• According to a 2018 survey, a quarter of LGBT people have accessed mental health services within the past year

  • LGBTQ affirmative therapy can offer a well-needed non-judgemental space

  • Therapist Neil Young explores how therapists can deepen their understanding of gender and sexual identity issues inside and outside the therapy room

As a profession grounded in the principles of compassion, empathy, authenticity and congruence, it is curious how little critical attention is given to the importance of gender and sexual identity development and expression as part of accredited psychotherapy trainings as well as in the day-to-day working of major therapy and counselling bodies.

When I run workshops about gender and sexual diversity, therapists and other professionals who attend are often surprised that my focus is not solely on the experiences of lesbian, gay, bisexual, trans and queer (LGBTQ) people. I always begin by facilitating a space, using the arts, where participants can explore their own gender and sexuality stories, sometimes for the first time, and then explore what this means for their therapeutic practice.

Here, I offer an overview of some important societal context about the experience of sexual and gender minorities in the UK and then offer a series of tips for working with clients on issues of sexual and gender diversity.


The ‘straight is great’ (and normal) mantra 

From birth all of us have been subject to homo- bi- and trans-phobia, which are all prejudices that seek to privilege heterosexuality – usually within marriage and tied to conventional, binary gender roles – over all other forms of relating. This structural privilege has made ‘coming out’ a necessary and ongoing process for LGBTQ+ people so that our lives can be rendered visible and valuable. It is interesting that as we have seen the levels of anti-LGBTQ prejudice fall in the last twenty years – with legal and cultural change – we are now seeing a sea change among teenagers and young adults who are increasingly resisting traditional, binary gender identities and not defining themselves as heterosexual.

Nonetheless while there has been positive change in attitudes towards lesbian and gay people – at the height of the AIDS crisis in 1987 64% of people surveyed by the British Social Attitudes Survey believed that same-sex relationships were ‘always wrong’ and this fell to 19% by 2017 – there remains a significant minority of the population actively holding homophobic views. Moreover, we remain caught in the midst of ongoing moral panics that fan the flames of hatred against trans children, young people and women – with the occasional coverage of a pregnant trans man thrown in for good measure – while bigoted views about bisexuality remain widespread and often unchallenged.

The impact of such toxic, learnt prejudice on people’s behaviour, sense of self and quality of life is all too real. The UK Government’s National LGBT Survey, which reported in July 2018, found that 68% of people with a minority sexual orientation avoided holding hands in public with their same-sex partner. The fears that interrupt ordinary, loving contact are often driven by the trauma of being attacked in the past and serve to push people back into the closet, against their wills. A 2018 Stonewall survey found that over a third of trans people had experienced a hate crime in the previous 12 months, while similar hate-based crimes against lesbian, gay and bisexual people went up 78% between 2013-2017, with Black and Asian LGBT people disproportionately affected.

In light of this evidence it is perhaps no wonder that according to the 2018 Government survey a quarter of LGBT people have accessed mental health services within the past year. Notably 2% of people had experienced – and another 5% had been offered – ‘conversion therapy’, which is essentially an abusive attack on someone’s sexual or gender identity dressed up as professional psychological help.

What you can do to bring about change 

Arguably, part of our work as therapists, and as human beings, is to be alive to how systemic power – at societal, cultural, community, familial and individual levels – plays out for us, our clients and within the therapeutic relationships we co-create. Understanding the diversity of gender and sexual identities and the ways that trauma can be produced and reproduced by the violent policing of gender expression and sexual identity can help us to deepen the work we are able to imagine and facilitate with people who have internalised toxic prejudice.

Here I briefly lay out some top tips to support your work with gender and sexual identity based on a 2017 BACP University & College Counselling journal article I wrote up following interviews in with counsellors, psychotherapists, a psychiatrist, an academic and a trans and non-binary youth worker.

  • Examine your sexual and gender identity and relationship style: we all have gender and sexual identities; have personal therapy and supervision with LGBTQ-affirmative practitioners where you can explore your own assumptions, beliefs and judgments.
  • Proactively educate yourself about LGBTQ issues: we have an ethical responsibility to seek out specialist training and resources to relieve the burden from LGBTQ clients of educating their therapists. For example, sharing this article with other therapists and professionals would be an excellent way to encourage debate.
  • Be open and know your limits: let clients know what you do and don’t know about gender and sexual identities and develop referral networks of organisations and individual therapists that you can safely refer on to.
  • Be an LGBTQ affirmative therapist: review your marketing and waiting room posters, leaflets and magazines to signal your support for diverse gender and sexual identities. Allow clients blank spaces to write in their preferred gender and sexual identities and check for preferred pronouns.
  • Allow space for uncertainty: given the negative historic pressures on clients to conform having time to safely explore who they are, at whatever age, can be invaluable.
  • Position yourself against anti-LGBTQ hate: empathise with and support clients who have experienced violence and prejudice to access healthy feelings of anger.
  • Too much gender and sexual identity can be a bad thing: be careful not to automatically link everyday problems in client’s lives back to their LGBTQ identities. This runs of the risk of pathology and of simply crucial client-led discussions of important issues in their lives.  
  • Be focused on what is happening for the client: avoid stereotypical responses that you would be unlikely to offer heterosexual or cisgender clients, such as simply suggesting that the client is unsure about their gender or sexual identity or going through a phase. 
  • Owning your mistakes can help the therapy: for example if you get someone’s pronouns wrong this can offer an opportunity to explore what meaning and feelings this has for the client.

Therapeutic work that can openly explore gender and sexuality issues,  including experiences of prejudice, can be hugely rewarding. Interestingly. evidence from the UK’s largest study of LGBTQ young people found that having a non-judgmental, supportive therapist was the most important factor in facilitating a successful working alliance. As qualified, experienced therapists you are already working from a strong set of skills. This article hopes to support the work you are already doing, as well as offering ideas for deeper, self-critical practice.

Neil Young is a verified welldoing.org psychotherapist in Central London. He has over 20 years’ experience as a queer community advocate – founding Mosaic LGBT Youth Centre in northwest London and working as an LGBT adviser for the Mayor of London. 

Further reading

Meet the therapist: Neil Young

Why it isn't as simple as 'coming out' for some in the LGBT community

The relevance of National Coming Out day

Working with gender identity in the therapy room