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“The Handbook of LGBTQ Affirmative Couple and Family Therapy does full justice to the enormous
diversity within the LGBTQ community. Each chapter is an eye-opening and rewarding reading
experience. The book abounds with specific treatment guidelines and clinical case examples for
practitioners. An impressive achievement!”
—Robert-Jay Green, PhD; Distinguished Professor Emeritus, California School
of Professional Psychology at Alliant International University

“Social justice meets psychotherapy in this timely innovative book. These diverse authors dem-
onstrate how to identify and transform oppressive narratives about race, gender, and sexuality
interwoven not only in LGBTQ couple and family life but in training and supervision practices. The
breadth of content includes often neglected topics for LGBTQ clients such as sex therapy, elders,
spirituality, and divorce. It is time to queer the field of couple and family therapy for clients of all
races, genders, and sexual experiences. This book leads the way.”
—Suzanne Iasenza, PhD; author of Transforming Sexual Narratives:
A Relational Approach to Sex Therapy (Routledge, 2020)

“This comprehensive text should be required reading for every family therapist, psychologist, and
social worker. It is superbly written, conveying complex ideas in a clear, thoughtful, practical, and
useful way. The authors offer an expansive contextual perspective on intersectionality, resilience,
and support from ‘outside the margins,’ with excellent case examples, thoughtful and practical
clinical suggestions, and a hopeful, resilience-focused orientation toward even the most complex
and difficult case situations.”
—Monica McGoldrick, MSW, PhD (h.c.); Director, Multicultural Family Institute;
Clinical Associate Professor of Psychiatry, RWJ Medical School, Rutgers University
 Handbook of
LGBTQ Affirmative
Couple and
Family Therapy
This comprehensive second edition inspires therapists to utilize clinical work to pragmatically
address intersectional oppressions, lessen the burden of minority stress, and implement effective
LGBTQ affirmative therapy.
A unique and important contribution to LGBTQ literature, this handbook includes both new
and updated chapters reflecting cutting-edge intersectional themes like race, ethnicity, poly-
amory, and monosexual normativity. A host of expert contributors outline best practices in
affirmative therapy, inspiring therapists to guide LGBTQ clients into deconstructing the hetero-
normative power imbalances that undermine LGBTQ relationships and families. There is also
an increased focus on clinical application, with fresh vignettes included throughout to highlight
effective treatment strategies.
Couple and family therapists and clinicians working with LGBTQ clients, and those interested
in implementing affirmative therapy in their practice, will find this updated handbook essential.

Rebecca Harvey, PhD, is Professor of Marriage and Family Therapy at Southern Connecticut
State University in New Haven, Connecticut. She has been proudly queering family therapy
practice, supervision, and training for over 25 years. Dr. Harvey is co-author of the book
Nurturing Queer Youth: Family Therapy Transformed.

Megan J. Murphy, PhD, is Professor and Director of the Couple and Family Therapy Program
at Purdue University Northwest in Hammond, Indiana. She is co-editor with Dr. Lorna Hecker
of Ethics and Professional Issues in Couple and Family Therapy (2nd edition).

Jerry J. Bigner, PhD, was Professor Emeritus in the Department of Human Development and
Family Studies at Colorado State University, and was the editor of the Journal of GLBT Family
Studies. He has had over 50 research publications and 20 chapters in texts relating to parent-
child relations as well as gay and lesbian family issues.

Joseph L. Wetchler, PhD, is Professor Emeritus of Marriage and Family Therapy at Purdue
University Northwest. He formerly served as Editor of the Journal of Couple and Relationship
Therapy and as Associate Editor of the Journal of GLBT Family Studies.
 Handbook of
LGBTQ Affirmative
Couple and
Family Therapy
2nd edition

Edited by
Rebecca Harvey, Megan J. Murphy, Jerry
J. Bigner and Joseph L. Wetchler
Second edition published 2022
by Routledge
605 Third Avenue, New York, NY 10158

and by Routledge
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN

Routledge is an imprint of the Taylor & Francis Group, an informa business

© 2022 selection and editorial matter, Rebecca Harvey, Megan J. Murphy, Jerry J. Bigner, and Joseph L. Wetchler;
individual chapters, the contributors

The right of Rebecca Harvey, Megan J. Murphy, Jerry J. Bigner, and Joseph L. Wetchler to be identified as the authors of
the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections
77 and 78 of the Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic,
mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any infor-
mation storage or retrieval system, without permission in writing from the publishers.

Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for
identification and explanation without intent to infringe.

First edition published by Routledge 2012

Library of Congress Cataloging-in-Publication Data

A catalog record has been requested for this book

ISBN: 978-0-367-20656-7 (hbk)

ISBN: 978-0-367-22387-8 (pbk)
ISBN: 978-0-429-27462-6 (ebk)

DOI: 10.4324/9780429274626

Typeset in Minion Pro

by codeMantra
This book is dedicated to all gender and sexual minorities, transgender
and gender expansive, and queer people who—by way of being—
share their gifts with the world through their resilience.
 Contents

Acknowledgments xiii
List of Contributors xv
Introduction 1
REBECCA HARVEY and MEGAN J. MURPHY

Section I Foundations of LGBTQ Affirmative Therapy

1 Evolution of LGBTQ Affirmative Couple and Family Therapy 9
REBECCA HARVEY, MEGAN J. MURPHY and TRACEY A. LASZLOFFY

2 Intercultural Issues in LGBTQ+ Couple and Family Therapy: Supporting

Empowerment and Resilience at the Intersection of Identities 25
AMNEY J. HARPER and ANNELIESE A. SINGH

3 Heteronormativity and Ethics in the Treatment of LGBTQ Clients 45

MEGAN J. MURPHY

Section II Working with Couples

4 We Cannot Change What We Cannot Name for Ourselves: Integrating
Attachment Theory into Couple Therapy with Gay Men 61
ROBERT ALLAN

5 Illuminating Strengths: Multiracial Feminist Couple Therapy with Queer

Women 75
MONTINIQUE MCEACHERN, DEBORAH COOLHART and DYANE WATSON

6 “There’s a Lot We Don’t Understand About Each Other”: Centering Bisexual

Partners in Couple Therapy 89
ERICA E. HARTWELL, KATIE M. HEIDEN-ROOTES and STEPH COOKE

7 Therapists’ Accountability and Engagement with Transgender and

Nonbinary Couples 105
LIVINGSTONE CARTER COX, KRISTEN E. BENSON and ALEX IANTAFFI

8 Affirming Diversity and Targeting Pleasure: Sex Therapy for

Gay Male Couples 121
MARIA MANUELA PEIXOTO

9 “I Could Never See You and Now I Dare Not Touch You”: Sex Therapy with
Lesbian Couples 135
BROOKS A. BULL and JASSY CASELLA TIMBERLAKE

10 Sexuality and Desire Landscapes in Transgender, Nonbinary, and

Genderqueer Relationships 149
ARLENE I. LEV and SHANNON L. SENNOTT

ix
x • Contents

11 Therapeutic Considerations in Same-Sex Divorce and Relationship

Dissolution 175
KEVIN P. LYNESS

Section III Family and Identity Considerations

12 Invisible Humans: Identity Development and Visibility Management in
Gender, Sexual, Erotic, and Relational Diversity 195
MARKIE LOUISE CHRISTENSON (L. C.) TWIST, RAVEN CLOUD
and SARAH A. HECHTER

13 I Have Too Many Mothers: Queer Families Raising Children 225

LINDA STONE FISH

14 Affirming Queerness: Raising Happy, Healthy Children 239

REBECCA HARVEY, PAUL D. LEVATINO, JONATHAN RUIZ,
and LINDA STONE FISH

15 Gender Affirmative Therapy with Trans and Gender Expansive (TGE)

Youth and Families: Listening to Youth and Thoughtfully Following
Their Lead 259
DEBORAH COOLHART and TRISTAN K. MARTIN

16 Helping LGBTQ Stepfamilies Meet Their Challenges 277

PATRICIA L. PAPERNOW

17 “I Will Always Come Home to You”: Affirmative Therapy with Clients

Practicing Consensual Non-Monogamy 297
SHEILA M. ADDISON and NOELLE CLASON

Section IV Special Issues

18 “I Didn’t Know I Had a Right to Exist”: Queer Elders and
Family Therapy 327
PAUL D. LEVATINO

19 Where Should We Go to Church? Or Should We Even Bother: Spirituality

and Religion in LGB Couples’ Therapy 347
STEVEN D. JOHNSON, SHARON S. ROSTOSKY, and ELLEN D. B. RIGGLE

20 Treatment of Partner Violence in Sexual and Gender Minority Couples 363

NATHAN MATHER, DEANNA LINVILLE, and TIFFANY B. BROWN

21 Treating LGBT Couples Experiencing Substance Use Disorders: Trauma-

Informed and Affirmative Therapy Approaches 381
MICHAEL SHELTON

22 Rewrite the Script: A Call for More Queer and Inclusive Couple
Enrichment Programs 401
SHOSHANA D. KEREWSKY, DARIEN T. COMBS, and NATHAN MATHER
 Contents • xi

Section V Training Issues

23 “Why Can’t We Just Learn about Normal Couples?”: LGBQ Affirmative
Training Strategies for CFT Faculty and Programs 417
CHRISTI R. MCGEORGE, ASHLEY A. WALSDORF, and KATELYN O. COBURN

24 Self-Disclosure: Considerations for Therapy and Supervision 433

STEPH COOKE, MARY R. NEDELA, DARAN SHIPMAN, and ERIKA L. GRAFSKY

25 Recovery from Sexual Orientation Change Efforts: Affirming the

Intersections of Marginalized Identities among Survivors 449
JEFFREY S. LUTES

26 Getting Personal: Queer Supervision 465

JANIE K. LONG, JACK GROTE, KYRA E. CITRON, MELANIE CAMEJO COFFIGNY,
MANISH KUMAR, TYLER LIAN, and SHOM TIWARI

Index 479
 Acknowledgments

So many people to thank who have made this book possible!

