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The Palgrave Handbook of the Psychology of Sexuality
and Gender
10.1057/9781137345899 - The Palgrave Handbook of the Psychology of Sexuality and Gender, Edited by Christina Richards and Meg John Barker
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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
Meg John Barker

Senior Lecturer in Psychology, The Open University, UK
Editorial matter, introduction and selection © Christina Richards and
Meg John Barker 2015
Individual chapters © Respective authors 2015
All rights reserved. No reproduction, copy or transmission of this
publication may be made without written permission.
No portion of this publication may be reproduced, copied or transmitted
save with written permission or in accordance with the provisions of the
Copyright, Designs and Patents Act 1988, or under the terms of any licence
permitting limited copying issued by the Copyright Licensing Agency,
Saffron House, 6–10 Kirby Street, London EC1N 8TS.
Any person who does any unauthorized act in relation to this publication
may be liable to criminal prosecution and civil claims for damages.
The authors have asserted their rights to be identified as the authors of this work
in accordance with the Copyright, Designs and Patents Act 1988.
First published 2015 by
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ISBN 978–1–137–34588–2
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Library of Congress Cataloging-in-Publication Data
Richards, Christina.
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, Meg John
Barker, Senior Lecturer in Psychology, The Open University.
pages cm
Summary: “The Palgrave Handbook of the Psychology of Sexuality and
Gender gives a thorough overview of all of the normative – and many
of the less common – sexualities, genders and relationship forms
including: Asexuality; Bisexuality; BDSM; Gay; Heterosexuality; Kink;
Lesbian; Further sexualities; Trans sexualities; Cisgender; Intersex; Further
genders; Non-binary gender; Monogamies; and Open Non-Monogamies.
The Handbook also considers psychological areas such as Clinical
psychology; Counselling psychology; Qualitative research; Quantitative
research; and Sex therapy as they relate to sexuality and gender as well
as intersectional areas such as: Ageing; Ethnicity; Class; Disability;
Health Psychology; and Religion. Contributions from leading scholars and
practitioners in this area combine cutting edge research with
considerations on both clinical practice and academic study of sexuality
and gender for psychologists from student to professor; and from any
discipline interested in these ubiquitous aspects of humanity.” —
Provided by publisher.
ISBN 978–1–137–34588–2 (hardback)
1. Sex. 2. Sex (Psychology) 3. Social psychology. I. Barker, Meg
John, 1974– II. Title. HQ21.R457 2015
155.3—dc23 2015002158
Contents
List of Tables and Figures xv
Acknowledgements xvi
Notes on Contributors xvii
Introduction 1
Christina Richards and Meg John Barker
Part I Sexuality
1 Asexuality 7
Mark Carrigan
The history of asexuality 7

Key theory and research 8
The asexual community 8
Confusions surrounding asexuality 10
The psychology of asexuality 11
Current debates 12
Implications for applied psychology and the wider world 15
Future directions 17
Longitudinal studies 17
Asexual relationships 18
Gender, intersectionality, and diversity 19
Summary 20
2 BDSM – Bondage and Discipline; Dominance and Submission;

Sadism and Masochism 24
Emma L. Turley and Trevor Butt
Introduction 24
History 26
Psychoanalysis and Freud 27
Stoller and the ubiquity of perversion 27
Psycho-medical perspective 28
Non-pathologising perspectives 29
Current debates 31
vi Contents
BDSM and feminism 33

BDSM as adult recreation 34
Implications for counselling and therapy 35
Implications for discrimination 35
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
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
Current debates 68
Summary 72
Contents vii
5 Gay Men 77
Damien W. Riggs
Introduction 77
History 78
Current debates 82
Implications for applied psychology and the
wider world 84
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
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
Summary 103
7 Lesbian Psychology 109

Sonja J. Ellis
Introduction 109
History 110
Lesbian identity 112
Lesbian relationships 114
Lesbian parenting 115
Lesbian health 117
Current debates 119
viii Contents

Summary 122
8 Trans Sexualities 129

Penny Lenihan, Tony Kainth, and Robin Dundas
Introduction 129
Trans sexualities 131
History 134
Key theory, research, and current debates 135
Summary 143
Part II Gender
9 Cisgender – Living in the Gender Assigned at Birth 149

Ester McGeeney and Laura Harvey
Introduction 149
Key definitions 150
History 150
Current debates and future directions 156
Conclusions 161
Summary 161
10 Further Genders 166

Meg John Barker and Christina Richards
Introduction 166
History 167
Current debates 173
Summary 179
11 Intersex/DSD 183
Katrina Roen
Introduction 183
History 185
Contents ix

Reviews and empirical studies 186
Updates and conceptual contributions 187
Current debates 188
Disclosure 188
Non-essential genital surgery on infants 189
Prenatal treatment and psychological outcomes 190
Gender identity and transition 190
Summary 192
12 Transgender – Living in a Gender Different from That

Assigned at Birth 198
Sarah Murjan and Walter Pierre Bouman
Introduction 198
History 199
Current approaches to assisting people with gender dysphoria 204
Current debates 206
Classification of gender dysphoria 207
Access to treatment 208
Summary 211
Part III Relationships
13 Monogamy 219
Ali Ziegler, Terri D. Conley, Amy C. Moors, Jes L. Matsick,
and Jennifer D. Rubin
Introduction 219
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
You’re still single? Repercussions for not ‘settling down’ 227

Monogamy and infidelity 228
Gender and monogamy 229
Summary 231
14 Open Non-monogamies 236
Nathan Rambukkana
Introduction 236
History 237
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
Summary 252
Part IV Psychological Areas
15 Clinical Psychology 263

Jan Burns and Claudia Zitz
Introduction 263
History 263
Current debates 273
Summary 277
16 Counselling Psychology 280

Dawn Clark and Del Loewenthal
History 280
Contents xi
Current debates 284

Case study 284
Steps to analysis 290
Summary 293
17 Health Psychology 300
Joanna Semlyen
Introduction 300
History 300
Critical health psychology 301
Current debates, key theory, and research 302
Gender, sex, and health 302
Gender and health psychology 302
Trans health psychology 303
Intersectionality 304
Sexuality and health psychology 304
Smoking and LGB 304
Cancer and LGB 305
Discrimination, disclosure, and health 305
LGBT and mental health 307
Understanding LGBT health 308
Researching LGBT health 309
Teaching LGBT health 310
Addressing LGBT health 310
Summary 311
18 Qualitative Methods 316

Sarah Seymour-Smith
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
Summary 329
xii Contents
19 Quantitative Methods 333

Gareth Hagger-Johnson
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
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
20 Sex Therapy 353

Michael Berry and Meg John Barker
Introduction 353
History 354
Key theory and current research 356
Diagnosis 356
Treatment 358
Current debates 360
Summary 368
Part V Intersections
21 Ageing 375
Paul Simpson

Definitions 376
Contents xiii
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 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
History and current debates 417
Summary 421
24 Ethnicity 427
Roshan das Nair
Introduction 427
History 429
xiv Contents
Key theory and research with implications for applied

psychology and the wider world 430
Stereotypes 434
Coming out from a race/ethnicity perspective 436
Same-sex sexuality in the Global South 436
BME same-sex sexuality in the West 437
Current debates 440
Summary 441
25 Religion 447
Rob Clucas
Introduction 447
History 449
Sexuality 449
Gender 450
Prejudice 451
Sex-negativity 451
Either/or 451
Current debates 453
Conclusions 457
Summary 458
Index 464
Tables and Figures
Tables
14.1 Content analysis of titles of PsycINFO-indexed articles on
polygamy, 2008–2013 240
19.1 Klein Sexual Orientation Grid (Klein, 1993; Klein et al., 1985) 336
19.2 Klein Sexual Orientation Grid rating guide 336
19.3 Non-threatening ways to ask about sexual behaviours (adapted
from Crawford et al., 2006) 343
20.1 Cognitive behavioural interventions traditionally used in sex
therapy 359
Figures
5.1 Lewes’ (1988) sexual results of the Oedipus complex as

determined by identification (or instinctual aim) and object choices 79
10.1 Gender distribution 168
10.2 Gender distribution with cultural impact 168
10.3 Spectra of gender (adapted from Barker, 2013) 170
19.1 Three overlapping components of sexual orientation 334
20.1 The biopsychosocial model of human sexuality (adapted from
Barker & Berry, 2013) 360
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
Christina Richards is an accredited psychotherapist with the British Associ-

ation for Counselling and Psychotherapy (BACP) and is an associate fellow of
the British Psychological Society (BPS), which she represents to National Health
Service (NHS) England’s Clinical Reference Group (CRG) on Gender Identity
Services. She is Senior Specialist Psychology Associate at the Nottinghamshire
Healthcare NHS Trust Gender Clinic and Clinical Research Fellow at West
London Mental Health NHS Trust (Charing Cross) Gender Clinic. She works
in this capacity as an individual and group psychotherapist and psycholo-
gist conducting psychotherapy, assessment, and follow-up clinics as part of a
multidisciplinary team, as well as conducting research, supervision, and ser-
vice improvement plans. She lectures and publishes on trans, sexualities, and
critical mental health, both within academia and to third sector and statu-
tory bodies, and is a co-founder of BiUK and co-author of The Bisexuality
Report.
As well as other papers, reports, and book chapters, she is the co-author of
the BPS Guidelines and Literature Review for Counselling Sexual and Gender Minor-
ity Clients (2013), Sexuality and Gender for Mental Health Professionals: A Practical
Guide (2013), and an edited collection on non-binary genders to be published in
2016. Website: christinarichards.co.uk; email: contact@christinarichards.co.uk;
Twitter: @CRichardsPsych
Meg John Barker is a writer, academic, counsellor, and activist specialising

in sex and relationships. Meg John is Senior Lecturer in Psychology at the
Open University and has published many academic books and papers on topics
including non-monogamous relationships, sadomasochism, counselling, and
mindfulness, as well as co-editing the journal Psychology and Sexuality. They
were the lead author of The Bisexuality Report, which has informed UK policy
and practice around bisexuality. They are involved in running many pub-
lic events on sexuality and relationships, including Sense about Sex, Critical
Sexology, and Gender and Sexuality Talks. Meg John is also a United Kingdom
Council of Psychotherapy (UKCP) accredited therapist working with gender
and sexually diverse clients, and wrote the relationship book Rewriting the
Rules.
xvii
xviii Notes on Contributors
Contributors
Michael Berry is a psychology researcher specialising in couple and sexual

therapies. He is currently completing a PhD in research psychology at Uni-
versity College London and clinical training at McGill University in Canada.
His PhD research examines the effectiveness of psychodynamic methods in sex
therapy and couples counselling, and the use of integrative treatment strate-
gies in the sexual health field. He has a strong interest in gender and mental
healthcare, and is Managing Editor of the International Journal of Men’s Health.
He has published research articles and chapters in a number of international
journals and books. Michael is particularly interested in the use of critical,
social constructionist, and existential psychotherapy models in the treatment
of sexual problems. His work evaluates how these models can be applied in the
psychotherapeutic treatment of diverse clinical groups, including lesbian, gay,
bisexual, trans, and queer (LGBTQ) clients, and in the treatment of problematic
out-of-control sexual behaviour. Additionally, he is a member of the Laboratory
for the Biopsychosocial Study of Sexuality at McGill University, where he is car-
rying out a mixed-methods research project examining women’s experiences of
multiple orgasms in both partnered and masturbatory sexual behaviour. In his
clinical work, Michael is currently co-developing a group therapy protocol for
the treatment of problematic out-of-control internet-based sexual behaviour in
young men.
Walter Pierre Bouman is a consultant psychiatrist-sexologist who works as

lead clinician at the Nottingham Gender Clinic, a nationally commissioned
clinical service for people with gender dysphoria and one of the largest of its
kind in Europe. He initially trained in psychiatry and psychotherapy in the
Netherlands, and has over 25 years of clinical experience in general adult and
older people’s mental health. Walter is an accredited member and supervisor
of the College of Sexual and Relationship Therapists (COSRT). He is regis-
tered with the UKCP as a psychotherapist. He is an experienced clinical tutor
and supervisor and has served the Royal College of Psychiatrists as a College
Tutor, Membership Examiner, and Training Programme Director. Walter served
the World Professional Association for Transgender Health (WPATH) on the
DSM-V Consensus Committee and on the Global ICD Consensus Group. He
represented the United Kingdom at the World Health Organization’s (WHO)
Protocol Development Meeting for Field Testing of ICD-11 Sexual Disorders and
Sexuality-Related Conditions. Walter is the former chair and a current mem-
ber of the CRG for Gender Dysphoria, whose remit is to develop a national
policy ensuring equity of access to and treatment for trans people at gender
identity clinic services. Walter is a strong advocate for the de-stigmatisation
and ‘de-psychiatrisation’ of gender dysphoria as a classified mental disorder.
Notes on Contributors xix
Walter is Deputy Editor of Sexual and Relationship Therapy – International Perspec-

tives on Theory, Research and Practice. He has published and co-authored widely,
including several good practice guidelines for transgender health.
Helen Bowes-Catton has been researching bisexual subjectivity, community,

and politics in the United Kingdom since 2004. A founder member of BiUK,
she was a co-author of The Bisexuality Report. Helen lectures in psychology and
sociology in Higher Education and Further Education institutions in the south
of England.
Jan Burns is Head of the School of Psychology, Politics and Sociology at

Canterbury Christ Church University, in the United Kingdom. Jan is a clini-
cal psychologist by background, previously working in services for people with
intellectual disabilities and forensic services. She has also been a programme
director of the Salomons Clinical Psychology Doctorate and supervised many
trainees throughout their training. Jan was also one of the founder members
of the BPS’s Psychology of Women section and remains a keen proponent of
clinical services, and those who deliver them, being sensitive and understand-
ing of gender and sexuality. Her publications reflect a wide range of interests,
but have a consistent theme of an interest in minority groupings and issues of
power. These include publications in the areas of health psychology, intellectual
disabilities, forensic services, gender and sexuality, the discipline of clinical psy-
chology, and professional development. In more recent years, she has become
involved in developing Paralympic sport for people with intellectual disabilities
and worked with an international research group which received the presti-
gious Research Councils UK award for ‘Exceptional Research Contribution’ for
the research. This research led to the reinclusion of athletes with learning dis-
abilities into the London 2012 Paralympic Games. Jan would describe herself as
an ‘applied scientist’ and prefers to engage in research which has a real impact
on improving people’s lives.
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, social movements, sociology of personal life, and the sociology of

higher education. As well as his research activity, he has a practical inter-
est in the use of social media within academic life, continuing to work as a
consultant and trainer. He is working on a book, Social Media for Academics,
due to be published in late 2015. He edits The Sociological Imagination with
Milena Kremakova. He co-convenes the Quantified-Self Research Network with
Christopher Till. He is a founding member of the editorial board of Discover
Society, social media associate editor for The International Journal of Social
Research Methodology, and assistant editor for Big Data and Society. He was co-
founder of the British Sociological Association (BSA)’s Digital Sociology group
and has previously supported the BSA’s activity in a range of capacities. He is
also a regular blogger and podcaster.
Dawn Clark is a registered chartered counselling psychologist and psychother-

apist practising in local authority, NHS, and prison services. She works clinically
with complex mental health presentations, addiction, psychosexual health,
offending behaviour, dual diagnosis, and specialist psychosexual presentations
in children, youth, and families services. Dawn is also a research psycholo-
gist with an interest in critical psychology and psychiatry, and her research
projects are diverse. These include the political aspects of early intervention
strategy, psychiatric diagnosis, psychological interventions in prisons, and ado-
lescent sexual behaviours and attitudes. Dawn has developed sexual health and
psychological therapy services for the NHS and local authority, and she has
produced lesson plans and resources for personal, social, and health educa-
tion (PSHE) and sex and relationships education (SRE) at local and national
levels. Her clinical work and research on pornography, sexting, and sexual
behaviour has contributed to changes in local government policy and devel-
opment of educational resources and good practice guides for practitioners
in sex, relationships, and sexual health. Dawn is a consultant and trainer for
practitioners working in local authorities and the NHS. She is also a regular
speaker on sex, gender, and sexual health services for Brighton and Sussex Uni-
versities Hospitals Trust, Sussex Partnerships NHS Trust, and the Royal Society
of Medicine. Her work with young people on sex, relationships, and sexual
behaviours has been featured in published educational materials, the Sunday
Times, and the BBC.
Rob Clucas is Lecturer-in-Law at the University of Hull. His current research

interests are in the field of sexuality, gender, and the law, with a particular
interest in church equality issues, and he is drawn to integrating Gestalt the-
ory into his research and teaching practice. He has published and presented on
the following issues: equality and the Church of England; a law-specific disci-
plinary approach to pedagogy in higher education; and, as B. Clucas, on legal
Notes on Contributors xxi
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.
Terri D. Conley is a professor in the Psychology and Women’s Studies fac-

ulty at the University of Michigan. She received her PhD in social psychology
from the University of California, Los Angeles, and her undergraduate degree
from the University of Wisconsin. In her research, Terri explores gender differ-
ences in sexuality, such as casual sex, desire, sexual fantasy, and orgasm rates;
monogamy and departures from monogamy; and also the relationship between
members of different groups, with a particular interest in marginalised group
members’ perceptions of dominant groups.
Roshan das Nair is Consultant Clinical Psychologist at Nottingham Univer-

sity Hospitals NHS Trust and Honorary Associate Professor at the University of
Nottingham. He completed his training in clinical psychology at the National
Institute of Mental Health and Neurosciences in India and his PhD in psychol-
ogy from the University of Nottingham, United Kingdom. He has previously
worked in the areas of sex, sexuality, and HIV/AIDS in Zambia and India.
Roshan was a board member of the Nottingham Sexual Health Providers forum
and was the Editor-in-Chief of the Psychology of Sexualities Review of the BPS’s
Psychology of Sexualities Section. He was also their representative on the Inter-
national Network on Lesbian, Gay, and Bisexual Concerns and Transgender
Issues in Psychology. He was a member of the Working Party responsible for
writing the BPS guidelines Working therapeutically with sexual and gender minority
clients and was a co-author of the BPS Position statement on therapies attempting to
change sexual orientation. He is Associate Editor and an editorial board member
for the journals Sexual and Relationship Therapy and Journal of Lesbian Studies.
His academic interests include HIV and sexual health in marginalised popu-
lations, the interface between ethnicity and sexuality, and critical appraisals
and discourse analysis of medicalised constructs such as ‘sex addiction’. He
is one of the trustees of BiUK. He is the co-editor of Intersectionality, Sexual-
ity, and Psychological Therapies: Working with Lesbian, Gay, and Bisexual Diversity
(2012).
xxii Notes on Contributors
Robin Dundas is Senior Specialist Psychology Associate at West London Men-

tal Health Trust Gender Identity Clinic. He recently trained in counselling
psychology at Regent’s University and has a special research interest in the
psychological effects of stigma and discrimination on trans* people.
Sonja J. Ellis is Principal Lecturer in (Social) Psychology at Sheffield Hallam
University, with a passion for both feminism and social justice. Her main
field of expertise is gender and sexuality, in particular LGBTQ psychology.
She has published numerous journal articles exploring, among other things,
homophobia at university, moral reasoning around lesbian and gay issues,
and engagement in the creation of positive social change. More recently, she
has – together with Jay McNeil, Louis Bailey, and others – been engaged in a
major piece of research exploring mental health and well-being in trans peo-
ple. With Victoria Clarke, Elizabeth Peel, and Damien Riggs, she is co-author
of the leading textbook in the field: Lesbian, Gay, Bisexual, Trans and Queer
Psychology: An Introduction (2010). She also has chapters in a number of other
books, including Intersectionality, Sexuality and Psychological Therapies: Exploring
Lesbian, Gay and Bisexual Diversity (das Nair & Butler eds., 2011), Out in Psy-
chology (Clarke & Peel eds., 2007), British Lesbian, Gay, and Bisexual Psychologies:
Theory, Research and Practice (Peel et al. eds., 2007), and Lesbian and Gay Psychol-
ogy: New Perspectives (Coyle & Kitzinger, 2002). Her current projects include the
development of pedagogical approaches to embedding inclusivity in the teach-
ing of psychology (funded by a Higher Education Authority (HEA) International
Scholarship), a collaborative project on ‘voluntary childlessness’ (funded by the
British Academy), and some new research on mental health and well-being in
lesbian women.
Panteá Farvid is Senior Lecturer in Psychology at Auckland University of

Technology in New Zealand. Her work includes examining the intersection
of gender, sexuality, power, culture, and identity. She has worked on large
projects examining the social construction of heterosexual casual sex and con-
temporary heterosexualities. Drawing on critical and feminist approaches to the
study of sex, sexuality, gender, heterosexuality, gender relations, and mascu-
line/feminine identities, she has an analytic interest in the personal narratives
of individuals, as well as the critical analysis of popular culture/media represen-
tations related to these. Currently, Panteá is working on projects examining the
sex industry in New Zealand (e.g. media representations of prostitution, men
who buy sex) and ‘cyber intimacies’ (e.g. Tinder, ‘sugar dating’ websites). She is
also working in collaboration with Auckland City Public Libraries to develop a
‘Teen Empowerment Programme’ for New Zealand youth that promotes critical
engagement with media and daily life. She has supervised numerous student
projects examining topics such as Fifty Shades of Grey, teen girls’ engagement
Notes on Contributors xxiii
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.
Gareth Hagger-Johnson’s research falls between epidemiology, quantitative

psychology, and statistics. He studies how health behaviours (including sexual
behaviour) and individual differences (including sexual orientation identity)
influence health, disease, and employment patterns over the life course. He
has worked on data from several large cohort studies, including the Aberdeen
Children of the 1950s (ACONF), Health and Lifestyle Survey (HALS), Lothian
Birth Cohort 1936 (LBC, 1936), Longitudinal Study of Young People in England
(LSYPE), and Whitehall II. He is also interested in the causes and consequences
of data linkage errors in administrative hospital data.
Laura Harvey is Lecturer in Sociology at the University of Surrey. Her work

takes an interdisciplinary approach, drawing on sociology, gender studies,
social psychology, and cultural studies. Her interests include sexualities, every-
day intimacies and inequalities, research with young people, the mediation of
sexual knowledge, feminist methodologies, and discourse analysis.
Nikki Hayfield is currently Senior Lecturer in Social Psychology in the Depart-

ment of Health and Social Sciences at the University of the West of England
(UWE), Bristol, United Kingdom. Nikki teaches social psychology and qualita-
tive research methods and methodologies to students at undergraduate and
postgraduate levels. Her PhD was a feminist mixed-methods exploration of
bisexual women’s (visual) identities. She has published journal papers and book
chapters on the topics of bisexualities and bisexual marginalisation. Nikki also
has experience and expertise in qualitative research methods in psychology,
and has authored and co-authored chapters and papers on qualitative data col-
lection and analysis. She has contributed to a number of qualitative research
studies on social-psychological topics, which have included perceptions of
volunteering, charity and pro-social behaviours, civil partnership, and young
people’s understandings of bisexuality. Nikki also supervises undergraduate and
postgraduate students who have chosen to use qualitative methodologies to
investigate social psychological topics, including genders and sexualities. She
continues to use and develop qualitative methodologies, focusing her own
xxiv Notes on Contributors
research mainly on the exploration of lesbian, gay, bisexual, and heterosexual

sexualities, relationships, and appearance. More recently, her research interests
have broadened to include (alternative) families and relationships. Nikki is a
chartered psychologist and member of the BPS.
Alex Iantaffi is Assistant Professor with the Program in Human Sexuality,
Department of Family Medicine and Community Health, at the University of
Minnesota. He is also a licensed marriage and family therapist and Editor-in-
Chief for the international Journal of Sexual and Relationship Therapy. His ther-
apeutic work is currently focused on transgender and gender non-conforming
youth, and their families. Alex also has experience working as a sex therapist
and with a broad range of clients and families in diverse relationships and fam-
ily systems. Alex has conducted research and published extensively on gender,
disability, sexuality, bisexuality, polyamorous parenting, Bondage and Disci-
pline; Dominance and Submission; Sadism and Masochism (BDSM), deafness,
education, sexual health, HIV prevention, and transgender issues. His scholarly
work has been increasingly focused on issues of intersectionality and sexual
health disparities. He is currently Principal Investigator for a study, funded
by the National Institutes of Health (NIH), on deaf men who have sex with
men (MSM), HIV testing and prevention, and technology. Alex is also engaged
in local, national, and international communities as an activist, speaker, and
trainer. In 2000 his PhD thesis on the experiences of women with disabilities
in higher education was awarded the Best Dissertation Award from the British
Educational Research Association; in 2012 he received the Breaking the Silence
Award from the University of Minnesota; and in 2013 he was awarded the Twin
Cities Deaf Pride Community Organization Awards for his current study on deaf
MSM and HIV.
Tony Kainth is a counselling psychologist currently working at WLMHT Gen-

der Identity Clinic in the role of senior specialist psychology associate. He
completed his doctoral training at City University, London, where his research
explored the role of psychological therapy in managing multiple minority iden-
tities. His specialist interests include sexuality, gender identity, ethnic minority
identities, and health psychology.
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
Education, University of Roehampton. He is an analytic psychotherapist,

chartered psychologist, and photographer. Del is Founding Editor of the
European Journal of Psychotherapy and Counselling, Universities Psychotherapy
and Counselling Association (UPCA) chair, and former founding chair UKCP
Research Committee. His books include Phototherapy and Therapeutic Photog-
raphy in a Digital Age; Post-Existentialism and the Psychological Therapies; Case
Studies in Relational Research; Relational Psychotherapy, Psychoanalysis and Coun-
selling (with Andrew Samuels); Against and for CBT (with Richard House);
Critically Engaging CBT; Childhood, Wellbeing and a Therapeutic Ethos; and
Postmodernism for Psychotherapists (with Robert Snell). Del’s forthcoming books
are Critical Psychotherapy, Psychoanalysis and Counselling, and Existential Psy-
chotherapy and Counselling after Postmodernism. Del also has a small private
practice in Wimbledon and Brighton.
Jes L. Matsick is a doctoral candidate in the dual degree program in Psychology

and Women’s Studies at the University of Michigan. Her works aim to elucidate
how people with less power (minorities) perceive those with more power (dom-
inant groups), identify ways in which societal norms surrounding gender and
sexuality influence health outcomes, and evaluate recruitment strategies in pro-
moting diversity in academia. At the intersection of these lines of research, Jes
examines stereotypes and prejudice based on gender, sexual orientation, race,
and relationship status.
Ester McGeeney is an early career researcher with a background in youth advice

and support. Her research is principally in the fields of gender, sexuality, and
youth culture, with a particular interest in creative and participatory research
methods. Ester is passionate about developing ways of using research to involve
young people and practitioners in organisational, policy, and political change.
She recently completed a PhD at the Open University in collaboration with
the young people’s sexual health charity Brook. Her doctoral research explored
young people’s understandings and experiences of ‘good sex’ and sexual plea-
sure. Ester has since continued to work with Brook to use the findings from
her doctoral study to develop training materials and explore innovative ways
of reanimating data for non-academic audiences.
Sara Mize is Assistant Professor and licensed psychologist at the Program

in Human Sexuality (PHS), Department of Family Medicine and Community
Health at the University of Minnesota Medical School. She is actively involved
in clinical work, teaching, and research. She is an eye movement desensitisation
and reprocessing (EMDR) trained clinician and a Sensorimotor Psychotherapy
Certified Advanced Practitioner. She is passionate about working with clients
using mindfulness and body-oriented approaches. In 2012, she began the first
xxvi Notes on Contributors
Body-Oriented and Mindfulness (affectionately named Da BOM!) Women’s Sex-

ual Health Group at PHS. She brings this orientation to her work in sexuality
and disability, relationship health, trauma recovery, and compulsive sexual
behaviour. She lectures on sexuality and disability both inside and outside the
University, and coordinates the disability section of the medical school course
on human sexuality. She is a reviewer for a number of professional journals. She
and her colleague, Alex Iantaffi, PhD, licensed marriage and family therapist
(LMFT), have published in the area of mindfulness and body-based approaches
to sex therapy and have received a grant to study sexuality, mindfulness, and
the body in ageing individuals.
Amy C. Moors is a doctoral candidate in the dual-degree program in Psychol-

ogy and Women’s Studies at the University of Michigan. Her research critically
examines societal values and norms regarding gender, sexuality, and family. She
focuses on social-contextual processes (e.g. bias, stigma, and hostile environ-
ments) that can impede the professional and personal lives of women, sexual
minorities, and people in non-normative relationships.
Sarah Murjan is a consultant psychiatrist who works as a clinician at the

