The Palgrave Handbook of The Psycholgy of Sexuality and Gender
The Palgrave Handbook of The Psycholgy of Sexuality and Gender
The Palgrave Handbook of The Psycholgy of Sexuality and Gender
and Gender
This page intentionally left blank
The Palgrave Handbook of
the Psychology of Sexuality
and Gender
Edited by
Christina Richards
Senior Specialist Psychology Associate and Clinical Research Fellow, Nottinghamshire
Healthcare NHS Trust and West London Mental Health NHS Trust, UK
Acknowledgements xvi
Introduction 1
Christina Richards and Meg John Barker
Part I Sexuality
1 Asexuality 7
Mark Carrigan
Introduction 24
History 26
Psychoanalysis and Freud 27
Stoller and the ubiquity of perversion 27
Key theory and research 28
Psycho-medical perspective 28
Non-pathologising perspectives 29
Current debates 31
v
vi Contents
3 Bisexuality 42
Helen Bowes-Catton and Nikki Hayfield
Introduction 42
History 43
First-wave sexology 43
Second-wave sexology 46
Early ‘gay-affirmative’ psychological research 47
Overlooking bisexuality: Sex research and sex surveys of
the 1970s and 1980s 47
Key theory and research 48
Early ‘bisexual-affirmative’ research: Acknowledging, defining,
and ‘measuring’ bisexuality as a distinct identity 48
Becoming visible: 1990s research on bisexuality 49
Bi-affirmative research in psychology since the
year 2000 50
Current debates, implications, and future directions 53
Activist–academic collaborations 53
Intersectionality 53
Researching beyond the organised bi community 54
Summary 54
4 Further Sexualities 60
Christina Richards
Introduction 60
Ageplay 61
Furry 61
Fetish 62
History 64
Key theory and research 65
Current debates 68
Implications for applied psychology and the wider world 69
Future directions 71
Summary 72
Contents vii
5 Gay Men 77
Damien W. Riggs
Introduction 77
History 78
Key theory and research 81
Current debates 82
Implications for applied psychology and the
wider world 84
Future directions 86
Summary 89
6 Heterosexuality 92
Panteá Farvid
Introduction 92
History 93
History of the term ‘heterosexuality’ 93
Creating the heterosexual 94
Early theorising of (hetero)sexuality 94
Second-wave feminist critiques of heterosexuality 95
Key theory and research 96
Theorising heterosexuality 97
Heteronormativity 98
Researching heteronormativity 98
Biological explanations 100
Mainstream psychology 101
Current debates and implications for applied psychology
and the wider world 102
Future directions 103
Summary 103
Introduction 129
Trans sexualities 131
History 134
Key theory, research, and current debates 135
Implications for applied psychology and the wider world 140
Future directions 141
Summary 143
Part II Gender
Introduction 149
Key definitions 150
History 150
Key theory and research 153
Current debates and future directions 156
Implications for applied psychology and the wider world 159
Conclusions 161
Summary 161
Introduction 166
History 167
Key theory and research 171
Current debates 173
Implications for applied psychology and the wider world 176
Future directions 178
Summary 179
11 Intersex/DSD 183
Katrina Roen
Introduction 183
History 185
Contents ix
Introduction 198
History 199
Key theory and research 201
Current approaches to assisting people with gender dysphoria 204
Current debates 206
Classification of gender dysphoria 207
Access to treatment 208
Implications for applied psychology and the wider world 209
Future directions 210
Summary 211
13 Monogamy 219
Ali Ziegler, Terri D. Conley, Amy C. Moors, Jes L. Matsick,
and Jennifer D. Rubin
Introduction 219
Key theory and research 220
Definitions of monogamy across biological and social sciences 220
Public health definition of monogamy 221
Lay definitions of monogamy 221
Why do people engage in monogamy? 222
History 223
Monogamy and sexual health 224
Current debates 225
Isn’t everyone monogamous? 226
Departures from monogamy 227
x Contents
Introduction 236
History 237
Key theory and research 242
Open non-monogamies and normative social and counselling
psychology 242
The theoretical questioning/exploration of extra-dyadic
romantic love 243
The effects of non-monogamies on women 244
The effects of multiple-partner parenting on children,
communities, and society 245
The psychological exploration of the minutiae
of non-monogamous living 247
Current debates 247
Implications for applied psychology and the wider world 249
Future directions 251
Summary 252
Introduction 263
History 263
Key theory and research 269
Current debates 273
Implications for applied psychology and the wider world 275
Future directions 276
Summary 277
History 280
Key theory and research 281
Contents xi
Introduction 316
Beginnings 316
Key theory, research, and current debates 318
Experiential research 319
Insider/outsider considerations 320
The middle ground: Experiential and critical 322
Critical research 325
Implications for applied psychology and the wider world 327
Future directions 328
Summary 329
xii Contents
Introduction 333
Defining key terms 333
History 335
The Kinsey studies 335
The Masters and Johnson studies 335
The Klein Sexual Orientation Grid 336
Gender identity: The Bem Sex Role Inventory (BSRI) 337
Key theory and research 337
National Survey of Sexual Attitudes and Lifestyles (NATSAL) 338
Longitudinal Study of Young People in England (LSYPE) 339
National Health and Nutrition Examination Survey
(NHANES, 2007–2008) 340
English Longitudinal Study of Ageing (ELSA) 341
Current debates 343
The importance of longitudinal data 343
Psychobiology of sexual orientation 344
Future directions: Implications for applied psychology
and the wider world 347
Towards wider measurement of gender identities 348
Summary 350
Part V Intersections
21 Ageing 375
Paul Simpson
Ageing 376
Ageism 377
Gender 377
Sexuality 378
History 378
Necessary withdrawal vs. continuity? 378
Ageing as a product of societal arrangements 379
Current debates 380
Different cultures of ageing 380
Ageing as radically socially constructed 381
Newer currents – ambivalent resources of ageing 382
Implications for applied psychology and the wider
world: Future directions 384
Summary 386
22 Class 391
Bridgette Rickett and Maxine Woolhouse
History, key theory, and research 392
Gender and class 394
Sexualities and class 398
Intersections of gender, class, and sexualities 400
Current debates and future directions 401
Implications for applied psychology and the wider world 402
Implications for theory and research 403
Summary 404
23 Disability 408
Alex Iantaffi and Sara Mize
Introduction 408
Defining disability 409
Disability and sexuality in psychology 412
Key theory and research 414
History and current debates 417
Implications for applied psychology and the wider world 419
Future directions 421
Summary 421
24 Ethnicity 427
Roshan das Nair
Introduction 427
History 429
xiv Contents
25 Religion 447
Rob Clucas
Introduction 447
History 449
Sexuality 449
Gender 450
Prejudice 451
Sex-negativity 451
Either/or 451
Key theory and research 452
Current debates 453
Implications for applied psychology and the wider world 455
Future directions 457
Conclusions 457
Summary 458
Index 464
Tables and Figures
Tables
Figures
xv
Acknowledgements
Christina Richards: For Phil (of course) . . . and for Claire, Margie, Monica, and
their families – for tea, peace, and the things words can’t properly describe.
I would also like to thank all my patients, as well as clinician colleagues and
activist friends across the world who have taught me so much; my colleagues at
Nottingham Centre for Gender Dysphoria who have welcomed me so warmly
and taught me more of these complex, beautiful areas in which we work – and
perhaps especially the administrative staff – Helen, Jane, and colleagues who
don’t get nearly enough credit for keeping the whole thing running; James,
Leighton, Penny, and Stuart at Charing Cross GIC for yet more years of knowl-
edge and friendship (and their gentle prods forwards); Surya for all her work
and being there when it counted; Clare for being ace and rather an inspiration;
my mother for showing me how to be a radical inside the system; and lastly
(but never least) Meg John Barker, who frustrates and inspires me in a way
which no one else quite manages and with whom I hope to have the privilege
of reciprocating until time or fate decreed otherwise.
Meg John Barker: I would like to acknowledge all of the psychologists – and other
scholars, activists, therapists, and friends – who have helped me in my learning
about gender and sexual diversity over the years. There are far too many to
mention, but particular thanks must go to the psychology staff at the University
of Gloucestershire and the Open University; the members of the Psychology
of Sexualities and Psychology of Women sections of the British Psychological
Society (BPS); all of the participants in the Critical Sexology, Sense about Sex,
and Gender and Sexuality Talks networks; and my pink, kink, poly, and queer
therapist friends and colleagues.
Particular gratitude must go to four of my main people, who have been
co-authors and so much more over the years: Darren Langdridge, Ros Gill,
Alex Iantaffi, and – of course – Christina Richards. I certainly hope to con-
tinue inspiring and frustrating Christina (and vice versa) for as long as we have
the opportunity, and I am immensely grateful to her for including me in this
project, on which she certainly took by far the heaviest load. The finished prod-
uct really is a wonderful testimony to all her hard work and creative thinking
around these topics.
xvi
Contributors
Editors
xvii
xviii Notes on Contributors
Contributors
Trevor Butt worked full time in the NHS as a clinical psychologist before
becoming a senior lecturer at the University of Huddersfield. He became Reader
in Psychology at Huddersfield in 1999, retired in 2007, and is now Emeritus
Reader in Psychology. He is co-editor of Personal Construct Theory and Prac-
tice and has authored Understanding People and Invitation to Personal Construct
Psychology, amongst many other publications.
Mark Carrigan is Research Assistant at the Centre for Social Ontology and Dig-
ital Fellow at the Sociological Review. He recently completed his PhD thesis in
sociology, which has sought to develop a framework for the empirical investi-
gation of personal morphogenesis. His research interests include sociological
xx Notes on Contributors
theory; medical ethics, particularly conjoined twins; human rights; and chil-
dren’s rights and welfare. With G. Johnstone and T. Ward, he co-edited the
Nomos collection Torture: Moral Absolutes and Ambiguities. He was supported
by the Arts and Humanities Research Board (AHRB) Research Leave Scheme for
the project ‘Children’s rights: autonomy and the welfare/best interests tension.
A Welsh perspective’, a study on the practice of the first Children’s Commis-
sioner for Wales. His PhD thesis was concerned with a modified application of
Alan Gewirth’s moral theory to the rights of children. He was the inaugural
chair of the LGBT Staff Network at the University of Hull and has been a
national trustee of the Anglican pressure group Changing Attitude. He is a
trainee Gestalt psychotherapist.
with Tumblr, teen girls’ daily engagement with mass media, heterosexual ‘infi-
delity’, and men’s and women’s experiences of online dating. Alongside her
academic position, Panteá is strongly dedicated to being involved within the
community, both politically and as an ambassador for social justice and equal-
ity. She was a political candidate, gender spokesperson, and gender policy
lead for one of the political parties contesting the 2014 New Zealand elec-
tion. Taking on the role of ‘critic and conscious’, she is also a frequent media
commentator in New Zealand when it comes to issues related to gender, power,
and sexuality.
Penny Lenihan is the lead consultant psychologist at the West London Mental
Health NHS Trust (Charing Cross) Gender Identity Clinic, where she specialises
in trans health-care and sexualities and runs the psychology service and the
clinical training placement programme.
Del Loewenthal is Professor of, and Convenor of Doctoral Programmes in, Psy-
chotherapy and Counselling, Director of the Research Centre for Therapeutic
Notes on Contributors xxv
Bridgette Rickett is Principal Lecturer and the Psychology Group lead at Leeds
Beckett University, where she has worked for 14 years. She is an organisa-
tional psychologist and a feminist researcher. In addition, Bridgette is a founder
member of the ‘Feminism and Health Research Group’ at Leeds Met Univer-
sity and co-lead on the research programme for the Centre of Applied Social
Notes on Contributors xxvii
Research (CeASR) – Sex, Gender, Identity and Power. Bridgette’s main research
interests are critical social psychological explanations of health; in particular,
feminist perspectives on class and health, including talk around femininity,
risk, class, and violence in the workplace; and organisationally situated sexual
harassment, harassment, and bullying. Lastly, Bridgette is interested in classed
understandings of equality, diversity, and organisational identities and, more
generally, debates and issues around class, gender, sexuality, identity work, and
space. Bridgette has published in journals such as Gender, Work and Organization,
Journal of Health Psychology, and Feminism and Psychology, and is Associate Editor
for the journal Psychology and Sexuality.
Paul Simpson was awarded a PhD in 2011 for a thesis addressing the ways
in which middle-aged gay men in Manchester deploy narratives resources to
navigate growing older. He is a qualitative researcher who specialises in inter-
view and observation methods and, in addition to LGBT ageing, is interested
in changing masculinities and gender relations in service and health sector
workplaces and their intersections with performances of masculinity in per-
sonal lives. He is currently Lecturer in Health and Social Care at Edge Hill
University and an Honorary Research Fellow in the Department of Sociology
at the University of Manchester. He is the principal investigator of an inter-
disciplinary, cross-institutional research project investigating older care home
residents’ narratives about sexual and intimate citizenship. He is also founder
of the Older People’s Understandings of Sexuality (OPUS) research group that is
currently co-located at the Universities of Manchester, Bradford, Edge Hill, and
Queensland.
An edited collection on sex and gender, for a major and highly respected
publisher, consisting of an eclectic selection of fiercely intelligent authors – all
recognised experts in their field – and from a variety of different backgrounds,
countries, and disciplines, themselves completing the set of pretty much all the
genders and sexualities covered in this book. What could possibly go wrong?
Well, quite a lot, apparently. People have had personal and professional
tragedies and triumphs over the course of the writing process: been promoted,
left institutions, started at others; lost computers, gained children, lovers,
friends. In short, life, in all its messy, beautiful complexity, has happened to
the people who wrote the book you now hold in your hands. Naturally, people
have responded in a variety of different ways to such events, and with myriad
philosophies drawn from personal as well as professional discourses. And so this
book is a reflection of that mix, that life, that variety of ways of thinking about
the world, of what even can be thought about – the epistemology and ontology,
if such words float your boat (and it may be worth purchasing a small dinghy
for some chapters if they don’t . . . ).
Maybe we shouldn’t say “going wrong”, though. Maybe having such a mix is,
in fact, what went right with this book. For within its pages you will see many
different positions on sexuality and gender, from hard quantitative analysis to
complex qualitative approaches and everything in between – and all with the
golden thread of psychology running throughout.
Please remember, though, that when writing a handbook of this sort the
editors are, inevitably, called upon to determine the nature of the contents.
Pleasurable as this is when the idea for the book is first mooted over tea
and cake, at the point of writing the proposal to the publisher it becomes a
taxonomic, almost epistemological, exercise which will, inevitably, not work
perfectly for everybody. The problem is that, to have some form of readabil-
ity, one must choose concise chapter headings which convey something of the
intent of the chapter – one must endeavour to carve the subject at the joints,
1
2 Introduction
if you will. The question is: Which joints? Some issues are discrete and easily
separated; however, many are contiguous – heterosexuality, bisexuality, gay,
and lesbian, for example; and some overlap – trans and intersex, for example.
We wondered whether we should, therefore, have one chapter on trans or two
(or three or four . . . ). We elected to have two – broadly concerning trans as
a sexuality and trans as a means of living gender (and a separate chapter for
intersex) – but, of course, this is not fully satisfactory. Similarly, we determined
to have separate chapters for gay men and lesbians, but not for heterosexual
men and heterosexual women, or bisexual men and bisexual women, although,
of course, their psychologies also both overlap and are discrete. There are omis-
sions. Educational and forensic psychologies would have been useful additions,
sadly lacking for want of space – and forensic psychology carries with it such a
Pandora’s box of non-consensuality, which runs counter to the other chapters,
that we hope, for this edition at least, you will forgive its omission.
Caveats primed, then, we turn to the constitution of the volume you hold in
your hands.1 The book consists of five sections: Sexuality, including chapters on
Asexuality, BDSM, Bisexuality, Further Sexualities, Gay Men, Heterosexuality, Les-
bians, and Trans Sexualities; Gender, including chapters on Cisgender, Intersex,
Further Genders, and Trans Gender; Relationship Structures, including chapters
on Monogamy and Non-Monogamies; Psychological Areas, including chapters
on Clinical Psychology, Counselling Psychology, Qualitative Methods, Quantitative
Methods, and Sex Therapy; and Intersections, including chapters on Ageing,
Class, Disability, Ethnicity, Health, and Religion. Each section or chapter may
be read individually, although naturally many areas cross over one another and
different stances on many topics may be found in different chapters by different
authors. In addition, each chapter will cover history; key theory and research;
current debates; implications for psychology and the wider world (especially
regarding applied psychological practice); and future directions for that area of
study. There will also be a bullet point summary, suggestions for further reading,
and box-outs including important points for students, applied professionals,
and academics, respectively.
As stated above, there are a range of different viewpoints included within
these chapters. We did not view it as our job as editors to champion views we
agreed with and quash those we didn’t – to become members of the Invisible
College, if you will. The place of academic publishing of this sort is surely to
promote well-written and researched views of all kinds (provided that they are
kind) and for others to rebut them, either through journals or by other means.
And so we hope there will be content here to nod along with, to cheer for, and
to incite red-penned marginalia for the obvious misinterpretation of this study
or that. We hope also, though, that the chapters will not offend and will thus
receive a fair reading. To that end, readers who are unfamiliar with terminol-
ogy may find the glossary in the editors’ Sexuality and Gender for Mental Health
Christina Richards and Meg John Barker 3
in the general culture regarding normative sexualities and genders – thus, if you
know what a condom is, you should know what a dental dam is, as they are
pretty analogous in terms of STI prevention.
Beyond applied psychological practice, however, we think that knowledge
transmission in this area is especially important in a world which appears
to lurch forward and then back again – with reactionary political influences
blaming ‘non-normative’ sexualities and genders for everything from disease
to climate change. Our hope is that research-informed practice and activism
may moderate this, as it has in the case of trans and same-sex attraction in
the West. Indeed, it is useful to look to the future in these areas while hold-
ing in mind that what was considered quite unacceptable rather recently has
often become commonplace now. Similarly, we hope that the research held
in these pages and elsewhere will moderate the tendency of groups who gain
some political leverage over time to jettison those parts of the group who are
further marginalised in some way – a crude example being the women’s move-
ment jettisoning lesbian rights, lesbian feminists who jettisoned trans rights,
and so on.
So, you have in your hands a book continuing references on everything from
prairie-vole partnerships (Getz & Carter, 1996) to Sartrean philosophy (Sartre,
2003 [1943]), to genital surgery (Boyle et al., 2005). We hope you enjoy it, we
hope you recommend it . . . but, most of all, we hope you use it.
Note
1. Or are reading on your e-reader and are thus depriving future generations of the plea-
sure of a dust-covered and yellowing treasure in the corner of a small and forgotten
second-hand bookshop with doorways which are surely too small for an average-size
human to enter – and which perhaps wasn’t there yesterday and, indeed, may not be
tomorrow . . . Ahem, we digress.
References
Boyle, M. E., Smith, S., & Liao, L. M. (2005). Adult genital surgery for intersex: A solution
to what problem? Journal of Health Psychology, 10(4), 573–584.
Denman, C. (2004). Sexuality. Basingstoke: Palgrave Macmillan.
Foucault, M. (1978). The history of sexuality (Vol. 1). New York: Pantheon.
Getz, L. L. & Carter, C. S. (1996). Prairie-vole partnerships. American Scientist, 84, 56–62.
Richards, C. & Barker, M. (2013). Sexuality and gender for mental health professionals:
A practical guide. London: Sage.
Sartre, J.-P. (2003 [1943]). Being and nothingness (trans. H. E. Burns). London: Routledge.
Weeks, J. (2007). The world we have won: The remaking of erotic and intimate life (new ed.).
London: Routledge.
Part I
Sexuality
1
Asexuality
Mark Carrigan
7
8 Sexuality
being subsumed under the category ‘asexuality’. This then raises the question
of whether it is coherent to talk about asexuality in terms of an underlying sex-
ual orientation. Certainly, we could interpret the diversity within the asexual
community in terms of psychosocial factors inflecting an underlying shared
orientation. But such a decision would be so obviously a priori, in the sense of
neither having been established by empirical evidence nor possibly becoming
so, that the justification should be methodological: is it useful to conceptualise
asexuality as a sexual orientation and, if so, why?
Perhaps the most powerful argument Bogaert (2006) makes about the desir-
ability of categorising asexuality as a sexual orientation is a moral one, arising
from a “need to be sensitive to societal trends”. He recognises the emergence
of the asexual community, particularly as manifested by AVEN, suggesting a
comparison to the gay rights movement of the 1960s and 1970s. Given that a
“sizable minority are choosing to identify with a term that is not part of the
traditional academic and clinical discourse on sexuality and sexual identity”,
he observes the relevance of the existing professional norm that “it is reason-
able and practical to use designations that individuals prefer (e.g. asexual, gay
lesbian, bisexual) when referring to sexual orientation” (p. 247).
Current debates
One of many interesting things about Asexuality Studies is the frequency with
which academic debates reflect points of contention within the asexual com-
munity. In fact, the relationship between the two is mutually reinforcing, with
academic research being discussed within the asexual community and reflective
Mark Carrigan 13
ideas about asexuality originating from within the community and entering
into research. Perhaps the most important example of this is the question
of how asexuality relates to hypoactive sexual desire disorder (HSDD). This
diagnostic category stands, as Flore (2014) puts it, as a ‘disordered other’ to
asexuality:
whether or not you are asexual. If you find that the asexual label best
describes you, you may choose to identify as asexual.
(AVEN, 2011)
assumptions concerning sex and sexuality can inadvertently lead one to act
in ways that marginalise or stigmatise asexual individuals. Though it might be
possible to preclude offence through careful use of language and circumvention
of potentially ‘difficult’ topics, such a strategy would obviously be of limited
use within a clinical or therapeutic setting. The difficulty here is one which can
only be negotiated, rather than finally resolved. Doing so successfully requires
an understanding of the issues faced by asexual people and an attentiveness
to specific experience of particular asexual people. It is easy to fall into a view
of asexuality that defines it as a negation or absence of sexuality. But doing so
obscures the variation within the asexual community and frames the lived expe-
rience of the people within this community in terms of what they are assumed
to lack.
Obviously, it is hugely important simply to recognise the possibility of
asexuality and to avoid assuming that someone is sexual. But it is also impera-
tive that an abstract knowledge does not license an assumption that an applied
professional knows the truth of a client’s circumstances on the basis of their
asexuality (stated or otherwise). For instance, while many asexual people do
identify with the lesbian, gay, bisexual, trans, and queer (LGBTQ) community,
this is far from universally accepted. Being aware of this fact can help avoid the
marginalising assumptions previously discussed being replaced by affirmative
ones which, though well intentioned, can nonetheless be just as incongruent
with the experiences of the people concerned.
Richards and Barker (2013) argue that it is unacceptable for professionals
to lack basic knowledge about the practices and identities of their clients.
Given how recently asexual identification has begun to spread, a lack of
basic knowledge about asexuality on the part of an applied professional likely
reflects a broader lack of knowledge within the social world. This makes an
effort to familiarise oneself with asexual practices and identities all the more
imperative. This can involve an engagement with the academic literature,
summarised in Carrigan et al. (2013) and Carrigan (2013) as well as ear-
lier in the present chapter. However, there is no reason to rely on academic
sources to familiarise oneself with the asexual community,14 with the diverse
and vibrant array of online asexual spaces providing near-endless opportu-
nities to engage with the community either directly or indirectly. The best
way to get a sense of the identities, meanings, and experiences which aca-
demic discourse necessitates be subsumed under the label ‘asexual’ is to spend
some time reading asexual blogs, listening to asexual podcasts, and watching
asexual YouTube videos. For instance, the YouTube video ‘Shit People Say to
Asexuals’ highlights the insensitive and uncomprehending statements which
asexual individuals will tend to encounter as a regular part of their day-to-
day life (Swankivy, 2012). Such humorous, sometimes angry, cultural products
represent the tip of the iceberg in terms of rich spheres of asexual cultural
Mark Carrigan 17
Future directions
Longitudinal studies
Part of what makes “maybe you’re just a late bloomer?” or “maybe you haven’t
met the right person yet?” so difficult as responses which asexual people
commonly receive when first identifying as such to others is the inherent
impossibility of knowing with certainty that these possibilities might never
apply. How can one be certain of something which, by definition, can only be
established at an indefinite point in the future? This is what renders the discov-
ery of other asexual people so important to those who are coming to reject the
assumption that their lack of sexual attraction is pathological (Carrigan, 2011).
It constitutes an evidential base concerning the life trajectories of others whom
they have identified as being like themselves, making it seem that asexuality
is a natural expression of human diversity, rather than a fleeting aberration or
a consequence of some underlying pathology. It provides a powerful retort to
the sometimes benignly motivated but usually hurtful proclamation that their
professed asexuality is ‘just a phase’.
But we still lack longitudinal data about asexual experience and asexual
identity. For instance, one participant detailed in Carrigan (2011) identified
as ‘a-fluid’, a familiar term that is immediately resonant of Diamond’s (2008)
account of sexual fluidity. Much of what has been discussed in the previous
18 Sexuality
sections connects to the possible fluidity, or lack thereof, among those who
identify as asexual. Diamond (2008) observes that the notion of sexual fluidity
runs contrary to the prevalent assumption that “individuals are, unequivocally,
one sexual type or the other” and this can lead those experiencing fluidity
to feel “doubly deviant, their experiences reflecting neither mainstream soci-
etal expectations nor perceived norms of ‘typical’ gay experience” (Diamond,
2008, p. 14). Given the earlier discussed comfort which communal identifi-
cation brings to many asexual people, with this constituting the culmination
of a process that leads from self-pathologisation to self-affirmation, the issue
of ‘a-fluidity’15 must be treated carefully. The putative fluidity of some asexual
identities does not indicate that these simply constitute a ‘phase’ but only that
situational factors might counteract an otherwise enduring asexual orientation.
The more problematic suggestion is that there may be some cases in which
an asexual orientation and/or an asexual identity are not sustained over time.
Such cases can easily be explained in terms of the individuals concerned having
never really been asexual. But, from a psychological perspective, such an expla-
nation seems problematically simplistic. These are questions which can only be
adequately addressed through longitudinal research.
Asexual relationships
Some of the pervasive confusions discussed earlier in the chapter can lead to
the marginalisation of asexual relationships. It is certainly an area that would
benefit from further empirical research, with Scherrer (2010b) reporting that,
for several participants in her study, “binary relationship categories, such as
‘single’ and ‘taken,’ or ‘friendship’ and ‘intimate,’ felt false”. This reflects find-
ings reported in Carrigan (2011, 2012), but we still lack comprehensive data
about asexual relationships. Recognising this absence should go hand-in-hand
with an appreciation of the question itself, with a diverse range of relational
forms being subsumed under the term ‘asexual relationships’. The reasons why
such ‘binary relationship categories’ might feel ‘false’ cannot be assumed to be
homogeneous, nor can this experience be assumed to be universal. As Chasin
(2013, p. 407) notes, the geographical dispersal of asexual individuals coupled
with a lack of identifying physical characteristics16 means that “many romanti-
cally inclined asexuals pursue romantic relationships with non-asexual people”.
Furthermore, many aromantic asexuals may, prior to their coming to identify
as such, find themselves in relations with non-asexual people. So, too, might
romantic asexuals. The limited data presented in Carrigan (2011, 2012) point
towards the complexity potentially encountered within asexual relationships.
This complexity reflects the cultural weight often placed on sexual intimacy
as a marker of fulfilment within relationships (Barker, 2012, pp. 69–70). How-
ever, we should also avoid assuming that asexual relationships are inherently
problematic. Just because this complexity obtains as a matter of empirical
generalisation does not mean it will necessarily be found in any particular
Mark Carrigan 19
fora (e.g. the asexual users of the Tumblr platform sometimes self-identify
as having distinctive tendencies and are sometimes identified by others as
such). It would also help shed light on the experiences of those allo-sexuals
or gray-As who, for a variety of reasons, find something of value within the
asexual community. Diamond’s (2008) work on fluidity, particularly in rela-
tion to an incongruence between sexual and emotional attachments,18 helps
shed light on why some people would find the conceptual vocabulary of the
asexual community helpful despite not being asexual themselves (Carrigan,
2011; Chasin, 2010). The elaboration of distinctions such as sexual attraction
vs. romantic attraction, so often conflated within wider sexual culture, have
obvious relevance beyond the asexual community. Given that, as Diamond
(2008, p. 77) observes, “traditional models of sexuality make no provision
for discrepancies between physical and emotional feelings”, it is easy to see
why those experiencing such a discrepancy might gravitate towards a com-
munity within which there are clearly defined and well-understood labels
for such experiences (i.e. heteroromantic homosexuals and homoromantic
heterosexuals).
Summary
Notes
1. Though not all of their work can be read in these terms.
2. This theoretical claim finds empirical reflection in the disputes within the asexual
community over whether ‘asexuality’ has been defined too broadly and so has lost
meaning as a category.
3. Originally 3436, with six responses deemed not serious and removed (Miller, 2011).
Mark Carrigan 21
4. The most jarring point about the census is that 92% of respondents were 30 or
under. This should not be grounds to reject the census, particularly given its size
and the lack of comparable demographic data; however, it should be a reminder that
we should not assume the patterning obtains outside this younger group of regular
internet users who are sufficiently involved with the asexual community online to
have seen the census and responded to it.
5. I have used the expression ‘community’ throughout the chapter. It is a term that
unavoidably carries theoretical baggage, which will be sidestepped here in the inter-
ests of brevity. It certainly should not be taken to imply the absence of dissensus,
either ‘online’ or ‘offline’, with increasing tensions between AVEN and other online
asexual spaces representing one of the most interesting developments in recent years.
6. See Carrigan (2013) for a discussion of the increasingly formalised gatekeeping role
adopted vis-à-vis researchers by AVEN.
7. These are a tiny subset of a much broader corpus. The Asexual Media Archive is
a valuable resource to better understand the treatment of asexuality in the media.
Details can be found at the end of this chapter.
8. Though, of course, familiarity should not be assumed to correlate with
understanding.
9. In the sense of the media attention which asexuality research has attracted, exam-
ples of which are included later in the chapter, as well as the growth of Asexuality
Studies as an interdisciplinary field of inquiry. See Carrigan et al. (2013); Milks and
Cerankowski (2014); Przybylo (2013) for an overview of this literature.
10. Though it would reject this claim, Kahan (2013) helpfully sketches out many of the
issues that could be explored to this end, though, as a work of literary criticism, it
only tangentially addresses this issue at the level of psychology or sociology.
11. See Carrigan (2012, 2013) for a fuller discussion of this point.
12. This is intended as a statement about tendencies within the literature, as opposed to
claiming that there have only been two responses to this underlying question.
13. Kahan (2013) offers some fascinating, though fragmented, insights into this history.
14. Though it is important to note that these two groups are not mutually exclusive,
with numerous asexual individuals making important contributions to the scholarly
literature.
15. While this term was introduced by a research participant, it is worth noting that it
seems absent from mainstream asexual discourse.
16. However, as Chasin, themself asexual, goes on to write, “we are not marked by purple
As, although some of us do wear black rings on our right middle fingers” (Chasin,
2013, p. 407).
17. See, for instance, Cerankowski and Milks (2014); Kim (2010, 2011); Przybylo (2011,
2013).
18. See Diamond (2008, pp. 77–81).
Further reading
Asexual Explorations. http://www.asexualexplorations.net/home/.
Asexuality Studies. http://asexualitystudies.org/.
Asexual Media Archives. https://www.youtube.com/user/asexualmediaarchives.
AVENues. http://www.asexuality.org/home/avenues.html.
Scherrer, K. S. (2008). Coming to an asexual identity: Negotiating identity, negotiating
desire. Sexualities, 11(5), 621–641.
22 Sexuality
References
Asexuality Visibility and Education Network (2011). General FAQ. Retrieved from http://
www.asexuality.org/home/general.html.
Barker, M. (2012). Rewriting the rules: An integrative guide to love, sex and relationships.
London: Routledge.
Bogaert, A. F. (2004). Asexuality: Prevalence and associated factors in a national probabil-
ity sample. Journal of Sex Research, 41(3), 279–287.
Bogaert, A. F. (2006). Toward a conceptual understanding of asexuality. Review of General
Psychology, 10(3), 241.
Bogaert, A. F. (2008). Asexuality: Dysfunction or variation. In J. M. Caroll & M. K. Alena
(Eds.) Psychological sexual dysfunctions. (pp. 9–13). Hauppauge, NY: Nova Biomedical
Books.
Bogaert, A. F. (2012). Understanding asexuality. Lanham, MD: Rowman & Littlefield
Publishers.
Bootle, O. (2009). No sex please: An asexual life. The Independent. Retrieved from
http://www.independent.co.uk/life-style/health-and-families/features/no-sex-please
-an-asexual-life-1646347.html.
Brotto, L. A., Knudson, G., Inskip, J., Rhodes, K., & Erskine, Y. (2010). Asexuality: A mixed-
methods approach. Archives of Sexual Behavior, 39(3), 599–618.
Carrigan, M. (2011). There’s more to life than sex? Difference and commonality within
the asexual community. Sexualities, 14(4), 462–478.
Carrigan, M. (2012). How do you know you don’t like it if you haven’t tried it? Asexual
agency and the sexual assumption. In T. G. Morrison, M. A. Morrison, M. Carrigan, &
D. T. McDermott (Eds.) Sexual minority research in the new millennium. (pp 3–19).
Hauppauge, NY: Nova Science.
Carrigan, M. (2013). Asexuality and its implications for sexuality studies. Psychology of
Sexualities Review, 4(1). Retrieved from http://markcarrigan.net/2013/12/03/asexuality
-and-its-implications-for-sexuality-studies-2/ [Accessed 11 December 2014].
Carrigan, M., Gupta, K., & Morrison, T. G. (2013). Asexuality special theme issue editorial.
Psychology & Sexuality, 4(2), 111–120.
Cerankowski, K. J. & Milks, M. (2010). New orientations: Asexuality and its implications
for theory and practice. Feminist Studies, 650–664.
Cerankowski, K. J. & Milks, M. (Eds.) (2014). Asexualities: Feminist and queer perspectives.
London: Routledge.
Chasin, C. D. (2011). Theoretical issues in the study of asexuality. Archives of Sexual
Behavior, 40(4), 713–723.
Chasin, C. D. (2013). Reconsidering asexuality and its radical potential. Feminist Studies,
39(2), 405–426.
Chasin, C. D. (2014). Making sense in and of the asexual community: Navigating rela-
tionships and identities in a context of resistance. Journal of Community & Applied
Social Psychology. [online first] (doi: 10.1002/casp.2203). [Formerly titled: Amoeba in
our habitat: The asexual community from an ecological perspective.]
Diamond, L. M. (2008). Sexual fluidity: Understanding women’s love and desire. Harvard:
Harvard University Press.
Evans, K. (2013). Re-thinking community in the digital age? In K. Orton-Johnson &
N. Prior (Eds.) Digital sociology: Critical perspectives. (pp. 79–95). Basingstoke: Palgrave
Macmillan.
Flore, J. (2014). Mismeasures of asexual desires. In K. J. Cerankowski & M. Milks (Eds.)
Asexualities: Feminist and queer perspectives. (pp. 17–34). London: Routledge.
Mark Carrigan 23
Introduction
BDSM is the umbrella term used to describe a set of consensual sexual practices
that usually involve an eroticised exchange of power and the application or
receipt of painful and/or intense sensations (Barker et al., 2007). The range
of BDSM-related activities is wide and complex. ‘BDSM’ denotes the assorted
consensual activities involved in the experience of participating in BDSM;
bondage and discipline (B&D), dominance and submission (D/s), and sadism
and masochism (SM). Practitioners and authors also often use the abbreviations
S/M, EPE (erotic power exchange), or WIITWD (what it is that we do) to describe
and discuss the same range of sexual practices and activities, as well as ‘top’ and
‘bottom’ and/or ‘dominant’, ‘submissive’, and ‘switch’ to signify the adopted
sexual role. Common examples of BDSM include, but are not limited to, spank-
ing, being restrained or tied up, and verbal humiliation. The term ‘BDSM’ is
commonly used and accepted among practitioners, and is the term that will be
used throughout this chapter. Regardless of definition, BDSM-related practices
are highly individual and subjective, and it should not be assumed that ‘one size
fits all’, as inclinations vary from person to person (Barker et al., 2007). BDSM
is practised by a range of individuals from across the sexual spectrum, includ-
ing homosexual, bisexual, and heterosexual people, as well as transgender and
cisgender individuals (Clarke et al., 2010).
Research investigating the prevalence of individuals with BDSM-related inter-
ests is limited. However, the few studies that have evaluated frequency report
that a sexual interest in BDSM is not particularly rare. Estimations vary between
22% of men and 12% of women (Kinsey et al., 1953) and 10% of the population
(Moser & Kleinplatz, 2006). The accepted view within the BDSM community is
that it is a meaningful lifestyle choice rather than a series of sexual encoun-
ters, and whatever form the BDSM takes depends totally upon the fantasies and
boundaries of those participating. The BDSM community places a very strong
24
Emma L. Turley and Trevor Butt 25
emphasis on safety and consent during all aspects of the practice. A common
misunderstanding is that, because of the nature of the sexual practices, many of
the activities are forced upon individuals against their will. This is not the case.
The BDSM community places safety and consent as central to enjoyment, and
the slogans ‘safe, sane and consensual’ (SSC) and ‘risk aware consensual kink’
(RACK) express this clearly. There can be instances, as with any sexual commu-
nity, where problematic issues arise, and, for BDSM, non-consent is frequently
positioned as the norm by the lay media. This is often evident in film and
television, particularly crime dramas that draw upon malevolent stereotypes of
BDSM enthusiasts as rapists and murderers.
While the news media might see sexualised BDSM as perverted, Anglo-
American culture has presented spanking and caning as punishment in a comic
form (Butt & Hearn, 1998). In the 1950s and early 1960s, comics, TV series
and sitcoms frequently represented bottom-smacking as lots of fun. Gay (1993)
shows how the depiction of cruelty as comic goes back at least as far as the
nineteenth century. But a clear sexual meaning has only emerged in the popu-
lar media very recently. Secretary (2002) broke new ground by depicting BDSM
as a salvation for a troubled woman. And the great success of Fifty Shades of Grey
in popular fiction testifies to the strong curiosity and attraction of BDSM to the
general public.
This chapter will outline the history of the psychological and psychiatric
focus on BDSM, emphasising the psychopathological framework within which
it has been cast. Mainstream psycho-medical theoretical perspectives will be
contrasted with current, non-pathologising research, leading to an examina-
tion of the current debates around BDSM. This will include a discussion of
the debate between the different conceptualisations of BDSM, and the impli-
cations for practitioners of consensual BDSM in terms of discrimination, legal
status, and self-concept. Finally, the chapter will consider future directions for
BDSM, with particular reference to claims for sexual citizenship and the fate of
different ‘sexual stories’ in the light of the nature of taboo.
(Continued)
History
This section will examine the history of the psychological and psychiatric focus
on BDSM. It will begin by outlining the work of Krafft-Ebing and the construc-
tion of the concepts ‘sadism’ and ‘masochism’, then briefly mention Freud’s
speculations about developmental influences and his concept of the infant as
polymorphous pervert. Finally, the work of psychoanalyst Robert Stoller and
his notion of the ubiquity of perversion will be discussed.
Victorian sexologists, such as Ulrichs and Krafft-Ebing, examined ‘sexual dis-
eases’ and developed a classification system for a range of ‘sexual types’ which
are still used: homosexual, bisexual, and heterosexual. Heterosexual intercourse
was seen as natural, and all other sexual expressions a perversion from this
norm. Sexologists thus categorised forms of sexual desire, including ‘sado-
masochist’ and ‘fetishist’, and situated these as perversions in need of treatment
and cure. They proposed that a sexual perversion was an illness over which the
individual had little control, and thinly disguised moralism behind a veil of
science (Krafft-Ebing, for example, labelled homosexuals as ‘abnormal degener-
ates’). Various sexual taxonomies were produced by sexologists, each explaining
in detail the definitions of sexual perversions and pathologies, the most well
known of which is Krafft-Ebing’s Psychopathia Sexualis (1886). The origins of
contemporary psycho-medical perspectives towards BDSM remain situated in
Victorian sexology. The very notion that certain sexual behaviours and activi-
ties are ‘abnormal’ and ‘pathological’ originated with early sexology and these
notions still exist within many areas of academia and medicine, as do the
detailed classification systems in the form of the Diagnostic and Statistical Man-
ual of the American Psychiatric Association (DSM) and International Classification
of Diseases (ICD). As a result of these perpetuated psycho-medical perspectives,
lay opinion tends to concur with the ‘experts’, often resulting in a negatively
biased public recognition of ‘perverted’ sexual practices such as BDSM. There
is no doubt that early sexology was pioneering, and was highly influential in
enabling a more open discussion and debate around sex. Some sexologists,
Emma L. Turley and Trevor Butt 27
such as Ellis and Symonds, were far more understanding and sympathetic
towards non-heteronormative sexualities (1879). However, the main legacy left
by these early sexologists is the idea of the sexual perversions and intolerance
towards them.
Psycho-medical perspective
Many of the practices associated with BDSM are still classified as ‘paraphilic
disorders’, a set of psychiatric disorders within DSM-5 and ICD-10, the diag-
nostic criteria of the World Health Organization. The previous edition of the
DSM (DSM-IV TR) classified as ‘paraphilias’ some unconventional sexual inter-
ests, which included a range of non-normative sexual behaviours and practices:
sexual sadism, sexual masochism, exhibitionism, and fetishism, among others.
The most recent edition, the DSM-5, published in 2013, offered some revi-
sions of the ‘paraphilia’ classification. The first of these was a removal of the
diagnostic category of ‘paraphilias’ from within the Sexual and Gender Identity
Disorders category into its own separate chapter, Paraphilic Disorders. Another
noticeable alteration is the change in diagnostic name from ‘paraphilia’ to
‘paraphilic disorder’. The purpose of this change is to recognise the distinction
between a non-normative sexual interest and a disordered sexual interest (www
.dsm-5.org). The differentiation between the two is dependent upon the pres-
ence of ‘clinically significant distress or impairment’, which would qualify an
individual for a diagnosis of paraphilic disorder. The diagnostic criteria for the
‘paraphilias’ was conceptualised for the DSM-III-R in 1987, and these remain
unchanged in the most recent edition. Criterion A in the manual defines
non-normative or atypical sexual interests; however, to receive a diagnosis of
paraphilic disorder an individual must also meet criterion B, which specifies
clinically significant distress or impairment, and the involvement of a victim
in the case of certain paraphilias. Criterion A specifies the qualitative nature
of the paraphilia, while criterion B details the negative consequences of the
paraphilia. The DSM notes that many individuals with non-normative sexual
interests do not have a mental disorder, and this renaming of the diagnostic cat-
egory acknowledges that it is possible for individuals to participate in consen-
sual non-normative sexual behaviours and practices without being diagnosed
with a psychiatric disorder (www.dsm-5.org). The specific disorders within this
category have also been renamed in an attempt to define the difference between
a non-normative sexual interest and a paraphilic disorder. The former ‘sexual
Emma L. Turley and Trevor Butt 29
sadism’ and ‘sexual masochism’ diagnoses have become sexual sadism disorder
and sexual masochism disorder. Other changes incorporate the inclusion of a
specific victim number for the disorders that included non-consenting individ-
uals, such as sexual sadism, along with severity ratings from 1–4, indicating
mild to very severe sexual urges to engage in the paraphilic behaviours.
While some view these revisions as a positive step forward towards depathol-
ogising non-normative sexual interests (Krueger & Kaplan, 2012), others argue
for a complete removal of the non-criminal paraphilias from the DSM. The
British Psychological Society (BPS) issued a statement detailing concerns that
the changes to diagnostic labelling might lead to the application of stigma-
tising labels to normal experiences (2011). Other arguments question the lack
of evidence base for the categories, citing that the issues experienced by indi-
viduals with a paraphilia are often applicable to those without a diagnosed
paraphilia (Shindel & Moser, 2011). The omission of a definition of severe
distress, along with a lack of empirical data linking higher than usual rates
of distress or increased risk of harm with BDSM participation, is also high-
lighted as problematic, since the DSM claims the new diagnostic classification is
based on the latest scientific knowledge and clinical expertise (Shindel & Moser,
2011). Critics of the DSM claim that the inclusion of these categories leads to
pathologisation and stigmatisation of and discrimination against practitioners
of BDSM, which can have serious implications for individuals.
Non-pathologising perspectives
Alternative perspectives to the mainstream psycho-medical approach now exist,
and there is a growing body of research aiming to challenge the connections
between BDSM and pathology, and to explore BDSM practices and communities
30 Sexuality
Current debates
There has always been a duality surrounding sexuality: the aspect of sex for
procreation and the aspect of sex for pleasure. It is argued that there has always
been tension between the procreative and pleasurable aspects of sex, and the
failure to resolve this conflict resulted in pathologising certain types of non-
reproductive sexual enjoyment, as we have already noted.
Spinelli (2006) argues that Western views regarding ‘normal’ and ‘per-
verted’ sexual relationships and activities continue to be informed by Victorian
assumptions about sex. Spinelli (2006) also notes that, unless the purpose of
sex is viewed as simply a means to conceive children, which is rarely the
case in modern Western society, biology and naturalness cannot be cited as
a guide to what is ‘normal’ and ‘abnormal’ sexual behaviour. Certain sexual
activities that were once considered to be ‘abnormal’ or ‘perverse’ are now per-
fectly acceptable. For example, in certain states in the United States, oral sex
between consenting adults was a criminal offence 30 years ago; however, in
Western societies this is considered acceptable sexual practice and has become
normative. Spinelli (2006) adds that these opinions were formed on the basis
of dubious biological theories, and therefore the tradition of categorising other
forms of sexual expression as ‘perverse’ should be challenged. Giddens (1992)
supports this view of evolving attitudes by highlighting the increasing indi-
vidualisation of society, along with a widening sphere of social acceptability,
32 Sexuality
Sexual Guilt scale, the Sexual Behaviours Inventory (SBI), the Eysenck Person-
ality Inventory (EPI), the Feminist Attitudes Scale, and the Locus of Control
Scale (LOC) to 93 self-identified BDSM enthusiasts. The results indicated that
none of the academic perspectives of pathology or misogyny were supported
by the data. Similarly, Connolly (2006) tested 32 self-identified practitioners of
BDSM for types of psychopathology, including personality disorders, obsessive-
compulsion, psychological sadism and masochism, and post-traumatic stress
disorder, by administering a questionnaire and psychometric tests. Connolly
concluded that, on measures of clinical psychopathology and severe person-
ality pathology, the sample was comparable to published test norms and to
DSM-IV estimates for the general population. Despite contrary research find-
ings such as those outlined, the dominant clinical position continues to situate
BDSM practitioners as pathological and in need of treatment.
Within psychiatry itself, there appears to be a wind of change blowing.
Denman (2004) offers a constructive suggestion on the definition of perver-
sion. She condemns the pathologising of BDSM and distinguishes between
transgressive and coercive sex. Transgressive sex is sexual behaviour that merely
transgresses prevailing social norms, whereas coercive sex involves activities in
which one party has not consented. Denman concludes there is no evidence
to support a connection between transgressive sex and pathology. It is coer-
cive sex that we should think of as perverted, not transgressive sex. This view
is reflected elsewhere in psychology and psychiatry, with psychologists such as
Richards and Barker (2013) advocating BDSM-positive clinical work.
for the purpose of concealing the operation of sexual power, and argue that
consensual contracts between men and women can never be equitable (Califia,
2000). By engaging in BDSM these inequalities are internalised and replicated,
thus reinforcing heteropatriarchy. Research conducted with members of the
BDSM community refutes this claim; Taylor and Ussher’s (2001) findings high-
lighted the ability of BDSM to ridicule, undermine, and destroy patriarchal
power, while Ritchie and Barker (2005) report that engaging in BDSM can
make explicit concealed gender dynamics. The pro-sex feminists argue that
female practitioners of BDSM have something that oppressed women do not:
choice. This is what separates women’s consensual BDSM from subjugated expe-
riences. Barker and Gill (2012) note that a new way of thinking about BDSM
is emerging among some feminist academics and BDSM activists which adopts
a both/and instead of the traditional either/or position. The debate here is far
from resolved, however, and is likely to continue for the foreseeable future.
take physical, social, legal, and financial risks to engage in such experiences.
There are also commonalities between the two activities in terms of suffer-
ing and endurance (Zuckerman, 1994). Le Breton (2000) noted that the more
intense the suffering experienced by extreme athletes, the higher the sense of
achievement, and therefore a higher sense of satisfaction was experienced.
law. Weait (2007) notes that in the United Kingdom BDSM is not a crime; there
is no law against being a sadomasochist; however, certain aspects of BDSM may
incite a criminal law response. Indeed, the ‘Spanner’ trial culminated in the
imprisonment of a number of men who were engaging in consensual BDSM
(see www.spannertrust.org for more information). In the United States the legal
status of BDSM is also ambiguous and state dependent. There is no federal
law that includes consensual BDSM practices; however, it can be considered a
crime in certain states, and prosecuted under laws pertaining to sexual abuse or
assault (www.ncsfreedom.org). It is not difficult to understand how individuals
who engage in BDSM can become victims of discrimination, as Wright (2006)
reported that BDSM-identified individuals had suffered violence and/or harass-
ment as well as job discrimination. Wright (2010) illustrated discrimination
against practitioners of BDSM by highlighting a child custody case where strict
visitation rights were imposed on a mother involved in a BDSM relationship
with her partner. The mother’s sexual relationship was the focus of the hearing,
despite the children being unaware of their mother’s sex life. This case indicates
how the court system can be biased against ‘out’ BDSM-identified individuals.
Evidence illustrates that less knowledge of BDSM is related to more negative
attitudes and misunderstandings. Currently, BDSM-identified individuals are at
risk of victimisation and discrimination as a result of these prevalent negative
perceptions. Stiles and Clark (2011) investigated the difficulties that arise from
being a member of a stigmatised subculture, and reported that a major issue
was the need to maintain a level of secrecy regarding their BDSM interests.
The findings of the study revealed that fear of negative consequences was the
main reason behind concealing BDSM-related interests, and various methods
of stigma management were employed to do this. Five levels of concealment
ranging from ‘absolute concealment’ to ‘fractional concealment’, with each
level revealing more information to others regarding participants’ interest in
BDSM, were outlined. The final, sixth level was ‘open’, indicating no conceal-
ment. The primary reason for the concealment was identified as self-protection:
participants were concerned about stigmatisation, resulting in threats to fam-
ily life, friendships, and job security. As a result of the stigma and stereotyping
attached to BDSM, and proliferated by most psycho-medical literature, individ-
uals with an interest in BDSM must employ complex stigma and impression
management strategies in order to protect themselves against discrimination
and victimisation, or face serious consequences.
Future directions
Gay, 1993 for a review), but people prefer to turn a blind eye to this, particularly
in an authoritarian culture. The high profile of BDSM highlights this in a way
that cannot be ignored. It is not surprising, perhaps, that the sexual meaning
of corporal punishment is acknowledged now in a way that was quite impossi-
ble when its use was widespread in schools. Indeed, the sexual discourse served
to undermine its judicial use in an emphatic way (Butt & Hearn, 1998). One
of the authors (TWB) remembers a tabloid newspaper article 30 years ago that
reported the outrage of a punishment cane manufacturer when he discovered
that his products were being sold in Soho sex shops. A visitor from Mars, or even
Scandinavia at the time, might have wondered why beating children was OK,
but consensual sex was not. Langdridge and Butt (2004) conclude, then, that,
paradoxically, BDSM can only be accepted as a legitimate expression of sexu-
ality in a highly civilised society. Ten years on from when they were writing,
this is still the case. The adoption of a more kink-friendly attitude to BDSM,
and its acceptance as a form of sexual citizenship, probably depends on the
proliferation of social liberalism in society generally.
Notes
1. The reinforcement of beliefs about heterosexual sex and sexuality that are perpetuated
in society via social institutions, policies, and procedures, leading to the view that
heterosexuality is the normal and natural expression of sexuality.
2. The implicit and explicit dominance of heterosexual men within a culture and/or
society.