First, it has been a delight and honor to work with Dr. Megan Murphy. I admire so much about
her: her practical, calm, working-class energy, her rigor, her humility and incisive strength. We
share an impatience for artifice but a love for the aspirational. Thank you for everything Megan!
I want to thank the chapter authors for giving Megan and I the leeway to focus this book and
their work in the specific ways we did. We endeavored to create a book that would highlight their
important contributions as we consider them leaders in our field and their voices vital.
I’d like to thank those at Routledge especially Clare Ashworth, Ellie Duncan, and Heather Evans
who were always professional and kind, encouraging and also patient as we navigated a bulk of
this work through a global pandemic.
Thanks to all those who generously mentored me especially Ellie Macklin and Linda Stone Fish
who saw something in me and helped me find it in myself. Also, very grateful to Bonny Slim
for walking with me in the darkest of times, helping me to trust my gifts, and generally being a
badass in the kindest, understated, midwestern sort of way.
Appreciation for all my friends who love and respect me enough to be real with me. Thanks espe-
cially to Paul Levatino for his insight, dedication, witty repartee, and bawdy jokes not necessarily in
that order. Thanks to Susan Eichenberger … for the walks, the respite, the trust, and the well-placed
gin and tonics. Thanks to Tracey Laszloffy for her stalwart, brilliant, and generous presence Big shout
out to the Mom Squad, Alexis Munson, and Shonna Marshall for knowing where the parenting went
awry and where the bodies are buried but showing up for PLB anyway, my deepest gratitude.
Thanks to my dad, Paul, for being affirming to me before I understood what that was. And for
introducing me to Provincetown as a teenager. That truly changed my life.
Thanks to my mom, Barb, for modeling courage and teaching me how to show up and do the
right thing even if it was hard. She instinctively taught me to trust marginalized people with a
compassion and commitment which I have worked hard to emulate. She may have been the first
in her line of brave feminists but definitely not the last!
Thanks to my sister, Heather, for a lifetime of true friendship with all of its ups and downs, tears
and laughs, and for generously sharing her many remarkable gifts, including the artwork for this
bookcover. Still no one I’d rather hang with than, funny, original, fierce, north side, you.
Thanks to Kris for her uncanny ability to be herself: sweet, smart, brave, unique, and fun. Which
has made it easier for me to do the same. So grateful for the joy and wonder of having met you.
We were worth the wait.
A big huge thank you you to my daughter, Sophia (next in the line of loving, bad ass feminists),
who made and ate a lot of ramen noodles during the completion of this book. I am so grateful
to Sophia for her commitment to our queer family and for her thoughtful challenges as well as
the generosity of our late night conversations about life when we (she) ought to have been asleep.
Watching her grow into her strength and her kindness is a marvel and a privilege.
Rebecca Harvey

xiii
xiv • Acknowledgments

Sincerest thank you to the authors of the chapters in this book for their contributions as they
captured the changes that have taken place since the publication of the first edition, and for
their patience as we worked on this book through the COVID pandemic. Appreciation goes
to Heather Evans, Ellie Duncan, and Clare Ashworth for their guidance in putting this book
together. Thank you to Joe Wetchler for entrusting me to edit the 2nd edition of the Handbook.
I am thankful to have had the opportunity to know Jerry Bigner as an instructor and later
colleague—I hope we were able to bring forward his energy and enthusiasm to this 2nd edition.
I appreciate Gardenia Alvarez’s assistance in keeping me organized and providing the behind-
the-scenes help as a graduate assistant.

I am very thankful to have Dr. Rebecca Harvey as co-editor and friend, with her absolute bril-
liance, creativity, and ability to keep me grounded. I could not have done this without you!

And I am so grateful to my husband, Joe, for his support, encouragement, and feedback on this
project. Thank you for being there with me.
Megan J. Murphy
 Contributors

Sheila M. Addison, PhD Darien T. Combs, MS, MEd

Couple & Family Therapy Program Counseling Psychology Program
Antioch University Seattle University of Oregon
Seattle, Washington Eugene, Oregon

Robert Allan, PhD Steph Cooke, MA

Couple and Family Therapy Program Human Development and Family Science
University of Colorado Denver Virginia Tech
Denver, Colorado Blacksburg, Virginia
Kristen E. Benson, PhD
Deborah Coolhart, PhD
Appalachian State University
Marriage and Family Therapy Program
Boone, North Carolina
Syracuse University
Tiffany B. Brown, PhD Syracuse, New York
Department of Family and Human Services
University of Oregon Livingstone Carter Cox, MS
Eugene, Oregon Harvard College
Office of BGLTQ Student Life
Brooks A. Bull, PhD Cambridge, Massachusetts
Collaborative Therapy & Coaching, PLLC
Northampton, Massachusetts Erika L. Grafsky, PhD
Human Development and Family Science
Kyra E. Citron, BA Virginia Tech
Stanford University, School of Medicine Blacksburg, Virginia
Palo Alto, California
Jack Grote, JD
Noelle Clason, MA
Atlanta Legal Aid Services
California Institute of Integral Studies
Atlanta, Georgia
Albany, California

Raven Cloud, MS Amney J. Harper, PhD

Las Vegas, Nevada University of Wisconsin Oshkosh
Oshkosh, Wisconsin
Katelyn O. Coburn, MS
Couple and Family Therapy Program Erica E. Hartwell, PhD
Kansas State University Marriage & Family Therapy Program
Manhattan, Kansas Fairfield University
Fairfield, Connecticut
Melanie Camejo Coffigny, BA
Duke University Sarah A. Hechter, MS
Durham, North Carolina Plainfield, Illinois

xv
xvi • Contributors

Katie M. Heiden-Rootes, PhD Janie K. Long, PhD

Medical Family Therapy Program Duke University
Department of Family & Community Durham, North Carolina
Medicine
Saint Louis University Jeffrey S. Lutes, MS
St. Louis, Missouri Private Practice
Austin, Texas
Alex Iantaffi, PhD
Edges Wellness Center Kevin P. Lyness, PhD
Minneapolis, Minnesota Antioch University New England
Keene, New Hampshire
Steven D. Johnson, PhD
Department of Psychiatry Tristan K. Martin, PhD
University of Kentucky Syracuse University & Synergy Center
Lexington, Kentucky Manlius, New York

Shoshana D. Kerewsky, PsyD

Nathan Mather, MS
Counseling Psychology and Human
Department of Family and Human
Services Department
Services
University of Oregon
University of Oregon
Eugene, Oregon
Eugene, Oregon
Manish Kumar, BA
Montinique McEachern, PhD
Duke University
Marriage and Family Therapy Program
Durham, North Carolina
Syracuse University
Syracuse, New York
Tracey A. Laszloffy, PhD
Center for Healing Connections
Norwich, Connecticut Christi R. McGeorge, PhD
Human Development and Family Science
Arlene I. Lev, MSW, LCSW-R, CASAC, CST North Dakota State University
Choices Counseling and Consulting & Fargo, North Dakota
University at Albany, School of Social Welfare
Albany, New York Mary R. Nedela, PhD
Department of Counselor Education and
Paul D. Levatino, LMFT Family Therapy
Marriage and Family Therapy Program Central Connecticut State University
Southern Connecticut State University New Britain, Connecticut
New Haven, Connecticut
Patricia L. Papernow, PhD
Tyler Lian, BS Institute for Stepfamily Education
Duke University Hudson, Massachusetts
Durham, North Carolina
Maria Manuela Peixoto, PhD
Deanna Linville, PhD Psychology for Positive Development
Department of Family and Human Services Research Center
University of Oregon Lusíada University of Porto
Eugene, Oregon Porto, Portugal
 Contributors • xvii

Ellen D. B. Riggle, PhD Linda Stone Fish, PhD

Department of Gender and Women’s Department of Marriage and
Studies and Family Therapy
Department of Political Science Syracuse University
University of Kentucky Syracuse, New York
Lexington, Kentucky
Jassy Casella Timberlake, MEd
Sharon S. Rostosky, PhD Northampton Sex Therapy, LLC
Educational, School, and Counseling Florence, Massachusetts
Psychology
University of Kentucky Shom Tiwari, BA
Lexington, Kentucky Lead for North Carolina Fellowship
University of North Carolina School of
Jonathan Ruiz, LMFT Government
Hamden, Connecticut Elizabeth City, North Carolina

Shannon L. Sennott, MSW Markie Louise Christianson (L. C.)

Center for Psychotherapy and Social Justice, Twist, PhD
Translate Gender, Inc. Department of Human Development and
Smith School for Social Work Family Studies
Northampton, Massachusetts Marriage and Family Therapy Program
University of Wisconsin-Stout
Michael Shelton, MS, LPC, CAADC Menomonie, Wisconsin
Community and Trauma Counseling Program
Thomas Jefferson University Ashley A. Walsdorf, PhD
Philadelphia, Pennsylvania Human Development and Family Science
University of Georgia
Daran Shipman, MA Athens, Georgia
Marriage & Family Therapy
Syracuse University Dyane Watson, PhD
Syracuse, New York Marriage and Family Therapy Program
Syracuse University
Anneliese A. Singh, PhD, LPC Syracuse, New York
Tulane University
New Orleans, Louisiana
 Introduction
REBECCA HARVEY and MEGAN J. MURPHY

As editors, we want to begin by acknowledging how truly groundbreaking the first edition of
the Handbook was when it came out in 2012. With affirmative therapy still in its infancy the
editors and contributing authors were truly leading the field and their work raised important
and difficult questions. For example, including affirming couples interventions, and premarital
or marriage preparation programs for LGBTQIA people in a time when same-sex marriage was
not legal (at the federal level in the U.S.) and was highly politicized led to queries about the field’s
assumptions about the nature of marriages, the legitimacy of LGBTQIA couples and families,
and the impact of widespread stigma on their relationships. In a similar vein, it took integrity
and courage to include a chapter on domestic violence knowing that to acknowledge violence
which occurs in some LGBTQIA relationships could provide fuel to anti-LGBTQIA efforts.
In short, the Handbook was a proclamation of the relevance, importance, and complexity of
LGBTQIA people and relationships. And many of us marriage and family therapists, supervi-
sors, faculty, and students owned and referred often to this volume over the years.
When we began this project, we knew that a 2nd edition of the Handbook was necessary—
even imperative—given the rapid changes experienced in the field and in U.S. culture as a whole.
Affirmative therapy is evolving in a time when the dichotomies of the past—dichotomies upon
which much of society has been founded and organized—are being called to question.
The gender binary, while certainly entrenched, is becoming (especially among young people)
a gender spectrum where many different ways of being are possible. This turns a discussion of
sexual orientation on its head, complicating notions of being “oriented” to one or both of two
possible genders into considerations of ways to be oriented to many (or few or even no) genders.
No longer constrained by thinking of gender as an either/or prospect allows for a more
expansive understandings of what a gender transition might entail and substantially broadens
participation. For who among us is not transitioning in some way, shape, or form in our own
identity project?
The intersectional nature of oppression has been firmly established by Black and Brown intel-
lectuals and scholars. As James Baldwin (1985) gracefully and provocatively points out, the ide-
alized cultural stories we tell about race, sexuality, and gender are inevitably and completely
bound together, laced through with violence and oppression. Baldwin (1985) writes of the U.S.:
All countries or groups make of their trials a legend or, as in the case of Europe, a dubious
romance called “history.” But no other country has ever made so successful and glamor-
ous a romance out of genocide and slavery; therefore, perhaps the word I am searching for
is not idea but ideal.
The American ideal, then, of sexuality appears to be rooted in the American ideal of
masculinity. This ideal has created cowboys and Indians, good guys and bad guys, punks
and studs, tough guys and softies, butch and faggot, black and white. It is an ideal so para-
lytically infantile that it is virtually forbidden—as an unpatriotic act—that the American
boy evolve into the complexity of manhood.