Nottingham Gender Clinic, a nationally commissioned clinical service for peo-
ple with gender dysphoria, and one of the largest of its kind in Europe. Sarah
trained in psychiatry in Nottingham and has over 20 years’ clinical experience
in mental health. She has worked in the Nottingham Gender Clinic for 15 years
and has extensive experience assisting trans people.
Nathan Rambukkana is Assistant Professor in Communication Studies at

Wilfrid Laurier University, Waterloo, Canada. His work centres on the study
of discourse, politics, and identities, and his research addresses topics such as
digital intimacies, hashtag publics, mixed-race representation, intimate privi-
lege, and non-monogamies in the public sphere. He has presented on the topic
of non-monogamy in the United States, the United Kingdom, and Canada and
is the author of the book Fraught Intimacies: Non/Monogamy in the Public Sphere
(forthcoming). He also has an edited collection on the topic of hashtag publics
under contract. He blogs at complexsingularities.net, tweets @n_rambukkana,
and can be reached at nrambukkana@wlu.ca.
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.
Damien W. Riggs is Associate Professor in Social Work at Flinders University

and an Australian Research Council Future Fellow. His research focuses on gen-
der/sexuality, mental health, and families, and he is the author of over 100
publications in these areas, including What About the Children! Masculinities,
Sexualities and Hegemony (2010). Damien is also a Lacanian psychotherapist in
private practice, where he specialises in working with gender-variant young
people.
Katrina Roen is a professor in the Department of Psychology at the University

of Oslo, Norway. Her research concerns issues of embodiment, youth, gender,
and sexuality, taking an interdisciplinary approach informed by feminist, queer,
and critical psychological understandings. Her current work focuses specifically
on intersex or diverse sex development and the way critical/queer psycholog-
ical understandings might intervene in dominant psycho-medical approaches.
The focus is on opening up understandings, challenging the assumptions that
make normalising treatment seem to be the only option for many parents and
intersex youth. She is also doing research on queer youth and self-harm. The
focus here is on the notion of embodied distress and an examination of how
self-harming and suicidal possibilities come to be entwined with queer youth
subjecthood in some instances. Her earlier work focused on adult transgender
identities and politics. Her work can be found in journals such as Psychology and
Sexuality, Body and Society, Signs, and Social Science and Medicine.
Jennifer D. Rubin is a doctoral candidate in the dual-degree program in Psy-

chology and Women’s Studies at the University of Michigan. Her research
broadly focuses on LGBTQ youth identity development, sexual desire and enti-
tlement to pleasure, monogamy as a social norm, and gender differences in
sexual behaviour and attitudes. Her current work assesses real and anticipated
experiences of social exclusion on Facebook for sexual minority youth and the
health consequences associated with these unique stressors.
xxviii Notes on Contributors
Joanna Semlyen is Senior Lecturer in Psychology at London Metropolitan

University, where she teaches health psychology and qualitative methodolo-
gies. She completed her PhD at City University. She is a registered health
psychologist and a chartered psychologist. She has published a number of arti-
cles in the field of sexuality and health, has co-edited the journal Psychology
of Sexualities Review, and is Past Chair of the BPS’s Psychology of Sexualities
(previously Lesbian and Gay) section. Her research focuses on lesbian, gay,
bisexual, and transgender health, and she is currently carrying out research
into heteronormativity and health, lesbian, gay, bisexual, and transgender
(LGBT) psycho-oncology, and longitudinal population health indices in sexual
minorities.
Sarah Seymour-Smith is Senior Lecturer in Psychology at Nottingham Trent

University. Her research interests include the study of gender across different
contexts such as men’s health (funded grants include projects on male obesity
and prostate cancer in African Caribbean men), non-custodial fatherhood, and
male sex offender identities. Other core areas of research include the study of
support groups (both face-to-face and online support). Sarah is a discursive psy-
chologist with expertise in teaching qualitative research at both undergraduate
and postgraduate levels.
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.
Emma L. Turley is Senior Lecturer in Psychology at Manchester Metropoli-

tan University. She is interested in gender, LGBTQ psychology, sexualities, and
erotic minorities, particularly BDSM and kink, and the ways that these are
understood and experienced from a non-pathologising perspective. Her PhD
examined the erotic experience of participating in consensual BDSM, and she
is currently working on a multi-institution research project investigating the
Notes on Contributors xxix
experience of masculinity in sexually submissive men. Emma’s other special

areas of interest include qualitative methodologies, especially phenomenolog-
ical psychology and experiential research, and the use of innovative research
methods. Outside work, Emma is a keen animal rights activist, with a penchant
for pet rats and good vegetarian food.
Maxine Woolhouse is Senior Lecturer in Psychology at Leeds Beckett Univer-
sity, United Kingdom. Her teaching focuses mainly on critical/feminist social
and health psychology, philosophical issues, and qualitative research methods.
In terms of research, Maxine is interested in discursive approaches to under-
standing how gender and social class intersect to shape identities, and, in
particular, how these inform so-called normal and disordered eating and body
management practices.
Ali Ziegler is Assistant Professor of Psychology at the University of Alaska

Southeast Ketchikan. Her research examines sociocultural explanations for gen-
der differences in sexual desires, fantasies, and behaviours. She is currently
focusing on research related to gender differences in sexual fantasies.
Claudia Zitz is a London-based clinical psychologist and systemic practitioner

working with young people and their families at the Tavistock Gender Identity
Development Service within the NHS, United Kingdom. Their research inter-
ests include postmodern perspectives on identities, particularly in relation to
diverse gender identities, sexualities, and embodied discourses.
Introduction
Christina Richards and Meg John Barker
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,
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
Professionals: A Practical Guide (Richards & Barker, 2013) to be of assistance – it

is also likely to be a useful place for further reading on applied practice with the
groups contained within this volume.
Why a handbook of psychology, then, and not simply an academic volume
on sexuality and gender in general? To some extent this volume is, indeed, a
general academic volume on sexuality and gender: one of the great strengths
of psychology is the breadth of the discipline – from the edges of medicine and
neuropsychology to social psychology and on into sociology and cultural stud-
ies – and that breadth is reflected in this volume. Indeed, many of the authors
have job titles other than psychologist and yet, being leaders in their field, were
selected as being the most appropriate for the job of writing a chapter pertain-
ing to psychological understandings. Of course, this follows the great tradition
of Freud (a medical doctor who won the Goethe Prize for literature rather than
the Nobel Prize for medicine) and Wundt (a medical doctor, physiologist, and
founder of modern psychology), as well as Kraft Ebbing, Ellis, and Hirshfeld
specifically in the area of sexuality. More recently, works by workers such as
Denman (a psychiatrist, e.g. 2004) and Weeks (a sociologist, e.g. 2007) have
had marked influence upon the practice of both academic and applied psychol-
ogy in the fields of sexuality and gender without the authors having psychology
as their main profession.
Psychology, then (whether it is undertaken by people having psychologist
as their professional title or not), with its complex subtle rigour and encom-
passing purview, is perhaps the best placed of all the sciences to consider such
complex and subtle notions as sexuality and gender. It is to be hoped that it
is flexible enough in its approach to accommodate the rate of change in this
most exciting and developing field. We also hope that it continues to navigate
the choppy waters of political and journalistic interest in sexuality and gen-
der without losing its soul: too often we see tenuous assertions being made by
television psychologists on the basis of a pretty scan of a single brain – which
makes good TV but demonstrates little – or on the basis of personal experience
rather than quantitative or qualitative research. Adjunctive to this is the impor-
tance of moving beyond the lab, clinic, or lecture hall and out into the world,
where psychological knowledge can be vital in informing debates around such
things as abortion, sex education, gender rights, sexuality rights, and the like,
not just in countries with a high GDP, but globally.
Our hope is that this volume will aid in these endeavours, through knowl-
edge transmission, certainly, but hopefully also as a means of inspiration to
seek new ways of thinking and understanding about sexuality and gender, and
as inspiration to take those knowledges and to apply them for the benefit of
others. As we have said elsewhere (Richards & Barker, 2013), we feel it is imper-
ative that applied practitioners in this area have the same level of knowledge
regarding the basics of their clients’ gender and sexuality as is readily available
4 Introduction
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
The history of asexuality
What is ‘asexuality’? While answers to this question would once have

predominantly involved references to biological processes, it is increasingly
likely that someone asking this question will receive a rather different response:
an asexual person is someone who does not experience sexual attraction. Bogaert
(2004) was an early and influential contribution to the literature on asexuality,
reporting on a secondary analysis of the National Survey of Sexual Attitudes
and Lifestyles (NATSAL), in which 1.05% of participants reported never having
experienced sexual attraction towards anyone. Follow-up studies on the next
generation of NATSAL found 0.5% of respondents falling into this category
(Bogaert, 2012, p. 45). While asexual people are numerous, it is still difficult
to be clear about how numerous they are. First, these results do not indicate
identification as asexual, but only experiences which have, in other instances,
led people to identify as such. Second, there are important questions which
can be raised about the criterion of having never experienced sexual attrac-
tion, reflecting different orientations to how we understand something like
‘asexuality’. The question “what is asexuality?” is much more complicated than
it can initially seem.
One way to go further is to look towards the commonalities and differences
which can be found among those who self-identity as asexual (Carrigan, 2012).
Another is to clarify what asexuality is not, so as to better understand the topic
by addressing the confusions surrounding it. Finally, we can look beyond self-
identification and consider asexuality as a sexual orientation (Bogaert, 2006).
This chapter will pursue all three strategies, using them as a framework through
which to make sense of a growing academic literature. It will then discuss some
of the key debates that have emerged within this literature, before turning
to their implications for applied practitioners. The chapter concludes with a
discussion of directions for future research and suggestions for further reading.
8 Sexuality
Key theory and research
The asexual community

The notion of ‘asexual’ as a social identity is a relatively recent one, consol-
idating through online community spaces and moving from the ‘online’ to
the ‘offline’ as these communities gave rise to activists and were discovered by
the media and academics. However, people not experiencing sexual attraction
is certainly not a new thing (Cerankowski & Milks, 2010), nor is identifying
oneself positively in these terms (Kahan, 2013). What does seem to be entirely
novel, however, is the affirmative community, partly virtual though, nonethe-
less, obviously real, which has both given rise to and been strengthened by
the growth of this identity. One identifiable strand within the asexuality litera-
ture, within which we might locate Carrigan (2011), Chasin (2010), Hinderliter
(2013), and Scherrer (2008, 2010a, 2010b), has been primarily concerned1 with
understanding the character of this community, the experiences of those within
it, and the relationship between the two.
Investigation of this community immediately cautions against a tendency to
assume we know what asexuality ‘is’. Przybylo (2011) warns that ‘asexuality’
as an identity category should be addressed with care, given that such cate-
gories delineate ‘inside’ from ‘outside’2 and, in doing so, foreclose certain ways
of being asexual while recognising others. What can appear to be a converging
self-identification as asexual might, nonetheless, mean very different things for
different people. Some asexual people experience romantic attraction, devel-
oping ‘crushes’ and pursuing relationships, while others do not. Some asexual
people are entirely indifferent to sex, some are viscerally repulsed by it, while
others can derive enjoyment from sexual acts without these acts being moti-
vated by sexual attraction. Carrigan (2011) suggested that this can be usefully
understood in terms of divergent attitudes towards sexual behaviour (positiv-
ity, neutrality, repulsion) and romance (aromanticism and romanticism, which
can take heteroromantic, homoromantic, biromantic, and panromantic forms).
Other identifications include gray-a, commonly understood to refer to those
falling within the ‘grey area’ between sexuality and asexuality, as well as demi-
sexuality, referring to the experience of sexual attraction as something ensuing
from romantic attraction and never independently of it.
Our few sources of information about the size of groups within the asexual
community, as opposed to the distribution of asexual people within the pop-
ulation at large, come from The Asexual Awareness Week Community Census.
Conducted in 2011 as part of a broader visibility project, this community-led
project collected responses from 34303 respondents about their demographic
characteristics (Miller, 2011). While there are obvious issues of self-selection
and social selection attendant to internet-based research, particularly when
recruitment is enacted through in-group networks, this is a broader point
Mark Carrigan 9
applicable to much of the existing literature on asexuality rather than a critique

that can be made specifically of the census (Carrigan et al., 2012).4 The results of
the census reflect the aforementioned diversity within the asexual community,
with 56% of respondents reporting identification as ‘Asexual’, 21% as ‘Gray-
asexual’, 21% as ‘Demisexual’, and 2% as ‘None of the above’. Attitudes towards
oneself having sex were variable, with a greater proportion of asexually iden-
tified respondents reporting complete repulsion (25%) than was the case with
Gray-As (8%) and Demisexuals (6%). However, reported indifference was lower
among these respondents (24%) than among Gray-As (32%) and Demisexuals
(34%). Significant numbers of respondents among these latter two groups, who
can too easily be reductively conceptualised as being ‘less asexual’ but not sex-
ual, reported an attitude of repulsion towards oneself having sex. Completely
repulsed Gray-As (8%) and somewhat repulsed Gray-As (43%), as well as com-
pletely repulsed Demisexuals (6%) and somewhat repulsed Demisexuals (31%),
serve as a reminder of the complexity of these categories (Miller, 2011). Another
important finding is those asexually identified respondents who reported that
they ‘Enjoy having sex’ (1%) and the larger number of Gray-As (4%) and
Demisexuals (11%) for whom this was true.
While the asexual community5 emerged online, with a number of diverse
strands preceding the Asexuality Visibility and Education Network (AVEN) and
the emergence of many other online spaces across a range of digital platforms,
we risk missing the reality and significance of these engagements if we construe
them solely as ‘virtual’. Certainly, the internet was crucial, with the diffusion
of information and communications technology in the late 1990s facilitating
an “ability to maintain contact with others irrespective of their geographical
location, with the flexibility of asynchronous contact and without huge cost
implications to the sender or receiver” (Evans, 2013, p. 82). This allowed an
otherwise geographically dispersed group to begin to talk, compare experiences
and elaborate new ways of thinking about their selves and their lives.
Nonetheless, the possibility to connect in such a way does not account for
the needs and desires served by such a connection, nor does the simple fact of
this communication being ‘online’ help us understand the rich array of ‘offline’
activities which have emerged around the globe. In fact, the online/offline
distinction arguably hinders us in making sense of the activities and associa-
tions which have emerged from these early beginnings. As will be discussed
later in the chapter, the need for support and acceptance that the community
serves, described by Scherrer (2008) and others, must be understood in terms
of the assumptions, habits, and judgements encountered within the broader
social and cultural context. Another risk is that talk of online communities
can convey an impression of inwardly looking groups talking to each other
about themselves. While these online dialogues have been important both
for individuals and for the asexual community as a whole (Carrigan, 2011),
10 Sexuality
they have gone hand-in-hand with many outward-facing strands of activity, in

which members of the community have sought in a variety of ways to engage
with journalists, academics, activists, and policy makers.6 For instance, AVEN
has project and media teams, with the latter collaborating with journalists
and broadcasters on many occasions. In recent years, asexuality has received
widespread attention in print and broadcast media around the globe (Bootle,
2009; Wallis, 2012; Westphal, 2004).7 It is receiving institutional recognition,
for instance as part of the Home Office’s hate crime strategy United Kingdom
(Home Office, 2012). It is also the subject of at least one novel, as well as a play,
both known by the author to be in preparation.
Confusions surrounding asexuality

Both empirical data and anecdotal evidence attest to the confusions which sur-
round the topic of asexuality (Carrigan, 2012). Its ironic ‘sexiness’ as a research
topic (Cerankowski & Milks, 2014) reflects these confusions. The fact that it
remains so counter-intuitive to many, even if it is becoming more familiar in
at least some quarters,8 contributes to its appeal as a research topic.9 Its inter-
estingness derives from its capacity to act as a new lens with which to view
sexuality (Bogaert, 2012), but this intellectual appeal as a starting point for
rethinking taken-for-granted assumptions is the flip side of the everyday dif-
ficulties faced by asexual people, with sheer intellectual non-comprehension
ensuring that stigmatising reactions to asexuality are pervasive.
One common confusion is to equate asexuality with celibacy, such that a lack
of sexual attraction (asexuality) is conflated with a choice to abstain from sexual
acts (celibacy). If the two groups are considered from a historical and sociolog-
ical perspective, this distinction can appear less sharp than it might initially
seem,10 as the voluntariness upon which the contemporary understanding of
celibacy depends can come to seem distinctly slippery when considered in spe-
cific contexts. However, for present purposes, it is more important to recognise
the frustration that this pervasive confusion causes for many asexual people.
More significant is the widespread assumption that everyone experiences sexual
attraction. This licenses the normative claim that everyone should experience
sexual attraction, such that its absence constitutes grounds for assuming the
operation of some pathology which has interrupted ‘normal’ sexual response.
This is a common assumption which is bound up within a broader cultural pol-
itics of (a)sexuality: for instance, Kim (2011) who explains how asexuality has
long been associated in a negative way with the lives of people with disabili-
ties (see Iantaffi & Mize, this volume). This assumption of the universality of
sexual attraction, such that its apparent absence is understood in pathological
terms,11 is deeply problematic, and, it will be argued, it is particularly impor-
tant to question this from the perspective of applied psychology. It can seem
a common-sense assumption until questioned, but it contributes to a situation
Mark Carrigan 11
in which many asexual people perceive themselves to be living in relatively

hostile environments (Gazzola & Morrison, 2011) and in which otherwise well-
meaning people can act in ways which are unintentionally stigmatising and
harmful to asexual people (Carrigan, 2012). As will be discussed, this experi-
ence of hostile circumstances can often be seen to explain the ‘distress’ which
is used to license a clinical attribution of pathology.
The psychology of asexuality
While these sociological and social psychological considerations might be par-
ticularly important when engaging with asexual people in an applied context,
underlying questions remain concerning the psychology of asexuality. Though
a sociological approach to the question “what is asexuality?” will tend to
reject, or at least complicate, the terms of the question itself, the main ten-
dency in the psychological literature on asexuality has been to treat it as a
sexual orientation. This issue was addressed in an early paper by Bogaert (2006),
which asked whether it is “useful to consider a lifelong lack of attraction as a
unique sexual orientation, distinct from, say, the three main categories of het-
erosexual/straight, homosexual/gay and bisexual?” (p. 244). As Chasin (2011)
notes, this treatment of asexuality as one of four mutually exclusive orienta-
tion categories has longer-standing roots within the sexualities literature. The
ensuing understanding of asexuality as the ‘fourth sexual orientation’ certainly
resonates with some within the asexuality community. However, one of the
problems with this is that it excludes those who experience sexual attraction
rarely, as well as those who have experienced it in the past but no longer do
(Chasin, 2011). The broader issue this raises concerning the need for longi-
tudinal research will be discussed later in the chapter. The important point for
present purposes is that this operationalisation of asexuality, whatever method-
ological virtues it may or may not possess, cuts rather uneasily across the
asexual community. If we assume the viability of the underlying concept that
asexuality is a ‘fourth sexual orientation’ which previously eluded systematic
recognition, this may not seem problematic. But the cases of those who rarely
or formerly experienced sexual attraction can illuminate the cases of those who
never have, and vice versa (Carrigan, 2011).
In an earlier paper, Bogaert (2004) recognises that “there may be a num-
ber of independent development pathways, perhaps both biological and
psychosocial, leading to asexuality” (p. 284). This suggestion is rendered yet
more plausible when we consider the aforementioned diversity within the
asexuality community. While the sociological literature has remained (neces-
sarily) agnostic on the aetiology of asexuality, it has established a strong body
of evidence that, if asexuality is a state susceptible to explanation, it certainly is
not a unitary state. Therefore, we should not only consider multiple pathways
leading to asexuality but recognise the possibility that a diversity of states are
12 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).
Important points for students
One obvious challenge to thinking about asexuality is its continued

absence from textbooks and syllabi. While visibility activism by asexual
people and their allies has contributed to a greater media profile for
asexuality, it is still striking by its absence within academia. This aca-
demic invisibility can lend support to a tendency to see asexuality as
pathological. It is important to remember that its invisibility does not
mean it does not exist. Even if some asexual people might experience dis-
tress, it is important to question the sources of that distress and ensure
that projects do not start from the assumption that asexuality is pathol-
ogy. There are many valuable resources online produced by the asexual
community which can be helpful, examples of which are detailed at the
end of this chapter.
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:
In the twentieth century sexologists singled out disturbances at the level of
sexual desire as conditions demanding mediation. States of low or no sex-
ual desire were conceptualized as effects likely to cause harm to individuals.
Psychiatric discourses of sexual desire build on an understanding of sexual
desire as instinctive and, insofar as it is natural, it is deemed the marker of
healthy sexuality. (p. 18)
The relationship between the categories of asexuality and HSDD is unavoid-

ably contested, with the former asserting as ‘normal variation’ what the latter
treats as pathology (Hinderliter, 2013). The question this relationship poses
has been asked bluntly by Bogaert (2008): “Should asexuality (defined as a
lack of sexual attraction or as lack of desire or both) be considered a sexual
dysfunction?” (p. 10).
These assumptions about what is quantitatively and qualitatively ‘normal’
in matters of sexual attraction are sometimes encountered by asexual people
directly, in the figures of clinicians and therapists who assume this ‘absence’ is
a problem to be fixed, but more frequently through the ‘common-sense’ reac-
tions of those around them, which are buttressed by a vague awareness of a
putative medical basis for their attempts to explain away asexuality. Certainly,
it might be that some asexual people experience the distress which licenses
the deployment of the diagnostic category, though it is far from clear that this
is as widespread as might be assumed by some (Bogaert, 2008; Brotto et al.,
2010; Prause & Graham, 2007). Furthermore, as Bogaert (2012, pp. 109–110)
recognises, it is important to recognise the social causes of this distress where
it exists, with precisely these ‘common-sense’ reactions (“were you abused as
a child?”, “is there something wrong with your hormones?”, etc.) constituting
an obvious reason why individuals persistently on the receiving end of them
might feel distressed.
Another related issue is the question of how ‘asexuality’ is operationalised
in empirical research. As Chasin (2011) notes, within the literature asexuality
is usually assumed to be a singular orientation (or lack of such) that precludes
other orientations. Carrigan (2011) approached this issue by conceptualising
the ‘umbrella definition’ as a common point of identification, reached for
divergent reasons and co-existing with a great deal of diversity among those
identifying as such. The risk is that we design research with too narrow a con-
cept of ‘asexuality’ and, by doing so, obscure this underlying diversity. If we
14 Sexuality
assume we know what ‘asexuality’ means at the start of investigation, we may