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3
Bisexuality
Helen Bowes-Catton and Nikki Hayfield
Introduction
One of the key themes of this chapter is the role of psychology in the
production of knowledge about bisexuality. From the early sexologists
to recent high-profile studies of sexual arousal, expert psychological dis-
course has shaped not only clinical and academic understandings of
42
Helen Bowes-Catton and Nikki Hayfield 43
History
First-wave sexology
Third gender and inversion theories of (bi)sexuality
We are used to defining an individual’s sexuality in terms of the gender of the
people they are sexually attracted to. To be heterosexual is to be attracted to the
‘opposite’ gender, to be lesbian or gay is to be attracted to the ‘same’ gender, and
to be bisexual is to desire ‘both’. However, early sexologists conceived of sexual-
ity quite differently, focusing on the gender of the desiring subject themselves,
and theorising non-heterosexual desires and practices as rooted in gender
variance. Thus, a ‘masculine’ woman would be attracted to other women; a
‘feminine’ man would be attracted to other men (Angelides, 2001; Oosterhuis,
2000; Terry, 1999). Accordingly, if a person desired both women and men,
it followed that they themselves must have both male and female character-
istics, which was termed ‘psychic hermaphroditism’ rather than ‘bisexuality’
(Oosterhuis, 2000; Storr, 1999).
Karl Heinrich Ulrichs (1826–1895), for example, was an early sexologist
and activist, who was noted for his ‘third sex’ theory of homosexuality
or ‘uranism’. He theorised that during foetal development, when human
embryos are essentially hermaphrodites with undifferentiated sex organs, a
division takes place that results in (heterosexual) men, (heterosexual) women,
and a (homosexual) third sex (Bullough, 1994). Those in the third sex cat-
egory were conceived as neither male nor female, and instead understood
as ‘sexual inverts’, who were female souls trapped in male bodies and male
souls trapped in female bodies (Weeks, 1989). Ulrichs developed an expan-
sive nomenclature for homosexuals and heterosexuals, but the theory relied
on a binary system of inversion. Therefore, he initially had no explanation
for anyone whom we would now understand as bisexual, because they did
not fit this dichotomy. He later recognised the diversity and variation in
human sexual behaviour and developed terms for bisexual men and women,
whom he then included within this ‘third sex’. His theory of a third sex
and of hermaphroditism as the underpinnings of sexuality were an impor-
tant influence on later researchers such as Krafft-Ebing (1886/1997), Hirschfeld
44 Sexuality
[t]here would thus seem to be a broad and simple grouping of all sexually
functioning persons into three comprehensive divisions: the heterosexual,
the bisexual, and the homosexual.
(Ellis, 1905/1942, pp. 261–262, quoted in Fox, 1995, p. 50)
It is well known that at all times there have been, as there still are, human
beings who can take as their sexual objects persons of either sex without the
one trend interfering with the other. We call these people “bisexual” and
accept the fact of their existence without wondering too much at it.
(Freud, 1937/1964, quoted in Young-Bruehl, 2001, p. 183)
It was Freud’s ideas that became hugely influential and dominant, especially
within psychoanalytic theory and treatment (Bullough, 2004). This is, for
example, reflected in how other psychoanalysts, such as Austrian Wilhelm
Stekel (1868–1940), also discussed bisexuality as about attraction rather than
gender and believed that everyone was innately bisexual (Storr, 1999).
46 Sexuality
Second-wave sexology
Little UK sex research took place during the post-war 1940s, but in the United
States there was a surge of interest in understanding human sexualities and
sexual behaviours (Bullough, 1994). This era of second-wave sexology saw a
move towards a more tolerant approach to sexual diversity. The most notable
sexologist of this time was Alfred Kinsey (1894–1956), who, with his col-
leagues, interviewed around 20,000 participants, asking them about their sexual
behaviours (Ericksen & Steffen, 1999). What was particularly notable about this
research was that the amount of same-sex behaviour reported by these partic-
ipants was far higher than previously assumed, which shocked scientists and
the public (Bullough, 1994). Kinsey argued that binary models (first theorised
by the early sexologists in their third sex/inversion models), which consisted
of two distinct and rigid categories of human sexuality (‘homosexual’ and ‘het-
erosexual’), did not capture the huge variance and diversity in human sexual
behaviours:
Like many of his predecessors, Kinsey believed that all humans had bisexual
potential. His well-recognised scale of sexual behaviour ranged from ‘exclu-
sively heterosexual’ (Kinsey, 0) to ‘exclusively homosexual’ (Kinsey, 6) with
graduations of same/other sex attraction (Kinsey, 1–5) in between (Kinsey et al.,
1948, p. 638). He theorised that an individual’s position on the scale could
change over time, reflecting his belief in sexual fluidity, although the scale takes
a ‘zero-sum’ approach to sexuality, by implying that increased attraction to one
gender means decreased attraction to the other. While his work only briefly
Helen Bowes-Catton and Nikki Hayfield 47
encounters with both men and women. However, his interview-based research
showed that many participants were unaware that it was possible to identify
as bisexual (Klein, 1978/1993, p. 15). Klein developed the Klein Sexual Orien-
tation Grid (KSOG) based on these interviews. The KSOG elaborated on the
Kinsey scale and attempted to capture some of the complexity of sexuality by
addressing attractions, fantasies, preferences, self-identification and lifestyle,
and changes over time, rather than just attending to sexual behaviour (Klein
et al., 1985, p. 38).
All of this ran in parallel with the emergence of bisexual identity communi-
ties during the late 1970s and early 1980s, and reflected the bisexual identity
politics of the time (Jeffreys, 1999; Off Pink Collective, 1988; Rose et al., 1996).
The most vocal bisexual-affirmative theorists and activists focused on estab-
lishing bisexuality as a valid ‘third’ sexuality alongside homosexuality and
heterosexuality (Rodríguez-Rust, 2000a, p. 33). To do this, theorists such as
Zinik (1985) and Money (1987, 1990) drew on Freud and other first-wave
sexologists to position bisexuality as the ‘original’ human sexuality, with binary
categories seen as an artificial rendering-asunder of what was once whole
(Highleyman, 1995, p. 264).
However, she also highlighted the tensions that existed between lesbian and
bisexual women, with many lesbians perceiving bisexual women in similarly
negative ways to those highlighted in the 1980s (see above), as well as seeing
bisexual women as promiscuous, unable to commit and wanting ‘the best of
both worlds’. Some lesbians in her study were mistrustful or hateful of bisexual
women and preferred not to be socially or politically involved with them.
The tensions between bisexuality and the lesbian and gay movement on one
side, and heteronormativity on the other, were a key theme of many pub-
lications during this period, which were strongly influenced by critiques of
lesbian, gay, bisexual, and transgender (LGBT) identity politics and the rise of
queer theory and activism (Angelides, 2001, p. 132; Rodríguez-Rust, 2000a).
Researchers such as the US health psychologist Mickey Eliason (1997) began to
draw attention to the concept of ‘biphobia’ using quantitative research mainly
exploring heterosexual people’s attitudes towards bisexuality. These studies
have tended to echo the findings of earlier research (see, for example, Zinik,
1985), and demonstrate that bisexuality continues to be understood negatively
(e.g. Spalding & Peplau, 1997) in ways which demonstrate the continuing cul-
tural currency of the associations between bisexuality and characteristics such
as confusion, immaturity, and indecision that were first made by the early
sexologists.
The second half of the decade also saw the emergence of bi-affirmative thera-
peutic literature, which set out to inform therapists of the unique issues facing
their bisexual clients. Firestein’s (1996) collection Bisexuality: The Psychology and
Politics of an Invisible Minority, for example, contained several chapters aimed at
clinicians working with bisexual people (see also Davies, 1996; Smiley, 1997;
Weasel, 1996), and this work continued into the new century (see, for example,
Firestein 2007).
being in a transitional stage from which they would finally ‘make up their
mind’.
Lab-based research carried out in the United States and led by J. Michael
Bailey, meanwhile, has explored male bisexuality using physiological measures
of sexual arousal in response to sexual stimulation such as films or photographs
(e.g. Rieger et al., 2005, 2013). Initial research (Rieger et al., 2005) found that
men who identified both ‘heterosexual’ and ‘homosexual’ visual stimuli as
arousing tended to respond physiologically to one or the other, but not both,
leading the researchers to conclude that they had not found evidence of a dis-
tinct bisexual arousal pattern. This led the New York Times to run an article
whose headline claimed that men were either ‘Straight, Gay, or Lying’ (Carey,
2005). An international furore followed, and the methodology of the study
was widely criticised; however, the research team were responsive to criticism,
working with the American Institute of Bisexuality on a follow-up study with
improved methodology, which did find evidence of a distinct pattern of arousal
among bisexual men (American Institute of Bisexuality, 2013; Rosenthal et al.,
2011). The misreporting of the original study illustrates both the continual cul-
tural currency of stereotypes about male bisexuality, and the depth of feeling
provoked by bisexual erasure.
Activist–academic collaborations
Psychological research into sexuality often captures the public imagination,
with far-reaching consequences for those studied. Throughout this chapter, we
have discussed the ways in which popular understandings of bisexuality have
been shaped by psychology, from the pathologising categorisations of the early
sexologists to the affirmative work of the 1970s and 1980s onwards. It is crucial,
then, for psychologists researching bisexuality to consider the possible effects of
their work on bisexual people and to take steps to minimise potentially negative
outcomes whenever possible.
One way of doing this is to establish close links with bisexual people, com-
munities, and activists. While academic and activist agendas on bisexuality
have always been closely linked, at times this relationship has been a tense
one, with academics embracing queer agendas and critiquing identity pol-
itics while activists continued to stress the political utility of establishing
bisexuality as an essential and immutable characteristic of the individual in
order to mobilise support for equality legislation (see, for example, Angelides,
2001, p. 133).
The first years of the twenty-first century, however, have seen academic–
activist relationships become increasingly collaborative, with representatives of
both groups working together to set research agendas, establishing crossover
conferences such as BiReCon in the United Kingdom and BECAUSE in the
United States with the aim of fomenting dialogue between activists, clinicians,
academics, LGBT organisations, and the wider voluntary sector. BiUK has also
collaborated with bi community activists to produce a set of guidelines for
social scientists researching bisexuality, which may prove a useful resource for
psychologists navigating these issues (Barker et al., 2012b; Eisner, 2013).
Intersectionality
For all the good intentions of those involved, one consequence of the close
links between bisexual activism and academia has been that empirical research
on bisexuality has often been rather inward-looking, foregrounding the expe-
riences and aspirations of the white, middle-class, socially liberal, highly
educated, and politically engaged bisexual activists and academics who have
found a voice within bi activism and research networks (see Barker et al., 2008,
for a discussion of the demographic characteristics of one such community).
Further, in recent years, the pervasiveness of institutionalised racism, clas-
sism, and ableism within organised sexual minority movements has become
an increasingly discussed topic on bi activist and academic blogs and email
lists, but there is very little consideration of such multiple marginalisations in
the empirical literature (although see Monro, 2010).
54 Sexuality
One area where there has been some progress towards intersectionality is in
the area of mental health. The poor mental health outcomes of bisexual people
are widely documented in research literature, which consistently demonstrates
that bisexual-identified individuals are more likely to suffer from poor men-
tal health than individuals of other minority sexualities (Jorm et al., 2002;
King & McKeown, 2003). There is also a nascent body of work on ageing and
bisexuality (Jones, 2011, 2012). Eisner’s (2013) book on bisexual politics also
explicitly addresses intersectionality from a bisexual perspective, particularly in
regard to trans* and racialised identities. However, it remains clear that there
is much to do to improve the intersectionality of psychological research into
bisexuality.
Summary
Note
1. Until 2000, Paula Rodríguez-Rust published as Paula Rust.
Further reading
Angelides, S. (2001). A history of bisexuality. Chicago/London: University of Chicago
Press.
Barker, M., Richards, C., Jones, R., Bowes-Catton, H., and Plowman, T., The Open
University. (2012a). The bisexuality report: Bisexual inclusion in LGBT equality and
diversity. Milton Keynes: The Open University Centre for Citizenship, Identities and
Governance.
Journal of Bisexuality (Taylor & Francis, 2000).
Moon, L. (2010). Counselling ideologies: queer challenges to heteronormativity. Aldershot:
Ashgate.
Richards, C. & Barker, M. (2013). Sexuality and gender for mental health professionals:
A practical guide. London: Sage.
Rodríguez-Rust, P. (Ed.) (2000b). Bisexuality in the United States: A social science reader.
New York: Columbia University Press.
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4
Further Sexualities
Christina Richards
Introduction
Most people find it difficult to grasp that whatever they like to do sexually
will be thoroughly repulsive to someone else, and that whatever repels them
sexually will be the most treasured delight of someone, somewhere.
(1984, p. 154)
60
Christina Richards 61
and practices may, rather ironically, not be to do with sexuality4 but may
be a matter of identity, comfort, play, etc.; however, we have included these
practices and identities within this chapter for purely pragmatic reasons of
space within the book and shall consequently focus on the sexual aspects
here. I appreciate that the reader may be unfamiliar with ageplay, furry, and
fetishism, so let us take them each in turn.
Ageplay
Ageplay involves an adult identifying as a baby or young child, and is also
known as adult baby/diaper5 lover (ABDL) or infantilism. There may be a sex-
ual aspect – not uncommonly associated with humiliation – or it may simply
involve an adult in the younger role (sometimes called a Little) being nur-
tured and soothed by a powerful caregiving adult (sometimes called a Big)6 who
enjoys such caring. Ageplay may involve various accoutrements of childhood,
such as young-looking clothes – whether for adults or specially made and pur-
chased from the internet – dummies, special furniture etc., and diapers. Some
adult babies will enjoy using these and being changed, whereas others will not
(Rulof, 2011). People may move between ages they enjoy roleplaying – from
pre-verbal to adolescent – or they may have an age which they identify with
more than others.
Given the power differential, there can be a crossover with BDSM/kink (see
also Turley & Butt, BDSM, this volume), with some of the same reasons for
taking part also applying here. A part of this can be ‘sissification’, in which an
adult male gains sexual gratification from being ‘humiliated’ by being ‘made’
to dress and act like a little girl. This is increasingly being frowned upon, as it
has sexist implications. Sissification aside, for many people, whether they wish
to be an adult baby or a caregiver, ageplay may involve the wish to return to
the uncomplicated world of the nursery, away from the trials and tribulations
of everyday [adult] life.
People involved with ageplay are often at pains to disassociate themselves
from paedophilia, with which it is often incorrectly elided, and, indeed, this
elision can be a major stressor for people from these communities. Rulof
(2011) points out that “Ageplay is only about roleplay between consenting
adults. No children are involved at all” (p. 37) and Harrington (2008) states:
“Ageplay, or age roleplay, is not for everyone, but it is also not a ‘precursor
to pedophillia’ ” (p. 12). Indeed, the psychiatric/psychological literature per-
taining to infantilism/ageplay refers to patients who are not paedophilic (e.g.
Evcimen & Gratz, 2006; Pate & Gabbard, 2003).
Furry
Furry refers to those people who have some identification with animals,
whether for reasons of sexuality or, quite often, for reasons of identity more
62 Sexuality
Fetish
Fetish is a broad term which might include most of the further sexualities listed
here as well as various others. In its widest sense, it refers to gaining sexual
satisfaction from a non-human partner or body part (hence shoe fetish, toe
fetish, etc.); however, it is generally used within communities and the more
progressive psychological/psychiatric literatures to refer to the enjoyment of
certain materials, not uncommonly rubber, denim, and leather, although pos-
sibly others such as silk, lace (cf. Skintwo.co.uk). People may attend events such
as Rubber Balls,8 where people will wear rubber to socialise, dance, drink, etc.
Similar events may be held for people who enjoy denim or leather. Leather
events not uncommonly cross over with the BDSM communities, with leather
daddies being people (usually men) into leather who consensually top or domi-
nate others (see also Turley & Butt, BDSM, this volume). Indeed, leather may
be used as an adjective for a number of self-explanatory identities, such as
leatherdyke, leatherman, or entities – leatherclub, leatherbar, etc.
There are, of course, many more further sexualities – almost as many as
one might imagine – associated with power, nurturance, sensation (visual,
tactile, audible, etc.), and so on.9 Indeed, as we have seen above, many of
these sexualities will overlap with one another as well as with other sexualities
within this book – the wearing of rubber pants in ageplay, for example, may
Christina Richards 63
overlap with having a fetish for rubber if a person is also aroused by the sensa-
tion, or, in an overlap between BDSM and ageplay, a person may enjoy being
dominated through being treated as a child. Of course, people with further
sexualities may also be heterosexual, bisexual, gay, or lesbian, and there is
some evidence to suggest slightly higher rates of non-heterosexual identities
in people engaged with further sexualities (Gerbasi et al., 2008; Richters et al.,
2008).
It is also important to recognise that calling these sexualities ‘fur-
ther sexualities’ does not mean that they are necessarily less common or
more problematic than the sexualities found in other chapters (including
heterosexuality) – rather, the epistemological and/or taxonomic separation is
such that they are not considered to be within the mainstream of the contem-
porary, often urban (quite often student), Western culture that social science so
often uses as a benchmark when describing its boundaries.
Because of this social separation, there is a paucity of research involving these
groups,10 with what research there is often being case studies of necessarily
troubled individuals in the medical and applied psychological literatures (e.g.
Croarkin et al., 2004; Dinello, 1967) – which, although considered below as part
of a wider debate around pathologisation, are of limited use in generalising to
the population as a whole. Such studies suggest that people involved with fur-
ther sexualities are predominantly male (Chalkley & Powell, 1983; Darcangelo,
2008), although this is at odds with the studies which suggest that women have
a more plastic sexuality11 (Diamond, 2007) and work on those people who iden-
tify outside the gender dichotomy (Herdt, 1996; see Chapter 12, this volume).
One place for more information on further sexualities in the established
literature is Richards & Barker (2013)12 ; however, outside such work there is
interesting information to be found within community websites and literatures,
as well as the grey literatures at the edges of the academy. The face validity,
depth, and vitality of such work must, of course, be balanced against the lack
of peer review, scholastic rigour, and the like. Nonetheless, it was felt important
to include these sexualities within this book so as not to further marginalise
them through exclusion – and, given the dearth of formal research in this area,
some such literatures have been drawn on for this chapter in addition to the
author’s clinical experience of individuals who have presented information on
these sexualities, but who have sought help for other matters.
With these caveats in mind, and given the brouhaha13 which so often
arises when considering further sexualities, we will next consider the place
of these and other further sexualities within [minority Western] culture and
their place within psychiatric/psychological taxonomies before turning to the
future of research and clinical practice. For clarity, as this is not intended to
be a forensic handbook, this chapter concerns itself only with those sexualities
which are not inherently coercive or harmful (focusing on fetish, ageplay, and
64 Sexuality
furry) – thus excluding paedophilia from consideration. This split between what
may be transgressive of cultural norms and what is actually coercive (Denman,
2004) will be considered in more detail below.
History
(Junginger, 1997; Laws, 2001); however, they had limited efficacy and are
understandably controversial (Krueger & Kaplan, 2002). More recently, espe-
cially in forensic settings, anti-androgens such as goserelin and cyproterone
acetate have been used (Thibaut, 2012); however, these necessarily only address
testosterone-induced sex drive and not the underlying causes and nature of the
person’s sexuality. For those people who have an obsessive element to their
sexuality, selective serotonin reuptake inhibitors (SSRIs) may be used (ibid.).
In addition, people have been treated with a range of psychological therapies,
including psychodynamic techniques which aim to treat conflicts arising from
developmental milestones (Wiederman, 2003), although with limited success.
Cognitive behaviour therapy (CBT) is a contemporary therapy that has also
been used, which aims to treat the type and frequency of any problematic
behaviours as well as addressing the thoughts which underlie them (Kaplan &
Krueger, 2012).
Due to a change in conceptualisation of further sexualities away from a
problem-based understanding and towards one of diversity (see below), there
has also been a recent marked turn away from pathologisation among those
people who have such identities and practices and towards a sense of com-
munity building and support. This mirrors the community building and
acceptance of homosexuality in many Western nations since the late 1970s
(Weeks, 2007). Such community building is often via the internet, although
sometimes through face-to-face group meetings, most commonly in large urban
areas (Richards & Barker, 2013; cf. Skintwo.co.uk).
As we can see from the content of this chapter, while communities are in the
process of forming (and so have a limited impact within the academy), what
little research there is15 on people with further sexualities generally involves
sex offenders and psychiatric patients. This raises questions as to the degree
with which the various confounds to these studies (such as the issues which
have driven a person to offend or to seek psychiatric care) can be separated
out in order to gain a clear picture of the populations under investigation. For
example, Kafka and Hennen (2002) found raised incidence of DSM Axis I dis-
orders in a group of paraphilic outpatients, half of whom were sex offenders,
Whereas Wise et al. (1991) found no raised incidences of psychopathology in a
non-clinical sample of people with ‘paraphilias’, and Hawkinson and Zamboni
(2014) similarly found that “ABDL16 behavior may represent a sexual subculture
that is not problematic for most of its participants” (p. 1).
This may be the reason why people from community groups present a picture
which is so at odds with the clinical literature, in that they generally assert that
they are ordinary people doing a somewhat unusual thing (e.g. Torture Garden,
66 Sexuality
How, then, are we to define and describe these boundaries around what con-
stitutes a further sexuality if we do not adhere to diagnoses on the grounds that
they often form a different group, and if we do not simply adhere to cultural
stereotypes and assumptions, especially those that elide the unusual with the
[criminally] pathological?17 – Where are the cleavage planes, as it were, that let
us determine what it is we are researching?
One of these planes – which applies more broadly too – is between
practice and identity (Richards & Barker, 2013). Thus, when considering
homosexuality,18 for example, a person may have sex with people of the same
gender, but not define as gay or lesbian – their practice is not their identity
(giving rise to the sexual health terms ‘men who have sex with men’ (MSM) or
‘women who have sex with women’ (WSW)). Similarly, a person may identify
Christina Richards 67
as gay but not be attracted to people of the same sex at that moment. A useful
analogy is that of being a computer gamer19 – most people in the urban West-
ernised world have played computer games at some point, either at a party, on a
smartphone, or during an idle time at an office – but few will identify as gamers.
Conversely, the gamer who is queuing up at midnight to buy the latest release
may not be playing a computer game, but is very much a gamer. Thus, prac-
tice and identity must be separated to some degree when considering sexuality,
especially further sexualities which may be subject to social opprobrium and
so lead people either to claim an identity as a source of community (although
they may not be practising at that time), or not to claim that identity (while
still practising) to avoid opprobrium (Wiederman, 2003).
This separation between practice and identity allows us to consider research
and theory in different ways – are we considering someone who identifies as a
heterosexual man, but who enjoys wearing rubber (someone who might be a
fetishist, but doesn’t have that identity as such) or are we considering someone
who is in an online fetish chatroom as someone who is into fetish, but who
isn’t wearing rubber, say, at that time? In addition, this identity/practice split
allows us to consider further sexualities as a practice (if not an identity) to be
a matter of degree rather than kind. Consider people wearing bunny ears and
leopard prints as being a matter of degree from furry practices, for example; or
calling a lover ‘babe’ or ‘sweetie’ or using a different voice with them as being
a matter of degree from ageplay practices; or enjoying the feel of silk or lace as
a matter of degree from fetish practices. While people in the mainstream may
not apply such labels to themselves, taken broadly, a great many nonetheless
enjoy some aspects of the further sexualities considered here.
Current debates
Despite (or perhaps because of) the mainstream acceptance of some aspects of
further sexualities, the delineation and separation of further sexualities from
other, more mainstream, sexualities remains hotly contested. As seen above,
one key debate is whether they should be pathologised, with harm being cited
as a reason for their exclusion from cultural normativity. This has led psy-
chiatrist Chess Denman (2004) to usefully differentiate between transgression
and coercion (and so identify another important cleavage plane), as I have
been doing in this chapter. In this understanding, those practices which are
transgressive of a given culture may receive opprobrium, but do not necessar-
ily cause harm through requiring a person to be coerced – this would include
things such as BDSM, for example, which may appear to involve coercion but,
in fact, have a strong emphasis on consent (cf. Langdridge & Barker, 2007). It is
important to remember that heterosexual penis-in-vagina (PiV) sex may also
be rape (and, indeed, Paraphilic Coercive Disorder was mooted for the DSM-
V on that basis; Beech & Harkins, 2012); however, neither BDSM nor PiV sex
necessitates coercion – unlike paedophilia, for example, which always involves
coercion as one party does not have the capacity to consent. In this way, we
can consider harm and further sexualities within a culturally bound psychiatric
context and split the ‘Paraphilic Disorders’ listed in the DSM-V (APA, 2013) into
three groups:
We can see, then, that if we examine the further sexualities we are considering
in this chapter – fetishism, ageplay, and furry – practices and identities all fall
into the transgressive rather than coercive groups. Indeed, when considering
matters of coercion, harm, and associated morality, it is worth noting the vastly
reduced chances of unwanted pregnancies and sexually transmitted infections
within most further sexuality practices.
The APA, while not utilising Denman’s cleavage plane of the transgressive/
coercive split, does explicitly recognise that many of the transgressive
‘paraphilias’ are essentially harmless unless they cause distress either to the
paraphilic person or to someone else. Indeed, the APA states that
Christina Richards 69
Thus, we can see that the APA does not view having an unusual sexuality to be
psychopathological unless there is also distress and/or harm involved.
The fact that these diagnoses, which include the cause of the distress (unlike
Depressive Disorders, say, which do not list a cause in the diagnosis), are
included and not other causal diagnoses we might imagine, such as Financial
Insufficiency Disorder (FID – distress at having insufficient money), and, indeed
why a simple symptom and syndrome taxonomy (without cause) is not used
instead, raises questions about the moral nature (as we have seen above) of
these explicitly scientific, but implicitly encultured, taxonomies (cf. Karasic &
Drescher, 2005). The recognition by the APA that many ‘paraphilias’ (which
I am calling ‘further sexualities’ here to differentiate them from the medical
and applied psychological discourses they are, gradually, extricating themselves
from) are not, in themselves, psychopathological is, as we have seen, reflec-
tive of the lack of evidence for broader psychopathology or other problematic
behaviours in these populations (e.g. Hawkinson & Zamboni, 2014). Why,
then, were the paraphilias not simply removed from the DSM 5? One explana-
tion is that it would be a “public relations disaster for psychiatry” (Spitzer, 2005
cited in Kleinplatz & Moser, 2005, p. 137); however, we might more charita-
bly consider the bureaucratic need for some form of diagnosis for those people
seeking assistance with associated distress – the argument against this being
that an Anxiety or Depressive Disorder alone would serve equally well, without
the need for a stated cause in the diagnosis itself.
boundaries are carefully policed, however. A little ‘lovemaking spice’ must not
cross over into something ‘perverse’ or ‘deviant’. Pink fluffy handcuffs are
acceptable – police handcuffs are not (cf. Storr, 2003). A leather jacket may be
acceptable, a leather skirt, possibly – leather underwear, no. Rubin (1984) again:
Arguments are conducted over where to draw the line and to determine what
other activities, if any, are permitted to cross over into acceptability . . . The
line appears to stand between sexual order and chaos. It expresses the fear
that if anything is permitted to cross over this erotic demilitarised zone, the
barrier against scary sex will crumble and something unspeakable will skitter
across. (p. 282)
Twenty years on we are still policing that line in all its social and medico-
legal complexity as it shifts, ebbs and flows with the cultural acceptance and
opprobrium afforded it by the current social milieu.
As an added layer of complexity, further sexualities are often policed within
individuals who have internalised such a partially approving/partially disap-
proving cultural gaze (cf. de Beauvoir, 1997 [1949]; Foucault, 1991 [1977]). This
is especially difficult as further sexualities may shift, ebb, and flow within indi-
viduals over time,22 with different tastes and desires becoming more prescient
and then abating, perhaps over a period of years (Barrett, 2007) – much as with
people’s appreciations of different kinds of foods. This is not to say that such
sexualities are ‘just a phase’, any more than a heteronormative woman’s attrac-
tion to males will be ‘just a phase’ as it alters from adolescence (a pop star
pin-up, for example) to adulthood (a good potential father with nice eyes, for
example).
Thus, applied professionals must navigate a tricky terrain within a complex
social milieu – potentially with affirmative practice to mitigate societal oppro-
brium (BPS, 2012) – while endeavouring in the consulting room not to police
the line mentioned above between what is ‘spicy’ and what is transgressive.
Additionally, professionals may usefully leverage their social power to enfran-
chise these marginalised communities through advocacy work outside the
judicial system in recognition of the emerging trends of non-pathological
communities.
Applied psychologists should be aware that the DSM-5 (and most likely
the ICD 11) clearly differentiates between sexualities which are causing
distress and/or harm, and those which are simply ‘unusual’.
Care should be taken in clinical practice not to further disenfranchise
those people who have a minority practice or identity which is not
Christina Richards 71
Future directions
Future directions for further sexualities will most likely consist of (policed)
expansion of social (and therefore clinical) acceptability, which will lead to an
apparent increase in numbers as more people come forward. More research will
certainly aid in this endeavour – perhaps especially that of a phenomenological
nature, which investigates lived experience and considers multiple meanings
and identities without endeavouring to diagnose or explain. For example, we
might imagine that there would be multiple meanings associated with iden-
tifying with a feline, for example: for some, it may be to do with freedom;
for others, wishing to be stroked and petted; for others, identification with
other aspects. Phenomenological research could draw this out in the depth and
complexity which are lacking in the current literatures. Such research could
be conducted alongside the research which focuses on (most likely a lack of)
psychopathology. Both these endeavours will be driven by more community
sample research, and a move away from generalising from clinical samples to
population samples. Certainly, the forthcoming ICD to be published in 2017
will re-evaluate the clinical veracity and utility of diagnoses for paraphilias
which are not, in themselves, harmful.
It is likely that community groups will continue to form, and perhaps will
continue to schism as people jostle for relative normativity (the “hey at least
we’re not like those guys” phenomenon); or, sometimes, positions outside the
mainstream (the “hey you guys are sell-outs – we’re the real radicals” position).
For this reason, it will be interesting to see the development of the asexual
communities and political efforts, as asexuality is, perhaps, just a little ahead
of the sexualities mentioned in this chapter in these regards (see also Carrigan,
Asexuality, this volume).
What is certain is that sexuality, and people at the margins of whatever is
socially acceptable at the time, will continue to be contested ground, with
people being marginalised for behaviours which, in the final analysis, are often
rather innocuous. Hopefully, psychologists will be able to aid those people who
72 Sexuality
are in need of assistance, reassure those who are not, and play a part in moving
society towards a place where more people are free to pursue their transgressive,
but not coercive, sexualities in comfort.
Summary
• Different cultures accept and reject sexualities in different ways which vary
over time.
• Further sexualities are not necessarily psychopathological.
• The internet has created communities of people with ‘unusual’ sexual
practices and identities who were previously isolated and remain rather dis-
enfranchised. These communities should be respected by researchers as safe
places which require humility and respect.
• The line between what is acceptable and what is not should be researched
carefully and generally only delineated in cases of coercion.
Notes
1. Or we might say ‘vagina engulfing penis’.
2. Bondage and discipline, dominance and submission, sadism and masochism.
3. Rather strikingly, it seems that furry-identified people have heightened aesthetic
awareness (Gerbasi et al., 2008). One wonders whether there is some ‘opening of
the eyes’ which occurs when people step outside cultural norms.
4. You may well question their inclusion in a Further Sexualities chapter on that basis.
And, indeed, it might be nice if, in future editions, we could separate the sexual
aspects from the non-sexual aspects as we have done with trans* (See also Lenihan,
Kainth, & Dundas, Trans Sexualities, and Murjan & Bouman, Trans Gender, this
volume).
5. This is an American term for what would be called a nappy in the United Kingdom.
6. Other terms sometimes used include ‘Daddy’ or ‘Mommy’, although these are,
understandably, loaded terms which not every person involved will be happy with
(Harrington, 2008).
7. This is actually what the fox says.
8. Yup – the pun is an intentional quip from the community.
9. Indeed, it’s an old joke, based on some degree of truth, that if someone can imagine
it there is internet porn about it (see Munroe, n.d.).
10. It seems that social science research is primarily involved in the slightly socially
unusual – but nothing too unusual or, alternatively, common – thus, we have little
research on heterosexuality or infantilism, but a great deal on gay people.
11. This has always smacked to me of keeping women ‘pure’ – women aren’t actually
lesbians, in the sense that a gay man is gay, merely plastic (cf. Barker & Gill, 2012) –
while fetishism remains a ‘male’ attribute irrespective of the notion that people with
a plastic sexuality would almost necessarily be fetishists.
12. Beautifully written and very reasonably priced . . . .
13. Ah, to be the editor of one’s own book – I heartily recommend you try it. I shall use
‘imbroglio’ later with impunity.
14. And there you are . . . .
Christina Richards 73
Further reading
Archives of Sexual Behavior is a journal which commonly has a variety of papers on these
topics from varying standpoints.
das Nair, R. & Butler, C. (2012). Intersectionality, sexuality and psychological therapies:
Working with lesbian, gay and bisexual diversity. Oxford: Wiley-Blackwell.
Denman, C. (2004). Sexuality. Basingstoke: Palgrave Macmillan.
Queen, C. & Schimel, L. (Eds.) (1997). PoMoSexuals. San Francisco: Cleis Press Inc.
Richards, C. & Barker, M. (2013). Sexuality and gender for counsellors, psychologists and health
professionals: A practical guide. London: Sage.
References
American Psychiatric Association (APA) (2013). Diagnostic and statistical manual of mental
disorders, fifth edition (DSM-5). Arlington, VA: American Psychiatric Publishing.
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5
Gay Men
Damien W. Riggs
In our culture, men who have sex with men are generally oppressed,
but they are not definitively excluded from masculinity. Rather, they
face structurally-induced conflicts about masculinity – conflicts between
their sexuality and their social presence as men, about the meaning of
their choice of sexual object, and in their construction of relationships
with women and with heterosexual men.
(Connell, 1992, p. 737)
Introduction
The epigraph above from the early work of Connell succinctly captures the
challenges in researching and speaking about the lives of gay men living in
Western societies. As Connell notes, while gay men living in such societies
experience oppression as a result of heteronormativity and homophobia, they
do so as men. What this suggests is that gay men in the West experience both
oppression and privilege (as a result of living in societies where having been
assigned male at birth or identifying oneself as male accords privilege which
comes at the expense of people assigned female at birth or who identify as
female). For gay men, this intersection of oppression and privilege results in
what Connell terms “structurally-induced conflicts about masculinity”. Specif-
ically, and as this chapter outlines with reference to psychological and social
scientific research on the topic, gay men living in Western societies are posi-
tioned in a relationship to norms of masculinity that are neither of their
making, nor necessarily indicative of their lived experience. Importantly, how-
ever, and as this chapter emphasises, there are other ways of understanding gay
men’s lives that make it possible to move beyond simply affirming the category
‘gay man’, and instead question the ways in which we think about this category
and its relationship to hegemonic masculinities.
By way of definitions, and as the paragraph above indicates, talking about
‘gay men’ as an a priori category is inherently problematic. As the section below
77
78 Sexuality
History
Psychology, psychiatry, and sexology have all played key roles in the issues
outlined above in the introduction in terms of the category ‘gay men’. To
summarise, battles have been fought over whether intimacy between men rep-
resents a pathology, or whether it represents but one facet of the wide variation
of human intimacies. Battles have also been fought over whether or not gay
men (or, to use the language in much of the literature, ‘homosexuals’) are
men much the same as men who prefer intimacies with women, or whether
or not gay men constitute an entirely different category altogether. In terms
of the latter battle, early sexologists such as Karl-Heinrich Ulrichs and Magnus
Hirschfield proposed the idea that homosexual people constituted a third sex
(with the other two categories being heterosexual cisgender women and het-
erosexual cisgender men). The term ‘Urning’ was used by Ulrichs to refer to ‘a
male-bodied person with a female psyche who desired men’ (Clarke et al., 2010,
p. 7). While Ulrichs later acknowledged that femininity was not necessarily a
hallmark of all men who desired intimacy with other men, this notion of gay
men as having a ‘female psyche’ has remained, and circulates – as indicated
in the introduction to this chapter – both within gay men’s communities and
within academic research.
Sigmund Freud, in his own work as a psychiatrist and founder of psychoanal-
ysis, refuted this idea that gay men constituted a third sex. While, since Freud,
psychoanalysis has been used in many sectors as a lynchpin for warranting
the argument that homosexuality constitutes pathology, Lewes (1988) suggests,
contrarily, that Freud saw intimacy between men as neither a sign of pathol-
ogy nor necessarily ‘normal’. Rather, Freud saw homosexuality as one specific
Damien W. Riggs 79
Castrated Phallic
1) Heterosexual 2) Heterosexual 3) Heterosexual
Castrated
Heterosexual
Feminine Feminine Masculine
Mother
Figure 5.1 Lewes’ (1988) sexual results of the Oedipus complex as determined by
identification (or instinctual aim) and object choices
80 Sexuality
homosexual men in terms of their ratings on the scale of masculinity and fem-
ininity were more significant than any categorical differences between the two
groups. This does not suggest that there were no differences between the expe-
riences of both groups – this was not Haslam’s aim. Rather, his aim was to
examine whether or not it was more appropriate to understand male sexual
orientation as a continuous distribution across men rather than as a binary
of homosexual and heterosexual, a hypothesis that his data clearly demon-
strated was the case. In the context of the present chapter, what this illustrates
is the fact that assumptions of femininity in regard to gay men are not sim-
ply unfounded, but actually prevent us from seeing gay men’s lives on their
own terms. As the research presented below would indicate, issues of mas-
culinity are perhaps one of the most significant concerns within psychological
research focusing on gay men, with this arguably being largely the product of
assumptions about gay men’s (lack of) masculinity.
Current debates
Given the points made above in regard to the flawed assumption that gay
men are inherently feminine, the question that must be asked, then, is how
and why, beyond academic research, femininity continues to be treated as the
hallmark of gay male subjectivity. Obviously, academic research, media com-
mentary, religious leaders, and political commentary play a significant role in
over-determining the meanings of gay men’s lives to a large degree (see Box
below for more on this). Psychological research suggests that the key point of
intersection between these sites of meaning-making and the everyday lives of
gay men is the individual’s family, and more specifically their parents. Research
on the self-reports of adult gay men in terms of their childhood experiences cer-
tainly affirms this supposition that the application of discourses of femininity
to gay men’s lives (and, thus, gay men’s vexed relationship to these discourses)
begins early on.
Pachankis and Bernstein (2012), for example, suggest that from an early age
gender non-conforming boys are made aware of the ways in which they
are scrutinised by their parents, and the expectations that are placed upon
them in terms of conforming to normatively masculine subjectivities. Impor-
tantly, in their research Pachankis and Bernstein sought to examine the impact
of such scrutiny and expectation upon adult gay men’s levels of anxiety
as induced by feeling constantly aware of scrutiny from other people, and
in feeling the need to conceal their gay identity (which included “attempt-
ing to appear more masculine, monitoring speech content, avoiding certain
locations, and avoiding being seen with other gay men to specifically avert
negative evaluations of their sexual orientation”, p. 109). Their findings con-
firmed this hypothesis, with early experiences of parental scrutiny being related
to self-monitoring and concealment, both of which led to higher levels of
anxiety.
Another, related, study of gender non-conforming young people conducted
by Toomey and colleagues (2010) found that, of their sample of 245 young peo-
ple, all the variance in terms of life satisfaction and depression was explained
by the degree of perceived discrimination they had faced on the basis of their
gender non-conformity. Similarly to Pachankis and Bernstein’s (2012) research,
then, Toomey and colleagues’ findings indicate the long-lasting and significant
effects of discrimination, and that such effects may for many people begin at an
early age. Perhaps even more concerning are the findings of Brady (2008), who
suggests that gender non-conforming boys are significantly more likely to expe-
rience sexual abuse as children than are boys who conform to normative gender
expectations. Importantly, Brady’s research does not seek to demonstrate that
early childhood abuse ‘causes’ some boys to become gay – his concern is not
with aetiology. Rather, his focus is on why retrospective reporting indicates
that gay men who in childhood were gender non-conforming were more likely
to be abused, and what this means for practice responses to such abuse. The
latter issue is addressed in the following section. In regard to the reasons for
84 Sexuality
the higher rates of sexual abuse of gender non-conforming boys, Brady sug-
gests two reasons. The first is that such abuse may be seen as ‘corrective’,
in that it is aimed at disciplining gender non-conforming boys and forcing
their adoption of a gender-normative subjectivity. The second is that, given
discourses of femininity outlined above in regard to gay men, gender non-
conforming boys may be viewed as feminine, and thus may be seen as easier or
more willing targets of sexual abuse by abusers than gender-normative boys. Of
course, a third explanation is possible, namely that gender non-conforming
boys – desperate for affirmation of their emotional experiences and feeling
rejected or judged by their parents – may be more susceptible to the advances
made by people who seek to abuse them. Importantly, this is not to attribute
blame to gender non-conforming boys in any way. Rather, it is to emphasise
how assumptions and stereotypes about gay men and femininity, along with
attitudes towards gender non-conforming boys, combine to produce a con-
text where the latter are at higher risk of and greater vulnerability to sexual
abuse.
The emphasis of this chapter has been on how gay men are located within
a relationship to normative notions of masculinity, and how this contributes
to gay men’s vulnerability in the context of Western homophobic and
heteronormative societies. This section extrapolates from the research already
presented above, in addition to presenting other research highlighting how
this vulnerability may manifest and thus result in some gay men presenting to
applied psychologists and other practitioners.
In regard to the research already presented, Pachankis and Bernstein (2012)
suggest – drawing on the stress reduction hypothesis – that gay men may
attempt to alleviate anxiety by engaging in compensatory behaviours such as
drug use. Such a claim, they suggest, is not intended to pathologise gay men,
but, rather, to acknowledge the detrimental effects of stigmatisation upon gay
men. Brady (2008) similarly suggests that adult gay men who experienced sex-
ual abuse as children are at increased risk for engaging in unprotected anal
intercourse. Again, Brady emphasises that this is not indicative of pathology
among gay men, but, rather, that early trauma and other stressors may leave
some gay men vulnerable to risk factors to which other men who have not
experienced trauma or who do not live with the effects of significant stressors
may be less vulnerable. When working with gay men who have experienced
childhood sexual abuse or who are particularly susceptible to anxiety resulting
from concerns about being judged, it is thus important to treat seriously such
traumas and anxiety, but not to conflate them with the man’s gay identity or
sexual practices (for more on this, see Box below).
Damien W. Riggs 85
Another implication for clinical practice with gay men is indicated by Wade
and Donis’s (2007) research on gay men and masculinity. Their research
looked at the degree to which their sample of gay men conformed to tra-
ditional notions of masculinity. For those men who most conformed, there
was a greater likelihood of reporting poor relationship satisfaction. Inter-
estingly, they also found that gender non-conforming gay men were more
likely than gender-conforming men to experience relationship satisfaction.
These findings are interesting, as they highlight the fact that, while gender
non-conforming gay men may experience a range of negative outcomes as
highlighted above, they may also exhibit strengths that are beneficial in the
context of long-term relationships. In terms of gender-conforming gay men,
then, it is important for psychologists to be aware of the challenges that may
come in working with gay couples who are gender-conforming in terms of
the impact upon their willingness to negotiate or work through emotional
difficulties.
86 Sexuality
Future directions
to and having sex with other men becomes more viable after transitioning.
As they suggest, being affirmed in their identity as males can lead to some
transgender men feeling comfortable engaging in sex with other men, provided
they are recognised as men. Scheifer suggests that some gay transgender men
may be comfortable with vaginal intercourse, provided they are being treated
as men by their partner(s). This research highlights the fact that masculinity,
embodiment, and anatomy must necessarily be treated as related but also sep-
arate factors. Reducing transgender men to their physical anatomy and what it
is normatively understood to represent discounts and marginalises their lived
experience as men. Better understanding of the lives of transgender gay men
and their negotiations with discourses of masculinity and intimacy with other
men is thus a key future direction for research in the area (for more on gay men,
masculinity, and sex, see Box below).
Another key area requiring attention is how gay men – cisgender and
transgender – develop their own forms of masculinity that sit in a relationship
to normative masculinities, while also potentially offering new ways of think-
ing about masculinity. Across the past century, gay men have developed a wide
range of subcultural movements that variously conform to, refute, or subvert
normative masculinities. Some such movements may be seen as emulating nor-
mative understandings of masculinity (such as the current focus on muscularity
88 Sexuality
in Western societies), while others may do so but at the same time subvert nor-
mative masculinities (for example, the leather scene). Two interrelated factors
are important to keep in mind in any discussion of how gay men engage with
normative discourses of masculinity. First, given cultural stereotypes outlined
throughout this chapter in regard to gay men and femininity, all gay men are
positioned in a relationship to such stereotypes. This is not to suggest that gay
men’s masculinities are dupes of cultural stereotypes, or that they are forever
failed representations. Rather, it is to recognise the power of cultural stereo-
types in shaping what is deemed intelligible within any cultural group. The
second point is that, whatever gay men’s masculinities may be, and whichever
way they relate to cultural stereotypes about gay men, Connell’s (1992) point
remains: gay men are men living in societies that privilege the experiences of
men.
A key example of some gay men’s complex relationship to discourses of
masculinity appears in bear culture: one shaped by an emphasis on rugged
masculinity. As Hennen (2005) reports in his ethnographic research on bear
communities, men who identified as bears within his sample were primarily
middle-class, and, thus, much of the embodiment they engaged in, which
involved presenting “bear masculinity” by wearing “jeans, baseball caps,
T-shirts, flannel shirts, and beards” (p. 26), was, in effect, “working-class drag”.
Hennen notes, however, that his participants appeared unaware that this was
what they were doing, and that class-consciousness was not evident. What
Hennen’s research echoes, then, is the point made above, namely, not only
that gay men are actively involved in reworking and subverting cultural norms
in regard to masculinity, but that, to a large extent, they do so in ways that are
constrained by available discourses about masculinity. As such, while, as Butler
(1997) has suggested, resignification of dominant discourses is possible, this can
often bring with it normalising and appropriative traces of the discourse itself
(in this case a middle-class appropriation of what is presumed to represent the
truth of working-class men).
Already, psychological research has begun to examine how some gay men
appropriate as much as resignify in their enactments of masculinity, specifi-
cally with regard to race. Research on sexual racism within gay communities
has highlighted how white gay men often bolster their own claims to mas-
culinity by constructing Asian gay men as inherently effeminate and passive
(e.g. Riggs, 2013). For Asian gay men, this construction is often extremely neg-
ative, with participants in Drummond’s research (2005) suggesting that the
depiction of them as effeminate contributes to their own sense of marginal-
isation within their home culture, as well as over-determining their possible
relationships with white gay men (in which they are expected to be pas-
sive and subservient). The assumptions that circulate among some white gay
men about Asian gay men thus again highlight how norms of masculinity
are enforced within gay men’s communities. The example of some white gay
Damien W. Riggs 89
men’s assumptions about African American gay men also illustrates this point.
As McBride (2005) has argued, white gay men often expect African American
gay men to be hypermasculine, an expectation shaped by racialised stereotypes
about African American masculinities more broadly.
To conclude, and as has been suggested throughout this chapter, it is impor-
tant to be aware of how gay men are rendered complicit with practices
of marginalisation when they take up normative discourses of masculinity,
premised as such discourses are upon the exclusion of those who do not or
cannot conform to them. Whether this be through gay men’s self-imposed nar-
ratives of femininity, in instances where certain gay men characterise other gay
men as either feminine or hypermasculine, or in gay men’s characterisations
of women’s identities, it is important that students, researchers, and applied
psychologists and other practitioners – regardless of their sexual orientation –
continue to examine and challenge the powerful ways in which normative
discourses of masculinity shape the experiences of all.
Summary
Further reading
Centre for Research on Men and Masculinities. Retrieved from https://lha.uow.edu.au/
hsi/research/cromm/index.html.
90 Sexuality
Greatheart, M. (2013). Transforming practice: Life stories of transgender men that change how
health providers work. Toronto: Ethica Press.
Riggs, D. W. (2008). All the boys are straight: Heteronormativity in books on fathering
and raising boys. Thymos: Journal of Boyhood Studies, 2, 186–202.
Thomas, G. (2007). The sexual demon of colonial power: Pan-African embodiment and erotic
schemes of empire. Bloomington: Indiana University Press.
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Brady, S. (2008). The impact of sexual abuse on sexual identity formation in gay men.
Journal of Child Sexual Abuse, 17, 359–376.
Brown, J. (2007). Therapy with same sex couples: Guidelines for embracing the subju-
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6
Heterosexuality
Panteá Farvid
Introduction
92
Panteá Farvid 93
factors) take into consideration the social context for shaping something like
‘heterosexuality’.
History
Theorising heterosexuality
The second-wave feminist critique of heterosexuality has led to in-depth the-
orising around the institution of heterosexuality in the contemporary context
by some critical and feminist work. Building on the work of Rich (1980) and
others (e.g. de Beauvoir, 1953 [1949]; Millett, 1970; Oakley, 1972; Rubin, 1975),
feminist scholars have argued that heterosexuality needs greater analytic atten-
tion within psychology (Kitzinger et al., 1992; Wilkinson & Kitzinger, 1993)
to remedy the heterocentrism evident in the discipline, even among feminists
(Kitzinger, 1994). Those in disciplines such as sociology have also given ana-
lytic attention to the topic (Herek, 1998; Ingraham, 2008, 2005; Jackson, 1995a,
1995b, 1996, 1999; Richardson, 1996).
Contemporary work has also critiqued the myth that heterosexuality is
a given, natural, and biologically determined (Kitzinger & Wilkinson, 1993;
Seidman, 2010; Tiefer, 2004). What gives heterosexuality its power and priv-
ilege is the taken-for-granted idea that it is a natural occurrence based upon
biological sex, as well as its links to procreation (Schilt & Westbrook, 2009).
Heterosexuality has been theorised as a privileged and invisible category,
akin to being white, able-bodied, and middle-class (Braun, 2000; Jackson,
2006), unless in the presence of the ‘other’ (non-heterosexuals) (Butler, 1990).
Heterosexuality is an institution which one does not see, and we, as social
actors, participate in an unacknowledged heterosexual world (Ingraham, 2005).
For example, no one has to come out as ‘heterosexual’ – the only time one’s
sexuality or sexual orientation is made relevant is when it deviates from the
norm (of heterosexuality). To be heterosexual is to be privileged over other
sexualities, as heterosexuality does not require ‘accounting for’ in the way other
sexualities/sexual orientations do. In addition, although heterosexuality is not
a monolithic entity, most heterosexuals do not typically experience some of the
98 Sexuality
Heteronormativity
The normative function of heterosexuality within daily life has been termed
heteronormativity (a term coined by Warner, 1991). As the successor to Rich’s
(1980) concept of compulsory heterosexuality, heteronormativity refers to the
“suite of cultural, legal, and institutional practices that maintain normative
assumptions that there are: only two genders, that gender reflects biological
sex and that only sexual attraction between these ‘opposite’ genders is natural
or acceptable” (Schilt & Westbrook, 2009, p. 441). Heteronormativity struc-
tures social beliefs, organisations, policies, and institutional practices (Hubbard,
2008; Seidman, 2009), as well as extending to the mundane everyday ways
that heterosexuality is privileged and taken-for-granted as normal and natu-
ral (Martin, 2009). Heteronormativity regulates those within and outside it
(Jackson, 2006), holding a cultural hegemony that reproduces the heterosexual/
gay binary and positions gay as its subordinate, at the same time as it
institutionalises heterosexuality as the norm (Hubbard, 2008).
Linked to heteronormativity is the concept of heterosexism (Kitzinger &
Perkins, 1993), which promotes “heterosexuality as the sole, legitimate expres-
sion of sexuality and affection” (Bohan, 1996, p. 39). Heterosexism occurs
at different levels – the everyday and the structural. Everyday heterosexism
denotes daily practices by which assumptions of heterosexuality govern the
thought and actions of individuals (Braun, 2000). For example, research has
documented how heterosexist assumptions reproduce heteronormativity in
after-hours medical calls (Kitzinger, 2005) as well as the depictions we see
on anniversary greeting cards (Clarke et al., 2010). Structural or cultural
heterosexism “includes the tacit communication of these ideas via soci-
ety’s norms, institutions, laws, cultural forms, and even scientific practices”
(Bohan, 1996, p. 39). Heterosexist assumptions not only marginalise those
who are non-heterosexual, in a number of ways, but perpetuate and maintain
heterosexuality as the norm.
