(p. 731) Beyond Lesbian and Gay: A Private Practice for Bisexual, Transgender, Polyamorous, and Kinky Clients
I am a licensed psychologist working in solo private practice near San Francisco. When I was first licensed in March 2002, I began working at a community mental health agency so that I had a stable income. I opened my private practice on the side beginning in July 2002, subletting three days a week at a colleague’s office in San Francisco. By 2004, I could make my private practice my sole income source, and I rented my own office. In 2008 I moved in with my partner, his wife, and their three children (then ages 11 to 17), creating a polyamorous household, and I relocated my practice closer to our home.
The Niche Activity
Today was a typical day at my office. My first client explored how to set boundaries at a sexuality workshop and grieved the ending of a relationship in which her partner had not respected their agreements around polyamory. My second client spoke of negotiations with his partner around their upcoming BDSM (bondage, domination, sadism, and masochism) skills demonstration at a kink event. My third client talked about coming out as transgender at her workplace. And so on …
A common thread among these sexuality and gender subculture clients is the need for a psychotherapist who is informed about their lifestyle and who is warmly accepting. Each of these subcultures also has unique themes to bring to psychotherapy. For polyamorous people, the element of negotiation is key, as there are many ways to have an open relationship. Themes include how often to see other partners, how to soothe one another through feelings of jealousy, how to (p. 732) maintain a sense of specialness as partners, whether it is okay to have dates with other partners in their home, and whom to come out to—boss, mother, kids?
People in kinky relationships also have negotiating and self-discovery to do. What activities are enjoyed—bondage, spanking, dominant-submissive role-playing? What safe words should be established for clear communication around desired intensity? How does one distinguish consensual BDSM from abuse? Where does one go to properly learn how to do rope bondage? Informed psychotherapists can help to normalize kink as something that approximately 2% of the general population engages in (Richters et al., 2008) and can provide local resources. They can help partners who are into kink to communicate their interests and boundaries and to dispel myths about how doms and subs “should” behave.
Bisexual individuals often feel caught between communities—they fear that they will be too outré for the straight mainstream but will not be accepted as “queer enough” by lesbians and gays. If there is a bisexual support or social group in town, it is often small. Myths and stereotypes abound, but there is also a sense of invisibility—if one walks down the street with one’s same-sex partner one is seen as gay, and if one walks down the street with one’s other-sex partner one is seen as straight. Psychotherapists can help their bisexual clients to identify books and support networks to help them feel a sense of belonging.
Transgender and genderqueer people seek psychotherapists who are familiar with the internal struggles of persons who are exploring their gender, as well as with the steps that a person takes to transition. Often there is sense of non-belonging, as their internal experience of their gender is not how society reflects their gender based on their appearance. There are wrenching decisions about coming out, amidst fears of rejection from loved ones, plus uncertainty about how to change their external appearance to truly reflect how they see themselves inside. The process is often long and painful, involving procedures like hormone injections, facial hair removal, and surgeries to remove breasts, transform genitals, or reshape the face. There are also logistical steps such as changing one’s legal name and gender, learning how to apply makeup or re-pitch one’s voice, and arranging for sensitivity training and single-use bathrooms at work. When one does not fully “pass” as one’s gender of choice, there may be shame about one’s appearance, embarrassment at being called by the wrong pronoun, or the fear of being attacked on the street. Psychotherapists who are gender-aware can help their clients explore their readiness for each of the steps that they will take, and learn about what support resources are out there.
Developing an Interest and Training in this Niche Activity
As a kinky, polyamorous, bisexual person myself, I came of age keenly aware of how few psychotherapy providers were aware of these populations’ needs. Very few graduate training programs even mention these themes in their curricula. I gave my university’s first trainings on working with bisexual and polyamorous clients while still a graduate student. The write-up of my talk, What Psychology Professionals Should Know About Polyamory (Weitzman, 1999), was the first article written about doing psychotherapy with polyamorous clients. It was informed (p. 733) from a combination of community immersion, political activism, group discussion, and life experience.
My training in how to work with transgender clients was more systematic. Not a member of the transgender communities myself, I represented myself as trans-friendly but not trans-aware at first. In the mid-2000s I attended the few workshops that were offered at that point, I followed postings on transgender email lists, and I sought consultation from a colleague about how to write letters allowing clients to receive hormones and surgeries. Eventually I felt informed enough to list transgender concerns among my specialties.
Not all of my clients are from sexuality and gender subcultures. Issues of work/life balance abound in the technological pressure cookers of the Silicon Valley, as well as typical concerns about anxiety, depression, and substance abuse. But I would say that over half of my clients fall into one or more of the categories of kinky, polyamorous, transgender, and/or bisexual, plus there are some who are lesbian and gay.
Joys and Challenges Related to this Niche Activity
I love this work because it is deeply satisfying to help people to express their gender and their sexuality and to feel pride in these aspects of themselves, and it feels good to help people to achieve the types of relationships that most fit their needs.
It can be a challenge to balance personal and professional needs in serving the subcultures of which I am a part. I have to keep appropriate professional boundaries in mind when attending gatherings that may be clothing-optional or sensually themed, or when speaking about my own experiences in support forums. I am often one of the few people wearing a bathing suit at clothing-optional poly pool parties, just in case a client arrives.
Another challenge is colleague prejudice. At a consultation group, if I speak about a client who is kinky, I run the risk of hearing derisive comments, which I then need to address. I have received negative attention from coworkers about the rainbow sticker on my door, and my choice of polyamory as a topic for Diversity Week. I have been blessed with many open-minded colleagues and the opportunity to practice in liberal cities, but there is always the fear of prejudice when one has a specialty that involves sexuality themes.