DOI: 10.4324/9780429274626-1 1
2 • Rebecca Harvey and Megan J. Murphy

These idealized stories (and the oppression they legitimize) become normalized, widely
integrated myths which validate and empower some lives just as other types of lives lived
are disqualified. In this way, the range of possibilities for each of us is decided and clarified.
Based on the intersections of where we come from, what we look like, how we embody gen-
der, or who and how we love or desire, we each learn our place and receive instructions for
how to consider and treat one another. To challenge these myths by recognizing and trying
to evolve out of their very serious limitations (as LGBTQIA, Black, Brown, working-class,
immigrant people among others have repeatedly endeavored to do) is to be anathema and
often to be detested to the point of dehumanization. The fingerprints of this are all over the
culture, within family and relational processes large and small, certainly within the mental
health fields, including marriage and family therapy and by extension solidly entrenched even
within affirmative therapy. To redress the harm done by any one of these stories is to be con-
fronted with all of these narratives at once and the complicated way they are layered on top of
one another in our own lives and the lives of our clients. To remedy heteronormative oppres-
sion, one must also address patriarchy, and to accomplish that one must also acknowledge
and rectify white supremacy, along with classism and colonialism. And this is a part of the
reason that a 2nd edition of the Handbook was necessary—to broaden the focus of affirmative
therapy to address heteronormativity and intersectionality and to explore how clinical work
can address societal level injustice with specificity and rigor in order to become truly affirm-
ing to all LGBTQIA people.
We came to this project in a tumultuous sociopolitical time when long-simmering divisions
have been stoked and manipulated, erupting in a breakdown of civility and brazen acts of rac-
ist, misogynistic insurrection, aggression, and violence. As human beings, our tribal identi-
ties across lines of race, gender, and sexuality (among others) have always been used to pit us
against one another, our own insecurities and resentments exploited as political strategies—all
of which leads us to the somber place we find ourselves today as these same strategies are being
employed in extraordinarily debased ways to nakedly serve the most powerful and the most
privileged at the expense of the most vulnerable. Times like these always fall hard on LGBTQIA
people and especially transgender Black and Brown folx who are a favored political punching
bag. The ambitious and the powerful, as always, freely trade on anti-LGBTQIA sentiment to
solidify political capital.
As systemic thinkers in the middle of this current context, we find the question of whether to
address societal injustice within therapy—and the lack of progress in doing so—frustrating. The
question has been asked and answered. Oppression at the societal level sparks parallel processes
within therapy sessions and within intimate relationships. Power influences systemic processes
at all levels. And that power can be used to dominate and undermine, or to collaborate and nur-
ture. It is not a question of whether we have power, both collectively as a field and individually as
practitioners, only how we decide to utilize whatever imperfect power we have.

Language and Labels

Frankly, one important and ongoing dilemma for affirmative therapy that is evident in this book
involves terminology. The language one uses or is labeled with by others raises questions of
inclusion and exclusion as well as agency, privilege, and power. The reader will note that begin-
ning with the title of this 2nd edition, we intentionally include “Q” as we wanted to specifically
include people who identify as queer in the title and content of the book. We use queer (as many
LGBTQIA people have come to do) as a proud reconditioning of a word used historically to iso-
late, demean, and diminish LGBTQIA people. We also prefer it because it resists heteronorma-
tive classifications, and highlights the gifts, resilience, and contributions offered by lives lived
outside of heteronormativity.
 Introduction • 3

Next, the reader will note that the authors who contributed to this book are not of one mind
when it comes to language. Though we have aimed for consistent use of terminology whenever
possible, it became readily apparent to us as we edited that there are various levels of inclusion
when it comes to LGBTQIA terminology. This is the state of the field. As editors, we ourselves
have learned from and been stretched by the work of the chapter authors in this Handbook. This
is part of the reality of affirmative therapy. We are challenged to develop and use common ter-
minology and shared meaning without being overly constrained by ideas tainted by heternor-
mativity, which are just simply not useful or out of date. In other cases, while recognizing that
relationship forms and structures are quite varied, some authors decided to focus on couples to
the exclusion of other relationship forms.
We also made an intentional decision to capitalize references to oppressed racial groups,
such as Black, Asian, and Latinx, while not capitalizing “white” in an effort to elevate and privi-
lege marginalized voices. We recognize that this goes against the current 7th edition of the
American Psychological Association Manual, but we believe that it is the right thing to do. We
have embraced the use of “they/them” pronouns, even when preceded in sentences by singu-
lar pronouns. We have eschewed the imposition of he/she, him/her, or other common uses of
binaries (unless clients explicitly identified themselves along these binaries) that, we believe,
further us-them “othering” that is not helpful or healthy, or representative of the complexity of
the human condition.
We recognize and acknowledge that the use of language is a multi-faceted, contested, signifi-
cant, and defining issue which we will not solve with the publication of this Handbook. Where
to draw the line is an ongoing question that we all will struggle with in our personal and profes-
sional relationships. What we might be certain of—if anything—is that meanings are going to
shift and change over time, and that we all play a part in contributing to challenging discourses
in our conversations with others.

Marriage Equality
Since the first edition was published, same-sex marriage was legalized at the federal level by
the Obergefell decision issued by the U.S. Supreme Court in 2015. This somewhat unexpected
ruling signified a major shift in recognition of the legitimacy of same-sex relationships. It was
cheered by many in the LGBTQIA community as it provided visibility and validation to same-
sex couples along with cultural privileges that come with marriage. Many got married as soon
as they were able, to share in the cultural meaning of marriage and to symbolize the depth of
their commitments to their partners with their friends and communities. This was also moving
and affirming to many LGBTQIA people, married or not, who felt a sense of full belonging and
access to full legal recognition for the first time in their lives.
Still others worried that same-sex marriage came at the price of increasing the burden of
minority stress and upholding the oppressive model of traditional, heteronormative marriage
as the standard for healthy relationships and family structure. LGBTQIA relationships often
queer traditional notions of marriage and call into question all its most sacred assumptions: that
only two people can be in a healthy relationship at a time, that success is defined mainly by not
divorcing, that relational commitments generally end with divorce, or that parenting ought only
to occur within the frame of marriage and a nuclear family.
Indeed, LGBTQIA relationships routinely challenge gender role expectations, as they are
often marked by open discussions about expectations regarding sexuality and monogamy,
and higher levels of relational equality. LGBTQIA relationships have demonstrated a capacity
to maintain lifelong commitments and a sense of ongoing dedication to ex-partner(s) which
extends after—sometimes long after—the dissolution of a marital relationship. These challenges
to the bedrock of heteronormative marriage—the very ideas used to stigmatize or minimize
4 • Rebecca Harvey and Megan J. Murphy

LGBTQIA relationships—are also skills, ideas, and practices which create more intimate, flex-
ible, vibrant marriages. They are also open challenges to the status quo notion that healthy mar-
riage, sexuality, and families belong solely to traditional, monogamous nuclear family systems.
Therapists must be aware of the emotional and relational toll it can take on LGBTQIA clients to
have their lives and relationships seen by others as rebellious, disrespectful, or even threatening
acts. No matter what legalization of marriage accomplishes, it does not necessarily change the
hearts and minds of family and friends who continue to view same-sex relationships as devi-
ant, pathological, or immoral. And any progress made in policy or attitude does not minimize
the depth of the oppression or hostility that some of us avoid and others must endure based on
our unique transgressions of the status quo. And thus Crenshaw’s (and others) intersectional
critique becomes such an important concept for affirmative therapy to address.
Affirmative therapists need to continue to challenge this deficit model of LGBTQIA experi-
ence and, despite increasing polarization, take a definitive stand protecting LGBTQIA families,
honoring how diverse notions of marriage and family structure strengthen rather than threaten
all marital and family relations. LGBTQIA people have developed relational ideas, processes,
and norms which evolved out of living and navigating on the margins. This has led to a sense
of freedom to create and recreate relational structures that are egalitarian, flexible, and creative
models of commitment. These new structures are now more readily available to all participants
in marriage, no matter their orientation or gender identity, who have been unsatisfied with the
power imbalances and rigidity of traditional marriage.

Heteronormativity
LGBTQIA people of all races and from all backgrounds must still reckon with the pervasive
constraining influence of heteronormativity—the idea that heterosexuality is the preferred or
“normal” sexual orientation—that is ever-present at all levels in governmental and workplace
policies, within mental health diagnoses and medical paperwork, and within relationships and
relational expectations.
Certainly, LGBTQIA people are resilient and most find ways to cope with pervasive hetero-
normativity; however, the effects of minority stress can be devastating to LGBTQIA people via
increased rates of poverty, family cut-off, self-harm, suicide, drinking and other drug use, and
interpersonal difficulties. And while much social progress has been made in the last decade,
there has been a demonstrable backlash against this very progress that has most specifically
fallen on transgender and nonbinary people especially those who are Black and Brown.
While acceptance and support for LGBTQIA people and families are globally at an all-time
high, we are also experiencing a global wave of reactionary right-wing authoritarianism where
governments intentionally fuel fear and hatred, and condone violence against LGBTQIA people,
people of color, immigrants, women, and religious minorities for political gain. We are on a roller
coaster ride of combative and reactionary policy decisions regarding LGBTQIA people. One
President of the U.S. (Obama) ended the U.S. military policy banning transgender soldiers from
serving in the military, only to have the next U.S. President (Trump) re-institute this ban. The
U.S. Supreme Court rendered a decision supporting religious freedom arguments allowing dis-
crimination against LGBTQIA people and families when such discrimination is based on religious
conviction. And yet the same Supreme Court decides to protect LGBTQIA people from employ-
ment discrimination. Even the most recent U.S. Census has become part of this trend as officials
have decided to reverse course and remove questions included for the first time in the previous
census aimed at identifying LGBTQIA-headed households, effectively erasing these households
in the official roles of the government. As these trends occur, a spike in LGBTQIA hate crimes has
occurred across the country, with transfeminine women of color being at highest risk.
 Introduction • 5

