't feel connected to it. I can't touch myself still. I don't feel like a woman. Even now with the operation, I still don't really have breasts. Sometimes I don't even bother to wear a bra.”
“What about underpants?”
“What do you think is wrong with me? Do you think I don't wear underpants? Of course I wear underpants.”
“If you don't feel you need to wear a bra because you don't feel you have breasts, I wondered if you don’t wear underpants because you feel you don't have a vagina or clitoris."
“Of course I wear underpants, what do you think is wrong with me?” she yelled. “How could you say that. I can’t believe it. You must think I’m disgusting.”
She got up and walked out of the office. I was not sure she would come back.
When Tanya did come back for the next session, she was angry for the first few minutes. But then she told me that after the session she remembered her mother sitting in the living room on the couch with her legs spread and touching herself.
“You mean your mother was masturbating in front of you?” I asked.
“Yes. She did it in front of my brother too. I wasn’t sure what she was doing. I asked her to stop, but she said she wasn’t doing anything.”
Tanya explained it was like listening to her older brother masturbate. She told her mother that her brother was making strange noises and she didn’t want to share the same room with him, and her mother told her it was nothing and she should just go back to bed. Tanya grew up in a dark, one-bedroom apartment. Her parents slept in the living room, and she and her older brother shared the bedroom. Her parents could have afforded a larger apartment and were even offered one for modest cost in the same building, but her mother did not want to move.
Her mother and brother overstimulated Tanya, and her mother’s denial gave Tanya no protection from the anxiety created by it. Tanya was forced to develop other ways of coping—being confused, not knowing if she was hearing things or not. Her anxiety was so overwhelming it interfered with her thought processes and her reality testing. Years passed in therapy before Tanya brought in a dream she identified as sexual.
“My car was damaged, someone hit it and the door and fender were all bent. I looked underneath, and it was perfect. I felt surprised and happy.”
“When did you have the dream?” I asked.
“I had the dream after our last session. I think it’s about myself. I am finally accepting that I am damaged on the outside, but I am all right inside.”
“Yes, it sounds like a positive dream. What comes to mind about looking underneath?”
“It was underneath the hood. Inside. But it sounds sexual doesn’t it? Maybe I realize that I am damaged outside, but I am not damaged sexually.”
“And you're surprised?” I chuckled.
“Yes, I have always been afraid of sex. Something is wrong with me. When I go to the gynecologist, she can’t even examine me.”
“Because you are so frightened that you have a spasm?” I asked.
“Yes,” she said. “”I have always been terrified of touching myself or someone touching me”. I’m terrified. I just see a man with a suit eating pizza and I think he’s cute and I feel terrified.”
“I think you have sexual feelings,” I said, “and then imagine he wants to have sex with you right there in the pizza store and then you are terrified.”
“Yes, I only feel the terror, but I must be having sexual feelings,” she said.
“I think you become overwhelmed by your sexual excitement and project it onto the other person and then feel terror. You know when you would lie in bed listening to your brother masturbating and coming, that was overstimulating. You knew it and went to your mother, but she denied the whole thing and told you to go back to your room. You couldn’t get any help protecting yourself from the overstimulation.”
“It was normal for him to masturbate. I know kids masturbate, but I shouldn’t have been in the same room. I should have had my own room, and when she just told me to go back to bed and ignore it, I must have felt flooded.”
“Exactly,” I agreed.
“You know, she said, “I had another dream last night. “I was watching somebody teach somebody how to dance. This young girl was very graceful, and she was moving very well. She knew how to dance. They were getting ready for a wedding.”
“How did you feel in the dream?”
“I felt good,” she chuckled. “I felt I could learn to dance. You know, they had dancing at my beach club on July 4th, and I didn’t dance. But next week, they’re having a DJ and they are doing line dancing, and I’m going to get up and learn how to do it. I’m going to join in.”
The following session, Tanya came in saying she had a dream about tongue kissing the night after the last session.
“I was eating dog food, and my mother was telling me I was eating dog food. I was licking the bowl like a dog and I got nauseated after she said that, and I threw up in the dream and, in my bed. I was gagging and choking.”
“What comes to mind about dog food?”
“Dogs go right for sexual gratification, they’re animals. They can’t delay gratification. Maybe I’m the one who’s bad because my mother tongue-kissed me in my dream. I was acting like a dog.”
“Maybe we're acting like a good dog—a loyal dog does whatever the master wants,” I said.