blind ourselves to the many differences which obtain between asexual people.
But there is, nonetheless, a prior problem of how to design research which seeks
to investigate asexual people in some way.
The major limitation to operationalising asexuality entirely in terms of self-
identification is that we exclude those who have not recognised themselves
and/or outwardly identified as asexual, but might under other circumstances.
This is a potentially diverse group in its own right, encompassing, inter alia,
those who are unfamiliar with the concept of asexuality, those who identify
as asexual but have not yet ‘come out’, and those who recognise themselves
as asexual but see this as a descriptive label with little personal salience to
them. Sociologists and social psychologists have tended to answer this question
in terms of self-identification as asexual (Carrigan, 2011, 2012; Chasin, 2010;
Scherrer, 2008). However, as Bogaert (2012, p. 38) reminds us, the evidence we
have suggests that this is a recent and predominantly Western phenomenon.
In contrast to this sociological tendency within the literature, psychologists
and sexologists have tended to depict “ ‘the asexual’ as an essential type of
person, and his or her lack of sexual desire/attraction as a curiosity to be
explained” (Scott & Dawson, 2014, p. 4). But this ignores the process through
which individuals come to identify as asexual and, in doing so, it abstracts
sexual attraction (or, rather, the lack thereof) from the lived life of the indi-
vidual and the social setting(s) within which this life unfolds (Carrigan, 2011,
p. 463). In an important way, it seems that both answers12 to the question
are quite problematic. So where does this leave us? To a certain extent this
will, in the final instance, stand as a methodological decision to be addressed
by particular researchers. So, for instance, Bogaert’s (2004) operationalisation
of asexuality was clearly conducive to secondary analysis of survey research
which had not directly addressed the question of asexuality. Nonetheless, it is
important that we better understand what ‘asexuality’ is over and above the
methodological dimension of this question, which can sometimes crowd out
other considerations.
These issues are connected to broader philosophical questions concerning the
nature of identity, which have occupied many within the asexual community
as well as theoretically oriented researchers. As Scherrer (2008) notes, asexuality
has a complicated relationship with essentialist notions of identity. The AVEN
community, which has been at the forefront of asexuality visibility, has tended
to advocate an anti-essentialist understanding of asexual identity. For instance,
as the Frequently Asked Questions (FAQ) and related pages on the AVEN site
make clear,
The definition of asexuality is ‘someone who does not experience sexual

attraction.’ However, only you can decide which label best suits you. Reading
this FAQ and the rest of the material on this site may help you decide
Mark Carrigan 15
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)
There is no litmus test to determine if someone is asexual. Asexuality is like

any other identity – at its core, it’s just a word that people use to help figure
themselves out. If at any point someone finds the word asexual useful to
describe themselves, we encourage them to use it for as long as it makes
sense to do so.
(Asexuality and Visibility Education Network, 2011)
In contrast, academic research has “largely defined asexuality as a lifelong lack

of sexual attraction and in doing so has positioned asexuality in line with
essentialist discourses of sexual orientation” (Chasin, 2013). Such essentialist
discourses have also found support from some within the asexual community,
with the Asexuality and Visibility Education Network (AVEN)’s aforementioned
tendency towards anti-essentialism representing an increasing point of con-
tention for some asexual people, who construe it as having ‘diluted’ the
meaningfulness of the category. Furthermore, the embrace of essentialism may
be motivated in part by a desire to reduce stigma against asexuality (Gazzola &
Morrison, 2011, p. 28).
Important points for academics
Though the growth of asexuality as a self-identification is relatively

recent, consolidating around online discussion spaces in the early twenty-
first century, it seems likely that this is not the case for the underlying
experience which now leads people to identify as asexual.13 If this is
so, the conspicuous absence of asexuality from the academic literature
becomes striking. The belated recognition that asexuality is now receiv-
ing has important implications for how sexuality is conceptualised more
broadly. Even where asexuality is not directly addressed, it is important
that claims about sexuality and intimacy are consistent with the reality
of asexuality.
Implications for applied psychology and the wider world
Drawing upon their research into experiences of discrimination among

asexuals, Gazzola and Morrison (2011, p. 36) warn that “non-asexual individu-
als may inadvertently offend asexual individuals” given the absence of “widely
recognised inoffensive language and behaviour norms”. Part of the difficulty
is that, as discussed in the Introduction, what can seem to be common-sense
16 Sexuality
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
production which can be found online. Some of this material is explicitly

intended as visibility and education activism, but this is far from true of all.
Some starting points to this end are included in the ‘Further reading’ section of
this chapter.
Important points for applied professionals
Many of our common ways of talking and thinking about sexuality

assume that everyone should experience sexual attraction and that its
absence represents a problem. For this reason, it is important that applied
professionals likely to work with asexual people try to sensitise them-
selves to the pervasiveness of these assumptions. It can be easy to slip into
ways of talking about sexuality which can leave asexual people feeling
marginalised or invisible. This should also involve an increasing aware-
ness of asexuality as a possibility, so that it is offered as an option to those
who report a lack of sexual attraction. But even in this sense it is impor-
tant to avoid the assumption that asexual people have uniform interests
or experiences.
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
relationship. Even if it is present, it should not be assumed that it is necessarily

problematic, given the many creative ways in which these culturally inscribed
difficulties can be negotiated in situated contexts. Making assumptions to the
contrary, for researchers, can obscure the creative ways in which those within
asexual relationships ‘rewrite the rules’ (Barker, 2012; Scherrer, 2010a) and, for
practitioners, can risk imputing a problem where one does not or need not
exist.
Gender, intersectionality, and diversity

There remains much theoretical and empirical work to be done to elucidate
the significance and consequence of the intersectional identities so prevalent
within the asexual community. While a full engagement with the conceptual
questions entailed in this would be far beyond the scope of the present chapter,
it nonetheless seems possible to offer some general thoughts about how such
an approach could proceed. Certainly, it is important to note at the outset that
the aforementioned diversity within the asexual community, for instance with
regard to variable orientations towards sex and romance, means that the viabil-
ity of ‘asexuality’ as a category with which other categories intersect is far from
self-evident. While the ‘umbrella identity’ still enjoys widespread salience, its
uncritical deployment in an analysis of lived lives can be problematic.
For instance, as Chasin (2011) observes, it is conceivable that asexual people
are more likely to be trans identified, and the prima facie evidence we have
supports this possibility. The asexual census discussed earlier in the chapter
certainly substantiates this, with 10% of the 3430 respondents reporting that
they considered themselves transgender, with another 10% reporting that they
were unsure. This connects to the broader issue of gender within asexuality
research. While there has been a rich strand of feminist theorising addressed
towards asexuality,17 empirical analysis of the gendering of asexual experience
has been less forthcoming. Given that, as Diamond (2008, p. 49) observes, “the
past quarter-century of research on this topic suggests that very few features of
sexual minority development are not differentiated by gender”, this issue clearly
calls for more empirical investigation to complement some of the excellent
theoretical work that has already been done.
One further related issue concerns the present and future alliances between
the asexual community and other sexual minority groups. These will inevitably
have some grounding in the intersectionality within the asexual community,
though we must be careful not to ignore some of the tension connected to
this. These fault lines periodically emerge within asexual discourse, includ-
ing conflicts between queer and non-queer identified asexual people. These
reflect much longer-standing discussions within the asexual community about
the degree to which asexuality should be included under the LGBT umbrella.
This issue would benefit from content analysis or online ethnography, particu-
larly given the apparent localisation of these debates around particular online
20 Sexuality
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
• Asexuality is a sexual identity, usually defined as not experiencing sexual

attraction, which has emerged in online discussion spaces and has rapidly
increased in visibility.
• However, while the identity of ‘asexual’ is relatively new, it seems unlikely
that the experiences underlying it are. This raises important questions about
why contemporary circumstances have led to the emergence of this identity.
• In spite of this shared identity as asexual, there is a great deal of diver-
sity within the asexual community. Important differences include attitudes
towards engaging in sexual behaviour (aversion, indifference, positivity) and
experience of romantic attraction (heteroromantic, biromantic, homoro-
mantic, panromantic).
• The increasing visibility of asexuality brings many common assumptions
concerning human sexuality into a new focus. It is important to recognise
the ubiquity of these assumptions and to avoid making them in an applied
context when engaging with asexual people.
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
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-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
Gazzola, S. B. & Morrison, M. A. (2011). Asexuality: An emergent sexual orientation.

In T. G. Morrison, M. A. Morrison, M. Carrigan, & D. T. McDermott (Eds.) Sexual
minority research in the new millennium. (pp. 21–44). Hauppauge, NY: Nova Science.
Hinderliter, A. (2013). How is asexuality different from hypoactive sexual desire disorder?
Psychology & Sexuality, 4(2), 167–178.
Home Office. (2012). Challenge it, report it, stop it. The Government’s plan for dealing with
hate crime. Easy Read Document. Retrieved from https://www.gov.uk/government/
uploads/system/uploads/attachment_data/file/97850/easy-read-hate-crime-action
-plan.pdf.
Kahan, B. (2013). Celibacies: American modernism and sexual life. Durham, NC: Duke
University Press.
Kim, E. (2010). How much sex is healthy? The pleasures of asexuality. In J. M. Metzl &
A. Kirkland (Eds.) Against health: How health became the new morality. (pp. 157–169).
New York: New York University Press.
Kim, E. (2011). Asexuality in disability narratives. Sexualities, 14(4), 479–493.
Miller, T. (2011). Analysis of the 2011 Asexual Awareness Week Community Census. Retrieved
from http://asexualawarenessweek.com/docs/SiggyAnalysis-AAWCensus.pdf.
Prause, N. & Graham, C. A. (2007). Asexuality: Classification and characterization.
Archives of Sexual Behavior, 36(3), 341–356.
Przybylo, E. (2011). Crisis and safety: The asexual in sexusociety. Sexualities, 14(4),
444–461.
Przybylo, E. (2013). Afterword: Some thoughts on asexuality as an interdisciplinary
method. Psychology & Sexuality, 4(2), 193–194.
Scherrer, K. S. (2008). Coming to an asexual identity: Negotiating identity, negotiating
desire. Sexualities, 11(5), 621–641.
Scherrer, K. S. (2010a). What asexuality contributes to the same-sex marriage discussion.
Journal of Gay & Lesbian Social Services, 22(1–2), 56–73.
Scherrer, K. S. (2010b). Asexual relationships: What does asexuality have to do with
polyamory? In M. Barker & D. Langdridge (Eds.) Understanding Non-monogamies.
(pp. 154–159). London: Routledge.
Scott, S. & Dawson, M. (2014). Rethinking asexuality: A Symbolic Interactionist account.
Sexualities.
Swankivy. (2012). Shit people say to asexuals (Video file). Retrieved from https://www
.youtube.com/watch?v=WBabpK_nvs0.
Wallis, L. (2012). What is it like to be asexual? BBC News Magazine. Retrieved from http://
www.bbc.co.uk/news/magazine-16552173.
Westphal, S. P. (2004). Feature: Glad to be asexual. New Scientist. Retrieved from http://
www.newscientist.com/article/dn6533-feature-glad-to-be-asexual.html.
2
BDSM – Bondage and Discipline;
Dominance and Submission;
Sadism and Masochism
Emma L. Turley and Trevor Butt
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.
‘BDSM’ denotes assorted consensual sexual activities: bondage and

discipline (B&D), dominance and submission (D/s), and sadism and
masochism. Many practitioners use ‘safe, sane and consensual’ as a guide-
line for these activities, and any coercion is confined to fantasy. It is
estimated that at least 10% of the population are interested in BDSM fan-
tasies. Krafft-Ebing, a nineteenth-century psychiatrist, is responsible for
the pathologising of BDSM and invention of the ‘sadist’ and ‘masochist’
26 Sexuality
(Continued)
labels. The notion of perversion rests on the logic of a contrast of ‘natural

sex’. This is based on sex as procreation, not sex as enjoyment. When we
reflect on it, we see that what is seen as an ‘unhealthy’ interest in pain
depends very much on context.
(See SM questionnaire: http://sexualitygender.wordpress.com/exercises/

6-bdsm-kink)
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,
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.
Psychoanalysis and Freud
Psychoanalysis was the first theoretical perspective to offer an account of the
reasons why sexuality should be understood separately from reproduction. As a
result of this separation, psychoanalysts proposed now well-known develop-
mental models tracing erotic pleasure to infancy. Freud (1920/1953) argued
that the conventional opinion which states that the desire for opposite-sex
relationships emerges at puberty and leads to reproduction was too narrow to
account for human sexuality. He concluded that sexual life begins in infancy,
that ‘genital’ and ‘sexual’ have different meanings, and, finally, that sexual plea-
sure involves the development of erogenous zones that may or may not lead to
reproduction. Freud’s thinking was particularly innovative, as he widened the
notions of what could be considered sexual. In his essays on sexuality (1905),
Freud argues that the object of the sexual drive is ‘soldered’ onto it. This obser-
vation is important in that it questions what is natural; it is not so surprising
that sexuality takes so many directions. Indeed, he characterised the infant as
a ‘polymorphous pervert’ (Freud, 1905/1977).
Stoller and the ubiquity of perversion

Robert Stoller’s (1975) work examining BDSM-related fantasy and the erotic
imagination provided a rich and empathic account aimed at understanding
those who participate, even recognising the concept of ‘consensual’ BDSM
(Stoller, 1991). Despite drawing on the vocabulary of psychoanalysis, frequently
referring to ‘perversion’, Stoller (1975) did not consider perversion in terms of a
description of behaviour. Rather, it is to be seen in the intention of the individ-
ual. Normative sexuality can thus be perverted when it embodies an attempt
to overcome, conquer, or otherwise harm the object. Butt (2005) re-examined
Stoller’s research, and contends that it attempts to make sense of the erotic
imagination in a way that does not pathologise BDSM. Stoller argued that per-
version is ubiquitous: that more or less every person and every erotic act can
be described as ‘perverse’. Butt (2005) draws on the work of Merleau-Ponty to
understand this point, and argues that the ambiguity of the lived world enables
individuals to experience a host of opposing emotions together, as is often expe-
rienced during BDSM: for example, feelings of humiliation and embarrassment
coupled with sexual excitement and anticipation.
Stoller’s (1975) work is certainly ambiguous; his persistence in the use of
psychoanalytic discourse and the language of pathology appears contradictory
to his sympathetic portrayal of BDSM enthusiasts. However, this early research
28 Sexuality
is useful in that it highlighted the workings of the erotic imagination, illus-

trating the ubiquitous nature of what Stoller referred to as ‘perversion’ (Butt,
2005). Stoller (1975) is also interesting in that he addresses the issue of sexual
thrill. Thrill occurs on finding an excitement in danger: perhaps on fairground
rides or visiting a chamber of horrors. He argues that a danger is made safe by
reframing it in an exciting way. Sexual thrill is no different. A danger to an
individual’s sexuality or gender development is transformed into an exciting
fantasy. This interesting thesis might still be seen, however, as pathologising
the ‘pervert’, albeit in a way that is not condemnatory.
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
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.
Historically, the concept of perversion was used to medicalise any sexual

activity that was transgressive. However, studies show no link between
psychiatric disturbance and an interest in BDSM. Therapy and coun-
selling that is ‘kink-friendly’ is increasingly available, and is not focused
on ridding the individual of his or her ‘perversion’. The new DSM-5 classi-
fication reflects the possibility of BDSM as a legitimate sexual expression,
and distinguishes between this and disorders arising from it. The notion
of perversion changes in the wake of movement in societal norms. It
might be better if we thought of perversion as referring to coercive and
not merely transgressive sex.
(See SM questionnaire: http://sexualitygender.wordpress.com/exercises/

6-bdsm-kink)
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
from a non-pathologising perspective. This section will detail some of these

alternative approaches before introducing the work of key researchers who
operate within the approaches that take a non-pathologising stance to BDSM
research.
Queer theory, a critical theory influenced by the work of Foucault and devel-
oped by Butler and Halpern among others, emerged in the 1990s as a reaction
to mainstream academic studies that positioned heterosexuality as the norm.
By exploring categories of gender and sexuality, queer theory aims to chal-
lenge this commonplace heteronormativity, which is considered as restrictive
and damaging. Foucault (1978) argued that perverse forms of sexuality are the
product of the exercise of power by the ruling classes for the purpose of self-
affirmation and control. Knowledge about sex by more powerful members of
society contributed to the development of a normalisation of human sexu-
ality and therefore determined what was ‘normal’ and what was considered
‘pathological’. Queer theory argues that BDSM is able to challenge and resist
mainstream sexual norms through various means, including enabling partici-
pants to play with concepts of power and gender and directing the sexual away
from heteronormative,1 genitally focused sexuality (Bauer, 2007).
Critical psychological perspectives, such as social constructionism, critique
and challenge mainstream psychological approaches and theories. Ideas central
to mainstream psychology are rejected and criticised for failing to acknowl-
edge the inherent power imbalances that exist between societal groups. Social
constructionism argues that language does not simply reflect reality: language
constructs reality and has a performative function in constructing social worlds.
One such construct is the notion of essentialism. Essentialist theories position
sexuality as an internal state or ‘essence’, the most common being sexual orien-
tation, which are governed by biological and/or psychological structures that
are responsible for sexual feelings and sexual behaviours (Clarke et al., 2010).
Rather than viewing an interest in BDSM as some biologically or psychologi-
cally determined state, social constructionism, instead, is interested in the ways
BDSM practitioners construct their sexual identities and interactions.
Phenomenological psychology is particularly concerned with the diversity
and variety of human experience, and the manners in which individuals
impose meanings on their worlds (Spinelli, 2006). Phenomenological psy-
chology encompasses a family of methodological traditions, each with its
own philosophical position. These tend to be divided into the transcendental
(or descriptive) and hermeneutic (or interpretive) approaches. Phenomenolog-
ical psychology, along with phenomenology more broadly, rejects empirical,
positivist perspectives that subscribe to Cartesian dualism and argues that tra-
ditional psychology had become preoccupied with achieving a natural science
status, focusing on objective, quantitative inquiry while ignoring the role of
meaning-making in human life (Giorgi, 2006). Phenomenological psychology
is interested in understanding the lived experience of a particular phenomenon,

while at the same time recognising one’s own preconceptions about that phe-
nomenon. Rather than relying on psycho-medical discourses around BDSM,
phenomenological psychology would question ‘What is it like to take part in
BDSM?’ in order to understand the lived experience of that participation.
Stemming from activist work (see Easton, 2007; Easton & Hardy, 2004;
Easton & Liszt, 1997), a growing body of non-pathologising researchers have
adopted alternative approaches to study a range of issues within BDSM. Moser
and Kleinplatz (2005, 2006) have written extensively on BDSM, with much of
this work focused on its removal from the DSM. Langdridge and Barker edited
the first collection of cross-discipline perspectives exploring BDSM from a non-
pathological perspective (2007). Researchers such as Turley (2012) and Chaline
(2008) have recently completed doctoral theses studying various aspects of
BDSM, along with the publication of a number of monographs by researchers
examining specific BDSM communities (see Beckmann, 2009; Newmahr, 2010;
Weiss, 2012). There are many academic and activist researchers taking a non-
pathological stance on BDSM Studies, too many to include here, though it is
important to recognise that the psycho-medical perspective on BDSM remains
the dominant and accepted approach within psychology and the wider world.
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
rather than something that is predetermined by biology, psychology, or reli-

gion. Kleinplatz and Moser (2005) make a similar point, arguing that Western
clinicians consider normative sexuality as monogamous, procreation-oriented,
young, and able-bodied. In addition, Willig (2008) argues that many psychol-
ogists perceive ‘risky’ sexual practices, such as BDSM, to be manifestations
of pathologies within the individual because ‘normal’ individuals would not
behave in a manner that risked their health. Behavioural choices that chal-
lenge health models lead to a conceptualisation of these ‘risky’ behaviours as
a product of psychopathology. Willig (2008) points out, however, that there
exist various and diverse rationalities behind engaging in the behaviours. For
example, some submissive participants in Turley’s (2012) research experienced
a sense of eroticism that was derived from the range of conflicting and con-
trary emotions experienced when submitting during BDSM. Emotions that are
conventionally considered incompatible and that are not usually experienced
together can become synthesised during BDSM and are converted into some-
thing erotic for the participants. Others reported that the lack of autonomy and
responsibility achieved during submission was a sexual highlight for them.
Research examining criminal sexual behaviour, such as rape and sexually ori-
ented murder, contribute to the notion that consensual BDSM is pathological,
as frequently the theorists do not make clear distinctions between consensual
sexual SM and offenders who engage in non-consensual sexual sadism. Despite
dominant psycho-medical discourses situating BDSM firmly within the realm
of pathology, various research studies have concluded that BDSM practition-
ers are no more dangerous than those who do not participate in BDSM. Dietz
(1990) distinguishes criminal sadists from BDSM practitioners by a number of
criteria. Criminal sexual sadists secure unwilling, non-consenting participants,
force sexual acts on their victims, and remain emotionally detached through-
out. Dietz argues that BDSM practitioners display none of these criteria, and are
not psychologically abnormal: a claim supported by findings from a range of
studies, such as Connolly (2006), Yost (2009), and Stockwell et al. (2010). Cross
and Matheson (2006) argue that, in the main, current academic understand-
ings of BDSM position it as pathological and/or misogynistic. They highlight
the consensus between medical and Freudian viewpoints, which treat BDSM
as a symptom of mental illness or maladjustment. For Freud (1920/1953),
enjoyment of sadism resulted from a weak super-ego, enabling the id to be
expressed via sexual violence, while masochists suffered from a modification of
the inherent death instinct.
The psycho-medical model also perceives sexual interest in BDSM as a prob-
lem to be solved (Willig, 2008). Cross and Matheson (2006) argue that some
radical feminists regard BDSM as being essentially misogynistic, positioning
all BDSM in terms of repetition of a heterosexual patriarchy. To assess these
views of BDSM, they administered a questionnaire containing elements of the
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.
BDSM and feminism

Broadly speaking, there are two feminist camps; the pro-sex and anti-SM posi-
tions. The pro-sex camp argues that BDSM is an example of healthy sexual
agency, while the anti-SM position contends that any and all instances of BDSM
perpetuate the power differences and inequalities between men and women
(Deckha, 2011).
The main points of the anti-SM feminist argument claim that all forms of
BDSM are incompatible with feminism because BDSM represents repetition of
violent heteropatriarchal2 relationships. The mutual exclusivity of the two was
central to the feminist sex wars, and still remains valid to anti-SM feminists
and academics (Ritchie & Barker, 2005). Califia (2000) contends that BDSM
is perceived to be the essence of misogyny, sexism, and violence by anti-SM
feminists, such as Dworkin and Griffin, who argue that lesbian BDSM is symp-
tomatic of self-hatred and internalised homophobia (Ritchie & Barker, 2005).
The arguments cited by pro-sex feminists using consent as a defence against
these claims are dismissed by anti-SM feminists, who contend that the issue
of consent simply permits the physical acting out of the internalised hatred
(Deckha, 2011). Anti-SM feminists also claim that apparent consent is utilised
34 Sexuality
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.
BDSM as adult recreation

An alternative reconceptualisation of BDSM is the view that it is a form of
adult recreation. There are calls for a shift in the way that BDSM is understood:
towards viewing it as recreation rather than pathological perversion. Williams
(2009) argues against the construction of BDSM as a form of ‘deviance’. The
concept of ‘serious leisure’ was proposed by Stebbins (2007) and framed as com-
mitment to the pursuit of an activity that requires special skill and resources
and provides particular benefits. Consistent effort is required, which involves
gaining knowledge, learning techniques, and developing specific skill sets to
engage safely in BDSM, along with the effort invested in planning, shopping
for equipment, constructing toys and equipment, and creating costumes, along
with practitioners’ descriptions of BDSM as fun, games, and play.
BDSM should be viewed as carefully planned serious leisure for the purpose
of exploring psychological and bodily sensations. Rather than conceptualising
BDSM as immoral and dangerous, it should be perceived as unconventional
and unusual (Williams, 2009). A comparison of BDSM with extreme sports
is pertinent here; indeed, leisure in the form of contact sports such as rugby
and boxing is not considered deviant, nor is it pathologised. It is the inher-
ently erotic and adult nature of BDSM that causes such unfounded reactions,
and, if BDSM was reconceptualised as serious leisure, it would lend support
to the argument against pathologisation (Turley, 2012). Parallels do appear to
exist between BDSM and extreme sports. The seeking of thrill and sensation by
extreme sports enthusiasts described by Zuckerman (1994) could also be applied
to practitioners of BDSM. Sensation seeking is characterised by the desire to
experience novel, varied, and intense sensations coupled with a willingness to
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.
Implications for counselling and therapy
Several ‘kink-friendly’ counselling and psychotherapy services have emerged
in contrast to the general misconceptions around BDSM espoused in the coun-
selling and therapeutic literature. Barker et al. (2007) reported that, in the main,
BDSM was largely ignored in texts written for counsellors and psychotherapists.
When it was included, however, the dominant psycho-medical discourses were
reproduced, assuming that an interest or participation in BDSM was unhealthy,
a result of childhood or family trauma or abuse, or assuming BDSM was abuse.
Other research details that therapists had asked clients to refrain from par-
ticipating in any BDSM-related behaviour (Kolmes et al., 2006). Confusion
regarding BDSM abounds in many therapeutic settings, as therapists and coun-
sellors rely on reproduced dominant discourses from their training, or general
misinformation in the lay media. Therapists often presume that the central
focus of BDSM is always pain and always about sex, and it was also presumed
that the adopted sexual roles are always static and fixed, rather than fluid, as
is often the case in BDSM (Barker et al., 2007; Diamond, 2009). Kolmes et al.
(2006) did encounter a number of more positive examples of good practice
during their study of BDSM clients engaging with therapy. They reported that
some therapists were open to and prepared to learn about BDSM, and were
comfortable with discussing BDSM and related activities along with promoting
safe BDSM for all involved.
Kolmes et al. (2006) highlight that, until BDSM is routinely taught as an
acceptable form of sexual expression during training, the relationship between
client, BDSM, and therapist may remain challenging. Along with enhanced
training, enabling therapists to recognise and understand their own beliefs and
judgements relating to BDSM is an important step towards acceptance and com-
prehension of clients’ interests. It is also worth noting that some therapeutic
models and approaches are more suited to working with clients with an inter-
est in BDSM due to their inherent underpinnings. Such approaches to therapy
would be less pathologising and more accepting of BDSM from the outset of
therapy (Barker et al., 2007).
Implications for discrimination

Given that psycho-medical discourse regarding BDSM informs public and lay
opinion, it is unsurprising that the general perception of BDSM is far from
favourable. Consolidating this view is the unclear position of BDSM and the
36 Sexuality
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.
The process of researching BDSM can lead to some unexpected issues

that researchers may not have encountered previously. The first author
experienced wide-ranging prejudice when conducting research on the
eroticism of BDSM; this stemmed from a number of sources, including

work colleagues, fellow researchers and various ethical review panels.
Presuppositions about the nature of BDSM and those involved in the
scene may influence others’ reactions to research and researchers in this
area. Potential participants and BDSM practitioners may question the
researcher’s position as ‘insider’ or ‘outsider’ (whether or not they are
involved in the BDSM culture), and this may affect participant reactions
and responses. Above all, it is important to adopt an open-minded and
non-judgemental attitude when investigating this topic, as this is likely
to lead to more successful and interesting research.
Future directions
Gayle Rubin (1984) proposed a distinction between what constituted acceptable

and unacceptable sex. Along with promiscuity, homosexuality, and cross-
generational sex, SM was clearly in the second category. It is clear that some
things have changed in the intervening 30 years. So, provided gay people live
in couples, preferably in civil partnerships, they have moved into the favoured
category.
Plummer (1995) suggested how ‘sexual stories’ proliferate and become
accepted. This process requires interviewers or counsellors who help people to
tell their stories, media in which the stories can flourish, and a receptive audi-
ence who can reframe their own experience in these terms. Some stories clearly
‘have their time’ and take off when those in the receptive audience reproduce
their own accounts. Plummer notes that, at the end of the twentieth century,
there appeared to be a proliferation of BDSM stories.
Nearly a decade later, Langdridge and Butt (2004) found little evidence of
a take-off velocity of such a sexual story. Following Weeks (1998), they note
the importance of a transgressive moment in the achievement of sexual citi-
zenship. They point out that the problem with BDSM is that it makes sexual
violence centre stage. Nothing is more taboo, and it is indeed a transgressive
moment. We have emphasised here that this is why the BDSM community
makes consensuality such a priority. The explicit nature of consent arguably
makes coercion less likely than in vanilla sex.
However, BDSM awareness serves to underline the possibility of sexual excite-
ment in power and control, albeit in fantasy (Turley, 2012). As Langdridge and
Butt (2004) observe, this leaves society in the uncomfortable position of ques-
tioning the motivations of those in positions of power. We begin to wonder
whether, for example, the beating teacher might get some secret or uncon-
scious delight out of exercising punishment. So, how can we confidently cede
authority to anyone if this is the case? How can we ever be sure their motives
are ‘clean’? Of course, the knowledge that people enjoy cruelty is not new (see
38 Sexuality
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
The term ‘bisexual’ is generally used in minority Western cultures to refer to

an individual who experiences sexual attraction to more than one gender –
or whose attractions are based on characteristics other than gender (e.g. build
or eye colour). As we will show in this chapter, psychology is deeply impli-
cated in the construction of current cultural understandings of bisexuality.
Within these understandings, gender and sexuality are most commonly con-
ceptualised as entirely dichotomous: ‘man’ and ‘woman’ and ‘homosexual’
and ‘heterosexual’ are understood to be distinct from, and opposite to, each
other. Bisexuality has been particularly problematic for researchers and aca-
demics because they have found it challenging to make bisexuality fit this
model of sexuality, which has its roots in the work of early sexologists and
has since gained scientific and cultural currency (Angelides, 2001; Firestein,
1996; Storr, 1999). Consequently, bisexuality has often been invalidated or sim-
ply overlooked by sexologists, psychologists, and social scientists more widely.
In this chapter we outline a brief history of how bisexuality has been con-
ceptualised within psychology and the social sciences before turning to more
recent research, issues, and debates. We end with recommendations for future
directions for research.
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
bisexuality, but also media representations of bisexual people and pop-

ular understandings of what it means to be attracted to people of more
than one gender. As this chapter shows, bisexuality has often been disre-
garded or dismissed in psychological literature, and this has also resulted
in the exclusion of discussions of bisexuality from textbooks aimed at
students of psychology (Barker, 2007).
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
(1914/2000), Havelock Ellis (1897/2004), and Freud (1905/1962) (Bullough,

1994).
Bisexuality as a primitive ancestral state

German-Austrian psychiatrist and sex researcher Richard von Krafft-Ebing
(1840–1902) was influenced by Ulrichs and also theorised homosexuality as
a form of inverted masculinity/femininity. He agreed with Ulrichs that all
human embryos are hermaphroditic during the early stage of development,
and that they become one sex or the other as they mature. Where Krafft-Ebing
differed from Ulrichs was that he saw bisexuality as part of the evolutionary
process, suggesting the possibility that humans’ evolutionary ancestors were
hermaphrodites (or bisexual people), and that bisexuality was therefore a pre-
developmental (or immature) state, or starting point, the root from which all
other sexualities evolved. In this way, Krafft-Ebing understood bisexuality as
a regression to a primitive ancestral state or lower life form that preceded
being attracted to only men or only women (Angelides, 2001; Oosterhuis,
2000).
The pathologisation of (bi)sexuality

For Krafft-Ebing and his contemporaries, then, any sexual activity that fell
outside the tightly constrained boundaries of heterosexual reproductive sex
was degenerate and pathological, and required explanation. So far, non-
heterosexual desires and practices had been theorised in terms of deviant
practices whose genesis lay in biological and/or psychologically rooted gen-
der variance. During this era, homosexuality continued to be pathologised and
psychologised, but as a sickness or mental illness rather than a form of deviance
(Weeks, 1989).
The theories of Sigmund Freud (1856–1939) were enormously influential in
shifting the theoretical terrain from biological to psychological aetiologies of
non-heterosexualities (Fox, 1995). Like Ulrichs and Krafft-Ebing, Freud’s ear-
lier work referred to psychic hermaphroditism as a combination of masculinity
and femininity. His work, like that of his contemporaries, initially theorised
bisexuality as the root of all sexualities, and he believed that all humans were by
nature bisexual, or had a bisexual disposition (Young-Bruehl, 2001). However,
he believed that, in the absence of psychological malfunction, most people
would resolve or repress their same-sex attractions during the Oedipal phase
and become heterosexual. Thus, while he theorised that everyone had bisexual
potential, in ‘normal’ social and psychological development the expectation
was that sexual attraction would become focused on the ‘opposite’ gender.
Bisexuality, like homosexuality, was thus a failure of psychosexual development
(Fairyington, 2008).
The emergence of (bi)sexual identity

The publications of these early sexologists show that by the early 1900s the
terms ‘psychic hermaphrodite’ and ‘bisexual’ were used to refer both to some-
one with the characteristics of males and females and to someone who was
sexually attracted to males and females. However, sexologists had begun to
move away from theorising sexual behaviour and towards describing sexual
identities:
Homosexuality appeared as one of the forms of sexuality when it was trans-

posed from the practice of sodomy onto a kind of interior androgyny [ . . . ]
The sodomite had been a temporary aberration; the homosexual was now a
species.
(Foucault, 1978, p. 43)
As part of this process of specification, bisexuality, along with homosexuality

and heterosexuality, began to emerge as a category of sexual identity. British
sex researcher Henry Havelock Ellis (1859–1939), for example, noted that
[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)
Similarly, the often overlooked German physician and pioneering homosexual

sexologist Magnus Hirschfeld (1868–1935) understood bisexuality to be about
love and desire for members of both sexes. This, too, reflects the turn towards
theorising sexual attraction and identity rather than masculinities and femi-
ninities (Brennan & Hegarty, 2007; Bullough, 1994). By the 1890s, Freud also
theorised bisexuality as an identity:
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
Early sexologists’ and psychoanalysts’ theories were complex and their

ideas often changed as their work developed and evolved. To summarise,
their early theorisations included understandings of bisexuality as a form of
homosexuality; as a predevelopmental (or immature) state; as a biological or
psychological failure to become attracted to only one gender; and as a distinct
form of sexual identity. It is clear to see how these understandings underpin and
inform contemporary (and often negative) conceptualisations of bisexuality.
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:
Males do not represent two discrete populations, heterosexual and homo-

sexual. The world is not to be divided into sheep and goats. Not all things
are black nor all things white. It is a fundamental of taxonomy that nature
rarely deals with discrete categories. Only the human mind invents cate-
gories and tries to force facts into separated pigeon-holes. The living world
is a continuum in each and every one of its aspects. The sooner we learn
this concerning human sexual behaviour the sooner we shall reach a sound
understanding of the realities of sex.
(Kinsey et al., 1948, p. 639)
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
discussed bisexuality per se (Bullough, 1994, 2004), Kinsey clearly acknowl-

edged the potential for individuals to be attracted to more than one gender,
and laid the ground for an understanding of sexual attraction and behaviour as
nuanced and fluid.
Early ‘gay-affirmative’ psychological research
During the 1950s, the first ‘gay-affirmative’ psychological research began to
emerge. For example, the clinical psychologist Evelyn Hooker (1907–1996)
conducted hugely influential research that challenged the notion that homo-
sexual people were mentally disordered/morally deviant (Hooker, 1957, see also
Riggs, Gay Men, this volume). Her research was a key factor in the removal
of homosexuality from the American Psychiatric Association’s (APA’s) Diagnos-
tic and Statistical Manual (DSM) (Bullough, 1994; Kimmel & Garnets, 2003).
Hooker’s research, along with June Hopkins’ (1969) similar ‘lesbian-affirmative’
research, eliminated bisexuality or collapsed bisexual identities into homo-
sexual and heterosexual ones (see also Ellis, Lesbian Psychology, this volume).
Nonetheless, this work is important to mention because it paved the way for
less negative conceptualisations, and what followed were studies of homosexual
identity development such as that by Cass (1979). However, these developmen-
tal theories often excluded bisexuality, or saw it as a stage of the ‘coming out’
process where the final destination was homosexual. As Fox (1995, p. 20) notes,
while homosexuality was now (to some extent) de-pathologised, the “tradi-
tional psychiatric position that sexual relationships with both men and women
are an indicator of immaturity and psychopathology” prevailed.
Overlooking bisexuality: Sex research and sex surveys of

the 1970s and 1980s
Despite the potential of Kinsey’s theories to eliminate binary categorisations,
subsequent sexologists continued to view sexuality as mainly dichotomous.
The large-scale sex surveys of the 1970s and 1980s either ignored bisexuality
altogether, dismissed it as fraudulent, or made only passing references to its
existence (see, for example, Cory & LeRoy, 1963; Hite, 1976/2000; Janus &
Janus, 1993; Masters & Johnson, 1966/1981, 1979; Schäfer, 1976).
In the early 1980s, researchers such as Paul (1985/2000) and MacDonald
(1981, 1983/2000) began to critique the dichotomous approach to sex research,
arguing that it had “imparted an artificial consistency to an inchoate sex-
ual universe” (Paul, 1985/2000, p. 11). Such research, they noted, faced
with sexual biographies that did not fit the now-hegemonic dichotomous
model, explained away bisexual behaviour, so that, rather than addressing
the deficits of sexological theory and research, blame was transferred to the
desiring subject, and bisexual desire and behaviour were accounted for either
as a transitory phase, as evidence of psychological disturbance, or as denial
48 Sexuality
of one’s ‘true’ homosexuality due to internalised homophobia (MacDonald,

1981).
This pathologisation and repudiation of bisexuality was magnified and
refracted by the HIV/AIDS crisis of the 1980s, when behaviourally bisexual men
(men who have sex with men and women but do not necessarily self-identify
as bisexual) became seen as vectors of transmission to the heterosexual pop-
ulation (Rodríguez-Rust, 2000a, p. 540). A discussion of the epidemiological
literature on bisexuality and HIV falls outside the scope of this chapter, but see
Rodríguez-Rust (2000b) for an in-depth review of the development of this field.
Early ‘bisexual-affirmative’ research: Acknowledging, defining,

and ‘measuring’ bisexuality as a distinct identity
Just as the pathologisation of homosexuality had led to the early ‘gay-
affirmative’ research of Hooker and Hopkins, the cultural repudiation of
bisexuality led to the birth of bisexual-affirmative research, beginning in the
1970s (Rodríguez-Rust, 2000a, p. 335).
Whereas second-wave researchers had overlooked bisexuality, or conflated
it with homosexuality, in the way that Freud, Hirschfeld, and Ellis had done,
research now emerged that recognised bisexuality as different and distinct from
homosexuality. These researchers pointed out that research that conflated non-
heterosexualities with one another was bad not just for social scientific and
clinical understandings of bisexuality, but for sexuality in general (see, for
example, Bell et al., 1981; Blumstein & Schwartz, 1976; Bode, 1976; Klein,
1978).
What followed was a clear focus on defining and understanding bisexuality as
a distinct identity. Researchers such as Klein (1978), Zinik (1985), and Hansen
and Evans (1985) critiqued dichotomous models of sexuality for their fail-
ure to accommodate bisexuality with many developing alternative models
that drew attention to the complex and fluid nature of sexuality in gen-
eral, and bisexuality in particular. They argued that such models not only
made bisexuality invisible, but had serious negative implications for bisexual
people, who were portrayed in both psychology and popular culture as con-
fused, conflicted, undecided, in a temporary position between heterosexual
and homosexual, or in denial of their ‘true’ heterosexuality or homosexuality
(Zinik, 1985, p. 9). These negative conceptualisations of bisexuality as an illegit-
imate sexuality put pressure on bisexual people to affiliate with homosexuality
or heterosexuality (or to ‘choose a side’).
The US psychiatrist and sex researcher Fritz (Fred) Klein (1932–2006) made a
key contribution to this work. Klein estimated that there were 30 to 40 mil-
lion people in the United States who were attracted to and/or had sexual
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).
Becoming visible: 1990s research on bisexuality

By the early 1990s, bisexual people on both sides of the Atlantic had founded
their own political networks, and also established themselves as a constituency
within the lesbian and gay movement (Rodríguez-Rust, 2000a, pp. 544–547;
Rose et al., 1996).
Accordingly, the 1990s and early 2000s saw a literature explosion in both
activist and academic publications, and across a variety of disciplines in the
social sciences and humanities, from epistemology and literary criticism to
geography (see, for example, Bi Academic Intervention, 1997; Hemmings, 1998;
Rodríguez-Rust, 2000b; Storr, 1999).
In the social sciences, much empirical research focused on the boundaries
between bisexuality and other sexual identities, continuing the critiques of
dichotomous categorisations of sexuality that had begun in the late 1970s.
In the United States, for example, Rust1 conducted and published questionnaire
research with over 400 lesbian and bisexual women. The results of her survey
showed that, while the lesbian and bisexual women in her research differed
in their relationships and identifications, they shared much commonality in
their feelings of sexual attraction and sexual histories (Rust, 1995). Rust argued
that distinct categories of sexuality cannot capture the range of sexual feelings
and experiences, based on how lesbian and bisexual women in her research
differed in their relationships, but shared much commonality in their feelings
of sexual attraction (Rust, 1995). Rust, therefore, argued that distinct categories
of sexuality cannot capture the full range of sexual feelings and experiences.
50 Sexuality
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).
Bi-affirmative research in psychology since the year 2000

Since the end of the 1990s, social scientific research on bisexuality has con-
tinued to expand. The rise of the internet has facilitated co-operation between
researchers, communities, and individual bisexual people, and the period has
seen the emergence of bodies such as the American Institute of Bisexuality,
founded in 1998, which promotes and funds research on bisexuality in the
United States and abroad. Since 2000, its official journal, the Journal of
Bisexuality, has enabled researchers to publish and disseminate their work in
a publication dedicated specifically to the topic, and has been a key inter-
national platform for much recent psychological work on the subject. In the
United Kingdom, meanwhile, a group of researchers led by Meg Barker and
Christina Richards formed BiUK, a national organisation for bisexual research
(established around 2004; see Barker, 2004; Barker et al., 2008), which has run
a biennial day conference on bisexual research since 2008 and which published
The bisexuality report in 2012 (Barker et al., 2012a).
As a result of the rise of social constructionist and critical approaches to

psychology, the first years of the twenty-first century have seen the emer-
gence of a range of qualitative work on bisexual identity development and
maintenance. This research, mainly focused on the experiences of bisexual
women, and often published in the Journal of Bisexuality, has used qualita-
tive research methods including discourse analysis to explore the difficulties
of articulating a coherent bisexual identity in the context of a dichotomous
system of sex/gender/sexuality (Ault, 1996; Berenson, 2002; Bower et al., 2002;
Bowes-Catton, 2007). Other Australian and UK research has taken a qualitative
approach to exploring individual bisexual people’s understandings and lived
experiences of their bisexuality, which often continue to include experiencing
biphobia and marginalisation from both the heterosexual and LGB communi-
ties (see, for example, Hayfield et al., 2013, 2014; McLean, 2004, 2007, 2008a,
2008b).
The mid-2000s saw the emergence of a body of UK-based qualitative
research by Barker and colleagues, which engaged bisexual communities
and explored their experiences of bisexuality in the context of commu-
nity spaces. Working from a standpoint perspective, these writers have often
focused on the agendas of activist communities and worked with these groups
to build links between activists, academics, clinicians, government bodies,
and the voluntary sector (see, for example, Barker & Yockney, 2004; Barker
et al., 2008, 2012a; Bowes-Catton et al., 2011; Jones, 2012; Voss et al.,
2014).
Meanwhile, traditional quantitative and lab-based psychological research has
continued to make important contributions to scientific understanding of the
relationships between desire, experience, and subjectivity.
Diamond (1998, 2008), for example, employed survey methodology to exam-
ine bisexual women’s identity from a longitudinal perspective. This research
aimed to address continuing psychological debates about whether bisexuality
should be understood as a stable sexual identity, a capacity for sexual flu-
idity (whereby women are theorised to have the potential for fluidity in
terms of the gender that they are attracted to), or a transitional phase. Tak-
ing place over a decade, the survey consisted of telephone interviews with
79 non-heterosexual women about their attractions, behaviours, and self-
identifications. Diamond found that, while her participants continued to be
attracted to more than one gender over the course of the study, two-thirds
of her participants changed their sexual identifications during the study, with
a third doing so more than once (Diamond, 2008). Most of the participants
who changed their self-identification moved between the categories ‘bisexual’
and ‘unlabelled’, and very few changed their sexual self-identity to ‘lesbian’
or ‘heterosexual’. Diamond’s results, therefore, provided support for psycho-
logical understandings of bisexuality as a ‘third’ sexual identity or a capacity
of fluidity, but undermined stereotypical constructions of bisexual women as
52 Sexuality
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.
Important points for applied practitioners
Research has consistently demonstrated that bisexual people suffer from

worse mental health outcomes than other sexual minority groups (Jorm
et al., 2002; King & McKeown, 2003). Lack of public understanding of
bisexuality may mean that bisexual individuals experience greater levels
of minority stress than lesbian and gay people, whose sexualities are often
seen as more ‘authentic’ (Angelides, 2001). Like other minority groups,
bisexuals who experience multiple marginalisations may find that minor-
ity stress is particularly acute in settings where they are unable to express
all of their identities.
Research also suggests that these difficulties are sometimes com-
pounded by negative experiences with mental health practitioners with
stereotyped views of bisexuality (Moon, 2010). For example, it has
been suggested that such stereotypes may lead to the over-diagnosis of
Borderline Personality Disorder/Emotionally Unstable Personality Disor-
der among non-monogamous bisexual women (Walters et al., 2012).
Practitioners working with bisexual clients need to be aware of the
importance of accepting and affirming clients’ stated sexual identities,
regardless of whether they correspond with sexual behaviours.
Current debates, implications, and future directions
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.
Researching beyond the organised bi community

As highlighted above, researchers have often drawn on bisexual communi-
ties when conducting their research. This has also meant that those bisexual
people who are not involved in communities or activisms may be less well rep-
resented in the academic literature. In order to improve the intersectionality,
representativeness, and scope of psychological research into bisexuality, it will
be necessary for psychologists to move beyond the ‘comfort zone’ of organised
bisexual communities, and seek out new ways of engaging with the concerns
and agendas of people outside them. Some of this work has already begun.
Anderson and colleagues, for example, have successfully recruited participants
in street settings (Ripley et al., 2011, p. 202), while one of the present authors
made use of local press to recruit participants who were not involved with
bisexual communities (Hayfield, 2011).
Academics researching bisexuality should ensure that they avoid com-

pounding bisexual erasure, address bisexuality separately from other
minority identities and familiarise themselves with issues currently of
concern to bisexual people. Future psychological research into bisexuality
will need to take into account the impact of intersections of race, class
and other identities on bisexual people’s experiences and well-being. For
more detailed guidance on researching and writing about bisexuality, see
Barker et al. (2012b).
Summary
• Psychology has played a key role in producing current popular understand-

ings of bisexualities, which are often negative.
• Psychological research has often overlooked, dismissed, or erased bisexuality.

• A substantial body of bisexual-affirmative psychological research has
emerged since the 1980s.
• Bisexual people continue to experience marginalisation and poor mental
health outcomes.
• Psychological work on bisexuality needs to move beyond bisexual
communities and engage with issues of intersectionality and multiple
marginalisation.
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.
Rodríguez-Rust, P. (Ed.) (2000b). Bisexuality in the United States: A social science reader.
New York: Columbia University Press.
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Ault, A. (1996). Ambiguous identity in an unambiguous sex/gender structure: The case of
bisexual women. Sociological Quarterly, 37(3), 449–463.
Barker, M. (2004). Including the B-word: Reflections on the place of bisexuality within
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Barker, M. (2007). Heteronormativity and the exclusion of bisexuality in psychology.
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bisexuality: A snapshot of bisexual identities in the United Kingdom. Journal of
Bisexuality, 8(1), 141–162.
56 Sexuality
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4
Further Sexualities
Christina Richards
Introduction
Human sexuality consists of a great variety of practices and identities pursued

with differing levels of passion and vigour and which are classed with differing
degrees of moral, political, and personal acceptance or opprobrium accord-
ing to time and place (Laws & Donohue, 2008). While many cultures and
moral/ethical systems assert that their boundaries around what is acceptable
and what is not are drawn from some firmament of truth – be it ecclesiasti-
cal, pragmatic, natural, historical, etc. – practices and identities, nonetheless,
inevitably vary and intersect in ways which people within those cultures may
find difficult to comprehend. As cultural anthropologist Gayle Rubin writes,
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)
Consider the accepted norms of bigamy and monogamy; genital mutilation;

penis-in-vagina (PiV1 ) sex; heterosexual and gay anal sex; fellatio; cunnilingus;
BDSM2 ; and so on. All of these are considered to be acceptable practices or iden-
tities in some cultures and times and to be taboo in others. Thus, the definition
of what constitutes a ‘further sexuality’ is rather complex and is bound to both
time and place (cf. Bhugra et al., 2010).
Somewhat tautologically, then, this chapter considers those sexualities that
do not fall fully within other chapters of this handbook as they are not so
‘mainstream’. Examples of such sexualities might include attraction to nature
(which Ellis, 1919, in a rather wonderful mix of gentility and pathologisation,
called ‘hyperaesthetic weakness’ (p. 184)3 ); attraction to specific body parts;
enjoying being trodden upon; etc. Those used as exemplars in this chapter are
fetishism, ageplay and furry. It is important to recognise that these identities
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
broadly (perhaps with sexuality as a part of that; cf. wikifur.com). Generally,

people have a specific animal which they most identify with, not uncommonly
a fox, a wolf, or a cat (Gerbasi et al., 2008), although many other animals
are not uncommon, and in a related area some people identify as mystical
creatures (known as Otherkin) and may identify fairies, elves, etc. (referred to
collectively as Fae) or vampires (sanguinarians), werewolves, dragons, unicorns,
and the like.
People may dress in such a way as to effect the animal they identify with, for
example with the addition of ears, tails, etc., or, occasionally, full body suits.
Similarly, people who cross over with ageplay and identify with a young ani-
mal use the term babyfur and may have the relevant attire for a somewhat
anthropomorphised younger animal.
Quite often people will dress in the manner of the animal they identify with
second most so as not to be disappointed by the necessarily limited approx-
imation of their preferred animal. Only in extremely rare cases are surgical
alterations undertaken. People engaged with furry identities and practices may
meet online or in person, sometimes at cosplay events in which people get
together to enjoy one another’s company in ‘costumes’. These events are gener-
ally non-sexual. Sex between furry-identified people may be called yiffing (after
the noise of the arctic fox7 ), whereas non-sexual scratching sensations may be
called scritching – a term which is entering into more general usage.
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
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
Further sexualities are often prohibited by religious edict or exegesis, and,
indeed, it has been argued that much of the current medicalisation of
‘paraphilias’ has been as a result of the secularisation of such ‘sin’ into a med-
ical discourse (Bullough & Bullough, 1977). This was driven by such works as
Krafft-Ebing’s (1886) Psychopathia sexualis: Eine klinisch-forensische studie (Sex-
ual psychopathy: A clinical-forensic study); Ellis’s (1897–1928) seven-volume
series Studies in the Psychology of Sex; and Hirschfeld’s (1938) Sexual Anomalies
and Perversions. More recently, there have been contentions around whether
there should be any medical intervention at all into some sexuality and gen-
der matters – as in the imbroglio14 over masturbation; ‘nymphomania’; the
removal of homosexuality from the Diagnostic and Statistical Manual (DSM)
III (Minton, 2002); and again in the recent (failed) attempt to remove gen-
der dysphoria from the DSM 5 (Karasic & Drescher, 2005). Thus, as sin moves
into medicine and out of ecclesiastical delineation it has become ‘perversion’
(Morgan & Ruszczynski, 2006) or ‘paraphilia’, as in the American Psychiatric
Association’s (APA) DSM, Version 5 (APA, 2013) and the World Health Organi-
zation’s (WHO) International Classification of Diseases (ICD) Version 10 (WHO,
1992). As further sexualities are (apparently) somewhat uncommon, only fetish
is coded specifically (as Fetishistic Disorder in the DSM 5), whereas furry and
ageplay would be Other Specified Paraphilic Disorder or Unspecified Paraphilic
Disorder (APA, 2013). In addition, common practices and identities such as
BDSM/kink (as Sexual Sadism Disorder and Sexual Masochism Disorder) and
‘transvestism’ (as Transvestic Disorder) are also classified as paraphilias within
the DSM 5, but are so common as to have their own chapters in this handbook
(see also Murjan & Bouman, Trans Genders and Lenihan, Kainth, & Dundas,
Trans Sexualities, this volume).
Historically, people have sought treatment for ‘perversions’ ‘deviance’, or
paraphilias’, sometimes because they were asked to by friends and family
(Crown, 1983); sometimes because there was a problem which needed address-
ing (as in the clinical literatures; Junginger, 1997); and sometimes because the
person felt that they were in need of treatment due to social opprobrium
when, in fact, their sexuality was harmless (Richards & Barker, 2013). Such
treatments have included aversion ‘therapy’, which paired the erotic stimuli
with an aversive stimulus through classical conditioning aimed at making the
erotic stimuli aversive. These ‘therapies’ included using electric shocks (Marks &
Gelder, 1967; Marks et al., 1965), nausea (Raymond, 1956), and foul odours
(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
2014; Understanding Infantilism, 2014), whereas the clinical literature tends

to concentrate on psychopathology (e.g. Pate & Gabbard, 2003; Pettit & Barr,
1980). This quite commonly leads to the clinician illusion, in which clinicians
assume that all people of a certain group have psychological problems because
everyone from that group they see has such problems. Of course, if we are
clinicians we will necessarily only see troubled people, unless we actively seek
out people from outside our clinical practice – for example in community
settings.
Minority stress may also play a part in this difference between clinical and
community samples, with psychopathology such as anxiety and depression
reducing when people find community and broader social support. This is one
of the key arguments for removal of the (non-coercive) paraphilias from the
DSM and ICD – that, as with the removal of homosexuality from the DSM in
1973 and the ICD in 1992, when differing practices and identities are seen as
part of ordinary human variation the people engaging with those practices are
generally better off socially and so psychologically (Moser & Kleinplatz, 2005).
Academic psychologists should carefully determine, and explicitly

delineate, the groups under investigation when researching further
sexualities – being especially careful not to elide forensic, clinical, and
population samples.
Ideally, research should be done with the communities themselves
involved so as to avoid unforeseen ethical stumbling blocks and to re-
enfranchise these oft-marginalised groups – see Barker et al. (2012) for
guidelines on researching bisexuality, which may be adapted.
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
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.
Further sexualities may be an especially interesting topic to consider writ-

ing about or researching; however, it is vital to consider who will benefit
from your work – if it is only you, then that is a form of exploitation.
Beware of the ‘giving a voice’ trope as it can have unsavoury power impli-
cations, especially if you are not a member of the groups being researched
(cf. Richards et al., 2014).
That said, be cautious also if you are a member of the group being
researched, as when authors are members of marginalised communities
and have necessarily had to fight to attain their position it can be all too
easy to present information, or to interpret results, in a manner which is
in line with your own identity or practices, but may be at odds with the
community’s and/or your participants.
68 Sexuality
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:
1. those which may be transgressive, but are not inherently coercive:

Voyeuristic Disorder; Exhibitionistic Disorder; Frotteuristic Disorder; Sex-
ual Masochism Disorder; Sexual Sadism Disorder; Fetishistic Disorder;
Transvestic Disorder;
2. those for which transgression and coercion are dependent on specifics; Other
Specified Paraphilic Disorder; Unspecified Paraphilic Disorder;
3. and that which is necessarily coercive; Paedophilic Disorder.
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
A paraphilic disorder20 is a paraphilia that is currently causing distress or

impairment to the individual or a paraphilia whose satisfaction has entailed
personal harm, or risk of harm, to others. A paraphilia is a necessary but
not sufficient condition for having a paraphilic disorder, and a paraphilia by
itself does not necessarily justify or require clinical intervention.
(APA, 2013, pp. 685–686)
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.
Where do such sexualities stand, then, pathologised as they often remain, in

terms of their place within the wider world? Certainly, some aspects of further
sexualities have always been at least somewhat within the mainstream, as we
have seen above, while other aspects are slowly gaining acceptance. The large
crossover with BDSM and fetish (for example, one may wear certain materials,
such as leather or rubber, in both; cf. Langdridge & Barker, 2007), as well as
BDSM and ageplay (for example, one may enjoy being dominated and cared
for, etc., in both; cf. Hawkinson & Zamboni, 2014), means that, as BDSM gains
further acceptance (as with the Fifty Shades of Grey publishing phenomenon21 ;
James, 2012), so do some aspects of further sexualities associated with it. These
70 Sexuality
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
causing distress and/or harm, but who nonetheless require interventions

for unrelated, or interrelated, matters. This is especially the case when
the client is subject to minority stress (depression and/or anxiety derived
from being in a minority which suffers from prejudice and social oppro-
brium; cf. Bouman et al., 2010). For example, clients who engage with
ageplay are often subject to negative depictions in popular culture which
can damage self-esteem and cause anxiety or depression, and may pre-
vent people who engage with ageplay accessing the usual professional
assistance which people from other groups might readily utilise.
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 . . . .
15. Note the ‘on’, rather than ‘with’ . . . .

16. Adult baby/diaper lover.
17. I understand that the assumptions inherent in this sentence are culturally bound,
but if we have too many iterations of cultural epoché and reflection here we’ll
end up with a Cultural Studies reader and I shall have to hand back my psychol-
ogy department tweed jacket (which would never do, as I’ve just had the elbows
repatched).
18. Homosexuality is used here as an aid to understanding. It is not considered to be a
‘paraphilia’.
19. For clarity, gaming is not a paraphilia either . . . .
20. Note the use of ‘disorder’ here – the APA differentiates between a paraphilia and a
paraphilic disorder.
21. See Barker (2013) for a consideration of the complexities of this.
22. And perhaps ebb and flow over time within societies as well. Krafft-Ebing (1906), for
example, writes: “Lovers of female handkerchiefs are frequent, and, therefore, impor-
tant forensically” (p. 255), whereas this is now almost unheard of. (Although perhaps
it will have a renaissance; one can never tell with sexuality – consider corsets).
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.
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.
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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
outlining historical research on the topic suggests, how intimacies between

men became understood as representing an identity category (i.e. ‘the homo-
sexual’) requires ongoing attention. This need for ongoing attention stems from
the fact that the category ‘gay men’ is often so over-determined that it becomes
difficult to talk about such men other than through highly regulated discourses
of sex assignation, sexual orientation, and gender role. The fact that such dis-
courses are perpetuated as much within gay men’s communities as they are
within academic research and psychological practice is a matter that will be
addressed throughout this chapter. With this point in mind, the chapter pro-
ceeds by using the category ‘gay men’ as a marker both of the diverse and
heterogeneous ways men who engage in intimacies with other men experience
their lives, as well as a marker of the category itself and the homogeneity it pre-
sumes. Mapping out these two, disparate forms of markers is thus the task of
this chapter, with a specific focus on the implications for future psychological
research and practice.
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
response to a child’s separation from their mother, and the imposition of an

external law as imposed by the father. The post-Freudian emphasis upon ‘strong
mothers and weak fathers’ as the ‘cause’ of homosexuality is thus a significant
(and, it could be argued, wilful) misinterpretation of Freud’s work. Instead, and
as the excellent table reproduced below from Lewes suggests, ‘homosexuality’ is
but one of the many differing compromise formations possible when becoming
a human subject involves settling for something that approximates the object
of one’s desire (Figure 5.1).
Importantly, and as Lewes’ table notes, both heterosexuality and
homosexuality are compromise formations. Also of note is the way in which
Lewes’ summary of Freud’s work challenges the conflation of homosexuality
with passivity or femininity. This issue will be given further attention in the
following section.
Instinctual aim: Passive Active
Identification: Mother Father
Castrated Phallic
1) Heterosexual 2) Heterosexual 3) Heterosexual
Castrated
Passive Active Active
Heterosexual
Feminine Feminine Masculine
Mother
Anaclitic Anaclitic Anaclitic

4) Heterosexual 5) Heterosexual 6) Heterosexual
Passive Active Active Anaclitic
Phallic

7) Homosexual 8) Homosexual 9) Homosexual
Father

Homosexual

Model of object choice: Narcissistic
10) Homosexual 11) Homosexual 12) Homosexual

Self

Object:
Narcissistic Narcissistic Narcissistic

Sexual orientation:
Social stance: Feminine Masculine
Sexual position: Passive Active
Figure 5.1 Lewes’ (1988) sexual results of the Oedipus complex as determined by
identification (or instinctual aim) and object choices
80 Sexuality
In regard to whether or not intimacy between men constitutes pathol-

ogy, then, we can see that early sexologists and psychiatrists did not view
homosexuality in this way. Other early sexologists, such as Havelock Ellis,
similarly refuted the belief that homosexuality constituted pathology, instead
viewing it as a ‘biological anomaly, akin to colour blindness’ (Clarke et al., 2010,
p. 9). While such recourse to biological determinism has been critiqued for its
normalising effects (e.g. Hegarty, 1997), it continues to be utilised in many
sectors to provide what are treated as aetiological accounts of homosexuality
(for example in LeVay’s 1993 claim that gay men’s brains are fundamentally
different from heterosexual men’s brains).
Yet, while early sexologists and psychiatrists viewed homosexuality as a part
of natural human sexual variation, throughout the mid-twentieth century a
considerable body of psychological research (in part drawing upon misinter-
pretations of Freud’s work) viewed homosexuality as a sign of deviance and,
thus, pathology. As a result, homosexuality was included as a disorder within
the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM)
up until 1973. This inclusion warranted research into the lives of gay men that
affirmed this pathologising approach, the legacy of which remains today. Even
when homosexuality was removed from the third edition of the DSM (III-R),
the diagnosis of ‘ego-dystonic homosexuality’ was retained in the first ver-
sion of the fourth edition. This diagnosis was putatively applied to men for
whom their desire for other men was experienced as distressing; however, it
was later argued that such distress is largely the product of the homophobic
and heteronormative cultural milieu in which gay men live, hence its removal
from subsequent editions of the DSM.
At the same time as homosexuality was removed from the DSM, how-
ever, the diagnosis of ‘gender identity disorder’ was introduced, a diagnosis
intended to acknowledge the distress experienced by people whose gender
identity differs from that normatively expected of their natally assigned sex.
While debates over the legitimacy of the inclusion of this diagnosis con-
tinue (the diagnosis is currently known as ‘gender dysphoria’ in the fifth
edition of the DSM – for more, see the chapter in this book on trans),
some have argued that gender identity disorder was introduced as a way
of ‘correcting’ the gender non-conforming behaviours of young children
(e.g. Corbett, 1996). While subsequent writers have refuted this claim (e.g.
Zucker & Spitzer, 2005), the addition and removal of these diagnoses high-
lights the ongoing role that psychiatry in particular plays in adjudicating
over the lives of non-gender-normative and non-heterosexual people. This
explains, at least in part, why psychological and psychiatric research, even
when it is not explicitly pathologising, still typically adopts highly normalis-
ing accounts of gay men as ‘effeminate’, an issue examined in the following
section.
Damien W. Riggs 81
As has been highlighted already in this chapter, much of the psychological

research on gay men to date has either been preoccupied with, or accepted
a priori, the claim that gay men are effeminate. This claim is based on the
assumption that men’s ‘normal’ sexual desire should be directed towards
women (and ‘normal’ sexual desire for women is constituted by desire for men).
Within such a logic, then, men who desire men are likened to women who
desire men, and therefore must be effeminate. What this ignores is the fact that
‘femininity’ is not an inherent characteristic of women; that ‘normal desire’ is a
social construction; and that gay men undertake a range of gender expressions
not predetermined by notions of femininity.
Perhaps the most important piece of psychological research that chal-
lenged this assumption of femininity (and passivity) among gay men was
the ground-breaking work of Evelyn Hooker (1957). Hooker identified a
matched non-clinical sample of homosexual and heterosexual men, and had
each man complete a number of “projective techniques, attitude scales, and
intensive life history interviews” (p. 20). Independent clinicians were then
asked to blindly rate each of the participants, focusing on both sympto-
mology and sexual orientation. The homosexual participants were no more
likely to be rated as showing pathological symptoms than were heterosex-
ual participants, and judges were not reliably able to identify one group
of participants from the other. Importantly, Hooker’s findings emphasised
that supposedly ‘homosexual cues’ – anality, open or disguised; avoidance
of areas usually designated as vaginal areas: articles of feminine clothing,
especially under-clothing, and/or art objects elaborated with unusual detail;
responses giving evidence of considerable sexual confusion, with castration
anxiety, and/or hostile or fearful attitudes toward women; evidence of fem-
inine cultural identification, and/or emotional involvement between males.
(p. 23) – were not unique to the sample of homosexual men, thus challeng-
ing the assumption that gay men had an inherent set of qualities marked by
femininity.
Another important study conducted somewhat more recently by Haslam
(1997) similarly indicated that the presumption of femininity among gay
men is unfounded. Responding to the supposition that gay men are categor-
ically different from heterosexual men in terms of their gender expression,
Haslam sought to identify whether a model of either continuity or contigu-
ity was more applicable to the case of male sexual orientation. One thousand,
one hundred and thirty-eight male participants (including heterosexual and
homosexual men) completed the Minnesota Multiphasic Personality Inventory-2
Masculinity-Femininity Scale. Through the use of sophisticated statistical mod-
elling, Haslam demonstrated that the overlaps between heterosexual and
82 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.
This chapter mentions a number of ways in which the assumption that

all gay men are feminine is reinforced. Additional examples of this might
be in the books and toys promoted and made available to boys, and for
adolescent and adult males, on social media such as Facebook or in ‘lads’
mags’. Research by Hansen-Miller and Gill (2011) suggests that, while
lads’ mags or ‘lad flicks’ (movies which target young men) tend to be less
explicitly homophobic than they were in the past (and may on occasion
Damien W. Riggs 83
include gay storylines or features), they primarily retain a narrative of gay

men as effeminate. Heterosexual masculinity, then, is constructed as all
that gay masculinity is not – it is seen as rugged, strong, and emotionally
distant. This binary of heterosexual and gay masculinity – as represented
in lads’ mags and lad flicks – thus presents yet another place where stereo-
types about gay men are perpetuated. While the claim that “it is all in
jest” is often used to dismiss the idea that stereotyped images of gay men
are offensive, it is nonetheless the case that caricatures of effeminate gay
men are often the butt of jokes in both lads’ mags and lad flicks.
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
Important points for applied psychologists and other practitioners
Brown (2007) makes an important point in his chapter on couples ther-

apy with gay men in regard to shame arising from both the effects of
abuse and the effects of discrimination. Brown emphasises the need to
acknowledge and work with shame as presented by gay clients, rather
than discounting it through the belief that shame should be separated
from a gay identity. In other words, Brown suggests that, in the rush to
affirm gay men, some applied psychologists and other practitioners may
shy away from talking about shame, in the presumption that in a just
society gay men should not be shamed on the basis of their sexual orien-
tation. Such a utopian approach, however, discounts the very real ways in
which many gay men experience shame, and that this must be acknowl-
edged and addressed in the therapeutic space. Kane (2004) takes this a
step further, in his discussion of whether or not gay applied psychologists
and other practitioners should disclose their sexual orientation to clients.
Kane suggests that, while typically there is an injunction to keep one’s
personal life separate from clients, in the case of gay applied psychologists
and other practitioners working with gay clients, it can be affirming for a
practitioner to disclose their sexual orientation. To do otherwise, it could
be suggested, may be taken by a gay client (who, for any given reason,
believes that their psychologist is gay, but who does not receive confirma-
tion of this from their psychologist) as an indication that homosexuality
is something to hide or to be ashamed of.
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
Other research on gay men’s relationships warrants attention in terms of

presenting issues in psychological practice. Parsons and colleagues (2013)
examined differences between gay men who were in monogamous relation-
ships, in open relationships, single, or in what they termed ‘monogamish’
relationships (i.e. relationships where the couple only had sex with other peo-
ple when both members of the couple were present, such as in threesomes –
see chapter on non-monogamous relationships for further details). Parsons and
colleagues found that men in monogamous relationships were less vulnerable
to health risks due to what was presumed to be exclusive sexual contact and less
drug use during sex. Interestingly, men in monogamish relationships reported
positive health outcomes similar to men in monogamous relationships when
compared with men in open relationships and single men. Parsons and col-
leagues suggest that this is because having sex with other people as a couple
potentially minimised the likelihood of unprotected anal intercourse happen-
ing with casual partners. Lacking from this research, however, was the inclusion
of men who were in polyamorous relationships. What the research findings do
suggest is the importance of acknowledging both the diverse relationship forms
that gay men enter into, and the differing needs and potential issues that may
come with each.
A final area relevant to clinical practice arising from empirical research on
gay men is the effects of norms of masculinity within gay men’s communities
upon gay men’s sense of self. Such norms, it has been suggested, impact upon
gay men in two ways (Filiault & Drummond, 2007). The first is to undermine
many gay men’s sense of self-esteem through the expectation that all gay men
should conform to a certain idealised body type (i.e. muscular). The second is
to contribute to the prevalence of eating disorders among gay men (the product
of another idealised body type – slimness – in addition to being associated with
a general emphasis upon body image). While some commentators have ques-
tioned the robustness of certain aspects of this empirical literature (e.g. Kane,
2009), it is nonetheless the case that gay men are more likely than heterosexual
men to present with issues related to eating disorders, and thus it is important
for clinicians to recognise how norms related to body image and masculinity are
as prevalent and regulated within gay men’s communities as they are dictated
to and imposed upon from outside gay men’s communities.
Future directions
In terms of future directions for psychological research, the findings sum-

marised above highlight the fact that more research is required into the diverse
ways in which gay men engage with discourses of masculinity. A key example
of this is in regard to transgender gay men. Research by Bockting et al. (2009)
and Scheifer (2006) suggests that, for some transgender men, being attracted
Damien W. Riggs 87
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).
Important points for researchers
As the findings reviewed in this chapter repeatedly demonstrate, prac-

tices of masculinity are as diverse among gay men as they are among
heterosexual men. This is particularly the case with regard to sex, where
the assumption that gay men who engage in receptive anal (or vaginal)
sex are passive or effeminate is challenged by empirical research. For
example, Kippax and Smith (2001) argue from their interview research
with Australian gay men that normative notions of insertor/insertee,
active/passive – particularly as they are shaped by normative discourses
of masculinity and femininity – are challenged by gay men, who negoti-
ate power dynamics in sexual encounters not necessarily on the basis of
which role each man undertakes in terms of sexual positions, but, rather,
their identification and object choice (thus illustrating the points made
in Lewes’ (1988) table reproduced above). Kippax and Smith’s findings
challenge researchers to go beyond normative accounts of power dynam-
ics in sexual relationships when attempting to understand the roles that
gay men take in the bedroom.
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
• While early sexological and psychological research sought a more inclu-

sive (if normalising) understanding of gay men, subsequent research in
many ways has both intentionally and unintentionally contributed to the
stereotype of gay men as effeminate.
• Empirical research, however, has challenged the binaries of homosex-
ual/heterosexual and effeminate/masculine as they circulate within Western
societies, and suggests a continuous rather than a categorical model of male
sexuality.
• Cultural stereotypes of gay men and gender non-conforming boys as effem-
inate have potentially contributed to some of the traumas, stressors, and
anxieties that gay men live with.
• Psychologists should be aware of the specific relational and individual issues
that gay men may present with, and refrain from attributing clinical distress
a priori to homosexuality.
• Gay men negotiate normative discourses of masculinity through resistance,
conformity, and subversion, but they do so as men living in societies where
men’s experiences are privileged.
• Normative understandings of masculinity may be wielded by some gay
men against other gay men in order to negotiate or manage their own
relationship with masculinity.
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.
References
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among female-to-male transsexuals in North America: Emergence of a transgender
sexuality. Archives of Sexual Behaviour, 38, 688–701.
Brady, S. (2008). The impact of sexual abuse on sexual identity formation in gay men.
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Brown, J. (2007). Therapy with same sex couples: Guidelines for embracing the subju-
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and Psychology Review, 3, 175–184.
Hansen-Miller, D. & Gill, R. (2011). ‘Lad flicks’: Discursive reconstructions of masculinity
in film. In H. Radner & R. Stringer (Eds.) Feminism at the Movies. New York: Routledge.
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6
Heterosexuality
Panteá Farvid
Introduction
Heterosexuality is both pervasive and normative in the current sociocultural

milieu. Due to its privileged societal status, heterosexuality is also (ironically)
quite elusive. Within the social science literature, heterosexuality is gener-
ally defined as a sexual or relational identity (belonging to individuals or
groups) and also as a social institution (which structures daily life). Histor-
ically, heterosexuality has largely been ignored in psychological theory and
research as a topic of, or for, analysis. Psychological theory has assumed
that heterosexuality is a ‘given’ and ‘normal’, and focused its research on
sexualities that sit outside this supposed norm (e.g. homosexuality, lesbianism).
Such research has functioned to further normalise heterosexuality, while
pathologising other ways of being sexual, without taking into account the
historical conditions that have produced heterosexuality as the ‘norm’. Psy-
chological research on heterosexual men and women has typically been carried
out in a completely taken-for-granted manner, with heterosexuality being over-
looked as a category of analysis and as a factor contributing to individual
psychologies and behaviours.
In this chapter, a brief history of the lack of psychological work on
heterosexuality is initially provided, followed by a comprehensive review of
the literature in the area of psychology (drawing also on materials from disci-
plines such as sociology, gender studies, history, and biology). Next, the current
debates in the field of psychology when it comes to theorising heterosexuality
are covered. This discussion encompasses mainstream and critical approaches
to understanding heterosexuality and delves into biological and social explana-
tions. Implications of these approaches are then discussed in terms of their
applicability to the wider world (e.g. social context, daily lives, daily prac-
tices, and social and relational identities/desires). Lastly, future directions for
research are highlighted, with an emphasis on approaches that (among other
92
Panteá Farvid 93
factors) take into consideration the social context for shaping something like
‘heterosexuality’.
History
Historically, heterosexuality as an object of analysis, in its own right, has not
been on psychology’s radar. There is a lack of research and theorising when it
comes to heterosexuality (as an institution, a sexual or relational identity, or
an everyday practice), within the history of psychology. Heterosexuality has
typically been approached as a natural ‘given’ and therefore largely escaped
analysis. What have been extensively investigated are non-heterosexualities,
which ostensibly violate the heterosexual norm. For example, homosexuality
remained in the Diagnostic and Statistical Manual of Mental Disorders until 1973
(see Riggs, Gay Men, this volume), indicating that it was firmly grounded as
a non-normative and pathological sexual orientation, even into the latter part
of the twentieth century. Heterosexuality has typically entered psychological
discourse only when describing the ‘other’ (e.g. in psychological research com-
paring ‘homosexuals’ and ‘heterosexuals’); however, the term ‘heterosexuality’,
the idea of heterosexuality, and related heterosexual constructs, do have a
history, even if this is outside psychology.
History of the term ‘heterosexuality’

The term ‘heterosexuality’ was first used in the late 1800s, with varying
meanings. For example, James G. Kiernan used the term ‘heterosexual’ in
1892 to denote anything but normality (Katz, 2007), and the term ‘het-
erosexual’ was used to signal varied ‘feelings’ for both sexes by an indi-
vidual (what we might refer to as bisexuality today). This tendency was
described as a perversion and associated with a psychological condition called
‘psychical hermaphroditism’ (Katz, 2007, p. 20). The well-known sexologist
Richard von Krafft-Ebing used the term ‘heterosexuality’ in Psychopathia sexualis
(1886) quite differently. For him, heterosexuality signified a procreative, sex-
differentiated, and erotic ‘sexual instinct’ that did not necessarily always have
procreation at the fore, but was instinctually driven by it. Heterosexuality, in
this context, was sex with the ‘opposite sex’, and (confusingly) was a ‘nor-
mal’ sex that was still associated with fetishism and non-procreative perversion
(Katz, 2007).
Reproduction was so tightly bound with sex for so many centuries that to
have sex for pleasure was considered lustful, if not always sinful. In this period,
heterosexuality was not deemed normal but seen as a perversion: an idea that
lasted until the 1920s (Katz, 2007), when heterosexuality came to occupy a
different meaning of being a normal sexuality that involved sex with someone
of the ‘opposite sex’, without any ties to reproduction.
94 Sexuality
Creating the heterosexual

While Krafft-Ebing saw heterosexuality as tied up with the reproductive instinct
(although not only about reproduction), it was Sigmund Freud (2000 [1905])
who popularised the idea that heterosexuality was biologically determined and
that people had an internal sexual libido from infancy. Freud was one of the
first in modernity to theorise that sex was pleasure-driven, developmental, and
intra-psychic, rather than merely about procreation. He also firmly positioned
his ideas as scientific versus morally bound or religious. His thoughts were
tied to, reflected, and partly created the shift from the later-Victorian procre-
ation ethic to the modern ‘pleasure principle’ (Katz, 2007). In a context where
same-sex sexuality was increasingly pathologised and male–female relations
normalised, Freud initiated a discussion of heterosexuality and homosexuality
as based on feelings versus sexual acts. This indicated a shift from acts of pro-
creation (and non-procreation) to emotions that dictated erotic drive, instinct,
desire, and love, which has become a modern-day norm (Katz, 2007).
One of the most important ideas Freud relayed was that sexuality developed
in stages and that both heterosexuality and homosexuality could be the out-
come of such development (even though heterosexuality was the preferred and
‘normal’ path). Through the 1920s and 1930s, the concept of heterosexuality
entered public consciousness in the West, and by World War II heterosexuality
was solidified in the sexual landscape (Fausto-Sterling, 2000; Katz, 2007), in a
way which was very much predicated on a two-sex binary model of masculinity
and femininity (Fausto-Sterling, 2000).
Early theorising of (hetero)sexuality

Freud and Krafft-Ebing (and another of their contemporaries, Havelock Ellis,
1859–1939) saw heterosexuality as the norm and homosexuality as the
‘inversion’ of this. Therefore, heterosexuality was good and normal, whereas
homosexuality was abnormal and bad: a division which would come to dom-
inate twentieth-century visions of sexuality (Katz, 2007). Having a differing
sexual orientation according to whether you were male or female was seen
as part of an individual’s overall sex role identity development. Here, attrac-
tion towards women was associated with a masculine identity and attraction
towards men with a feminine identity (Storms, 1980). According to Freud
(1959 [1922]), an unresolved Oedipal complex would compel a boy to iden-
tify with his mother sexually and to “transform himself into her” (p. 40) and
become feminine – in that he would be attracted to males; whereas unresolved
penis envy would lead a girl to “manifest homosexuality and exhibit markedly
masculine traits” (p. 50).
Freud’s binary model of sexuality was addressed by Alfred Kinsey in the mid-
twentieth century when Kinsey and his colleagues examined a wide range of
sexual behaviours within the United States (Kinsey et al., 1948, 1953). Based on
Panteá Farvid 95
these observations, Kinsey devised a heterosexuality/homosexuality rating scale

with exclusively heterosexual at one end and exclusively same-sex attracted
(what Kinsey called homosexual) at the other. It was Kinsey’s assertion that,
although most individuals reported being heterosexual and a minority reported
being gay, almost all reported feelings, thoughts, or behaviours that were
somewhere in between. Kinsey (1953) critiqued the notion that “behaviour is
either normal or abnormal, socially acceptable or unacceptable, heterosexual
or homosexual [sic]” as “many persons do not want to believe that there are
gradations in these matters from one to the other extreme” (p. 639). Kinsey
saw erotic orientation as shaping sexual orientation based on an individually
learned erotic responsiveness to either men or women (Kinsey et al., 1948,
1953; see also Bowes-Catton & Hayfield, Bisexuality, this volume).
Kinsey’s model was revised to a two-dimensional model in the 1970s under
the assumption that heterosexuality and homosexuality could be “separate,
orthogonal erotic dimensions rather than opposite extremes of a single, bipo-
lar dimension” (Storms, 1980, p. 785). This theory argued that individuals can
have independent homoerotic or heteroerotic orientations, rather than a uni-
dimensional model in which it is an either/or situation (Storms, 1978, 1980).
Therefore, in this model, one may be highly attracted to men and women, or
not feel great attraction to men or women, with one orientation or attraction
not affecting the other. The preference for this interpretation can be contextu-
alised in terms of the gay rights movements, which closely followed Kinsey’s
work in terms of chronology. Such groups were invested in positioning them-
selves as a separate category from heterosexuals but as deserving of equal rights
(Bernstein, 2002).
In the 1970s, postmodern theories of sexuality departed from the view that
sexuality was inborn, natural, and inevitable. Sexual script theory asserted
that sexuality was shaped by already available and socially produced sexual
scripts on which people could draw on, to make sense of and enact their sex-
uality (Byrne, 1977; Gagnon & Simon, 1973). Foucault’s (1978) revolutionary
work on the history of sexuality was seminal in future thinking on the social
construction of heterosexuality. It asserted that sexuality was not an inter-
nal biological drive (or libido) but a product of complex power systems that
produced particular ways of being sexual (with some versions privileged over
others).
Second-wave feminist critiques of heterosexuality

The first historic break (in modernity) from the assumption of heterosexuality
as normal and biologically determined came from second-wave feminists
within the West. Betty Friedan (1963) was one of the first to note that
heterosexuality did not seem to treat men and women equally, but heavily
disadvantaged women. Others explicitly critiqued male supremacy under patri-
archy and the heterosexual ‘caste system’ wherein women were positioned as
96 Sexuality
inferior to men (Millett, 1970). Biological sex was increasingly differentiated

from culturally mediated gender, which was identified as a psychological and
cultural construct that was mainly transmitted via socialisation (Oakley, 1972;
Wittig, 1993); where femininity (and women) were subordinate to men (and
masculinity) (Millet, 1970). Gayle Rubin (1975) coined the term ‘sex/gender
system’ to denote the obligatory heterosexuality which positioned men and
women in different ways: “the set of arrangements by which a society trans-
forms biological sexuality into products of human activity, and in which these
transformed sexual needs are satisfied” (p. 159). From this perspective, women
and men were ascribed differing gender roles that supported a heterosexual
system, under patriarchy, which subjugated women and benefited men.
The ideology of heterosexuality was theorised to promote a heterosexual
hegemony (based on Gramsci’s work) that limited the possibility for alternative
ways of being (Small, 1975). Heterosexuality started being theorised by femi-
nists as not being given or inborn, but as part of a social system that required
urgent analysis and critique (Wittig, 1992). Much like the pre-1900s distinction
between heterosexuality and homosexuality, Wittig noted that “straight society
is based on the necessity of the different/other” (1992, pp. 28–29). This flourish-
ing feminist work focused specifically on heterosexuality as an institution and
sought to problematise the taken-for-granted nature by which heterosexuality
was normalised. It was theorised that heterosexuality was problematic due to its
integral ties to patriarchal social and economic systems, and that this system,
and participation in heterosexuality, greatly disadvantaged women.
The most explicit critical analysis of heterosexuality came in 1980 with the
work of Adrienne Rich (1929–2012), who highlighted the pressure on women
to be heterosexual. She argued that women were not born heterosexual, nor
did they freely choose to become heterosexual, but that they were coerced into
heterosexuality by a social system that required ‘compulsory heterosexuality’
from them. Rich (1980), like others, criticised biological approaches to under-
standing heterosexuality, asserting that this ‘sexual orientation’ was not innate
or predetermined, but socially and culturally produced as naturalised.
Such interrogations of heterosexuality by feminist theorists, combined with
postmodern theories of sexuality, paved the way for contemporary critical
research and theorising regarding heterosexuality. Much of mainstream psy-
chological research has largely ignored such interrogations of heterosexuality
and tends to hold more biological, essentialist views, or models that combine a
biological and a developmental/social approach (Barker, 2007).
Given the history of feminist and other discussions about heterosexuality,

it is surprising that in the majority of social science literature it is rare for
Panteá Farvid 97
heterosexuality to be acknowledged, and even more so for it to be criticised

(Richardson, 1996, 2004). As Seidman (2005) has noted, the impact of the
“regimes of normative heterosexuality” on heterosexuality have largely been
ignored (p. 40). Even within some critical and queer theorising, analysis of
heterosexuality has focused typically on the regulation of homosexuality or
the necessity of homosexuality to give heterosexuality meaning rather than
explicitly theorising heterosexuality (Weeks, 1996). The only work that has
been conducted about what heterosexuality is, or means, has emerged from
other critical and feminist perspectives (within and outside psychology). Femi-
nist psychology in particular has devoted scholarly attention to examining the
nature and manifestations of heterosexuality as an institution, as a sexual and
relational identity, and as an everyday practice. Other mainstream approaches
to psychology tend to only examine heterosexuality in the context of its sexual
‘others’ that ostensibly defy the heterosexual norm (Richardson, 1996).
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
daily difficulties or prejudice, that people of other non-heterosexualities might,

for violating deeply entrenched norms and social values about how social and
sexual relations should manifest.
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
Broader social representations and cultural practices aside, heterosexuality

is something that is performed and achieved in the everyday (Coates, 2013;
Gough & Edwards, 1998). Language and social interactions are very much
involved in reproducing the heteronormative order where heterosexuality
is naturalised, but also remains invisible (Kitzinger, 2005). For example,
research has examined the way mothers’ talk with their children promotes
heteronormativity by assuming (and promoting) future heterosexual love
relationships (like heterosexual marriage), while rendering invisible gay and
lesbianism (Martin, 2009).
The norms discussed above have implications for individual psychologies,
identity constructions and social/relational activities. Heteronormativity
shapes who we are and can be, and, for those who do not fit in, it can cre-
ate stigmatisation and difficulty. The masculine and feminine subjects created
by contemporary heteronormative discourse are multiple and complex, but still
tend to reify aspects of traditional and sexist identities, and these have implica-
tions for the options available to individuals in terms of practice. It is important
to remember that such subjectivities are not unitary, and are experienced and
enacted differently by different people (Martin, 2009).
Aside from critical approaches to understanding heterosexuality, there is
a plethora of biological research that seeks to account for differing sex-
ual orientations – without delving specifically into what heterosexuality is
or means. From this perspective, heterosexuality is the assumed norm and
seemingly does not warrant analysis, although this is, of course, a massive
oversight.
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
When it comes to biological research and heterosexuality, only the differences

between sexual orientations have been investigated. Over several decades,
research has examined the ‘cause’ or characteristics of homosexuality. This
includes research on the neuroanatomical differences between straight and gay
people (Allen & Gorski, 1992; Byne et al., 2001; LeVay, 1991; Swaab et al.,
1997), bodily shape and size (Bogaert & Blanchard, 1996; Bogaert & Friesen,
2002; Martin et al., 2008), prenatal androgens in animals (Domínguez-Salazar
et al., 2002; Roselli & Stormshak, 2009; Stockman et al., 1985) and humans
(Hickey et al., 2010; Hines et al., 2004), and genetic factors (Hamer et al.,
1993; Pillard & Bailey, 1998). Most of this research has been controversial and
inconclusive.
For example, one of the first well-known and controversial studies in this
area was the work of Simon LeVay (1991), who examined the variations in
hypothalamus structure between heterosexual and gay men. A cohort of 41
cadavers were autopsied (19 were those of gay men who died of AIDS, 16 were
presumed to be heterosexual, and six were presumed heterosexual women).
One part of the hypothalamic structure was found to be twice as large in
heterosexual men versus gay men, leading the author to suggest that sexual
orientation may be testable at a biological level, involving neurotransmitters.
Although his work has not been successfully replicated (e.g. Byne, 2001), the
study gained huge media attention, as well as major critiques regarding the
sample, procedure, and assumptions imbued within the work. The work was
highly popular in scientific and legal accounts, as it cited and reiterated a
number of heterosexist, sexist, and culturally imperialist norms, confirming
assumptions about a sexual dichotomy, and the idea that gay men and women
are the same (Hegarty, 1997).
The assumption at the core of such studies is that biological variation
between heterosexuals and non-heterosexuals dictates bodily or physiologi-
cal differences (even if the direction of the relationship is not always clear).
Such work has been critiqued for promoting the ideal of two discrete sexualities
(see Bowes-Catton & Hayfield, this volume); that gay men are more feminine
than straight men, and that lesbian women are more masculine in a variety
of ways than heterosexual women. Another issue with these works is not so
much whether they find significant differences between heterosexual people
and same-sex attracted people, or the ‘causes’ of varying sexual orientations,
but the question of ‘so what?’ about their findings. What is the use and pur-
pose of such research? What norms and ideals do they draw on and maintain?
Could such ‘etiological’ work (scarily) lead to attempts of remedying or curbing
non-heterosexualities?
Mainstream psychology
When it comes to heterosexuality/sexual orientation research, personality,
clinical and developmental psychological theories are less common (Bem,
102 Sexuality
1996). There is, however, a plethora of research in psychology examining

various aspects of sexual orientation and its links to psychosocial well-being
(Rieger & Savin-Williams, 2012). This research typically involves mapping out
the experiences and identity development of gay, lesbian, bisexual, or trans
individuals, particularly with regard to prejudice and discrimination (Herek,
1998), without necessarily examining the nature, structure, and foundations of
heterosexuality. One of the best-known developmental theories of sexual ori-
entation argues that children who do not conform to gender roles in childhood
feel different from same-sex children, and ultimately eroticise them, becoming
attracted to them sexually and/or romantically in later life (Bem, 1996). This
theory, known as the ‘exotic becomes erotic’ phenomenon, is a staged model
that includes genetic and biological factors as well as social and developmental
ones (Bailey et al., 2000). More recent developmental research has continued to
examine heterosexuality and heterosexual identity development during ado-
lescent years, mapping the various pathways that can impact sexual identity
development (Morgan, 2012; Tolman et al., 2003; Worthington et al., 2002).
Current debates and implications for applied psychology

and the wider world
Considering that heterosexuality is not typically approached as a topic of

analysis in its own right by most of mainstream psychology (and other ‘scien-
tific’ disciplines), the debates about heterosexuality happen at two levels. One
level is more implicit and relates to the paradigms or epistemological under-
standings of the different approaches (covered above) when it comes to the
origins and nature of sexuality. There tends to be a split between researchers.
Some approach heterosexuality from an essentialist or biological standpoint –
assuming that is it normal, natural, and biologically determined (Pillard &
Bailey, 1998). From this perspective, it is often asserted, “there is no evidence
that one’s postnatal social environment plays a crucial role in gender identity
or sexual orientation” (Bao & Swaab, 2011, p. 214; Swaab, 2007). Then there are
theorists who approach this topic from a constructionist viewpoint – asserting
that what we consider normal and natural sexuality is a socially and culturally
produced artefact (Tiefer, 2004). There are also researchers who fall somewhere
in between – noting that biology and/or hormones must have some impact on
our sexual preferences and sexuality, but that these are also somehow socially
or culturally mediated (Barker, 2007).
The biological essentialist view positions heterosexuality as normal, natu-
ral, and the inevitable outcome for reproductive success. From this perspec-
tive, non-heterosexuality has been investigated due to its otherness and the
causes of varying sexual orientations linked to genes, prenatal hormones, and
brain neuroanatomy. Critical and feminist research specifically examining the
Panteá Farvid 103
institution, daily manifestations, and politics of heterosexuality has debated

various aspects of how heterosexuality plays out and what it means for us.
For example, the power relations imbued within heterosexuality have been
identified as masking rape and sexual coercion (Gavey, 2005); media represen-
tations about casual sex continue to idealise heterosexual monogamy (Farvid &
Braun, 2013, 2014); and heterosexual sexual practice continues to follow highly
scripted and gendered norms (van Hoof, 2014), which can have negative impli-
cations for women’s (and men’s) health and well-being (Beres & Farvid, 2010).
Consequently, queer, critical, postmodern, constructionist approaches do not
seek to ‘explain’ same-sex attracted people – or champion the rights of such
minority groups – but to move their focus on to questioning “The operation of
the heterosexual/gay binary . . . and to focus on heterosexuality as a social and
political organising principle, and [its] politics of knowledge and difference”
(Seidman, 1996, p. 9).
There is an ongoing debate regarding the politics of the source of same-
sex attraction/sexual desire. Arguments around whether sexualities, and in
particular non-heterosexualities, are inborn or chosen create many tensions.
Biological explanations are favoured by those who are liberally minded as a
way of legitimising homosexuality, albeit promoting an essentialist view of
heterosexuality that positions heterosexuality as the norm (Hegarty, 2002). The
notion that homosexuality is ‘chosen’ is favoured by others who use this notion
to condemn and seek to ‘fix’ this abnormality (Hegarty, 2002).
Future directions
Additional research is required to examine the nature and function of

heteronormativity and how it shapes the daily lives of heterosexuals and non-
heterosexuals. We also need to interrogate the varieties and different manifes-
tations of heterosexuality, as well as the hierarchies that exist within it. “There
is clearly a strong case for opening up the ‘black box’ of heterosexuality to
explore the many possible articulations of heterosexual desire that are included
or excluded within a dominant construction of heteronormality” (Hubbard,
2008, p. 645). More direct conversations across the varying paradigms and
approaches that study heterosexuality are needed to provide us with a more
comprehensive psychological study and mapping of the phenomenon that is
heterosexuality.
Summary
• Heterosexuality is normalised and pervasive.

• Most psychological research takes for granted that heterosexuality is ‘nor-
mal’.
104 Sexuality
• Heterosexuality has a history and changes shape over time.

• Heterosexuality involves institutional, sexual identity, and everyday dimen-
sions.
• We must consider biological, developmental, and social dimensions for a
comprehensive understanding of heterosexuality.
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
Lesbian psychology is “psychology which is explicit about its relevance to

lesbians [ . . . ], does not assume homosexual pathology, and seeks to counter
discrimination and prejudice against lesbians” (Kitzinger, 1997, p. 203). Prior to
the late 1970s, psychological theory and research on lesbians was uncommon.
Where it did exist, it focused primarily on lesbianism as pathology, attributable
to genetic predisposition and/or early socialisation (e.g. see Bene, 1965; Loney,
1973; Wittenberg, 1956). As a result, many lesbians were subjected to psychi-
atric ‘treatment’ with the aim of curing them of their lesbianism. Since the late
1970s – as a function of both the removal of homosexuality from the DSM in
1973 and the rise of second-wave feminism – there has been a seismic shift in
the emphasis of psychological theory and research towards the normalisation
of lesbianism.
As part of this shift, psychology turned its focus away from lesbians (and
gay men) as pathological, focusing instead on homophobia (Smith, 1971) as a
pathological behaviour. While well established within the psychology of sex-
uality/ies today, work on homophobia focuses primarily on the attitudes of
heterosexual persons towards lesbians and gay men (and others) as if the lat-
ter were a homogeneous group. The lesbian population in itself is very diverse
(including, for example, non-Western, trans, and polyamorous lesbians) but,
on the basis of gender alone (i.e. lesbians undoubtedly differ from gay men),
this body of work is very limited in what it can tell us about lesbians’ experi-
ences, and how – specifically – lesbians (as lesbians and as women) are affected
by homophobia. It is, therefore, not explicit about its relevance to lesbians, and
so does not form part of the field referred to in this chapter as ‘Lesbian psychol-
ogy’. For similar reasons, work on heterosexism – the “ideological system that
denies [ . . . ] and stigmatises any non-heterosexual form of behavior, identity,
relationship, or community” (Herek, 1990, p. 316) – has also been excluded
from this chapter.
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
The beginning of lesbian-affirmative psychological research and theorisation is

marked by the work of a single psychologist. The research of June Hopkins
(1969, 1970), a British clinical psychologist, was the first to systematically
explore lesbianism using conventional psychological methods. In one of her
studies, Hopkins assessed 24 lesbians and 24 heterosexual women using the
16PF personality test (Cattell, 1957). While she hypothesised that there would
be no personality differences between lesbian and heterosexual women, the
findings of this study did identify some key differences. However, contrary to
the dominant discourse of the time, lesbians proved better adjusted than het-
erosexual women, in that they were more independent, more resilient, more
dominant, and more self-sufficient than their heterosexual counterparts.
It was not, however, until the late 1970s that we saw the beginnings of a field
of lesbian-affirmative psychological research. While still very limited in quan-
tity and scope, published research at that time followed the lead of Hopkins
in using conventional psychological approaches but comprised one-off stud-
ies by US researchers. In the main, these were studies exploring psychological
adjustment (e.g. Adelman, 1977; Oberstone & Sukoneck, 1976), and quality
of lesbian relationships (Peplau et al., 1978). Overwhelmingly, the findings of
these studies suggested that lesbians were well adjusted and satisfied with their
Sonja J. Ellis 111
relationships, and, contrary to popular belief, were fully functioning members

of society (e.g. see Albro & Tully, 1979).
Second-wave feminism and the women’s rights movement in the early 1980s
created a more ‘lesbian-friendly’ climate. As a result, there emerged a prolif-
eration of psychological studies on lesbianism, including research on lesbian
parenting (e.g. Golombok et al., 1983; Kirkpatrick et al., 1981), lesbian rela-
tionships (e.g. Caldwell & Peplau, 1984; Peplau et al., 1982), and internalised
homophobia (e.g. Brown, 1986; Sophie, 1987). Together, these early studies
suggested that lesbian families and relationships were ‘just like’ heterosexual
ones, but that marginalisation and stigma caused lesbians to experience neg-
ative self-feelings. However, the majority of early work focused on identity
development. Much of this arose out of – and in response to – generic stage
models of ‘homosexual’ identity formation (e.g. Cass, 1979; Coleman, 1982).
In 1985, Joan Sophie published an extensive critique of stage theories of les-
bian identity development (see also Elliott, 1985). Based on interviews with
14 US lesbians, Sophie highlighted a range of problems with the stage model
approach, including the assumption that lesbians move through the stages in
a linear fashion and the notion that they arrive at a stable or fixed identity.
She concluded that there were a variety of paths that women took in com-
ing to identify as lesbian, and that this was inadequately captured by stage
models. Building on Sophie’s work, Chapman and Brannock (1987) developed
an alternative stage model which better reflected the diversity that both they
and Sophie had identified. However, essentialist process models such as these
were subject to ongoing debate well into the 1990s. Alternative models (e.g. see
Eliason, 1996; McCarn & Fassinger, 1996) have proposed limited changes and
still conform to a highly structured, systematised, and reductionist approach to
lesbian identity.
With few exceptions, the first three decades of lesbian psychological the-
ory and research almost exclusively originated in the United States, includ-
ing the landmark text of the field – Lesbian psychologies: Explorations and
Challenges (Boston Lesbian Psychologies Collective, 1987) – which documented
the breadth of the field at that time. However, it is noteworthy that three of
the most influential works have come from British psychologists: June Hopkins
(1969, 1970), Susan Golombok (Golombok et al., 1983), and Celia Kitzinger
(1987). Hopkins’ work has already been discussed, and Golombok’s is discussed
later, so it is Kitzinger’s work I turn to now.
Celia Kitzinger’s book The Social Construction of Lesbianism is a pivotal work
in the field of lesbian psychology – not so much because it has changed
the psychology of lesbianism (although it has to some extent in the United
Kingdom) as because, like Hopkins and Golombok, Kitzinger challenged the
status quo of lesbian psychology. Using traditional psychological methods (Q-
methodology – see also Hagger-Johnson, Quantitative Methods, this volume),
112 Sexuality
Kitzinger undertook a study of lesbian identity which launched a provocative

critique of the (then) emerging field of lesbian and gay psychology. Com-
bining radical feminism and social constructionism, she argued that a liberal
humanist approach to the study of lesbians represented a new development
in the oppression of lesbians, substituting one depoliticised construction of
lesbianism for another (Peel & Kitzinger, 2005). Essentially, what she was argu-
ing was that the lesbian (and gay) psychology of the time overwhelmingly
positioned lesbianism as a private or personal ‘choice’, ignoring the way in
which time, place, and culture construct lesbianism and therefore give it polit-
ical meaning. This theme is picked up in a later text (Kitzinger & Perkins,
1993) which argues that, for lesbians, psychology – in particular, psychological
therapy – is a bad thing, and antithetical to the feminist agenda.
Lesbian psychology primarily comprises four areas of study: lesbian iden-

tity, lesbian relationships, lesbian parenting, and lesbian health. Work
within the field is largely United States-based empirical work under-
pinned by a positivist approach, with a few key (historical and contempo-
rary) British studies underpinned by critical realist and occasionally social
constructionist approaches. From the emergence of ‘lesbian-affirmative
psychology’ in the 1970s the field has expanded substantially over the
past 40 years. However, to a greater or lesser extent, lesbian psychology
has been superseded by lesbian, gay, bisexual, trans, and queer (LGBTQ)
psychology, under which the experiences and concerns of lesbians have
largely been subsumed. While this has enabled a better understanding of
the experiences of LGB (and sometimes TQ) people as a collective, it has
obscured the ways in which these issues apply specifically to lesbians.
Focusing on lesbianism as normative, psychological research and theorisation

has largely moved away from earlier areas of interest. Lesbian psychology
today covers four main areas: lesbian identity, lesbian relationships, lesbian
parenting, and lesbian health.
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
consequence, at points of follow-up, many women who had once identified