Intersectionality
Intersectionality—the interconnected identities that impact privilege and oppression expe-
rienced in society—first appeared in the late 1980s with Kimberlé Crenshaw’s work, and was
included in the family studies literature in the 1990s and 2000s, with a real explosion in focus in
the 2010s. The idea of intersectionality poses critical questions for addressing the mental health
concerns of clients who identify as LGBTQIA. Yet, the field of family therapy has lagged behind
in incorporating intersectionality into theoretical tenets and practical interventions—and inter-
sectionality is still not widely acknowledged in the field or taught in family therapy programs.
We are finalizing this edition against the backdrop of a heightened Black Lives Matter move-
ment with associated civil unrest and protesting against the senseless killing of so many Black
people, including Breonna Taylor, George Floyd, Atatiana Jefferson, Rayshard Brooks, and
Daniel Prude. We grapple with the continued centering of whiteness within LGBTQIA stud-
ies and in LGBTQIA-affirmative family therapy. We must ask: who are we affirming when we
conduct affirmative therapy? When we write or read about “lesbian couples,” are we implicitly
imagining white lesbian couples? There is evidence to suggest that for many white therapists,
this is the case. In a parallel way, we hope to trouble the rigid categories of sexuality and gender.
Transgender, nonbinary, and bisexual folx inherently challenge the status quo through their
very being which has prevented them from being given full consideration. Using the previous
example, when considering “lesbian couples,” it would be easy, perhaps common, to erase the
potential bisexual identity or the potential transgender identity of these partners if we cleave to
these rigid categories. Intersectionality calls for an explicit naming of identities, including those
of our clients and of ourselves. It calls us to account for intersectionality in our scholarly work,
research, case studies, and classrooms. Indeed, it also callus upon us to name and understand
our own intersectional experiences. We (RH & MJM) come to this work as two white people
and as such we have benefitted from unearned privileges that white people commonly assume.
We have blind spots and are doing anti-racist work imperfectly. Having two white editors is
certainly a limitation of the current edition and we hope that, moving forward, more marginal-
ized people will be empowered to speak and write about their own experiences. As a field and
as individuals, we need to encourage and support these efforts wherever possible. We know as
editors that we have fallen short of our own aspirational hope in publishing this book. We have
taken some small steps to ameliorate these shortcomings, knowing that it is not enough.
Our aim is to present a comprehensive Handbook that pushes the boundaries of the field and
that challenges chapter authors to step into intersectionality, to highlight the importance of
seeing relationships in all their wonderful complexity while attending and attuning to experi-
ences of privilege and oppression that play out in relationships. We wanted an explicit focus on
experiences of oppression woven throughout case vignettes, all against a backdrop of the hetero-
normativity that is ever-present in U.S. culture.
Martín-Baró writes “…the principle holds that the concern of the social scientist should
not be so much to explain the world as to transform it” (1994, p. 19). With this in mind, we
encouraged authors to focus on clinical work when revising or writing their chapters, hoping
they would show what their clinical approach would look like when approaching their chapter’s
topic. Where possible, authors illustrated their clinical work with a line-by-line dialogue that
can give the reader a reference point for implementing LGBTQIA-affirmative therapy into their
own practice. In other cases, brief vignettes highlighting important concepts were included
throughout the chapter. We asked for a clinical focus because we want to highlight the practice
of affirmative therapy—what it can look like and sound like to chip away day after day, session
after session at the oppressive narratives that dominate our lives and those of our clients. We
believe that this is important, transformational work.
6 • Rebecca Harvey and Megan J. Murphy

By intentionally muddying notions of boundaries and dichotomies, we have come to realize

that the sections of this book are interconnected and not easily distinguishable. Ethical con-
siderations appear in nearly all the chapters; clinical issues with couples are related to clinical
issues with families; intercultural considerations impact sex therapy … hopefully, the overlap-
ping nature of clinical issues, identity management, historical and political backgrounds, and
patriarchy, racism, and heteronormativity is evident.
We strongly believe that the future of LGBTQIA-affirmative therapy is connected to an embrace
of intersectionality, and a resistance against abuses of power inherent in the intersecting politics of
racism, misogyny, and classism. We must—as Baldwin suggests—mature and evolve as we seek to
move toward health and therefore toward justice. To accomplish this, we must resist false equiva-
lences, challenge the training we received as professionals which advises us to remain “neutral,”
and deepen our critique of white supremacist, patriarchal dichotomies. This process is ongoing.
We look forward to seeing continued evolution toward social justice for all.

References
Baldwin, J. (1985). The price of the ticket: Collected nonfiction 1948–1985. St. Martin’s Press.
Martín-Baró, I. (1994). Writings for a liberation psychology. Harvard University Press.
 Section I
Foundations of LGBTQ Affirmative Therapy
 1
Evolution of LGBTQ Affirmative
Couple and Family Therapy
REBECCA HARVEY, MEGAN J. MURPHY and TRACEY A. LASZLOFFY

Queer author and essayist Carmen Machado describes (2019) the dilemma queer people face
when attempting to understand, articulate or contextualize their own lives.
the late queer theorist José Esteban Muñoz pointed out that “queerness has an especially
vexed relationship to evidence…when the historian of queer experience attempts to docu-
ment a queer past, there is often a gatekeeper, representing a straight present.” What gets
left behind? Gaps where people never see themselves or find information about them-
selves. Holes that make it impossible to give oneself a context. Crevices people fall into.
Impenetrable silence.
(Machado, 2019, p. 18)

Affirmative therapists enter those impenetrable silences to assist, but to be effective they must
first unlearn lessons taught by predominantly western heteronormative cultures. In his critique
of Western psychology, Martín-Baró (1994) writes:
…the most serious problem of positivism is rooted precisely in its essence; that is, in
its blindness toward the negative. Recognizing nothing beyond the given, it necessarily
ignores everything prohibited by the existing reality; that is everything that does not exist
but would, under other conditions, be historically possible.
(Martín-Baró, 1994, p. 21)

The quotes provide a useful way to imagine the trajectory of affirmative therapy: where it has
been and most especially where it must now position itself going forward.
Affirmative therapy emerged in the late 1980s and 1990s as a response to the widespread pathol-
ogizing of Lesbian, Gay, Bisexual, Queer, and Transgender or Gender expansive(LGBQ &TGE)1
people in the mental health fields and society at large. Beginning mainly as a challenge to the
assumption that homosexuality2 was inherently disordered, it has been evolving ever since, mir-

1 Terms used to describe people who are minoritized for diverse sexual orientation and gender identities are
constantly evolving and increasingly nuanced. Umbrella terms are useful for honoring the connections and
similarities which exist among this varied group of people, yet they are problematic when they are not specific
enough or conflate identities that require separate focus. We do our best in this chapter of striking a balance
between connection and conflation, honoring similarities without minimizing unique experiences. Throughout
this chapter, we use a few alternate terms depending on the focus of our writing: LGBTQ refers to lesbian, gay,
bisexual, transgender, and queer; TGE when referring more specifically to people who are transgender or gen-
der expansive; Queer as an umbrella term to refer generally to those who are not cisgender or heterosexual.
2 Homosexuality was a psychiatric diagnosis which subsequently became a popular cultural term used to
describe same-sex sexual desire, behavior, and identity. We consider it an outdated word, based in pathology
and therefore only use it when referring to its historical relevance.

DOI: 10.4324/9780429274626-3 9
10 • Rebecca Harvey et al.

roring shifting social attitudes (Giammattei & Green, 2012) to include gender-affirming thera-
pies (Chang & Singh, 2016; Coolhart & Shipman, 2017; Lev, 2019) and a variety of methods and
approaches which support the health and wellness of LGBTQ individuals, couples, and families
(Johnson, 2012). As affirmative therapy continues to evolve, it must contend with (and be a part
of) increasingly nuanced challenges to traditional, patriarchal, heteronormative white supremacist
ideas of sexuality and gender (Singh, 2016). This includes contending directly with the same rac-
ist, sexist, heteronormative blind spots reproduced from the larger culture and then baked into its
own construction. As individuals and families navigate multiple pathways to the development of
healthy sexuality and gender identity, along with diverse constructions of intimate relationships,
marriages, and families, it is imperative that clinicians are able to navigate outside of the tradi-
tional confines of a patriarchal, heteronormative gender binary. In particular, affirmative therapy
must develop a truly intersectional lens (Addison & Coolhart, 2015), be intentionally anti-racist
and anti-sexist in practice, and advocate for full inclusion of bisexual and transgender and/or
gender-expansive (TGE) people.
This chapter begins by examining the historical context that gave rise to the need for an
affirmative therapy. We acknowledge hierarchical societal forces that have shaped the mental
health field in general, and the field of Marriage and Family Therapy (MFT) more specifically.
We explain how these forces have constrained our comprehension of the complexity and fluidity
of gender and sexuality, and by extension, have contributed to the marginalization and oppres-
sion of those who do not conform to traditional notions of gender and sexuality. We consider the
field of MFT—founded in a challenge to the positivist, mechanistic worldview that has governed
so much of modern psychological thought—and recommend it to fully extend its own systemic
principles to examine and mitigate the effects of sociocultural injustice on individual mental
health and family relations. We identify and discuss several issues that affirmative therapy must
grapple with if it is to become truly affirming to all LGBTQ people.

The Sociocultural Context of Patriarchy and Hierarchical Dualism

At the core of Western society3 is a patriarchal social organization which emphasizes individ-
ual agency separating the world accordingly into distinct oppositional entities such as light/
dark, good/bad, spirit/flesh, mind/body, healthy/unhealthy, white/black, and of course, male/
female. These polarities are arranged hierarchically with socially assigned differential values
such that categories placed first are valued and regarded as superior, whereas categories placed
second are devalued and regarded as inferior. With differential valuation comes differential
power. It is this paradigm that enables and multiplies oppression by manipulating and control-
ling access to power allowing some to prosper at the expense of others (Frye, 1983). Patricia
Hill Collins (2000) referred to this as “an intersecting system of oppressions” which interrelate
and reinforce one another (p. X). Similarly, bell hooks (2004) uses the term “imperialist white
supremacist capitalist patriarchy” (p. 17) to refer to the interlocking nature of systemic oppres-
sions that “grant power and privilege to some, while disproportionately disadvantaging others”
(Fitts, 2011, p. 112) on the basis of categorical separations such as race, gender, class, sexuality,
nationality, and so forth.4 These socially constructed classifications form the basis for a system of
structural inequalities and interlocking oppressions which are justified by claims that these cat-
egorizations and inequalities exist independently and reflect immutable, universal differences.