Researching heteronormativity
Based on such theorising and insights, a string of research has examined how
heterosexuality is naturalised and organised institutionally (Ingraham, 1996),
via social and cultural practices and representations (Ingraham, 2008) and in
the mundane everyday (Martin, 2009). These investigations are based on the
assertion that heteronormativity structures daily life on many levels, above and
beyond sexuality and sexual attraction (Jackson, 2011). On a structural level,
there are numerous policies and government-sanctioned activities that protect
Panteá Farvid 99
and promote heterosexuality, such as legal benefits for married couples, mar-
riage promotion workshops (Heath, 2009), tax breaks for families with children,
and other social and economic policies that protect monogamous, lifelong, and
procreative relations between men and women.
The knowledge that is produced via scientific research and taught at
schools and universities tends to perpetuate heteronormative assumptions.
University textbooks have been analysed for the way they enact institu-
tional heterosexual hegemony (often in their depiction/representation of the
other/gay) (Barker, 2007; Phillips, 1991). Phillips (1991) identified how intro-
ductory sociological texts from the 1940s to the 1980s moved from depicting
heterosexist ideas in blatant ways (homosexuality as deviance) to more subtle
ways, with homosexuality as inadequate/inaccurate and heterosexuality as the
norm (Phillips, 1991). Similar depictions have occurred in psychology texts –
although psychology texts tend to draw on more reductionist and biologi-
cal approaches to sexuality. Introductory psychology texts in the 1980s either
excluded Lesbian/Gay psychology or depicted it in chapters covering abnormal
psychology or psychopathology (King, 1988). Research on textbooks post-2000
indicated that there have been improvements in the way that lesbian and gay
heterosexualities are presented (Barker, 2007), but there tended to be excessive
focus on the origins of homosexuality, and discussion about intimate relation-
ships and sexuality across this lifespan were largely heteronormative (Barker,
2007). Barker (2007) also noted how discussions of sexual orientation were
based on biological essentialism, as fixed and dichotomous (with topics such
as bisexuality rarely covered adequately). Men and women were portrayed as
‘opposites’ and there was a lack of discussion when it came to sex/gender
diversity outside pathologising language that drew on the two-gender model.
Classrooms have also been identified as heterosexist, with challenges to this
heterosexism attracting great opposition from students and creating concerns
regarding job security for instructors (Eyre, 1993).
Beyond the structural, heteronormativity is actively (re)produced in social
and cultural contexts (Cameron & Kulick, 2003). This includes representa-
tional norms and tropes within the media (Farvid & Braun, 2006, 2013,
2014; Gill, 2008, 2009; Kolehmainen, 2012) that promote heterosexuality
and the heterosexual couple as the idealised norm (Dean, 2011). There are
multitudes of organised and ritualistic practices, such as weddings, baby
showers, hen/stag dos, high school balls/proms, and dating, that are nor-
malised within heteronormativity (Dean, 2011; Ingraham, 2008). Even with
the increasingly common and visible diverse family structures, such as adopted,
gay/lesbian/bisexual, surrogates, step-families, blended families, and extended
families, “only a [ . . . ] specific order based on the heterosexual couple and the
nuclear family around it continues to be [ . . . ] privileged and naturalised” (Rossi,
2011, p. 19).
100 Sexuality
Biological explanations
Biological approaches (within and outside psychology) presume “that
heterosexuality is so well understood, so obviously the ‘natural’ evolution-
ary consequence of reproductive advantage, that only deviations from it are
theoretically problematic and need investigation” (Bem, 1996, p. 320). Such
research typically comes from the viewpoint that “whatever cues attract men
and women to each other, it is hard to escape the conclusion that they are
more or less wired in, the product of an evolutionary history parallel to that
of sexual reproduction itself” (Pillard & Bailey, 1998, p. 348). Hence, inquiries
into heterosexuality are not common from this perspective – heterosexuality
and homosexuality are merely seen as sexual orientations, and the main topic
of study is the cause and characteristics of non-heterosexualities.
Five dimensions of sexuality are often said to interact, from this biological
perspective, to create different ways of being sexual. These are: genetic aspects
(in terms of chromosomes); human genitals (internal and external structures
and reproduction); non-genital morphological characteristics (e.g. changes that
occur at puberty); neurological dimension (brain structures); and behavioural
dimension (sexual orientation and sex-typical behaviour) (Ellis & Ames, 1987).
Panteá Farvid 101
Mainstream psychology
When it comes to heterosexuality/sexual orientation research, personality,
clinical and developmental psychological theories are less common (Bem,
102 Sexuality
Future directions
Summary
Further reading
Barker, M. & Langdridge, D. (Eds.) (2010). Understanding non-monogamies. New York:
London, Routledge.
Ingraham, C. (2008). White weddings: Romancing heterosexuality in popular culture (2nd ed.).
New York: Taylor & Francis.
Jackson, S. (1999). Heterosexuality in question. London: Sage.
Richardson, D. (Ed.) (1996). Theorising heterosexuality. Buckingham: Open University
Press.
Wilkinson, S. & Kitzinger, C. (Eds.) (1993). Heterosexuality: A feminism & psychology reader.
London: Sage Publications.
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7
Lesbian Psychology
Sonja J. Ellis
Introduction
109
110 Sexuality
One of the key issues to note when studying lesbian psychology is the
extent to which the term ‘lesbian’ is problematic. Lesbians come in all
shapes and sizes – literally! More importantly, though, not all women
who relate socially, emotionally, and sexually to other women may
define themselves as lesbian. For example, they may define as bisexual
or use more unusual labels (e.g. ‘pansexual’; ‘heteroflexible’), unequivo-
cally define as heterosexual, or not use labels at all. Furthermore, identity
labels can be problematic. For example, someone who is trans (or who has
a trans history) may define as lesbian but may not necessarily identify
as a woman. Labels are also constrained by social definition. It is com-
monly assumed that a ‘lesbian’ is a woman who is exclusively attracted
to other women; yet there are many lesbian women who have had
(or even continue to have) sexual relationships with men. Both gen-
der and sexuality are very complex, so when you see the term ‘lesbian’
in this chapter it is intended to encompass a wide range of people –
not just those who identify as lesbian and/or who engage exclusively in
woman-to-woman sex.
History
Lesbian identity
The psychological study of lesbian identity over the last decade or so has
been marked by a theoretical shift away from identity development (the pro-
cess of coming to identify as lesbian) to focus instead on identity management
(Whitman et al., 2000). Identity management refers to the strategies used to
Sonja J. Ellis 113
either conceal one’s lesbian identity (e.g. passing) or to defend and validate
one’s lesbian identity. Due to the heterocentricity of social contexts, iden-
tity management is a universal phenomenon for lesbians (and other LGBT
people). One British study (McDermott, 2006) explored identity management
in the workplace, concluding that for lesbian women identity management
is mediated by social class. In particular, working-class women frequently
adopt survival strategies (e.g. passing as heterosexual) due to more often being
employed in workplaces where heterosexuality was heavily policed. However,
theory and research have tended to overlook the ongoing and contextually
situated nature of coming out as a mundane, everyday occurrence (e.g. see
Kitzinger, 2000). An in-depth study by British sociologist Victoria Land explored
the way in which the assumption that everyone is heterosexual is embedded
in Western culture and everyday language. It is this heterosexist presumption
that necessitates the need for lesbians (and others) to routinely come out in
conversation (for additional detail, see Land & Kitzinger, 2005).
The majority of recent research on coming out has been undertaken in rela-
tion to minority ethnic (ME) populations. For example, United States-based
research with Black and Latina lesbians (e.g. see Espín, 2012; Miller, 2011;
Reed & Valenti, 2012) suggests that for these groups there is a fine line between
being out and maintaining relationships with family and cultural communi-
ties. For this reason, ME lesbians developed strategies which enabled them to
sustain links with their families and communities – for example, avoiding dis-
closure in family contexts (e.g. see Espin, 2012; Miller, 2011) and/or sometimes
sleeping with men (e.g. see Reed & Valenti, 2012) while building lesbian/gay
support networks outside those contexts. Psychological research on British ME
lesbians is almost non-existent, confined to just two studies of Muslim lesbians.
In these studies, Asifa Siraj (2011, 2012) explored the incompatibility between
Islam and being lesbian through the eyes of Muslim lesbians. She highlighted
the way in which, for this group of women, the perceived schism between sex-
uality and religion made it difficult to reach a sense of congruence between
the two identities. As a result, these women often faced the prospect of sever-
ing ties with their faith (and community) in order to be themselves. For those
interviewed, membership of Imaan (a support group for Muslim lesbians) was
a lifeline which helped them to deal with the isolation they felt, and provided
a safe (and anonymous) forum within which to reinforce their identity.
Another key theoretical shift here is a move away from categories of iden-
tity to what has been termed by some (e.g. Farquhar, 2000) a ‘post-lesbian
world’. Whereas sexual identity labels (e.g. ‘lesbian’) had previously been seen
as fairly robust, recent work (e.g. Diamond, 2003, 2005; McDonald et al., 2011)
seems to suggest that this is not necessarily the case. In her longitudinal work,
Diamond (2003, 2005) found that women’s sexuality tended to be fluid rather
than fixed, with sexual attractions and experiences changing across time. As a
114 Sexuality
Lesbian relationships
Despite being a central topic of lesbian psychology, there is surprisingly little
recent theory and research around lesbian relationships. In the United King-
dom, the legalisation of civil partnerships in 2005 generated much debate and
research around same-sex marriage (e.g. see Kitzinger & Wilkinson, 2004; Peel
& Harding, 2004) to the exclusion of that on same-sex relationships more
generally. Therefore, we know very little about the functioning of, quality
of, and satisfaction in relationships between women (regardless of whether
or not they identify as lesbian; see also Bowes-Catton & Hayfield, Bisexuality,
this volume). Research from outside the United Kingdom suggests that same-
gender couple relationships are similar to other-gender couple relationships in
terms of relationship style and conflict resolution (Kurdek, 2004); and that,
for both same-gender and other-gender relationships, psychological, physi-
cal, and financial well-being are associated with the health of relationships
(Ducharme & Kollar, 2012). It is also suggested that female same-gender couples
organise the division of labour within their relationships differently from other
couples. For example, Kurdek (2007) found that female same-gender partners
tend to do the same tasks equally often, whereas other-gender and male same-
gender couples tend to divide up tasks, with each partner taking responsibility
for specific tasks.
In the therapeutic psychological literature, attention has been given to the
issue of closeness in female same-gender relationships. Historically, it was sug-
gested that such relationships were dysfunctional due to ‘fusion’ or ‘merger’,
Sonja J. Ellis 115
Lesbian parenting
Largely attending to the theoretical notion that mothers and fathers provide
distinctive contributions in the personal and social development of children,
much effort has been invested in demonstrating that children are not psy-
chologically disadvantaged by being raised by lesbian couples. One of the
first psychological studies with British participants (Golombok et al., 1983)
116 Sexuality
Lesbian health
Following its establishment as a field in the 1990s, lesbian health psychology
was largely defined by multiple large-scale national studies of lesbian health
undertaken in the United States (e.g. see Bradford et al., 1994; Roberts et al.,
2004a, 2004b, 2004c), the United Kingdom (Fish & Anthony, 2005; Fish &
Wilkinson, 2003), and New Zealand (Saphira & Glover, 2000). The content of
the surveys varied somewhat, so they are not directly comparable; however,
collectively they suggest that there are differences in the health concerns and
behaviours of lesbians compared with those of ‘heterosexual’ women (Fish,
2009). For example, Julie Fish (see Fish & Anthony, 2005; Fish & Wilkinson,
2003) surveyed over 1000 lesbians across the United Kingdom about their par-
ticipation in and experiences of breast screening (i.e. breast self-examination,
mammography) and cervical screening, and their perceptions of risk in relation
to breast and cervical cancer. Findings of the study suggest that lesbians are
118 Sexuality
much more likely to avoid cervical smear tests than heterosexual women (27%
vs. 15%) (Fish & Anthony, 2005), with “I don’t need one”, “negative aspects
of the procedure”, and “I’m too busy” being the most frequently cited rea-
sons for non-attendance (Fish, 2006). Conversely, lesbian women were found
to be more likely to attend a mammogram but less likely to re-attend than their
heterosexual counterparts (Fish & Anthony, 2005). In the case of breast self-
examination (BSE), only 20% of lesbians surveyed reported not engaging in
BSE, with commonly cited reasons including “I don’t know what I’m looking
for”, “I’m frightened in case I find something”, and “I don’t think I’m at much
risk” (Fish & Wilkinson, 2003).
Research on the physical health of lesbians has been fairly limited, although
there is some work around body image (e.g. Huxley et al., 2013; Yost &
Chmielewski, 2011). Commonly, it is believed that lesbians are somewhat ‘pro-
tected’ from cultural expectations about weight, in that such expectations are
believed to be about attractiveness to men. However, Huxley and colleagues’
(2013) study indicated that all lesbian participants experienced some degree of
body dissatisfaction and felt that the pressure to be thin applied as much to
them as it did to their heterosexual peers.
The other main topic of investigation within lesbian health psychology
is lesbians’ experiences of healthcare. Overwhelmingly, these studies suggest
that there are a number of barriers to lesbians accessing and benefiting from
healthcare. For example, in Fish and Bewley’s (2010) study of close to 6000 les-
bians in the United Kingdom, it is widely reported that healthcare professionals
typically assume heterosexuality in their interactions with patients. Fish and
Bewley cite an example where a participant was asked by a doctor whether she
was sexually active. When she responded ‘yes’, the following question about
contraception suggested that what the doctor was, in fact, asking was whether
she was heterosexually active. These situations leave lesbian women with the
dilemma of whether or not to come out. Their findings suggested that, even
when lesbians did disclose their sexual orientation, professionals were often
unable to provide them with advice relevant to their health risks. Similar issues,
including healthcare professionals’ ability to consider that a patient may be les-
bian, to acknowledge and respect lesbians, and to have a knowledge of the
health concerns of lesbians, have also been raised in other studies (e.g. Barbara
et al., 2001; Bjorkman & Malterud, 2009).
It might be expected that sexual health would be a key area of concern within
lesbian psychology. Although there are a small number of studies that specifi-
cally focus on ‘lesbian’ sexual health issues (e.g. Bailey et al., 2004; Evans et al.,
2007), the sexual health, and sexual health needs, of lesbians and other ‘women
who have sex with women’ (WSW) are largely absent from the psychologi-
cal literature. This absence is mainly attributable to the widespread (and false)
assumption that STIs cannot be transmitted through woman-to-woman sex.
Sonja J. Ellis 119
Current debates
Once a field of lively debate, lesbian psychology today lacks the vigour it had in
the 1980s and early 1990s, when it was driven forward by the feminist move-
ment and psychologists committed to a feminist approach to women’s issues.
120 Sexuality
While there is still a steady proliferation of studies, the field today lacks momen-
tum and is impoverished by a relative absence of theorisation and debate. Over
the last decade or so there have been important theoretical questions raised –
what are the politics of sameness and difference approaches to lesbian parent-
ing? (Clarke, 2002), what counts as a healthy lesbian? (MacBride-Stewart, 2007),
and who counts as a lesbian? (Tate, 2012) – but these have not developed into
debates. It is as though nobody is listening any more, and what (very limited)
work is being done is produced in a theoretical vacuum.
In the early days of lesbian psychology, lesbian feminism (and femi-
nism more generally) underpinned much of the psychological work on
lesbians. But, just as this approach superseded a medicalised approach to
lesbian issues, feminist approaches have largely given way to an LGBTQ
psychology in which lesbian perspectives have been subsumed within and
marginalised under the umbrella of LGBTQ psychology (Ellis & Peel, 2011).
While organising collectively in this way has significantly advanced gay
issues/perspectives within psychology, it has been at the expense of a con-
temporary understanding of lesbianism. As Ellis and Peel (2011) highlight,
“lesbians have not immediately (or easily) been able to prioritize their issues
within LGBT . . . frameworks” (p. 199).
Whatever the field in which applied psychologists and other practitioners are
working, it is important to be aware that the experiences of lesbians (as lesbians)
are not necessarily the same as the experiences of men (gay or otherwise). Simi-
larly, the experiences of lesbians (as women) may differ markedly from those of
other women. It is therefore important when engaging with theory, research,
and practice models to critically reflect on their application, particularly where
these have been developed with LGBT people (as a homogeneous collective) or
with women (as a homogeneous category).
Also, in applied settings it is common for practice models around relationship
issues to have been developed with the heterosexual couple in mind. It is there-
fore important to be vigilant around heteronormativity and not assume that
such models can be applied unproblematically to same-gender relationships.
Future directions
In lesbian psychology a lot of ground has been covered over the past 40 years,
and the contemporary field is marked by emerging areas of study. For example,
just in the last few years we have seen the first psychological studies on highly
relevant topics around lesbian parenthood. Among these are papers on the dis-
solution of lesbian families (Gartrell et al., 2011), co-mothers’ experiences of
maternity healthcare (Cherguit et al., 2013) and lesbians’ experiences of preg-
nancy loss (Peel, 2010). The psychological literature on lesbian parenting has
really come of age. However, there are still sizeable gaps in our knowledge of
lesbian identity, relationships, and health. Despite considerable work over the
years by Connie Chan and Oliva Espin, with the exception of lesbian identity,
we know almost nothing about ME lesbians: Asifa Siraj’s two small-scale studies
(2011, 2012) on Muslim lesbians appear to be the only studies of British ethnic
minority lesbians. Similarly, despite considerable legal and social change in the
United Kingdom over the past 20 years, we know little about the way in which
these changes have impacted on the lives and experiences of lesbians in Britain.
Furthermore, there are whole areas of lesbian psychology that are largely absent
from the psychological literature. Little is known about lesbians’ experiences of
and the responses of significant others to initial disclosure of a lesbian identity;
and knowledge of the experiences of and challenges faced by older lesbians is
virtually non-existent.
Given this scenario, there is plenty of scope for future research. However,
the development of lesbian psychology has largely been impeded by its being
subsumed within the broader field of LGBTQ psychology. On one level, it
makes sense to present sexualities research as a unified field; after all, many
experiences are common to lesbian and gay persons (and sometimes bisexual
122 Sexuality
and trans persons as well). However, in doing this we lose a nuanced sense
of how lesbians (both as lesbians and as women) are affected by and experi-
ence the phenomena we investigate as psychologists. So, as Esther Rothblum
cautions, “We must continue to ask ourselves what it means to be a lesbian,
and not dilute our research by combining lesbians with the experiences of
individuals with other sexual orientations, behaviours, and gender identities”
(2004, p. 505).
Summary
This chapter:
Further reading
Ackbar, S. & Senn, C. Y. (2010). What’s the confusion about fusion? – Differentiating
positive and negative closeness in lesbian relationships. Journal of Marital and Family
Therapy, 36(4), 416–430.
Chabot, J. M. & Ames, B. D. (2004). ‘It wasn’t “let’s get pregnant and go do it” ’: Deci-
sion making in lesbian couples planning motherhood via donor insemination. Family
Relations, 53, 348–356.
Clarke, V. (2002). Sameness and difference in research on lesbian parenting. Journal of
Community & Applied Social Psychology, 12, 210–222.
Sonja J. Ellis 123
Fish, J. (2009). Our health, our say: Towards a feminist perspective of lesbian health
psychology. Feminism & Psychology, 19(4), 437–453.
Land, V. & Kitzinger, C. (2005). Speaking as a lesbian: Correcting the heterosexist
presumption. Research on Language and Social Interaction, 38(4), 371–416.
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128 Sexuality
Introduction
Trans is a term often used to describe gender minorities (Lev, 2004), and refers
to people who are in some way transgendered. It is also used to describe people
who ‘transgress’ gender boundaries and who may be considered gender variant
in relation to conventional and binary gender norms, that is, socially scripted
male and female gender roles. Trans men is frequently used to describe men who
are living in a male gender role, but were ‘natally assigned’ (by the culture they
were born into) as female, and trans women to describe women living in a female
gender role who were natally assigned as male. People may describe themselves
as trans men and trans women – although they still live, by varying degrees,
within the gender role associated with their natally assigned gender – in order
to experience themselves as being more congruent with their gender identity.
Transgender (now increasingly referred to as ‘trans’) is a broad term encompass-
ing a variety of gender identities including transsexual, genderqueer, gender
variant, third sex, androgynous, drag king/queen, transvestite, cross-dresser,
and/or people who are undergoing, or have undergone, hormone treatment
and/or surgery to modify their body to fit with their gender identity (Shaw
et al., 2012).
Although, historically, they have been a highly stigmatised, marginalised,
and invisible group of individuals, the advent of trans political activism, forms
of communication such as the internet, and the more recent passing of pro-
tective legislations (Equality and Human Rights Commission, 2008; Gender
Recognition Act, 2004) have meant that a diversity of trans people have become
more visible and vocal in the United Kingdom and the United States over the
last three decades. As a result of this, a focus on trans phenomena within a
variety of academic disciplines, particularly within the field of transgender stud-
ies, has identified trans people’s experiences of sexuality and gender as being
erased or rendered invisible against a cultural backdrop of normative, binary
129
130 Sexuality
Trans sexualities
Trans people can identify as gay, heterosexual, lesbian, bisexual, pansex-
ual, asexual, or queer, among other labels. When talking about trans-specific
sexualities, though, people often think of ‘Transvestic Fetishism’ (DSM-IV-TR).
In DSM-5, the newer diagnosis of Transvestic Disorder requires “significant
distress or impairment in social, occupational or other important areas of
functioning” for diagnosis, with additional specification of ‘with fetishism’,
which requires being sexually aroused by fabrics, materials or garments, or
‘autogynephilia’ if sexually aroused by “thoughts or images of self as female”.
Trans people who are distressed by wearing female clothing over time (at least
six months according to DSM-V), which they find very sexually arousing, can
be easily diagnosed and thereby pathologised.
Has this led, though, to any wearing of gender-specific clothing resulting
in sexual arousal which does not correspond to that usually worn by the
natally assigned sex being pathologised too? This can be automatically seen
as ‘fetishistic’ or as a way of differentiating between individuals who are
transsexual and those who have a sexual motivation. It may sometimes be
seen as an acceptable stage on the pathway to transsexualism, where the act
of putting on female clothing or the transition itself was previously eroticised
but no longer is . It seems very challenging, though, within current Western
discourse around gender and sexuality to conceptualise it as a legitimate
expression of sexuality which intersects with gender.
Trans people, in common with the rest of the population, have diverse sex-
ual identities (Moradi et al., 2009). We do not have space to explore them all
here, so we have selected some to look at in more depth, as examples that
highlight common issues in relation to trans sexualities. Importantly, as Barker
and Richards (2013) remind us, trans people do not have a discrete repertoire
of sexualities compared with cisgender individuals (i.e. people with a gender
identity that is consistent with their assigned gender role) but are, by and
large, proportionally similar to the general population. However, in spite of
new trans-positive discourses and identities, attraction to a trans gender expres-
sion and, by extension, trans people is not fully legitimised within established
sexualities or orientations, particularly if the object of attraction is not trying to
achieve the ideal male or female gender presentation supported by their culture.
Sexual attraction to more transgressive or non-binary gender presentation
is potentially devalued, considered fetishistic or a less preferable ‘alternative’
to those who present in a more conventional gender role within Western
culture. This is arguably borne out by Reback and Larkins’ (2006) research,
which explored “heterosexually identified men who have sex with men and/or
132 Sexuality
for some, other gender minority people may feel that identifying their gender
and/or sexuality along binary and/or normative lines expresses their own expe-
rience both clearly and authentically: some may clearly identify themselves
as heterosexual men and women as opposed to being trans or transgender in
any way. A brief historical context gives some perspective on the extensive and
varied terrain of gender and sexuality confronting trans people today.
History
Butler (1990) states that “the category of sex and the naturalized institution
of heterosexuality are constructs, socially instituted and socially regulated fan-
tasies or ‘fetishes,’ not natural categories, but political ones” (Butler, 1990,
p. 126). Following the rise of feminism and the advent of postmodern thought,
it is becoming increasingly accepted that binary models of sex, gender, and
sexuality, including non-normative, ‘new’, ‘modern’, or ‘alternative’ identities
and expressions, are contemporary conceptualisations of complex constructs.
Laqueur (1990), for example, reminds us that, from as early as 2 AD until
around 1800, male and female bodies were viewed as being fundamentally the
same; the primary difference between them was thought to be the location
of the genitalia. Male sexual organs were historically seen as being externally
visible and females were believed to have the same biological structures inter-
nalised. The shift from a single to an, albeit biologically more accurate, binary
model of sex in the last two centuries has potentially presented a number of
problems, despite the observation that a further shift from the binary model to
a more multifaceted model is underway (Fausto-Sterling, 2000; Sanger, 2010).
The work of Michel Foucault, which has been highly instrumental in les-
bian, gay, bisexual, and trans (LGBT) liberation movements, outlines the way
in which understandings of binary and more contemporary or radical forms
of sexual and gender identities are not givens or truths that have existed
throughout history (Foucault, 1978, 1980, 1987, 1988). Foucault successfully
demonstrated that sex and gender are specific to our times and the develop-
ment of state governance across the Western world over the last three centuries,
and have been constructed through the interaction of knowledge with institu-
tional power structures, such as medicine and law. He identified that sexuality
and gender do not exist as independent truths or realities in isolation from
their histories and social and institutional settings. Rather, the application and
state enforcement of various forms of knowledge, generated within a variety
of distinct, though related, scientific fields that emerged over the last three
centuries (e.g. biology, psychology, and endocrinology), has meant that gen-
der, sex, male and female, and the social roles that these categories underpin
eventually became reified and standardised. Viewed from Foucault’s perspec-
tive, ‘normal’ sexuality and gender are better understood as an effect of the
Penny Lenihan et al. 135
Students
self” (McKenzie, 2010, p. 92) and that this sense of the gendered self is a process
that is ongoing throughout one’s lifespan (McKenzie, 2006, 2010). While the
sense of a gendered self could be seen as an internal process of development
or identity formation, sex, gender, and sexual orientation are also described
as being socially constructed/interpreted (e.g. Dozier, 2005; Money, 1995). The
broad spectrum of sexual identities and categories is representative of the mul-
titude of diverse experiences of trans people and non-trans people alike. The
dominance of heteronormative discourse can be viewed in many psychological
developmental theories that relate to sexuality and gender variance, the most
notable and perhaps widely critiqued of these being psychoanalysis (Lev, 2004).
One criticism of psychoanalysis has been its construction of trans phenom-
ena as inextricably linked to sexuality as a form of developmental ‘failure’
caused by problematic parental relationships (Lev, 2004). For example, many
psychoanalytic or psychodynamic theories involve mother and father ‘blame’
theories that hold that what manifests as ‘abnormal’ or ‘normal’ adult sexu-
ality or gender is intertwined with how individuals’ parents relate to them
throughout a process of psychosexual development. These theories take the
binary sex and, by extension, gender of primary caregivers as the poles around
which individuals’ ‘normal’ or unhealthy and abnormal sexuality and gender
are formed (Chiland, 2000, 2003; Hakeem, 2006, 2008; Lev, 2004). In direct
relation to the conflation of sexuality and gender, Stoller (1973, p. 282) asserts:
“I believe that homosexuality can be roughly quantified according to the inten-
sity of transsexual wishes. For males, those with the least transsexual desires are
the most masculine.” Problematically, in clinical practice, these theories can be
superimposed over the lived experiences of trans people themselves, reinforcing
experiences of pathologisation, erasure, and invisibility.
Another issue underlying the understanding, identification, and expression
of trans sexual desire is that knowledge generated in the realms of medicine,
psychology, and psychiatry, and applied through diagnostic manuals such as
the DSM and the ICD, frequently not only influences trans lives (in terms of leg-
islation and access to medical care) but can problematically construct popular
(mis)understandings of trans phenomena (Bouman et al., 2010).
It has been argued that the DSM in particular is more political than scien-
tific in its diagnostic criteria (e.g. Zur & Nordmarken, 2013). Presentations of
institutionalised materials that promote political rather than scientific epis-
temologies have been suggested to reinforce the marginalisation of a diverse
range of sexual identities and expressions. Lev (2004) also describes an histor-
ical (and perhaps ongoing) tension between diagnostic criteria being used for
social control and repression as opposed to healing. Despite diagnostic man-
uals being revised and reformulated to reflect current societal norms, Frances
(2010) states that “[o]ld disorders are almost never discarded; yet new disorders
and lowered thresholds have taken ever bigger bites out of normality” (p. 492).
Penny Lenihan et al. 137
that have reified the questionable notion that there is a distinct and recog-
nisable group of trans people whose desire to feminise or masculinise their
bodies is solely motivated by ‘autogynephilia’ or ‘autoandrophilia’. It could
be argued that this assertion is an effect of the fact that sexual motivation
in trans people is generally framed as illegitimate or ‘other’ and therefore an
object worthy of scientific abstraction from the ‘ordinary’ realms of human
sexual experience. Following this, it is perhaps important to shed some light
on these trans specific phenomena by considering that cisgendered, heterosex-
ual people who dress up to go out on a Saturday night and experience sexual
arousal looking at themselves in the mirror are not thought to be autoan-
drophilic or autogynephilic; nor are those cisgendered people who, for sexual
reasons, modify their bodies in order to hypermasculinise or feminise them-
selves through anabolic steroids, breast augmentation, and procedures such as
penis extension.
There are clearly pitfalls inherent in existing, dominant psychiatric and psy-
chological epistemologies for trans people and their sexual experiences and
identities. Nonetheless, a number of psychological disciplines have begun to
explicitly position themselves in order to better embrace gender and sex-
ual diversity. Many have made a professional commitment to inclusivity in
research and practice in order to avoid the pathologisation or marginalisation
of individuals based on sexual orientation or gender. Indeed, the majority of
psychological disciplines, even those more traditionally associated with the
pathologisation and exclusion of trans-gender and sexual phenomena, are
beginning to align themselves with an open and politically aware approach
to trans experience and identity.
Recent BPS guidelines (BPS, 2012) have highlighted the need for all psycho-
logical professionals to become aware of the negative effects of social stigma
and discrimination on sexual and gender minorities. Counselling Psychology’s
Practice Guidelines also directly challenge the pathologisation of these indi-
viduals and the way in which they can be positioned via heteronormative
assumptions (BPS, 2006; Larsson et al., 2012), indicating growing aware-
ness of the impact of existing popular and scientific understandings on the
subjective experiences and freedoms of trans people. Additionally, although
research remains limited, clinicians working in the LGBT field have begun to
make important distinctions between sexuality and gender, broadening under-
standings of trans sexual experience and identity. For example, sexuality and
gender have been uncoupled within the field of counselling psychology and
the complex distinctions between these categories more fully explored and
expanded upon (Fassinger & Arseneau, 2007; Moradi et al., 2009). Trans peo-
ple are now being understood increasingly on their own terms, and many are
now able to effectively articulate sexual experiences and have them not only
heard, but also understood in clinical and social settings. Regardless of these
140 Sexuality
Professionals
Future directions
relationships. For example, some authors (e.g. Nuttbrock et al., 2009) describe
the phenomenon that many trans women, due to early, strict familial and soci-
etal prohibitions on their gender and sexual expression, find that they struggle
to experience recognition or affirmation of their gender identities outside sex-
ual relationships, particularly those formed through prostitution. Frequently
there is the suggestion that many trans people find it difficult to gain affirma-
tion and establish intimate relationships in their preferred gender roles with
either existing or potential romantic partners. Anecdotally, however, contrary
to the existing commentary and research, it would seem that many trans people
encountered in various clinical and/or social settings demonstrate wide-ranging
and diverse relationship experiences, sexual identities, and statuses.
In spite of the clear need for further research into these issues, Richards et al.
(2014) remind us that trans people are “not places to hang an argument”,
and that many (trans) people, understandably, may not wish to contribute to
research into intimate aspects of their lives. It is important, therefore, when
examining the limited research available, or in posing new questions regarding
trans experience, to question the motivation behind research endeavours that
frame trans individuals and their (sexual) partner(s) as pathological, fetishistic
or eroticised, or as objects designed to affirm specific gender and/or sexual iden-
tities. Also, it should be noted that there is a lack of focus in research into trans
sexuality on functional and mutually rewarding relationships, which occur in
a multitude of forms for trans people. Although, as emphasised in this chapter,
trans sexualities should not be viewed as specific to a particular group of peo-
ple different from the cisgendered population, the direction forward is also
potentially to move beyond mere acceptance of trans sexualities towards pos-
itively affirming trans individuals and bodies within the existing diversity of
sexualities, not as a homogeneous group, but as individuals with unique sexual
desires and experiences.
Academics
Summary
Further reading
Barker, M. & Richards, C. (2013). Sexuality and gender for mental health professionals:
A practical guide. London: Sage.
Bornstein, K. & Bergman, B. (Eds.) (2010). Gender outlaws: The next generation. Berkeley:
Seal Press.
Lev, A. I. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant
people and their families. New York: Routledge.
Moon, L. (Ed.) (2008). Feeling queer or queer feelings: Radical approaches to counselling sex,
sexualities and genders. Hove: Routledge.
Namaste, V. K. (2000). Invisible lives: The erasure of transsexual and transgendered people.
Chicago: University of Chicago Press.
Prosser, J. (1998). Second skins. New York: Columbia University Press.
Stryker, S. & Whittle, S. (2006). The transgender studies reader. New York/London:
Routledge.
Wilchins, R. A. (1997). Read my lips: Sexual subversion and the end of gender. New York:
Firebrand Books.
144 Sexuality
References
Asexual Visibility and Education Network (2012). Retrieved from http://www.asexuality
.org [Accessed 28 April 2014].
Barker, M. & Richards, C. (2013). Sexuality and gender for mental health professionals:
A practical guide. London: Sage.
Blanchard, R. (1988). The concept of autogynephilia and the typology of male gender
dysphoria. Journal of Nervous and Mental Diseases, 177, 616–623.
Bornstein, K. (1994). Gender outlaw: On men, women, and the rest of us. New York:
Routledge.
Bornstein, K. (1998). My gender workbook. New York: Routledge.
Bouman, W. P., Bauer, G. R., Richards, C., & Coleman, E. (2010). World Professional Asso-
ciation for Transgender Health consensus statement on considerations of the role of
distress (Criterion D) in the DSM diagnosis of Gender Identity Disorder. International
Journal of Transgenderism, 12(2), 100–106.
British Psychological Society (2006). Division of counselling psychology: Professional practice
guidelines. Leicester: BPS.
British Psychological Society Professional Practice Board (2012). Guidelines and litera-
ture review for psychologists working therapeutically with sexual and gender minority clients.
Retrieved from www.bps.org.uk [Accessed 12 March 2012].
Butler, J. (1990). Gender trouble: Feminism and the subversion of gender. New York:
Routledge.
Carol, L., Gilroy, P. J., & Ryan, J. (2002). Counseling transgendered, transsexual, and
gender-variant clients. Journal of Counseling & Development, 80(2),131–139.
Chiland, C. (2000). The psychoanalyst and the transsexual patient. International Journal
of Psychoanalysis, 81(1), 21–35.
Chiland, C. (2003). Transsexualism: Illusion and reality. New York: Sage.
Dozier, R. (2005). Beards, breasts and bodies: Doing sex in a gendered world. Gender &
Society, 19, 297–316.
Equality and Human Rights Commission (2008). Sex Discrimination (Amendment of
Legislation) Regulations: Discrimination against transsexual people (on grounds of gen-
der reassignment). Retrieved from www.equalityhumanrights.com [Accessed 6 August
2012].
Eyler, A. E. (2007). Primary medical care of the gender-variant patient. In R. Ettner,
S. Monstrey, & A. E. Eyler (Eds.) Principles of transgender medicine and surgery. (pp. 15–32).
New York: Haworth Press.
Fassinger, R. E. & Arseneau, J. R. (2007). I’d rather get wet than be under that umbrella:
Differentiating the experiences and identities of lesbian, gay, bisexual, and transgender
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New York: Basic Books.
Foucault, M. (1978). The history of sexuality Vol.1. New York: Pantheon.
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Foucault, M. (1987). The use of pleasure: The history of sexuality: 2. London: Penguin.
Foucault, M. (1988). The care of the self: The history of sexuality: 3. New York: Random
House.
Frances, A. (2010). The first draft of DSM-V. British Medical Journal, 240, c1168.
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Reback, C. J. & Larkins, S. (2006). Once in a blue moon: Toward a better understanding of
heterosexually identified men who have sex with men and/or preoperative transgender women.
Funded by the City of Los Angeles, AIDS Coordinator, contract #C-102523.
Rich, A. (1980). Compulsory heterosexuality and lesbian existence. Signs: Journal of
Women in Culture and Society, 5, 631–660.
Richards, C. (2011). Transsexualism and existentialism. Existential Analysis, 22(2),
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Richards C. & Barker M. (2013). Sexuality and gender for mental health professionals:
A practical guide. London: Sage.
Richards, C., Barker, M., Lenihan, P., & Iantaffi, A. (2014). Who watches the watchmen?
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Whittle, S., Turner, L., & Al-Alami, M. (2007) Engendered penalties: Transgender and
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Part II
Gender
9
Cisgender – Living in the Gender
Assigned at Birth
Ester McGeeney and Laura Harvey
Introduction
149
150 Gender
Key definitions
In everyday language, the terms ‘sex’ and ‘gender’ are often used interchange-
ably; we may be asked about the ‘sex’ or ‘gender’ of an unborn baby or asked
to indicate on official documents what our own ‘sex’ or ‘gender’ is. Feminist
activists and scholars have sought to distinguish between ‘sex’ and ‘gender’,
emphasising that ‘gender’ refers to social norms and inequalities rather than
innate biological characteristics (Crawford, 2012; Oakley, 1985[1972]). ‘Sex’
therefore is a word that refers to the biological differences between male and
female: the visible difference in genitalia and the related difference in procre-
ative function. ‘Gender’, however, is a matter of culture: it refers to the social
classification into ‘masculine’ and ‘feminine’ (Oakley, 1985[1972], p. 16).
This distinction has been subject to intense debate, with many feminists
arguing that sex can also be understood as a socially constructed category
(Butler, 1993). While some position biological characteristics like hormones,
chromosomes, and genitalia as inherently ‘male’ or ‘female’, theorists like
Butler argue that these are socially produced norms.
The term ‘cisgender’ has its roots in the campaign for recognition and rights
for trans* people. The category of cisgender challenges the representation of
cisgender as a universal norm, presenting it instead as one of many possi-
bilities for gender identification. Although the term remains contested, it is
increasingly used in academic as well as activist and popular spaces.
History
Research and writing on cisgender take a wide range of (often conflicting) theo-
retical approaches. Unlike research on trans*, which often explores why trans*
people are not cisgender, research on cisgender rarely focuses on why cisgender
people are not trans*. Psychological theory about cisgender tends to focus on
two broad areas of analysis: the question of how people come to see themselves
(and be seen by others) as a particular gender; and how gender works in social
and psychological life. One of the key fault lines within this theoretical liter-
ature concerns how far gender is the result of biological and/or social factors.
These debates are grounded in different approaches to the nature of reality and
different perspectives on what we can know about the world around us. In this
section we will give a brief overview of the key theory in this field, highlight-
ing theoretical debates and pointing to the relationship between theory and
empirical research.
As we outlined above, much of the early psychological research on cisgender
located its origin in biological differences. Research in this tradition has argued
that physical differences in genitalia, chromosomes, and hormones produce
male and female bodies, and relate this to the identities and behaviours asso-
ciated with masculinity and femininity. This theoretical approach to gender is
sometimes labelled biological essentialism. For example, Kimura and Hampson
(1994) conducted experiments to measure the cognitive abilities of female par-
ticipants at different stages of their menstrual cycles. They found that there
was a relationship between changes in cognitive ability and levels of oestro-
gen, arguing that higher levels of oestrogen correlated with better scores on
tests of manual dexterity and articulatory speed, and worse scores on tests of
visual-spatial skill. Kimura and Hampson (1994, p. 61) conclude “that the group
differences between men and women in some specific cognitive abilities are to
a significant degree a product not only of current but also of early hormonal
environments”.
154 Gender
First, who is included within this category? Second, what role does inequal-
ity play? Third, where are there similarities?
(2009, p. 171)
with the expectation that they should have the sexual skills and confidence to
negotiate safer sex with their partners, while also managing norms of female
sexual respectability.
In recent years, discursive approaches have been critiqued for failing to take
into account the sensory nature of embodied experience (i.e. Brown et al.,
2009). Over the past decade there has been a shift across the social sciences,
referred to as the ‘affective turn’ (Clough & Halley, 2007), which includes con-
tributions from psychobiologists and neuroscientists interested in embodied
emotional states, as well as social theorists attempting to theorise “our power
to affect the world around us and our power to be affected by it” (Hardt, 2007,
p. 10). For scholars working in these fields, the focus is on rethinking the
boundaries between the human and non-human, as human beings are seen
to be increasingly embedded and embodied in not just the biological, but also
the technological world (Wolfe, 2009).
Current psychological work reflects and contributes to these debates as
researchers use a range of new technologies – from neuroimaging techniques
to social media technologies – to gain insights into gendered minds, bod-
ies, and behaviours. In studies on cyberbullying in Denmark and the United
Kingdom, for example, Kofoed and Ringrose (2012) followed children’s inter-
actions in/through online and offline spaces: from the classroom, to the
school playground, through internet chatrooms and mobile phones. Draw-
ing on Deleuze and Guattari (1987), Kofoed and Ringrose use the concept
of an assemblage to think about how bodies interact with non-human tech-
nology. They argue that this enables them to understand how sexualised
and gendered signifiers, such as ‘fat slag’ or ‘khabba’ (‘whore’ in Arabic),
affect and discipline girls’ bodies in different ways, depending on the cul-
tural, racial, and classed contexts of the spaces within which young people are
operating.
As well as drawing on critical social theory to re-examine the relationship
between gender and the ‘posthuman’ body, psychological inquiry is increas-
ingly influenced by key developments in neuroimaging techniques over the
past two decades that have allowed unprecedented insights into the struc-
tural details of the brain and its patterns of neural activity (Fine, 2010b).
Functional magnetic resource imagining (fMRI), for example, measures brain
activity through detecting changes in blood oxygenation and flow that occur
in response to neural activity. Using this technology, researchers can ask
participants to complete different tasks while observing brain processes and
structures associated with thought, perception, and action. Such techniques
have been widely used to measure differences between cisgender male and
female brains and, controversially, to explain differences between male and
female behaviours and skills. Shaywitz and colleagues (1995), for example,
158 Gender
what counts as a ‘real’ man or woman varies hugely across generations, between
different subcultures. Bornstein (1998, 2013) aims to guide her reader towards
an understanding that gender is a choice and a performance rather than an
innate identity or set of behaviours and characteristics. In this way, the ‘gender
workbook’ offers a series of tools that could be completed by readers individu-
ally or used by practitioners in one-to-one or group work settings as a way of
exploring and challenging gender stereotypes and how these are embedded in
family norms and cultural practices.
Conclusions
Summary
• The term ‘cisgender’ refers to those people who choose to stay living in the
gender assigned to them at birth.
• The terms ‘sex’ and ‘gender’ are often used interchangeably in popular
and academic literature. This chapter uses the term ‘gender’ to include the
biological, social, and cultural aspects of masculinity and femininity.
162 Gender
Further reading
Bornstein, K. (2013). My new gender workbook: A step-by-step guide to achieving world peace
through gender anarchy and sex positivity. New York & Abingdon: Routledge.
Crawford, M. & Unger, R. (2004). Women and gender: A feminist psychology (4th ed.).
New York: McGraw-Hill.
Fine, C. (2010). Delusions of gender: The real science behind sex differences. London: Icon
Books.
Maccoby, E. & Jacklin, C. (1974). The psychology of sex differences. Stanford: Stanford
University Press.
Tavris, C. (1992). The mismeasure of woman. New York: Touchstone.
References
Ansara, Y. G. & Hegarty, P. (2012). Cisgenderism in psychology: Pathologising and
misgendering children from 1999 to 2008. Psychology & Sexuality, 3(2), 137–160.
Archer, J. (2006). Testosterone and human aggression: An evaluation of the challenge
hypothesis. Neuroscience & Biobehavioral Review, 30(3), 319–345.
Baron-Cohen, S. (2003). The essential difference. London: Allen Lane.
Batsleer, J. (2013). Youth working with girls and women in community settings: A feminist
perspective. Farnham: Ashgate.
Baumeister, R. F. (1988). Should we stop studying sex differences altogether? American
Psychologist, 43, 1092–1095.
Bluhm, R., Jacobson, A. J., & Maibom, H. (2012). Introduction. In R. Bluhm, A. Jaap
Jacobson, & H. Lene Maibon (Eds.) Neurofeminism: Issues at the Intersection of Feminist
Theory and Cognitive Science. (pp. 1–10). New York: Palgrave Macmillan.
Bornstein, K. (1998). My gender workbook: How to become a real man, real woman, the real
you or something else entirely. New York & London: Routledge.
Bornstein, K. (2013). My new gender workbook: A step-by-step guide to achieving world peace
through gender anarchy and sex positivity. New York & Abingdon: Routledge.
Brook (2010). Brook gender 2010. Retrieved from http://www.youtube.com/watch?v=
Ut4WI_lwcZI&feature=relmfu [Accessed December 2013].
Ester McGeeney and Laura Harvey 163
Brown, S. D., Reavey, P., Cromby, J., Harper, D., & Johnson, K. (2009). On psychol-
ogy and embodiment: Some methodological experiments. Sociological Review, 56(S2),
197–215.
Burr, V. (1998). Gender and social psychology. London: Routledge.
Buss, D. M. & Schmitt, D. P. (1993). Sexual strategies theory: An evolutionary perspective
on human mating. Psychological Review, 100(2), 204–232.
Buss, D. M. & Schmitt, D. P. (2011). Evolutionary psychology and feminism. Sex Roles, 64,
768–778.
Bussey, K. & Bandura, A. (1999). Social cognitive theory of gender development and
differentiation. Psychological Review, 106 (4), 676–713.
Butler, J. (1993). Bodies that matter: On the discursive limits of ‘sex’. New York: Routledge.
Butterfield, S. & Loovis, M. (1993). Influence of age, sex, balance, and sport participation
on development of throwing by children in grades K-8. Perceptual and Motor Skills, 76,
459–464.
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gender. Berkeley: University of California Press.
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University Press.
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64(3), 170–180.
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New York: McGraw-Hill.
Crenshaw, K. (1991). Mapping the margins: Intersectionality, identity politics, and
violence against women of color. Stanford Law Review, 43, 1241–1299.
Darwin, C. (1859). On the origin of species. London: John Murray.
Deleuze, G. & Guattari, F. (1987). A thousand plateaus: Capitalism and schizophrenia (trans.
B. Massumi). Minneapolis: University of Minnesota Press.
Denmark, F., Russo, N. F., Frieze, I. H., & Sechzer, J. A. (1988). Guidelines for avoiding sex-
ism in psychological research: A report of the ad hoc committee on nonsexist research.
American Psychologist, 43, 582–585.
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Sex Roles, 37(7–8), 477–494.
Einstein, G. (2012). Situated neuroscience: Exploring biologies of diversity. In R. Bluhm,
A. Jaap Jacobson, & H. Lene Maibon (Eds.) Neurofeminism: Issues at the intersection of
feminist theory and cognitive science. (pp. 145–176). New York: Palgrave Macmillan.
Fausto-Sterling, A., Gowaty, P. A., & Zuk, M. (1997). Review essay: Evolutionary psychol-
ogy and Darwinian feminism. Feminist Studies, 23(2), 402–417.
Feminist Webs (2012). The exciting life of being a woman: A handbook for women and girls.
Milton Keynes, UK: Hammer/on Press.
Fine, C. (2010a). Delusions of gender: The real science behind sex differences. London: Icon
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differences in the brain. Current Directions in Psychological Science, 19, 280–283.
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164 Gender
Introduction
In this chapter, we cover those gender forms which fall outside the common
binary of women and men. However, as we will see, bisecting the world into
women and men – or, indeed, women, men, and others – is not necessarily
a useful way of conceptualising things. Consequently, we have entitled this
chapter ‘Further Genders’ in order to be comprehensible to readers who are
unfamiliar with gender forms other than woman or man (whether trans or
cisgender1 ).
Another commonly used umbrella term, which we use throughout the
chapter, is non-binary. Broadly speaking, this includes people who:
As we will see, many people’s realities, whether they use this terminology or
not, are something outside the strict categories of man (e.g. always wears blue,
is aggressive, smokes a pipe) and woman (e.g. always wears pink, is passive, does
knitting). Therefore, this chapter considers both those who explicitly identify
outside the gender binary and those whose experience may be regarded as to
some extent non-binary.
166
Meg John Barker and Christina Richards 167
Another point to consider here is that the terms above may well be unfamil-
iar to many readers precisely because this remains such an under-researched
area (and, indeed, an under-represented area in wider Western culture). As we
will see, the vast majority of psychological research and theory has assumed
that gender is binary – often to the point of searching for differences between
(two) genders. Relatively little work has challenged the categories of women
and men, although there has been a fair amount of theory in some areas of
other disciplines (such as sociology, cultural studies, gender studies, and trans
studies) questioning the gender binary: most notably queer theory.2 We touch
upon this during the chapter while focusing upon the burgeoning body of
knowledge within psychology. Of course, when we refer to ‘psychology’ here
we are speaking of a minority Western model of psychology which has histor-
ically not engaged fully with global identities and experiences. Consequently,
while this chapter endeavours to be broader in scope, it necessarily reflects this
bias in its reporting of the literature.
History
In the early years of Western psychological thinking, the binary gender system
was viewed as self-evident, and deviations from it were generally regarded as
psychopathological (Krafft-Ebing, 1886) or as the outcome of a developmental
process (Freud, 1905). Generally speaking, women’s experience was neglected
and the focus was upon men’s lives and realities. Up to the 1960s, psycho-
analysts and psychologists tended to look for overall human explanations for
psychological phenomena (generally studying men), and assumed that women
would naturally be inferior (Tavris, 1993). However, more recently, both aca-
demic psychology and popular psychology have turned towards a ubiquitous
view of the genders as different, or ‘opposite’, with the majority seeking expla-
nations for why women differ from a perceived masculine norm (see Hegarty &
Buechel, 2006) and a minority suggesting that women’s experience may be
superior to men’s (e.g. Gilligan’s, 1982, work on women’s supposedly more
care-based moral reasoning).
Neither of these understandings (of men as superior to, or more normal
than, women) questions the gender binary or includes the possibility of gender
fluidity or flexibility. Furthermore, subsequent mainstream and critical work
in this area has questioned the obsession with gender differences, finding that
women and men are far more similar psychologically than they are different
(Maccoby & Jacklin, 1974). Indeed, a moment’s thought allows one to recog-
nise that there are no psychological areas in which men and women are entirely
discrete (Fine, 2010). Additionally, there are often larger differences between
people of the same gender in different cultures than there are between people
of different genders in the same culture. Despite this, psychologists tend to add
168 Gender
Population
frequency
Masculine Feminine
Culture
Population
frequency
Masculine Feminine
part of this impact. However, as we will now see, even this conceptualisation
(of gender on a spectrum) is limited.
The most influential psychological researcher to study gender in a way that
included the possibility of non-binary experience was Sandra Bem (e.g. Bem,
1981, 1995; Bem & Lenney, 1976; Bem & Lewis, 1975). Bem challenged the pre-
vailing view that people were healthier if they conformed to the psychological
characteristics most associated with their gender (i.e. masculine men and femi-
nine women). She created a measure of gender, the Bem Sex Role Inventory (BSRI),
which contained questions relating to 60 traits: 20 stereotypically masculine, 20
stereotypically feminine, and 20 neutral filler items. Including masculinity and
femininity separately in this way moved away from the common view that mas-
culinity and femininity were polar opposites, and opened up the possibility that
people could, for example, be high or low on both masculinity and femininity
simultaneously. Participants were classified as sex-typed (high on the gender
traits commonly associated with their birth-assigned sex and low on those of
the ‘other sex’); sex-reversed (low on the gender traits commonly associated
with their birth-assigned sex and high on those of the ‘other sex’); androgynous
(displaying both stereotypically masculine and stereotypically feminine traits);
or undifferentiated (low on both).
Once validated, Bem used the BSRI to compare androgynous participants
with those who were more sex-typed (e.g. Bem & Lenney, 1976; Bem & Lewis,
1975). For example, Bem and Lenney (1976) found that sex-typed individuals
struggled more than androgynous people to engage in behaviours associated
with the ‘other sex’ even if it was in their best interests to do so. Bem con-
cluded that those who were androgynous were better able to adapt to their
situation and, therefore, that psychological androgyny was the healthiest kind
of gender.