Business Aspects of this Niche Activity
Many clients find me via directories that have been created specifically to help people to find therapists who are friendly to sexuality subcultures. The Kink Aware Professionals Directory (https://ncsfreedom.org/resources/kink-aware-professionals-directory/kap-directory-homepage.html), the Poly Friendly Professionals List (http://www.polyfriendly.org), the Bisexuality Aware (p. 734) Professionals Directory (http://www.bizone.org/bap/), and “A List Of Therapists Experienced in the Treatment of Transgender Persons” (http://drbecky.com/therapists.html) are international resources. In the San Francisco Bay Area, there is also Gaylesta (http://gaylesta.org/locate-a-therapist) and Bay Area Open Minds (http://bayareaopenminds.org/about/members/). In my ads on these websites I note my specialties (both sexuality-related and psychologically related) as well as which types of insurance I accept. My work is frequently reimbursed by insurance companies. Commonly coded diagnoses include gender dysphoria, depression, anxiety, adjustment disorder, and partner relational concerns.
As psychotherapists we have an ethical commitment to working within our scope of practice, so the most important first step in developing this niche area into a practice strategy is to attain competence in it, via reading, supervision, workshop attendance, and community immersion. Once informed, it is most helpful to promote one’s practice via the directories mentioned above, and via the LGBT-focused therapist directories in one’s own region.
For More Information
In closing, I would like to recommend some resources that can help psychotherapists to develop skills in working with these groups. Interested professionals can learn more by joining the American Association of Sexuality Counselors and Therapists (https://www.aasect.org/) or by attending classes at the Institute for the Advanced Study of Human Sexuality (http://www.humansexualityeducation.com/about-iashs.html). For those interested in community support around researching these topic areas, there is also the Community-Academic Consortium for Research on Alternative Sexualities (https://carasresearch.org/about-us).
For working with transgender clients, Transgender Emergence (Lev, 2013) is frequently recommended, and the American Psychological Association is releasing a new book titled Affirmative Counseling and Psychological Practice with Transgender and Gender Nonconforming Clients (Dickey & Singh, 2016). Another important book on transgender themes is Trans Bodies, Trans Selves! (Erickson-Schroth, 2014).
For working with polyamorous clients, I have written an article titled “Therapy with Clients who are Bisexual and Polyamorous” (Weitzman, 2006). “Making Friends with Jealousy: Therapy with Polyamorous Clients” (Easton, 2010) is an excellent article that addresses jealousy themes. Two recently acclaimed books are More Than Two (Veaux & Rickert, 2014) and The Polyamorists Next Door: Inside Multiple-Partner Relationships and Families (Sheff, 2013). The comprehensive website Alt.Polyamory (Polyamory.org) has a useful FAQ section about many polyamory themes.
And for kink, there is Sexual Outsiders: Understanding BDSM Sexualities and Communities (Ortmann & Sprott, 2012). Good articles include those by Kolmes (2015), Barker and colleagues (2007), and Kleinplatz and Moser (2004).
Resources and References
Barker, M., Iantaffi, A. & Gupta, C. (2007). Kinky clients, kinky counselling? The challenges and potentials of BDSM. In L. Moon (Ed.), Feeling queer or queer feelings: Radical approaches to counselling sex, sexualities and genders. (pp. 106–124). London, UK: Routledge.Find this resource:
Dickey, L. & Singh, A. (Eds.) (2016, in press). Affirmative counseling and psychological practice with transgender and gender nonconforming clients. Washington, DC: APA Books.Find this resource:
Easton, D. (2010). Making friends with jealousy: Therapy with polyamorous clients. In M. Barker & D. Langdridge (Eds.), Understanding non-monogamies (pp. 207–211). London, UK: Routledge.Find this resource:
Erickson-Schroth, L. (Ed.). (2014). Trans bodies, trans selves: A resource for the transgender community. New York: Oxford University Press.Find this resource:
Firestein, B. A. (2007). Becoming visible: Counseling bisexuals across the lifespan. New York: Columbia University Press.Find this resource:
Ka’ahumanu, L., & Hutchins, L. (1991). Bi any other name: Bisexual people speak out. Bronx, NY: Riverdale Avenue Books LLC.Find this resource:
Kleinplatz, P., & Moser, C. (2004). Toward clinical guidelines for working with BDSM clients. Contemporary Sexuality, 38(6), 1–4.Find this resource:
Kolmes, K. (2015). An introduction to BDSM for psychotherapists. Retrieved from http://societyforpsychotherapy.org/an-introduction-to-bdsm-for-psychotherapists/
Lev, A. I. (2013). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. New York: Routledge.Find this resource:
Ortmann, D. M., & Sprott, R. A. (2012). Sexual outsiders: Understanding BDSM sexualities and communities. Lanham, MD: Rowman & Littlefield Publishers.Find this resource:
Richters, J., De Visser, R. O., Rissel, C. E., Grulich, A. E., & Smith, A. (2008). Demographic and psychosocial features of participants in bondage and discipline, “sadomasochism” or dominance and submission (BDSM): Data from a national survey. Journal of Sexual Medicine, 5(7), 1660–1668.Find this resource:
Sheff, E. (2013). The polyamorists next door: Inside multiple-partner relationships and families. Lanham, MD: Rowman & Littlefield.Find this resource:
Tucker, N. S. (1995). Bisexual politics: Theories, queries, and visions. New York: Routledge.Find this resource:
Veaux, F., & Rickert, E. (2014). More than two: A practical guide to ethical polyamory. Portland, OR: Thorntree Press, LLC.Find this resource:
Weitzman, G. (1999). What psychology professionals should know about polyamory. Retrieved from http://www.polyamory.org/~joe/polypaper.htm
Weitzman, G. (2006). Therapy with clients who are bisexual and polyamorous. Journal of Bisexuality, 6(1-2), 137–164.Find this resource: