Too Many British Mental Health Professionals Don't Understand Gender and Sexuality
It's hard to seek guidance for your questions about sexuality, or polyamory, or kink, or gender if your therapist doesn't understand any of it themselves.
Lisa has been affected by depression since she was a teenager. She's been diagnosed with anxiety, bipolar disorder and obsessive compulsive disorder, and has attempted suicide several times.
Brought up as a boy in Zimbabwe, Lisa began dressing in drag in her twenties. She was arrested and put in prison for six weeks before being subjected to electric shock treatment as a "cure". After being deported from Zimbabwe, Lisa came to live in England, where she went through gender reassignment. This, coupled with her mental health problems, Lisa believes, was simply too much for mainstream therapists to cope with.
"They just don't know how to manage my situation," Lisa says. "I am quite a masculine person from Africa, who's six foot four. I am transgender and I stand out. I've had very unique experiences and they don't know how to deal with that."
Kerry has depression and anxiety and, at 17, was referred for therapy, feeling suicidal. The fact that Kerry is genderqueer and pansexual – though these aren't labels Kerry would have used as a teenager – was not the issue. Kerry's therapist, however, had different ideas.
"For some reason, this male psychiatrist latched onto me mentioning I was gay, not the part where I was expressing how I'd been bullied by students and teachers," Kerry says. "He went on to tell me that, 'When you find a man, get married, get a house and a job everything will be fine.' I think sexuality and gender become the scapegoat when not understood correctly."
Since I began researching this feature, I've come across many stories like Kerry's and Lisa's. If gender and sexuality are myriad, so too are ways of misunderstanding them. However, one thing seems certain: trusting every therapist to be clued-up on these issues is a mistake.
"We know that LGB&T people are more likely than the wider population to experience suicidal feelings, self-harm and mental health problems such as depression and anxiety," says Geoff Heyes, policy and campaigns manager at mental health charity Mind. "Despite this, there's still a lack of local services which successfully cater to their needs."
Just this January, the UK Council for Psychotherapy and the Department of Health brought together 14 organisations to sign a Memorandum of Understanding promising to end the practice of conversion therapy (any type of talking therapy which attempts to change sexual orientation). It seems staggering that such an agreement was still needed at the beginning of 2015, and critics have pointed out that the memorandum has a major omission: it fails to mention therapies aimed at converting transgender people back to their birth gender.
While outright "trying to talk someone out of being gay" is now rare in the UK, a kind of conversion therapy-lite still seems to exist, especially at the margins of gender and sexual diversities. I heard stories of people whose therapist refused to acknowledge their gender; people whose kink so horrified their therapist it became the focus of all subsequent sessions. A sex worker told me her therapist implied that she must have been abused to take up such work; a lesbian woman was asked if she'd consider a heterosexual relationship.
In response to clear need, specialist services have sprung into action, promising access to therapists who won't try to convert you, turn your sexuality into a massive pathology or simply look bewildered.
Pink Therapy caters to people who are lesbian, gay, bisexual or transgender and others who are gender or sexually diverse. Under this umbrella fall people who are asexual, celibate, polyamorous, non-monogamous, those involved in BDSM or kink and anyone on the gender spectrum.
"I've no idea how anyone could ever think that mainstream therapists are neutral around gender and sexuality," says Pink Therapy CEO, Dominic Davies. "Some are positive and affirming, some are well informed and others bear the same kind of prejudices as anyone raised in a heteronormative society where they've not had to question and deconstruct their assumptions."
Like the rest of us, therapists are a product of their environment, so of course they bring a particular worldview to their practice – more than ever, perhaps, in the fraught realms of gender and sexuality. In an ideal scenario, these assumptions will be examined during training, but with sex and gender diversities barely covered in standard courses, prejudices endure into careers and, somewhere along the line, rear up to slap clients in the face.
"My therapist couldn't understand why anyone – particularly someone with mental health issues – would voluntarily enter into a poly relationship," says Jodie. "She totally didn't get any of the pluses of polyamory. She asked directly if I'd tried being in a monogamous relationship, which was insulting as I'd often talked of the years I spent forcing myself into monogamous, heterosexual relationships. None of those went well or were fulfilling or healthy relationships."
Psychologist, author and lecturer Meg John Barker is part of London Sex and Relationships Therapy, a group of therapists who specialise in gender and sexual diversity. Barker believes that mainstream therapists have a long way to go, particularly in understanding those who don't fit into a tidy man/woman gender binary.
"Many of the therapy trainings still include nothing on gender, or even explicitly teach that gender is binary and that any other experience is pathological," Barker says.
"I've heard from both bisexual and non-binary people that therapists have tried to change them to be 'one thing or the other'. Many therapists have issues with people who engage in behaviours that are considered 'gender non-normative', particularly people they perceive as 'men' wearing 'women's clothes'."
It's the same story in the world of kink. If your bedroom repertoire extends much beyond a pair of fluffy handcuffs, you might be interested to know that the Diagnostic and Statistical Manual of Mental Disorders classifies a significant proportion of kink as "paraphilia" – i.e "weirdo stuff" – meaning your spanking session is viewed as a pathology. The manual was updated in 2013 (DSM-5) and now only "paraphilia" that causes mental distress is singled out as needing fixing, but the category itself still exists.
Paul (not his real name) is into what he considers a "normal" level of BDSM. He likes role play, a bit of bondage and being sexually dominant. Not enough, he says, to put himself in a special category or seek out a specialist therapist.
"It's not any more than I thought everyone was doing," he says. "But last year a therapist told me my 'sexual practices' were wrong and needed curing. I'd just come out of a relationship and she said a lot of what was wrong with me mentally was because of my sexual actions."
It's clearly unhelpful for a therapist to insist that every problem must be related to a client's sexuality or gender. There may be a correlation, there may not. Like the next person, people who are trans, or poly, or kinky are subject to being fucked up by all manner of life events, not to mention plain old brain chemistry (depression, for instance).
Likewise, there's a difference between being fucked up by society's perceptions of you (stigma) and being fucked up by your "difference" itself. In many cases, it's dealing with an onslaught of negative reactions that's the problem.
"For the majority of non-binary folk, gender has got nothing to do with the issues they come to therapy with," Barker says. "However, due to the discrimination and invisibility that non-binary people experience, they do currently face higher levels of mental health difficulties than binary gender folk. This means it may be relevant to discuss these matters in therapy. In either case, it's useful to have a therapist who's clued up about non-binary gender."
And if you think being in a sexual minority is hard, try being from an ethnic minority at the same time. Brace yourself for a therapist who breaks into panic sweats at the merest mention of kink.
"We make assumptions that people from other cultural, ethnic and religious backgrounds aren't kinky, non-monogamous or queer," says psychotherapist Ronete Cohen. "In my experience, nothing is further from the truth. But it can be even more difficult to find a therapist, since the few sex-positive therapists around won't necessarily be knowledgeable about your cultural background. There is a real mismatch: the advice white, Western therapists give won't be appropriate for your needs, while the likelihood of finding a suitably aware therapist within your community is very small."
"You can go deep into long-term psychotherapy training but learn nothing much about working with gender and sexual diversities."
Tania Glyde is a therapist and author with an interest in sexual diversities. She says it's partly lack of affordable training that's leaving therapists unable to cope with anything apart from the most meat and potatoes version of gender or sexuality.
"You can go deep into long-term psychotherapy training but learn nothing much about working with gender and sexual diversities," Glyde says. "One of the biggest roadblocks to change is money. Training costs a fortune, and this excludes a number of people and makes the population of people who qualify very homogenous. This applies to race, ethnicity and class, and also to those who are gender or sexually diverse."
We're lucky to have the services that cater to the UK's soaring rate of mental health issues, and should be grateful to those who work in them. But these services are among the gatekeepers of "normality"; this is the place you go at your most vulnerable, trusting you'll get your head together enough to carry on with life. It's vital, then, that understandings of normality are wide enough to encompass everyone.
It would be hard to argue that the patriarchal, heteronormative society we live in is working for everyone, and those who chip away at its rigid boundaries should be supported.
Kerry finally received help through an LGBT charity and is now training to be a therapist themself. Lisa has also accessed psychotherapy and says she has turned her life around. She's volunteering at Mind in Springfield.
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