The big issue: Are you GSRD competent?
Therapy Today, June 2023

More and more people in our population today identify with sexual orientations other than heterosexual and within a wider spectrum of gender identities than the binary of male and female. It is more likely for counsellors and psychotherapists to receive enquiries from these diverse populations, no matter where we are located geographically. Yet the counselling and psychotherapy profession still largely operates with the heteronormative, mononormative and cisgenderist lenses because most of the textbooks and training programmes we learn from are dominated by case study examples of heterosexual people and, in the context of couples therapy, by monogamous dyads. LGBTQ+ people, rather than being woven in throughout textbooks and trainings, are usually mentioned in one chapter or module on ‘special populations’.

Heteronormativity is the assumption that heterosexuality is the ‘normal’ and everything else is alternative (or weird). Mononormativity places monogamy as the ‘gold standard’ of relationships and everything else as alternative (or peculiar). Cisgenderism assumes that being cisgender is the natural gender expression and everything else is abnormal (or a threat).

The heteronormative, mononormative and cisgenderist biases, or unchecked blind spots, are captured in a study by charity organisation Galop,¹ which found that 80% of LGBTQ+ people were satisfied with a support service that was LGBTQ+ specific, but only 38% were satisfied with a generic support service. The stark difference in satisfaction reflects poor trainings in gender, sexual and relationship diversity (GSRD) and working with LGBTQ+ people. This finding is consistent with my own clinical experience of working with LGBTQ+ clients who specifically seek therapy from a GSRD therapist due to past negative experiences of therapy.

There is still much homophobia, biphobia and transphobia in the world. Safe therapeutic spaces for LGBTQ+ people are absolutely essential – often they make the difference between someone deciding to end their life or not. I believe that our counselling and psychotherapy profession can do better in ensuring that all therapeutic spaces are safe for LGBTQ+ clients. One of the key ways every practitioner can do this is by ensuring they are competent to work with GSRD.

The field of GSRD has developed exponentially over the past few years, with more clinicians writing and teaching about it. For several decades counsellors and psychotherapists who specialise in working with these diverse populations have helped develop a therapeutic philosophy of ‘GSRD therapy’ – so much so that it is now becoming a modality of its own. I teamed up with Dominic Davies, founder of Pink Therapy, to create the core competences of GSRD therapy when we were invited to contribute a chapter for the fifth edition of The SAGE Handbook of Counselling and Psychotherapy, edited by Terry Hanley and Laura Anne Winter, published in 2023.² The chapter has now become the first text on GSRD therapy as an emerging modality.

The term GSRD was coined by Dominic Davies and Meg-John Barker. It is a term used to encompass all gender identities, biological sex diversity, sexual orientations and relationship styles:

• Gender diversity includes people on the wide range of gender identities: cisgender, transgender, agender, bi-gender, cross-dressers, genderqueer, gender fluid and non-binary. It also includes First Nations
  and/or indigenous genders excluded by colonising categories.
• Biological sex diversity includes intersex people and people who are born with sex characteristics (including genitals, gonads and chromosome patterns) that do not fit typical binary notions of male or female bodies.
• Sexuality diversity describes all sexuality, sexual orientations and identities, including lesbian, gay, bisexual, pansexual and those on the asexual spectrum. This term also encompasses people on the erotic diversity spectrum, including those who engage in bondage and discipline, dominance and submission, sadochism and masochism (BDSM), kink and fetish.
• Relationship diversity includes people on the aromantic spectrum, people involved in BDSM/kink power exchange relationships, sex work relationships, people in multi-partnered relationships (swingers, non-monogamous, polyamorous people, etc), as well as those in ‘monogamish’ forms of partnerships.³

Heteronormativity

It is good practice for us all to check our heteronormative, mononormative and cisgenderist biases. We all have them because they are so pervasive in our society:

1. If a client told you that they don’t experience any sexual attraction for anybody, would you think that this is because of past sexual trauma? Or would you explore if this client might be asexual?
2. If a heterosexual-presenting couple arrives in your consulting room for couples therapy, would you be curious about their sexual orientations? Would you assume they are heterosexual? Or would you entertain the possibility that they could be bisexual?
3. If a client discloses that they are only sexually aroused when they practise BDSM or a specific kink, what would you make of it? Would you think that it is probably due to past trauma? Would you think they are ‘addicted’ to kink? Or would you think that it may be part of their erotic orientation?
4. If a client identifies as polyamorous, would you think that they are likely to have an avoidant attachment style or an intimacy disorder because they are avoiding monogamy? Or would you allow for the possibility that they could be on the relationship diversity spectrum?
5. If a gay man told you that he goes to sex clubs every weekend to have unprotected sex, how would you feel? Might you perceive this client as self-harming? Or perhaps a ‘sex addict’? Or would you be curious about how this sexual behaviour could actually be normative and functional for them?