However, in Bem’s later work she moved away from the idea of androgyny
as inherently liberating because the concept still reinforces the idea that there
are psychologically masculine and feminine traits, rather than recognising that
such understandings are bound in time and place. Bem (1981) argued that gen-
der was not useful as an organising category beyond the description of genitalia,
and that psychology – and wider culture – should move away from the use
of gender categories entirely. Her gender schema theory focused on examin-
ing how children internalise concepts of ‘appropriate’ gender roles, and how
this affects their behaviours. Here Bem focused on the learned nature of gen-
der schemas and how their dynamic construction provided for the possibility
of change. Therefore, overall, Bem’s work opened up the possibility both for
gender experience to incorporate masculinity and femininity, and for gender
fluidity and flexibility.
We return to Bem’s (1995) more recent psychological theories later in
the chapter. For now, it is important to point out that her work has not
170 Gender
gone without criticism. Particularly, the theories do not always capture the
multidimensionality of gender (Carothers & Reis, 2012) (Figure 10.3).
Multidimensional gender
Critics of gender theories that are based on notions of masculinity and
femininity have pointed out that how people identify with these depends
a lot on what aspect of stereotypical masculinity or femininity we are
talking about. Try putting a cross on the following spectrums as to where
you would place yourself if you were referring to masculinity and femi-
ninity broadly, or if you were using the terms to mean: ‘delicate or tough’,
‘emotional or rational’, or ‘submissive or dominant’.
Masculine Feminine
Delicate Tough
Emotional Rational
Submissive Dominant
Biological research into gender reveals that, at all levels of analysis, there is
diversity rather than a strict binary (Joel, 2012). This includes such things
as genotype and phenotype (body morphology and neuroanatomy), and it is
the case within both human and non-human domains (Fausto-Sterling, 2012).
Within humans, 1–2% of the population has some form of intersex condition
(see Roen, Intersex, this volume), and if neurological intersex is included this
number would be far higher (cf. Richards & Barker, 2013). However, it is impor-
tant to remember that many intersex people identify as male or female. One
biological study has explicitly studied a group of people who identify out-
side the gender binary and found evidence for a neural substrate associated
with bigender experience (switching between masculine and feminine identity)
(Case & Ramachandran, 2012).
Perhaps due to such biological underpinnings, non-binary identity and
experience is relatively ubiquitous both geographically and over time (Herdt,
1996). However, such identity and experience obviously varies according
to the cultural context in which it occurs. For example, we might con-
sider the Hijra identity in India; the Tom, Dee, and Kathoey identities in
Thailand; or the Bissu, Calabai, and Calalai identities in some communities
in Indonesia. It is vital not to reduce such identities and practices to con-
temporary minority Western understandings of binary or non-binary genders,
as diverse cultural understandings may well not fit within such a worldview.
Psychologists should also be cautious of slipping into academic colonialism
through overly critical or celebratory discourses regarding such experiences and
identities.
Intersections between biology and culture are perhaps best viewed
as biopsychosocial in that, in additional to biological aspects impacting
psychological experience, there will inevitably be feedback from the social
context in which people find themselves to their cognitions, neural connec-
tions, and behaviours. These will, in turn, inevitably affect the sociocultural
context. This positioning of people as an inextricable part of their cul-
ture is particularly vital in the case of non-binary people within a largely
binary culture wherein the disjunct between these two states must be
172 Gender
Current debates
resources for psychologists to engage with when exploring how this, albeit
limited, subset of people are negotiating non-binary gender in a binary world.
Key current debates in this area concern aspects of language, mental health,
medical interventions, legal recognition, and negotiation of public space. These
topics are all touched upon in the remainder of this chapter.
The impact of gendered language on experience is well documented within
psychology: for example, the usage of ‘man’ for ‘human’ (and similarly
gendered words) impacts on comprehension of texts by women (Weatherall,
2005), and cisgenderist language impacts on the sense of exclusion of trans
people (Ansara & Hegarty, 2012). Thus, it does not take much of a leap to pre-
dict that binary language, and misgendering of non-binary people, will likely
have similar effects.
One key way in which non-binary people have developed language in order
to enable recognition and representation of their experiences is to adopt non-
or different-gender language. Saltzburg and Davis (2010) found that young
non-binary people frequently struggled with imposed gendered titles (such as
Mr/Ms), as well as with family members who often wanted to use their birth
names rather than chosen names. Family members may also struggle with non-
binary alternatives to relationship terms (e.g. sibling instead of sister/brother;
offspring instead of son/daughter; parent instead of mother/father).
In considering new and preferred terms we restrict ourselves to consid-
ering English language forms, but it is vital to note that there are dif-
ferent approaches in other languages, particularly those within which all
nouns are gendered, such as French. Within English, perhaps the most com-
mon set of non-binary gender pronouns is the use of the existing terms
they/their/them/themself. This is grammatically correct in the singular, and
there are examples of its singular usage dating back to the likes of Chaucer
and Shakespeare. However, some still do not like its association with plurality,
although others enjoy this for its troubling of the notion that people are singu-
lar selves (Barker, 2013). Other popular pronoun sets which have been explicitly
developed include: xe/xyr/xem/xyrself (which has been adopted by schools
in Vancouver, BBC, 2014), Sie/hir/hir/hirself, and Per/per/pers/perself (from
Piercy, 1976).
We listed, in the Introduction, many of the identity terms which are emerg-
ing for diverse non-binary experiences; however, it is worth noting that the
US survey studies of Harrison et al. (2012) and Kuper et al. (2012) both found
‘genderqueer’ to be the most common term. Participants frequently related to
more than one gender term (either over time or concurrently). Some terms
were specific to certain cultural traditions, for example two-spirit (US First
Nations) and Mahuwahine (Hawaiian), and some people devised their own
unique genders, for example ‘birl, OtherWise, gender blur’ (p. 20) (Harrison
et al., 2012). Rankin and Beemyn (2012) further found that some people
Meg John Barker and Christina Richards 175
However, Bem (1995) was also aware that such proliferation could lead to
further ‘straightjackets’, as people struggled to fit into new narrowly defined
identities. This is a danger with all marginalised communities, as new sets of
norms are frequently developed which end up excluding as well as including
(Barker, 2013). For example, in terms of appearance, the vast majority of images
of androgyny are young, white, and slim (Boldly go, 2012), and authors such
176 Gender
Regarding the mental health of non-binary people, it seems that, while children
and adults who are non-binary in traits may be more psychologically healthy
due to having higher self-esteem (Allgood-Merton & Stockard, 1991) and a more
flexible approach (Harter et al., 1998), those who identify as non-binary and/or
express themselves in ways that explicitly trouble binary gender face similarly
high levels of mental health difficulties to those of trans people more broadly
(McNeil et al., 2012).
Harrison et al. (2012) found that, like their trans participants, non-binary
participants often reported being refused medical care and as having attempted
suicide at some point (43%); 32% reported physical assault due to bias, and 15%
sexual assault due to bias, which were higher rates even than those reported by
trans men and trans women. It seems likely that, in addition to anti-trans bias,
many non-binary people experience the kind of erasure or invisibility which
is faced by those whose sexualities do not conform to a binary. This is known
to take a toll on mental health. It seems likely that, depending on expression
and context, some non-binary people are more likely to experience anti-trans
bias and others invisibility. In addition, people may well experience others’
reactions differently (e.g. depending on whether they are hoping to be noticed
or to go unnoticed). Further research is necessary to explore the diversity of
experience in this area and the mechanisms through which treatment by others
impacts mental health.
Intersecting with this, quantitative psychological research on binary gender
stereotypes compellingly points to a priming effect on people’s experience (see
Barker & Duschinsky, 2012). For example, people inflate their perceptions of
their ability on gender-stereotyped subjects (maths for boys, arts for girls) after
reading about gender stereotypes or even after just ticking a gender box (see
Fine, 2010). Exposure to such gender stereotypes disadvantaging one’s own
gender diminishes confidence and interest (Correll, 2004) as well as actual
performance (McGlone & Aronson, 2006). Although the research has yet to
Meg John Barker and Christina Richards 177
gender. Also remember that people who appear to be binary may be non-binary,
and people who appear to be non-binary may be binary – so checking rather
than assuming is essential.
Future directions
Summary
Notes
1. Cisgender people are those people who are content to remain in the gender they were
assigned at birth (see Harvey & McGeeney, Cisgender, this volume).
2. Queer theory is an area of study which, drawing on postmodernist thought, seeks to
deconstruct accepted categories and to examine fluidity, complexity, and multiplicity
in a variety of domains, including gender and sexuality (Jagose, 1997).
180 Gender
Further reading
Barker, M. (2014). Non-binary genders. Rewriting the rules. Retrieved from http://
rewritingtherules.wordpress.com/2014/06/04/non-binary-genders-talk [Accessed 1
August 2014].
Bornstein, K. & Bergman, S. B. (Eds.) (2010). Gender outlaws: The next generation. New York:
Avalon Publishing Group.
Fausto-Sterling, A. (2012). Sex/gender: Biology in a social world. New York, NY: Routledge.
Richards, C. & Barker, M. (Eds.) (2013). Sexuality and gender for mental health professionals:
A practical guide. London: Sage.
Richards, C., Bouman, W. P., & Barker, M. (forthcoming). Non-binary genders. London:
Palgrave Macmillan.
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sexual orientation identities in an online sample of transgender individuals. Journal of
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182 Gender
Introduction
183
184 Gender
these terms are often popularly associated with the idea of ambiguous genital
appearance, thus making it hard to talk about the various aspects of diversity
of sex development, many of which have nothing to do with atypical genital
appearance at all.
Sex development naturally produces a wide range of diversity, and that diver-
sity can relate to all or any of the following: chromosomal make-up, hormonal
production and response, gonadal development, and genital appearance. For
some people whose sex development pattern diverges from norms, it may be
possible to detect a chromosomal variation. For some, there may be detectable
variation in the development of ovaries or testes. For some, there may be vari-
ation in genital appearance. For some, the variation is very small (e.g. a penis
whose urethral opening does not appear at the tip, or a clitoris that appears
visibly larger than typical). For some, the variation only becomes apparent at
puberty, perhaps because menstrual bleeding is expected but does not happen,
and investigations reveal that there is no uterus and/or no vaginal opening.
For some, the variation only becomes apparent much later in life, perhaps due
to an accident leading to internal investigations that reveal structures (such
as an internal gonad) that were not expected. For many, we must assume, the
variation is subtle and is never noticed.
This means that we do not know how many people may have sex devel-
opment varying in some way from norms. Those who have tried to produce
an estimate have added up the incidence of the numerous different diag-
noses reflecting sex development that diverges from normative male or female,
suggesting that this could relate to 2% of live births (Blackless et al., 2000),
although those wishing to retain the concept of intersex/dsd for strictly clinical
purposes may be critical of such a figure, and would rather work with a more
restricted definition (Sax, 2002). On the other hand, it can be argued that such
figures are under-estimates, given that much of the diversity concerned is harm-
less and may not come to medical attention, particularly in regions of the world
where medical control of birth is less common, and many people do not have
access to medical care. The fact that dsd is often addressed as a medical issue
is anomalous: most instances of diversity do not have direct health implica-
tions. Some (e.g. those with salt-wasting congenital adrenal hyperplasia) do
need hormonal treatment in order to survive. Aside from this kind of medi-
cal intervention, which relates to a specific diagnostic group, the main health
implications shared across many people are psychosocial: all who vary from sex
development norms potentially face shame and stigma.
The silence and shame associated with dsd, and with the associated medical
interventions, mean that many who experience dsd do not share this infor-
mation with anyone, even family members, and face negative long-term
emotional consequences (Lev, 2006). Some avoid intimate relationships and
health services in an attempt to avoid difficult conversations about their sex
Katrina Roen 185
History
Some key moments in the contribution that psychology alone has made to
this field could be marked out through just a few authors. First, the work of
John Money and colleagues provided a framework of understanding that sup-
ported ‘normalising’ genital surgery on infants on the grounds that this was
supposed to provide the necessary conditions for psychological well-being and
the development of normative gender identity (Money, 1975; Money et al.,
1955). Second, the work of Suzanne Kessler offered a feminist social-psychology
critique of this framework of understanding and the medical practices and
assumptions that went with it (Kessler, 1990, 1998). Third, there is a body of
work examining the role of gonadal hormone influences on sexual differen-
tiation in behaviour and gender identity (e.g. Berenbaum, 1998; Hines, 1998;
Jurgensen et al., 2007; Meyer-Bahlburg et al., 2006). Fourth, there have been
some productive contributions from clinical psychologists, for example, pre-
senting psychological evaluations of intersex children (Slijper et al., 1998),
addressing how to talk about intersex/dsd with affected children (Carmichael &
Alderson, 2004), and addressing ways of supporting women born with atypical
genitalia (Liao, 2003).
Finally, some recent psychological work has drawn from feminist and norm-
critical frameworks to highlight the problems that still persist, even if concerns
about non-essential surgery on infants, and problematic disclosure practices,
were to be resolved (Boyle et al., 2005; Chadwick et al., 2005).
The point of identifying these examples is not only to suggest historical junc-
tures, but also to demonstrate the diverse epistemological contributions that
psychologists make to this field. For some, the point is to collaborate with
biomedical scientists to improve the accuracy of binary gender predictions and
sex assignment, while, for others, it is important to address the topic at both
systemic and individual levels, thinking critically about binary sex/gender and
envisaging alternative (non-binary) possibilities.
During most of the latter half of the twentieth century, the optimal gender
policy was in practice in most instances where an infant with ambiguous sex
came to medical attention. This means that, following the understandings put
forward by Money and colleagues (Money, 1975; Money et al., 1955), surgical
alteration was carried out early in life, and information about the interven-
tion was kept from the child, who was to be raised unambiguously within the
assigned gender. The surgical creation of unambiguous-looking genitalia, and
the secrecy about the initial ambiguity, was supposed to be important for ensur-
ing healthy and unambiguous gender identity development for the child. Many
186 Gender
adults today have been treated by medical professionals who were operating
according to this approach.
Later in the twentieth century, an alternative approach was put forward.
Termed the true-brain sex policy (Kipnis & Diamond, 1998), this was based
on the understanding that the development of gender identity cannot be con-
trolled so completely by parental and medical interventions but, rather, may
develop in (so far unpredictable) ways based on neural traits.
In addition to these models, there are theories that question binary sex,
suggesting, instead, that sex and gender development could better be concep-
tualised as multiple rather than as binary (Schweizer et al., 2013). There is a
substantial body of literature offering critiques of binary-sex models (Fausto-
Sterling, 1993, 2000), medical models (Kessler, 1998), and the idea of brain sex
(Jordan-Young, 2010, 2012). Much of this critique does not come from within
psychology, but it is highly pertinent for psychological understanding of this
field of research and practice.
et al., 2010; Wisniewski & Mazur, 2009). One review, for instance, examined
the conceptual frameworks used by researchers seeking to interpret the role
of androgen exposure in psychosexual development (Stout et al., 2010). This
contributes to thinking about what kinds of psychosocial outcomes matter and
how those outcomes are conceptualised.
A number of psychosocial empirical studies have also been carried out with
people directly affected by intersex/dsd (Sanders et al., 2012; Schönbucher et al.,
2008). One such study has focused, for example, on experiences of treatment,
and reported that adult participants had substantially negative experiences
of treatment and found non-disclosure and secrecy particularly burdensome
(Brinkmann et al., 2007).
(Continued)
Current debates
Disclosure
Activists and researchers have shown clearly, from the 1990s onwards, the
damage that was caused by the policy of not telling people about their diag-
nosis and early-childhood treatment (Alderson et al., 2004; Kitzinger, 2000).
Accordingly, the policy has changed. It is now widely understood by health
professionals that people need to be told about their diagnosis and treat-
ment. While the policy has changed, the practice has not changed consistently
(Roen & Pasterski, 2014). Carmichael and Alderson draw together a variety
of useful ideas about talking with children about dsd, about their diagnosis
and treatment, engaging them in processes of decision-making and consent
to treatment, and supporting them through processes of disclosure to oth-
ers (Carmichael & Alderson, 2004). Carmichael and Alderson acknowledge the
value of resources and approaches through which these conversations can be
made age-appropriate. They also acknowledge that applied psychologists will be
working, in some instances, with children whose genitalia have been surgically
altered without their consent, and in other instances with children who are
growing up with atypical genitalia and the suggestion that surgery will be on
offer when they are able to consent. This is exactly the situation that some psy-
chologists are now working in, and requires a level of sensitivity to normative
pressures that all children and youth face in relation to gender and sexuality.
In the course of my own research, I am participating in conversations and
meetings with health professionals specialising in this area, and I have noticed
tensions and uncertainties that persist about the process and timing of disclo-
sure. In many instances, it is seen as most appropriate for the parents to tell
the child or young person relevant information in an age-appropriate way. Not
all parents, however, are equipped or willing to do this. This can mean that a
young person remains unaware of their diagnosis, or does not correctly under-
stand why they are undergoing, or have undergone, treatment. Further, people
who underwent childhood treatment before the 1990s could still be unaware
of their medical history if they were subject to the policy of non-disclosure.
Katrina Roen 189
This means that disclosure is still very much an issue, and something that
psychologists can contribute to by building understanding about what kinds of
information can usefully be disclosed, when, how, and by whom. In addition
to the issue of disclosure to the person centrally concerned is the question of
disclosure to others. Psychologists working clinically in this field are supporting
clients to consider ways of disclosing information about their sex development
to others, including family members and (potential) partners. This is vital work
for psychologists to do, as it is a step towards breaking the silence and stigma
surrounding sex development in general and dsd in particular.
Any applied psychologist could potentially come into contact with people who,
given a supportive environment, may want to talk about their experiences of
sex development. It is worth being ready for this by being sensitive to the
importance of language use and knowing about relevant support groups and
sources of information.
There is an opportunity for a wider range of health professionals and
researchers to have constructive input to the ongoing discussion about what
kind of medical interventions are appropriate, and at what ages, for promot-
ing psychosocial well-being. In addition, it would be possible for psychologists
and others to engage in systemic interventions that make it less daunting to
talk about one’s experience of sex development and the extent to which it may
192 Gender
vary from norms. Interventions could, for instance, include making intersex-
aware information available and visible in health centres and workplaces so
that colleagues and clients understand this is not an issue to be kept in shameful
silence.
Future directions
Summary
Others address the topic at both systemic and individual levels, thinking
critically about binary sex/gender and envisaging alternative (non-binary)
possibilities.
• It is now widely understood by health professionals that people need to be
told about their diagnosis and treatment process, told repeatedly and in an
accessible way, and told in age-appropriate ways. This means talking with
children about dsd, about their diagnosis and treatment, engaging them
in processes of decision-making and consent to treatment, and supporting
them through processes of disclosure to others.
• Despite there being broad agreement on the principle of disclosure, a health
professional working with a young person today may find that that young
person is not aware of their diagnosis, or does not correctly understand why
they are undergoing, or have undergone, treatment. Further, people who
underwent childhood treatment before the 1990s may still not know about
their medical history if they were subject to the policy of non-disclosure.
• An ongoing debate in this field relates to non-essential genital surgery on
infants. Pressure to stop non-essential genital surgery on infants and small
children continues, with a variety of activists, clinicians, and researchers
contributing constructively to this debate. Some changes are underway in
some parts of the world, but this is patchy.
• Psychological work to reduce the level of stigma associated with sex diver-
sity, sexual anatomy, sex development, and the medical diagnosis of DSDs
would make a useful contribution.
• Psychologists could usefully promote systemic interventions making it less
daunting to talk about one’s experience of sex development and the extent
to which that may vary from norms. Interventions could, for instance,
include making intersex-aware information available and visible in health
centres and workplaces so that colleagues and clients understand this is not
an issue to be kept in shameful silence.
Note
1. Here, dsd is written with lower case letters. This signals a critical distance from the
medical terminology: DSD, meaning Disorder of Sex Development.
Further reading
Accord Alliance website: www.accordalliance.org
Dsdfamilies website: www.dsdfamilies.org
EuroPSI website: www.europsi.org
Kessler, S. J. (1998). Lessons from the intersexed. New Brunswick: Rutgers University Press.
Liao, L. M. & Roen, K. (2014). Intersex/DSD post-Chicago: New developments and
challenges for psychologists. Psychology & Sexuality: Special Issue, 5(1).
194 Gender
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Katrina Roen 197
Introduction
198
Sarah Murjan and Walter Pierre Bouman 199
trans females where it is pertinent that they are trans – otherwise, as with the
men, simply ‘female’ is preferred. This is because, importantly, many trans peo-
ple do not wish to be defined by being trans when it is not relevant, and most
frequently wish to self-identify as simply men and women.
This chapter primarily focuses on those trans people who engage with clinical
services and seek treatment – such as cross-sex hormones and surgery – to make
their body more congruent with their gender identity and who therefore may
be diagnosed with ‘gender dysphoria’ or ‘transsexualism’. It is important to
recognise that being trans need not be a clinical matter and that trans people
self-identify in a variety of ways independently of whether or not they seek,
or receive, any diagnosis; have received cross-sex hormone treatment; or have
undergone surgery.
History
Their beard falls off; their genital organs atrophy; their amorous desires dis-
appear; their voice becomes feeble; their body loses its force and energy, and
at last they come to a condition where they partake of feminine costume,
and assimilate to women in many of their occupations.
(Beard, 1886)
Hippocrates described them as Anandrii, and believed the disease was due to
excessive riding on horseback.
There are many examples across the world of gender role change (Nanda,
2008), often in institutionalised form, such as the Mujerados of the Pueblo
Indians of New Mexico, the Hijras of India, the Samoan Fa’afafine and Native
American/First Nations Two-Spirit 2 . People, which encompass wide variations in
social gender role and sexuality among the many varied groups, of which there
are many descriptions (Lang, 1998). The history of trans men has perhaps been
generally less visible, although there are many accounts of natal women living
as men, working and marrying without attention, sometimes only found to be
natal women at death and at other times suffering great adversity and even
death upon discovery. In Thailand the term Kathoey was traditionally used to
describe gay and effeminate men, as well as people who might be understood
to be transgendered in other cultures, and is now most commonly used to refer
200 Gender
to trans women. There are complex reasons why there may be a greater percent-
age of transgendered individuals in Thailand than probably anywhere else in
the world. This includes different beliefs around, and attitudes towards, biolog-
ical sex and gender as well as easy access to hormones and surgery without the
requirement for any psychological evaluation. The expression of gender identity
and sexual orientation is, therefore, clearly complex and culturally mediated.
With the growing awareness of cultural diversity in the understanding of sex
and gender roles, there has been a rise in trans movements. These encompass
a wide range of gender variance and often challenge the binary system of sex
and gender. Specialists in the field of gender dysphoria, such as applied psy-
chologists and psychiatrists, may be seen, by some, as enforcing such systems,
although there is also work being done to assist non-binary people (see Barker &
Richards, Further Genders, this volume). In the past, however, psychologists
and psychiatrists often took a less pragmatic view, with early psychoanalytical
theories including neurosis in relation to oedipal concerns, castration com-
plexes, and ‘faulty’ identification (Fenichel, 1930; Segal, 1965). Attempts to
treat people with psychoanalysis were unsuccessful, and individuals, therefore,
understandably sought medical treatments rather than therapy. Other early
theories concerned learning and development, such as the influence of parents’
wish for an opposite-sex child (Stoller, 1964) or social gender identity develop-
ment (Money, 1957). These theories have been found to have little evidence
to support them, and much of the research done by Professor Money was later
discredited.
In terms of medical assistance for transgender people, this has been under-
taken for nearly 100 years, with considerable advancements in this time.
Norman Haire3 reported the case of Dora-R of Germany in 1921, who, under the
care of Magnus Hirschfeld, a German sexologist and advocate for sexual minori-
ties, underwent surgical transition between 1921 and 1930. Hirschfeld intro-
duced the term ‘transsexualismus’ in 1923 and in 1930 supervised the second
case to undergo genital reconstructive surgery – Lili Elbe of Denmark. David
Oliver Caudwell, an American sexologist, introduced the term ‘transsexualism’
in 1949 for those wishing to change physiological sex, and distinguished
between biological and psychological sex. However, he regarded surgery as an
unacceptable response and advocated that transsexualism be seen as a mental
disorder.
In 1948 Harry Benjamin, an American endocrinologist and sexologist, began
treating trans women using Premarin, an oestrogen which had been introduced
in 1941. Testosterone also became available and was used to treat trans males,
but it is worth noting that trans males were seen as far less prevalent than trans
women, and their treatment developed at a slower pace and perhaps less visi-
bly. During the war, penile reconstructive surgery was developed due to injuries
faced by soldiers, and these techniques became available to trans men. Harry
Sarah Murjan and Walter Pierre Bouman 201
Although many trans women may describe feeling that that they were girls
from as far back as they can remember and trans males may describe feeling
that they were boys from as far back as they can remember, there is a process
of trans identity formation. Many describe the distress of puberty as their body
develops in an unwanted fashion and draw distinctions with their peers’ expe-
riences in consolidating a trans identity. Trans people may draw distinctions
between themselves prior to transition and cis women and men with regard
to relationships, and may point to aspects of their gendered role and expres-
sion which concur with their internal gender identity. For many, the process of
identity formation usually begins by discovering the trans label and is followed
by identification with other trans people. A process of identification with their
204 Gender
gender of identity and rejection of the other may occur, if it has not already
done so.
Once a trans identity has been established, the trans person may consider a
gender role transition, if this has not already been made. There are many factors
to be considered that may influence a trans person’s decision to transition:
social factors, such as family and partner relationships, friendships, and neigh-
bourhoods; personal experiences, such as experiences of adversity or rejection;
personal circumstances, such as occupational or financial circumstances; and
historical and cultural factors; that is, trans people born in the same culture
or historical period may experience events differently from those in another.
It is important to recognise that there are many varied trans narratives and that
trans people may present at all stages of life.
Current debates
Access to treatment
There are inherent difficulties in providing psychological support to individuals
who are required to have psychological evaluation prior to treatment. Ten-
sions for the trans individual and the mental health practitioner (who may,
of course, be trans themselves) may arise between the gatekeeping role and
the psychotherapeutic role. Many trans people may object to the applied psy-
chologist or psychiatrist gatekeeper when they have a problem which is not a
psychological or psychiatric one.
Informed consent models emphasise the autonomy of the individual in
choosing their treatment within a framework of consent. Clearly, clinicians can
only consent individuals to treatments that are likely to have some benefit and
unlikely to do harm. There are debates as to whether the threshold for poten-
tial benefit will be higher in a publicly funded healthcare setting, such as the
NHS in the United Kingdom, than in private insurance-funded healthcare and
private practice. The levels of psychiatric morbidity and physical health may be
very different in different settings, and treatment must be advised accordingly.
There is the need to balance the right to self-determination versus the need
to ensure benefit and reduce risk of harm such as regret or poor psychosocial
outcomes.
As guidelines have progressed, the requirements made of trans individuals
in order to progress to various stages of treatment have relaxed, but may still
be seen as unnecessary and paternalistic. A prime example of this would be
the requirement that two signatures of approval from qualified mental health
professionals be provided before GRS is undertaken. This requirement, which is
advocated in the existing standards of care (Coleman et al., 2012; Wylie et al.,
2014), has been challenged from a medical-ethical perspective (Bouman et al.,
2014).
There remain considerable difficulties in relation to non-binary genders.
It has been argued that people who identify as non-binary may choose a nar-
rative that gives them access to the treatment they need (this may apply to all
trans people, based upon ideas about clinicians’ expectations). Others may feel
pressurised to undergo treatment such as genital surgery for fear of not present-
ing as a ‘true transsexual’. Additionally, there is a paucity of research in the area
and little to guide the professional in terms of outcomes of treatment for this
group.
Sarah Murjan and Walter Pierre Bouman 209
As seen above, many of the wider debates in this field concern the implica-
tions for applied psychologists and their colleagues. There are often difficulties
for trans people in accessing psychological treatments, despite the fact that
trans people have higher than average rates of mental distress due to discrim-
ination. There may be a debate between generic and trans-specific services,
but it is important to remember that being trans is no protection against the
whole range of mental health difficulties, and not every presenting issue will be
related to being trans. It is, therefore, important that non-specialist psycholo-
gists, counsellors, and other clinicians have some basic awareness of trans issues
in order to be able to provide therapy that is affirmative and trans friendly.
Many trans people have to negotiate changing relationships and may seek
family and relationship therapy. Family members and partners may seek indi-
vidual therapy when confronted with the reality of the trans person (although
many will be accepting from the start). For some there may be issues around
self-blame, mourning, and grief reactions for the person they may feel they
have lost, with all the accompanying expectations, rejection, anxiety, and
shame. These things can be usefully worked though with a positive approach
to trans, as many trans people go on to live rich lives with a good job, family
life, and so on (Richards & Barker, 2013).
(Continued)
Future directions
gender, which may impact on the stage at which trans people ask for assistance
and can create frustration. Some countries require a trans person to undergo
genital surgery in order to gain legal recognition of their gender, whereas in the
United Kingdom there is no such requirement. Legal systems are evolving, and
in 2011 Australians were given the right to list their gender as indeterminate
on their passports. In 2014, an Australian resident successfully fought in the
High Court to be recognised legally as of non-specific sex. In Germany in 2013,
laws were changed to allow an ‘indeterminate’ sex on birth certificates. What
impact these changes will have on the numbers of trans people identifying as
neither male nor female remains to be seen.
Although much more research is needed, it is clear that many more trans
people in many countries are coming forward for assistance – for psychological
and psychosocial matters as well as for physical treatments – and, consequently,
the prevalence of various trans identities is likely to be much higher than previ-
ously thought. Perhaps as part of this change, the gap between the prevalence
of trans females and trans males seeking such assistance is narrowing. Applied
psychologists working in services for trans people will need to take account of
these changes, as well as the changing social and political landscapes, which
will be of interest to academic psychologists who work in this ever-evolving
and fascinating field.
Summary
• Being trans (like being lesbian, gay, or bisexual) is not a mental illness and
is independent of sexuality, in the sense that trans people display the whole
range of human sexualities irrespective of gender identity.
• Trans identities are varied and different treatments are appropriate for dif-
ferent individuals. Individuals and their partners and families may need
counselling and support through different stages of transition and treat-
ment.
• Some trans people undergo transition from one point on a notional gen-
der continuum to another, most commonly between a birth assignation of
female to male (trans men) or a birth assignation of male to female (trans
women). This typically involves changes to social role and presentation, and
may necessitate their taking cross-sex hormones and/or having surgeries.
• Psychological assessment and treatment has evolved and is an important
part of the treatment of trans people – although formal psychotherapy may
not be appropriate and, indeed, may be harmful if mandatory.
• Physical treatments such as cross-sex hormones and surgery can have huge
benefits in certain people who have been counselled carefully and are able to
give fully informed consent. Risks in terms of regret or poorer psychosocial
outcome appear to be low.
212 Gender
• Being trans is one aspect of a person’s life and may not be relevant when a
person seeks psychological interventions for an unrelated matter.
Note
1. Gender non-conformity may be a contentious term because ‘conforming’ gender roles,
expressions and identities differ across times and cultures and may not be as healthy
as non-conforming ones. See Harvey and McGeeney Cisgender (Chapter 9), this
volume.
2. An English term that emerged in 1990 out of the third annual inter-tribal Native
American/First Nations gay/lesbian American conference in Winnipeg.
3. A gynaecologist who was a campaigner for sexual reform and promoted birth control.
4. Cisgender is used to describe those whose gender identity matches their birth-assigned
gender.
5. This is sometimes referred to as ‘transvestitism’, although this is often an offensive
term and is not used here.
Further reading
Cromwell, J. (1999). Transmen & FTMs. Urbana and Chicago: University of Illinois Press.
Ettner, R., Monstrey, S., & Eyler, A. E. (Eds.) (2007). Principles of transgender medicine and
surgery. New York, NY: The Haworth Press.
Kreukels, B. P. C., Steensma, T. D., & De Vries, A. L. C. (2013). Gender dysphoria and disorders
of sex development: Progress in care and knowledge. New York, NY: Springer.
Serano, J. (2007). Whipping girl: A transsexual woman on sexism and the scapegoating of
femininity. Emeryville, CA: Seal Press.
World Professional Association for Transgender Health (WPATH) (2011). Standards of
care for the health of transsexual, transgender and gender nonconforming people (7th ed.).
Minneapolis, MN: WPATH.
References
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disorders (4th ed.). Washington, DC: APA.
American Psychiatric Association (APA) (2013a). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: APA.
American Psychiatric Association (APA) (2013b). Gender dysphoria fact sheet. Retrieved
from: http://www.dsm5.org/Documents/Gender%20Dysphoria%20Fact%20Sheet.pdf
[Accessed 9 June 2013].
Andreazza, T. S., Costa, A. B., Massuda, R., Salvador, J., Silveira, E. M., Piccon, F., Carvalho,
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Sarah Murjan and Walter Pierre Bouman 213
Introduction
People are curious about the state of other people’s love lives, especially in
the early phases of a relationship. New couples are oftentimes asked questions
about their forming romance: “Are you exclusive?”; “Do you have a title?”; “Are
you together?”; or “Did you have the talk?” But what do these questions really
mean? What types of information are people actually trying to gather when
they ask these questions?
It turns out that these questions and their subsequent responses are actu-
ally quite complex, and this complexity is perhaps demonstrated most clearly
through people’s use of the term ‘monogamy’ as a defining component of
their romantic relationship. If people in romantic relationships identify as
monogamous, either explicitly or implicitly, what does this descriptor sig-
nify? Are all monogamous couples monogamous in the same way? We will
attempt to answer these questions by (a) providing an overview of the idiosyn-
cratic definitions of monogamy across disciplines and contexts, (b) presenting
a brief history of psychological research on monogamy, (c) discussing cur-
rent debates surrounding monogamy, and (d) suggesting potential avenues for
future research.
Inarguably, monogamy is currently the ideal and primary relationship script
within the Western world. This monogamy script operates on three intersect-
ing levels – the cultural, interpersonal, and psychological – to define, regulate,
and reward ‘normal’ behaviour by punishing deviations from monogamy
(Anderson, 2010; Conley et al., 2012a; Gagnon & Simon, 1973; Moors et al.,
2013). Similarly to other dominant institutions (i.e. sexism, heterosexism, and
racism), individuals often adopt monogamism without question or challenge.
As Anderson (2010) notes, the governing institution of monogamy is often
equated with ‘morality’ as heterosexuality is with ‘family values’ (p. 867).
At the cultural level, political and religious structures function to privilege
219
220 Relationships
Abramson, 1993; Ryan & Jethå, 2010). Because this definition focuses on one
sexual partner for life, it is generally not applicable to the great majority of
human behaviour (Barash & Lipton, 2002; Ryan & Jethå, 2010). It is because
of this lack of applicability to actual human behaviour that this definition is
typically not used within the domains of psychology or public health.
An example may help highlight the differences between sexual monogamy
and social monogamy. Prairie voles (small, mouse-like rodents) typically have
a primary partner with whom they share parenting responsibilities (Getz &
Carter, 1996). Biologists have often misinterpreted social monogamy among
prairie voles as representing a sexually monogamous commitment (Williams
et al., 1992). However, voles actually have offspring with many other partners
across their lifetimes. Thus, prairie voles are socially monogamous according to
a biological sciences definition, but not sexually monogamous.
History
were less likely to use barrier methods in their primary relationship than
individuals engaged in consensually non-monogamous relationships. Further
research indicated that ostensibly monogamous individuals were also more
likely to make condom use mistakes, such as putting the condom on the wrong
way or not pinching the tip of the condom, than individuals in consensually
non-monogamous relationships (Conley et al., 2013). Thus, these findings sug-
gest that consensual non-monogamy may provide a safer avenue for sexual
expression than failed attempts at monogamy (i.e. cheating).
Despite monogamy’s status as the ideal romantic relationship (Conley
et al., 2012a), the current research does not support the cultural truism
that monogamy is superior across multiple domains, including sexual health.
Though these findings are controversial, we suggest that further evidence is
needed to identify benefits of monogamy in the domain of sexual health.
Current debates
one’s actions), which serve to correct and/or punish behaviours that deviate
from societal norms. Likewise, social, relational, and institutional frameworks
pressure individuals to avoid extradyadic sexual encounters and reinforce the
notion that an individual will “lose it all” if he or she strays from tradi-
tional norms of monogamy (Emmers-Sommer et al., 2010; Weaver, 2007). For
instance, infidelity is the most common trigger for breakups in heterosexual
relationships (Metts, 1994) and same-sex unions (Kurdek, 1991) and divorce
among married couples (Amato & Previti, 2003).
Future directions
Summary
Further reading
Barash, D. P., & Lipton, J. E. (2002). The myth of monogamy: Fidelity and infidelity in animals
and people. New York: Holt Paperbacks.
Conley, T. D., Moors, A. C., Matsick, J. L., & Ziegler, A. (2012). The fewer the merrier?:
Assessing stigma surrounding consensually non-monogamous romantic relationships.
Analyses of Social Issues and Public Policy, 13(1), 1–30.
Conley, T. D., Ziegler, A., Moors, A. C., Matsick, J. L., & Valentine, B. A. (2012).
A critical examination of popular assumptions about the benefits and outcomes
of monogamous relationships. Personality and Social Psychology Review, 17(2),
124–141.
Finkel, E. J., Hui, C. M., Carswell, K. L., & Larson, G. M. (In press). Suffocation of marriage:
Climbing Mount Maslow without enough oxygen. Psychological Inquiry, 25, 1–41.
Perel, E. (2006). Mating in captivity: Reconciling the erotic + the domestic. New York, NY:
HarperCollins.
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ing and monogamism among undergraduate heterosexual men. Journal of Social and
Personal Relationships, 27(7), 851.
Ali Ziegler et al. 233
Aral, S. O. & Leichliter, J. S. (2010). Non-monogamy: Risk factor for STI transmission
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Infections, 86(3), 29–36. doi: 10.1136/sti.2010.044149.
Barash, D. P. & Lipton, J. E. (2002). The myth of monogamy: Fidelity and infidelity in animals
and people. New York, NY: Holt Paperbacks.
Barker, M. (2005). This is my partner, and this is my . . . partner’s partner: Constructing a
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Barker, M. & Langdridge, D. (2010). Whatever happened to non-monogamies? Critical
reflections on recent research and theory. Sexualities, 13(6), 748–772.
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couples. Archives of Sexual Behavior, 14(5), 395–412.
Britton, P. J., Levine, O. H., Jackson, A. P., Hobfoll, S. E., Shepherd, J. B., & Lavin, J. P.
(1998). Ambiguity of monogamy as a safer-sex goal among single, pregnant, inner-city
women: Monogamy by whose definition? Journal of Health Psychology, 3(2), 227–232.
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Assessing stigma surrounding consensually non-monogamous romantic relationships.
Analyses of Social Issues and Public Policy, 13(1), 1–30.
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responses from Study 1 in Conley, Moors, Matsick, et al., 2012.
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Journal of Sexual Medicine, 9(6), 1559–1565.
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463–465.
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Social Psychological and Personality Science.
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examination of popular assumptions about the benefits and outcomes of monogamous
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14
Open Non-monogamies
Nathan Rambukkana
Introduction
236
Nathan Rambukkana 237
with current normative frameworks. With definite parallels to the more firmly
established shift that brought LGBT* and queer3 lifestyles into the mainstream
and that have made same-sex marriage a reality (or present struggle) in a grow-
ing number of countries, this cultural movement creates tensions and new
problematics in psychology and cognate fields.
Major issues relating to psychology involve the following: (a) the status
of open non-monogamies in relation to normative social psychology (with
implications within applied psychology for individual, couples, and family
practitioners); (b) the theoretical questioning of the notion of healthy roman-
tic love between more than two people; (c) the effects of non-monogamy (and
polygamy particularly) on women; (d) the effects of multiple-partner parenting
on children, communities, and society; and (e) the psychological exploration
of the minutiae of non-monogamous living (e.g. the psychology of overcom-
ing jealousy, and of non-normative relationship dynamics/structures such as
compersion, sister wives, triads, and New Relationship Energy4 ).
Debates within this literature are linked to divides such as those
between mononormative and anti-mononormative perspectives5 ; on swing-
ing, polygamy, and polyamory; between activist and critical approaches
to polyamory; between pro-legalising and pro-criminalisation approaches to
polygamy; and between and among multiple forms of open non-monogamy
(e.g. privileging polyamory over polygamy and swinging, or the identification
of non-monogamous over polyamorous).
Implications are discussed for such wider fields as counselling and therapy,
law, media and representation, urban and social planning, and politics; and
for academic fields such as sociology, LGBT* and queer. Studies, kink studies,
critical race studies, women’s studies, history, religious studies, communication
studies, cultural studies, philosophy, politics, and medicine.
The future of work on open non-monogamies is also briefly touched on,
including new categories of analysis and emergent forms such as the new
monogamy, polygamy legalisation, non-monogamous as identification, poly
children growing up, further impacts of new marriage legislation in different
countries, more cross-cultural and cross-categorical work, and the impact of
changing demographics.
History
A content analysis of these 128 articles, discounting the 39 animal and insect
studies (mostly non-relevant), yields 33 overlapping content categories (see
Table 14.1).9
The largest categories of analysis by volume are Polygamy and health/health
education (n = 32), African polygamy/African American polygamy (n = 26),
and Marriage and family studies (n = 26), with smaller significant clusters
(n = 15–20) on Women’s and gender issues, Polygamy and children/adolescents,
Polygamy and HIV/AIDS/STIs, Polygamy and sexuality, and discussions of
Nathan Rambukkana 241
O’Neil & O’Neil, 1970; Smith & Smith, 1970). The early 1970s was a hotbed
of engagement with ideas around open marriage, open families, and swing-
ing, but this level of activity was not sustained. Roger H. Rubin noted that,
after a focused re-examination of the family form in the 1960s and 1970s,
research on some matters (such as same-sex relationships) became part of main-
stream research endeavours, while others (such as work on swinging, group
marriages, and communes) were largely ignored (2001), and, by one account,
as early as the mid-1970s researchers were already seeing a decline in such
behaviours (Fang, 1976). After a confluence in the mid-1980s (D. Dixon, 1985;
J. Dixon, 1985; Duckworth & Levitt, 1985; Jenks, 1985a, b; Murstein et al.,
1985; Wolf, 1985) followed by a fallow period in the mid-to-late 1980s and
1990s with a handful of studies (Fine, 1992; Jenks, 1992, 1998; Musso, 1988),
such research took a marked upswing in the mid-to-late 2000s, possibly cor-
responding with a renewed interest in open non-monogamies brought on by
polyamory discourse, including a revival of the older, less identitarian, idiom of
open relationships (see, for example, the prominent mainstream reception of
Jenny Block’s Open: Love, Sex and Life in an Open Marriage (2008) (Rambukkana,
2015). A more recent example of this less identitarian discussion of open non-
monogamies is Meg Barker’s Rewriting the Rules: An Integrative Guide to Love, Sex
and Relationships (2012).
Finn et al., 2012; Zimmerman, 2012), and bisexual and polyamorous clients
(Keppel, 2006; Weitzman, 2006). While, as discussed above, there is a large
body of work on polygamy and health in general (e.g. Miller & Karkazis, 2013;
Tamini & Kahrazei, 2010), and mental health specifically (e.g. Hamdan et al.,
2009; Shepard, 2013), little of this work has addressed counselling or ther-
apy needs for those in continuing polygamous arrangements, though some do
tackle these issues, addressing topics such as how nurses and policy makers can
mediate negative effects of polygyny while acknowledging positive ones (Tabi
et al., 2010), and how approaching the issue using an Islamic base and focusing
on improving children’s experience might be a way to mediate negative effects
(Al-Krenawi et al., 1997).
Walshok, 1971), and balanced (e.g. Grold, 1970) work on swinging, some
work suggested that a positive bias among researchers might be skewing the
results of some studies (Biblarz & Biblarz, 1980). Studies of polygamy have
also addressed this question. While the majority of studies on polygamy simply
assume or presume that experiences with non-dyadic love will be negative, oth-
ers actively explore the question (e.g. Elbedour et al., 2007; Calder & Beaman,
2014; Cook, 2007). In opposition to work on polygamy, writing on polyamory
tends to favour positive depictions and studies, including the major self-help
manuals and activist texts, the most famous being The Ethical Slut: A Guide
to Infinite Sexual Possibilities (Easton & Hardy [Liszt], 1997, 2009), sometimes
wryly referred to as the bible of polyamory. But even in academic work, as
Haritaworn et al. (2006) point out, the majority of writing is still positive, with
critical writing being a more recent phenomenon (Barker & Langdridge, 2010a;
Rambukkana, 2015).
Current debates
In summary, they argue that, while there is clear value to these complicating
perspectives, it is also important to strike a balance moving forward and to use
these tensions to forge stronger politics in the long run (Barker & Langdridge,
2010a, p. 756).
Finally, a less formal debate exists between and among multiple forms of
open non-monogamy, in that proselytising for (or against) a given model
of non-monogamy often explicitly draws other forms of non-monogamy
into the discussion. A key example of this is how polyamory received lim-
ited societal recognition in Canada in the 2011 Reference re: Section 293
Nathan Rambukkana 249
One implication that we can draw from this review is that, as with same-sex
sexuality, extradyadic relationships are receiving increased societal recognition
and attention that manifests across disciplinary bounds. This coming of age of
open non-monogamy discourse (facilitated, in no small part, by the connec-
tions afforded by new media and globalisation) is half postmodern intimacy
and half return of the repressed; an at-times-awkward, at-times-fruitful con-
vergence, it is a collision of old, buried, and new figurings of intimacy all at
once. With respect to the world as a whole, to intergovernmental agencies and
networks, and to individual states, it presents a challenge: at present it is an
unstable system, with forms of intimacy and coupling that are variously legal,
illegal, and a-legal in different jurisdictions. Given diasporic flows and political
movements towards larger collective governance (such as the European Union,
the African Union), it is an issue that we need to collectively address, one that
250 Relationships
Future directions
Future directions for open non-monogamies work will take into account
the changing and ageing demographics of non-monogamists, the evolving
sociocultural milieus they are interacting with, and developments in – or intro-
ductions of new – discourses that subtend them. Despite the upholding of
s. 293 in Canadian jurisprudence in 2011, as Lori Beaman notes, ‘the “issue”
of polygamy has by no means been resolved [and,] for better or worse, it can-
not be simply legislated away’ (2014, p. 2). As cases continue to alter the legal
frameworks in Canada, the United States, the United Kingdom, and other juris-
dictions, it will be the role of academic work to reflect upon those changes
and their new or reorganised constraints and possibilities – e.g. as the growing
legal availability of same-sex unions changes the normative domestic back-
drop against which extramarital or co-marital relationships are considered.
The same is true of polyamory, swinging, and open non-monogamies broadly.
Polyamory’s limited societal recognition in Canada under the judicial interpre-
tation of s. 293 (Bauman, 2011; Rambukkana, 2015) and the 2005 legalisation
of Canadian swing clubs (Tibbets & Skelton, 2005) are testaments to this. Sim-
ilarly, as understandings of non-monogamies as alter-normativities trickle out
into educational and policy frameworks, into professional practice and into
clinical practice (e.g. the fact that a pathologised multi-partner sexuality was
considered but rejected for inclusion in the DSM-V (Moser, 2013)), the effects of
such changes and new normativities will also be objects of study.
The changing demographics of open non-monogamists will also create
new opportunities for study, such as new critical work on polyamory (much
of it by self-reflexive practitioners secure enough in the societal landedness
of open non-monogamies to challenge existing orthodoxies and practices),
potentially opening up a more closed and enclaved discourse (Rambukkana,
2015) to new practitioners, in ways similar to how critiques of homonor-
mativity (Duggan, 2003) and homonationalism (Puar, 2007) have opened up
sometimes-privileged versions of LGBT* and queer cultures. Indeed, discus-
sion of polynormativity (Rambukkana, 2015; Wilkinson, 2010; Zanin, 2013)
has already joined discussion of mononormativity (Ritchie & Barker, 2006) in
critical polyamory discourse, a trend that will hopefully continue. As children
from non-monogamous family formations hit adolescence and adulthood, this
will be a further new site of study, as well as of intervention for clinicians in
family, relationship, and couples practices.
New critical work will also need to address changes to, and additions of,
non-monogamous discursive categories, such as the recent popularity of the
term ‘the new monogamy’ for foregrounding open committed relationships
(Anapol, 2010). More work will also need to consider open non-monogamies
252 Relationships
Summary
Note
1. This review is limited in scope due to its mostly English-language and minority
Western culture sources.
2. Or, more archaically, wife swapping.
3. I use ‘LGBT* and queer’ here, for three reasons. First, I acknowledge a range of
Trans* identities in line with the current activist mobilisation of this term (e.g.
Killerman, 2012). Second, the asterisk at the end of ‘LGBT*’ – Lesbian, Gay, Bisexual
and Trans* – can also be seen to speak to multiple, additional identities in line with
Nathan Rambukkana 253
Further readings
Barker, M. & Langdridge, D. (Eds.) (2010). Understanding non-monogamies. New York, NY:
Routledge.
Calder, G. & Beaman, L. G. (Eds.) (2014). Polygamy’s rights and wrongs: Perspectives on harm,
family, and law. Vancouver, BC: UBC Press.
Sheff, E. (2013b). The polyamorists next door: Inside multiple partner relationships and
families. Lanham, MD: Roman and Littlefield.
Lifestyles, 8(1) (1985). Special issue on swinging.
Sexualities, 9(6) (2006). Special issue on polyamory.
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Part IV
Psychological Areas
15
Clinical Psychology
Jan Burns and Claudia Zitz
Introduction
History
Understandings of the distinction between gender and sex have been in exis-
tence since long before the arrival of a type of psychology called clinical psy-
chology, and with it the idea of ‘practice’, not just theory and research. As such,
clinical psychology had a foundation of ideas to draw upon, offered by early
sexologists. Of particular relevance is Krafft-Ebing and his work Psychopathia
Sexualis (1886), aimed at physicians, psychiatrists, and judges, described as a
“medico-forensic study” and with parts written in Latin to “discourage the lay
reader”. This text was one of the first presentations of case studies describing
“sexual pathology”, including fetishism, sadomasochism, and homosexuality.
Here, life, and hence sexuality, is described as a “never ending duel between
animal-instinct and morality” (p. 6), with ‘normal women’ positioned as hav-
ing little ‘sensual desire’ (p. 14), but desirous of spiritual ‘love’; and men,
by nature, being the active sexual aggressor. Religiosity, anthropology, and
263
264 Psychological Areas
biological determinism are heavily drawn upon to justify the views presented,
and, as a result, pathology is considered as anything which deviates from the
natural bringing together of men and women to fulfil the biological function of
procreation. When deviation from the norm occurred, it was seen as a product
of a breakdown in morality brought about by psycho- or neuro-pathological
conditions.
It was during this era that psychology in its different forms rapidly devel-
oped, and clinical psychology as a professional discipline became distinct from
psychiatry. The British Psychological Society (BPS) was formed in 1901, and the
first edition of the British Journal of Psychology declared that “Ideas in the philo-
sophical sense do not fall within its scope; its enquiries are restricted entirely
to fact” (as cited in Pilgrim & Treacher, 1992, p. 23). Thus, psychology welded
itself tightly to a scientific belief structure based on ‘truths’, in which the sci-
entific purpose was to uncover such truths through careful categorisation and
measurement (positivism), with gender and sexuality being viewed through the
lens of essentialism (as having unmodifiable characteristics) by researchers who
were positioned as distinct and objective. There were many advantages to the
neophyte discipline of psychology attaching itself at the turn of the eighteenth
century to the coat tails of the physical sciences, and, once established, it rose
quickly in terms of power, status, and wealth. Indeed, in the United States the
term ‘clinical psychologist’ had been coined and the first ‘clinic’ established in
1896 (Strickland, 1988). As clinical psychology established itself as a science,
‘sexual deviancy’ became a focus for its gaze, and its practitioners happily took
up the position of ‘experts’ on this topic.
Meanwhile, a different type of science was establishing itself, stemming from
the revolutionary thoughts of Freud. While holding to many essentialist ideas,
Freud moved away from trying to establish neurological ‘facts’ to talk about
unseen and unmeasured internal drives which directed behaviour and feel-
ings, the most central being a sexual drive (libido), and suggested that all adult
psychological dysfunction stemmed from interruptions of or deviations from
libido development. Freud’s theories have been much debated and developed
since then, but at that time he made two startling assertions: (a) that children
are born sexualised beings, that is, that sexuality does not develop as a con-
sequence of physical development but is there from the very beginning and
(b) that sexuality is at the centre of our essence as humans, the expression of
sexuality is normal and it is the repression of sexuality which is problematic,
rather than its expression being an indication of pathology. From Freud and his
followers psychoanalysis was born, and the idea that through intensive analy-
sis unconscious, damaging events may be made conscious and repaired, and
pathology reduced.