“Dog food looks like shit. I was eating shit. All my life I was eating shit. I was an obedient dog. Every day I was choking and gagging before I went to school. In the dream I said, ‘I must get it out of me.’ Something was stuck in my throat. It’s a feeling of fear. You know, my brother can’t swallow pills; he gags also.”
“Really!?”
“What could be stuck in my throat? Do you think this is at the bottom of why I can’t touch myself or have sex?” she asked.
“Yes, I think that your mother was crazy, and she masturbated in front of you and acted like nothing was happening and kissed you sexually and acted like it was normal. When you told her your brother was masturbating and you didn’t want to share a room with him, she said it was nothing and you should forget it. I think this is only the tip of the iceberg. I think there’s a lot you haven’t been able to tell me yet. Maybe you’re afraid I’ll think you’re bad.”
“Yes, I think so. You know, she would sit with her legs spread apart and pull her underpants to the side and play with herself. She did it while we were watching TV. My father was there sometimes, and he never said anything. My brother was there. If I asked her to stop, she would ignore me.”
Homosexual Feelings
Tanya was angry because I did not hear the doorbell—she had to ring twice, and the clock in my waiting room was four minutes fast. Anything that questioned reality (e.g., what time is the session) threw her into questioning everything. I also thought it might make her feel that I was out of control or her feelings toward me could get out of control. Maybe she felt I was like her mother if the time was wrong and I didn’t hear her. It threw her into a panic attack and made her question reality.
The next session, Tanya came in saying that she was upset and sad after our last session. It might have been from talking about how sexually stimulating her house was and that she might have felt aroused by it, or it might have been about my clock being wrong. She said the erroneous clock made her feel crazy. Then she moved on to talk about being angry at a teacher with whom she worked. She thought he was gay but that he could not deal with it because he was religious. Then she talked about being angry at her friend’s husband, who always talked about women he wanted to screw. Tanya thought it was a defense against his homosexual feelings.
“It’s interesting that in both cases you’re angry at people who are denying their homosexual feelings,” I said.
“Do you think I’m homosexual?”
“No,” I said, “but I think you might be afraid that you have sexual feelings about me.”
“That would be inappropriate, wouldn’t it?”
“No, I don’t think feelings are appropriate or inappropriate—they just are what they are. We don’t have control over our feelings, only our actions. Considering your mother’s sexually provocative behavior toward you, I don’t think it would be surprising if you had sexual feelings about me.”
“How would you feel if I had sexual feelings toward you?” she asked.
“I would feel happy for you that you were able to be in touch with your sexual feelings, whatever they are. You haven’t been able to experience them at all.”
“After the last session I had this tension in my inner thighs. Do you think that was a sexual feeling?” she asked.
“Yes, I think that was sexual tension.”
“How do you get rid of sexual tension?” she asked.
“Well,” I said, “you could masturbate or have sex with someone else. Sexual tension gets built up and then released when you have an orgasm.”
“I have to get a Pap smear on Wednesday. I’m afraid I won’t be able to do it. I feel like canceling it.”
“Are you afraid of having sexual feelings during the exam?” I asked.
“Yes, what if I have sexual feelings during the exam? What should I do?”
“You don’t have to do anything. You can just have them, and eventually it will pass.”
“Oh,” she said, seeming relieved.
Fear of Driving Me Away
Tanya walked into my office and sat down clutching her purse on her lap.
“I couldn't find a parking spot. It's getting harder and harder to find a spot around here. It makes me so frustrated,” Tanya said.
“What about that?” I asked.
“It makes me feel so annoyed and angry.”
“Maybe you're annoyed and angry at me?”
“No, I just can't stand how hard it is with all the traffic and it's so hard to find a spot. It makes me not want to come.”
“Maybe you had some feelings about coming today?” I asked.
“I was thinking about stopping,” she cried. I have too many feelings about you. I'm sorry, my feelings are too strong…”
“What are you sorry about?” I asked.
““You don't want me, you wish I'd go away,” she said angrily”.
“What is it about you that makes me want you to go away?”
“I'm sorry, I have too many feelings about you.” She picked up her purse and hugged it.
“You mean I can't stand your feelings about me?”
“I'm sorry. I want too much; you won't want to give it and you'll want me to go away.” Tears flowed down her cheeks.
“Why would your feelings be so intolerable to me?”
“I want to talk to you all the time. I'm sorry.”