as lesbian had relinquished this label in favour of an alternative that they felt
better reflected their sexual history. Similarly, McDonald and colleagues (2011)
suggest that, for some women, invoking the category ‘lesbian’ might import
specific constructions of lesbian (e.g. as sinful; as pathological; as devoid of
sexual desire; as associated with feminism), causing them to adopt alternative
labels, or to shun labels altogether.
Appearance is one of the ways in which lesbians can be recognisable and
visible to one another (Clarke & Spence, 2013; Huxley et al., 2014). Histori-
cally, a more ‘masculine’ or ‘butch’ look was the stereotypical look of a lesbian,
but, with lesbians being more socially accepted, appearance norms have shown
some degree of change. An analysis based on interviews with British lesbians
(Huxley et al., 2014) suggested that, while over time there has been some degree
of diversification in lesbian style, appearance norms were still often policed.
Consequently, lesbians were likely to conform to appearance norms early in
the coming-out process, or to at least ‘look the part’ when out on ‘the scene’.
However, lesbians who were more comfortable with their identity tended to
resist appearance norms, preferring to adopt a more individual look.
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
in which relationships are characterised by closeness at the expense of individ-

uality (e.g. see Burch, 1982; Kirkpatrick, 1991). However, since the late 1990s
this reading of female same-gender relationships has been heavily critiqued.
In particular, it has been suggested that female same-gender relationships have
been misunderstood and misinterpreted in a way which confounds relational
strength with dysfunction (Biaggio et al., 2002; Pardie & Herb, 1997). Fur-
thermore, it has been suggested that the view of these couples as ‘fused’
or ‘merged’ may be the result of assessing female same-gender relationships
by heteronormative standards (Ackbar & Senn, 2010; Hill, 1999). Based on
the analysis of results from a series of standardised measures administered to
77 Canadian women, Ackbar and Senn (2010) found that relationship sat-
isfaction was enhanced by greater closeness. They therefore concluded that
therapists need to more clearly distinguish between positive and negative forms
of closeness in female same-gender relationships.
Psychological work has also focused on domestic abuse within female same-
gender couples. The key theoretical observation of this work has been the
reliance – by psychologists and practitioners – on heteronormative and femi-
nist thinking around violence (i.e. that it is perpetrated by men against women
as a display of power), which has left the victims of domestic abuse in female
same-gender relationships devoid of a framework for understanding what has
happened to them, and has impeded the efforts of practitioners to respond
appropriately to partner abuse between women (Barnes, 2011; Ristock, 2001).
An understanding of domestic abuse in female same-gender couples has been
inhibited by some studies’ reliance on standardised scales (e.g. the Conflict Tac-
tics Scale). These scales have been designed with a heteronormative context in
mind (Ristock, 2003) and therefore are not well suited for understanding the
way in which domestic abuse is played out between same-gender partners. To
better understand ‘lesbian’ domestic abuse, Janice Ristock undertook an inter-
view study with 80 Canadian lesbians (see Ristock, 2003). Analyses showed that,
while most of those interviewed identified themselves as victims of abuse, many
saw the victim and perpetrator roles as unclear and/or shifting over the course
of their relationship. Research on this topic commonly reports women’s experi-
ences to be heterogeneous (see Irwin, 2008; Ristock, 2003), but common factors
include feeling isolated and experiencing difficulty in seeing one’s partner’s
behaviour as abusive (Bornstein et al., 2006; Merlis & Linville, 2006).
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
used interviews and questionnaires to systematically compare the psychosexual

development of 37 children reared in lesbian-headed households with 38 chil-
dren reared in heterosexual-headed households. No differences were found
between the children of these two groups in gender identity, sex role behaviour,
or sexual orientation, and they did not differ on most aspects of emotions,
behaviour, and relationships. Similar findings were seen in an American study
by Kirkpatrick and colleagues (1981) and also in comparative studies under-
taken more recently (e.g. Golombok et al., 1997; MacCallum & Golombok,
2004).
Theory and research around lesbian parents and their families is the best
established. To date, studies of lesbian parenting have been undertaken in a
wide range of countries, including the United Kingdom (e.g. Golombok &
Tasker, 1996; Golombok et al., 2003), the United States (e.g. Gartrell et al.,
2000), Australia (e.g. McNair et al., 2008), The Netherlands (e.g. Bos et al.,
2004), Germany (e.g. Herrmann-Green & Gehring, 2007), France (e.g. Vecho
et al., 2011), and Israel (e.g. Ben-Ari & Livni, 2006). Overwhelmingly, this
research confirms the consensus of earlier work that a mother’s sexual ori-
entation is not an important factor in determining children’s psychological
well-being or gender development. Comparative studies show that children
raised by lesbian mothers are just as well adjusted as children raised by het-
erosexual couples, and have a comparable quality of life (e.g. see Bos et al.,
2007; Golombok et al., 2003; van Gelderen et al., 2012). However, lesbian par-
ents appear to differ from their heterosexual counterparts in a few important
ways. In particular, lesbian mothers appear to experience higher levels of satis-
faction with their partners (Bos et al., 2004, 2007); engage more frequently in
imaginative play with their children (Golombok et al., 2003); and raise their
children to be more open and tolerant of diversity (Golding, 2006).
Early studies mainly focused on lesbian mothers raising children conceived
(and initially raised) in heterosexual families. Since 2000 the focus has shifted
to ‘planned lesbian families’: that is, families in which children have been born
and raised by lesbian couples using donor insemination (DI) as a means to
become parents (Tasker & Golombok, 1998). Much of this work has focused on
the particular challenges faced by lesbian families in raising children in a society
where their families are not necessarily validated and stand out from the social
norm. These studies (e.g. Kranz & Daniluk, 2006; Stevens et al., 2003) indicate
that lesbian parents evidence a great deal of planning and consideration of
issues in terms of managing prejudice and in being open and honest with their
children (in an age-appropriate way) about their own sexual orientation and
about how their children came into existence. One key study (Chabot & Ames,
2004) explains the decision-making process that lesbian couples go through to
have children via DI – a far more complex process than would typically be the
case in a heteronormative context.
Sonja J. Ellis 117
Despite overwhelming evidence that being raised in a lesbian family is not

detrimental to the psychological well-being of children, lesbian families are still
subject to stigmatisation (e.g. see Clarke, 2001; van Gelderen et al., 2012). Les-
bian parents commonly face accusations that their children are ‘missing out’
due to the absence of a male role model, often without supporting evidence
for these claims. An analysis of talk show data by Clarke and Kitzinger (2005)
showed that lesbian parents responded to this particular argument by high-
lighting the presence of role models in extended family and in society more
generally.
In the absence of a structured (and scripted) model of family and parenting
for lesbian families, parents have to construct their own ways of doing family:
in particular, constructing a legitimate parental identity for the ‘non-biological’
mother (Bergen et al., 2006). While this is often achieved through legal means
(e.g. civil partnerships, adoption of the child by the non-biological parent),
social recognition is also important: this may include adoption of the non-
biological mother’s surname as part of the child’s name and the use of parallel
address terms for both mothers (e.g. ‘Mummy’ and ‘Mama’; ‘Mummy T’ and
‘Mummy M’) (Bergen et al., 2006; Hequembourg, 2004). However, it has been
noted that non-biological mothers are not readily accepted by society (e.g. see
Padavic & Butterfield, 2011) and often feel the need to justify the quality of
their parenting or demonstrate the active part they have played in the concep-
tion and birth process (Bos et al., 2004). Much of the emphasis has been on
legitimising lesbian families to achieve social acceptance. However, Tasker and
Granville (2011) have shifted the focus to better understand the way in which
lesbian parents and their children understand their own families. The analyses
of their data suggested that, at least in the global West, lesbian parents and their
children construct family in similar ways to heterosexual families.
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
This (wrongly) constructs lesbians as having no sexual health needs, ignoring

the fact that lesbians may get raped by men, or have sex with men through
choice or for money (Lampon, 1995). Moreover, it assumes that STIs and other
sexual health issues stem exclusively from sexual practices, ignoring the risks of
transmission through IV drug use and self-insemination. Medical research sug-
gests that the transmission of STIs through woman-to-woman sex is low, but
there is some potential risk (e.g. see Evans et al., 2007; Marrazzo et al., 2005)
US studies of perceptions of risk and susceptibility among lesbian women sug-
gests that few WSW believe themselves to be ‘at risk’ and most are ill informed
of the potential risks posed by exposure to vaginal fluid (Dolan & Davis, 2003;
Montcalm & Meyer, 2000). The notion of ‘safer sex’ for lesbians is invisible in
mainstream health promotion, with the occasional promotion of dental dams.
However, the promotion of dental dams can be complicit in the pathologisation
of woman-to-woman oral sex by constructing it as inevitably risky or danger-
ous (MacBride-Stewart, 2004). For example, dental dams are not promoted to
men who perform oral sex on their female partners.
Another key area is the mental health of lesbians. As with many other areas,
what we know about the mental health of lesbians is very limited because les-
bians have tended to be studied together with gay men (and/or BTQ people).
Studies (e.g. King et al., 2008; Pitts et al., 2006) typically suggest that lesbians
(and gay men and bisexual people) are at greater risk of suicide, self-harm,
depression, and anxiety than their heterosexual peers. For example, a US sur-
vey sample of 524 lesbians, 143 bisexual women, and 637 heterosexual women
(Koh & Ross, 2006) found that 56.7% of lesbians and 53.2% of bisexual women
had been treated for depression compared with only 42.1% of heterosexual
women. Another US study (Irwin & Austin, 2013) explored suicidal ideation
in lesbians living in the Southern United States, finding them to be at greater
risk than heterosexual women. While there has been a steady trickle of studies
exploring the incidence of mental health issues in the lesbian (and/or GBTQ)
population, few have systematically explored factors affecting lesbians’ men-
tal health. However, in one study Oetjen and Rothblum (2000) administered a
series of standardised measures to 167 lesbians to explore predictors of depres-
sion. Lack of social support from friends and family was found to be a predictor
of depression, whereas other factors (e.g. relationship satisfaction, level of out-
ness) were found to be poor predictors. To date there are no British studies
exploring mental health in lesbians.
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.
Important points for applied psychologists and other practitioners
Lesbians are marginalised within mainstream heteronormative society,

and are also often the subjects of overt prejudice. For these reasons, the
experiences of lesbians (as women) are not necessarily the same as those
of heterosexual women, whose experiences are (positively) reinforced
Sonja J. Ellis 121
by heteronormativity. Similarly, due to gendered expectations and the

gendered organisation of society, lesbians’ experiences are not necessar-
ily the same as gay men’s experiences. It is therefore very important in
applied settings not to apply models/approaches uncritically to lesbians
(as individuals, couples, or triads/quads; see also Rambukkana, Open Non-
Monogamies, this volume). For example, many approaches to relationship
therapy are based on normative heterosexual relationships, frequently
underpinned by gendered notions of behaviour and interaction. Often
these approaches are assumed to apply to lesbian relationships, with an
assumption of mirrored female behaviour. However, lesbian relationships
seldom operate in this way. Lesbian psychology can help practitioners
to better understand the differences between lesbians and heterosexual
individuals/couples/triads/quads.
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:
• defined lesbian psychology as “psychology which is explicit about its rel-

evance to lesbians . . . , does not assume homosexual pathology, and seeks
to counter discrimination and prejudice against lesbians” (Kitzinger, 1997,
p. 203);
• provided an overview of lesbian psychology from its inception in the late
1960s, and marked by the early contributions of June Hopkins, Letitia
Peplau, Susan Golombok, Joan Sophie, Celia Kitzinger, and others;
• provided a review of contemporary theory and research spanning the last
15 years covering key areas that define lesbian psychology: lesbian identity,
lesbian relationships, lesbian parenting, and lesbian health;
• highlighted the way in which lesbian psychology today is characterised by
an absence of theoretical debate, largely brought about by the decline of (les-
bian) feminism and the rise of an LGBTQ psychology under which lesbian
psychology has been subsumed;
• highlighted the importance for applied psychologists and other practitioners
to think critically about heteronormative practices and approaches before
applying them to lesbian clients;
• suggested that, to better understand the lives and experiences of lesbians, it
is necessary to disaggregate the study of lesbians from the study of individ-
uals with other sexual orientations, behaviours, and gender identities.
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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8
Trans Sexualities
Penny Lenihan, Tony Kainth, and Robin Dundas
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
gender and heterosexuality (Bornstein, 1994, 1998; Namaste, 2000; Prosser,

1998; Stryker & Whittle, 2006). What has been frequently observed, although
it currently remains under-researched, is that sexuality and gender tend to be
conflated within the majority of Western liberal capitalist societies, insofar as
gender expression is assumed to automatically signify sexuality (Fassinger &
Arseneau, 2007).
The collapsing of sexuality into gender and the erasure of non-normative
sexual and gender expressions can perhaps be best understood as an effect
of a variety of overriding assumptions about sexuality and gender within
Western culture, identified within feminism as ‘heteronormativity’ (Warner,
1991). Heteronormativity assumes that sexuality and gender fall into rela-
tively fixed binaries of male and female. It also supports ‘heterosexism’, or
the notion that heterosexuality, that is, male/female sexual relations, is the
most natural or ideal, as opposed to other forms of sexuality (Rich, 1980). As a
result of the dominance of heteronormativity, gender variations from a binary
male/female model have frequently been marginalised and pathologised. As a
result of heterosexism, sexual orientations and types of relationships includ-
ing homosexuality, bisexuality, asexuality, kink, and polyamory have struggled
to gain acceptance within the majority of social spaces within Western cul-
ture. Deviations from accepted and established normative gender roles have,
therefore, until very recently, gone largely unrecognised and are still frequently,
often violently, prohibited (Turner et al., 2009; Whittle et al., 2007; Wilchins,
1997a, 1997b). Censure and prohibition have also problematically obstructed
the identification and expression of non-normative or trans sexual desires, with
profound, negative implications for people of a variety of gender identities.
Androgynous or gender-neutral trans people, who experience themselves as
neither male nor female, may particularly find that they do not fit comfort-
ably into dichotomous gender labels (Carol et al., 2002; Eyler, 2007). These
individuals may find it difficult to describe or communicate their gendered
experience within common discourses that assume only two genders (see also
Barker & Richards, Further Genders, this volume). The negative construing of
some sexualities and trans as ‘less than’ and ‘other’ can also make finding terms
that are inclusive and inoffensive when describing trans individuals’ sexual
experiences and identities a challenging task. Language has the potential to
inhibit as well as enable the articulation of sexuality and gender (Lev, 2004),
restricting and changing what we want to say. It would be impossible, in the
context of this chapter, to define all the terms in common and professional
usage; that would potentially require a lengthy and involved chapter in itself.
The term trans sexualities, as we are using it, can be defined as sexualities that
include a trans element core to individuals’ sexual experience and expression.
These can range from the subtle and potentially playful interchange of gen-
der roles within sexual relations common to most relationships, to the more
Penny Lenihan et al. 131
concrete realisation and enactment of trans sexualities from within a trans

identity and body.
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
preoperative transgender women”. Their research suggests that men who

have sexual encounters with preoperative trans women, rather than explic-
itly acknowledging their attraction to trans women and their bodies, tended
to engage in various compartmentalising strategies, in order to retain their
heterosexual identities (and, presumably, the status conferred by this iden-
tity). For example, heterosexual male participants described their trans partners
as being an object of sexual desire because they were more sexually avail-
able than cisgendered women and were described as more attractive due to
their (conventionally) hyperfeminine presentation. In order to maintain their
heterosexuality, while emphasising the feminine qualities of their trans part-
ners, these men chose not to attend to the fact that their sexual partners had
penises. While this research focused on experiences and perspectives of het-
erosexual males, by contrast, there is little research that explores trans people’s
relational and sexual experiences in such situations, representing an important
omission. There is also a lack of research exploring attraction to trans men and
those who identify their gender in non-binary terms.
Trans people’s sexualities are presupposed by cultural understandings that
shape experiences of sexual desire and identity in problematic ways, often
involving stigmatisation and shame due to lack of acceptance and recog-
nition on their own terms. Arguably, all sexualities blend into and already
exist through heteronormative, socially sanctioned sexual behaviour. However,
when these sexualities become explicitly associated with trans people, they
tend to be abstracted from their relational and societal contexts and held up
for closer, often scientific scrutiny. This way of conceptualising trans sexual
behaviour and interests should be viewed as discriminatory when we consider
that trans people are so diverse as to be indistinguishable from the main-
stream. In spite of the pressure exerted by societal expectations, perhaps due to
increased solidarity and support within trans communities, some trans people
are now feeling able to be more open about expressing their sexualities outside
the boundaries established by heteronormative discourse.
An example of a less visible and less recognised sexual expression or iden-
tity for trans people that warrants brief exploration is asexuality. Asexuality
has become an increasingly common and accepted identity among trans
people and non-trans people alike (see Carrigan, this volume). For trans peo-
ple, though, identifying as asexual can sidestep binary, cisgendered prejudice
against their sexuality, while being a legitimate sexuality in its own right.
Asexuality may be defined as not experiencing sexual attraction (Asexual Visi-
bility and Education Network, 2012), but, as celibacy, can also mean a conscious
choice not to act on sexual desire, perhaps in order to take ownership of one’s
sexuality. Similarly to a queer political position, claiming an asexual identity
could constitute an empowering move for those whose sexuality is misinter-
preted or misunderstood by others (for example, where sexuality and gender are
confused). Trans people may particularly encounter a lack of sense of ownership

of a sexual identity when their desires are translated through heteronormative
discourses that do not correspond with their own experience.
A trans and cisgender sexuality that spans a broad range of behaviours
and desires is BDSM (bondage, dominance, sadism, and masochism) (see also
Turley & Butt, BDSM, this volume). BDSM practices include many sexual and
social roles, relations, and practices: so much so that they should be considered
simultaneously minority and mainstream, normative and transgressive. BDSM
relations involve a continuum of common sexualised and non-sexualised
behaviour, including roleplay. The roleplaying possibilities within BDSM can
potentially be affirming and satisfying for those who feel confined by their
bodies within a particular gender role. Additionally, roleplay can be a way to
enact, play upon or reverse the power dynamics that gendered relations often
imply, but rarely make explicit. BDSM also potentially serves as an opportunity
for individuals to align themselves with or enact a gender role that is more con-
gruent with their gender identity, which may be otherwise prohibited within
other relationships or social settings, and to explore this in both sexual and
social terms (Langdridge & Barker, 2007; Turley & Butt, BDSM, this volume).
In this sense, what may seem erotically transgressive and undesirable to some
may be equally experienced as defining and exciting by others, depending on
the individuals’ perspectives and desires; BDSM potentially provides an open,
exploratory, sexual, and social relational space in which to establish individ-
ual boundaries and contours in terms of gender and sexual expression and
identity.
Kuper et al. (2012) identified in their comprehensive research that many trans
individuals, particularly adolescents and young adults, are adopting a ‘queer’
political stance (i.e. reclaiming the existing, dominant language, labels and
categories for sex and gender by imbuing them with new, subversive mean-
ings and values) in order to resist the assumptions inherent in existing gender
and sexual categories. A new generation of trans people seems to be embrac-
ing ‘genderqueer’ sexualities (see, for example, METRO Youth Chances, 2014)
by reclaiming sexual experience as an integral part of a trans identity. Many
young trans people presenting in the authors’ clinical setting are challenging
the taboos around sexual desire for trans bodies and people by reframing this
within a sexual preference for gender fluidity or ambiguity that is not defined
by the limits of heteronormativity and gender-specific sexual orientations. Per-
haps one of the most radical moves within the genderqueer movement is being
made by those progressively choosing not to identify themselves or define their
sexuality in terms of gender at all (Kuper et al., 2012). While some of these
sexualities may be perceived as either outside or challenging heterosexist or
heteronormative assumptions, it is also important to note that, while estab-
lishing a non-normative identity may be affirming and potentially liberating
134 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
development of a whole ‘society of normalisation’ (Foucault, 1979, p. 54, cited

in Fausto-Sterling, 2000).
If one accepts Foucault’s history of sex, sexuality, and gender, it is unsurpris-
ing that many dominant theories of sexuality and sexual identity that still hold
sway today are founded on the premise that biological sex precedes gender,
which in turn precedes sexuality and sexual identity. One of the first moves
away from these views was set in motion by the separation in the 1970s of
biological sex from gender by Money and Ehrhardt (Fausto-Sterling, 2000).
Sex has traditionally referred to physical attributes, with gender latterly con-
ceived as “a psychological transformation of the self – the internal conviction
that one is either male or female and the behavioural expressions of that con-
viction” (Fausto-Sterling, 2000, p. 3). Fausto-Sterling explains that this new
definition challenged existing, highly dominant notions that biology, nature
and therefore concrete reality lay at the heart of the gender norms and gender
inequalities that were supported by the culture during the last two centuries
(Fausto-Sterling, 2000).
Students
Trans is an umbrella term often used to describe gender minorities and

refers to people who are in some way transgender. Trans 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. The term trans sexualities can be defined as sexualities that include
a trans element core to individuals’ sexual experience and expression.
These can range from the subtle and potentially playful interchange of
gender roles within sexual relations common to most relationships, to
the more concrete realisation and enactment of trans sexualities from
within a trans identity and body. Trans people can identify as gay, het-
erosexual, lesbian, bisexual, pansexual, asexual, or queer, among other
labels. Many may have multiple sexual identities.
What are the ways in which your own course material might patholo-
gise, ‘other’ or erase trans sexualities? Are there ways in which you could
question your own assumptions and stance in relation to sexuality and
gender to avoid this?
Key theory, research, and current debates
Recent developmental theories contend that the self-perception of our sexual

orientation develops after we have established a stable sense of our “gendered
136 Sexuality
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).
One example of a discarded ‘disorder’ is homosexuality, which was removed

from the DSM in 1973. Lev asserts that removal was due to the political
shift in viewing homosexual behaviour as “common and therefore ‘normal’ ”
(2004, p. 151) as opposed to deviant and pathological. This would suggest that
diagnostic classifications in psychiatry can pathologise behaviours based on
social acceptability and that statistical uncommonness equates to disordered or
dysfunctional behaviour. The current version of the DSM (DSM 5) aims to focus
more on clinically significant distress in relation to individual experiences, as
opposed to pathologising variant experiences and identities by labelling them
as ‘disorders’. For example, the DSM 5’s shift from listing paraphilias to describ-
ing paraphilic disorders once again makes the distinction between what may
be seen as ‘atypical’ sexual practices and preferences for such practices versus
preferences that result in clinically significant distress or impairment.
Directly relevant to these issues is ‘transvestism’, touched upon earlier.
In terms of popular understanding, when thinking of trans people and sexu-
ality, ‘cross-dressing’ and ‘transvestite’ are terms that many people still bring
to mind in order to identify or describe trans people’s sexual experience and
expression. These terms are often assumed to imply some form of fetishism or
a sexual dimension where one does not exist. For many trans people, dressing
in a style of clothing traditionally associated with their preferred gender role
is frequently not a predominantly or even vaguely sexual experience, but is, in
fact, a profound and authentic form of self-expression. Dressing in the cloth-
ing of another gender can also be, however, a highly stimulating, liberating,
and satisfying sexual activity for some individuals. Combinations of sexual and
non-sexual experiences of ‘cross’ dressing are possible for a variety of people
who may or may not identify as trans. One of the reasons for this confusion is
arguably that ‘Fetishistic Transvestism’ is defined within ICD 10 as “the wear-
ing of clothes of the opposite sex principally to obtain sexual excitement and
to create the appearance of the person of the opposite sex”, defined “by its
clear association with sexual arousal and the strong desire to remove the cloth-
ing once orgasm occurs and sexual arousal declines” (ICD, 2008, F65.1). The
effect of this, if perhaps not explicitly the purpose, has been to highlight and
identify not only a discrete set of problematic behaviours but, by extension, a
problematic category of person: ‘fetishistic transvestites’.
A less pathologising, othering position is available once we acknowledge how
gendered the whole notion of ‘women’s clothing’ or ‘men’s clothing’ is: the sub-
jectiveness of defining it in terms of hypothetical gendered possession rights, as
in ‘wearing women’s dresses’, and how culturally defined differences in cloth-
ing choices are. Some clothing, particularly that designed for women, is erotic
in that its purpose is to sexually arouse, but that becomes an issue if the per-
son being aroused by the clothing is not only wearing it but is of a different
sex from those normally wearing it. The taboo nature of such behaviour can in
138 Sexuality
itself be sexually arousing, and clinically significant distress may be related to

