Therapy with Sexual Minority Women: Equity not Equality
7 March, 2023
As a sexual and neurominority myself, I am passionate about training therapists in how to most effectively work with groups that are all too frequently misunderstood in therapy. This International Women’s Day, I want us to think about what ‘embracing equity’ means for how we support sexual minority women (including lesbian, bisexual, queer and questioning clients) in therapy.
Equality would mean providing the same therapeutic input to everyone. Equity refers instead to fairness and justice – it involves recognising that we do not all experience the same level of acceptance, and acknowledging and making adjustments in relation to these imbalances and injustices.
Many therapists still believe that if they are affirmative and don’t hold critical judgments then they will be able to work effectively with sexual minority clients. Unfortunately, research that I supervised conducted by Dr. Geraldine McNamara suggested that this was not the case.
Research by Grella and colleagues (2009) indicated that sexual minority women are far more likely to access therapy than heterosexual women, regardless of whether they have a mental health diagnosis or not. However, despite these higher client levels, this unfortunately does not correspond to better therapeutic outcomes, or increased training in working specifically with sexual minorities.
Quite the opposite. Sexual minority women frequently reported therapists as either overemphasising their being a sexual minority as a source of psychological distress, or ignoring or avoiding the possible impact on their health and wellbeing of living in a world that frequently stigmatises, misunderstands, pathologises and demonises sexual minorities.
Sharing minority stress theory with clients
Minority stress theory (advanced by Ilan Meyer) is a helpful starting point for therapists in this work. It helps us to clearly see that it is not being a sexual minority woman in and of itself that lends itself to increased risk of mental health challenges and addictions. It is living in a social environment where we experience ongoing stigma, prejudice and discrimination.
The concept of minority stress can also be helpful to share with clients. For many sexual minority women, myself included, it can be transformative to learn that how we are thinking and feeling makes absolute sense (given the unfair treatment and responses we have received at various points in our lives, particularly in previously close and trusted relationships) and is not something that should be pathologised or seen as a character flaw.
An ACT perspective – exploring messaging, engaging values
When working with sexual minority women in therapy, I find it helpful to explore the explicit messaging they received from primary caregivers, family members, educators, and peers. I also ask them to share any implicit messaging or sexualisation they witnessed about female same-sex sexual attraction and interactions.
From an ACT perspective, we cannot get rid of unwanted and unhelpful messages. However, we can learn to see them for what they are – stigmatising, ill-informed and frequently misogynistic.
I often ask some, or multiple of the following questions to help my sexual minority clients move from a place where past vulnerabilities dictate their actions and interactions, to one where they can consciously connect to their values and allow these to guide them:
- Are the sources of these messages credible speakers to you?
- How would you respond to another sexual minority woman if they were receiving these harmful messages?
- Can you bring this same warmth, compassion and understanding to yourself now as you navigate your life as a sexual minority woman?
- What are the values you wish to embody as a sexual minority woman? For example, authenticity, courage and intimacy
- How would your way of connecting to others look different if it was about embodying these values rather than trying to get away from unwanted and unhelpful responses from those who stigmatise sexual minorities?
Equality of therapeutic input would involve asking the exact same questions and responding in the exact same way regardless of whether a client is heterosexual or a sexual minority. This can do a lot more harm than good to sexual minority clients.
The vital place of therapist self-reflection
As therapists, we might also try asking some additional questions of ourselves. We can consider how our life experiences and internalised messaging around sex and gender have affected us. We can reflect on how these messages have helped us to live more fully – or to become more censored or guarded. We can wonder about how the messages we have received about our identity, orientation or behaviour affect the way we go about our daily lives and our relationships with others.
We can then bring this sensitivity to our work with sexual minority women to give them the equitable therapeutic input they have been longing for – to be deeply seen, heard and understood as a whole person; more than our sexual orientation, yet very much shaped by how others have responded to us and other sexual minorities.