“If you want to talk to me all the time, do I have to do it?” I asked. “Why can't you want whatever you want?”
Tanya looked surprised. “Because I want you to do it!”
“If I felt I had to do whatever you want, I wouldn't be able to stand your feelings. But I don't feel I have to do things just because you want them, so I can allow you to want whatever you want.”
“I don't think my mother could stand my feelings,” she whimpered.
“No,” I agreed, “because she felt she had to do something about them and she couldn’t, so she wanted you to go away.”
Transference and Countertransference
Tanya’s transference changed during various times in the treatment. At the beginning, she experienced me as if I were her mother who wanted her to go away. But this was not a neurotic transference onto me; rather, she induced in me the feelings her mother had about her. She pleaded for me to lie to her but wanted to believe me. She wanted me to feel what her mother had felt but be a better mother than hers had been. It was a struggle for me; I felt harassed by her pleading and guilty for not feeling empathic. I found it difficult to bear her pain and her rage at the hand she had been dealt. Her demands for reassurance made me feel helpless, which is probably how her mother felt. I had to find a way to help her accept reality but also console her.
Later in the treatment, when she was finally able to deal with her sexual feelings, the transference shifted. She was not able to tell me what had occurred with her mother. Rather, she created an enactment of it so that I would understand what she had felt as a girl. I became confused about reality just as she had—e.g., is she wearing underpants?
Final Thoughts
Tanya would remain in treatment with me for over ten years. When she terminated, she was a much more integrated person. She felt like a sexual woman and got over her social phobia enough to develop close friendships with both men and women. Tanya was able to accept the gaslighting, denial, and lack of boundaries in her family. She became closer to her brother and convinced him to seek treatment.
Of course, there were many other issues in her treatment that I have not dealt with in this article—e.g., her envy of me for not having a misshapen arm and leg. I have only highlighted the issues of denial of her disability and the lack of boundaries and sexual overstimulation in her family.
I think it was important that I told Tanya her disability was visible for two reasons. First, she knew that it was. If I denied it, it would imply that it was so horrible that I couldn’t deal with it. I would be like her mother – distorting reality because I could not tolerate Tanya’s pain. Second, Tanya did not trust her parents because they consistently lied to her. She called me constantly to confirm our appointments. And when applying for a handicapped license and being told she would have to wait 60 days, she called them daily to confirm it. So I had to be truthful to build her trust, even though it enraged her.
Some therapists might have avoided confronting Tanya about exposing herself to me. It was awkward and uncomfortable for me, and it enraged her. However, I think it was a major turning point in the treatment. As a result, she was able to tell me about her mother’s exhibitionism; she became more able to identify and process her own sexual feelings, which reduced her projection of them onto men. She also made progress in being able to comfort herself.
Although Tanya was not able to have a sexual relationship with a man, she bought a dog and named him “Sigmund” as a testimony to how much psychoanalysis had helped her. She did the macarena with the husband of her friend and felt sexually aroused. She understood that her sense of sexual abnormality had more to do with her mother than polio.She also made progress in being able to find comfort. Although she was not able to have a sexual relationship with a man, she was finally willing and able to treat herself to massages regularly and was able to masturbate. Overall, Tanya had come a long way. Her social and sexual anxieties were greatly diminished and she had a much more fully developed sense of self. It was very hard work for Tanya, and in a different sense, for me as well.
David Nylund on Narrative Therapy, Curiosity and Queertopia
Narrative Therapy 101
You make it sound as if it’s a process of rewriting a life script in which the therapist is a co- editor or the editor. How do they work together to rewrite this story?
the problem is the problem, the person is not the problem. Peoples’ lives and problems are always relational and informed and shaped by the larger culture, especially around issues like normative ways of being related to race, class, gender and sexuality. And some of those dominant norms help shape peoples’ lived experiences and can contribute to their problems. So, the narrative therapist enters through an invitational conversation from a stance of curiosity about these alternative stories and what they might mean. I think the job of the narrative therapist is not to determine whether these alternative stories are good or bad, but to invite their client to become curious about them. And that might be an entry point into some new stories, and that entry point is often referred to as a unique outcome.
One of the things that is important in Narrative Therapy, but also one of its challenges, is that it requires clinicians to rethink some taken-for-granted ideas in our field, especially around identity. From a modernist perspective, therapists like Jill Friedman and Gene Combs refer to internal states of identity. It’s based on this idea that identity is fixed, it’s static, it’s inside the person. It’s often linked to biology, and it’s outside of language and history and context. From a narrative perspective, it’s more of what I like to call intentional states of identity.
narrative therapists practice a kind of curiosity about how things might be other than what they have been – a curiosity about hope and possibility.