3 This chapter focuses exclusively on Western societies since this is the context we know best and practice in;
however, it is important to acknowledge that the preponderance of human societies around the world are
steeped in patriarchy.
4 For our purposes, we will refer to these systems as White Supremacist Colonialist Patriarchy (WSCP) or sim-
ply interlocking systems.
 LGBTQ Affirmative Couple & Family Therapy • 11

A foundational tenet in the White Supremacist Colonialist Patriarchy (WSCP) paradigm is

misogyny, which informs specific conceptualization and treatment of gender and sexuality. The
social construction of gender as a “natural,” essential binary conceives of males/masculinity and
females/femininity as mutually distinct, oppositional, and complementary in nature (Butler,
1990; Fausto-Sterling, 2000; Rich, 1986). Historically, because men and masculinity are con-
sidered superior, they necessarily dominate over women who are considered inferior and in
need of male guidance and protection, although men/masculinity may also be complemented by
women/femininity. In this way, a hierarchy is constructed with males/masculinity valued and
empowered over females/femininity which is devalued and disempowered.
Similarly, just as gender is constructed as a binary, sexuality is also similarly situated. Gender
and sexuality are interwoven so that being a man/masculine requires sexual attraction toward
and sexual behavior exclusively with women; likewise, being a woman requires sexual desire
toward and sexual behavior exclusively with men. Heterosexuality is expected, elevated, and
valued, while LGBQ sexualities are devalued and oppressed. If differences in access to power
and privilege are to be maintained, they must be justified by a robust distinction between gen-
ders which in part is why heterosexuality is deemed compulsory. In other words, to ensure
the maintenance of gender power imbalances, it is critical to sharply bifurcate gender which
requires heterosexuality. Moreover, these binaries are then promoted and defended by (a) natu-
ralizing traditional gender roles and imbuing these with exclusive meaning; (b) extolling the
virtue of heterosexual marriage and nuclear family structures then providing exclusive signifi-
cance and privileges to these traditional relationships; and (c) weaponizing heteronormativity
and homophobia (Pharr, 1997) along with misogyny, white supremacy, and classism. It is within
this societal context that the entire mental health system and the field of MFT have been formed.

The History of Gender and Sexuality in Mental Health

The mental health field was formed within racist, sexist, homophobic power structures that
reflect WSCP values in society at large, and as a result modern psychology has legitimated these
biases and reproduced them within its own theories and interventions. As Martín-Baró (1994)
noted, “psychologizing has served, directly or indirectly, to strengthen the oppressive struc-
tures by drawing attention away from them and toward the individual subjective factors” (p. 19).
One of the clearest examples of how this occurs within in the mental health system is with
regard to psychiatric diagnoses that reinforce oppression by locating the source of dysfunc-
tion within individuals while focusing scant attention to the social context and forces which
shapes their lives. An early example of this occurred in the 19th century with the fabrication of
Drapetomania, a mental illness invented during slavery to pathologize the desire that enslaved
people had to flee captivity; the framing of this diagnosis is centered in white supremacist ideol-
ogy which locates the “problem” of running away as a deficit within the individual rather than
within an oppressive system of slavery which any human being would wish to flee. Similarly,
hysteria could be found in the Diagnostic and Statistical Manual of Mental Disorders (DSM)
until its removal in 1980 (Tasca et al., 2012). As defined in the DSM, this diagnosis could only
be applied to women and contained a range of vague symptoms, including anxiety, irritability,
and sexual forwardness; any of these symptoms could better be understood in the context of
what were unreasonable expectations of women in society—to be servile, ever pleasant, devoid
of sexuality, and accepting of her place in the hierarchy.
The WSCP worldview inherent in the development of the DSM and the diagnoses within it
conveniently ignores the dominant groups’ access to power and the resultant impact on inter-
personal relationships or society at large. By focusing on the individual victims rather than
the perpetrators of oppression and violence, these disorders minimize the societal level power
dynamics of relational domination which both normalizes perpetration by the oppressor group
12 • Rebecca Harvey et al.

and pathologizes the experience of domination by the oppressed group. The ability to determine
what can be ignored thus ensures that these power dynamics remain effectively invisible, per-
vasive, and unchallenged. There is no DSM diagnosis appropriate to people who display racist,
sexist, ableist, misogynistic behavior, despite the great damage done on an individual, family,
and societal scale as a result of these beliefs.
Another example of the ways that the mental health field has buttressed patriarchy by pathol-
ogizing marginalized peoples can be found in the way the DSM has often confused sexual ori-
entation and gender identity by conflating and problematizing any manifestations of these that
violated patriarchal gender norms (Lev, 2013; Nealy, 2017). This conflation emerges from within
the confines of patriarchy where biological sex, sociocultural gender, and sexual desire are inex-
tricably connected. Arguably, what mainly unites lesbian, gay, bisexual, and transgender and
gender expansive people is the way they transgress WSCP gender expectations. The facts of
queer lives, their romantic/sexual relationships, and their families challenge and destabilize the
gender binary and traditional notions about family life (Harvey et al., 2020). As such they share
the experience of marginalization and oppression which occur as a result of these transgres-
sions. It is these same heteronormative assumptions which first drove the diagnosis of homosex-
uality and was then later used to officially pathologize transgender people. As a result, there is a
distinct yet parallel trajectory in how psychiatric diagnoses first progressed from “mental illness
to human diversity” (Lev, 2013, p. 292), first for gay/lesbian people, and then for TGNC people.5
With the inclusion of homosexuality as a psychiatric diagnosis in the second edition of
the DSM in 1968 (Burton, 2015), long-standing religious and cultural biases were legitimized
under the cloak of science and objectivity which were used to police gender role expectations,
sexual attraction, and behavior. In the following years, fueled by increasing social acceptance
of LGBTQ people, the mental health fields would adopt, defend, revise, and abandon a series
of mental disorders pertaining to sexual orientation and gender identity (Lev, 2013; Nealy,
2017). One of the early steps in this direction occurred in 1973 when the American Psychiatric
Association (APA) reversed itself and removed homosexuality from the DSM. With this removal
there was no official means within mental health fields to address still pervasive concerns about
gender variant behavior among boys and men. Many in the medical and mental health fields
persisted in searching for the etiology of homosexuality (Lev, 2013) and developed interven-
tions to treat it and other gender-non-conforming behaviors (Nealy, 2017). For example, fol-
lowing the official removal of homosexuality from the DSM, a number of related diagnostic
codes were developed, retained, and then revised, including Ego-Dystonic Sexual Orientation
in the DSM-III (American Psychiatric Association, 1980), and in the DSM-IV-TR (American
Psychiatric Association, 2000) a subcategory of Sexual Disorders Not Otherwise Specified [NOS]
which described “Persistent and Marked Distress about Sexual Orientation” (p. 582).
The first diagnosis pertaining to gender identity was included in 1980 directly following the
1973 removal of homosexuality from the DSM. As a result, some in the LGBTQ community
perceived that Gender Identity Disorder was created as an alternate path to discourage femi-
nine gender expression, including gay identity among boys/men (Nealy, 2017). Conversely, some
advocates for transgender people supported the creation of this diagnosis assuming that treat-
ment and medical intervention would be developed only if a psychiatric diagnosis legitimized
the need (Lev, 2013). Gender Identity Disorder endured through two additional revisions of the
DSM and finally was revised in the DSM-5 to Gender Dysphoria. The intent in replacing “dis-
order” with “dysphoria” was to move away from language that focused on transgender identity
being inherently pathological. Dysphoria instead emphasizes the role of distress which occurs

5 See Lev (2013) for a more detailed discussion of the evolving interplay of the diagnoses related to sexual orien-
tation and gender identity.
 LGBTQ Affirmative Couple & Family Therapy • 13

for some persons when their assigned birth is dissonant with their experienced or affirmed gen-
der. Therefore, the problem lies less in the inherent identity of an LGBQ or TGNC person and
more on the pathology created by what has subsequently come to be known as minority stress
or the distress one feels from the stigma and shame that results from living in a heterosexist,
heteronormative culture (Bowleg et al., 2003; Burton, 2015; Chen & Tryon, 2012; Levitt &
Ippolito, 2014). These revisions are important progressions for TGNC health and wellness
(Nealy, 2017) yet, despite progress, the latest iteration of the DSM (American Psychiatric
Association, 2013) continues to pathologize and stigmatize TGNC people. As Nealy (2017)
pointed out:
At the root of this stigma is the fact that gender dysphoria (and its predecessor gender iden-
tity disorder) is a psychiatric, not a medical diagnosis. The fact that the diagnosis is located
within the DSM labels it as a mental illness. Consequently, all transgender people who
desire to medically transition must assume the stigma of being diagnosed as mentally ill.
(p. 24)

Outside of this gender binary, many genders and sexualities are possible, but the mental
health field has struggled to see anything outside of what WSCP assumptions and social toler-
ance would allow (Giammattei & Green, 2012). The diagnostic codes reflect and often weapon-
ize the WSCP cultural view of individuals who live outside of heteronormativity. Confined by
WSCP assumptions about a gender binary, mental illness is the only available language which
can explain how someone can feel dissonance between their assigned sex at birth (usually con-
nected with physical genitalia) and their internal experience of gender (Nealy, 2017), just as it
was previously the only way to explain sexual desire for someone whose assigned sex is the same
as one’s own, or before that to explain why an enslaved person would want to escape or why a
woman might desire sex or often feel irritable and angry.
LGBTQ people were originally seen and treated as a monolith, aggregated together for the
ways they transgressed patriarchy (Harvey et al., 2020) with the differences between them—
including gender identity, sexual orientation, race, ethnicity, and class—routinely not addressed.
The result was a racist, sexist, heterosexist view that often erased bisexual and especially TGNC
people altogether just as it overemphasized white, middle-class, male worldviews. There has
been a slow progression on the part of mental health systems to depathologize, and begin to see,
know, and understand this varied group on their own terms.

Gender and Sexuality in Marriage and Family Therapy

When family therapy emerged in the 1950s, it resisted conventional ways of conceptualizing,
diagnosing, and treating mental illness which emphasized the individual as the site of both
pathology and intervention. Instead, MFT emphasized family relationships, pattern, and pro-
cess in order to understand how human behavior makes sense in a larger context. Based on the
systemic assumption that all parts of a system are interrelated, symptoms in one member of a
system indicated something about health and wellness of the entire system. As a result, systemic
therapists broadened treatment to include the entire family system. The paradigm shift from
an individual to a family focus was revolutionary at the time and it brought forth creative new
treatment options and viewed mental illnesses as a problem often developed and maintained
within relational dynamics rather than being located within the individual.
MFT as a field still proudly embraces this systemic paradigm shift from an individual, linear view
to a holistic, systems approach, and it uses this shift to distinguish itself from other mental health pro-
fessions. While family therapy convincingly expanded mental health from an individual to a family
focus—and was well positioned to question the WSCP status quo—the systemic conceptualization
14 • Rebecca Harvey et al.

generally stopped there. The field operated in a self-congratulatory fashion for several decades until
feminists began pointing out the lack of attention to the dynamics of power that regulated family
relations as well as the effect of this on women and other vulnerable members of the system.