Hence, by the end of the nineteenth century two parallel developments were
occurring: clinical psychology with its labs, clinics, measurements, and search
for facts; and psychoanalysis with its individual therapy, interpretations, and
Jan Burns and Claudia Zitz 265
Within DSM I, ‘deviant sexuality’ was included under the heading ‘Personal-
ity Trait Disturbance’ and included “homosexuality, transvestism, paedophilia,
fetishism and sexual sadism (including rape, sexual assault, mutilation)” (p. 36).
Despite positivist claims to objectivity, the inclusion of certain marginalised
types of sexual expression was clearly influenced by the value systems in place
at that time, including religious belief structures and statistical beliefs about
majority behaviours defining ‘normality’. The unhappiness of those who prac-
ticed ‘deviant sexual’ behaviours was held up as further evidence of existing
pathology and the need for treatment. It is perhaps unsurprising that the
individuals practising such ‘deviant’ behaviours were distressed, given the dom-
inant attitudes and, indeed, that many of these behaviours were outlawed,
meaning that the individual had to manage not only the stigma associated with
their sexual interests but the stress of potential criminalisation if caught. Oral
histories clearly capture the trauma of this positioning, such as this gay man’s
experience documented in Smith et al.’s (2004), study: “I felt totally bewildered
that my entire emotional life was being written up in the papers as utter filth
and perversity” (p. 1). Such accounts point clearly to the amount and source
of stress that people holding minority/marginalised positions experience, pro-
viding an explanation of the higher incidence of psychological problems often
experienced by these groups, which is often misattributed to their difference as
opposed to the societal reaction to such difference (King et al., 2008).
Treatments at this time very much echoed the two main streams of clin-
ical psychological practice, one being dominated by psychoanalysis and the
other by behaviourism. Both streams followed the medical model of diagnosis,
underpinned by a theory of causality, leading to individual damage (psycho-
logical or neurological) and a treatment plan aimed at rectifying the damage
located in the individual. For some, usually those who could pay privately,
this resulted in extensive psychodynamic psychotherapy aiming to locate and
rebalance the trauma which had interrupted normal psychosexual develop-
ment and so place it back on the rails. However, the more likely treatment for
those who did seek help, or were required to, was behavioural aversion therapy.
This included shock treatment and drug-induced nausea in response to stimuli
which were expected to induce deviant sexual arousal (see Richards, Further
Sexualities, Chapter 4, this volume). Other treatments included the admin-
istration of hormones, electroconvulsive therapy, systematic desensitisation,
hypnosis, and religious counselling. While occasional research reported some
success with these methods, it is unclear how much the impact of ceasing such
unpleasant treatments affected reported efficacy (APA, 2009).
As the liberated values of the 1960s and the impact of the ‘sexual revolu-
tion’ took hold, clinical psychology also started to develop a wider gaze, being
no longer just interested in distress but also in the promotion of well-being,
and the hinterland between ‘illness’ and unhappiness. This was in part due
Jan Burns and Claudia Zitz 267
reflected within psychiatry, such that ‘Homosexuality’ was removed from DSM
I and replaced by ‘Sexual Orientation Disturbance’ in DSM II (1973), and in
that same year the American Psychological Association (APA) issued a position
statement supporting the civil rights protection of same-sex attracted people.
‘Sexual Orientation Disturbance’ was replaced by ‘Ego-dystonic Homosexuality’
in DSM III (1980), and in 1986 it was removed completely from DSM IV. The
WHO, with its parallel taxonomy of the International Classification of Diseases
(ICD-10), only followed suit in 1990.
Consequently, clinical psychologists started seeing people not because they
were homosexual, but because they had difficulty coming to terms with their
sexual identity. There was a certain irony that those who had been so damned
for their sexuality were now in danger of being pathologised for finding it diffi-
cult to fully embrace their sexuality in a still largely prejudicial world. However,
clinical psychologists also started to see people because of their lack of sexual
behaviour, or perceived sexual dysfunction, and thus became involved in sexual
counselling and sex therapy. The move away from the individual and the devel-
opment of more systemic therapeutic approaches also opened the clinical door
to couples or relationship therapy. The work of Masters and Johnson (1970)
built the foundations to sex therapy, and focused on reducing anxiety through
clear, directive, behavioural, relatively brief, problem-focused techniques and
exercises which concentrated on non-demand pleasuring (sensate focus) in the
context of reduced self-monitoring (spectatoring).
This approach also started to draw on the emerging field of cognitive
behavioural therapy (CBT), where not just one’s behaviours but also one’s
thoughts matter. The rise of CBT is emblematic of the departure within clin-
ical psychology from a wholly essentialist perspective (immutable underlying
shared essences) to more of an acceptance of constructionist influences, where
there is greater acknowledgement that ‘reality’ is co-constructed. Here, what we
‘think about’ or how we ‘construct’ our viewpoint is what is important, and so
to change our psychological state we must look towards challenging and chang-
ing our thoughts and the internal structures by which we judge relevance or
importance. Nevertheless, it has also been argued that CBT still operates within
an essentialist framework, with manualised protocols for ‘conditions’ such as
depression, and assumes there are rational (i.e. ‘right’) thoughts in relation to
an accepted, shared ‘reality’ (Gilbert, 2009).
Society’s attitude towards sexuality became a global debate with the arrival
of the originally named ‘gay plague’ of AIDS/HIV in the mid-1980s. The impact
of this disease reopened debates about ‘gay morality’ and particularly exposed
gay men’s lives to public scrutiny, comment, and judgement. One essentialist
viewpoint was that homosexuality was ‘wrong’, encouraging both religious
(the ‘wrath of God’) and biologically deterministic (nature’s way of eradicating
faulty genes) discourses about its genesis to surface (Ruel & Campbell, 2006).
Jan Burns and Claudia Zitz 269
As the disease became better understood, and a civil rights fight back occurred,
it became apparent that it was not just a gay disease, but one that could affect
anybody sexually active or undergoing certain medical procedures, and, indeed,
the division between gay and straight was perhaps not so clear cut. With this
acknowledgement came a diversification of possible identities, including ‘men
who have sex with men’ (MSM) and bisexuality, and the realisation that sexual
identities may be fluid and contextual, such as MSM in prison populations.
In terms of clinical psychology, the rise of services for people with HIV
produced a whole new area of specialism. Within the Division of Clinical
Psychology (DCP) of the BPS, the HIV Special Interest Group was set up in
1989, then widened to include sexual health, and renamed the Faculty for HIV
and Sexual Health. One of the purposes of the Faculty is to provide guidance
for psychologists in the United Kingdom working therapeutically with sex-
ual and gender-minority clients and to influence the training of psychological
practitioners with regard to working in this area.
When formulating with clients around maintaining factors for issues of distress
relating to sexual or gender identity, there are some key theories and frame-
works which are particularly relevant for clinical psychologists. First, the theory
of minority or marginalisation stress, proposed by Lindquist and Hirabayashi
(1979), suggests that people who are part of a stigmatised minority group within
a society are often exposed to compounded stress as a result of prejudice, dis-
crimination and the threat of violence. There is a large body of evidence which
links traumatic and stressful events, including micro-level stressors such as
minor everyday acts of aggression or discrimination, to the development of
associated emotional and mental health difficulties (King et al., 2008). Hence,
non-heterosexual and non-cisgender4 people within a heteronormative society
tend to be exposed to increased stress and, as such, have a higher vulnerability
to the development of associated difficulties, such as anxiety and depression,
substance use, eating disorders, deliberate self-harm, and suicidality (King et al.,
2008). A recent UK audit of referral data has shown that half of the young peo-
ple with gender identity issues accessing the NHS have experienced bullying
(Holt et al., 2014). Hence, the socio-political environment of sexual and/or gen-
der minority individuals is a hugely important area to emphasise when clinical
psychologists formulate and develop interventions.
A further theoretical framework which lends itself to therapeutic practice
with gender/sexuality-variant individuals is ‘intersectionality’, which takes the
theory of minority or marginalisation stress further and offers a way to think
about such experiences in more intricate, nuanced, and individualised ways.
The term ‘intersectionality’ has been attributed to Crenshaw’s seminal work
270 Psychological Areas
Formulation is central
Formulation is the way in which clinical psychologists try to understand
the problems which people face. When a person comes with a problem
related to their gender or sexuality, it is the responsibility of the clinical
psychologist to work with the person to build up a shared, rich picture
which is informed by the changes which may have taken place in soci-
ety’s attitudes towards gender and sexuality over that person’s lifetime
and to understand the impact this may have had on them.
Intersectionality
Intersectionality is a theory which was originally developed in the field
of sociology and black American feminism, but has influenced research
and debate across a range of disciplines, including clinical psychology.
Intersectionality is concerned with identities and explains how differ-
ent social identity categories such as ethnicity, class, gender, religion,
Jan Burns and Claudia Zitz 271
(Continued)
Formulation is central
Formulations should be based on theory and evidence. The person’s dis-
tress should be seen within their individual context, but placed within
a framework of understanding which theory and evidence offers. Sexu-
ality and gender research has much to offer in terms of understanding
the impact of intersecting, competing, and conflicting roles which may
be central to the distress experienced by the person. Hence, it is vital
that clinical psychologists are both active researchers and consumers of
research. Clients can benefit from evidence-based practice, but research
can also benefit from practice-based evidence.
Intersectionality
Intersectionality is a very useful theoretical framework when design-
ing research studies or trying to make sense of complex findings, as
it allows the researcher to address both particularity and complexity.
Hence, intersectionality is a particularly applicable approach for inter-
disciplinary research, as it offers a converging theoretical framework
which can encompass research from multiple, traditional, and emerg-
ing disciplines in order to address culturally embedded, complex research
enquiries.
engender hope (Di Ceglie, 1998). In such situations, multi-agency working and
a supportive network model approach are advocated (Eracleous & Davidson,
2009). In practice, this may occur in different ways. For example, in the work
with trans* youth this includes organising network meetings with schools
and other professionals, challenging binary and heteronormative assumptions,
offering psycho-education, advising on practical concerns such as toilets, use
of names and pronouns, and writing to institutions and organisations to chal-
lenge trans*-discriminatory policies. Thus, affirmative interventions by clinical
psychologists entail not only clinical engagement with gender-diverse young
people and their families, but also taking a proactive role to challenge the
marginalising effects of wider societal and cultural practices and structures of
discrimination. To influence the social barriers gender-diverse people face on
a societal level requires clinical psychologists to actively engage with policy
change and to carry out more research at systemic levels rather than focusing
on individual gender non-conformity, considering top-down and bottom-up
processes of change, and giving emphasis to a plurality of voices.
Current debates
include gender identifications other than male or female. Gender diversity was
only addressed more recently in the comprehensive BPS guideline (2012) for
psychologists working therapeutically with sexual and gender-minority clients.
In 2013, the Australian Psychological Society (APS) followed suit with a com-
parable guideline for work with sex and/or gender-diverse clients (APS, 2013).
One of the key messages of the BPS guidance is the importance of positioning
individuals within their historically and culturally specific socio-political con-
text and challenging psychopathological views of diverse gender and sexual
identities.
In 2011, the DCP in the United Kingdom published good practice guidelines
on the use of formulation, and proposed that formulations should be used as an
alternative rather than an addition to diagnosis (DCP, BPS, 2011). This stance
was a daring move by the DCP and reflected a wider debate about the usefulness
and validity of diagnosis as well as the potential of psychiatric diagnoses to
have actively harmful effects through stigma (Ben-Zeev et al., 2010). Within
an epistemological context, it also points to a postmodern epistemology taking
a critical stance towards claims of truth, as well as questioning and opening
up relations of power and the constitutive nature of language. Johnstone and
Dallos (2014) argue that the process of formulation should be collaborative; be
shared with the client; be useful rather than true; and be culturally sensitive
and show critical awareness of a wider social context.
Within gender identity clinics, clinical psychologists have taken on an impor-
tant role alongside other disciplines, and it has become a discrete specialist
field of professional practice. Even though many individuals with non-binary
or trans∗ gender identifications never access specialist gender identity services,
some do. In practice, clinical psychologists working in gender identity services
in the United Kingdom will participate in diagnosing gender dysphoria (DSM-
V) or transsexualism (ICD-10) in addition to formulating to these, guided by the
World Professional Association for Transgender Health standards of care (WPATH,
2011) and the Good practice guidelines for the assessment and treatment of adults
with gender dysphoria (Royal College of Psychiatrists (RCP), 2013). Linking for-
mulation and diagnosis in this context may be reflective of such clinics’ close
integration into the medical establishment and the management of access to
physical interventions such as hormones and surgery.
Formulation is central
A formulation should be grounded in up-to-date theory and evidence,
and should be person-specific, not based on a specific categorisation of a
problem. It needs to incorporate a person’s context and history and draw
out the implications of this in terms of understanding the individual’s
distress. It should also lead to a clear set action plan which is acceptable to
the person. Understanding the changing history and cultural context of
sexuality and gender is vital in developing a formulation when a person
presents with distress relating to these issues.
Intersectionality
Intersectionality illustrates how different social identity categories, such
as ethnicity, class, gender, religion, and so on, interrelate and position
individuals in unique and sometimes concurrent, multiple positions of
oppression and/or privilege. When working with a person, it is thus
important not to make generalisations or assumptions based on one
(marginalised) identity position, but to carefully explore with a client
how divergent identities may interrelate and may offer multiple expe-
riences of oppression and/or access to power and privilege, at times
concurrently. Clinicians will need to engage in a process of reflexive prac-
tice to examine their own positioning pertaining to social identity norms
and reflect how these may impact their therapeutic relationships and
practices.
This multi-layered approach has implications for the positioning and clini-
cal orientation of clinical psychologists who work with gender and sexually
diverse clients. Clinical psychologists working with individuals who present
to gender identity, DSD, sexual health, and mainstream mental health clinics
can play a pivotal role in determining whether clients receive treatment, and
at times take on a ‘gatekeeper’ role. The challenge of such a role is well
articulated through the debate about the inclusion of gender dysphoria, and
previously gender identity disorder, in the DSM or transsexualism within the
ICD. Opponents’ main arguments stipulate that diagnosing through labelling
and medicalisation reinforces stigma, because it locates the problem in the indi-
vidual and does not question society’s perpetuating role of eliciting distress
(BPS, 2011). Furthermore, it undermines individuals’ right to self-actualise and
self-designate their gender, promoting a system of cisgenderism (Ansara &
276 Psychological Areas
Future directions
Richards et al. (2014) discuss in more detail the complex issues and ten-
sions clinicians face by being gatekeepers, particularly when they hold clinical
responsibility for the treatment decisions. Informed consent and the decision-
making processes attached to potentially irreversible physical interventions can
be particularly potent when working with people with very complex needs, and
especially in the context of additional histories such as forensic or severe men-
tal health issues. Clinical psychologists no longer hold on to the privileged
position of experts but are expected to co-construct a formulation with the
individual, within an expected breadth of explanation ranging from under-
standing the condition as described by the individual to the place of that
condition in the broader social, economic, and political world, and the reflexive
impact of that positioning upon the individual’s experience and response. From
this position they are then expected to assist the individual and those others
involved in complex decision-making about access and take up of treatment.
This is no small requirement, and it is also why continued registration with
regulatory bodies is predicated on the expectation of continued professional
development and access to sufficient, ongoing, quality clinical supervision, in
addition to monitoring that one’s own ability to practise is not impaired due
to poor psychological or physical health status. However, despite the challenge
and complexity of working in this area, the contribution of clinical psychology
is well valued, with opportunities for multidisciplinary working increasing and
the breadth of the application of clinical psychology ever widening. Clinical
psychology practice, especially in this area, requires examination of personal
and societal values and a keen sense of justice. The psychological practitioners
attracted to work in this area share the intersectionality of their professional
status with their gender/sexuality identity; some of them will not be hetero-
sexual or cisgender and, as such, will bring added value to their practice. Being
able to recognise this demonstrates that clinical psychology has travelled some
distance and undoubtedly offers a more promising future than one might have
predicted from its early activities in relation to human sexuality and gender
development.
Jan Burns and Claudia Zitz 277
Summary
Note
1. Named after where it was held: Boulder, Colorado, US.
2. The DSM 1 was 130 pages long and listed 106 mental disorders; the recent publication
of DSM 5 is 927 pages long and contains over 300 disorders.
3. UK entry into the profession is now about 85% female, of whom around 95% describe
themselves as heterosexual/straight. Retrieved from www.leeds.ac.uk/chpccp/index
.html [Accessed 3 July 2014].
4. ‘Cisgender’ refers to someone whose gender identity matches the sex they were
assigned at birth.
5. It should be noted, however, that many individuals occupying marginalised sexual
or gender positions are extremely resilient despite such challenges, and, as they do
not appear within clinical services, it is sometimes easy for practitioners to draw
over-definite conclusions about the psychological vulnerability of such marginalised
groups.
6. trans* with the asterisk is used to include a wide range of gender identifications includ-
ing transgender, transsexual, trans woman, trans man, but is also inclusive of identities
not starting with the prefix trans e.g. genderqueer, non-binary etc. The asterisk is based
on a web search facility where the asterisk functions as a wildcard and placeholder.
Further reading
Butler, C., O’Donovan, A., & Shaw, E. (Eds.) (2009). Sex, sexuality and therapeutic practice:
A manual for therapists and trainers. East Sussex: Routledge.
278 Psychological Areas
Das Nair, R. & Butler, C. (2012). Intersectionality, sexuality and psychological therapies:
Working with lesbian, gay and bisexual diversity. West Sussex: Wiley & Sons.
Johnstone, L. & Dallos, R. (Eds.) (2014). Formulation in psychology and psychotherapy:
Making sense of people’s problems (2nd ed.). East Sussex: Routledge.
Richards, C. & Barker, M. (2013). Sexuality and gender for mental health professionals:
A practical guide. London: Sage.
Wren, B. (2014). Thinking postmodern and practicing in the enlightenment: Managing
uncertainty in the treatment of children and adolescents. Feminism & Psychology, 24(2),
271–291.
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American Psychological Association (2000). Guidelines for psychotherapy with lesbian, gay,
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American Psychiatric Association (2000). Diagnostic and statistical manual of mental
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Ansara, Y. G. & Hegarty, P. (2012). Cisgenderism in psychology: Pathologising and mis-
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271–291.
16
Counselling Psychology
Dawn Clark and Del Loewenthal
History
280
Dawn Clark and Del Loewenthal 281
self where social influences distorted it (Rogers, 1959, 1967) perhaps provides
one of the most basic potential starting points in applied practice, with subjec-
tive client distress linked to social pressures to conform to gender/sexual-role
expectation. Rogers drew his ideas from phenomenology, and in the United
States phenomenology and humanism became linked, transforming existen-
tialism into a focus on ‘self-actualising’ (Hollway et al., 2007). In Europe,
phenomenology and philosophy remained linked and tied to less optimistic
views of humanity, with a central focus on individuals in relation to the social
world.
It is only fairly recently in Westernised societies that sexual selves (despite
same-sex sexual orientations being documented since the Greeks) have come
to be defined as heterosexual or homosexual as a result of the biological
sex of partners (Weeks, 2000). This is a shift from describing the sexual
behaviour of a person to using sexual behaviours to define the self, which
suggests that sexual minorities are different from the heterosexual majority
based on sexuality and leads to far more assumptions about sexual minor-
ity identities which far exceed their sexuality (Hicks & Milton, 2010). Many
would argue that this does not sit comfortably with theories of the self,
Freudian theory of psychosexual development or contemporary analytic con-
cepts, such as intersubjectivity (Habermas, 1987; Trevarthen, 1986), which
goes beyond a self-contained model of the self (Boothby, 2005). In relational
psychoanalytic versions of intersubjectivity, the person is made up of intro-
jected parts of others (Ferenczi, 1905; Klein, 1946) and introjected social
expectations regarding gender or sexuality (see Chodorow, 1978; Mitchell,
2000). In terms of sexuality, with its multiple dimensions of behaviour,
attraction, emotion, fantasy, and social aspects, such as morals or political
constraints (Hicks & Milton, 2010), we might wish to consider how much
knowledge of the gendered/sexual self is actually consciously available to
the individual (Gyler, 2010). Perhaps we should also ask how much of an
individual’s sense of sexual/gendered self is given meaning in relationship,
not least within the therapeutic relationship. Frequently, phenomenological
perspectives see the self in terms of a relationship between an individual’s
social world and their experience of that world. In direct opposition to
notions of fixed identities connected to our genders or sexual partners, our
most dominant perspectives would suggest that sexuality and gender are
dynamic and socioculturally dependent (Diamond, 2000), incorporating ele-
ments of subjectivity (see Henriques et al., 1984), performativity (see Butler,
1999), free choice (see Sartre, (2003 [1943]), and embodiment (see Merleau-
Ponty, 1965), and our understandings of these concepts are couched within
historically, culturally, and politically situated knowledges (see Harraway,
1999).
284 Psychological Areas
Trainee psychologists might want to think about how they engage with
bodies and embodiment, in their work with clients (see Fausto-Sterling,
2000; Grosz, 1994) and in their own supervision and therapy.
Student psychologists might also wish to explore the centrality of the
gendered self in psychoanalytic/psychodynamic modalities (see Boothby,
2005; Gyler, 2010; Mitchell, 2000) with respect to a relational, intersub-
jective approach (see Aron, 2006; Aron & Mitchell, 1999; Benjamin, 1995,
2004).
Students may also want to further their studies on attachment (Bowlby,
1973, 1988) and attachment in psychotherapy (Wallin, 2007) with per-
spectives focusing on attachment in sexuality and sexual relationships
(see White & Swartz, 2007).
Students could also consider how factors such as class may affect peo-
ple’s experience and expression of sexuality (see Guttwell & Hollander,
2006; Skegs, 2010) and gender (Walkerdine et al., 2001).
Current debates
Case study
Kirsten is a trainee counselling psychologist. She is white and middle-class and
self-identifies as a heterosexual cisgender woman. Kirsten receives little formal
training in gender or sexuality. Kirsten says she has never been homophobic,
knows a lot about ‘gay issues’, goes to ‘Pride’, and has gay male friends. Kirsten
claims a commitment to “non-judgemental practice” and says she “empathises
with the LGBT community”. Although she has worked with gay and lesbian
clients, who she does think have “quite a lot of problems” because of their sex-
uality, Kirsten admits she prefers working with gay men rather than lesbians
because she finds lesbians “a bit too butch” whereas gay men are “generally
softer”. Kirsten thinks many clients have internalised homophobia and this
upsets her because sexual minorities have rights and she wants to “help them”
overcome this. Today Kirsten presents a client in supervision whom she found
“difficult”. Leon was a working-class, mixed-race (Afro-Caribbean) scaffolder.
Dawn Clark and Del Loewenthal 285
He had served two prison sentences for GBH and theft. Leon presented to the
service with stress following arguments with his ex-wife about access to his
three children, which he had fought for in the family court. There were also
issues with Leon’s new partner, who did not want the children staying every
other weekend. Kirsten, who couldn’t understand this, had asked why Leon’s
girlfriend didn’t like children. Leon, who was in a relationship with another
man but had not identified on monitoring forms as ‘gay’ or ‘bisexual’, corrected
her on this. Kirsten tells her supervisor she had felt embarrassed at her assump-
tions but struggled with Leon’s presentation as she thought he was “denying his
sexuality because of internalised homophobia”, which she thought they should
“work on”. When she raised this with him, Leon became angry, storming out
of the session, and Kirsten felt quite frightened. Leon subsequently cancelled
his sessions. Kirsten tells her supervisor she thinks Leon was “in denial about
his sexuality and needed more therapy”. Kirsten also wondered whether Leon
was ‘really’ bisexual or whether Leon’s ‘homosexuality’ may have even been
‘situational’, as he had begun having sex with men in prison, so perhaps he
wasn’t “really, properly gay”. He did have a wife and children and was certainly
more aggressive than she would expect of a gay man. Kirsten tells her supervi-
sor she is confused and upset because she couldn’t ‘help’ Leon: perhaps he was
not ready to confront his ‘issues’.
Although ‘Kirsten’ is not a real trainee, research would suggest she is well rep-
resented on counselling psychology courses (Anhalt et al., 2003) and research
samples (Vacha-Haase and Thompson, 2004). She is also well represented from
our experiences in the prison/offending services, and in the sexual health ser-
vices one of us (Clark) has worked in, whereas ‘Leon’, despite being represented
in such services, is rarely recruited in research samples as he does not conform
to labelling (Diamond, 2003). Moreover, research would suggest a significant
majority of trainees, like Kirsten, would be ill prepared for some of the issues
raised in this case study. UK research indicates that counselling psychologists
believe they had inadequate training on sexual minority issues (Moon, 1992,
2002). Others in the United States feel similarly (Sherry et al., 2005). The neces-
sity of the inclusion of a section in the Handbook of Professional and Ethical
Practice for Psychologists, Counsellors and Psychotherapists dedicated to the ethical
practice of working with lesbian and gay men would suggest we still have a way
to go before we can be as confident as Kirsten that we know a lot about ‘gay
issues’ in psychology (see Moon, 2005).
Kirsten also overlooked Leon’s presenting issues, which were stress connected
with access to his children and arguments with his partner and ex-wife. Kirsten
reformulated these into issues connected to Leon’s sexuality. Research would
suggest therapists are more inclined to do this with non-heterosexual clients
(Hicks & Milton, 2010). Kirsten also believes non-heterosexual clients have “a
lot of problems”, and, despite studies indicating that self-identifying lesbians
286 Psychological Areas
and gay men seek therapy at a higher rate than self-identifying heterosexu-
als (Cochran et al., 2003), we might want to be mindful that these groups
are members of a stigmatised minority with a heightened exposure to stress
(Herek & Garnets, 2007) due to social, rather than individual, factors (Ritter &
Terndrup, 2002). Our trainee Kirsten appears to locate these problems within
her clients, rather than in the sociocultural context. Interestingly, this could be
influenced by Kirsten’s familiarity with overt celebrations of gay life, such as
‘Pride’ marches, or people automatically having ‘gay rights’, which may tend
to obfuscate the more insidious forms of heterosexism embedded in societal
structures (Yep et al., 2003). Moreover, this illuminates a critical issue here in
terms of homogenising practices in sexual minority research, which is biased
towards knowledges and understandings drawn from the ‘activist community’,
to which many sexual minority individuals do not belong. Kirsten’s notion
of a unified ‘Lesbian, Gay, Bisexual and Transgender (LGBT) community’ has
been evidenced as a factor which can make it harder for therapists to under-
stand those, like Leon, who remain outside it (Asta & Vacha-Hasse, 2013).
Simple conceptualisations of inclusive ‘LGBT’ research can deny the difference
between these groups and within them (Phillips et al., 2003). This may be due
to the homogenising practice of using this acronym, which can obfuscate the
differences within and between the groups. For example, sexual minority rep-
resentation is often class-biased; there are vast differences between gay men
and lesbians in terms of experience and gender equality; bisexual-only-focused
research is rare; and many transgender people self-identify as heterosexual.
In these respects (which are certainly not exhaustive), we might want to be
mindful of the potentially homogenising effects of the LGBT acronym, which
may erroneously imply to psychologists that there is a unified, equally repre-
sented ‘LGBT community’ and can lead us to deny the subjective experience of
many sexual and gender minorities (DeBlaer et al., 2010).
Further to this, Kirsten’s assertion that she has never been ‘homophobic’
may also require unpacking. Focusing on a decontextualised construct like
‘homophobia’ discursively allows Kirsten to navigate around our own hetero-
sexual privilege (Johnson, 2006) and deflect any guilt about this (Ji, 2007).
Protestations that we are not ‘homophobic’ avoids recognition of the ways
we might inadvertently perpetuate inherently negative messages and perva-
sive power relations in our society (Smith & Shin, 2008). This also helps Kirsten
dodge any complicity in heterosexist/heteronormative practices like psychol-
ogy. As Yep and colleagues (2003) assert, “heteronormativity is everywhere.
It is always, already present in our collective psyches, social institutions, cul-
tural practices and knowledge systems” (p. 11). Social justice in counselling
psychology for sexual minorities cannot be achieved by heterosexuals such as
Kirsten simply accepting, affirming, or celebrating ‘LGBT communities’ (Smith
et al., 2012). This would require a systematic dismantling of heteronormative
Dawn Clark and Del Loewenthal 287
our uses of binary discourses (Seidman, 1996). These bring about an ‘either or
stance’ and may be implicated in Kirsten’s denial of any fluidity in sexual ori-
entation with regard to whether Leon is ‘bisexual’ or ‘really’ gay, and she might
want to think further about her ideas concerning ‘situational homosexuality’,
which is at odds with this (Troiden, 1998, p. 270). It seems, for Kirsten, that
being ‘really gay’ may mean a liberated, often educated and middle-class,
activist gay man who takes part in pride marches and is certain of his rights
to equality and to community, which, as we stated before, is unsurprising, as
these individuals may be more likely sampled in research, which reminds us
that it is important to consider factors like this before subscribing to evidence
in research in counselling psychology which may fall short of its purported
inclusive, social justice agenda (Asta & Vaccha-Hasse, 2013).
We should also probably acknowledge here how some of Kirsten’s assump-
tions and beliefs may also be influenced by central constructs to the discipline
of counselling psychology, namely her notions of ‘empathy’ and of ‘non-
judgemental’ clinical practice (Greenberg & Elliot, 1997; Orange, 2002). These
are often recanted by applied psychologists and professionals as though they
were givens or explicitly achievable states, which is highly debatable. Can we
really put ourselves in the place of the other and empathise with their sub-
jective experience? Kirsten certainly seemed to struggle to empathise with the
‘butch lesbian’. Moreover, what is an assessment session or case formulation
if it is not a series of judgements? Kirsten judged Leon’s presentation as being
led by his sexual orientation – an error of judgement in assessment and formu-
lation. Importantly, these were social, not clinical, judgements. Indeed, there
is cogent argument that most clinical judgements in psychology (diagnostic
or therapeutic) are predominantly little more than social judgements driven by
dominant ideologies in our culture (Burr, 1995; Davies, 2013; Evans et al., 2011;
Kutchins & Kirk, 1997). The history of homosexuality as a psychiatric category
is a case in point.
As counselling psychologists, we should be interrogating issues such as those
raised in this case study in research and practice to avoid becoming ‘compla-
cent in the deceptive reassurance that [we] are relatively tolerant or basically
open-minded about [issues] decidedly more complicated and elusive than is
immediately apparent’ (Rudolf, 1988, p. 166). However, where and with whom
might we explore this? Like Kirsten, many clinical supervisors and therapists
have often not explored their own sexuality and gender in any real depth,
and there is rarely training in these areas for psychologists (Toporek & Vaughn,
2010). Moreover, can we study sexuality and gender as objects in themselves?
And can we really be open to difference in this climate of professionalisation?
A non-defensive engagement with our own gendered selves and sexualities may
help us to approach this with our clients with a view to attaining and exploring
intimacy and relationship. However, we are embedded in our own experience,
Dawn Clark and Del Loewenthal 289
and attempts at being open to difference in such radically changing times may
actually be becoming more, than less, of a challenge for psychologists.
Research (see Smith et al., 2012) illustrates that psychologists may sub-
ject patients/clients to micro-aggressions concerning their gender and
sexuality. Micro-insults are characterised by behavioural or verbal acts
which convey rudeness, insensitivity, or snubs: they may often be out
of the awareness of the perpetrator, but clearly convey hidden, insulting
messages (see Sue, 2010). Micro-invalidations are communications that
subtly exclude or nullify the feelings, thoughts, or experiential reality of
a person (see Sue & Sue, 2008).
Steps to analysis
1. Begin by identifying and listing direct messages (“Boys don’t play
with dolls”) and indirect messages (media representations of sex as
enjoyed only by the young or attractive) of sex/gender/heteronormative
roles/expectations received.
2. Identify potential and actual consequences of these messages, both positive
and negative.
3. Try to identify the external messages that may have been internalised.
A good indicator of this will be in the way we draw upon everyday discourses
without examining the power relations within them, or the possible sources
of those power relations and ideological assumptions (“I can’t leave my hus-
band with the baby all night. He won’t be able to cope” or “A lesbian couple
would probably be better at raising children than two gay men”).
4. We may then begin to decide, after exploring the positives and negatives of
those internalised messages, which we might like to keep and which to try
to dispose of. However, this is not an easy task, as many messages are so
deeply embedded in our sociocultural context and are constantly produced
and reproduced by it. Some beliefs are so strong that we may be unwilling
to let go of them, or perhaps may not be able to let go of them, so changing
those beliefs should not be forced; rather, we should concentrate on those
beliefs becoming more conscious as a source of difficulty or being more easily
identified for change or improved awareness.
5. We can then move from identification of internalised messages to conscious
acknowledgement, awareness, or plans for change.
6. Here we might implement the planned change and explore it in terms of
changing thoughts, attitudes, evidence, and behaviour.
In respect of the above exercise, which obviously has capacity for expan-
sion and far wider exploration than the space for this chapter will allow, we
also might want to engage with the inherent power relations (positive and
negative, direct and indirect) in applied psychologies/therapies themselves.
Drawing from an academic understanding of power similarly to feminist ther-
apists (Evans et al., 2011), using a framework adapted from French and Raven’s
(1959) taxonomy of power and influence, we can become more mindful of
how power circulates in the consulting room and academia. Acknowledge-
ment of power and our engagement with it as applied or research professionals
should, perhaps, be at the forefront of all critical or social justice-focused work
in counselling psychology. In brief, coercive power is described as “one’s ability
to manipulate the behaviour of others” (French & Raven, 1959, p. 156), and
with respect to psychology/therapy this should be self-explanatory. Legitimate
power “stems from internalised values in p which dictate the o has legitimate
right to influence p and that p has an obligation to accept this influence”
Dawn Clark and Del Loewenthal 291
(French & Raven, 1959, p. 159). When a client is referred to us, this legitimates
our right to influence that client, and in many cases the client may be obliged
to accept that influence. Expert power is that of the ‘expert’ to influence others’
behaviour with their accepted knowledge base (Raven, 1992). This power base
is, perhaps, the one with which counselling psychologists, with their scepti-
cism concerning expert discourses and their pluralist approach, should already
be engaging – though this is never a given, as most traditional psychologi-
cal approaches which influence the discipline do draw from expert discourses.
Here, perhaps we might want to ask who is the expert and why (Burchill et al.,
1991) and acknowledge that this notion of ‘expert’ is connected to informa-
tional power. This can be indirect or direct power based on information (Raven,
1992, 1993). Here, the counselling psychologist’s necessary background in tra-
ditional psychology perspectives may influence their power, as they draw from
research and perspectives which may not accommodate the client in question
but, rather, fit the world view of the psychologist and psychology itself (Parker,
1995). Referent power operates when the target of influence “would comply
because of a sense of identification with the influencing agent or a desire for
such an identification” (Raven, 1993, p. 233). This power relation in therapy
may play out where a client feels they may have a therapist who is unable to
accommodate their own experience. These simple exercises and explorations
can be very powerful, for want of a better word, and may illuminate issues
or bring about awareness in sex/gender/sexuality work which may otherwise
remain dormant. However, we would suggest that therapists familiarise them-
selves with academic perspectives on power and deconstruction in therapy (see
Parker, 1999) and use the role analysis as a self-reflexive tool before using it
with clients or in clinical supervision sessions. Analyses of therapist gender-
role expectation, socialisation, and their power and influence in the areas of
sex, gender, and sexuality should be integral to the reflexive practices of all
counselling psychologists.
Foucault often wrote about the body, but his writings largely overlook
sexuality and sex (Foucault, 1972, 1976, 1977, 1980, 1981, 1982, 2003).
Academics might want to reconsider discourse with regard to gender
(see Wodak, 1997) and recent developments with regard to discourse
and sexuality: for example, in the ideological powerplays in binary dis-
courses (Smith et al., 2012) led by advances in queer theory (Seidman,
1996). However, we might also want to take a critical approach to the
ways discursive psychologists and discourse analysts argue bodies are
constituted in discourse (Parker, 1995).
292 Psychological Areas
Future directions
Summary
Further reading
Foucault, M. (1979 [1976]). The history of sexuality Volume 1: An introduction. London:
Allen Lane.
Gyler, L. (2010). The gendered unconscious: Can gender discourses subvert psychoanalysis?
London: Routledge.
Moon, L. (2008). Feeling queer or queer feelings? Radical approaches to counselling sex,
sexualities and gender. Hove: Routledge.
White, K., & Swartz, J. (2007). Sexuality and attachment in clinical practice. London: Karnac.
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Counseling Psychologist, 36, 462.
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Wodak, R. (1997). Gender and discourse. London: Sage.
Woolfe, R., Strawbridge, S., Douglas, B., & Dryden, W. (2010). The handbook of counselling
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Worrell, J. & Remer, P. (2003). Feminist perspectives in therapy. Hoboken, NJ: Wiley.
Worthington, R., Bielstein, H., Savoy, F. R., and Vernaglia, E. R. (2002). Heterosexual
identity development and multidimensional model. The Counseling Psychologist, 30, 46.
Yep, G. A., Lovass, K. E., & Elia, J. P. (2003). Introduction: Queering communication:
Starting the conversation. Journal of Homosexuality, 45, 1–10.
17
Health Psychology
Joanna Semlyen
Introduction
History
300
Joanna Semlyen 301
However, this gap in life expectancy is narrowing in Western society. The reason
is two-fold: men have reduced their rates of smoking, are involved in fewer acci-
dental deaths and suicides, and so are living longer. At the same time, women
are mimicking and adopting typically ‘masculine’ health risk behaviours and,
as such, are increasing their morbidity and mortality (Blackman et al., 2011).
turn, can lead to them experiencing greater mental health problems (Lombardi,
2001).
Intersectionality
Being part of more than one minority group leads to greater marginalisation
and subsequent cumulative health inequalities. Older trans people experience
a particular set of health inequalities. In a recent study, Fredriksen-Goldsen et al.
(2014) found a high prevalence of depression and anxiety in this group, a high
level of victimisation (often associated with subsequent mental health prob-
lems), and a low level of social support. Isolation such as this is frequently
related to higher stress and poorer physical health in the general population.
Topics of relevance to a trans health psychology would be the importance of
tailored and inclusive health education and health promotion for this popula-
tion and their health providers, recognition of the differences within the non
cisgendered population and between cis and non cisgendered populations: and
a careful focus on mental health.
UK LGB population data are very rare; however, a recent study in the United
Kingdom has demonstrated that both lesbians and bisexual adolescents have
increased odds of smoking compared with their heterosexual counterparts
(Hagger-Johnson et al., 2013). The study also found increased hazardous drink-
ing in the study’s lesbian and gay youth. In addition to increased risk from a
sexual minority status, evidence suggests that risks for smoking in this group
also include mental ill-health, life dissatisfaction, alcohol use, exposure to
tobacco marketing, and single relationship status (Balsam et al., 2012). Smoking
cessation programmes need to take into account the needs of LGB smokers.
There is very little peer-reviewed evidence of smoking cessation interven-
tions in LGB population, and yet the increased prevalence would place this
overlooked group as a health psychology intervention priority (Harding et al.,
2004).
Future directions
synonymous with being ‘out’. For others, it may mean being able to disclose
one’s sexuality to a healthcare professional, and we know there is evidence
that disclosure is likely to increase the likelihood of seeking and gaining help
for mental health problems (Meckler et al., 2006). If an LGBT person is not
comfortable with their own sexuality/gender identity, it is reasonable to expect
that they are probably less likely to engage with healthcare services, and this
reduction in engagement could lead to poorer overall health (Wilkinson, 2002).
Non-heterosexuals and trans people are not one homogeneous group.
Instead, they represent different and interacting gender identities and
sexualities, with diverse health needs and issues, different illness prevalence
and disease risks, and dissimilar health service experiences. For example,
research shows that bisexuals have poorer health. One US study using data
from the Massachusetts Behavioral Risk Factor Surveillance Survey found that
bisexuals are more at risk of health disparities than lesbian and gay participants
(Conron et al., 2010). Moreover, the diversity of health issues and lived experi-
ence within LGBT people is also important. For example, Kitzinger (2001) talks
about a distinct lesbian health, and there is a growing interest and awareness of
bisexual health being different and differently experienced from Lesbian and
Gay health (Barker et al., 2012). Health psychology interventions need to be
LGBT sensitive: interventions need to acknowledge particular ways in which
LGBT conceptualise and understand health and how they perceive ways of
improving health. LGBT people’s differing health needs and health must be
understood.
publication rates. Moreover, this picture is not changing over time, so LGBT
health psychology remains marginalised (Lee & Crawford, 2007).
Indeed, on a wider level, literature indicates that one of the issues preventing
targeted resources is a lack of known statistics on this population. Population
studies with large datasets allowing diversity within the LGBT study sam-
ple would also allow us meaningful comparative analyses and thus facilitate
guidance on targeted health psychology interventions and resources.
Summary
Note
1. Homosexuality was considered a criminal offence (until 1967 in England, 1980 in
Scotland, and 1982 in Northern Ireland) and a mental illness (until 1973).
2. The mental health professionals in this study were members of either the British Psy-
chological Society, the British Association for Counselling and Psychotherapy, the
United Kingdom Council for Psychotherapy, or the Royal College of Psychiatrists.
Further reading
Clarke, V., Ellis, S. J., Peel, E., & Riggs, D. W. (2010). Lesbian, gay, bisexual, trans and queer
psychology: An introduction. Cambridge: Cambridge University Press.
Clarke, V. & Peel, E. (Eds.). (2007). Out in psychology: Lesbian, gay, bisexual, trans and queer
perspectives. New York, NY: John Wiley & Sons.
King, M., Semlyen, J., Tai, S. S., Killaspy, H., Osborn, D., Popelyuk D., & I. Nazareth.
(2008). A systematic review of mental disorder, suicide, and deliberate self harm in
lesbian, gay and bisexual people. BMC Psychiatry, 8(70), 1–17.
Lyons, A. C. & Chamberlain, K. (2006). Health psychology: A critical introduction.
Cambridge: Cambridge University Press.
Marks, D. F., Murray, M., Evans, B., & Estacio, E. V. (2011). Health psychology: Theory,
research and practice. London: Sage.
312 Psychological Areas
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18
Qualitative Methods
Sarah Seymour-Smith
Introduction
Gender and sexuality invoke a wide spectrum of topics which attract the
interest of both the media and academia, but the impact of our gender and
sexuality is also an everyday presence for many of us. One example of this
is outlined in Liz Peel’s (2001) work on what she refers to as “mundane
heterosexism”. Peel’s argument is that overt forms of sexism are easy to chal-
lenge due to their easily identifiable quality, whereas more subtle forms of
heterosexism are not as easy to address. Peel (2001) makes the point that in
the Western social context heterosexist views are normative yet still impact on
the lives of those who do not ‘fit’ into the norm, but responding to such sexism
is difficult due to its pervasive presence.
Qualitative research can be broadly categorised as a means of finding out
about people’s experiences and meaning-making and can be broadly glossed
into two camps: experiential research, which aims to document people’s expe-
riences, views, and practices; and critical research, which aims to interrogate
dominant meanings and deconstruct these (Clarke et al., 2010). Each camp
has its own theoretical assumptions about the way that data are collected and
analysed, with early research focusing on case studies. These days we have
numerous ways of conducting qualitative research, and in this chapter some
of the principal methods are introduced, with some of the key debates. The
first section introduces early research in the field and explains why qualita-
tive research in the area of gender and sexuality is important. Next, the goals
and focus of three key qualitative research methods are illustrated with recent
research examples.
Beginnings
Gender and sexuality are both important categories and a means of locating and
understanding our place in the world; they are omnipresent and thus impact
on all aspects of our lives, from our relationships to our work, albeit more so
for those who ‘deviate’ from mainstream understandings.
316
Sarah Seymour-Smith 317
(Continued)
A plethora of qualitative methods are now available to choose from, for exam-
ple: thematic analysis (Braun & Clarke, 2006), grounded theory (Charmaz,
2006), interpretative phenomenological analysis (Smith et al., 2009), discourse
analysis (Wiggins & Riley, 2010), and conversation analysis (Sidnell & Stivers,
2012), to name a few. The question, issue, or topic that is addressed through
qualitative research determines the approach that is ultimately undertaken and
the claims that can be made. Similarly, the choice of data collected involves a
consideration of how best to address the phenomena at hand. Semi-structured
interviews are the most common form of qualitative data collection, and are
ideally suited to exploring experiential or life history and narrative types of
research where a key goal is to give ‘voice’ to participants. Focus groups are also
common and are useful for exploring perceptions, beliefs, and attitudes. Media
data (such as newspapers, radio talk, and television), online support groups, and
videos uploaded onto YouTube provide an easily accessible route for exploring
how certain issues are constructed. Data can also be collected through observ-
ing or video/audio recording various phenomena or sites of interest, such as
classroom interactions or counselling sessions. However, whatever data are col-
lected should adhere to the guidelines provided by the British Psychological
Society in line with issues such as informed consent. Furthermore, while qual-
itative research is typically described as inductive, even conversation analysts,
who tend to work with ‘naturalistic’ data (data that would arguably exist if
the researcher were not present, such as telephone conversations or meal time
Sarah Seymour-Smith 319
Experiential research
Experiential research prioritises participants’ interpretations of their life world,
giving voice to, and validating, their experiences and practices (Braun &
Clarke, 2013). As such, this approach is ideal for studying gender and sexu-
ality (Smith et al., 2009) in a way that can produce a better understanding of
how individuals make sense of meanings from their own frame of reference.
Interpretative phenomenological analysis (IPA) is one such approach, which
is becoming increasingly popular. Led by Jonathan Smith, IPA is influenced by
theoretical traditions of phenomenology (with a focus on the way individuals
experience and gain knowledge of the world around) and hermeneutics (the
interpretative analytic process) (Shaw, 2010; Smith et al., 2009; Willig, 2005).
IPA is a critical realist approach and assumes a chain of connection between
people’s talk and their emotional state (Smith & Eatough, 2007). However,
while taking seriously the intent to encourage participants to reflect on, or
interpret, their own experiences, IPA researchers refer to the double hermeneutic
to acknowledge the impact of the researcher in the data collection and inter-
pretation process (Shaw, 2010). IPA is also an idiographic approach, meaning
that analyses are grounded in the individual level and built up on a case-by-case
basis (Shaw, 2010). As a consequence, IPA studies typically work with relatively
small, fairly homogeneous samples in order to explore detailed experience, yet
can still explore similarities and differences between cases. It is further argued
that it is possible “to move to more general claims with IPA but this should only
be after the potential of the case has been realised” (Smith et al., 2009, p. 3).
Recent research about understanding the impact of the human
immunodeficiency virus (HIV) diagnosis among gay men in Scotland (Flowers
et al., 2011) provides a good illustration of an IPA approach. Changes in the
management of HIV with the introduction of anti-retroviral therapies (ARTs)
320 Psychological Areas
and increased HIV testing have arguably transformed HIV from a fatal disease to
a chronic manageable infection (Flowers et al., 2011). Gay men constitute 48%
of UK people diagnosed since 2010 (Health Prevention Agency, 2010). Flowers
and colleagues were keen to understand the impact of such diagnoses. Their
study focused on 14 HIV-positive gay men and took a novel team approach
to analysis, with Paul Flowers (a gay man familiar with HIV) and Stephanie
Crouch (a heterosexual woman with limited HIV experience) both coding each
interview (manually and with NVivo software, respectively) in order to verify
each other’s analytic insights.
IPA revealed the temporal and psychological aspects associated with identity
and stigma. Three themes were identified: crisis, loss, and challenges; inte-
grating HIV and experiencing a sense of damaged identity; and adjustment
and assimilation. HIV diagnosis led to an intense period of crisis for the men,
often with attempts to reclaim a pre-diagnosis version of their identity. Flowers
et al. critiqued the current trend to conceive ART as changing the prognosis
of many living with HIV to ‘a chronic manageable infection’ with reduced
negative psychological impact. Indeed, their study highlights how the psy-
chological concerns still endure despite the improvements in prognosis. The
research also highlighted a generational pattern, with younger, more recently
diagnosed, participants describing a slightly easier adjustment to HIV diagnosis
in contrast to the older participants. They also identified the relational difficulty
of an HIV-positive identity, which led to fears about stigma. Analysis of one
data extract in particular highlighted the perceived loss of control about disclo-
sure of their status when confronted with changed appearances as a result of
lipodystrophy (fat-redistributing side effects of first-wave ARTs). However, the
participants also discussed the notion of identity assimilation, which resulted
in improved attitudes about their identities post diagnosis. The study exempli-
fies how taking participants’ experiences seriously can highlight problems with
current perceptions of the success of HIV treatment. Without such research, a
biomedical model might consider that improvements to treatment equate to an
HIV-positive identity as ‘normalised’ without fully understanding the complex
lived realities of changing psychological concerns.
Insider/outsider considerations
Flowers et al.’s (2011) research took a novel approach of using both insider and
outsider perspectives. The majority of my own research is about masculinities,
mostly in relation to men’s health but also applied to other issues such as
male sex offenders. As a white, middle-class, middle-aged, heterosexual, fem-
inist woman, what right do I have to study men? Furthermore, what problems
might be associated with this?
In psychology we often warn against insiders conducting research on the
grounds that the research may lack critical distance and possibly result in biased
Sarah Seymour-Smith 321
(Continued)
analysis, then, is the story itself, and researchers from different fields have iden-
tified a number of methods of analysis. According to Labov (1982), every good
narrative tends to contain six organising elements: the abstract, a section that
orients to the contextual details of the story, a complicating action, an evalua-
tion, a resolution, and finally a coda. Labov’s structural model of narrative, and
his suggestion that all narratives have common properties, is informative, but
has been criticised for telling us little about the relationship between the teller
and the recipient (Riessman, 1993). Many have argued, instead, that life sto-
ries are reflexive and are “interpretative feats” (Bruner, 1987) which constitute
reality (a more critical stance).
According to Linde, the analysis of narrative should move
from their families and friends, from popular culture that surrounds them
and from the stories of other ill people, storytellers have learned formal
structures of narratives, conventional metaphors and imagery, and standards
of what is and is not appropriate to tell. Whenever a new story is told, these
324 Psychological Areas
Telling stories, then, can bring order to disorder (Murray, 2008), but what hap-
pens when that disorder is difficult to transcend? One example of narrative
analysis which considers the consequences of ‘tellability’ in some depth is
the case study of the life story of a man who experienced spinal cord injury
and became disabled through playing the highly gendered ‘masculine’ sport of
rugby union football. This was the work of Brett Smith and Andrew Sparkes
(2008), who considered how Jamie (a pseudonym) moves from one form of
embodiment (a fit and active man) to another (to a man with limited mobil-
ity due to paralysis from the neck down). Jamie was interviewed three times
over a period of a year. The paper highlights the pressure from therapists and
other health professionals for individuals like Jamie to construct ‘success’ sto-
ries. Following the work of Frank (1995), it is argued that bodies give stories
their particular shape and direction, and the ‘restitution narrative’ determines
a basic plotline of bodies as being healthy, then sick, but with a projectable
new health in the future. Pressure to adhere to this restitution story line for
Jamie came from his time inside a rehabilitation centre, but on leaving there
was also prominent cultural pressure outside this environment. Put bluntly,
individuals finding themselves disabled through spinal cord injury are encour-
aged to have hope in a successful outcome, and stories not fitting this mould
are anxiety provoking and are thus difficult to hear. When this desired out-
come became unrealisable for Jamie, his stories became more chaotic. Frank
(1995) argued that narrative wreckage often results in such circumstances, with
stories becoming incoherent and without a plot. The ‘chaos’ narrative (Frank,
1995) is drawn upon by Smith and Sparkes as Jamie’s narration became that of
one without sequence or a discernible causality. Through detailed analysis of
extracts from Jamie’s harrowing life experiences, Smith and Sparkes sensitively
highlight the despair that Jamie discloses and discuss how Jamie presents his
life as out of his control. Jamie, separated from his wife, children, and friends,
felt isolated, alone and without hope. The analysis of data extracts presented
highlights the absence of dialogical relations in his life. Furthermore, Jamie
experienced pain in his paralysed limbs which was discounted by medics and
left his stories invalidated, making it harder to reconstruct a positive, tellable
story, and leaving him with an untellable one. Smith and Sparkes (2008) argued
that Jamie’s story highlights the need for society to relax the boundaries of what
is tellable to enable such stories to be heard. If story telling can repair narrative
wreckage, we need to pursue opportunities for individuals to be voiced. They
suggested that counter-narratives may provide alternative routes to enable new
body–self relationships to emerge.