With unchecked assumptions and biases, therapists can unintentionally engage in conversion practices. For example, an asexual client might be encouraged to engage in trauma therapy in order to ‘cure’ their lack of interest for sex; a polyamorous person might be encouraged to believe they would be happier if they were monogamous, or a kinky person might be encouraged to be vanilla (or the other way around), and so on.

One example of homophobia I encountered recently was when I struggled to find a professional to make the index for the new Pink Therapy publications Erotically Queer and Relationally Queer.^3,5 Three indexers refused the job because they did not agree with the content. It is so much part of our ‘normal’ that such homophobia becomes unnoticeable or even not worthy of mention. Many LGBTQ+ people endure much worse. Many report being attacked in the streets, here in the UK, just for holding the hand of their same-sex partner. There is much need for therapeutic spaces to help our LGBTQ+ clients survive and thrive in this world.

LGBTQ+ people, like everyone else, grow up in a heteronormative, mononormative and cisgenderist world. They are taught by parents, school and society, from infancy and throughout their lives, to think of themselves through those lenses. Therefore, many LGBTQ+ people may come to therapy because they believe there is something wrong with them. This belief is often due to internalised homophobia, biphobia or transphobia, but it is not detected, and clients often don’t have the awareness in identifying the problem as such. If therapists are not GSRD-informed, it would be easy for them to accidentally collude with their clients’ sense of self-defectiveness. For example, if a gay man expresses distress because his sexual behaviours feel out of control, it is important for the therapist not to assume that the client’s assessment of their own problems is the actual real problem, because there is a difference between feeling out of control and being out of control. A careful GSRD-informed assessment may identify that the ‘out of control’ feeling is actually informed by the underlying emotion of shame induced by a sex-negative and heteronormative society.

Many sexual behaviours are normative and functional yet they are perceived as ‘wrong’ if they do not fit society’s norms. For such clients, GSRD knowledge is paramount in order not to further pathologise a client who might already feel broken or worthless. The acute shame induced by our heteronormative, mononormative and cisgenderist society is often the very reason why some LGBTQ+ clients seemingly consent to conversion practices. The reality is that they do not consent to changing their sexual orientations or their gender identities; what they want is to stop feeling broken, worthless and unlovable.

A GSRD-informed therapist does not collude with clients’ sense of brokenness; instead they help their clients locate the source of their distress in the heteronormative, mononormative and cisgenderist world rather than within themselves.

The essence of GSRD therapy is therefore an affirmative therapeutic process for all people within the range of gender, sexual and relationship diversity who are oppressed and marginalised by heteronormativity, mononormativity and cisgenderism.