Reinforcing the Gender Binary

Until the 1980s, much of the MFT field failed to address considerations of power that occur at
the societal level and then affect individuals and families. For example, the field has effectively
failed to address highly politicized terms “marriage” and “family” that appear in the field’s mon-
iker, which have repeatedly been—and continue to be—used to advance a conservative agenda
at the expense of LGBTQ people. Various feminist scholars beginning in the late 1970s warned
against this pointing out how (a) therapeutic neutrality in the face of power imbalances main-
tained and promoted a patriarchal status quo that was often oppressive and sometimes violent;
(b) how women’s roles and oppression were overlooked in classic therapy theories; and (c) how
foundational MFT theories tended to reinforce traditional gender roles and male dominance
(Avis, 1985; Brown, 1986; Walsh & Scheinkman, 1989; Walters et al., 1988). In her influential
article published in Family Process in 1978, Rachel Hare-Mustin highlighted how the field of
family therapy, despite its purported focus on systems, lacked the perspective to account for its
own gender assumptions and therefore failed to contextualize women’s experiences. Mothers
were blamed for causing mental illnesses (including schizophrenia and homosexuality) in their
children by being overly involved and lacking differentiation or healthy communication skills
(Bograd, 1990). Moreover, women and women’s roles were repeatedly minimized and pathol-
ogized. Hare-Mustin (1978) noted that structural family theory openly emphasized and pro-
moted enforcement of parental hierarchies in which fathers are expected to exert leadership
and exhibit control of the entire family, including their wives. Similarly, Bowen’s family systems
approach elevated independence, rationality, emotional repression, and self-control as markers
of health (Avis, 1998; Walsh & Scheinkman, 1989). It was no coincidence that differentiation (i.e.
health) was associated with characteristics reserved for an idealized masculinity. Hare-Mustin
asserts that “Bowen’s Differentiation of Self Scale can readily be identified as a sex stereotyped
masculinity-femininity scale with femininity at the devalued end” (Hare-Mustin, 1978, p. 2).
One consequence of the failure to recognize the influence of social context on family theories
of health and pathology has been the wholesale acceptance of traditional gender role expec-
tations and corresponding WSCP definitions of marriage and family which profoundly affect
everything that comes after, especially intimacy. Under patriarchy, everyone is denied the full
spectrum of humanity. Oppression is a double bind which means that for oppressed groups,
“you’re damned no matter what you do.” Men—white men specifically—can assume a way of
being in the world that leads to some measure of valuation and power even though they suffer
by virtue of having to deny their vulnerability. For women, no matter what, the result is devalu-
ation and mistreatment. Hence, if women follow the script, they accommodate to oppression,
diminish themselves, and are judged as weak. If they defy it, they are judged harshly as bossy or
bitchy. Multiply this oppression exponentially for those who also experience oppression based
on race, age, sexuality, and class.
Despite some progress, the field’s treatment of power, gender, and sexuality continues to
replicate the invisibility of these critiques within the larger society. The feminist critique itself
while revelatory was limited by its “single-axis framework” (Crenshaw, 1989, p. 140) wherein it
reflected dominant white (women’s) voices that appeared to speak for all women. In making the
same mistake that systems theory did—challenging parts of the status quo while upholding the
larger patriarchal, racist ideas—white feminists effectively marginalized the voices of Black and
Brown women whose oppressive experiences as women could not be understood separate from
their oppressive experiences as racially minoritized women (Crenshaw, 1989).
 LGBTQ Affirmative Couple & Family Therapy • 15

Inching toward Intersectionality

Slowly, feminist critiques led to increased acknowledgment that differential access to power
affected interpersonal and intimate relationships. This, in turn, provided credibility to the con-
cerns of other marginalized groups that were being widely ignored in the field. In the late 1980s,
family scholars’ writings about race began to be published with more frequency (Boyd-Franklin,
1984, 1987; Hardy & Laszloffy, 1994, 1995, 1998), challenging the white-centeredness of the
field, including the feminist thinkers who had not accounted for race and racial power in their
critiques (Hardy & Laszloffy, 1994, 1995, 1998; Laszloffy & Hardy, 2000). Still, these writings for
many years were considered outside the mainstream white narrative of the family therapy field.
A similar surge of writings about sexual orientation emerged in the 1990s, with several notable
articles that introduced the idea that sexual orientation might be important for family therapists
to consider (Clark & Serovich, 1997) which was followed by a flurry of writing regarding TGNC
in the 2010s (Connolly et al., 2016; Coolhart & Shipman, 2017; Giammattei, 2015; Lefevor et al.,
2019; Leland & Stockwell, 2019; Malpas, 2011; Porter et al., 2016; Singh, 2016; Singh & dickey,
2017). In writing about each of these critical areas—race, sexual orientation, gender—there was
a need to differentiate one group from the other; that the challenges LGBTQ people face, for
example, are different from those cisgender, heterosexuals face because of their different places
in societal hierarchy and the power each group had access to in their lives. To advance these
issues meant necessarily highlighting each in a binary way which magnified differences between
groups in order to make them accessible for exploration. Scholarly work about oppressed groups
was framed in isolation from other marginalized groups. On the one hand, these writings
importantly challenged white men’s experiences as the standard norm. On the other hand, they
upheld the status quo by adhering to a pattern of universalizing “us-versus-them” contrast that
neglects the overlaps and commonalities between groups. So important nuances of identity were
rarely considered, for example, how identifying as both racially minoritized and LGBTQ dra-
matically altered one’s experience of both identities; or how one might be TGNC and also lesbian
or gay and how these coinciding experiences affected family life. As each “category” of concern
was written and addressed, we slowly began to understand not only that identity shapes who we
are, but that they are not separate parts of ourselves—rather, they intersect in particular ways
that shift over time as well as shift as we engage in particular relationships; this all takes place
within a larger sociopolitical cultural context that influences how our particular identities have
access to power or not.
Intersectionality as a concept is grounded in Black feminists’ work and has evolved over time.
Curtis et al. (2020) offer the following definition:
Intersectionality as a means of describing how broad social categories such as race, gen-
der, and class, along with more specific social categories, such as an ‘essential worker,’ for
example, interacts with interdependent systems of privilege, discrimination, and disad-
vantage to influence the lived experiences of individuals, families, and communities.
(p. 513)

The definition underscores the overlapping nature of multiple systemic oppressions experi-
enced by individuals based on social categories associated with one’s identity.

Pathologizing Homosexuality, Reinforcing Heteronormativity

Like other mental health disciplines, MFT was so soundly steeped in heteronormativity that
originally it could only accommodate the existence and experience of LGBTQ people by pathol-
ogizing them along with their family systems (Giammattei & Green, 2012; Hatterer, 1970;
LaSala, 2013). Giammattei and Green noted that foundational systemic theories are filled with
16 • Rebecca Harvey et al.

microaggressions toward LGBTQ people (Giammattei & Green, 2012), which Sue (2010) noted
are often unintentional thoughts or actions rooted firmly in oppressive assumptions about
minoritized peoples. In this case, the most important founders of systemic thinking felt entitled
to widely and openly pathologize “homosexuals” and blame dysfunctional family systems for
producing homosexual offspring. At the same time, white male sexuality was unselfconsciously
centered so that gay men became particular targets of disdain (Giammattei & Green, 2012),
scorned for their effeminacy or for other transgressions of masculinity which made them more
like women and therefore inferior, while women’s (homo)sexualities were so irrelevant as to not
even be a serious consideration and were routinely minimized or ignored.

Problematizing LGBTQ Identity

Following the removal of homosexuality as a psychiatric diagnosis, family theorists, mirror-
ing the culture around them, began to shift away from focusing on disordered identities and
instead focused on the problems that family systems faced by virtue of having a member with
an LGBTQ identity. Gradually, case studies were offered up in mainstream family therapy jour-
nals which included same-sex couples, heterosexual partnerships where one party (usually the
husband) was in the process of coming out, or parents seeking help when their child was com-
ing out (Giammattei & Green, 2012). The central focus of this work was on “the problem” of
LGBTQ identity and on managing the negative impact of it on couples and families (Hudak &
Giammattei, 2014; LaSala, 2013; Stone Fish & Harvey, 2005). This meant that when LGBTQ lives
were represented in clinical work, their LGBTQ identity was emphasized as the source of mental
health problems. While this was less pathologizing than a label of mental illness, it continued to
locate the problem within an individual or perhaps a family.
Moreover, these case studies were presented using theories and interventions not developed to
specifically consider or include LGBTQ experience and by clinicians who rarely if ever extended
their systemic assessment to include their own inherent bias. So even if they cared to, they could
not alter their theories to better accommodate LGBTQ identity or people, nor certainly could
they imagine that in so doing they might actually improve upon their original theories. The
cumulative effect was to underemphasize the role of more universal couple and family problems
within LGBTQ lives while overemphasizing the universality of family therapy treatments domi-
nated by heteronormative discourse. Giammattei and Green (2012) wrote, “This is evidenced by
the frequency with which the concepts of marriage, couple, and family are used in research, the-
ory, training, and conference presentations without specifically naming heterosexuality, even
though heterosexuality seems the taken-for-granted reference point in these contexts” (p. 5).
The culmination of all of this is the continued marginalization of LGBTQ lives as heteronorma-
tive standards are repeatedly reinforced with the assumption that couples, families, marriages,
husbands, and wives belong universally to heterosexuals and heterosexuality.

LGBTQ People Studied as a Monolith

As previously discussed, queer experiences of gender and sexuality were problematized and
conflated by the culture at large and then interwoven into the mental health system within both
treatments and diagnoses. With the gradual shifting of attitudes came increased recognition that
LGBTQ people faced unique stressors. Theorists and clinicians—rightfully so—became interested
in understanding the unique experiences that LGBTQ people shared. But the pattern of conflation
persisted and LGBTQ individuals, couples, and families were studied as if they were a monolithic
category, as if all LGBTQ experience was easily summarized against the enormous presence of
cisgender, heteronormative (white, Judeo-Christian) experience. While indeed there were and are
important differences between cisgender, heterosexual experience and LGBTQ experience, the
entirety of LGBTQ experience is not so easily summarized without employing an intersectional
 LGBTQ Affirmative Couple & Family Therapy • 17

understanding (Singh, 2016). This lack of contextual understanding had the effect of emphasizing
the similarities between all gender and sexual minorities while minimizing the differences in their
lived experiences. The coming out process, family of origin relationships, and couple dynamics
were studied as if all non-heteronormative people were similar enough to generalize about with-
out taking into consideration all the ways they were different (Harvey et al., 2020). While shared
experiences of oppression served at times to unite LGBQ with TGNC people (e.g. the Stonewall
riots), it has been a lopsided, unequal, and sometimes uneasy alliance with some identities (TGNC,
bisexual, and the experience of Black and Brown LGBTQ people) getting short shrift and little
attention. The view of LGBTQ people created even in affirmative therapy and theory has centered
on the experience of white, relatively wealthy, educated men, and women since it is these people
who are historically mostly likely to be in the empowered positions to theorize, write, and pub-
lish. Lost is the intersectional nuance of genders and sexualities created and expressed through a
diverse spectrum of salient identity markers such as race, ethnicity, class, and immigration status.