Sarah Seymour-Smith 325
Critical research
Discourse analysis moves away from the notion of language as a transpar-
ent medium used to convey pre-existing knowledge, which most experiential
approaches adhere to, and, instead, views language as the site where we actually
constitute knowledge. Discursive approaches treat language as action, with the
primary focus on considering how phenomena are constructed, oriented to,
and displayed in social interactions. How different discourse researchers con-
ceptualise the term ‘discourse’ varies on a continuum from a broad focus at one
end, as in Foucault’s (1978) historical analysis of developing social practices
such as those associated with sexuality, to a fine-grained conversation analytic
focus on turn taking, as in Sacks’ research on telephone calls to a suicide pre-
vention service (Sacks, 1992), at the other. Discursive approaches take a social
constructionist view of identity as constituted and reconstituted through dis-
course: thus, identity is viewed as flexible, contextual, relational, situated, and
inflected by power relations (Gergen, 1999). Distinctions between discourse
traditions are informed by different theoretical positions and methodological
practices, although boundaries between approaches are often blurred as dis-
course researchers borrow from different theoretical resources and synthesise
new approaches, which are hard to decipher for the novice discourse researcher.
However, a key focus for all approaches continues to be on discourse in the form
of talk and text, with a major interest in “the ways in which discourse is ori-
ented to actions within settings, the way representations are constructed and
oriented to action, and a general caution about explanations of conduct based
in the cognition of individuals” (Potter & Wiggins, 2007, p. 74).
Discursive approaches offer useful ways of thinking critically about taken-
for-granted assumptions about the world. One such focus has concerned the
issue of sexual consent and rape. O’Byrne et al. (2006) discussed how the
miscommunication model (Tannen, 1992) claims that there is a dichotomy
between the conversational styles of men and women, such that men and
women do not understand each other. This model informs much expert opin-
ion on rape, culminating in advice being aimed at women to clearly say ‘no’
to unwanted sexual advances. O’Byrne et al. (2008) employed discursive psy-
chology (Edwards & Potter, 1992; Potter & Wetherell, 1987) with insights from
conversation analytic work (Sacks, 1992) to analyse their data. Their work fol-
lows Kitzinger and Frith’s (1999) research, which argued that advice to say ‘no’
was misguided and that it is not necessary for a woman to verbalise ‘no’ for
her to be heard to be refusing sex. This argument is built upon conversation
analytic studies which have examined the normative way in which refusals are
achieved (we do not ordinarily just say ‘no’ to an invitation; refusals are typi-
cally achieved in a much more face-saving way, with acknowledgement of the
offer couched with some kind of excuse for turning it down).
326 Psychological Areas
All three of the studies described in some detail in the previous section have
clear applications to the ‘real world’. Understanding the current impact of a
positive HIV diagnosis can challenge current thinking, and the psychological
difficulties that Flowers et al. (2011) reported could be helped by referral to
therapy in some cases. The lives of individuals who are stuck in a ‘chaos’ nar-
rative would also benefit from a therapeutic environment. Narrative therapy
(White & Epston, 1990) has been developed in order to take on board a rela-
tional and contextual view of the healing process whereby therapy is structured
around separating the problem from the person. Finally, rape prevention pro-
grammes could use the knowledge regarding refusals to inform their policy and
training and to form more viable alternatives. Academic researchers should try
to engage in a dialogue with relevant parties in order to make good use of
their work.
One place where academics could extend their input is to work alongside
social activists in their area. Lines of communication between activists and
academics could ensure a dialogue that could result in a productive relation-
ship. Consider the ‘SlutWalk’ protests that happened as a response to rape
culture. The rallies began in response to a Toronto police officer, Consta-
ble Michael Sanguinetti, who suggested that “women should avoid dressing
328 Psychological Areas
Future directions
the clinic. Speer suggested that reporting a compliment from a third party
(such as “you’re the most convincing one I’ve seen”) was one way that trans
men and women were able to ‘evidence’ their success at passing. Speer argued
that patients thus ‘do gender’ while engaging in other actions not necessar-
ily concerned with gender. However, one issue about this work that should
be considered is the notion that ‘passing’ is a compliment to all trans people.
Speer grounds her argument in the way that participants themselves appear
to treat this as a compliment, but the idea that ‘passing’ is a valued goal may
be a contested issue (see the chapter on trans for further discussion of this),
and researchers need to be aware of imposing their own frames of reference
onto such issues, just as cisgender people do. Studying gender as it is dis-
played in interactions (whether institutional or mundane interactions) avoids
the problem of researchers imposing gendered analyses onto data.
Other future directions in the field include giving voice to marginalised
groups of women/men/LBGT communities and ‘hard to reach’ populations.
However, caution must be taken in treating such categorisations of people
as homogeneous groups, reducing people to a single identity or point in
their lifespan (Richards et al., 2014). It is important to consider our agendas
when conducting such research, and it is crucial to recognise the diversity of
experience in order to capture the multiplicity within such members and to
respect their humanity (Richards et al., 2014). A good example of research on a
‘silenced’ sexuality comes from Barker and Langdridge (2008). However, there
are many other ‘forgotten’ or under-represented groups for gender and sexuality
researchers to explore.
This chapter is merely a starting point for those considering qualitative
research on gender and sexuality. Unfortunately, it was not possible to discuss
all methods of analysis in such a small space. Hopefully, the chapter has pro-
vided some idea of the range of ways to tackle such projects. However, there are
numerous psychology research method books which outline how to conduct
and report such work in the Further reading section below.
Summary
• Key issues in qualitative research include whether to elicit data (as in inter-
views) or to focus on naturally occurring data (such as online conversations
or media representation), and whether the researcher is positioned as an
insider, outsider, or both, in relation to the group they are studying.
• There are also important issues to consider around which groups are
over- and under-researched, and the ethics of accountability towards the
communities and issues being studied.
Further reading
Braun, V. & Clarke, V. (2013). Successful qualitative research: A practical guide for beginners.
London: Sage.
Forrester, M. A. (2010). Doing qualitative research in psychology: A practical guide. London:
Sage.
Lyons, A. & Coyle, A. (Eds.) (2007). Analysing qualitative data in psychology. London: Sage.
Silverman, D. (2005). Doing qualitative research: A practical guide. London: Sage.
Willig, C. (2005). Introducing qualitative research in psychology: Adventures in theory and
method. Maidenhead: Open University Press.
References
Allen, L. (2010). Queer(y)ing the straight researcher: The relationship between researcher
identity and anti-normative knowledge. Feminism & Psychology, 20, 147–164.
Barker, M. & Langdridge, D. (2008). Bisexuality: Working with a silenced sexuality.
Feminism & Psychology, 18(3), 389–394.
Barker, M., Yockney, J., Richards, C., Jones, R., Bowes-Catton, H., & Plowman, T. (2012).
Guidelines for researching and writing about bisexuality. Journal of Bisexuality, 12(3),
376–392.
Braun, V. & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research
in Psychology, 3(2), 77–101.
Braun, V. & Clarke, V. (2013). Successful qualitative research: A practical guide for beginners.
London: Sage.
Bruner, J. (1987). Life as narrative. Social Research, 54(1), 109–129.
Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative
analysis. London: Sage.
Clarke, V., Ellis, S. J., Peel, E., & Riggs, D. (2010). Lesbian, gay, bisexual, trans and queer
psychology: An introduction. Cambridge: Cambridge University Press.
Clarke, V. & Peel, E. (2004). The social construction of lesbianism: A reappraisal.
Feminism & Psychology, 14(4), 485–490.
Connell, R. (1987). Gender and power. Cambridge: Polity Press.
Crossley, M. L. (2000). Introducing narrative psychology: Self, trauma and the construction of
meaning. Buckingham: Open University Press.
Edwards, D. & Potter, J. (1992). Discursive psychology. London: Sage.
Flowers, P., McGreggor, D., Larkin, M., Church, S., & Marriott, C. (2011). Understand-
ing the impact of HIV diagnosis amongst gay men in Scotland: An interpretative
phenomenological analysis. Psychology & Health, 26(10), 1378–1391.
Foucault, M. (1978 [1976]). The history of sexuality: Volume 1: An introduction (trans.
R. Hurley). London: Allen Lane.
Sarah Seymour-Smith 331
Frank, A. (1995). The wounded storyteller: Body, illness and ethics. Chicago: University of
Chicago Press.
Gavey, N. (2005). Just sex? The cultural scaffolding of rape. London and New York, NY:
Routledge.
Gergen, K. J. (1999). An invitation to social constructionism. London: Sage.
Health Prevention Agency (2010). Retrieved from http://www.hpa.org.uk/web/HPA web
File/HPAweb_C/1237970242135.
Health Protection Agency (2010). Retrieved from http://www.hpa.org.uk/web/
HPAwebFile/HPAweb_C/1237970242135.
Jarviluoma, H., Moisala, P., & Vilko, A. (2003). Gender and qualitative methods. London:
Sage.
Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. (1948). Sexual behaviour in the human male.
Philadelphia: W.B. Saunders.
Kinsey, A. C., Pomeroy, W. B., Martin, C. E., & Gebherd, P. H. (1953). Sexual behaviour in
the human female. Philadelphia: W.B. Saunders.
Kitzinger, C. (1987). The social construction of lesbianism. London: Sage.
Kitzinger, C. & Frith, H. (1999). Just say no? The use of conversation analysis
in developing a feminist perspective on sexual refusal. Discourse & Society, 10,
293–316.
Kong, S. K., Mahoney, D., & Plummer, K. (2003). Queering the interview.
In J. A. Holstein & J. F. Gubrium (Eds.) Inside interviewing: New lenses, new concerns.
(pp. 91–110). London: Sage.
Labov, W. (1982). Speech actions and reactions in personal narrative. In D. Tannen (Ed.)
Analysing talk and text. (pp. 219–247). Washington, DC: Georgetown University Press.
Lieberman, M. A. (2008). Gender and online cancer support groups: Issues facing male
cancer patients. Journal of Cancer Education, 23, 167–171.
Linde, C. (1993). The creation of coherence. Oxford: Oxford University Press.
Murray, M. (2008). Narrative psychology. In J. Smith (Ed.) Qualitative psychology.
A practical guide to research methods. (pp. 111–131). London: Sage.
O’Byrne, R., Rapley, M., & Hansen, S. (2006). “You couldn’t say ‘no’, could you?”: Young
men’s understanding of sexual refusal. Feminism & Psychology, 16, 133–154.
O’Byrne, R., Hansen, S., & Rapley, M. (2008). “If a girl doesn’t say ‘no’ . . . ”. Young
men, rape and claims of ‘insufficient knowledge’. Journal of Community & Applied Social
Psychology, 18, 168–193.
Peel, E. (2001). Mundane heterosexism: Understanding incidents of the everyday.
Women’s Studies International Forum, 24(5), 541–554.
Potter, J. & Hepburn, A. (2005). Qualitative interviews in psychology: Problems and
possibilities. Qualitative Research in Psychology, 2, 281–307.
Potter, J. & Wetherell, M. (1987). Discourse and social psychology: Beyond attitudes and
behaviour. London: Sage.
Potter, J. & Wiggins, S. (2007). Discursive psychology. In C. Willig & W. Stainton-Rogers
(Eds.) The Sage handbook of qualitative research. London: Sage.
Richards, C., Barker, M., Lenihan, P., & Iantaffi, H. (2014). Who watches the watchman?
A critical perspective on the theorization of trans people and clinicians. Feminism &
Psychology, 24, 248–258.
Riessman, C. K. (1993). Narrative analysis. London: Sage.
Ringrose, J. & Reynold, E. (2012). Slut-shaming, girl power and ‘sexualisation’: Thinking
through the politics of the international SlutWalk with teen girls. Gender & Education,
24(3), 333–343.
332 Psychological Areas
Introduction
333
334 Psychological Areas
‘bisexual’. These labels are modern identity categories, are not universal, are
used to identify with a particular set of cultural and historical assumptions,
and can be stigmatised. Stigma can result in people being reluctant to report
Lesbian, Gay, or Bisexual (LGB) identity, even in anonymous surveys.
Some commentators have argued that LGB categories in surveys/
questionnaires have the unintended effect of ‘creating’, not just ‘recording’,
LGB citizens (Browne, 2010). Put differently, LGB identity categories are socially
constructed, and asking people to adopt a category reinforces that category.
For these and other reasons, some researchers choose to focus on behaviour
and attraction rather than identity (e.g. in the English Longitudinal Study of
Ageing, described below). Nonetheless, there are strong arguments for record-
ing sexual orientation identity in quantitative surveys, so that inequalities can
be monitored. In the United Kingdom, for example, sexual orientation identity
is a ‘protected characteristic’, meaning that public bodies have a responsibil-
ity to promote and monitor equality of opportunity in relation to it. Without
data available on sexual orientation identity, inequalities cannot be demon-
strated, and so there is an argument for recording sexual orientation identity
even though it is a socially constructed category (Figure 19.1).
Gender identity – There are many different terms used to describe gender
identities. The Equality and Human Rights Commission recently published a
report which provided some definitions of key terms related to gender identity
(Balarajan et al., 2013). Because these terms are used in different ways by dif-
ferent researchers, it is helpful to have available a set of definitions. These are
not universally agreed, and, as seen elsewhere in this book, these terms are all
contested and difficult to define precisely:
FtM – Female to male transsexual person (changing or has changed gender
identity), or trans man. This term is problematic, however, for people who may
dispute that they previously were female and are now male (rather than having
always been male, for example).
Gender – Gender is socially constructed and can refer to cultural norms for
behaviours, activities, or attributes. The following terms are considered gender
Identity
Behaviour Attraction
terms: man, masculine, woman, feminine. In contrast, male and female denote
biological sex.
Gender identity – This is how a respondent identifies with a gender category.
How someone identifies in a survey however, may differ from how they identify
elsewhere.
Gender reassignment – This refers to the process of changing gender identity
and is used in the Equality Act to describe anyone having transitioned, cur-
rently transitioning or intending to transition. The term ‘transsexual person’ is
used as an umbrella term to cover all three scenarios.
Intersex – Some individuals are born with what is now known as Disorder of
Sex Development, which can involve genital abnormalities. This can lead to
inconsistency between gender identity and gender role as described by others
at birth, defined as being intersex.
MtF – Male to female transsexual person (see FtM above).
Although the definitions above are helpful, it is important to note that some
people will have their own definitions of gender and gender identity. Similarly,
researchers may use terms interchangeably, or introduce terms of their own.
Dialogue between researchers and concerned communities is recommended
when undertaking research in this area.
History
Having defined key terms, this section provides a very brief introduction to the
history of quantitative research in relation to sexuality and gender. It is impor-
tant to understand the impact these studies had on subsequent research, and
the impact the work had on the public understanding of sexuality. Before the
studies described below, there was very little quantitative work to draw upon.
Table 19.1 Klein Sexual Orientation Grid (Klein, 1993; Klein et al., 1985)
A Sexual attraction
B Sexual behaviour
C Sexual fantasies
D Emotional preference
E Social preference
F Het/Homo lifestyle
G Self-identification
A to D E to G
One limitation of the KSOG is that, although it allows for variation across all
21 scores (7 × 3), when factor analysing the data, researchers have found that
one factor accounted for the majority of the variance in two modestly sized
but different samples (around 60% with most items loading >0.40 on the first
factor). The second factor referred to the social components of the scale, per-
haps because these are quite different from the questions concerning individual
characteristics. The general factor of sexual orientation suggests that people
vary mostly according to same-sex verses opposite-sex orientation. There may
be no need to have so many components in the scale. The authors argue that
“there is such a thing as sexual orientation and it is legitimate for people to use
the term in a way that encompasses a wide variety of aspects of life” (Weinrich
et al., 1993). They noted one exception – in both their samples socialisation
was not captured by the general sexual orientation factor. Whether we choose
to socialise with men or women, they argued, is not something that varies along
with sexual orientation.
tends to consist of large population surveys, designed to have large sample sizes
and to generalise to the wider population.
of men and 10.1% of women had used condoms inconsistently in the past
year with two or more sexual partners. The increase in risky behaviours cor-
responds to the observed increase in HIV and STI transmission, and the effect
sizes were considered large (odds ratio > 1.5). However, consistent condom use
also increased, which, the authors suggest, could reflect adoption of safer sex
messages. Results from NATSAL-2010 were recently published and are described
below in the section on future directions.
• Which of the following best describes how you think of yourself? Heterosex-
ual or straight; Gay or lesbian; or Bisexual.
• How old were you when you first had sexual intercourse?
• Which of these precautions or forms of contraception do you use most
regularly?
• Which other precautions or forms of contraception do you use most
regularly?
• Have you ever had sex without using precautions or contraception? Please
do not include any times when you might have been trying for a
baby.
• How often would you say you have sex without using precautions or con-
traception? Please do not include any times when you might be trying for
a baby.
• Have you ever contracted a sexually transmitted infection (such as
Chlamydia, gonorrhoea or genital warts)?
This last question is unusual, but may be informative, given that few other
studies identified have included it. Most published studies have focused on
STI prevalence, leaving open additional detailed analyses on sexual iden-
tity and sexual behaviour. NHANES is relatively unusual in that sexual
behaviour data are available for respondents aged under 18 (parental informed
Gareth Hagger-Johnson 341
consent was obtained). This stands in contrast to LSYPE, where the study
team waited until cohort members were 18, which could have introduced
recall bias.
This study has been used to show that sexual activity is most often initiated
in adolescence and common STIs are acquired soon after sexual debut (Forhan
et al., 2009). Focusing on females aged 14–19 in NHANES, 24.1% and 37.7% had
any of five STIs, referring to all and sexually active respondents, respectively.
There were important differences by ethnic group, age, number of lifetime
sexual partners, and age of sexual debut. For example, non-Hispanic black par-
ticipants were at particularly high risk, as were those with more than three
lifetime partners. However, human papillomavirus (HPV) infection accounted
for nearly 75% of the overall prevalence figures, which could mask important
differences for each STI. Syphilis and HIV were not included in the analysis. The
authors suggest that early skill-based sex education, vaccination, and screening
can be used to reduce prevalence.
1. Which statement best describes your sexual experiences over your lifetime?
Please include all sexual experiences including sexual intercourse, fondling
and petting.
2. Which statement best describes your sexual desires over your lifetime?
• Attitudes to sexuality
• Sexual drive
• Sexual desire
• Sexual behaviour
• Sexual intercourse (vaginal, anal, oral)
• Masturbation
• Erectile dysfunction
• Orgasm frequency
• Men: the ability to have and maintain an erection
• Women: the feeling of orgasm or climax
• Feelings of obligation to have sex
• Frequency of sharing sexual likes/dislikes with partner
• Feelings of emotional closeness when having sex with partner
• Overall satisfaction with sex life
• Oral medications (e.g. Viagra)
• Frequency of having an uncomfortably dry vagina
• Pain/discomfort during/after sexual activity
• Worry about sex life
• Whether sought help/advice and from where
• Sexual orientation: attraction (see sexual orientation identity)
• Sexual orientation: behaviour (see sexual orientation identity)
• Number of lifetime sexual partners
As with LSYPE, much of these data remain unanalysed but are available to
students and researchers who want to look at them.
Table 19.3 Non-threatening ways to ask about sexual behaviours (adapted from
Crawford et al., 2006)
In the last six months, which of With how many With how many
the following activities have males? females?
you engaged in?
Kissing
Oral sex
(and so on)
You can obtain questions for your own research from the UK Data Service
(see ukdataservice.ac.uk), which includes the questions used in NATSAL
surveys.
Different kinds of same-sex sexual orientation (identity, behaviour,
attraction) can lead to substantively different results (see Marshal et al.,
2009).
Current debates
We have now considered key terms, historical work, and current research, and
noted that there are lots of quantitative data on sexuality and gender which
have not been analysed. In this section, we consider some of the current debates
and possible ways forward for the field.
are both different from ‘age’ or ageing effects, which refer to changes within a
person over the age range.
Age, period, and cohort effects can be difficult to disentangle. For example,
does the higher rate of same-sex behaviour in younger men reflect a feature
of our society at this time, a feature of the younger generation born more
recently, or simply their age? It is likely that all three components are rele-
vant. To address these kinds of questions, sophisticated statistical techniques
are needed. A method called age/period/cohort modelling is used to try to sep-
arate the effects, but it requires data that cover a wide age range (to explore
birth year or cohort effects), have been repeated at different times (to explore
period effects – these effects can be particularly sensitive to policy/legislative
changes), and follow the same people over time (to explore ageing effects
among the same people). Such data are often difficult to obtain, particu-
larly in the area of sexuality research, which is relatively underfunded. As the
authors noted, cross-sectional surveys are taken “against the backdrop of chang-
ing social norms, demographic trends, and changing legislation and policy”
(Mercer et al., 2013). It is also worth noting that the first NATSAL survey was
interview and self-report based, but the second and third surveys involved a
computer self-completion element. This may have introduced self-report bias
if social desirability influenced how people responded differently when using
different methods. Consider whether you might provide different answers to
questions about your behaviour if you were asked by an interviewer in your
home, by a researcher on the telephone, or when responding to questions on a
computer.
A key limitation of NATSAL, then, is its cross-sectional design, with no
longitudinal element. We cannot explore how the participants might change
throughout their lives. It would be helpful to get longitudinal data on sexual
behaviour that follow the same people, but also recruit new participants in the
younger age range. These kinds of study designs are called ‘accelerated cohort’
studies and can help use separate age effects from ‘cohort’ (generational) effects
and calendar (year-by-year) effects.
fell out of favour from the 1970s onwards due to political and other reasons
(Hagger-Johnson, 2008), and it became difficult to reconcile the theory with the
near-universality of homosexual and bisexual behaviour seen among humans
worldwide. Other ‘explanations’ were needed. It is also worth noting, however,
that even today claims are made that homosexuality can be ‘cured’, and in
several countries homosexual behaviour is illegal.
Developmental instability. The theory of developmental instability refers to
how the body developed and marks of its vulnerability to stressors. Put simply,
it refers to the quality or integrity of the body and brain, and the variation
seen in the population in how well various bodily systems operate. ‘Fluctuating
asymmetry’ is a term referring to any feature seen as indicating develop-
mental instability. Such features have included non-right-handedness, 2D:4D
ratio, facial symmetry, the width and length of ears, and so on (Rahman &
Wilson, 2003). In this theory, homosexuality is seen simply as a marker of
instability, positively correlated with other markers. One source of environ-
mental stress is thought to be maternal stress, suggesting that hormones
produced by the mother during pregnancy contribute to developmental insta-
bility, leading to facial asymmetry and homosexuality. Again, the evidence
supporting these claims is mixed, and studies suffer from various sources of
bias, including selection bias (the kinds of people who volunteer for these stud-
ies may differ in important ways from those not in the sample) and recall
bias (can mothers accurately recall stress during pregnancy after so many
years?). Critics have pointed out that homosexuality is seen here as a form
of development in the ‘wrong’ direction, which can became problematic in sit-
uations where the data present a different picture (Hegarty, 2013; Kanazawa,
2012).
Maternal hormone hypothesis. According to this hypothesis, a maternal
immune mechanism retains a ‘memory’ of how many male foetuses have been
created, and modifies the neurodevelopment of subsequent foetuses. The evi-
dence supporting this hypothesis is mixed, and it can difficult to ascertain
whether foetuses were carried to full term. The evolutionary theory behind the
hypothesis is that, when a mother already has several sons, there is less ‘need’
for another heterosexual son and there is more benefit to inclusive fitness if sub-
sequent sons have traits often associated with homosexuality. A related set of
studies considered maternal stress, introduced below. For a detailed discussion
of these traits, see McKnight (1997).
Selective fitness and balanced polymorphisms. This theory suggests that
homosexuality has a genetic component, correlated with other traits, such as
sex appeal, charm, and seductiveness. For women who are attracted to these
traits in men, their offspring will carry some of the same genetic material,
ensuring that homosexuality remains in the population (McKnight, 1997).
Heterosexuality and alternatives therefore become ‘balanced polymorphisms’
Gareth Hagger-Johnson 347
We now consider some of the next steps for quantitative research in this area.
Particular reference is made to gender identity and its measurement, because
this is far less studied and fewer data are available than for sexuality identity.
This is something we can expect to change in the years ahead, as researchers are
starting to recognise the need for closer monitoring of equality opportunities –
not just in relation to sex (men and women) and sexual identity, but also in
relation to gender reassignment or people intending to undergo gender reas-
signment. We begin by looking at recent recommendations on how to measure
gender identities.
348 Psychological Areas
• Male
• Female
• Intersex
• I prefer not to say
It is also recommended that (1) this question appears before any others;
(2) an explanation for collecting this information is provided; (3) confidential-
ity/anonymity are assured where possible. When used with question 2 below,
we can capture data on any change that has occurred and what the person’s
current gender identity is.
Q2. Which of the following describes how you think of yourself? Please tick
one option.
• Male
• Female
• In another way:
When this question was tested in pilot studies, the terms ‘man’ and ‘woman’
were found to be problematic. The option ‘In another way’ was considered
important because people may not identity as male or female (see also the
chapter on non-binary gender in this book).
Q3. Have you gone through any part of a process (including thoughts or
actions) to change from the sex you were described as at birth to the gender you
identify with, or do you intend to? (This could include changing your name,
wearing different clothes, taking hormones or having any gender reassignment
surgery.)
Q4. Continuing to think about these examples, which of the following options
best applies to you?
This question, combined with question 3, provides data on where people are in
the process of gender reassignment. In the United Kingdom, for example, the
2010 Equality Act requires public bodies to promote equality for those under-
going gender reassignment. It covers intentions, current change, and historical
change.
• Trans man
• Trans woman
• Transsexual person
• Gender variant person
• Cross dressing person
• Transvestite person
• Intersex person
• In another way:
• I prefer not to say
This question can be used to record heterogeneity in the trans population. The
authors of the report noted that it provides an opportunity for people to express
themselves in their own way. Note the use of the word ‘person’ to denote a
human identity, rather than a category. The list is not exhaustive.
(Continued)
their gender identity and want to declare this change, or are currently
changing their identity.
It may be helpful to challenge resistance to measuring sexual and gen-
der identities by comparing them to the introduction of ‘ethnic group’ as
a question on surveys, and by highlighting the low refusal rates for such
questions.
Summary
• There are no universally agreed methods for measuring gender and sexual
orientation in quantitative research, but it is important to try to record
this information in order to monitor health and other inequalities in the
population.
• In the United Kingdom and other countries, official guidance is now avail-
able on how to standardise the wording of questions in surveys that refer to
gender identity and sexual orientation identity.
• Sexual orientation can be recorded in quantitative studies by referring
to identity, behaviour, or attraction. These may overlap but are different
‘dimensions’ of sexual orientation.
• Several large-scale population data sets already contain sexual orientation
data, and are freely available for researchers to analyse.
• The author of this chapter argues that gender and sexual orientation should
be measured routinely in all quantitative studies, as for other demographic
variables (e.g. ethnicity). Others disagree, arguing that such categories
are socially constructed and that researchers are in fact ‘creating’ sexual
minority citizens, not simply recording data about them.
Further reading
Balarajan, M., Gray, M., & Mitchell, M. (2013). Monitoring equality: Developing a gender
identity question. London: Equality and Human Rights Commission.
McKnight, J. (1997). Straight science?: Homosexuality, evolution and adaptation. London:
Routledge.
Mercer, C., Tanton, C., Prah, P., Erens, B., Sonnenberg, P., Clifton, S., Macdowall, W.,
Lewis, R., Field, N., Datta, J., Copas, A. J., Phelps, A., Wellings, K., & Johnson, A. M.
(2013). Changes in sexual attitudes and lifestyles in Britain through the life course
and over time: Findings from the National Surveys of Sexual Attitudes and Lifestyles
(NATSAL). The Lancet, 382(9907), 1781–1794.
Office of National Statistics (2010). Measuring sexual identity: An evaluation report. London.
Rahman, Q. & Wilson, G. D. (2003). Born gay? The psychobiology of human sexual
orientation. Personality and Individual Differences, 34(8), 1337–1382.
Gareth Hagger-Johnson 351
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identity question. London: Equality and Human Rights Commission.
Bem, S. L. (1974). Measurement of psychological androgyny. Journal of Consulting and
Clinical Psychology, 42(2), 155–162.
Browne, K. (2010). Queer quantification or queer(y)ing quantification: Creating lesbian,
gay, bisexual or heterosexual citizens through governmental social research. In K.
Browne & C. Nash (Eds.) Queering methods and methodologies: Queer theory and social
science methods. (pp. 231–249). London: Ashgate.
Crawford, D., Macsween, K., Higgins, C., Thomas, R., McAulay, K., Williams, H., Harrison,
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of sex roles in psychology. In T. Lester (Ed.) Gender nonconformity, race and sexu-
ality: Charting the connections. (pp. 62–83). Madison, WI: University of Wisconsin
Press.
Hegarty, P. (2013). Gentlemen’s disagreement: Alfred Kinsey, Lewis Terman, and the sexual
politics of smart men. Chicago: University of Chicago Press.
Johnson, A. M., Mercer, C. H., Erens, B., Copas, A. J., McManus, S., Wellings, K., Fenton,
K.A., Korovessis, C., Macdowall, W., Nanchahal, K., Purdon, S., & Field, J. (2001). Sexual
behaviour in Britain: Partnerships, practices, and HIV risk behaviours. The Lancet, 358
(9296), 1835–1842.
352 Psychological Areas
Kallmann, F. J. (1952). Twin and sibship study of overt male homosexuality. American
Journal of Human Genetics, 4(2), 136–146.
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595–623.
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Klein, F., Sepekoff, B., & Wolf, T. J. (1985). Sexual orientation: A multi-variable dynamic
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Routledge.
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Lewis, R., Field, N., Datta, J., Copas, A.J., Phelps, A., Wellings, K., & Johnson, A.M.
(2013). Changes in sexual attitudes and lifestyles in Britain through the life course
and over time: Findings from the National Surveys of Sexual Attitudes and Lifestyles
(NATSAL). The Lancet, 382(9907), 1781–1794.
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20
Sex Therapy
Michael Berry and Meg John Barker
Introduction
353
354 Psychological Areas
that sex therapy research and practice – especially critical approaches to these –
have for applied psychology and psychotherapy, and indicate future directions
for clinical practice and for research.
History
Sex therapy has developed against the backdrop of two important elements: a
scientific model of sexual behaviour and sexual functioning, and a psycholog-
ical understanding of human sexuality that links sex to cognitive and emotive
processes (thoughts and feelings). The relatively recent development of these
fields means that the specific and targeted use of psychotherapy in treating sex-
ual problems is itself a relatively recent phenomenon (Berry, 2013). Of course,
we may perceive an important psychological dimension – in the form of a
placebo effect, or implicit psychological influence – in the treatment practices
of ancient and medieval societies mentioned above. However, the theoretically
grounded and scientifically based practice of sex therapy today is the prod-
uct of recent developments in psychology, medicine, and related disciplines.
Sex therapy, as it is currently understood, is based principally on a psycholog-
ical conceptualisation of human sexuality (Bancroft, 2006). Consequently, the
emergence of sex therapy as a distinctive discipline has important precursors in
the history of psychological thinking about sex.
The first of these precursors is arguably found at the beginning of the twen-
tieth century, when a number of influential psychological researchers and
theorists turned their attention towards human sexuality and began consid-
ering the ways in which sexual identities and behaviours – and problems with
these – emerged, thus laying the groundwork for the development of contem-
porary sex therapy. Perhaps key among these is Sigmund Freud, who is credited
with developing many important theories on the role that sex plays in the
psychology of the individual (Hartmann, 2009). For instance, well-known con-
cepts such as neurosis, repression, the Oedipus complex, and the presence of
unconscious factors in our sexual lives continue to influence the ways in which
people think about the psychology of sexuality. Indeed, throughout the first
half of the twentieth century, sexual issues were most often treated by psychi-
atrists, who tended to work within a psychoanalytic or psychodynamic model
of practice, heavily influenced by the work of Freud (Goodwach, 2005). It is
important to note, however, that Freud’s work has been subject to considerable
criticism among psychologists and sexologists in recent decades. It has been
argued that many of Freud’s theories are largely non-falsifiable – meaning that
they cannot be tested by objective scientific measures (McCarthy, 1981).
Nonetheless, three theories, which can be traced to Freud, are particularly
important in contemporary sex therapy. First, it is believed that sexuality
is an important part of a person’s psychology throughout their life course,
and even from infancy (Fonagy, 2008; Freud, 1961). Second, it is understood
Michael Berry and Meg John Barker 355
Masters and Johnson’s research was largely responsible for the important his-
torical shift in the field of psychological treatment for sexual problems from
psychoanalytic and psychodynamic models towards cognitive behavioural
theories and treatment systems. While Masters and Johnson acknowledged psy-
chodynamic aspects of sexual dysfunction, they argued that the formerly dom-
inant psychodynamic–psychiatric treatment methods were too lengthy and
costly, and of questionable clinical efficacy. By contrast, cognitive behavioural
therapy (CBT), they suggested, could generally be completed in a few sessions,
with much of the therapeutic work being done by the patient as homework.
Furthermore, their CBT paradigm had exceptionally high (self-reported) rates
of efficacy. Overall, their influential work contributed to a shift towards a dis-
tinctive sex therapy model, largely founded on cognitive behavioural models
of intervention. Many view the treatment system developed by Masters and
Johnson as the first expression of sex therapy as a distinct field of treatment.
More recent researchers have argued that the absence of a psychological com-
ponent is a significant weakness of the Excitation-Plateau-Orgasm-Response
model (Basson, 2001; Kaplan, 1979; Tiefer, 1991). To compensate for this omis-
sion, Kaplan proposed a revised model of sexual response that included a stage
of sexual desire (Kaplan, 1974, 1979; Levine et al., 2009). Kaplan positioned the
desire phase prior to the excitement phase, as a psychological state that primes
the individual for physiological excitement and arousal (Atwood & Klucinec,
2007; Kaplan, 1979). It was also argued that the plateau phase was redundant,
and could readily be conceived as part of the excitation phase (Robinson, 1976).
This conceptual evolution resulted in a more recent model of human sexual
response: the Desire-Excitement-Orgasm-Resolution (DEOR) cycle, which has
been used in mainstream psychodiagnostic systems to conceptualise sexual dys-
functions. These include the Diagnostic and Statistical Manuals of the American
Psychiatric Association (DSM) and the International Classification of Diseases
of the World Health Organization (ICD) (Shrestha & Segraves, 2009). In this
chapter we focus on the DSM, given that this is the more recently updated of
the two, and that the ICD generally follows the DSM in its categorisations.
Diagnosis
In May 2013, a new edition, The DSM, 5th Edition (DSM-5) (American Psy-
chiatric Association, 2013), was published to replace the previous DSM, 4th
Edition, Text Revision (DSM-IV-TR) (American Psychiatric Association, 2000).
The categories of sexual dysfunctions in the DSM-5 relate to any disruption
of Kaplan’s (1974) revision of Masters and Johnson’s (1966) ‘sexual response
cycle’. While the DSM-5 now makes it clear that sexual response is not always
Michael Berry and Meg John Barker 357
a linear process, and that distinction between the stages of the cycle may be
artificial, key categories do relate to desire, arousal, and orgasm. They are as
follows:
As can be seen, there are categories for: lack of desire or sexual interest; ‘erectile
disorder’ or female lack of arousal; and ‘female orgasmic disorder’ or ‘delayed
ejaculation’ (still commonly known in sex therapy as ‘erectile dysfunction’).
In addition to this, there are categories of ‘premature (early) ejaculation’ and
of ‘penetration disorder’. These latter suggest not only that desire, arousal, and
orgasm are necessary for functional sex to have occurred, but also that penis-
in-vagina (PIV) intercourse is an essential feature, given that it is considered
a disorder for a vagina not to be able to be penetrated and for ejaculation to
happen prior to penetration (Barker, 2011a).
A number of diagnostic criteria are, however, common across the sexual
dysfunction diagnoses in DSM-5. These include:
Thus, a person would not be diagnosed with a sexual dysfunction unless they
were distressed by it and it had persisted for six months. Additionally, a number
of diagnostic categories specify that symptoms must be experienced on all or
almost all (75–100%) occasions of sexual activity.
The diagnosing practitioner is also encouraged by the DSM-5 to consider
whether the sexual problem is: lifelong (present throughout the individual’s
entire sexual history), acquired (emergent at a specific point in the individ-
ual’s sexual history), generalised (present in all sexual encounters/activities)
or specific (present only in certain activities, or with certain partners), and
whether the condition is likely psychogenic (due to psychological factors alone)
or combined (due to both psychological and physiological factors).
358 Psychological Areas
(1) partner factors (e.g. partner’s sexual problems; partner’s sexual health
status); (2) relationship factors (e.g. poor communication; discrepancies in
desire for sexual activity); (3) individual vulnerability factors (e.g. poor body
image; history of sexual emotional abuse), psychiatric comorbidity (e.g.
depression, anxiety), or stressors (e.g. job loss, bereavement); (4) cultural
or religious factors (e.g. inhibitions related to prohibitions against sexual
activity or pleasure; attitudes towards sexuality).
(APA, 2013, p. 423)
Treatment
Alongside these diagnostic categories, a sizeable number of standard treatment
practices are cognitive and behavioural, and find roots in the model introduced
by Masters and Johnson, and developed by Kaplan. Key writer and researcher
in this area, John Bancroft, suggests that this model was based less on a core
theoretical foundation, and more on clinical application: “it became widely
used”, he states, “because it proved effective” (2006, p. 372). As such, it may
be argued that mainstream sex therapy is largely technique-driven, rather than
theory-driven. Table 20.1 outlines a number of the main cognitive behavioural
interventions that have traditionally been used in sex therapy.
Many contemporary psychologists and psychotherapists in this area take an
integrative approach to clinical practice (Meana & Jones, 2011; Perelman, 2005;
Toates, 2009; Weeks, 2005), guided by the biopsychosocial model of healthcare
Table 20.1 Cognitive behavioural interventions traditionally used in sex therapy
Intercourse In intercourse prohibition, the therapist advises a patient not to have sexual intercourse, temporarily, while Masters and
Prohibition they work to resolve other issues, or work to realize a particular therapeutic technique (for instance, in the first Johnson (1966)
steps of sensate focus exercises, the patient would be advised not to have full intercourse). Masters and
Johnson (1970)
Sensate Focus Sensate focus exercises are a step-by-step system of sexual activity in which the therapist advises the patient to Masters and
move gradually, over the course of several sexual encounters, through a series of initially non-coital sexual Johnson (1970)
activities with their partner. By design, these activities increase in stimulus intensity and genital focus and, Masters, Johnson
theoretically, culminate (at the end of a number of sessions) in sexual intercourse. Exercises typically include and Kolodny
some progressive combination of: clothed non-genital touching, clothed genital touching, naked non-genital (1982)
touching, naked-genital touching, non-thrusting containment, and thrusting penetration.
Stop/Start Used in the treatment of early ejaculation, the start-stop technique is usually carried out with a partner. In this Semans (1956)
Technique intervention, the partner repeatedly brings the man close to orgasm, through penile stimulation, stopping Kaplan (1974)
stimulation before orgasm is reached. This intervention is intended to train/condition the client to identify the
sensations that preceed orgasm, what Kaplan designated as “premonitory orgastic sensation” (Kaplan, 1974,
p. 303).
Squeeze Used in treating premature ejaculation, the squeeze technique is used when the male reaches the point of Masters and
Technique “ejaculatory inevitability,” the point just prior to orgasm, where the man no longer has control over the Johnson (1970)
ejaculatory process. In this technique, when the man has attained a full erection, and is nearing the point of
ejaculatory inevitability, the men’s partner places their thumb on the frenulum of the penis, and the first and
second fingers on the top of the penis, in-line with the thumb, applying a firm pressure. “As the man responds
to sufficient pressure,” Masters and Johnson State, “he will immediately lose his urge to ejaculate. He may also
lose 10 to 30 percent of his full erection” (1970, p. 104). Stimulation is then resumed, and the process repeated.
Systematic Sex therapists using this technique hold that many sexual problems are caused, or contributed to, by anxiety. Annon (1974)
Desensitization The patient is taught specific skills and techniques to combat anxiety (based on the premise that “if a state Annon (1975)
incompatible with anxiety can be produced then anxiety cannot cccur”) (Drummond & Kennedy, 2006,
p. 169). Systematic desensitization often uses gradual/graduated exposure, combined with relaxation
techniques.
359
360 Psychological Areas
Biological Social
Psychological
Figure 20.1 The biopsychosocial model of human sexuality (adapted from Barker &
Berry, 2013)
practice. The biopsychosocial model, which the World Health Organization holds
as a process of care standard in the sexual health field, prescribes attention to
the biological, psychological, and social aspects of the client’s sexual problems
(Montorsi et al., 2010; World Health Organization, 1993). Figure 20.1 provides
a graphical overview of the biopsychosocial model of human sexuality.
However, the wide-scale implementation of this model in clinical sex ther-
apy has proven challenging – with a number of researchers suggesting that the
biopsychosocial paradigm has often been a matter of ‘lip-service’ rather than
actual practice (McDonald, 2009a), as the next section will illustrate.
Current debates
One set of issues with diagnosis are highlighted by Levine’s (2006) hypothetical
example of a male client who experiences some incidence of quick ejaculation.
This experience fosters a sense of anxiety about the sexual encounter and worry
about future performance. In turn, such anxious ideation prevents the client
Michael Berry and Meg John Barker 361
Barker & Iantaffi, forthcoming; Lenihan et al., this volume; Murjan et al., this
volume).
For this reason, critical psychologists and sex therapists have proposed
that categorical diagnoses of sexual dysfunction and sexual disorder serve to
unduly pathologise clients and patients, and create a sense of pressure and
stigma around sexuality and sexual problems (Kleinplatz, 2012a). A number
of researchers point to the creation of categories of sexual dysfunction/illness
as part of a biomedical model that defines categories of health/pathology with
largely arbitrary cut-off points (McCarthy & McDonald, 2009a; Tiefer, 2010a,
2010b). It is increasingly argued that sex therapists may benefit from an idio-
graphic approach to sexual dysfunction, which tends to interpret the client
according to their unique, specific, and subjective experience. This is opposed
to the nomothetic approach, which attempts to explain the client’s experience
according to a set of universal and generalisable traits. Any sexual experience
(including desire, arousal, erections, orgasms, or their lack) has very different
meanings for each person, related to the relationships and wider culture in
which they are embedded (Barker, 2011a). Therefore, instead of ‘treatment’ of
problems with specific medical or behavioural interventions, the therapeutic
task becomes one of understanding clients’ experiences and what they mean
for them, perhaps through the medium of formulation.
Critical psychologists and practitioners point to a fundamental tension
between traditional notions of sexual normality – which have informed the
development of classic diagnostic, assessment and treatment models – and
newer models that emphasise diversity, a range of experience, and the impor-
tance of the client’s subjective experience (Kleinplatz, 2012a). Here, there is an
important tension between traditional cognitive behavioural techniques and
more recent critical methodologies, which acknowledge a high level of diver-
sity in sexuality and its problems. In our own work, we strongly emphasise the
importance of understanding the client on their own terms, within the frame-
work of their lived experience (Berry & Barker, 2013). This requires a sensitive
and nuanced understanding of key elements of the client’s identity, including
race, sexuality, gender, socio-economic position, and other elements of their
lived experience in the social world. Whereas traditional sex therapy has paid
limited attention to such factors, recent work has begun to foreground them
(Levine et al., 2010). Such a framework may be grounded in an affirmation of
the sexual rights of individuals within an expanded notion of sexual well-being,
as in the World Health Organization’s definition of sexual health, which states:
social life. It is not merely the absence of dysfunction, disease and/or infir-
mity. For Sexual Health to be attained and maintained it is necessary that
the sexual rights of all people be recognized and upheld.
(PAHO/WHO, 2000, p. 6, quoted in Giami, p. 18)
Additionally, the traditional model of sex therapy largely rests on the assump-
tion that healthy sexuality will follow a particular behavioural course, defined
by the sexual response cycle described earlier. Increasingly, critics have argued
that this model is predicated on a heterosexual model of penile–vaginal pene-
trative sex, which takes orgasms (especially men’s orgasms) as the goal of the
behaviour, in which the man takes an active role and the woman a passive
one (Kleinplatz, 2012a, 2012b; Nichols & Shernoff, 2007). Related to this is the
fact that the conventional model of sexual behaviour used in the sex therapy
field tends to be dyadic: that is, it is generally assumed that sexual relationships
will follow a one-to-one monogamous relationship pattern. Solo sex and sex
between more than two people are rarely considered in sex research (Barker &
Langdridge, 2010). Narrowly limited categories of health and normality serve
to create exclusionary criteria of sexual health and illness, which at best fail to
recognise – and at worst pathologise – sexual diversity.
In addition to this, a model of sexual behaviour based on the centrality of the
orgasm, whether within a heterosexual dyad or not, also contributes to a goal-
focused paradigm of sexuality – which has been argued to contribute to, rather
than ameliorate, sexual distress (Barker & Iantaffi, forthcoming). More critical
sex therapists advocate the value of a pleasure-focused or process-focused model,
in which the experience of enjoyable sex – without the demand for an orgasm,
or particular types of highly specified behaviours – is prioritised (Leiblum &
Wiegel, 2002; Metz & McCarthy, 2007).
Taken together, research challenging the idea of quantitative thresholds and
predetermined behavioural paths for healthy sexual desire and behaviour sug-
gest that it may be impossible to define sexual health according to strict
quantitative standards. Accordingly, critical evaluation of the subjective aspects
of an individual’s sexuality is necessary in practitioners’ efforts to understand
and treat sexual problems.
(Continued)
Conventional discourses about sexual behaviour and gender roles are seen as
potentially constraining: limiting the ways in which clients feel they can expe-
rience or enact their sexuality and exaggerating or even artificially instilling
negative and self-defeating views. A social constructionist orientation to sex
therapy involves questioning and analysing dominant social notions of ‘real
men’ and ‘real women’. For example, popular understandings of male sex-
uality, perpetuated by male sexual disorders, entrench a ‘performance-based’
model that obscures or disregards the important role of intimacy and pleasure
in sex for many clients (Grace et al., 2006). Binary conceptions of sexuality
and gender may contribute to particular, narrowly restricted, forms of sexual
behaviour scripts – the particular types of behaviours that are considered accept-
able (see Harvey, Bowes-Catton, and Barker & Richards, this volume). Drawing
on constructionist, feminist, and queer perspectives may help the practitioner
to engage the client in understanding their sexual scripts and the meanings
they associate with sexuality – including their standards of sexual function and
dysfunction, normality and abnormality.
One example of social constructionist and feminist-informed sex therapy can
be found in Barker (2011b), where the author describes their work with a young
woman who had been diagnosed with ‘vaginismus’. Rather than focusing on
the sexual problem, the therapist explores the wider worldview of the client –
within the context of prevailing discourses – and how sex fits into this. Through
shared understandings of the popular ‘Bridget Jones’ view that it is vital for
women to find a romantic relationship, the client and therapist are able to
see the sense in the client’s continued engagement in painful sex, as well as
exploring the taken-for-granted assumption that failing to do so would result in
her male partner breaking up with her. This situation is situated within a wider
context of the client attempting to embody a conventional femininity which
involves pleasing everybody else and being a good daughter, good friend, and
good girlfriend. Frustration at the restrictions this places on her enables the
client to tune in more to her own desires and goals, and to consider whether
this relationship is good for her, rather than focusing only on the desires of her
partner.
Obviously, a light touch needs to be employed when engaging clients in
such work, inviting them to identify – and perhaps deconstruct – prevailing
discourses in the world around them, rather than directing them, for exam-
ple. However, certainly in this case, elements of the ‘vaginismus’ experience
were illuminated which would not have become apparent by employing
conventional sex therapy approaches towards less painful penetrative sex.
One of the most important implications of new and emerging critical sex
therapy approaches is the challenge they represent to conventional assump-
tions about sexual health and behaviour. Traditionally, sex therapy has reflected
and perpetuated wider social discourses, defining normality and abnormality,
366 Psychological Areas
healthy and unhealthy, in ways that align with the popular view (see Drescher,
2010). Increasingly, however, some psychologists and practitioners in this field
have argued for a more critical and open stance towards sexual diversity in both
sex therapy and popular understandings and representations (see Barker et al.,
forthcoming).
Future directions
We agree that it behoves all psychologists engaging with sex research and clin-
ical practice to look deeply into their own assumptions about sex as well as
looking critically outwards to the cultural messages around them. Uncritical
practices in sex therapy often serve to reproduce and reinforce problem-
atic assumptions about what constitutes sex and sexual problems. Critical
368 Psychological Areas
approaches work to shift the social norms and roles that maintain clients’ suf-
fering. Such critical approaches involve tuning in to the unique experiences
and meanings of each client, as well as turning out to challenge the dominant
discourses that surround them, taking an interdisciplinary approach such that
our work can be truly biopsychosocial.
As with clinicians, academics are well advised to take note of the dis-
courses and debates surrounding diagnostic categorisations and practices.
There are a number of journals, including Psychology and Sexuality and
The International Journal of Sexual Health (formerly the Journal of Psychol-
ogy & Human Sexuality), that focus specifically on sexual issues in the
psychological field.
Summary
Note
1. A type of poisonous beetle that was used as an aphrodisiac.
Further reading
Masters, W. H., Johnson, V. E., & Kolodny, R. C. (1982). Human sexuality. New York, NY:
HarperCollins.
Kleinplatz, P. J. (Ed.) (2012). New directions in sex therapy: Innovations and alternatives.
New York, NY: Routledge.
Michael Berry and Meg John Barker 369
Leiblum, S. R. (Ed.) (2007). Principles and practice of sex therapy. Surrey: Guilford Press.
Masters, W. H., Johnson, V. E., & Kolodny, R. C. (1982). Human sexuality. New York, NY:
HarperCollins.
Tiefer, L. (1995). Sex is not a natural act and other essays. Boulder, CO: Westview Press.
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Part V
Intersections
21
Ageing
Paul Simpson
There has been much anxiety in economically developed parts of the globe,
such as Britain, Northern Europe, and North America, about ageing soci-
eties (Arber & Attius-Donfut, 2000). Increasing longevity in Britain (the main
focus of this chapter) has concentrated attention on ageing in media and aca-
demic debate (Higgs & Gilleard, 2010). This debate is preoccupied with the
‘demographic time-bomb’, which views age as a burden and ageing societies
as problematic, given the welfare services that need to be sustained by tax
revenues from decreasing numbers of those of working age. While this doom-
laden story of intergenerational conflict has not gone unchallenged (Arber &
Attius-Donfut, 2000), it overshadows consideration of ageing and later life as
multidimensional experiences that are the combined results of socio-economic
and cultural influences. The dominant cultural narrative of ageing across much
of the ‘Western’ world is one of loss, decline, and isolation, where demen-
tia represents a proxy for later life. But this account obscures affirmative and
ambivalent experiences of ageing – an awareness gap I address below. In the
context of Britain (a minority ‘Western’ culture), ageing as female, lesbian, gay,
bisexual, trans, queer, or intersex (LGBTQI) often involves economic, social,
and cultural exclusion. But marginalised social positioning can encourage the
development of political and narrative resources to help people negotiate with
and contest ageing stereotypes and reclaim a measure of self-worth.
This chapter examines how ageing has been thought in social psychology,
social gerontology, and sociology, from early ‘functionalist’ theories (1950s) to
the present, where ageing is viewed as contingent. I address both normative
(heterosexual) and non-normative ageing and gendered identities (LGBTQI),
and contend that gender and sexuality intersect with differences of class, race,
and biography to affect experiences of growing older. (See also Das Nair’s
account in this collection of the intersections between race and ageing.) Social
375
376 Intersections
class intersects with race and gender, given the greater longevity of the white
middle classes and the ‘feminisation of old age’ whereby women outlive men
on average by almost five years (Arber & Ginn, 1991). Such ‘intersectional’
approaches are better equipped to grasp the multidimensional character of
ageing. Further, I contend that the organisation of society (the class and gender
orders), along with the symbolic order of discourses (ways of thinking) about
human differences and individuals’ differential capacities to resist ageism, affect
whether people experience growing older as more or less satisfying. After
discussion of key debates, the chapter offers food for thought for applied psy-
chologists and other professionals supporting older people, as well as an agenda
for research.
Definitions
I will first provide definitions of ageing, ageism, gender, and sexuality, whose
meanings are never fixed and have been understood differently across time and
space.