The Narrative Therapist
As a social worker, I have a commitment to social justice. A lot of narrative therapists also have this experience of standing outside the norm in their own lived experience, in a good way, like a rebel or an outlaw. You know, like a commitment to a broad notion of queer. It’s not necessarily tied to gender and sexuality, just this broader definition of queer as a critique of norms and of normativity. I know that a lot of narrative therapists are committed to critiquing taken-for- granted assumptions or norms. I think that a narrative therapist is also drawn to new ideas and staying curious. It requires not just learning, but kind of more of an unlearning. It can be really challenging for people, especially if you’ve invested time in a model like CBT. It can be hard to give that up a bit.
What Counts as Evidence?
And alliance starts with how the client is doing. You create a culture of feedback. So, it’s interesting that some of the core ideas of feedback-informed treatment line up with narrative, right? Creating a culture of feedback, checking in, privileging the client’s voice. So, that’s one of the ways, strategically, we’ve been able to give narrative a voice. We use those measurements and the online program that gives all this data.
To me, unfortunately, it’s a reality that you need to have numbers. So, that’s one way we do it, and then there is a growing body of research on the effectiveness of narrative. It tends to be mostly qualitative. So, there is some evidence, but again, qualitative doesn’t earn the same merit as quantitative.
I think a lot of narrative therapists are just subversive, and they might also be able to work more independently in their private practices. It always helps if somebody in the agency who is a leader or director is supportive of narrative. That can help.
Narrative Thoughts on Gender
Narrative Therapy is informed by post-structuralism, and one of post-structuralism’s theoretical allies is queer theory, so there’s this connection between queer theory and narrative, because both are informed by social constructionism and post-structuralism, which pay close attention to dominant norms and language that can oppress folks.
So, it opens up that kind of dialogue about who gets to decide what’s normal. A lot of the conversations will be around these deeply entrenched gender norms, like masculinity, femininity, and around sexual identity. And I think it gives you some vocabulary; narrative offers a vocabulary to have those conversations.
And from there, she discussed a friend who supports her gender identity. And that led into some of the restraints and limitations of masculinity and toxic masculinity. I just kind of hovered around that, and then I said, “If you were to get a further appreciation of your bravery in living the counter story, what difference will that make towards your next step?” And that led to a conversation of coming to one of our programs at the Gender Health Center. It’s a respite program. It’s often more of a social context for trans folks who are feeling really isolated and disconnected to meet. You know, three days a week, they have this respite program. It’s for six hours and just kind of a place to hang out, relax, be yourself. They do some narrative work there, but it’s more just a meeting place.
So, by the end, she was open to going to that place. And then we talked about her ability to be more overt in her gender expression, and I noticed that she was wearing painted fingernails and earrings. We then talked about what those acts meant about her and ability to navigate her world, given that her parents wouldn’t be supportive because of their faith. I asked her to consider, “If I move forward, does that mean I’m no longer sinning?” And these kinds of discourses. That was the conversation, and then we had a reflecting team. And of course, in the team, there was various therapists who were queer or trans, so now this client is seeing community and support. One even shared that they also came from a deeply conservative religious tradition, and they talked about their journey and how they were able to move forward in their own life. So, that kind of gave the client some hope and inspiration.
Even Well-Meaning Therapists…
The client might identify as a trans woman but be expressing their gender in a way that’s read as masculine in our culture. And so, what the well-meaning clinician might do is mis-gender the person by not using the pronouns that the client identifies with. The therapist might not share their own pronouns, it’s sort of taken for granted that there’s a normal gender. They might focus more on voyeuristic curiosity about genitalia and might have normative ideas of what it means to be trans. And for trans folks, there’s no one monolithic trans experience.
And then, I think the therapist who’s cisgender–this being a term for somebody whose gender identity is congruent with the sex they’re assigned at birth–may have a lot of unearned privilege in many areas. I am cisgender and don’t get misgendered. If I go to a doctor, the forms are very clear for me. My gender is right there, I click the box male. I don’t have to worry about spaces like restrooms and public bathrooms. I don’t have to worry about questions about my genitalia or dating or all that sort of stuff. Cisgender people don’t necessarily have to worry about being harassed in public because of their gender presentation. So, I think therapists who have cisgender privilege often don’t really take that into account in their work with transgender people.
Another thing that I’ve been really thinking about a lot more lately is the Black Lives Matter movement and some articles I’ve read around transgender allies. I see myself as an ally, but I’ve been reading some material asserting that simply being an ally is not enough. It becomes an identity, a noun, not a practice, and you know the ally almost gets centered, and people build their whole career on being an ally and profit from it, but not necessarily helping the community. That was really hard for me to look at because I do good work. I try to use my voice to support marginalized communities like trans folks. I’m writing a book on it, I do speaking engagements, and so it got me to rethink about what is my role? Am I putting myself out there? Is there any sacrifice? And so, there’s these new ways of rethinking allyship and referring to being an ally as more of a co-conspirator or an accomplice. And that’s happening in Black Lives Matter movements. We don’t want white allies, we want white co-conspirators, where you hold your white colleagues and friends accountable. So, it would be like me, as a cisgender person, really holding other cisgender people accountable for when they make transphobic comments. So, I think those are some of the things that might contribute to well-meaning therapists who are cisgender inadvertently imposing certain ideas that are cisnormative or transphobic.
In a queertopia, we would dismantle the gender binary. There would just be multiple genders. There wouldn’t be a need to police sexuality, you know, these hierarchies of gay and straight. There would be a loosening up of these strict identity categories, because I think identity categories can be useful, but they also impose restraints and limitations.
If somebody comes out as gay, there’s all these normative ideas of what it means to be gay. So, it can become another opportunity for policing and surveillance. There would be more of a loosening up of these identity categories. There wouldn’t be a DSM. There would be more work in the communities and community work rather than just individual clinical work. I think it would also be intersectional, so there would probably be a lot of focus on anti-racism and looking at some of the ideas about what it means to be male. There would be a loosening up of those ideas. And there would be a lot of just understanding of people’s identities and lived experiences, not necessarily related to their biology, their genitalia. Those are some of my thoughts about what a queertopia would look like.
Hierarchies of Worthiness
We have this queertopian vision where mental health would get out of the way of people’s journey or transition, but that’s not the reality. Things are better. The standards of care when working with trans folks have moved a bit more towards depathologizing trans identities. In the DSM-IV, there was Gender Identity Disorder, now it’s Gender Dysphoria. The WHO (World Health Organization), in their next ICD – version XI, will no longer include gender dysphoria in the mental health section. It will be in the sexual health section. So, there is this movement forward. There are more trans voices, including trans folks who are providers, therapists. So, that’s the ideal, where it’s moving. But there still is this requirement by insurance companies and by physicians to diagnose a person with gender dysphoria. It needs to be medicalized in some way or psychiatricized, and since that’s the reality, I’m going to try to use my privilege, my credentials, to help make that gatekeeping as painless as possible, to not go through too many hoops.
What that might mean for me is that instead of a trans person having to see a mental health professional for a three to six session evaluation–which is a big cost and presents a barrier for so many folks, because this population is underemployed or unemployed–I don’t charge them if they need a letter. And I do it as fast as possible. I don’t really question them around whether they have a legitimate trans identity. I’m just using the letter to be an advocate, using letters as another form of co-conspiracy. It’s me saying, “You need this, I’m going to do it as fast as possible. One day, I hope we don’t have to do this, but in the meantime, you know, this is a way I’m trying to help support you.”
Final Thought
I’m working with one young trans man who then consulted another one of my clients and their parents because they’re earlier in their journey and had some questions. The dad is really concerned about hormones and their effects. So, I’ll use my other families’ experiences to help each other. I find that in my work with queer and trans youth, I’m always amazed and honored about how they’ve had to live their life and that they have these amazing ideas we can learn from as adults.
Coping with Infidelity in Professional Couples
Couples seek therapy for many reasons, but among the thorniest issues are those involving infidelity. Of course, circumstances vary widely, so it’s difficult to isolate causes that are equally relevant for all. Given that, I’ll focus on themes that have emerged with some professional couples with whom I have worked that have been married for some time (10+ years), with demanding careers, and for whom these issues arise after having children.
They may have met in college or graduate school. They became fast friends first, and they never imagined that would change. Both were career-minded and imagined living a life of significance, healthier and happier than that of their parents. They recognized one another as good, bright and hard-working persons. They felt heard, understood, and supported. They shared a vision of life.