Considering Race
Similar to the way heterosexuality is centered and routinely amplified, whiteness has been cen-
tered in all constructs related to family and relationships. This happens pervasively and often
indirectly and hence is rarely named or acknowledged. The preponderance of scholarly work
addressing “LGBTQ Families” does not name race except when referring to people of color.
Hence, when race is not named, the subjects are almost always white (Hardy & Laszloffy, 1994).
Family science and family therapy all routinely fail to account for race in meaningful ways, giv-
ing privilege to white accounts and experiences of the way family ought to be. Writings about
race, racism, and the impact of slavery, Jim Crow and chronic discrimination are still scarce in
the family studies field. Addressing race is seen as a layer to address after one understands fam-
ily rather than a more nuanced approach which understands one cannot be separated from the
other. Finally, while recognizing the impact of minority stress on the lives of minoritized people
has been a step in the right direction in the fields of Family Science and MFT, doing so while
remaining neutral, disinterested, and uncommitted to more fundamental second order change
continues a systemic pattern of focusing change within individuals and families who are forced
to accommodate oppression for survival.

Affirmative Family Therapy

A specific definition of affirmative therapy has been difficult to elucidate since its inception in the
1980s. Johnson (2012) noted the lack of clarity about whether affirmative therapy is a theoretical
approach or a set of specific intervention(s). Beginning with an exclusive focus on sexual orienta-
tion, there has been a wide array of loosely connected affirmative methodologies which eventually
were adapted to address gender identity as wider cultural acceptance has evolved. Harrison (2000)
conducted a thematic analysis and surmised that affirmative therapy was originally marked by
a non-pathological view of homosexuality and some level of knowledge on the part of the thera-
pist about the experience of people with same-sex desire. Harrison also noted that a few articles
mentioned advocating for clients specifically and LGBTQ people generally by challenging societal
oppression. Ritter and Terndrup (2002) loosely defined affirmative therapy as being characterized
by therapists who (a) are accepting of homosexuality as part of natural human variation; (b) are
reasonably free of heterosexist bias and prejudice; (c) have a working understanding of gay, lesbian,
and bisexual experience; and (d) possess a willingness and capacity for self-examining how they
themselves are influenced by heterosexism (Ritter & Terndrup, 2002, pp. 1–2).
Affirmative care was broadened to specifically address transgender experience, includ-
ing gender-affirming therapies which Coolhart and Shipman (2017) characterized as “therapy
which assumes that transgender and gender-nonconforming identities are natural variations of
18 • Rebecca Harvey et al.

humanity that should be normalized and affirmed” (p. 113). Singh (2016) expanded on the idea
to include self-reflection on the part of the therapists regarding their gender bias and assump-
tions, as well as paying special attention to intersectional issues and identities relevant for TGNC
people.
At a minimum, affirmative therapies all take a non-pathologizing stance toward gender and
sexual diversity and toward LGBTQ identity. Affirmative therapists must be willing to thor-
oughly examine all components of treatment for the messages they send to and about LGBTQ
people (Hadland et al., 2016), as well as understanding that the source of any pathology is rooted
within a dysfunctional social context that devalues and discriminates against those who are
LGBTQ rather than inherently within LGBTQ people themselves.

Actions in Support of the Evolution of Affirmative Therapy

The following section discusses our ideas for how affirmative therapy needs to evolve and
expand so it remains relevant, best meets clients’ needs, and affirms the interests and identities
of all people, especially those who are LGBTQ in our rapidly changing world.

Center Ethics and Intersectionality The highly questionable ethics regarding how LGBTQ people
have historically been treated by the mental health fields are instructive examples about how
considerations of power and influence create huge blind spots in ethical codes which persist even
to this day (see Chapter 3). Historically, the mental health response has been to locate pathology
within the individual and ignore societal level dysfunction and oppression (Martín-Baró, 1994).
Even the MFT field, primed as it is to discern systemic interactions, has often failed to see its
own position and homeostatic function within the WSCP power structures. Affirmative therapy
was necessitated by the inability to discern unjustifiable power imbalances and the multiple,
intersecting instances of oppression this reproduces at the societal level and within intimate
family relationships. The need to attend to intersectionality arises from the WSCP roots of the
U.S. (and other countries colonized by imperialist white Europeans), and the way that these val-
ues are baked into the practice of psychotherapy, broadly defined. Martín-Baró (1994) notes that
these biases are inherent when a field advocates for its access to influence within an oppressive
power structure, which requires a contribution to the status quo that limits the ability to then
challenge that status quo. Yet, we have an ethical responsibility, rooted in a communal sense of
care and concern for others, to locate our focus of analysis on larger structures and manners of
domination if we are to have any hope of effecting long-lasting, meaningful change beyond the
therapy room. Great strides have been made toward justice, and now with a clear illustration of
exactly how our theories, ethical codes, and even leaders in the field can fail us and more impor-
tantly our clients, it is incumbent upon us to address this failure.

Intersectional Clinical Work What has become clear in the last decade or so is that LGBTQ
people and families are diverse and complex. But affirmative therapy has suffered from a lack
of intersectionality creating large gaps in understanding the experience of people at the cross-
roads of multiple oppressions. While there are important patterns and similarities, there is no
universal LGBTQ experience. Oppression is reinforced, recreated, and experienced through
unique interactions of race, class, gender, sexuality, religion as well as individual personality
and family dynamics. If affirmative therapy is to be actually affirming to all LGBTQ people,
it must welcome and address the full intersectionality of LGBTQ experience. Therapists must
become adept at understanding how current sociocultural political systems undermine all
LGBTQ families and to intervene differently and specifically based on these intersections.
One gap that must be addressed in affirmative therapy is race that, like gender, is a founda-
tional dimension of diversity and shapes all aspects of our lives. We live in a racially segregated
 LGBTQ Affirmative Couple & Family Therapy • 19

society, and depending on our racial location, there are dramatic differences in our access to
power, resources, and valuation. LGBTQ people of color comprise nearly 22% of people in same-
sex relationships and they experience unique manifestations of microaggressions because of
their multiple marginalized identities as sexual, gender, and racial minorities (Balsam et al.,
2011; Bowleg et al., 2003; Chen & Tryon, 2012; Levitt & Ippolito, 2014). Additionally, LGB people
are more likely to enter into interracial relationships, have had more interracial romantic part-
nerships, and have more racially diverse community connections than cisgender heterosexual
people (Horowitz & Gomez, 2018). Hence, the experiences of LGBTQ people who are white
differ from those who are people of color. This difference matters and needs to be continually
acknowledged and addressed directly in affirmative therapy scholarly work (das Nair & Thomas,
2012) through (a) intentional resistance of a monolithic presentation of LGBTQ families; and
(b) exploring and naming race (especially whiteness) in case studies, research, supervision, and
case presentations.
Class is another variable that warrants consideration when examining the experiences of
LGBTQ persons. Given that LGBTQ people have lower incomes and higher levels of poverty
than corresponding cisgender, heterosexual people (Badgett et al., 2019), it is especially impor-
tant to factor class location into our assessment of the experiences of LGBTQ persons and to
have particular sensitivity to the ways that being poor or working class is uniquely stressful. This
is even more important given that in the U.S., there is a widening economic disparity coupled
with a tendency to privilege the interest of the upper or middle classes while minimizing class
differences and either ignoring or blaming the poor for their own economic distress. The burden
of shame multiplies for the LGBTQ person who is also struggling financially. Hence, efforts to
understand the experiences of LGBTQ persons must include a consideration of class as a pow-
erful organizing principle and the burden of multiple stigmatized identities that increase the
likelihood of shame. Like with race, when class is unnamed, the experiences and expectations of
middle- and upper-class lives are centered.
In short, LGBTQ people and families are not a monolith and cannot be effectively understood
as such. Affirmative therapists must get better at understanding how pressures of interlocking
systems of domination at the macro level are being expressed at the micro level of intimate rela-
tionships. Affirmative therapists must be mentored to capably name intersectional differences,
track how power differentials based on these differences manifest themselves within families,
and be able to tailor treatments rather than rely on those standardized on WSCP norms to inter-
vene and build protection against oppression.

Challenge the Gender Binary As discussed previously, WSCP dominance demands the
preservation of a sharply divided construction of gender that clearly defines who/what is
or is not “a man.” Human beings are more fluid and non-binary than can be easily under-
stood within the limitations of our current sociopolitical social constructs (Diamond, 2003;
Zoeterman & Wright, 2014). This rigid gender binary interferes with our ability to grasp the
complexity and fluidity of gender, thereby inhibiting our ability to freely see and experience
the full range of possible ways of being. To build therapeutic alliances which honor evolving
identities requires a willingness to see what is difficult to see, given the filter of heteronor-
mativity and to then ask how clients see and name their own lives and experiences (Harvey
et al., 2020).
Moreover, it is important to recognize that the gender binary—amplified and sometimes
weaponized as it is—constrains everyone’s ability to freely participate and fully express the
range of human experience and emotion (Giammattei, 2015; Harvey et al., 2020). This inhibits
intimacy (Knudson-Martin & Mahoney, 2009; Real, 2002) and profoundly affects family life
(Knudson‐Martin & Laughlin, 2005; Real, 2007) for everyone, no matter how one identifies
20 • Rebecca Harvey et al.

their gender or sexuality. Affirmative therapy need not challenge whether general differences
exist between men and women. Rather, it needs to challenge (a) the overemphasis placed on
these differences; (b) the minimizing of differences between men as a group and women as a
group; and most importantly (c) the devaluing of these differences.

Consider Language One way of challenging the gender binary is to carefully consider and
rethink our use of language. The ever-expanding number of labels for queer identities (lesbian,
gay, bisexual, transgender, queer, questioning, intersex, asexual and pansexual) makes sense “…
because we are attempting to use heteronormative ideas to categorize human experience which
often fall outside of these constructs and therefore resists these attempts” (Harvey et al., 2020, p.
545). Despite current positive cultural shifts and increase in available literature, society at large
and the field of MFT continue to rely on language that reinforces the gender binary rather than
imagine a gender spectrum.
As part of resisting the gender binary, affirmative therapy must resist conflating experi-
ences of LGBTQ people and instead fully explore the singularity of each identity and even
more specifically, each client’s unique experience of that identity. Inclusion for groups who
have been so pervasively marginalized cannot be assumed or taken for granted. For example,
even when the terms transgender and bisexual have been included in the titles of articles
and chapters, often they are not sufficiently addressed in the text or, when included, were
assumed to be the same as the lesbian and gay experience. Multiply that for TGNC people
of color whose life experiences have been rarely centered in mental health literature. We need
to focus on these terms and fully explore identity with a critical consciousness that facilitates
deconstructing the gender binary and the systemic oppression which underpins it.