Ageing
This is commonly understood in economically developed societies as a natural,
biological process marked by dependency in infancy, moving towards greater
autonomy in the teenage years and adulthood, followed by physical and cog-
nitive decline in later life, and culminating in dependency towards the end
of life. But ageing is not just physical; it is socially constructed by the ideas
we have of this complex social process (and is also unequal when we consider
influences of class, gender, and race). Indeed, young people are ageing, though
we call it ‘development’. How age/ageing is considered in Britain (a minor-
ity Western case) is changing, given that the boundary between youth and
adulthood is being blurred by prolonged economic dependency on parents
into the mid-twenties (Thomson, 2009). But there are important global dif-
ferences in how age and ageing are thought and practised. The infantilisation
of old people (treating them like children because they may depend on others)
is not universal and appears to be a largely ‘Western’ blip. Chinese, Islamic,
and Jewish cultures often respect the wisdom of age. The Shebro society of
Sierra Leone would interpret loss of speech and function (or what in Britain we
disparagingly call being ‘gaga’ or demented) not as pitiful relapse into mind-
less infancy but as being closer to spirits and ancestors. The Kallai society
(Papua New Guinea) calls into question the notion of progress as ‘Western’
when, rather than dismissing old(er) women as ‘past it’ (as is common in
consumerist societies), it validates them as sexual beings (Hockey & James,
1993).
Moreover, the idea of ageing as a phased phenomenon reflects both pop-
ular thinking and ‘life cycle’ or ‘life stage’ models of ageing in industrial
Paul Simpson 377
Ageism
While older people are often stereotyped as dependent, post-sexual, and associ-
ated with mortality, such definitions can occlude the bidirectional character of
ageism whereby youth is stereotyped as immature, irresponsible, and promis-
cuous. Following Bytheway (1995), ageism is defined as social relationships
resulting from both how society is structured and discourses that reproduce
stereotypes of age/ageing but which weigh predominantly against older people.
Gender
Social difference is never neutral. In ‘the West’, the gender order (male and
female) rigidified as a consequence of Enlightenment thought and with the
rise of industrialisation – from the mid-eighteenth century onwards (McIntosh,
1968). In more recent years, ambiguous categories have emerged to challenge
this rigid, heteronormative binary (Butler, 1990; see also Barker & Richards,
Further Genders and Roen, Intersex, this volume). But heterosexual masculin-
ity tends to be prized over other genders in most realms of existence. Gender,
then, is defined as socially constructed and thus varying over time and across
cultures. It represents the categorisation of human beings – commonly based
on bodily characteristics, for example as masculine or feminine, which help
organise social experience in hierarchical terms, though their meanings are
historically and culturally variable.
378 Intersections
Sexuality
How we are understood as sexual beings also varies historically and culturally.
Indeed, the late nineteenth and early twentieth-century ‘sex scientists’ laid the
groundwork for contemporary thinking of sexuality as an innate property of
the self and, thus, an aspect of identity (Hawkes, 1996). The heteronormative
binary of straight and gay has been challenged for excluding a range of sexual
(and gender) possibilities (Butler, 1990). For instance, one can be, or rather ‘do’,
ambiguous, bisexual, pan/polysexual, queer, or heteroflexible. (See also Bowes-
Catton & Hayfield, Bisexuality, this volume.) Sexuality is defined as a product of
historically influenced socialisation processes, which both shape sexual experi-
ence and constitute a hierarchy involving relations between unequal (though
never fixed) forms of sexual expression.
History
(Continued)
Current debates
they make. Indeed, the individual projects of the (ageing) self central to this
theory could be used to support the increasing retreat from collective welfare
provision and the blaming of individuals for ageing ‘badly’ – failing to invest
properly for later life. This theory’s notion of empowerment is contradictory,
in that much of what passes for self-empowerment might be compelled by the
organisation of society and discourses that encourage expectations that old(er)
people should remain socially productive for longer. The theory also overlooks
gender inequalities in later life related to women’s lower incomes due to career
breaks for child-rearing and greater pressures on older women to act their age
(Rosenthal, 1990). They can find their sexuality under greater surveillance from
adult children and wider society.
Ageing trans women, too, could encounter ageism, sexism, and transphobia
on top of these experiences. In addition to these forms of exclusion, Donovan
(2002) has shown how, as a trans individual, she found difficulty in securing
employment and appropriate healthcare over the life course. One can assume
that ageing as a trans person is subject to cultural, psychological, material,
quasi-legal, and, consequently, health-related disadvantage. This is echoed by
Rosenfeld (2010), who also observes that becoming trans later in life especially
can risk exclusion by one’s biolegal family.
Newer currents of intersectional work have also added another strand of com-
plexity in addressing how ethnic difference affects ageing. Wray (2003a) has
observed that ethnicity has been neglected in social studies of ageing and social
policy. Support services for older people generally regard personal resources and
quality of life in ethnocentric ways, being framed within ‘Western’ individu-
alistic values of self-sufficiency, whereas African and British Caribbean old(er)
people commonly understand care and empowerment in more collective terms.
Resembling Silver’s argument above about the reflexive positioning of older
people and Jewish women especially, Wray (2003b) argues that older black
women’s intersecting experiences of ageism, sexism, racism, and class disad-
vantage enable them to develop critical responses that applied psychologists,
social gerontologists, and various other practitioners could learn from.
Ageing is:
In line with the above discussion, those framing social policy, applied psychol-
ogists, and various practitioners supporting older people need to consider how
forms of individual and social differentiation interact to shape identities, rela-
tionships, and social experiences. This will involve the kind of anti-oppressive
approaches to care that feature in social work training (Dominelli, 2002).
Paul Simpson 385
Summary
• Everyone ages, and ageism can work both ways, though it works in such
a way that ageing (something to be denied/avoided) is attributed to older
people.
• While functionalist and successful ageing theories tend to view ageing as a
problem (the latter can lead to responsibilising of those deemed to be grow-
ing older unsuccessfully), structured dependency theories risk homogenising
old(er) people as socially excluded.
• Ageing has become more complex, and intersectional approaches that view
it as bound up with gender, sexuality, race, class, and biography are better
equipped to explain its complexities.
• Professionals supporting older people should integrate into their prac-
tice understanding of how various influences intersect and impact upon
individuals’ lives.
• Research on ageing needs to address: the sexual needs of old(er) people; how
to maintain and develop services for older people (and LGBTQI people espe-
cially) in conditions of austerity; the specifics of bisexual, trans, and intersex
ageing; and recognition of older people’s involvement in reciprocal relations
of care.
Further reading
Cronin, A. & King, A. (2010). Power, inequality and identification: Exploring diversity
and intersectionality amongst older LGB adults. Sociology, 44(5), 876–891.
Estes, C., Biggs, S., & Phillipson, C. (2003). Social theory, social policy and ageing: A critical
introduction. Maidenhead: Open University Press.
Gilleard, C. & Higgs, P. (2000). Cultures of ageing: Self, citizen and the body. Harlow: Pearson
Educational Limited.
Heaphy, B. (2007). Sexuality, gender and ageing: Resources and social change. Current
Sociology, 55(2): 193–210.
Simpson, P. (2013). Alienation, ambivalence, agency: Middle-aged gay men and ageism
in Manchester’s gay village. Sexualities, 16(3–4), 283–299.
References
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constraints. London: Sage.
Arber, S. & Ginn, J. (1995). Only connect: Gender relations and ageing. In S. Arber, &
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Cruikshank, M. (1991). Lavender and gray: A brief survey of lesbian and gay aging studies.
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Dominelli, L. (2002). Anti-oppressive social work: Theory and practice. Basingstoke: Palgrave
Macmillan.
Donovan, T. (2002). Being transgender and older: A first person account. Journal of Gay
and Lesbian Social Services, 18(4), 19–22.
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introduction. Maidenhead: Open University Press.
Featherstone, M. & Hepworth, M. (1993). Images of ageing: Cultural representations of
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Gott, M. (2005). Sexuality, sexual health and ageing. Maidenhead: Open University
Press.
Gott, M., Hinchliffe, S., & Galena, E. (2003). Barriers to seeking treatment for sexual
problems in primary care: A qualitative study with older people. Family Practice, 20(6),
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Hafford-Letchfield, P. (2008). What’s love got to do with it?: Developing supportive prac-
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Hawkes, G. (1996). A sociology of sex and sexuality. Maidenhead: Open University Press.
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and Nicholson.
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Simpson, P. (2013b). Alienation, ambivalence, agency: Middle-aged gay men and ageism
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511–528.
22
Class
Bridgette Rickett and Maxine Woolhouse
This chapter will present research and theory in the field of psychology that
help us to understand how gender, sexuality, and class articulate together to
fashion our everyday understandings of other people, ourselves, and the spaces
and places we inhabit.
The first part of the chapter asks how psychology has conceived of class and
how class is understood to relate to our experiences, practices, and relationships
with people and place. Second, we look more closely at research and theory
in psychology that have examined how gender and class intersect in impor-
tant and interesting ways. Moving on to reviewing literature and theory that
have attended to sexualities and class, we aim to map out some of the fascinat-
ing findings that have emerged from this very small, but growing, literature.
The chapter will then focus on recent, illuminating research that has honed
in on some precise ways in which our gender, sexuality, and social class are
understood by us and others in intersecting and multiple ways.
Within the discipline of psychology, social class has a wide variety of mean-
ings, definitions, and modes of measurement, but is often understood simply
as socio-economic status or ‘SES’ (pertaining to the relative social position of
individuals based on differences in income, educational attainment, and occu-
pation). However, some work in psychology and in social sciences conceives
of the term ‘class’ in a much more complex manner: class can be consid-
ered a social category which reflects practices, values, histories, and the social
‘capital’ associated with these (e.g. Langston, 1988). Accordingly, Lott (2012)
understands social class as comprising both social and material structures and
ideology, which are mutually reinforcing to “produce and maintain inequal-
ity” (ibid., p. 651). In this way, social class can be thought of as both a social
construction (e.g. produced and reproduced in and through discourse and
discursive practices) and simultaneously structured through unequal access to
material resources and social, economic, and political power. Therefore, using
these ideas, class may or may not be related to actual differences in income (see
391
392 Intersections
Diemer & Seyffert, 2013 for a discussion of debates about the conceptualisation
of social class).
The first thing to note in a chapter on gender, sexuality, and class is the
startling paucity of research on class within psychology (Lott & Bullock, 2010).
For example, Lott (2012) notes that, in the two volumes of the fifth edition of
Fiske, Gilbert, and Lindzey’s (2010) Handbook of Social Psychology, social class is
covered in little more than one page. This has led many authors to attempt to
explain the reasons for such an important omission of thought on the subject.
For example, Sayer (2005, p. 1) has argued that “class is an embarrassing and
unsettling subject”.
compared with the more affluent. For example, despite the rhetoric of edu-
cation being the route to happiness and success, children from poor families
are educationally disadvantaged from the start; the schools available to them
are inadequately resourced, teachers have lower expectations (than those of
middle-class children), and their parents are assumed to be disinterested and
lacking in competence to help their children (Lott, 2001, cited in Lott, 2012).
Later, children from poor families encounter financial barriers to accessing
higher education and, should they manage to get there, experience a lack of
sense of belonging, which, in turn, predicts social adjustment and academic
performance (Ostrove & Long, 2007). Aside from educational disadvantages,
Lott (2012) notes that the psychological and physical health implications of
these experiences leave working-class people subject to discrimination and
stigmatisation.
In the therapeutic domain, Smith et al. (2011) investigated classism in
the context of the counsellor–client relationship. Specifically, they explored
the influence of clients’ social class on the early diagnostic impressions of
counsellors-in-training. The authors reported that counsellors with higher lev-
els of “belief in a just world” (i.e. “people get what they deserve in life”)
were more likely to view hypothetical clients from poor or working-class back-
grounds as unpleasant to work with and more dysfunctional than clients from
more privileged backgrounds, findings which (as the authors suggested) imply
that poor and working-class clients may receive less than favourable treatment
in the counselling context.
In relation to class and affect, Power et al. (2011) conducted an intriguing
experimental study investigating gender, class, and emotion. The study was
informed by arguments that the expression of emotions is, in part, governed
by power relations (Hochschild, 1979), whereby, for example, those in more
powerful positions are at liberty to express anger in ways that people of ‘lower’
status are not; the more powerful attempt to suppress anger in ‘subordinates’
as a form of social control (Stearns & Stearns, 1986, cited in Power et al., 2011),
and people in less powerful positions are likely to appease their oppressors by
expressing submissive emotions such as shame and gratitude (Tiedens et al.,
2000, cited in Power et al., 2011). Indeed, Power et al. (2011) found that, when
presented with a poor white woman who expressed either anger or shame
about her poverty, participants (students at a prestigious university) responded
more positively to the expression of shame; the poor woman’s expressions
of anger prompted the participants to feel anger towards the woman. Con-
versely, the poor woman’s expression of shame produced expressions of pity
from the participants. The authors argued that performances of emotion may
legitimise existing hierarchical power relations; expressions of shame from
poor women about their poverty suggest taking responsibility for it, which,
in turn, justifies the circumstances of the more privileged. Responding with
anger towards angry poor women is a mechanism of silencing them and “they
394 Intersections
It won’t make much difference whether Susan passes the entrance exam,
they won’t think she’s good enough to go there and they won’t think I’m
good enough either.
(Reay, 1998, p. 161)
these so-called failing mothers, while, at the same time, these abject feminine
subjects invite the viewer to identify “against what we must not be” (ibid.,
p. 227), thus fuelling attempts to transform ourselves into the normative bour-
geois feminine subject (Ringrose & Walkerdine, 2008). However, the authors
note how the pathologised “working class failure” (ibid., p. 237) depicted
in such programmes is crucially represented as resulting from individual bad
choices and ignorance, serving to screen out the poverty, deprivation, and
social exclusion which commonly structure the lives of those featured in the
shows.
In the broad area of health, and in particular food, eating, and body manage-
ment practices, Woolhouse et al. (2012) examined the talk of predominantly
working-class teenage girls in the context of focus group discussions. Feminist-
informed poststructuralist discourse analysis was employed, a mode of analysis
that aims to identify dominant discourses, or ways of talking, that are drawn
upon and resisted to construct identities. Woolhouse et al. (2012) specifi-
cally explored the ways in which classed and gendered discourses were drawn
upon in order for the girls to make sense of various ways of eating and
body management practices. Perhaps unsurprisingly, a key finding was that
eating was generally constructed as an ‘unfeminine’ activity, involving expres-
sions of desire, appetite, greed, and animality. For example, when discussing
the different ways in which boys and girls ‘can’ eat (producing a general
consensus about the social acceptability of boys eating greater quantities, con-
suming ‘unhealthier’ foods, showing greater enthusiasm for food and feeling
more comfortable eating compared with girls), one of the participants (Celia)
accounted for this disparity by stating: “cos girls aren’t supposed to eat like
pigs are they?” to which another participant responded “like [girls should be]
ladylike”.
The authors accounted for such talk by considering longstanding construc-
tions of women ‘as body’ (e.g. Bordo, 2003) and ruled by their bodies, which
are regarded as unstable, out of control, and inherently weak (Ussher, 1989),
yet simultaneously voracious, threatening, and in need of control (Bordo,
2003). Therefore, for a woman to exhibit control over her appetites sig-
nifies moral and sexual virtue, and constitutes her as ‘properly’ feminine
(controlled, delicate, dainty, passive, and so forth). Yet, as implied by the
participants, this idealised version of femininity is very much classed (i.e.
‘ladylike’), built upon bourgeois feminine characteristics (Walkerdine, 1990,
1996).
Edley and Wetherell’s early (1997) work with public school boys’ experi-
ences in school with a focus on the ‘cults’ (p. 205) of masculinity within this
middle-class, educational context is a rare example of research that explores
the more privileged domain of middle-class living and experience. Here the
Bridgette Rickett and Maxine Woolhouse 397
authors report how the boys are often caught between two contradictory,
hierarchically structured positions of boyhood, where ‘hard’ boys and sporty
boys were both structurally (through representation in awards and positions
of power and esteem, e.g. head boy) and discursively privileged, and other
masculinities that fall outside this position were constructed as ‘wimps’ or ‘new
men’, differentiated into a lower social order.
The sociologist Dianne Reay’s (2002) work later referred back to these findings
when she told us the compelling story of Shaun, using narrative analysis to
tease out the main features of a white, working-class boy struggling to achieve
academically during his first year of secondary school. This research provides
an acute example of how processes of class work through the individual as
Shaun struggles to reconcile being a tough boy in the playground and being
a high-performing boy in the classroom. Unlike Edley and Wetherell’s (1997)
boys, being a tough boy in the playground, while privileged in terms of social
order, is derogated in school structures and processes, and, in turn, being a high
achiever is highly valued in educational discourse, structures, and processes.
This causes a classed and gendered collision of identities for Shaun, forcing a
split for him into what he sees to be a double person. Reay (2002) powerfully
argues that this dilemma or split “lies at the very heart of class differentials in
attainment” (p. 228).
In addition, Courtenay’s research has aided us to begin to think about how
masculinity and class could be implicated in explanations of health practices.
According to Courtenay (2000), men want to demonstrate dominant ideas
around manhood that are culturally defined though classed (and raced) posi-
tions. However, despite differential positions, all these ideas about manhood
commonly reject what is feminine and often also embrace what is considered
to be unhealthy. For example, unhealthy practices (such as extreme risk-taking)
are often used to enable power positions (‘risk-taker’ vs. ‘coward’, for exam-
ple) to reproduce unequal power relations between them and women and less
powerful men.
Lastly, American Counselling Psychologist William Ming Liu’s research work
(e.g. Lui et al., 2009) has mapped out many applied repercussions for the classed
nature of how masculinities are practised and understood. His 2009 work looks
at homeless working-class men’s experiences, examining the stories these men
tell about their lives. In these, masculinity is suffused with status and class,
with the construction of a successful masculinity being drawn as independent,
achieving, and being a breadwinner. But these constructions are themselves
classed in ideology that fashions itself differentially according to class (i.e. hard-
working labourer versus successful lawyer). Through this research, Liu argues
that men who do not meet the normative expectations of what is successful for
working-class men may experience frustration and shame.
398 Intersections
women, the understanding of their sexuality by their colleagues was less likely
to be considered threatening or risky, whereas for working-class women their
sexualities were more likely to be seen as risky to perform while at work, forcing
them to engage in a number of practices, such as masquerading as heterosex-
ual, which, in turn, placed a greater burden on their psychological health.
So for working-class women the impact of both their class and their sexual-
ity colluded to ensure that their experience of being a lesbian at work was
risky, stressful, and, as McDermott terms it, ‘dangerous’ for them and their
health (p. 201).
Other psychologists have made clear attempts to research communities that
do not fit a heteronormative and middle-class focus. For example, Flowers and
Buston (2001) have looked at the experiences of young gay men in working-
class communities. While an explicit theorising of how class is intersected
with masculinities for young, gay men is not a main aim of this research,
we do see heterosexuality problematised in the stories emerging from young,
gay working-class men. This research focuses on the sociocultural context of
heterosexuality and sees this as central to understanding accounts of identities
and experiences. Using interpretative phenomenological analysis, interviews
with young men revealed multiple barriers to ‘being’ gay. For example, one
theme centred on the view that a gay identity was a derided one, resulting in
a need to ‘live a lie’ and conform to the default assumptions of being straight.
Interestingly, we also see the emergence of stories that see gay identities as
being continuous and spatially located, highlighting the importance of differ-
ing locales in the construction and performance of gay identities (i.e. home,
school, and the workplace). In addition, the authors conclude that access to
positive representations within working-class communities is of crucial impor-
tance for gay men and lesbians in providing access to possible identities and
practices that are valued and respected.
As with gender (and other forms of identity, e.g. ‘race’, age, ability),
sexuality intersects with class in ways which shape our practices and sub-
jective experiences and may produce very different outcomes depending
on the marginalised or privileged status of our sexuality and class loca-
tion. As students of psychology, practitioners, or academics, it is therefore
paramount that we recognise the privileging of heterosexuality and the
persistent homophobic cultural climate that people of marginalised sex-
ual identities contend with on a daily basis. However, as the research
reviewed above clearly indicates, we cannot assume that people sharing
400 Intersections
(Continued)
A first feature of the reporting of this story was the drawing up of two fac-
tions of women, who were presented as being involved in a war/fight. Within
this fight, two clear positions were constructed: the ‘old guard’ (characterised as
cis-gender, second-wave, working-class feminists who are drawn as out-of-date,
‘ugly’, and angry older women) and what researchers termed the ‘young pre-
tenders’ (members of the trans community depicted as inauthentic, immature,
hysterical, educated but unknowing).
Throughout the texts there is a continual and wilful mis-gendering of trans
women, coupled with a stark depiction of their lives and activities as an effort-
ful and economically privileged performance of womanhood. This enables a
questioning of the authenticity of womanhood for trans women (i.e. effortless
womanhood versus effortful womanhood). In doing so, heavily classed notions
around self-care product consumption are drawn upon; for example, the use
of a ‘Bic’ versus a ‘litre of yak’s butter’ is used to derogate easy, cheaper-to-
buy products commonly associated with working-class consumption, whereas
other, more expensive, perhaps exclusive products, usually denoting middle-
class consumption, are held up as desirable. All in all, a purposeful attempt is
made to present trans women as inauthentic, using their classed privilege to
purchase the accoutrements and time to ‘perform’ womanhood.
Analysis of these media texts illuminates the intersection of gender,
sexualities, and class in action. Throughout the texts there is a clear classed and
gendered discourse on the appropriateness of language and action (Day, 2012).
Here, educated trans women are ridiculed for the consumption of self-care
products and the perceived ‘effort’ required to maintain markers of femininity,
while women, written as cis-gender and working-class, are positioned as act-
ing outside normative boundaries by being angry, argumentative, ‘never one
to miss out’ on a ‘fight’. Similar to what other feminist authors have argued,
here women’s bodies in general are constructed as leaking, uncontrollable, and
extranormative (e.g. Tyler, 2008). But these depictions are also heavily drawn
from constructions of gender, sexuality and class, with trans women’s bodies
presented as out of control, difficult to ‘maintain’, while older (cis-gender) fem-
inists are ugly (‘bitten old trout’) and ‘disgusting’. Arguably, both positions are
also drawn from ideas around class, with the ‘bitten old trout’ and the ‘yak
butter’-using women’s bodies both keenly rendered as extranormative. This
analysis leaves us with important questions that need to be asked. For example,
who is deemed to be respectable, valued, or heard within these texts?
those working in applied psychology. For example, Liu et al. (2004) and Liu
(2012) have argued, social class is of the utmost importance in the areas of
counselling and clinical psychology, and other therapeutic domains. That poor
and working-class groups suffer most with mental health problems has been
well documented (e.g. Liu et al., 2004). Furthermore, social class is associated
with the effectiveness of therapy (Carter, 1991 cited in Liu et al., 2004), and
clients “who do not reflect the middle-class values of traditional therapy (e.g.
verbal ability, timeliness, psychological mindedness) may not receive the best
treatment” (Sue & Sue, 1990, cited in Liu et al., 2004, p. 4).
Liu et al. (2004) and Liu (2012) suggest that as psychologists we need to reflect
on our own class positioning, personal histories, and any experiences of clas-
sism (Liu, 2012). In addition, we need to consider that issues underpinning
‘problems’ are likely to differ across the class spectrum, as are understandings
of them, and therefore it is necessary for practitioners to take this into account
(Liu et al., 2004). It is also important that we explore with the people we work
with how social class is understood and how it is ‘played out’ in our interper-
sonal relations and social interactions (Liu, 2012). Lastly, we echo Liu’s (2009)
sentiments by cautioning against treating anyone requiring our help as ‘help-
less’ or without identity by being acutely aware of the gendered, sexual, and
classed world in which they have lived, do live, and hope to live.
Summary
setting, will help to keep class experience ‘live’ for us and the people we
work with.
• As academics, we could enrich the complexity of our research by moving
away from the idea that social class can now be dismissed as unimportant or
is an embarrassing subject by taking social class into account when engaging
in our own work.
• The exclusion of social class from research and theory raises epistemo-
logical questions about whose experiences are being used to generalise
understandings of our lives and practices.
• Our work could also benefit from a recognition of our own classed posi-
tioning (including our access to material, social, and economic resources,
and our value systems, which may be informed by these) and how this may
shape our worldview and the psychological theories we adhere to.
• If we are to have a renewed and concerted focus on class in psychology,
we must be very wary of the fact that this could marginalise gender and
sexualities if it fails to recognise the intersectional politics of class.
• Emotional pain and distress often accompanies experiences of derogation
and subjugation because of gender, class, or sexuality. Any future research
will need to take these highly charged stories of emotional life seriously.
• A focus on class also needs to be widened to include other class groups rather
than just focusing on the poor and working classes. This would address
the overwhelming tendency of research and theory in psychology to leave
middle-class culture and practices unexamined.
Further reading
Kraus, M. W. & Stephens, N. M. (2012). A road map for an emerging psychology of social
class. Social and Personality Psychology Compass, 6(9), 642–656.
Liu, W. M. (Ed.) (2013). The Oxford handbook of social class in counseling. New York: Oxford
University Press.
Lott, B. & Bullock, H. E. (2007). Psychology and economic injustice: Personal, professional,
and political intersections. Washington, DC: American Psychological Association.
Task Force on Resources for the Inclusion of Social Class in Psychology Curricula
(2008). Report of the Task Force on Resources for the Inclusion of Social Class in Psychol-
ogy Curricula. Retrieved from http://www.apa.org/pi/ses/resources/publications/social
-class-curricula.pdf.
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23
Disability
Alex Iantaffi and Sara Mize
Introduction
408
Alex Iantaffi and Sara Mize 409
Defining disability
Within a common medical model, disability can be defined as a ‘lack’ or
‘deficiency’, be it physical, sensory, or mental. Several pieces of legislation in
various countries are framed within this model and usually define a person
as having a disability if they have an impairment that posits a substantial
limit to that person’s capacity to conduct activities regarded as essential to the
conduct of everyday life (Hahn, 1993; Kanter, 2003; Stucki et al., 2007). This
medical model firmly places disability as residing within the individual. The
definition and diagnosis of disability are external and governed by medical sci-
ence. Within this framework, an ideal normative body is considered health-full,
whereas a body with a disability is considered to be lacking in health, and to
be synonymous with constructs such as sick, impaired, incapacitated, defective,
and, ultimately, abnormal (Barnes & Mercer, 1997).
The medical model of disability is inextricably linked to the idea of impair-
ment and located in specific areas of the body. For example, someone might be
described as having a physical disability if their mobility is affected by paralysis,
illness, or other causes. If someone’s senses are affected, they might be described
as having a sensory disability, such as deafness or blindness. If a person’s mind
is impacted by a disability, they are considered to have a mental disability. The
latter could be a cognitive and/or a developmental disability, such as autism,
or one that is caused by mental health issues, such as schizophrenia or severe
depression.
Within this model, the temporal nature of the disability, that is, whether
it is considered to be permanent or bound within a certain period of time,
is defined by the body’s ability, or inability, to heal or recover from the
impairment seen as the root cause of the disability. Disability can, there-
fore, be clearly defined, categorised, measured, and located within a specific
individual.
A social model of disability would, instead, take disability out of the indi-
vidual context and place it firmly within society. Within this model, disability
is the result of a society organised only around certain bodies that have been
defined as normative (Oliver, 2004). In this framework, norm is far more central
a construct than health, given that disability is seen as a byproduct of norma-
tive structures, legislations, institutions, and cultures. The substantial limit to
a person’s capacity to conduct activities regarded as essential to the conduct of
everyday life is, this time, posed by systemic barriers. These barriers are seen
as part of a system that has placed some bodies as the norm and has failed
to include a broader range of bodies and possibilities. In the social model of
disability, it is society that constructs the body with a disability as ‘other’, rel-
egating people with disabilities to lesser citizens due to lack of access (Barnes,
2000; Barton, 1997).
410 Intersections
In this model, for example, stairs become the root cause of disability, rather
than any impairment located in the body. Solutions are not seen as medical
interventions but, rather, as societal interventions involving access legislation,
education, and services (Oliver, 2009). Because the definition is not located
within the body, categories such as sensory, physical, or mental are applied to
access systems and not necessarily to an individual. For example, to provide
captioning or audio description for a movie at a theatre is to provide sensory
access to a broader range of the community, rather than purely to a specific
individual. Within this model, the temporal nature of disability is defined by
society’s ability to apply principles of universal design as far as possible, rather
than the capacity, or otherwise, of an individual body to heal. A social model of
disability posits that we are all interdependent but that we have fostered a myth
of independency in our society by organising ourselves in a way that makes
certain types of dependency more or less visible. For example, many of us living
in urban centres are dependent on food growers to meet our dietary needs, yet
this is considered to be a normal part of society’s functioning, whereas being
dependent on a wheelchair or caregiver is seen as being an exceptional need
and, as such, outside societal norms.
Feminist theories of disability also place disability within society. In these
theories, disability is not biological destiny but a construct that is also
affected by its intersection with gender (Begum, 1992; Garland-Thomson, 2003;
Gerschick, 2000; Lloyd, 1992; Morris, 1992). Similarly to the social model of
disability, these theories posit that disability is created by society’s empha-
sis on normative bodies, devoid of any materiality, including illness. Within
this framework, minority Western cultural emphasis on health and normativ-
ity places bodies with a disability at the margins because we do not want to
be reminded of mortality, interdependency, limitation, and pain (Morris, 1992,
1996; Wendell, 1996).
Feminist perspectives bring the body back into the social model of disabil-
ity by acknowledging the materiality of bodies in general and the embodied
nature of everyday lives. For example, feminist academics with disabilities high-
light how knowledge production is commonly seen as a task of the mind, even
though it entails a material production, like the ability to access libraries, read
printed books, photocopy them, use software, or listen to lectures (Potts &
Price, 1995). In this framework, it is not only those with disabilities who
have bodies affected by the possibility of death, pain, dependency, and limi-
tation. All bodies are impacted, but culturally we have invested in only seeing
some bodies, and not others, as needing to deal with these issues. Within this
model, disability becomes society’s way of ‘othering’ the body and banishing
the minority Western cultural fear of the body’s limitation and mortality to
the realm of those whose bodies cannot hide their limitations and mortality
(Wendell, 1996).
Alex Iantaffi and Sara Mize 411
During the 1980s and 1990s, when these three models emerged and estab-
lished themselves, the field of Disability Studies, multidisciplinary in nature,
also solidified (Barnes et al., 2002). Increasingly this has been criticised by
authors with more intersectional lenses who have been pushing the field
towards questioning and studying ableism, that is, the fact that Western minor-
ity culture is organised around and favours bodies without disabilities, from a
perspective that includes sex, gender, race, and sexuality (Erevelles & Minear,
2010; Söder, 2009). One example of this kind of model is Crip Theory, which
draws on a range of critical theories on gender, race, ethnicity, and sexuality
to address society’s attempts to define bodies and pleasure as either normative
or deviant (McRuer, 2006, 2011; Sandahl, 2003). You might have noticed how
terminology to describe sexuality varied in the examples above as we moved
from one model to another. There are, of course, several models of sexuality
as well as of disability. Given that this whole book is dedicated to the topic of
412 Intersections
sexuality, we will not dwell on defining those models and theories of sexuality.
Nevertheless, we invite you to notice how certain models of disability might
work in concert with models of sexuality. For instance, when addressing the
medical model of disability, we referred to biological aspects of sexuality and
used terminology such as sexual functioning.
As you read this chapter, you will notice that we will draw on these mod-
els and that research, debates, and clinical practices around disability and
sexuality are deeply affected by the models adopted. For example, within
a common medical model, the issue of disability and sexuality will be
more focused on issues such as medication and their impact on sexual
functioning, benefits and contraindications of sexual activities, or dif-
ferent bodies’ ability to orgasm. Within a social model, the discussions
would be more centred around the stigma surrounding disability and its
impact on the infantilisation and desexualisation of people with disabil-
ities, as well as the systemic barriers people with disabilities might face
when trying to have sex, such as sometimes being placed in facilities
that will actively discourage and even punish as pathological any form of
sexual pleasure, including masturbation. Feminist models would tackle
similar issues, but, together with more critical and intersectional theo-
ries of disability, they would also include perspectives on how gender,
sexuality, and race intersect with disability in ways that challenge easy
categorisations of health, identity, desire, and pleasure.
While many people with disabilities are still overlooked as sexual beings by
many healthcare providers (Coleman et al., 2013; Haboubi & Lincoln, 2003;
O’Dea et al., 2012), research continues to address disability and sexuality as an
area of interest from multiple standpoints: neurological, psychological, social,
Alex Iantaffi and Sara Mize 415
political, legal, and equitable. In the past ten years, scholarship on this topic has
become more frequent, as have debates on issues of social policy. One of those
issues has been that of people with disabilities using professional sex workers to
meet their needs. This is a controversial issue. On one hand, it reinforces some
of the stigma and myths around the sexualities of people with disabilities by
representing them as undesirable within a mainstream context and as only hav-
ing access to sexual pleasure through professional sex workers (Samuels, 2013).
On the other hand, several disability rights advocates have been campaigning
for years for the right of people with disabilities not to be criminalised when
using the services of sex surrogates and/or sex workers (Sanders, 2007). This
issue also challenges our societal notions of personal and public, as activists
have questioned why professional sex work cannot be covered by funds pro-
vided for personal care, troubling the difference we tend to make between need
and desire (Appel, 2010).
The above example illustrates how complex the area of sexuality and disabil-
ity is. A common research pitfall in this area is seeing disability as one-faceted,
rather than as complex and intersectional: for example, by considering only
disability as the main identity of enrolled participants in a study without con-
sidering their gender, sexual orientation, race/ethnicity, socio-economic status,
or legal status (e.g. having a legal guardian). These issues highlight some fun-
damental concepts that seem to emerge across various research studies on
disability and sexuality: the body, citizenship, and access.
The body takes centre stage in most of the work on disability and sexual-
ity, whether as the site of intervention from a medical perspective or the locus
where social constructs and relationships are negotiated. The body becomes
the site of both control and resistance. This is evident in research highlight-
ing reproductive health issues for many people with disabilities. Control of
the bodies of people with intellectual disabilities, especially women, for exam-
ple, has often been seen as part of the decision-making realm of healthcare
providers, parents, and other caregiving individuals and institutions (Brady,
2001; Greenwood & Wilkinson, 2013; Jennings, 2013; McCaman, 2013; Roy
et al., 2012; Stefánsdóttir & Hreinsdóttir, 2013; Tilley et al., 2012; West, 2013).
This control has too often been enshrined in legislation, and as recently as
2011 Human Rights Watch released a briefing paper on the sterilisation of
women and girls with disabilities (Human Rights Watch, 2011). While ster-
ilisation might seem extreme, birth control is routinely prescribed in similar
fashion to people with intellectual disabilities who were assigned female at
birth. Some of the arguments used are based on research reporting alarming
rates of abuse among people with disabilities, and see enforced birth control as
a form of protection. This reinforces the stereotype of people with disabilities as
a vulnerable, infant-like population, needing to be protected from sexuality and
devoid of meaningful sexual agency. In fact, sexual agency can often be seen
416 Intersections
extremely narrow navigation path with few, if any, options. For example, when
access to language is provided for a therapy session in sign language there may
be a very limited number of interpreters to choose from, if choice is even pos-
sible, based on what the agency or individual providing therapy considers a
reasonable adjustment.
Access to services goes, of course, well beyond interpretation and can include
issues of access to clinical language and materials, physical access to envi-
ronments, and the provision of emotionally safer spaces. Within the areas of
disability and sexuality, sexual access, reproduction access, and other types of
access, such as transition-related healthcare access, also become salient. Access
is not only complex; it also implies the question of who is giving or gain-
ing access to whom. If I am a hearing provider working with a deaf patient
and we use a sign language interpreter, who is the recipient of access services?
In the minority Western cultural script, it is the deaf person who is seen as
having a sensory disability, regardless of their potential identity as part of a
linguistic minority. However, from a deaf culture perspective, it is the hearing
person who is incapacitated by an inability to sign, in this example, and there-
fore unable to access directly a distinctive linguistic minority. The minority
Western cultural script is not immutable, and it has been challenged by disabil-
ity activists through writing, art, and even advertising campaigns, as described
in the following section (Berne, 2008; McRuer & Mollow, 2012; Olsson, 2012).
Body, citizenship, and access continue to be hot topics in many of the current
debates on disability and sexuality, especially considering that the field is still
relatively new as an area of scholarship. Intersectional approaches, in partic-
ular, have brought together insights from a range of critical theories in race,
gender, disability, and sexuality studies (McRuer, 2006, 2011; Sandahl, 2003).
Intersectionality as a concept was first introduced by legal scholar Kimberlé
Crenshaw (1989) and has been increasingly used in a move towards greater
inclusivity. This concept posits that the way in which complex bodies and
communities experience oppression is deeply interconnected and cannot be
disassembled or its parts analysed separately. Within this framework, disabil-
ity and sexuality are seen as deeply interconnected to all other parts of our
experiences and identities, such as race, gender, ethnicity, class, education, and
language. Crip theory (McRuer, 2006, 2011; Sandahl, 2003), mentioned ear-
lier in this chapter, is one example of intersectional debates on disability and
sexuality.
Some of the ways in which intersectional perspectives are doing so is
through challenging the historical erasure of complex bodies and lives
and increasing their visibility, from medical education to performing arts.
418 Intersections
For example, disability activists and artists have become increasingly vis-
ible in challenging mainstream understandings of desirability that con-
sider people with disabilities as having no erotic capital, that is, sex-
ual attractiveness as a social value/currency. Much of this visibility has
been through performing groups like ‘Sins Invalid’ (Berne, 2008) and
social media campaigns like ‘American Able’ (Olsson, 2012) and ‘Enhance
the UK: Undressing Disability’ (http://enhancetheuk.org/enhance/undressing-
disability/undressing-disability-the-campaign/). The Undressing Disability
campaign has published a beautiful, glossy lingerie calendar featuring per-
sons with disabilities in famous locations in the United Kingdom, while
the American Able campaign produced pictures resembling images of a pop-
ular North American clothing ad campaign portraying people with visible
disabilities.
This lack of erotic capital is based on the assumption that people with dis-
abilities are not able to express their sexuality in ways that are seen as falling in
line with cultural scripts on gender and sexuality. People with disabilities whose
gender and/or sexuality may fall beyond the boundaries of what is considered
to be legitimate, good, or normal in minority western systems, that is, those
who identify as trans*, non-heterosexual, or having kinky desires, are often
seen as deviating from normative scripts because of their impairment (Iantaffi,
2009). This not only invalidates those people who have disabilities and iden-
tify as gender and sexual minorities, but also reinforces narrow ideas of what
constitutes good and legitimate sexual expression. If people with disabilities
are seen as taking refuge in identities and practices that are viewed as ‘other’
because mainstream identities and behaviours are denied to them, then those
identities and practices are also implicitly being defined as other and inferior to
mainstream identities and behaviours (Iantaffi, 2013).
Another site of debate and resistance in the field of disability and sexual-
ity is the impact of genetics research, another area in which body, access, and
citizenships are crucial. Advances in clinical genetics and genetic research in
general have brought to public awareness ethical issues around the lives of peo-
ple with disabilities and their right to continue to exist. Disability movements
have often had little access to genetic research and the clinical and policy deci-
sions that might be based on this, given that within this framework the goal is
often to eliminate disabilities. The possibility of erasing people with disabilities
goes even further than the denial or reduction of citizenship and into the right
for specific bodies to exist (Bumiller, 2009; Clayton, 2003; Hodgson & Weil,
2012; Madeo et al., 2011; O’Brien, 2011; Savulescu, 2001; Shakespeare, 1998,
1999).
Some writers remind us that eugenics ideals survive through much genetic
research or are, at least, historically connected with it (Miller & Levine, 2012;
Phelan et al., 2013). These ideals have historically underpinned the Holocaust
Alex Iantaffi and Sara Mize 419
and legislation regulating the control of the sexual and reproductive health
of people with disabilities for the ‘greater good’ (Baker, 2002; Evans, 2004;
Mitchell & Snyder, 2003; Pfeiffer, 1994; Savulescu, 2001). It is worth noting
that the Nazi party and scientists trialled their methods on people with disabil-
ities to test what would be acceptable to the general population before moving
on to targeting Jewish people, any resistance supporters, and gender and sex-
ual minorities (Hashiloni-Dolev & Raz, 2010). Current debates questioning
genetic research and clinical genetics remind us of the destructive potential of
those scientific and technological advances, especially for those whose bodies,
citizenship, and access to social and cultural governance are marginalised.
At the same time that genetic advances are hotly debated within and out-
side the disability movement, the sexuality of people with disabilities has been
under the media spotlight after Hollywood turned its attention to the issues
in the Oscar-nominated film ‘The Sessions’. As discussed earlier in this chapter,
the issue of access to sex workers for people with disabilities holds a paradox:
providing sexual access and potentially reinforcing the idea of people with
disabilities as lacking any erotic capital. Despite this paradox, the increased
attention to disability and sexuality has brought to mainstream discussion sev-
eral of the issues addressed in this chapter so far. Attention in this area has
meant more awareness of resources addressing not only the right of people with
disabilities to have sex but also how to have sex beyond mainstream images.
These images, in fact, do not usually include key issues of communication;
boundaries negotiation; mobility, props, and accommodations; and, perhaps
more importantly, the reality that our bodies are more diverse, limited, and
fragile than the majority of representations in mainstream minority Western
culture.
These issues are the realm of more sex-positive approaches in clinical practice
and research on disability and sexuality. Within research, this approach has
encouraged further study of the human orgasm and corroborated claims about
the existence of non-genital orgasms (Komisaruk & Whipple, 2011), expanding
our understanding of pleasure and sex as well as opening up possibilities for
sex therapy with people who would have previously been discounted as more
limited candidates (e.g. men with spinal cord injuries affecting areas T11–L2,
S2–S4). This clinical approach can also be applied to agendas for psychological
research that supports the concept of a continuum of functioning rather than
perpetuating the binary of disabled verses non-disabled.
By this point, it might seem self-evident that the area of disability and sexuality
is complex, multifaceted, and fairly vast. What does this all mean in practice
for scholars, applied professionals, and students? First of all, we would like to
420 Intersections
invite you to pay attention to your disciplinary lens. The models presented
here will fit more or less neatly with those prevalent in your field. For example,
clinicians working with people with disabilities on sexuality issues will need to
pay attention to both medical and social issues.
Critical, intersectional lenses will also be helpful in better addressing the
needs of patients or clients, as they support a more holistic and systemic
approach to caring for the whole person. One of the first things to consider
is whether you have a shared understanding of sex and sexuality with your
client. Another important task to perform early on is an assessment of your
client’s experience of disability. This assessment includes things like the phys-
iological impact but also how they view their disability, whether internalised
ableism plays a role in their life and, if so, how, and how others around the
client relate to the disability.
Once there is a shared understanding of definition and of the biopsychosocial
landscape for the client, an important area to explore is goal-setting. What
are the client’s hopes and dreams? For example, if the disability is acquired,
is there a desire to be fixed and go back to experiences that preceded the dis-
ability’s onset? What scaffolding might be necessary for the client to be willing
to consider new definitions of sex and pleasure?
Future directions
Summary
living. This model places disability within the individual and sees it as a
problem to solve.
• The social model of disability posits that it is created by society and its failure
to adhere to inclusive principles of universal design, making it impossible for
some bodies to navigate everyday life successfully and/or smoothly.
• Feminist theories of disability also place it within society. In this framework,
both disability and sexuality are constructs, as is gender.
• Psychology does not have a unified perspective on disability and sexuality.
Different psychological theories approach disability and sexuality according
to their principles (e.g. cognitive behavioural approaches are likely to be
more solution-focused).
• The persistent desexualisation and infantilisation of people with disabilities
contributes to the erosion of their citizenship.
• Sex-positive approaches to inclusive sex therapy challenge our cultural
scripts that define sex as intercourse. Research into non-genital orgasms
supports this.
• Clinicians working with people with disabilities on sexuality issues need to
pay attention to both medical and social issues.
Further reading
Kaufman, M., Silverberg, C., & Odette, F. (2007). The ultimate guide to sex and disability:
For all of us who live with disabilities, chronic pain, and illness. Berkeley, CA: Cleis Press.
Kim, E. (2011). Asexuality in disability narratives. Sexualities, 14(4), 479–493.
McRuer, R. & Mollow, A. (Eds.) (2012). Sex and disability. Durham, NC and London: Duke
University Press.
Rainey, S. S. (2011). Love, sex, and disability: The pleasures of care. Boulder, CO: Lynne
Rienner Publishers.
Schulz, S. L. (2009). Psychological theories of disability and sexuality: A literature review.
Journal of Human Behavior in the Social Environment, 19 (1), 58–69.
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24
Ethnicity
Roshan das Nair
Introduction
427
428 Intersections
History
people) are missed out. These groups are sometimes erroneously seen as being
in between. Take, for instance, those who are bisexual, or those who are
mixed race. Resisting such dichotomies makes categorising people complex;
but people are complex!
It is perhaps for ease of coding, therefore, that psychology researchers and
theorists have mainly considered one identity (such as gender, ethnicity, sex-
uality) at a time. However, to conceptualise any of these identities as static
and not intermixed is to present a very narrow view of individuals; a view
that mainly focuses on the dominant or privileged groups. Warner (2008) has
helpfully developed a ‘best practices guide’ to intersectional approaches in
psychological research, and argues that treating identity as a process situated
within social structural contexts facilitates the research process. This, I believe,
is sound advice. The following sections demonstrate how research focused on
one identity marker may miss out the essence of the individual by failing to
recognise other identity markers.
I begin this section by appraising two very influential systematic reviews: one
examining race and mental health, and the other examining sexuality and
mental health.
The systematic review by Kamaldeep Bhui and colleagues (2003) that con-
sidered ‘ethnic variations’ in pathways to and use of specialist mental health
services in the United Kingdom concluded that “There is strong evidence of
variation between ethnic groups for voluntary and compulsory admissions”
(p. 105), and some evidence of variation in pathways to specialist care, with
Roshan das Nair 431
Black patients having had more complex pathways to specialist care. There are
several staggering findings here. For instance, “Black people on in-patient units
were four times more likely to experience a compulsory admission compared
with White people” (p. 114). Therefore, there is a possibility that racism (and
perhaps even institutional racism) has a role to play in this finding. But what
was significant was that “[n]o papers reported investigations of discrimination
as a risk factor” (p. 114).
This is an interesting finding in itself. But, looking more closely at the data
generated by this review, it is also interesting to note that the review authors
do not make reference to the sexuality of the participants in any of the stud-
ies reviewed, nor do they acknowledge that this is one variable that can itself
be related to poor mental health and difficulties in accessing mental health
services – just like socio-economic status, age, and gender (the three factors
that the reviewers acknowledge). Among the primary papers included in the
review, factors such as class, past admissions, police involvement, and living
alone were adjusted for. Furthermore, it is interesting that Bhui et al. (2003) do
not mention sexuality as a consideration in their ‘future priorities’ section of
the review. Therefore, the absence of sexuality is an intriguing silence.
The Michael King et al. (2008) systematic review on mental disorder, sui-
cide, and deliberate self-harm in lesbian, gay, and bisexual people is another
significant publication. King et al. reviewed 25 studies and concluded that,
cumulatively, studies showed that “LGB people are at higher risk of mental
disorder, suicidal ideation, substance misuse, and deliberate self harm than
heterosexual people.” What is interesting here is that, while the reviewers
note and comment on the demographics of participants from the various
included studies – for example, age, gender, whether they were a student or
employed sample – there is no mention of the race or ethnicity of any of these
participants.
Another recent study by Apu Chakraborty and colleagues (2011) on the
mental health of “the non-heterosexual population” [sic] of England aimed
to “relate the prevalence of mental disorder, self-harm and suicide attempts
to sexual orientation in England” (p. 143). For this aim, the use of the Adult
Psychiatric Morbidity Survey 2007 (n = 7403) of people living in private UK
households was entirely appropriate. However, the authors also aimed “to test
whether psychiatric problems were associated with discrimination on grounds
of sexuality” (p. 143). The authors acknowledge that a cross-sectional survey
methodology makes it difficult to answer this aim, but nonetheless suggests
that discrimination is associated with poor mental health. In making com-
parisons between heterosexual and homosexual individuals, the authors make
statistical adjustments for “appropriate sociodemographic confounders” (which
include gender and ethnicity), but do not actually conduct a subgroup analysis
based on either of these demographic variables. This would have made for
interesting reading.
432 Intersections
Therefore, when assertions are made about BME or LGBT groups having
higher incidence of mental health problems, a critical approach needs to be
taken to understanding who the participants in such research were. This is of
significance, as, in most cases, samples are only categorised on the basis of
their association with one identity marker or category. These categories are
best regarded as necessary evils and approximations. They are sometimes not
clearly and consistently used by research participants, nor are they used sen-
sitively by some researchers. Take, for instance, the category of South Asian.
Some studies will club South Asians broadly within the ‘Black’ or ‘non-white’
category, while others may use census indicators and subclassify South Asians
more specifically as being ‘Indian’, ‘Pakistani’, or ‘Bangladeshi’. The latter is
perhaps a better option, but it creates the illusion of homogeneity based on the
notion of nation states. Therefore, any category of race and ethnicity can at
best only be described as a proxy.
Furthermore, ethnicity (particularly when coded as ‘nationality’) is problem-
atic if it does not consider other demographics such as gender, religion, and
class (see das Nair & Hansen, 2012; das Nair & Thomas, 2012c; Ellis, 2012).
People identifying as a Christian or Muslim can have very discrepant ethnic
‘Pakistani’ experiences within Pakistan. Similarly, the South Indian manual
labourer and South Indian scientist working in Dubai do not share the same
diasporic ‘Indian’ experience of migrant workers. As bell hooks reminds us,
class matters:
Race and gender can be used as screens to deflect attention away from the
harsh realities class politics exposes. Clearly, just when we should all be pay-
ing attention to class, using race and gender to understand and explain its
new dimensions, society, even our government, says let’s talk about race and
racial injustice. It is impossible to talk meaningfully about ending racism
without talking about class. Let us not be duped.
(hooks, 2000, p. 7)
If we examine sexuality categories, we will find that studies run into similar
problems of closing in on difference. Consider the King et al. (2008) review, for
instance. Out of the 25 studies they reviewed, only seven of them actually sep-
arated out bisexual sexual identity, while, in the rest of the studies, groups were
collapsed as LGB or LGBT vs. heterosexual, thereby obfuscating differences that
exist within sexual minority groups (see chapter on bisexuality elsewhere in this
volume). In the case of the Chakraborty et al. (2011) study, bisexuals were cat-
egorised as ‘non-heterosexual’. Furthermore, the notions used in such surveys,
whereby bisexuals are categorised as ‘equally attracted to men and women’, are
misleading.8 When we consider bisexual research in particular, categorisation
becomes even more complicated, given that bisexuality is more challenging
434 Intersections
to define or perhaps more variously defined than are sexual identities such
as gay or lesbian. The King et al. (2008) review included studies in which
sexuality was defined as (1) same-sex attraction, (2) same-sex behaviour, (3) self-
identification as LGB, or (4) a point on the Kinsey scale. I think collapsing
bisexual behaviour from bisexual self-identification is problematic, because –
although not exclusively – we do know that in some instances there is a
movement from bisexual behaviour to bisexual self-identification, the latter
developing with experience, support, and competence of claiming a sexual
identity that one is comfortable with. And more self-identification and disclo-
sure has been shown to reduce distress (e.g. Jordan & Deluty, 1998). Therefore,
even within bisexual groups, the manner in which people identify or do not
self-identify will have an impact on how their sexuality impacts on their mental
health and how they view their sexuality impacting their mental health.
Stereotypes
Stereotypes are useful as cultural markers of interaction between various groups
of people, be they ethnic minorities or sexuality minorities. A stereotype itself
does not have the power to hurt, but, as Kumashiro (1999) suggests, it does
harm when it “derives from a particular history of how that stereotype has been
used and a particular community of people who have used that stereotype and
who constitute that history” (p. 494). Stereotypes can, therefore, have perni-
cious effects in relation to prejudice and discrimination (Dovidio & Gaertner,
2010). Indeed, we have several examples of racial, gender, sexuality, mental ill-
health, and other stereotypes. However, much research on stereotypes relates to
one specific identity, and most has focused on a single social identity (Ghavami
& Peplau, 2012). This suggests an interesting omission in research, especially
given that intersectional stereotypes do exist and have the potential to be
equally damaging as single-identity stereotypes. For instance, Richard Fung
(1991) has referred to stereotypes of East Asian (gay) males as being cast as
‘sexless’: “if Asian men have no sexuality, how can we have homosexuality?”