Core competences

There are six core principles that make GSRD therapy effective as a modality:²

1. Practise a commitment to social justice. This is part of the GSRD philosophy, which proposes that people’s mental health problems are precipitated and maintained by the homophobia, biphobia and transphobia in our society. Helping clients shift their mindset from ‘I am broken’ to ‘heteronormativity is hurting me’ reduces clients’ shame about their struggles and helps them relocate the source of their distress in the appropriate place, which is external oppression, and not within themselves, like some kind of disease. Of course, a thorough psychological assessment of clients is still important, but we must not ignore the context in which LGBTQ+ people and those outside of heteronormativity, mononormativity and cisgenderism live.
2. Demonstrate cultural humility and cultural competence. It is important to remind ourselves that the diversity in gender, sex, sexuality and relationships is so wide that it is impossible to know it all. Cultivating cultural humility is important because it encourages us to keep learning, not only from GSRD textbooks but also from LGBTQ+ voices in the media, podcasts and so forth. The more we learn, the more we become culturally competent, and we can then work effectively with understanding the specific needs of LGBTQ+ people.
3. Understand the specific adverse effects of oppression. Oppression is one of the experiences that all GSRD clients face. It is essential to understand the effects of oppression, what it is like to be othered, and the likelihood that LGBTQ+ clients were misunderstood in childhood, or bullied at school, just for being who they are. Oppression is pervasive and continuous, so the therapist needs to be attuned to it so they can guide their clients with the appropriate self-care resources to continue navigating an oppressive world.
4. Practise trauma-informed care. Many GSRD populations will have post-trauma stress symptoms due to bullying, attacks and surviving conversion practices, discrimination, and so on. Therefore, it is important for a GSRD therapist to have good knowledge of working with trauma, to help clients reduce their post-trauma symptoms. Trauma-informed care also helps clients develop good strategies to increase resilience and manage the ongoing adverse experiences of being othered.
5. Gain knowledge of contemporary sexology. Having good contemporary knowledge in sexology helps therapists to avoid unduly pathologising their clients’ sexual behaviours that are not heteronormative.
   For example, there is a growing understanding that the conceptualisation of ‘sex/porn addiction’ is embedded in heteronormative and mononormative theories that encourage the pathologising of LGBTQ+ people, especially gay men and men who have sex with men (MSM).⁶ Gay men generally do not have the same relationship with their porn use as heterosexual men. For many gay men it can be a healing and transformative experience to see their sexual desire and sexual fantasies that affirm their sexuality in porn because they are so often ostracised in society due to homophobia. Indeed, even though countries like the UK may be more accepting of LGBTQ+ people, the topic of gay sex (and anal sex) continues to be taboo. It is worth mentioning here that a 2021 study conducted by the UK Government⁷ found that some conversion practices are offered through the misdiagnosis of ‘sex addiction’. Contemporary sexology can also help with talking about sex openly with LGBTQ+ clients and people who have a kink or fetish because it is an important part of people’s lives, and these populations often did not benefit from inclusive sex education. Normalising the diversities of sexual desires, arousals, behaviours and fantasies in therapeutic conversations can be profoundly healing for people outside of the mainstream.
6. Integrate core GSRD theories. A GSRD therapist needs to have thorough knowledge of core GSRD theories and how to apply them with their clients. For example, it is important to understand the existence and adverse effects of minority stress – the micro-stress that LGBTQ+ people feel due to oppression. Often such micro-stress causes them to be hypervigilant to threats, to hide their authentic self for protection, and to internalise the homophobia, biphobia and/or transphobia around them. Combatting minority stress is difficult but it is possible, by helping clients engage in safe connections and develop a sense of belonging within their LGBTQ+ communities and with their genuine heterosexual allies. Another useful theory is understanding how intra-community minority stress manifests, especially among gay men, who can be competitive and even rejecting of each other because of the pressure they feel to be perfect due to internalised homophobia. The GSRD therapist needs to be attuned to microaggression and listen for it in their clients’ narrative so that they don’t overlook or dismiss some important expression of distress, even if it is seemingly small or insignificant. For example, a work colleague might start treating a client slightly differently since they came out. Or someone might tell an LGBTQ+ person that Pride is no longer needed because LGBTQ+ people have all the legal rights they need, and might ask why there isn’t a straight Pride. Or a friend can’t understand why the client won’t go with them on holiday to a country that upholds anti-gay laws (there are currently 67 such countries, according to Human Dignity Trust).

Therapists also need to be sensitive to intersectionality and how various parts of a client’s identity interact with each other. For example, a trans, black, monogamous, lesbian who works as a manager will have a very different set of interactions to a white, kinky, cisgender, gay man with sight impairment who works in retail. They will be positioned in different categories by society, and people will project different things onto them. The GSRD therapist needs to be comfortable with these discussions to help their clients make sense of it for their wellbeing. All of these theories can be integrated with a strengths-based affirmative approach to facilitate the client’s therapeutic process, not only for surviving our imperfect world but also for thriving.

Updating our knowledge

GSRD is a timely emerging modality as more and more people are identifying as LGBTQ+, polyamorous, kinky or non-binary. As counsellors and psychotherapists we need to update our GSRD knowledge not just to stay contemporary and relevant in our practice but, most importantly, also to avoid accidental harm to these populations because of heteronormative, mononormative and cisgenderist thinking. We counsellors and psychotherapists need to help each other so that we can stay curious to our fast-developing understanding of human diversity. Instead of fearing that we will get something wrong, instead of beating ourselves up for being ‘not good enough’, instead of being stuck in certainties and deciding not to venture out of our existing knowledge, let’s be open to change, and let’s adapt our profession to make every single therapeutic space safe for LGBTQ+ clients. It starts with incorporating the six core competences of GSRD therapy, and weaving this emerging modality into our counselling and psychotherapy trainings and textbooks.