Focus on Training Affirmative therapy family therapists must be adequately mentored and
trained using practices which include (a) increased interaction with LGBTQ people (includ-
ing faculty, supervisors, students, and clients), topics, and LGBTQ experiences (Godfrey et al.,
2006); and (b) examining the influence of heterosexist or heteronormative beliefs and atti-
tudes on the self of therapist (Long & Serovich, 2003). Carlson et al. (2013) found that there
was a positive relationship between exposure to these training techniques, along with men-
torship by supervisors who took an affirmative stance, and MFT students’ increased sense
of competence with LGBTQ clients. Although a study by Rock et al. (2010) found a major-
ity of MFT students reported not having received any training of this kind, a later study by
McGeorge and Carlson (2016) which surveyed faculty from MFT programs found a majority
of faculty reporting affirmative stances in their own beliefs and within the curriculum of their
MFT programs, suggesting that the field was progressing along with the wider culture.

Self of the Therapist Work An essential component of the evolution of affirmative therapy
involves therapists being committed to self-examination. We are all socialized in a culture
marked by domination and separation; hence, we all absorb the misogynistic, racist, classist,
elitist, heterosexist, homophobic messages and are constrained by them in our personal as
well as our professional lives. Power often invites those with privilege (and we all have some
measure of privilege) to rush for a resolution of what feels uncomfortable or to feel over-
whelmed with paralysis. Neither is very useful. It is incumbent upon each of us to examine
and critique ourselves, and allow others to also examine and critique us, as a way of miti-
gating the power that we exact in relationships. We are likely to only see our lack of power
through our experiences of oppression and marginalization. We need to welcome account-
ability by engaging in relationships with people who risk challenging our privilege and the
power we have as a result of that privilege.
 LGBTQ Affirmative Couple & Family Therapy • 21

Affirmative therapy is not a destination to rush toward or arrive at. Truly becoming more affir-
mative requires an intentional effort to reject paralysis and non-action and to become aware of the
power we hold that is both related to our individual identities and given authority by the larger
sociocultural political landscape; we need to risk that power by being vulnerable in relationship,
exhibiting humility in the lack of knowledge that we truly possess, and seek comfort and security
knowing that we will always be learning. To do so is to embrace activism and to resist the pull of
dominant discourses that put forward racism, sexism, classism, all wrapped in colonialism. This is
the future of affirmative therapy; it is the future of all therapies that embrace social justice.

Summary
Affirmative therapy emerged in the 1980s and 1990s as a direct challenge to widely held hetero-
normative biases in the mental health fields. It was necessitated by the inability or unwillingness
to consider the undue influence of power on the mental health system which itself emerged from
sociocultural paradigms characterized by domination, misogyny, white supremacy, and colonialism.
Oppression in all forms is derived from and reinforced by these interlocking systems of domination
whereby living beings are divided into rigid categories that maintain an unequal access to power and
resources. This domination has had destructive effects on all people but certainly on LGBTQ people
who inherently threaten the binaries of gender and sexuality that much of this paradigm rests on.
Family therapy had some success challenging decontextualized, individualistic notions of
mental health; however, it did not go far enough to represent LGBTQ people’s lived experiences
and relationships. Affirmative therapy has challenged the decontextualization of queer people
and has fostered the creation of therapeutic spaces wherein LGBTQ people might be met, under-
stood, and known on their own evolving terms. But as originally developed, affirmative therapy
is necessary but not sufficient for the world into which we are heading: a world of increasing
polarization, naked economic disparity, increasingly brazen racial injustice, and a bevy of alter-
nate facts designed to muddy the waters and protect the status quo.
Incorporating intersectionality is still very new to the field (Addison & Coolhart, 2015). That
we have not made more significant movement recognizing and attending to larger socio-cultural-
political contexts within affirmative therapy speaks to the intractable power dynamics at play in
maintaining the WSCP status quo. The field is still dominated by wealthy white male voices (and
now white female voices). Until the mantle of leadership fully includes marginalized peoples—
those of color and those who are LGBTQ—making this same mistake will be hard to avoid.
Going forward, the practice of affirmative therapy must directly challenge relational domina-
tion by supporting LGBTQ individuals and families to recognize and mitigate systemic abuses
of power while affirming their own strength, beauty, and necessity. What might be possible
in the absence of pervasive heteronormativity? Or pervasive sexism or racism? We do not yet
know. What affirmative therapy looks or sounds like is evolving today in clinics, classrooms,
and supervision sessions. We look forward to seeing its continued evolution.

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 2
Intercultural Issues in LGBTQ+
Couple and Family Therapy
Supporting Empowerment and Resilience at the
Intersection of Identities
AMNEY J. HARPER and ANNELIESE A. SINGH

Introduction
More often than not in the scholarship on lesbian, gay, bisexual, trans, queer, questioning
(LGBTQ+) couples and families, there are silences with regard to the inclusion of the needs and
concerns of LGBTQ+ people who hold additional historically marginalized identities. Instead,
LGBTQ+ practice and research typically neglect to explore issues of race and ethnicity, gender
identity and expression, ability status, social class, immigration status, and other salient identities
LGBTQ+ couples and families may hold. In doing so, the overall focus of this area in psychother-
apy with LGBTQ+ couples and families becomes synonymous with dominant groups in society,
namely, white, middle-class, gay men—and a Western perspective on couples and psychotherapy.
Heeding the call of Kimberle Crenshaw regarding intersectionality theory (1991), it is crucial that
therapists understand the wide range of experiences LGBTQ couples and families have as well as
how interlocking oppressions (e.g. racism, sexism, classism, ableism) uniquely affect their lived
experiences of multiplicative privileges and oppressions. This takes on special importance, given
current population trends, which project that the U.S. will become “minority white” by 2045
(Frey, 2018) and that racial/ethnic diversity is no longer being driven by immigration, but instead
by birth rates in the U.S., as suggested by the Population Reference Bureau (Mather et al., 2019).
Therefore, we must note that
children are at the forefront of racial/ethnic change in the United States, creating a diver-
sity gap among generations. Only half of the population under age 18 are projected to be
non-Hispanic white by 2020, compared with three-fourths (76 percent) of those ages 65
and older.
(Mather et al., 2019, pp. 11–12)

However, it is also important to note that while white people will be in the minority, wealth
and power will still be concentrated in white communities due to generations of racist policies
and practices within the U.S. (e.g. gerrymandering, voter ID laws, housing loan discrimination;
Poston & Saenez, 2017).
As LGBTQ+ identities intersect with various cultural identities, what results are interlock-
ing systems of power and oppression (Crenshaw, 1991) that LGBTQ+ people must navigate and
which uniquely impact the individual’s experience within the context of their relationships.
Therefore, a major component of ethical and competent practice in this regard is ensuring an
intercultural approach to counseling. An intercultural approach refers to therapist intentions to
validate and affirm the wide range of cultures from which LGBTQ+ couples and families come

DOI: 10.4324/9780429274626-4 25
26 • Amney J. Harper and Anneliese A. Singh

from, and the recognition that therapists bring their own biases, attitudes, and worldviews into
the therapeutic relationship. The purpose of this chapter is to describe key components of an
affirmative, intercultural approach to therapy with LGBTQ+ people which supports their resil-
ience and empowerment in the face of interlocking oppressions. These key components include
(a) specific ways that multiple and interlocking oppressions LGBTQ+ couples and families expe-
rience can create barriers and unique developmental and relational challenges; (b) the impact
of oppression on intimacy within couples, families, and also within the relationship between
client and therapist; (c) expecting and assessing for the resilience of LGBTQ+ people as they
navigate multiple streams of oppression; and (d) the capacity of therapists to be multiculturally
competent and effective at mitigating the deleterious effects of oppression on mental health. In
this chapter, we describe each of these components. In doing so, this chapter also troubles the
traditional definitions of couple and family that are used to frame LGBTQ people as well as clini-
cal practice with LGBTQ+ people.

Case Study 1: Addition to the Family?

Jazmín and Isidora have been married for six years. They married a year and a half after they
began dating. Jazmín (she/her/hers) is a 26-year-old trans woman whose family immigrated to
the U.S. when she was two years old from Ecuador. Her parents recently shared that the fam-
ily did not have documentation when Jazmín was in high school. Her family initially had been
following formal regulations to be able to stay in the U.S.; however, her father was arrested and
thus lost his eligibility for U.S. citizenship. Jazmín’s family had built a life and community in
the U.S., so they decided to stay in the U.S., recognizing the many challenges they would face
without documentation papers. Currently, Jazmín has minimal contact with her family because
after she shared her gender identity, they insisted on deadnaming1 her, refused to use pronouns,
and neglected to attend her wedding because they do not believe that her gender identity is in
alignment with their Roman Catholic religious beliefs.
Isidora (they/them/theirs) is a 28-year-old first-generation Guatemalan American. Isidora
identifies as nonbinary. Isidora lives with fibromyalgia and has survived domestic violence and
multiple sexual assaults. Isidora has shared with their family and work colleagues that they are
queer. Isidora shared their nonbinary identity with friends last year. They are not out as non-
binary to their family or at work. Their family is marginally supportive, and are also Roman
Catholic. Isidora has a tense, but mostly positive relationship, with their family. There is a lot of
silence around their identity, largely based on things their family doesn’t understand about their
gender identity. From many things they have said and done, Isidora is certain that their family
will not understand and they do not feel comfortable coming out at this time.
When they met, Jazmín had just begun her social and medical transition. At the time of their
marriage, they describe being madly in love and having nearly everything in common. Much
of the energy of the relationship initially was focused on Jazmín’s transition, and then recently
on Isidora’s coming out as nonbinary. They have been quite inseparable over the past six years,
and have provided excellent support to one another. However, recently Jazmín started talking
to Isidora about having children. Isidora never imagined their life with children and assumed
Jazmín felt the same. At the time they were married, the couple made a mutual decision to not
have children, but recently Jazmín has changed her mind. Isidora is very concerned about how
managing fibromyalgia and trauma would be complicated by parenthood. Additionally, due to
the difficulty within their families, Isidora doesn’t want to bring a child into the current politi-
cal climate. While Isidora values family highly, they are cautious about having children because

1 Deadnaming refers to using the name given to a transgender person at birth instead of their current name.
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