Then, as the demands of their careers pulled them into individual tracks of ambition and responsibility, and as they began to have children, their friendship suffered—intimacy too. It wasn’t fully conscious yet, but they had become rutted in role-based “necessities” of duty and obligation. A shift occurred from a vital pursuit of happiness to accountabilities to children, home, and career—life felt burdensome.
The Sources of Disenchantment
The relative ease with which life’s demands were managed in the early, pre-parental years were gone. Back then, there was more time, unpressured and less distracted opportunities to talk. Everything was easier then, even though financial resources were limited. So, what had their success really purchased?
The couple was left feeling that life had somehow gotten away from them. They were overwhelmed and learning that feelings are a complex and nuanced form of meaning, confusing enough to experience let alone to articulate. It was easier when there was more breathing space, when they could get away for a weekend of hiking or big-city stimulation. Sometimes that alone, without talk was enough.
Taking on work-related duties, struggling to realize career aspirations, life became more serious. Then, with kids and parenting added to the mix, along with the financial demands of mortgage, child care, and interruption to a second income; it all added up to a loss of the enchanted vision of life they had in the beginning. Exchanges became strained. Soon they decided it just wasn’t worth the effort to argue.
They began wondering “is this all there is?” Exhausted by work strain, stressed by unrelenting demands, and lacking the friendship they once provided one another, they began to foreclose on the possibility of making things better. But settling is not very satisfying is it? Thus, arises the restless yearning.
Desperate Delusions
For these couples there is seldom a desire to abandon one’s partner. Very few had seriously considered divorce even as they began to look elsewhere for affection. Intact bonds remained that coexisted with urgent needs for emotional intimacy. They could not see a way to reconnect within the marriage. It’s a cognitive, emotional, and moral quandary that they’re unable to resolve, it looks impossible.
That’s where the desperation comes in. It may be equally felt by both members of the couple. But neither is able to frame the issues, broach the conversation, and make them “discussable.” They’ve learned (come to believe) that contentious tones, demanding voices and fault-finding quickly follows. So, they conclude, “I can’t meet my needs here; the situation won’t allow it.”
What they believe they cannot achieve in reality, they seek to address through fantasy and delusion, or perhaps more benignly framed—wishful thinking. Yes, there’s also the sense that they deserve something more and better given how hard they’re working. So, they seek “justice” through a kind of “let’s pretend.” They want to believe that there’ll be no harm as long as no one finds out. Sometimes drinking helps contain the cognitive dissonance. It’s regression in service of play, to invoke Freud, and a symptom of arrested development in the marriage.
The Bubble Bursts, Work Begins
When the truth comes out, a period of crisis ensues. Soon it becomes clear that the act of infidelity only ruptured a relationship that was already suffering from deep, long-standing strains. Upon reflection, both knew things were not going the way they wanted them to. In some cases, partners had even taken separate bedrooms, started vacationing separately, becoming more roommate than spouse.
But the initial disclosure brings jolting pain. Anger, embarrassment, and betrayal are only a few of the emotions that should be expected. It’s not a victimless act. The aggrieved party is deeply hurt. And the unfaithful party frequently suffers a different shame and loss of self-respect that he or she must endure without much sympathy while seeking redemption and forgiveness.
The saving grace for many of these couples is that they usually have reason enough to at least attempt reconciliation and repair. And if they seek help soon enough, before acting out their emotions in ways that make their problem even more difficult to address, their odds improve immensely. Because they are bright and hard-working, they may be able to use that ethic to persevere with the task at hand in some or all of the following ways.
Containment. The couple must have a safe place to process their feelings, and therapy must help them learn how to do even more of this outside the consulting room. Initially, they’ll struggle with managing the intensity of their exchanges outside of therapy.
Learning. The couple must now acquire the interpersonal communications skills to navigate emotionally charged conversations that they had earlier concluded were not possible. They will learn that doing good in their relationship requires knowing how to do good.
Forgiveness. Learning that infidelity is at least partly attributable to arrested development as a couple, a lack of insight, knowledge, skill, and hope concerning what was missing and how to correct it, helps both find a way to forgive.
Forgiveness is something we do for ourselves as much as for our partner. When we lose our capacity for the love, openness, and honesty to discuss the divide that is growing between us, it is not because we willfully intend to do harm to one another. We fail due to our fears and ignorance, our desperation and loss of hope. We lose the ability to focus more on coulds than shoulds.
This is what they learn in therapy.