Hill Collins (2000) refers to the manner in which ‘controlling images’ of BME
women in society serves to justify their position in relation to men and in rela-
tion to other, White, women. As Pyke and Johnson (2003) point out, this is
part of the process of ‘othering’, “whereby a dominant group defines into exis-
tence a subordinate group through the creation of categories and ideas that
mark the group as inferior (Schwalbe et al., 2000, p. 422). Controlling images
reaffirm whiteness as normal and privilege white women by casting them as
superior” (p. 36).
Ghavami and Peplau (2012) compared perceived cultural stereotypes using a
free-response procedure, to generate ten attributes for one of 17 groups: “Asian
Americans, Blacks, Latinos, Middle Eastern Americans, or Whites” (p. 113); men
or women; or ten gender-by-ethnic groups (e.g. Black men or Latina women).
They found that gender-by-ethnic stereotypes contained unique elements that
Roshan das Nair 435
were not the result of adding gender stereotypes to ethnic stereotypes. Interest-
ingly, also, they found that stereotypes of ethnic groups were generally more
similar to stereotypes of the men than of the women in each group. This study
is excellent in that it demonstrates how, using intersectionality theory and
social dominance theory, we can demonstrate the complexities of such stereo-
types and how the intersections of these social categories produce differences
in the way groups are perceived.
The interaction between gender (and gender-stereotypical behaviours) and
sexuality has also been researched in terms of ethnicity (e.g. das Nair, 2013).
Here we find that expectations of what constitutes masculinity and femininity
are read through the lens of race/ethnicity. Therefore, an East Asian effeminate
man may not be read as ‘gay’ simply because of his race. Such stereotypes have
an impact on how people view themselves and their bodies and body image.
Similar stereotypes are also prevalent in the United Kingdom. Some of these
are of particular importance to BME LGBT people: for instance, the assump-
tion that, because a person is Asian, ‘gayness’ is only a passing phase till their
parents find a heterosexual partner for them. This has real consequences for
those seeking to form long-term partnerships with others of the same sex. BME
LGBT people may also experience prejudice from their own ethnic commu-
nities because of the notion that being gay is something that White people
do. Therefore, when, for instance, a South Asian or East Asian person stresses
the importance of their sexuality, they may be considered as betraying their
own kind (in terms of ethnicity) and may be pejoratively called a ‘coconut’ or
‘banana’ (brown/yellow on the outside but white inside). For some trans peo-
ple, their gender could be elided with sexuality in some cultures. Therefore,
some trans women may be considered ‘gay’ simply because they are perceived
not to fit with the idea of who a woman is or should be. Furthermore, trans
people may have or have had specific cultural stereotypes applied to them (e.g.
the hijras in India are often perceived to be dangerous or sex workers, despite
their occupying various professional roles in India). Therefore, for most LGBT
people coming out is a challenging event that could be fraught with problems.
This may be even more problematic for BME individuals. The next section deals
with coming out from a race/ethnicity perspective.
(Continued)
migrants, and those for whom English is not their main language). Assuming
that sexual identity and desire/activity are synonymous might be erroneous.
Second, it points to the transmutation of an act to an identity. Foucault (1980)
describes this in his History of Sexuality. Historically, ‘sodomy’ (considered the
most abhorrent of sexual activities by the Abrahamic religions) was seen as a
sin that needed repenting or penance; then ‘homosexuality’ became a medical
condition to be treated; and, finally, ‘gay’ became a socio-political identity that
needed to be articulated and celebrated. While it could be argued that this is a
prototypical ‘Western’ phenomenon, I would argue that this is a supranational
phenomenon that may have originated in the West but has found a culturally
adapted version in different regions of the world. Therefore, even though only
two participants in our study identified as ‘gay’, the trajectory of the majority
of the participants’ coming-out stories closely followed well-rehearsed and doc-
umented steps or ‘stages’ seen among gay-identified individuals in the West.
This is all the more striking given that the majority of the participants used
indigenous sexual identity labels (such as koti, Double Decker.) to self-define
their sexuality.
Two processes appear to be operating here: one that relates to indigenous
sexual identity labelling, and another that relates to same-sex sexuality devel-
opment that follows a Western ideal of being ‘out’ and monogamous coupling
with a same-sex partner. Thus, it is no surprise that, in the model we proposed
of same-sex identity development in an Indian context (Pandya et al., 2013),
the trajectory followed by most of our participants could almost have been
mapped out on more established Western models, such as those proposed by
Cass (1979) and Troiden (1989). We can speculate that this ideal way of being
‘gay’ has been transmitted by globalisation of the gay identity and lifestyle
through Western media, either directly or indirectly through their influence on
regional and local media (for instance through Bollywood films such as ‘Dunno
Y . . . Na Jaane Kyon’ (English: ‘Don’t Know Why’), Dir. Sanjay Sharma, 2010),
or through the influence of non-governmental organisations (NGOs who work
with sexual minorities), that have perhaps accepted this Western ideal of gay
sexuality development. The globalisation of ‘gay’ has been documented else-
where (e.g. Cate, 2000), and it is recognised that the assimilation of global
gay identities and lifestyles does not take the form of a passive absorption and
that such an identity formation is not necessarily an unquestioned good (see
Corboz, n.d.). This has relevance not only for the ‘native’ ethnic subject, but
also for diasporic BME subjects. This will be the focus of the next section.
groups. I have discussed these challenges and triumphs elsewhere (see Butler
et al., 2010; das Nair, 2006; das Nair & Thomas, 2012a, 2012b).9
There are three questions in relation to BME coming out (das Nair, 2006):
These are the questions I ask myself when, in therapy, I see a BME individ-
ual questioning their sexuality. These questions help not only the therapist,
but also the client in their decision-making process of negotiating coming out.
I now consider each of these questions in turn. But, before that, a caveat: I only
discuss the issues related to ‘problems’ BME LGBT face, because oftentimes this
is what I come across in therapy. Therefore, this is necessarily a skewed perspec-
tive, and there are some BME LGBT people who happily negotiate being both
BME and LGBT individuals with few or no challenges.
(i) Many BME non-heterosexuals feel compelled to come out. They feel that
if they do not come out they are not being ‘true’ to themselves (because that is
what they’ve been told by other out and proud LGBT people) or because they
feel that is the only way they can be non-heterosexual (based on dominant
cultural discourses). Some BME non-heterosexuals have found ways of nego-
tiating ways of being non-heterosexual without publicising it, particularly to
their families. Through the use of the internet, people access websites such as
Gay Lesbian MOC,10 to find an individual or a couple of another sex to arrange a
‘marriage of convenience’. The website avers that “you will no more hear people
asking about when you are going to get married. No one will ever question your
sexuality again. No more pressure, as if like a heavy burden has been lifted off
your shoulders.” These websites are interesting because they demonstrate how
people are satisfying their sexual desires while helping their ‘spouses’ fulfil their
own wishes, and their respective families have their aspirations for their sons
and daughters satisfied. In such relationships, spouses agree to terms of engage-
ment that may include other partners, decisions around having children, and
so on. Others form a marriage of ‘understanding’. This is more common among
(but in no way exclusive to) bisexual BME individuals who may wish to have an
open relationship with their partner and others of the same sex. Beckett (2010)
proposes a strategy of ‘coming in’ for BME non-heterosexual people, which
includes the “conscious and selective invitation of people into one’s ‘club of
life’ ” (p. 204). These are not problem-free options, but some individuals are
beginning to view these as viable options, and others are exploring their way
through such relationships.
(ii) Ravichandran (2010) summarises some of the perils of coming out for
BME LGB people. Many BME families and communities do not understand
or accept same-sex sexuality, particularly same-sex sexual identities, and can
Roshan das Nair 439
Current debates
Future directions
The two current debates I have just highlighted relate to the future direc-
tions of intersectionality of ethnicity with gender and sexuality. One of the
most pressing issues for the theory of intersectionality in relation to gender,
sexuality, and ethnicity is how to translate this theory into practice. This is,
it must be added, an issue for many aspects that intersectionality seeks to
address. There have been some efforts to address this (e.g. Budryte, forthcom-
ing; Choo & Ferree, 2010). Choo and Ferree (2010), for instance, suggest three
styles of conducting intersectional research: placing the marginalised/minority
group and their perspectives in the centre of research; placing the process in
relation to power dynamics, multiple sites of oppression, and interactions in
Roshan das Nair 441
the centre; and, finally, “seeing intersectionality as shaping the entire social
system pushes analysis away from associating specific inequalities with unique
institutions, instead looking for processes that are fully interactive, historically
co-determining, and complex” (p. 129).
Qualitative methods have largely been the mainstay of intersectional
research, perhaps because of the challenges inherent in quantitative designs,
such as sample sizes, number of variables, and how each of these variables can
be identified and accurately measured. These are larger ontological and epis-
temological challenges that relate to any aspect of intersectionality research,
including research on sexuality, gender, and ethnicity. Therefore, what a quan-
titative approach to the study of intersectionality would look like is something
that requires further thought and demonstration.
Finally, although most people who embrace poststructuralism will clearly
see the limits (or threats) of categorical thinking and the additive nature of
misguided intersectionality (as Lewis, 2009, deftly articulates as: “gender +
class ++ race + + +”), such thinking has not been fully banished. While there
is an attraction to viewing intersectionality as additive, particularly by those
who feel that this is one way they can be heard, this ultimately does the
project of intersectionality a disservice, because it becomes one person’s strug-
gle. Intersectionality, for me, emerged from group processes and best describes
group identity, fractions, and cohesion. This is an area that will require more
debate.
In concluding, I quote from a recent systematic review of LGB people’s health
in the United Kingdom (Meads et al., 2012), which, perhaps predictably, con-
cludes that the mental health of LGB people is worse than that of the general
population. However, how this review differs from other reviews cited in this
chapter is the manner in which intersectionality is considered, if not in the
analysis of the review, at least in the discussion. The authors make a very valid
point, so I quote them in full:
People occupy many social positions, and these positions intersect and
interact in complex life worlds. The interaction produces multiple complex
patterns and outcomes, one of which is health. It is not yet clear empiri-
cally whether the interaction in the intersections is additive, synergistic, or
of some other type. This is an important deficit in our knowledge. (p. 30)
Summary
• BME and LGBT people appear to have poorer mental health compared with
White or heterosexual cisgender people. However, the interactive effects of
being both BME and LGBT have not been well studied.
• Stereotypes of BME LGBT people can have negative psychological impact on
individuals. This may also be related to overt and covert forms of racism
from the general public and LGBT people also.
• Coming out has largely been conceptualised as an unquestioned good, but
for some BME individuals there may need to be other ways in which people
can express and explore their sexuality, which are less alienating to them or
their families and communities.
• There are now some good guidelines as to how intersectionality can be incor-
porated into psychological research, but psychological research (particularly
therapeutic research) still tends to focus on single identity markers.
• Although there is an attempt to incorporate intersectionality within eco-
nomic and political spheres, the challenges of translating intersectionality
from theory to practice still pose a problem for researchers and policy
makers.
Note
1. Page numbers are not provided for direct quotations when these have been taken
from websites, such as blogs or newspaper articles. However, weblinks are provided
to take the reader to the source of the quotation.
2. The concepts of race and ethnicity are complex, and definitions are often contested.
For this chapter I use the term ‘race’ to mean a group of people who share vari-
ous sets of physical characteristics (usually as a result of their genetic makeup) who
differ from other groups (e.g. ‘Caucasian’), whereas by ethnicity I mean a group
of people who identify with each other on the basis of a common sociocultural
or national experience or heritage (e.g. ‘Indian’). This term is sometimes merged
with ‘nationality’, which normally refers to citizenship of an individual. Therefore,
I may be Dravidian by race, Indian by ethnicity, and British by nationality. The
Institute of Race Relations uses the British term Black and Minority Ethnic (BME)
to describe people of non-white descent: http://www.irr.org.uk/research/statistics/
definitions/.
3. I use the term ‘practitioners’ as a shorthand for applied psychologists, therapists, and
other psychology practitioners.
4. Cole (2009) proposes three questions we might ask as a strategy for address-
ing intersectional questions in psychology research: Who is included within this
category? What role does inequality play? Where are the similarities?
5. See Miriam Dobson’s simple explanation of intersectionality: http://miriamdobson
.wordpress.com/2013/04/24/intersectionality-a-fun-guide/.
6. ‘Nigrescence’ is a term used mainly in academia to describe the ‘process of becom-
ing Black’. It is sometimes used to describe complexion, but more often it is used to
describe acceptance and identity formation of one’s Black ethnicity. Like other mod-
els, several stages have been proposed, and the model has been revised and expanded
to include more stages of development.
Roshan das Nair 443
Further reading
Crenshaw, K. (1991). Mapping the margins: Intersectionality, identity politics, and
violence against women of color. Stanford Law Review, 43(6), 1241–1299.
das Nair, R. & Butler, C. (2012). Intersectionality, sexuality, & psychological therapies:
Exploring lesbian, gay, and bisexual diversity. London: Wiley Blackwell/BPS-Blackwell
imprint.
Sex Roles Journal, 68(11–12), June 2013 is a special issue on Intersections of LGBT,
Racial/Ethnic Minority, and Gender Identities.
Taylor, Y., Hines, S., & Casey, M. E. (2010). Theorizing intersectionality and sexuality (genders
and sexualities in the social sciences). Basingstoke: Palgrave Macmillan.
Yip, A. K. T. & Page, S.-J. (2013). Religious and sexual identities: A multi-faith exploration of
young adults. Farnham: Ashgate.
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pathways to and use of specialist mental health services in the UK. Systematic review.
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Budryte, D. (forthcoming). The concept of ‘intersectionality’ and its relevance in a diverse
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25
Religion
Rob Clucas
Introduction
This chapter considers the intersection between gender, sexuality, and religion.
By ‘religion’ I mean organised systems of faith and worship rather than per-
sonal systems of belief or ideas of the transpersonal or spiritual (Clarkson, 2003,
chapter 6). A religious person will have beliefs in some supernatural power(s);
will reverence, worship, and usually attempt to obey what they understand
to be the powers’ demands or requirements; and will usually perceive these
requirements to be part of a scheme for some kind of improvement or reward
in the present or the afterlife (Oxford English Dictionary Online, 2014).
I acknowledge that there are different views about the appropriateness of
distinguishing religion and spirituality. Lynch (1996, p. 199) maintains an
essential distinction: “[s]piritual experience is engagement with God in our-
selves. Organised religions have, in a sense, interrupted the direct relationship
between ourselves and God in ourselves and attempted to own or control that
spiritual link.” In contrast, Yip (2010, p. 35) deliberately refers to ‘spiritual-
ity/religiosity’ to subvert common polarised constructions of ‘religiosity’ as
uncritical deference, and ‘spirituality’ as reflexive and critical (and therefore
superior). In this chapter, I retain the distinction, because much of the context
of my discussion concerns religious institutions and communities, and legisla-
tive regulation of religious–institutional, rather than purely spiritual, activities
and groups.
In this chapter, I give more attention to Christianity than other religions. This
is in part because of my specialised knowledge and the constraints of space,
and partly because of the historical dominance of Christianity in the West
and its historic and current influence on social and legal norms. Where pos-
sible, I draw connections with other Abrahamic religions (Islam, Judaism) and
indicate broader reading; however, I write from a minority Western worldview,
which inevitably impacts on this chapter.
447
448 Intersections
I use a number of terms to refer to people from gender and sexual minorities,
usually some variation on ‘non-heterosexuality’ and ‘being trans’ or ‘non-
cisgender’; often ‘LGBT’ (lesbian, gay, bisexual, trans). I do not repeatedly draw
attention to the distinction between non-heterosexual acts/practices and iden-
tities: see the Introduction to this collection. Where research is limited to
lesbian and gay people, I do not automatically assume that this is applicable
to others, such as bisexual people. Trans issues and trans people are, of course,
not limited to binary gender reassignment. Nonetheless, I focus primarily on
transsexual issues here, partly due to lack of space, partly because mainstream
religious institutions in the United Kingdom have a limited understanding of
trans as being transsexual (or cross-dressing), and partly because the legal recog-
nition of trans people (e.g. Equality Act, 2010; Gender Recognition Act, 2004)
is limited to persons engaged with the process of gender reassignment. Where
it seems appropriate to do so, I address the intersection of religion with non-
heterosexuality and being trans together; at certain points I discuss trans issues
in a separate section. Due to space constraints, I confine my sexuality discus-
sion to non-heterosexuality rather than alternative sexualities such as BDSM
and the nuances of queerness.
Writing about ‘religion’ in general gives the impression of a monolithic,
unchanging entity that does not necessarily reflect the actuality of people’s
experiences, which is extremely diverse. LGBT people may challenge a variety
of religious norms (institutional, theological, pastoral, political, and unre-
flectingly heteronormative) to a greater or lesser degree, depending on their
particular context.
Religion is often a significant matter in the life of an LGBT person, and can be
an important source of support and community for individuals. Yet, religions
in general are an influential source of norms and agencies of social control that
tend to centre on conservative readings of the dominant normative gender and
sexuality values – though there are exceptions to be found, for example in queer
paganism.
It is usual for religious people to feel some sense of affiliation to a religious
community or communities, with attached religious obligations (for exam-
ple regular confession and participation in the Roman Catholic Mass) and
community-oriented social activities (celebration of festivals, study and prayer
groups, community outreach work, etc.). Members may be warned that their
faith will die if they absent themselves from religious community, like a coal
that has been removed from the fire or the barbeque (e.g. Launch, 2014).
It is often possible for a person to socialise exclusively within their religious
community even when they live within broader secular society.
Where an LGBT person’s identity or practice conflicts with their understand-
ing of their religious faith, or with their community’s particular interpreta-
tion of (assumed) religious norms, there is potential for significant conflict.
This conflict may be situated within the person, between the individual and
Rob Clucas 449
community, or both. One type of the former arises from a perceived incom-
patibility between non-heterosexual and religious identities (Coyle & Rafalin,
2008). A second type occurs when a person internalises homophobia, bipho-
bia, or transphobia (Davies, 1996; Hillier et al., 2008; Jowett & Peel, 2012),
which may manifest in self-harm and suicide attempts. ‘Between the individ-
ual and community’ conflict may occur when an individual reveals their gender
or sexual difference, or this is discovered.
Some religious communities are practically co-extensive with ethnic commu-
nities (e.g. Orthodox Judaism; British Muslim communities). Others may exist
as minority groups within the broader ethnic or socio-political grouping (e.g.
practising UK Christians; Christian Indian communities). These different types
of alignment pose their own distinct challenges. An LGBT minority ethnic indi-
vidual may literally risk losing their world and support as they know it. Even
persons situated within a broader secular context may, nonetheless, risk signif-
icant loss: their life and community may be significantly different from those
of a non-religious person of the same gender, ethnicity, class, and so on, and
it should not be assumed that they will feel a clear sense of fit within broader
secular society.
In the rest of this chapter, I give a brief history and overview of psychological
and related work in this area; present key theoretical positions and up-to-date
research; outline current debates in the area, and discuss the implications for
applied psychology and the wider world (particularly therapeutic contexts),
before outlining future directions for inquiry.
Think about some values that are deeply important to you, which impact
on the way you live your life (these may be religious values or not). How
would it be for you to give these up? What (if anything) would you lose,
and what (if anything) would you gain?
History
This section outlines the history of the intersection of religion and gender
and sexual minorities, highlighting psychological, therapeutic, and legal points
of note.
Sexuality
It is generally assumed that the Abrahamic religions have been implacably
opposed to non-heterosexuality throughout history, evidenced by the prohi-
bitions in the Priestly Code of Leviticus and the Sodom and Gomorrah/Lut
narratives: antipathy towards context-specific same-sex acts is supposed to
450 Intersections
Gender
Gender changes of various kinds are present in different societies in every his-
torical period: what differs is the significance a particular culture attaches to
them (Ramet, 1996, p. 1). Dominant conservative traditions of Abrahamic reli-
gions today tend to condemn gender minorities as well as sexual minorities
(for Islam see Kugle, 2010; for Judaism see Zeveloff, 2014). Even more toler-
ant groups such as Quakers have incidents of hostility to trans people (Audrey,
2014).
Religion tends to be perceived as hostile to gender difference on one of
two grounds. The first is an unsophisticated conflation of gender differ-
ence with non-heterosexuality: a masculine female-bodied person ‘must’ be
a cisgender lesbian person, for example, or a feminine male-bodied person
‘must’ be a cisgender gay person (and being lesbian or gay is perceived as sin-
ful). The second source of hostility is ideological: a modern (Thatcher, 2012,
pp. 44–45), socially conservative adherence to an essentialist conception of
two (and only two) discrete and immutable genders. Within Christianity, this
Rob Clucas 451
Prejudice
Religiosity is a general predictor of intolerance (Allport & Ross, 1967) and not
being an ally of LGBT people (Burgess & Baunach, 2014). It seems paradoxical
that religions that preach tolerance should be populated with predominantly
less tolerant people (Loewenthal, 2000, p. 132). Exceptions to general religious
intolerance are found in persons with a ‘Quest orientation’, people who
This means that, because of their religious beliefs and affiliations, religious
LGBT people are likely to be situated in less accepting environments than their
non-religious peers, although these environments also contain a significant
minority who are less prejudiced (Allport & Ross, 1967, p. 432).
Sex-negativity
Many religions see sexuality as an obstacle to spirituality (cf Kugle, 2003,
p. 192). Isherwood (2006, p. 16) lays the blame of Christian sex-negativity on
early theologians rather than scripture or Christ himself. Religious individuals
may experience difficulties related to enjoyment of sexuality as a whole, due
to internalised attitudes that the spirit is ‘good’ and the needs of the body are
‘bad’ or to be ignored (see Lynch, 1996, p. 200; Thatcher, 2012).
Either/or
An assumption is often made that LGBT people will not be religious, which
perhaps accounts for the exclusive discussions in lesbian and gay psychology
(Peel et al., 2007) and the psychology of religion (Argyle, 2000; Loewenthal,
2000). This dichotomous assumption was a frequently cited microaggression
in Shelton and Delgado-Romero’s study of LGBQ clients in therapy (2011;
see below). This ‘either/or’ understanding is reflected in much contemporary
debate about the relationship of (conservative) religion to (LGBT-positive) secu-
lar society, from the Equality Act, 2010, and legitimate religious discrimination
against LGBT people (see Clucas, 2012), to same-sex marriage.
452 Intersections
Attitudes towards sexuality and gender are located within their particular
socio-political contexts. Religious institutions and communities are themselves
distinct contexts, which will vary according to faith, denomination, religious
tradition, geographical area, and so on. It should not be assumed that all com-
munities of the same faith will present broadly similar environments for gender
and sexual minority people.
Non-heterosexual communities are not necessarily places of ease and security
for religious LGBT people. Ellis notes the barriers (noise and highly sexualised
environment) to non-sexual social encounters in ‘scene’ spaces for her lesbian
and gay interviewees (2007, p. 120), which may be particularly problematic
for individuals wishing to adhere to norms to do with chastity and mod-
esty. Yip observes that many Lesbian, Gay, Bisexual, Trans, Queer, Questioning
and Intersex (LGBTQI) people experience misunderstanding and even hostility
from the secular LGBTQI community, who construct LGBTQI people of faith as
‘sleeping with the enemy’ (2010, p. 42).
Cognitive dissonance and distress are often the result of difficulty in recon-
ciling sexuality with religious and cultural beliefs (Shaw et al., 2012, p. 56). De
Jong and Jivraj (2002) note that “[M]any Muslim gay men and lesbians [ . . . ]
feel that they are forced to make a difficult or impossible choice: either to aban-
don Islam or to oppress their sexual orientation.” The same seems to be true of
Orthodox Judaism (Coyle & Rafalin, 2008).
Individuals belonging to marginalised groups seem to experience a higher
prevalence of mental disorders. This is known as ‘minority stress’. This is not
a de facto indication of psychopathology (Richards & Barker, 2013, p. 80) but,
rather, the consequence of living with stressful stigma, prejudice, and discrimi-
nation (Meyer, 2003; Rostosky et al., 2007). Possible stressors experienced by an
LGB person include: matters in the external environment, such as workplace
discrimination; the expectation of stressful events; internalised homophobia;
the perceived need to conceal one’s sexual orientation (Berghe et al., 2010,
p. 154); and the perception of discrimination that is expected, though it may
not actually exist (das Nair & Fairbank, 2012, p. 187). In the context of religion,
it is easy to see that an LGBT person may experience discrimination within their
religious community; expect to experience discrimination; internalise negative
religious attitudes regarding gender and sexual minority issues; feel the need
to conceal their sexuality or gender; and perceive discrimination even where it
may not exist, and all of these factors are likely to have a negative impact on
their mental health.
Moving away from more overt discrimination and hostility, it is useful to
consider the impact of microaggressions, that is:
Rob Clucas 453
Current debates
performed same-sex blessings for more than 30 years (The Unitarians, 2014).
British Baptists officially view marriage as between a man and a woman, but
appear to allow individual churches and ministers to act according to their
consciences in the case of same-sex marriage (Woods, 2014). The Metropolitan
Community Church (MCC), originating in the United States, has given long-
standing support to LGBT people, and Brighton MCC was the location for the
first religious same-sex marriage in the United Kingdom (McCormick, 2014).
Trans people have even less recognition in organised religion than LGB people,
but some liturgical resources exist (see Tanis (2003, appendix) and references to
trans naming rights in Latimer (2012)).
Future directions
Conclusions
Despite increasing social and legal acceptance of gender and sexual minori-
ties in the secular West, the intersection between religion and sexuality and
gender is fraught with tension, and individuals’ experiences are very diverse.
Some LGBT people inhabit accepting local religious communities or organisa-
tions; all LGBT people are part of a broader field where dominant conservative
458 Intersections
Summary
• LGBT identities/practice may conflict with religion in some way: this conflict
may be situated within the person, between the individual and commu-
nity, or both. Many religious LGBT people feel that they are forced to
choose between their religion and their sexuality or gender difference.
This ‘either/or’ understanding of religion and gender and sexual diversity
pervades our current thinking.
• LGBT people may (but will not necessarily) experience exclusion from reli-
gious spaces because of their gender or sexual difference; religious LGBT
people may also experience exclusion from secular LGBT community spaces
because of their religiosity.
• LGBT individuals experience minority stress due to their experience of
stigma, prejudice, and discrimination, which results in a higher preva-
lence of mental disorders. LGBT individuals also experience frequent
microaggressions, even in encounters with well-meaning people (including
in therapeutic environments).
• LGBT people experience differing degrees of acceptance throughout a
range of contexts. No mainstream religion unequivocally accepts non-
heterosexuality; differential legislative protections and entitlements seem to
have an impact on LGBT mental health, but there is as yet no research on
the impact of differential institutional religious relationship recognition on
LGBT mental health; jurisdictions with comprehensive pro-LGBT laws may
maintain significant inequalities.
• Our current understandings of non-heterosexual identities, relationships
and practices cannot simply be mapped on to ancient religious condem-
nations of same-sex acts, although many religious groups attempt to do so.
There is a growing range of scholarly work and faith group activism that
integrates gender and sexual minority difference with religion that may be
of assistance to the conflicted LGBT person.
Rob Clucas 459
Further reading
Clucas, R. (2012). Religion, sexual orientation and the Equality Act 2010: Gay bishops
in the Church of England negotiating rights against discrimination. Sociology, 46(5),
936–950.
das Nair, R. & Butler, C. (Eds.). Intersectionality, sexuality and psychological therapies: Working
with lesbian, gay and bisexual diversity. Chichester, West Sussex: British Psychological
Society and John Wiley and Sons, Ltd.
Mann, R. (2012). Dazzling darkness: Gender, sexuality, illness and God. Glasgow: Wild Goose
Publications.
Roughgarden, J. (2004). Evolution’s rainbow. Berkeley, CA: University of California Press.
Shelton, K. & Delgado-Romero, E. A. (2011). Sexual orientation microaggressions: The
experience of lesbian, gay, bisexual and queer clients in psychotherapy. Journal of
Counselling Psychology, 58(2), 210–221.
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Index
464
Index 465
birth assigned, 198 243, 245, 246, 247, 250, 251, 252,
birth certificates, 211 264, 267, 273, 285, 287, 290, 324,
birth control, 212, 415 376, 377, 381, 393, 395, 400, 438,
bisexual, 43, 44, 45, 49, 50, 53, 54, 55, 439, 443
238, 252, 286, 334, 339, 385, 401, chromosomes, 100, 150, 153
443, 452, 456 cisgender (cis), 2, 24, 78, 87, 131, 133,
Black and Minority Ethnic (BME), 2, 155, 140, 149, 150, 151, 152, 153, 154,
170, 248, 271, 272, 274, 301, 326, 155, 156, 157, 158, 159, 160, 161,
350, 384, 411, 414, 415, 417, 427, 162, 166, 172, 175, 177, 179, 201,
428, 429, 430, 431, 432, 433, 435, 202, 204, 205, 212, 270, 276, 277,
436, 439, 440, 441, 442, 443, 449 284, 303, 329, 394, 442, 448, 450
see also queer people of colour (qpoc) cisgenderism, 162, 275
blame, 47, 84, 136, 209, 451 Clark, Dawn, 36, 280, 281, 283, 285, 287,
body hair, 177 289, 291, 292, 293
bondage and discipline, dominance and class, 2, 53, 88, 97, 113, 155, 170, 239,
submission, sadism and masochism 248, 271, 272, 284, 286, 288, 292,
(BDSM), 24, 26, 28, 29, 32, 33, 64, 68, 301, 320, 326, 375, 376, 379, 380,
72, 133, 266 381, 382, 383, 384, 387, 391, 392,
see also masochism; sadism; 393, 394, 395, 396, 397, 398, 399,
sadomasochism 400, 401, 402, 403, 404, 405, 407,
bottom, 137, 140, 243, 246, 288, 346 414, 416, 417, 431, 433, 441, 443, 449
see also submissive clinic, 3, 264, 328, 329
Bouman, Walter Pierre, 63, 64, 72, 136, clinical judgement, 288
173, 177, 198, 199, 201, 203, 205,
clinical psychology, 2, 186, 263, 264, 265,
207, 208, 209, 211
266, 267, 269, 274, 276, 277, 280,
Bowes-Catton, Helen, 42, 43, 45, 47, 49,
403, 428
51, 53, 95, 101, 114, 172, 365
clinician, 66, 189, 360, 456
Bowlby, 294
clinician illusion, 66
brain, 3, 100, 102, 150, 157, 158, 186, 202,
346 clitoris/clit, 184
breaking up, 365 closet/closeted, 385
breast, 117, 118, 139, 177, 204, 310 clothing, 81, 131, 137, 138, 177, 418
bullying, 156, 308 club, 433, 438, 439
Burns, Jan, 263, 265, 267, 269, 271, 273, Clucas, Rob, 447, 449, 451, 453, 454, 455,
275, 277 457
Butch, 114, 284, 288 coercion, 33, 37, 63, 64, 66, 68, 72, 103,
290, 443
C cognitive behavioural therapy (CBT), 65,
camp, 33, 247, 316 268, 356
cancer, 117, 303, 305, 310, 321 coming out, 47, 113, 306, 307, 435, 436,
Carrigan, Mark, 7, 8, 9, 10, 11, 13, 14, 15, 438, 439, 442, 443, 456
16, 17, 18, 19, 20, 21, 71, 132, 361 communication, 9, 98, 129, 237, 252, 289,
cat, 28, 43, 62, 433 305, 306, 326, 327, 419, 428
celibacy, 10, 132 community, 8, 9, 10, 11, 12, 13, 14, 15,
children, 1, 13, 31, 36, 38, 61, 63, 79, 80, 16, 19, 20, 21, 24, 25, 29, 31, 34, 37,
83, 84, 99, 100, 102, 115, 116, 117, 50, 51, 53, 54, 55, 61, 62, 63, 65, 66,
157, 159, 168, 169, 176, 185, 188, 67, 70, 71, 72, 78, 86, 88, 109, 113,
189, 190, 192, 193, 200, 202, 203, 122, 132, 140, 159, 160, 171, 172,
205, 207, 222, 231, 237, 240, 241, 173, 175, 177, 178, 206, 207, 236,
466 Index
community – continued D
237, 238, 241, 245, 254, 267, D/s, 24, 450
274, 284, 286, 288, 309, 310, das Nair, Roshan, 277, 375, 427, 429, 431,
321, 329, 330, 335, 368, 378, 385, 432, 433, 435, 437, 438, 439, 441,
386, 399, 401, 402, 410, 416, 417, 443, 452, 453, 456, 457
432, 434, 436, 437, 438, 439, 442, data collection, 318, 319, 421
447, 448, 449, 452, 453, 455, 456, dating, 99, 174, 223, 225, 226, 282
457, 458
demisexual, 9
comorbidity, 35
demographics, 237, 251, 252, 254, 431,
compersion 433
see frubble
denim, 62
condom, 4, 156, 160, 225, 338, 339, 340
Dental Dam, 4, 119
confusion, 10, 35, 50, 81, 122, 137, 138,
depression, 66, 83, 119, 201, 205, 244,
245
246, 268, 270, 303, 304, 306, 307,
congenital adrenal hyperplasia (CAH), 361, 409, 432, 453
184, 190, 273
desire, 13, 14, 15, 21, 26, 27, 34, 43, 45,
Conley, Terri, 219, 220, 221, 222, 224, 47, 51, 79, 80, 81, 94, 103, 114, 132,
225, 227, 229, 230, 231, 232, 236 133, 136, 137, 138, 139, 140, 175,
consent 220, 228, 238, 263, 291, 341, 342,
see informed consent 356, 357, 361, 362, 363, 368, 396,
continua, 46, 133, 211, 226, 325, 336, 414, 415, 420, 436, 437, 455
419, 429 deviance, 34, 44, 64, 80, 99, 241
contract, 227 diagnosis, 28, 69, 80, 131, 188, 190, 193,
conversion therapy, 450, 456, 457 199, 206, 207, 208, 266, 267, 275,
see also reparative therapy 276, 305, 306, 317, 319, 320, 327,
counselling, 2, 35, 139, 143, 205, 211, 356, 360, 368, 409, 432
237, 239, 240, 241, 242, 243, 252, Diagnostic and Statistical Manual (DSM),
266, 268, 280, 281, 282, 284, 285, 26, 28, 29, 31, 33, 47, 64, 65, 66, 68,
286, 287, 288, 289, 290, 291, 292, 69, 80, 109, 131, 136, 137, 207, 247,
293, 294, 303, 311, 318, 393, 395, 251, 265, 266, 268, 275, 276, 277,
397, 403 356, 357, 361, 368
counselling psychology, 2, 139, 242, diaper, 61, 72, 73, 76
280, 281, 282, 284, 285, 286, 287, see also nappy
288, 289, 290, 292, 293, dichotomy, 43, 63, 101, 175, 325
294
dilation, 344
counsellor, 393
disability, 2, 155, 345, 408, 409, 410, 411,
couple, 86, 99, 114, 120, 230, 242, 290, 412, 413, 414, 415, 416, 417, 418,
413, 428, 438, 443 419, 420, 421, 422, 428
crime, 25, 29, 31, 32, 36, 253, 254,
discipline, 3, 24, 31, 72, 97, 157, 231, 241,
311
263, 264, 265, 267, 277, 280, 281,
critical psychology, 162, 187, 281 288, 291, 292, 293, 311, 353, 354,
cross-culture, 226 391, 392, 412
cross-dressing disclosure, 121, 185, 187, 188, 189, 193,
see transvestism 306, 308, 309, 456
cultural studies, 237, 252 discourse, 12, 16, 19, 21, 27, 35, 38, 51,
cunnilingus, 60 64, 88, 93, 100, 110, 131, 132, 136,
cure, 26, 201, 308, 317 138, 140, 149, 151, 156, 173, 237,
cybersex, 254 238, 239, 242, 249, 251, 253, 254,
Index 467
267, 318, 325, 329, 391, 395, 396, 129, 138, 139, 142, 151, 152, 159,
397, 401, 402, 408, 416 171, 175, 177, 179, 183, 184, 190,
discourse analysis, 51, 318, 396, 401 192, 200, 229, 230, 242, 248, 273,
discrimination, 15, 25, 29, 35, 36, 83, 102, 274, 277, 281, 286, 288, 292, 309,
109, 122, 139, 140, 155, 179, 205, 310, 311, 317, 329, 334, 335, 347,
270, 272, 274, 276, 302, 303, 306, 348, 349, 350, 362, 363, 366, 379,
307, 308, 310, 311, 385, 393, 413, 380, 428, 440, 448, 451, 454, 457, 458
431, 432, 434, 439, 440, 451, 452, erectile dysfunction (ED), 342, 357, 361
453, 454, 456, 458 erection, 342, 361, 367, 413
disease, 4, 199, 221, 268, 269, 301, 302, erogenous, 27
309, 310, 320, 363 erotic, 24, 27, 28, 32, 34, 64, 70, 93, 94,
disorder, 13, 28, 29, 33, 64, 68, 69, 80, 131, 95, 102, 137, 385, 418, 419
137, 183, 193, 200, 204, 205, 207, ethics, 60, 160, 190, 208, 210, 236, 239,
247, 254, 267, 273, 276, 317, 324, 244, 245, 285, 293, 330, 355, 383, 418
335, 340, 357, 360, 361, 362, 413, 431 ethnic, 113, 121, 306, 321, 339, 340, 341,
Disorder of Sex Development (DSD), 183, 384, 427, 430, 432, 433, 434, 435,
190, 191, 193, 272, 275 437, 439, 443, 449, 456
see also divergence of sex development ethnicity
(DSD); diversity of sex development see black and minority ethnic (BME)
(DSD); Intersex; variation of sex exercise, 1, 30, 289, 290, 440
development exhibitionism, 28
dom experiments, 153, 222, 236
see top extended family
dominance, 24, 38, 72, 130, 133, 136, 140, see family
379, 392, 435, 447
dominant F
see D/s face-to-face, 65
donor insemination, 116, 122 Fae, 62
drag, 88, 129, 198 faith
dress, 61, 62, 139, 168, 198, 205 see religion
drug, 84, 86, 119, 266, 302, 307, 338 family, 30, 35, 64, 82, 99, 113, 117, 119,
DSD, 2, 171, 175, 183, 184, 185, 187, 190, 122, 154, 161, 174, 184, 189, 204,
192, 193, 202, 273, 275, 335, 348, 205, 209, 219, 222, 228, 230, 237,
349, 375, 377, 385, 386, 387, 452 240, 241, 242, 244, 245, 251, 253,
Dundas, Robin, 64, 72, 129, 173, 205 254, 285, 306, 323, 383, 384, 413, 414
dysmorphophobia, 204 fantasy, 27, 28, 37, 283
Farvid, Panteá, 92, 93, 95, 97, 99, 101, 103
E fault, 19, 153
education, 9, 15, 17, 132, 159, 179, 190, fellatio, 60
240, 246, 254, 273, 304, 310, 377, female, 25, 34, 42, 43, 70, 73, 77, 78, 94,
393, 395, 410, 416, 417, 421, 443 114, 115, 118, 119, 129, 130, 131,
effeminate, 80, 81, 88, 89, 199, 435 134, 135, 138, 143, 149, 150, 151,
electric shock, 64 152, 153, 157, 158, 160, 161, 166,
Ellis, Sonja J., 47, 109–28, 120, 308, 433, 171, 172, 175, 177, 184, 198, 199,
452 207, 211, 220, 228, 229, 267, 272,
embody, 365, 383, 386 274, 277, 284, 310, 320, 325, 328,
equal rights, 95 333, 334, 335, 348, 355, 357, 363,
equality and diversity, 9, 11, 12, 13, 17, 365, 375, 377, 385, 393, 396, 400,
19, 30, 43, 46, 53, 65, 99, 111, 116, 401, 415, 428, 429, 439, 450, 455
468 Index
female to male (ftm), 334, 335 394, 399, 401, 427, 429, 431, 432,
see also trans woman 434, 435, 436, 437, 438, 448, 450,
feminine, 43, 79, 81, 82, 84, 89, 94, 100, 451, 452, 455, 456, 457, 458
101, 132, 150, 168, 169, 170, 171, gay, lesbian, 11, 24, 26, 37, 42, 43, 44, 45,
175, 176, 177, 199, 335, 337, 377, 46, 47, 48, 49, 52, 64, 65, 66, 73, 78,
395, 396, 397, 450 79, 80, 81, 82, 89, 92, 93, 94, 95, 96,
femininity, 44, 78, 79, 81, 82, 84, 88, 89, 97, 99, 100, 101, 103, 109, 111, 122,
94, 96, 149, 153, 161, 169, 170, 365, 130, 136, 137, 175, 195, 207, 263,
395, 396, 401, 402, 416, 435 266, 268, 283, 285, 287, 288, 304,
feminisation, 376 307, 311, 317, 335, 338, 345, 346,
feminist, 19, 33, 34, 95, 96, 97, 102, 112, 350, 361, 400, 431, 434, 437, 443, 450
119, 120, 150, 152, 154, 160, 185, gender dysphoria, 201, 203, 207, 276
186, 245, 248, 254, 267, 271, 290, see also transsexualism
292, 317, 328, 365, 396, 398, 401, gender fluid, 133, 166, 169
402, 408, 410, 414 genderfuck, 166
femme, 57 gender identity, 80, 102, 116, 129, 131,
fetish, 62, 63, 64, 67, 69, 75 133, 152, 154, 158, 160, 185, 186,
Fetishistic Transvestism, 137 190, 198, 199, 200, 201, 202, 203,
financial, 35, 69, 114, 204, 222, 393 204, 205, 207, 211, 212, 270, 275,
fluidity, 17, 18, 20, 46, 51, 140, 179, 288, 277, 280, 300, 303, 306, 309, 328,
317 334, 335, 337, 347, 348, 350, 453
focus group, 318, 326, 328, 348, 396, 416 gender identity disorder (GID)
forced Marriage, 439, 443 see transsexualism; gender dysphoria
formulation, 267, 272, 275, 276, 277, 280, genderless, 166, 198
288, 289, 323, 362 gender presentation, 143
foster, 242, 273, 362, 367 genderqueer, 129, 133, 160, 166,
fox, 44, 45, 47, 62, 72, 239 174, 198
freud, 3, 26, 27, 32, 44, 45, 48, 49, 78, 79, gender reassignment surgery (GRS), 204,
80, 94, 154, 167, 264, 265, 353, 354 208, 210, 348
friends with benefits, 236 gender role, 78, 96, 102, 129, 130, 131,
friendship, 1, 18, 64, 119, 236, 284, 306, 133, 137, 138, 142, 152, 154, 160,
323, 324, 365, 383, 386, 450, 455 169, 198, 199, 200, 204, 205, 212,
frubble, 237, 247, 253 292, 335, 353, 365
furry, 60, 61, 62, 64, 67, 68, 72 genders, 1, 2, 4, 38, 64, 98, 130, 140, 143,
152, 166, 167, 168, 171, 173, 174,
G 175, 177, 178, 198, 200, 202, 207,
gamer, 67 208, 272, 277, 283, 377, 429, 450
gay, 2, 11, 12, 16, 18, 25, 37, 38, 43, 47, gender status, 177
48, 49, 50, 52, 60, 63, 66, 67, 72, 73, generation, 7, 133, 143, 170, 292,
77, 78, 80, 81, 82, 83, 84, 85, 86, 87, 344, 380
88, 89, 93, 95, 98, 99, 101, 102, 103, genital reconstruction surgery (GRS)
109, 112, 113, 119, 120, 121, 131, see gender reassignment surgery (GRS);
134, 172, 177, 199, 211, 212, 231, sex reassignment surgery (SRS)
236, 238, 243, 252, 266, 268, 269, genitals, 100, 179, 204
274, 277, 284, 285, 286, 287, 288, genotype, 171
290, 300, 302, 304, 305, 307, 308, geographical location, 9, 170
309, 310, 311, 317, 319, 320, 333, gonad, 184
334, 336, 339, 347, 350, 361, 375, great sex, 222
377, 378, 379, 382, 383, 385, 386, guilt, 33, 220, 228, 286
Index 469
K M
Kainth, Tony, 64, 72, 129, 173, 205 mainstream, 18, 21, 25, 29, 30, 60, 63, 67,
kink, 35, 38, 61, 64, 130, 236, 237, 239, 68, 69, 71, 92, 96, 97, 101, 102, 119,
252, 361 133, 149, 152, 160, 167, 168, 237,
kissing, 228 242, 275, 281, 282, 300, 304, 309,
310, 311, 316, 317, 356, 392, 404,
413, 415, 418, 419, 439, 448, 453,
L
454, 457, 458, 459
label, 14, 15, 16, 114, 198, 203, 436
male to female (MtF), 211, 335
language, 15, 16, 27, 30, 78, 99, 100, 113,
130, 133, 138, 150, 154, 155, 156, male/ man, 26, 42, 43, 52, 61, 63, 67, 72,
158, 168, 174, 191, 239, 252, 275, 77, 78, 81, 82, 84, 89, 94, 95, 114,
282, 293, 325, 402, 417, 428, 429, 117, 129, 130, 131, 132, 134, 135,
437, 455 136, 138, 143, 149, 150, 151, 152,
153, 157, 158, 160, 161, 166, 171,
law, 25, 35, 36, 70, 79, 98, 99, 101, 117,
172, 174, 175, 177, 184, 198, 207,
121, 134, 174, 211, 228, 237, 240,
211, 220, 228, 231, 238, 266, 267,
241, 249, 251, 252, 254, 276, 307,
272, 274, 284, 285, 288, 292, 310,
380, 384, 400, 414, 415, 417, 436,
320, 321, 324, 328, 334, 335, 346,
447, 448, 449, 453, 454, 457, 458
348, 355, 357, 360, 363, 365, 377,
leather, 62, 69, 70, 88
401, 421, 429, 435, 436, 450, 455
leatherman, 62
mammoplasty, 204
Lenihan, Penny, 64, 72, 129, 131,
man
133, 135, 137, 139, 141, 143, 173,
205, see male
362 marginalisation stress, 66, 307, 452, 458
lesbian, 2, 4, 12, 16, 33, 43, 47, 49, 50, 51, see also minority stress
63, 66, 73, 99, 101, 102, 109, 110, marriage, 99, 100, 114, 220, 225, 229, 231,
111, 112, 113, 114, 115, 116, 117, 236, 237, 239, 240, 241, 242, 246,
118, 119, 120, 121, 122, 131, 172, 248, 250, 252, 253, 254, 377, 438,
175, 211, 212, 236, 238, 245, 252, 451, 454, 455, 456
274, 277, 284, 285, 286, 287, 288, masculine, 43, 79, 83, 89, 94, 100, 101,
290, 300, 302, 304, 305, 307, 308, 114, 136, 150, 152, 167, 168, 169,
309, 310, 311, 317, 333, 334, 336, 170, 171, 175, 176, 303, 324, 335,
339, 347, 375, 383, 385, 386, 394, 337, 377, 383, 408, 450
398, 399, 400, 427, 431, 432, 434, masochism
438, 443, 448, 450, 451, 452, 456, 458 see BDSM; sadism; sadomasochism;
lesbian gay bisexual transgender queer masturbation
(LGBTQ)/LG/LGB/LGBT etc.+, 19, 50, Matsick, Jes, 219, 236
53, 113, 120, 134, 139, 141, 172, 176, McGeeney, Ester, 149, 151, 153, 155, 157,
237, 238, 239, 240, 243, 251, 252, 159, 161, 177, 179, 212
253, 284, 286, 302, 303, 306, 307, media, 8, 10, 21, 25, 35, 37, 82, 99, 101,
308, 309, 310, 311, 326, 394, 398, 103, 152, 155, 156, 157, 173, 179,
400, 427, 432, 433, 435, 437, 438, 237, 249, 252, 290, 316, 318, 330,
439, 442, 448, 449, 450, 451, 452, 343, 364, 375, 380, 401, 402, 418,
453, 454, 455, 456, 457, 458 419, 427, 428, 437
lifespan, 99, 136, 220, 225, 226, 329, 413 medical/medicine, 3, 13, 25, 26, 28, 29,
loewenthal, Del, 280, 281, 282, 283, 285, 31, 32, 35, 36, 63, 64, 69, 98, 119,
287, 289, 291, 292, 293, 451 134, 136, 138, 149, 160, 174, 176,
loss, 121, 320, 375, 376, 378, 379, 380, 183, 184, 185, 186, 187, 188, 190,
449 191, 192, 193, 200, 206, 207, 208,
Index 471
sex (phenotype) – continued sexually active, 118, 221, 269, 341, 347,
161, 169, 175, 179, 183–93, 198–212, 385
226, 229, 237, 242, 244, 246, 249, sexually transmitted infection (STI), 4, 68,
250, 251, 263, 268, 273, 274, 277, 230, 338, 339, 340, 341, 385
280, 283, 284, 287, 289, 290, 291, sex work, 221, 415, 419, 435
292, 302, 317, 318, 333, 335, 336, Seymour-Smith, Sarah, 316, 317, 319, 321,
337, 342, 343, 344, 345, 347, 348, 323, 325, 327, 329, 364
353, 385, 394, 404, 411, 420, 429, Simpson, Paul, 226, 375, 377, 378, 379,
430, 435, 436, 437, 438, 449, 450, 381, 383, 385, 387
451, 453, 454, 455, 456, 458 sissy, 61
sex addiction, 361 slag, 157
sex education, 3, 160, 341, 367, 416 slut, 239, 244, 245
sexist, 61, 100, 101, 159, 162, social constructionism, 30, 112, 364
317, 455 social opprobrium, 67
sex offenders, 65, 320 social psychology, 3, 122, 161, 237, 392
sex reassignment surgery (SRS), 204, 208,
sociocultural, 92, 160, 171, 229, 251, 286,
210
290, 345, 353, 399, 442
see also gender reassignment surgery
socio-economic, 339, 362, 375, 378,
(GRS); genital reconstruction
379, 381, 383, 385, 391, 392, 400,
surgery (GRS)
415, 431
sex shop, 38
sociology, 3, 21, 92, 97, 167, 206, 237,
sex therapy, 160, 268, 336, 353, 354, 355, 252, 282, 375, 378, 379, 412
356, 357, 361, 362, 363, 364, 365,
solo sex, 363
366, 367, 368, 413, 419
spanking, 24, 25
sexual abuse, 36, 83, 84, 413
spiritual, 263, 447, 455
sexual attraction, 7, 8, 10, 11, 13, 14, 15,
spouse, 230, 454
17, 20, 42, 44, 45, 47, 49, 98, 113,
statistics, 310, 350, 442
131, 132, 336, 456
stereotype, 89, 152, 379, 383, 415, 434
sexual dysfunction, 13, 268, 355, 356,
stigma, 15, 29, 36, 111, 138, 139, 184,
357, 361, 362, 368, 413
189, 190, 192, 193, 205, 220, 225,
sexual encounter, 132, 141, 220, 224, 229,
227, 245, 266, 275, 305, 320, 334,
232, 357, 360
362, 413, 415, 416, 452, 458
sexual health, 66, 118, 119, 224, 225, 232,
straight, 11, 52, 96, 101, 177, 223, 269,
269, 275, 285, 310, 353, 360, 361,
277, 333, 339, 345, 350, 378, 383,
362, 363, 364, 365
386, 398, 399, 429
sexual identity, 12, 20, 45, 46, 51, 102,
subculture, 36, 65, 236
113, 133, 135, 268, 272, 333, 339,
347, 350, 413, 414, 429, 433, 434, submission, 24, 32, 72, 75
436, 437 submissive, 24, 32, 170, 393
sexual orientation, 7, 11, 12, 15, 78, 81, see also bottom
82, 83, 89, 93, 94, 95, 96, 97, 99, 100, suicide, 119, 176, 303, 307, 308, 325, 431,
101, 102, 116, 118, 122, 130, 133, 439, 449
135, 136, 139, 200, 202, 247, 274, supervisor, 285
283, 288, 304, 333, 334, 335, 336, support groups, 191, 318, 383, 439
337, 340, 341, 342, 344, 345, 350, surgery, 4, 129, 177, 185, 188, 189, 190,
415, 416, 436, 450, 452, 453 193, 199, 200, 201, 202, 204, 206,
sexual relationship/encounter, 31, 36, 47, 207, 208, 210, 211, 275, 348, 381
132, 140, 141, 154, 220, 224, 227, swinger, 242
229, 232, 289, 357, 360, 363, 421 switch, 24
Index 475