shame at acting against social prohibitions of how ‘men’ should behave. Trans
men (natally assigned females living partly or fully in a male gender role) tend
not to have been caught up in the sexual pathologising of clothing choices and
accompanying sexual arousal and expression. There is less stigma, though, to
natal females wearing male clothing, and the clothing itself is generally less
designed to elicit sexual arousal.
Currently diagnostic categories, rather than being used to intentionally
exclude or pathologise trans individuals, or being taken as concrete, inflexible
realities in themselves, generally serve health professionals as a way of clin-
ically identifying and describing complex phenomena in a language that is
communicable across psychological and medical disciplines. Nonetheless, they
are clearly pathologising insofar as they define cross-dressing (wearing the tra-
ditional clothes of the opposite gender) as a ‘Gender Identity Disorder’ (Lev,
2004). Regardless of the diversity and uniqueness of individuals’ experiences of
dressing in cross gender-specific attire, one of the impacts of the demarcation
and application of transvestism as a psychiatric or psycho-medical category is
that it frames these behaviours and expressions, at least within the realm of gen-
eral, popular discourse, as disordered or sexually abnormal. More profoundly,
rather than merely describing behaviour, it also delineates and constructs a
problematic type of identity or person. This means that those for whom cross-
dressing is an authentic expression of sexuality are viewed as somehow sexually
perverse (or, more profoundly problematically, as sexual perverts), and, for
those for whom it has no sexual dimension, there is potentially a suspicion or
implication that this is also the case. In spite of the myriad other facets of these
individuals’ experience and identity, sexual and otherwise, by merely choosing
or feeling the need to express themselves in non-normative gender or sexual
terms through clothing, they risk becoming most prominently identifiable via
an unwanted, stigmatised, sexualised identity.
Related to this association and conflation or confusion of gender and sexual-
ity within psychological/psychiatric diagnostic understandings of trans sexual
phenomena is the terminology used to identify and describe the sexual desire
of trans people towards gendered aspects of their own bodies and genitalia.
Autogynephilia and autoandrophilia refer to sexual arousal at the thought of one-
self as a woman or a man, respectively, and are employed to refer exclusively
to trans people who are sexually aroused by the self-image or enactment of
a gender that does not correspond with their natally assigned sex. There is
extensive literature on this subject (Blanchard, 1988; Moser, 2009) in spite of
the fact that it is considered a rare phenomenon (Richards & Barker, 2013).
This academic interest could be argued to arise from the fact that these sex-
ual experiences have been identified as exceptional, abnormal, or pathological.
The result of this interest has been the development of a wealth of theories
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
professional commitments and moves towards greater understanding, however,

the problem remains that trans as a rubric covers multiple normative and non-
normative sexual identities and experiences. Some of these are aligned with
heteronormative discourse, and some defy not only popular understandings of
gender and sexuality, but also the labels and identities used and accepted within
trans communities themselves.
A problematic and potentially inescapable effect of the dominance of binary,
heteronormative ideas about sex and sexuality can be that alternative or sub-
versive forms of sexual expression and identity are framed (negatively) in direct
relation or resistance to powerful culturally and historically supported dis-
courses and understandings. As outlined throughout this chapter, these assert
that heterosexual intimate and sexual relationships between cisgendered part-
ners are the most feasible and valid (Love, 2007; Halperin, 2009). When viewed
from this perspective, articulating or embodying a genuinely new, subversive
or liberated sexuality becomes nearly, arguably entirely, impossible, as all are
framed within or against heteronormativity. Valentine (2006) makes the impor-
tant point that unhooking sex from gender, while useful for clinicians and
necessary to the freedoms of many minority individuals, potentially further
concretises sex and gender in a binary way, potentially obscuring the expe-
riences of those who span a combination of sexualities and genders, some
linked and some not. The importance of being identified/identifiable in a clear
and coherent way, in terms of a distinct gender and/or sexuality, is argued to
potentially erase the complexity and fluidity of experiences of sexual desire.
Another potential point worth making is that differentiating sexuality from
transsexuality can communicate, albeit inadvertently, that sexuality somehow
‘contaminates’ a transsexual identity, and, by extension, trans people.
In spite of the aforementioned moves towards greater understanding of trans

phenomena, it has been adequately demonstrated that existing theory and
currently held beliefs raise potential problems in working therapeutically
with trans people. Also, although there has been an emphasis within this
chapter on the importance of not overly distinguishing between trans and
cisgender sexual experience, there are arguably specific biopsychosocial issues
that trans people will confront, largely due to social and cultural pressures and
discrimination, that need to be understood and assimilated within psycho-
logical or psychotherapeutic theory and practice. Problematically for practice
in this field, the existing psychotherapeutic literature relating specifically
to trans is very scarce. Barker and Richards (2013) have moved psycho-
logical therapies forward in raising awareness of practice with gender and
sexual minorities, and postmodern, narrative, and queer theory have been
utilised therapeutically in addressing some of the issues facing LGBT people,

although these frequently lack a focus on trans-specific issues (Moon, 2008).
Richards (2011) writes comprehensively on existential and phenomenological
psychotherapeutic approaches and their ability to speak clearly to trans expe-
rience and identity in terms of concepts such as authenticity, temporality, and
the potential realities of trans identity. Other modalities potentially have much
to offer in clinical work with trans people, as indicated within the person-
centred (Livingstone, 2008) and Gestalt (Hawley, 2011) literature. The potential
application of these approaches with trans people, however, needs to be more
deeply explored and published.
Professionals
Pre-existing socio-political (and medico-legal) factors can dictate which

pole of any sexual/gender binary is deemed normal/deviant, power-
ful/powerless, right/wrong. Indeed, certain expressions of LGBT identity
being viewed as deviations from norms or as pathological only serve
to reinforce the notion that sexual identities are internal and fixed
while perhaps ignoring (political) power and oppression as central to the
formation of these hegemonic discourses around deviance and pathol-
ogy. Psychological therapies such as existential-phenomenological psy-
chotherapy can highlight the contradictions or paradoxes inherent in
assumptions regarding binary and ‘real’ or ‘natural’ gender and sexual-
ity, and allow a focus on the more fluid, mysterious or contradictory fine
grain of sexual experience through an empathic, exploratory therapeu-
tic relationship. This could offer a template through which to learn new
ways in which to relate to stigmatised, self-regulating and limiting forms
of sexuality and sexual identity. It could also help make the invisible
visible.
How might professionals question pathologising practices within clin-
ical settings? Could examining assumptions and being reflexive about
one’s own personal stance in relation to sexuality and gender help to
provide an affirmative service to trans people?
Future directions
In addition to the lack of focus on trans issues within therapeutic approaches,

there also appears to be a paucity of research examining how trans indi-
viduals experience relationships or sexual encounters. Much of the existing
literature tends to focus on problematising and pathologising trans people’s
142 Sexuality
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
Trans phenomena within a variety of academic disciplines, particu-

larly within the field of transgender studies, have identified trans peo-
ples’ experiences of sexuality and gender as being erased or rendered
invisible against a cultural backdrop of normative, binary gender and
heterosexuality. What has been frequently observed, although it cur-
rently remains under-researched, is that sexuality and gender are fre-
quently conflated and gender expression is assumed within the majority
of Western liberal capitalist societies to automatically signify sexual-
ity. Counter-intuitively, separating out sexuality from gender may not
provide logical solutions to this situation for a range of trans people.
How might researchers use epistemological reflexivity in order to ques-

tion their knowledge, and be led by trans narratives rather than theoreti-
cal concerns in order to produce non-pathologising and useful research?
How might researchers redress power imbalances when researching trans
subjectivities?
Summary
• In spite of being a highly diverse group of individuals with a variety of

normative and non-normative sexual and gender identities, trans people
are often defined in terms of the binary male and female gender and
heterosexuality.
• Gender presentation and sexuality are often assumed to be fundamentally
linked in Western societies; however, this is frequently not the case for trans
and non-trans people.
• Trans people do not have a discreet set of sexualities, but should be viewed
as proportionally similar to the general population. However, it is important
to understand that gender minority individuals’ sexual experiences may be
erased or coloured by societal and cultural norms.
• It is important to be reflexive when using scientific or more popular
terms to describe trans people’s sexual and gender identities and experi-
ences, and to consider how they may have been shaped by history and
culture.
• An open, exploratory, epistemologically reflexive and affirmative stance is
needed in research and practice with gender minority sexual issues.
Further reading
Barker, M. & Richards, C. (2013). Sexuality and gender for mental health professionals:
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
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Part II
Gender
9
Cisgender – Living in the Gender
Assigned at Birth
Ester McGeeney and Laura Harvey
Introduction
Hardly a day goes by without a headline about ‘fundamental’ differences

between men and women. Self-help books claim that men and women are
from different planets, and we are surrounded by often contradictory repre-
sentations of what it means to be a ‘normal’ man, woman, boy, girl. How can
psychology help us make sense of these debates, and understand social norms
of masculinity and femininity?
Much mainstream psychological research has taken as its starting point a
gender binary, in which male/female and masculinity/femininity are opposing
poles. The persistence of this gender binary, including in popular and medical
Western discourse, is such that the birth of a baby, or the announcement of
pregnancy, is still so often accompanied by the question “Is it a boy or a girl?”
This chapter will explore psychological approaches that have examined the
experiences, identities, and behaviours of people who stay in the gender they
are assigned at birth (cisgender). We will ask how psychologists understand
the relationship between gender, biology and society, and discuss the differ-
ent methods researchers have employed to investigate cisgender. The chapter
begins by outlining the emergence of key theoretical debates in psychological
research and exploring recent critical approaches to the relationship between
gender, the body, and the social world. In the final section we consider the
implications of these historically situated debates for practitioners working with
cisgender young people and adults.
Most of the psychological work we explore in this chapter was conducted
before the term ‘cisgender’ came into usage in the mid-1990s. While the term
is becoming more commonplace, its explicit use is still not widespread in con-
temporary gender scholarship (Ansara & Hegarty, 2012). We therefore draw on
research that does not explicitly define cisgender as its topic of analysis, yet
149
150 Gender
implicitly focuses on cisgender experiences, identities, or norms. We would

argue that, despite differences in definition, the insights from this research are
crucial in making sense of psychological understandings of cisgender. While
the focus of the research discussed below is on the experiences of cisgender
people, much of this will also have relevance for trans* people who identify as
men or women.
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
Psychologists from different theoretical backgrounds, using a range of method-

ological approaches, have investigated whether, why and how differences
between humans can be attributed to their gender. Topics as diverse as brain
size, hormones, parental interaction, genetics, attitudes, playground behaviour,
and language have all come under the attention of psychologists seeking
to make sense of cisgender and the differences between cisgender women
and men. Even where gender is not the explicit focus of psychological
research, it has become commonplace for psychologists to include binary gen-
der as a demographic variable and analyse the results accordingly (Johnson &
Repta, 2012).
Ester McGeeney and Laura Harvey 151
The psychological search for gender differences needs to be understood in

the context of wider developments in the natural and social sciences and in
relation to questions of power, inequality and, social relations. Early empiri-
cal psychological research on cisgender at the end of the nineteenth and early
twentieth centuries was carried out against the backdrop of increasing pub-
lic discourse about gender equality and changes in the structure of Western
societies, including industrialisation. The influence of Darwin’s evolutionary
theories had prompted a social-scientific concern with the differentiation of
categories of people through precise measurement (Russett, 1989). In this con-
text, bodies became sites to explore psychological difference, with particular
focus on establishing ‘natural’ hierarchies within the categories of ‘race’ and
‘gender’ via the measurement of skulls and facial features and behavioural
data (Russett, 1989). Research on gender in the nineteenth century thus often
sought to establish whether men and women had essentially different abil-
ities, comparing female participants against a white male ‘norm’ (Helgeson,
2002).
One of the first reviews on ‘sex differences’ research, in 1914, pointed to the
conflicting nature of findings on gender differences, suggesting that the social
context of research had much to do with the conclusions reached:
The general discussions of the psychology of sex, whether by psychologists

or by sociologists show such a wide diversity of points of view that one feels
that the truest thing to be said at present is that scientific evidence plays
very little part in producing convictions.
(Woolley, 1914, cited in Hyde, 2005, p. 581)
Despite such inconsistencies, scholars have continued to search for a relation-

ship between gender and differences between people throughout the twentieth
and early twenty-first centuries. Psychological work has focused on the ques-
tion of whether there are gender-related differences in cognitive ability, such
as spatial abilities (Reilly & Neumann, 2013), mathematical skills (Duffy et al.,
1997), social behaviour, such as empathy and aggression (Archer, 2006) and
physical activities, such as throwing (Butterfield & Loovis, 1993), and dif-
ferences in psychological well-being, such as self-esteem (Kling et al., 1999).
Research in this area has found varying levels of correlation between gender
and the different psychological phenomena measured (Helgeson, 2002; Hyde,
2005).
A review of over 2000 studies by Maccoby and Jacklin (1974) found evi-
dence for gender differences only in verbal, visual-spatial, and mathematical
ability and aggression, although their review was critiqued for not taking into
account the small size and bias in the samples of many of the studies reviewed
(Helgeson, 2002). In contrast, meta-analyses of psychological work in this area
152 Gender
involve aggregation of findings while taking into account questions of sample

size, methodological validity, and the types of study included (Hyde, 2005). For
example, Reilly and Neumann (2013) conducted a meta-analysis of research on
the relationship between gender role identity and the cognitive spatial skill of
mental rotation, in which participants are asked to judge whether images of
three-dimensional shapes are the same when rotated at different angles. Reilly
and Neumann argued that there is a correlation between masculine gender roles
and mental rotation. Such findings are commonly used as evidence for media
claims that men are, for example, “better at map reading” than women (e.g.
Highfield, 2007).
Some critical psychological researchers have questioned the search for gen-
der differences in mainstream psychology, pointing to the many similarities
between genders, and the differences within genders (Hyde, 2005). For sev-
eral decades, feminist researchers have interrogated the findings of psycho-
logical research on gender differences, arguing that the research questions,
methodology, interpretation, and reporting of data can all contain gender bias
(Marchbank & Letherby, 2007). This includes the use of only male participants,
the role of stereotypes in the labelling of variables and interpretation of find-
ings, and the over-emphasis of statistical differences between gender groups
(Denmark et al., 1988).
Reviewing the work on gender differences in the late 1980s, Baumeister
(1988) argued that the analysis of gender differences has been helpful in ensur-
ing that psychological research has made women’s experiences more visible
and reduced the generalisation of findings based on predominantly male par-
ticipants. However, he suggested that psychology needed to move on, positing
that the continued focus on gender differences “perpetuates the distinction
and contributes, perhaps, to the persistence of stereotypes and discrimina-
tion” (1988, p. 1093). Many feminist researchers have similarly argued that
psychology should be more concerned with challenging the impact of gender-
based generalisations and exploring participants’ everyday experiences of living
gendered lives (Marchbank & Letherby, 2007). This body of critical work high-
lights the importance of attending to the social contexts within which research
is conducted and calls for careful interpretations of studies that observe corre-
lations between gender and behaviours or abilities. For example, while some
researchers have found evidence of higher physical aggression and violence
among male adults, there is little evidence to support the stereotype that aggres-
sion is caused by testosterone, as some researchers have claimed (Archer, 2006).
As we further explore below, contemporary critical work in this field documents
the diversity of people’s experiences of living as a cisgender man, woman, boy,
or girl and suggests that there is a complicated relationship between social con-
text, biology, and gender identity that cannot be understood by simple cause
and effect models.
Despite the ongoing critical debate around the continuation of gender-

differences research, there is consensus among psychologists that gender
remains a relevant topic for analysis. Gender appears as a form of social
organisation in most societies, including access to resources and the regulation
of our everyday lives (Kimmel, 2004). Given this context, even research which
challenges the origin or existence of gender differences or norms necessarily
engages with cisgender as a social and psychological phenomenon. The ques-
tion of gender differences thus rests on broader debates within psychology and
other human and social sciences about the nature of gender as a category,
including how gender is formed and the relationship of cisgender to biological
and social factors, which we will now turn to discuss.
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
Similarly, evolutionary psychological approaches build on Darwin’s (1859)

theory of evolution to argue that psychological gender differences have
evolved genetically through human social adaptation and natural selection
(Buss & Schmitt, 2011). For instance, Buss and Schmitt (1993) contend
that men and women have evolved with psychological differences in rela-
tion to sexual behaviours and feelings. Evolutionary psychological ideas
are often taken up in journalism and popular writing. Wright’s contro-
versial book The Moral Animal (1994) is a case in point. Wright claimed
that selection and adaptation had resulted in men preferring to have long-
term sexual relationships with women who were less available for sex (as a
sign of increased likelihood of fidelity). Wright’s approach has been criti-
cised, however, for naturalising a sexual double standard in which women
are stigmatised for overt displays of sexuality. Furthermore, Darwinian fem-
inists have argued that Wright’s theories are based on an oversimplified
reading of Darwin, arguing instead for an approach that emphasises evo-
lutionary variability and the potential for political change (Fausto-Sterling
et al., 1997).
One of the most influential theorists of the psychology of cisgender at the
turn of the twentieth century was Freud, who drew on his work as a psy-
choanalyst to theorise the development of cisgender identity in relation to
unconscious processes of identification, and heterosexual attraction to a par-
ent. Freud’s approach to gender and sexuality has been both expanded and
critiqued by feminist and queer theorists. For example, feminist psychoanalyst
Chodorow (1978) has theorised the relationship between mother and daugh-
ter, particularly the role of mothering, as the central defining factor in cisgender
development for girls.
Psychoanalytic theory is not alone in foregrounding the role of parenting
in the development of gender identity and behaviours. Psychological theories
of socialisation propose that the social and cultural environment is signif-
icant in the creation of gender norms and roles (Marchbank & Letherby,
2007). For example, social learning theory builds on both evolutionary psy-
chological approaches and sociological approaches to argue that individuals
cognitively acquire gender roles through a combination of the modelling of
gender in their environment (by family members, teachers, and so on), pro-
cessing the responses they receive to particular behaviours (such as rewards
and punishments), and through direct tuition in gender norms (Bussey &
Bandura, 1999).
At the more sociological end of the spectrum of psychological theory,
social constructionist approaches present gender as something that is achieved
socially through interaction and language, foregrounding questions of power.
In this theoretical tradition, gender is something that people and groups
do rather than an intrinsic attribute (Kimmel, 2004). Frosh et al.’s (2002)
ethnographic study of boys in London schools, for example, documented the

diverse and multiple ways in which the boys in their study were ‘doing boy’.
Building on Connell’s (1995) influential sociological work on the social con-
struction of dominant, or ‘hegemonic’, masculinities, Frosh and colleagues
argued that the production of masculinity is relational, and that, although
there are multiple versions of masculinity available to boys and young men,
hegemonic characteristics of masculinity, such as ‘toughness’, are more highly
valued in certain contexts.
Psychologists drawing on poststructuralist theory also foreground questions
of meaning, culture, and interaction in their work. For example, discursive
psychologists explore the role of language and interactions between individ-
uals, groups, and media representations in the construction of gender. Judith
Butler (1993) is perhaps one of the most significant poststructuralist scholars of
gender, arguing that gender is not an innate characteristic, but achieved per-
formatively through repetitious acts such as gestures, an argument also made
by interactional sociologists (West & Zimmerman, 1987), as we discuss further
below.
Recently, some social-psychological work on gender has incorporated
insights from sociological and cultural approaches that theorise gender in
relation to its intersection with other social categories such as race, social
class, disability, and sexuality (Crenshaw, 1991). For example, Malson et al.
(2002) explored how young Asian and white women in the United King-
dom constructed their identities through talk. They found that, in talking
about appearance, style, and taste, the young women constructed both their
own and others’ gender, ethnicity, social class, and sexuality, including con-
structing ‘hybrid’ identities in the multicultural areas in which they lived.
Intersectional approaches to cisgender thus foreground questions of multiplic-
ity in the experience of gender, often focusing on issues of power, privilege, and
discrimination.
Cole (2009) argues that psychologists can examine how multiple forms of
social difference and discrimination interact, and the impact this has on peo-
ple’s experiences and identities. Discussing psychological work on women’s
sexuality, Cole (2009) suggests that psychologists should ask the following
questions when taking an intersectional approach to their work:
First, who is included within this category? Second, what role does inequal-
ity play? Third, where are there similarities?
(2009, p. 171)
Many of the theoretical debates discussed above remain in contemporary

psychological research, with continued focus on gender differences and the
role of society and biology, as we further discuss below.
156 Gender
Although not always explicitly stated, psychological gender research

has historically focused on cisgender experience and behaviours, to the
exclusion of other genders.
The historical context in which research takes place has an impact on
the questions asked and the interpretation of the data.
When reading research about gender, think carefully about what is
being claimed – correlation does not always mean causation.
Current debates and future directions
In this section of the chapter we turn to more recent psychological work

on cisgender, looking at key debates about the relationship between the
body, gender, and psychology. In the previous section we argued that social
constructionist theories have been influential in shifting the focus from
an exploration of differences between cisgender men and women, to an
interest in the role of language and interaction in creating gender mean-
ings and identities (Burr, 1998). Researchers adopting this approach have
drawn on poststructuralist theories of discourse and performativity (e.g. Butler,
1993; Foucault, 1972) that suggest that language does not merely ‘reflect’
the social world, but produces social meanings, identities, and power rela-
tions (Jackson & Westrupp, 2010). Approaching gender as a form of social
and cultural practice, researchers have asked key questions about the rela-
tionship between discourse, gender, sexuality, and the body in different
social contexts. For example, how are discourses of bullying in contem-
porary schools gendered and sexualised? What norms do these discourses
reproduce about what it means to be a ‘girl’ or a ‘boy’, a ‘victim’ or a
‘bully’? How are these norms embodied, negotiated, and subverted by chil-
dren living in different locations and historical moments? (Ringrose & Renold,
2010).
There are numerous recent studies that explore the contradictory and
dynamic construction of cisgender through talk and interaction (see Speer &
Stokoe, 2011, for overview), as well as in and through a range of media pro-
grammes and texts (Gill, 2009). For example, Harvey (2012) combined data
from a survey and interviews with media analysis to examine the discursive con-
struction of condom use and to argue that talk about condom use positions men
and women in different ways. For some of the cisgender women in Harvey’s
study, the requirement to take responsibility for condom use formed part of
feelings of sexual confidence, pleasure, and control. Others, however, struggled
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
used fMRI techniques to observe patterns of activity in male and female

brains while participants were completing a series of linguistic tasks, such as a
‘rhyme-judgement’ task in which participants were shown two nonsense word
strings and asked whether or not they rhymed. The researchers observed that,
in the male brains, only the left hemisphere was seen to be active, whereas the
female participants appeared to be using both hemispheres while solving the
same tasks.
Shaywitz and colleagues’ (1995) research forms part of a body of work that
suggests women’s brains are more inter-hemispheric than those of their male
counterparts (see Fine, 2010a, for overview). Shaywitz and colleagues claim
that their data provide “clear evidence for a sex difference in the functional
organisation of the brain for language” (1995, p. 607) and offer support for
the “long-held hypothesis that language functions are more likely to be highly
lateralised in males and to be represented in both cerebral hemispheres in
females”. Meta-analyses of such studies suggest, however, that findings are
inconsistent and unreliable, with more evidence of similarity between males
and females than difference (Fine, 2010a).
Despite such inconsistencies and complexities, there is a burgeoning pop-
ular science market that sets out to explain the ‘essential difference’ (Baron-
Cohen, 2003) between men and women in terms of ‘hard-wired’ differences
between male and female brains (Fine, 2010a). This genre, and the body of
research on which it draws, has been subject to sustained critique for its
methods of research design and data interpretation as well as the ways in
which it promotes gender stereotypes and presents deterministic accounts
of gender identity (see Bluhm et al., 2012, for overview). Fine (2010a) has
coined the term ‘neurosexism’ to describe how stereotypical understandings
of male and female behaviours are used within popular and academic liter-
ature to reinforce dominant gendered social norms. Fine argues that there
is a tendency in much neuroscientific research and reporting to underesti-
mate the environmental influences on human behaviour and to suggest that
“the mind is something stable in the head of a person” (2010a, p. xxvi).
Rather than providing evidence of ‘hard-wired’ (Baron-Cohen, 2003) sex dif-
ferences between male and female brains, Fine argues that these studies raise
a series of (as yet unanswered) questions about whether differences in brain
structure shape psychological differences, or whether it is psychological differ-
ences that are shaping differences we can now observe in the structure of the
brain.
Despite the problematic ways in which neuroscientific technologies have
been used in the study of cisgender, this emerging field contains excit-
ing possibilities for generating new psychological understandings of the
relationship between gender, the body, and the social world (Einstein,
2012).
There is much academic debate about gender research, focused in par-

ticular on the most effective methodologies for research, and debate
about the relationship between the body, the mind, language, and
representation.
Academic research has increasingly sought to explore how gender
relates to other social categories such as ethnicity, social class, disability,
and sexuality.
While researchers across disciplines often take contrasting approaches,
interdisciplinary conversations are becoming more common and can
help generate new ideas.
Much of the research detailed above emphasises how psychological research

has approached the question of cisgender. Here we consider the implications of
these debates for practitioners working with children, young people, and adults
in a range of health, education, and community settings: how can practitioners
support the people they work with to acknowledge the power of hegemonic dis-
courses of gender, while also exploring the diversity of people’s experiences of
living as a girl or a boy, a man or a woman? Further, how can fields of policy and
practice develop integrated approaches to gender that consider physiological as
well as social and psychological differences?
Drawing on research on young people’s gender identities, Robb (2007)
suggests that one implication for youth practitioners is the importance of recog-
nising the diverse and complex ways in which young people experience gender.
Robb argues that, against a backdrop of uneven and rapid social change, young
people need support with establishing their gender identities in relation to their
peers, families, and communities. This involves recognising the plurality of
young people’s gender identities, especially in contexts where that diversity
may be threatened by dominant cisgender and heterosexual norms. In prac-
tice, he suggests this could involve holding ‘gender workshops’ (Segal, 1990)
in which young people can be encouraged to challenge sexist stereotypes and
explore gender diversity.
Practitioners and activists working within the fields of critical sexuality edu-
cation and critical youth work have long advocated creating ‘safe spaces’ (Fine,
1988) to explore hegemonic gender norms and enable young people to imag-
ine alternative gendered subject positions and more diverse ways of living and
‘doing’ gender and sexuality. Kiely (2005), for example, suggests that young
people in Ireland could be given the opportunity to critically analyse and
160 Gender
subvert dominant discourses of sexuality and gender in relationship and sex

education lessons through doing activities such as deconstructing song lyrics
and exploring the empowering and/or limiting positions that they offer young
people. While the challenges of carrying out this work in often highly regulated
environments should not be underestimated, there are several organisations
working with young people that have produced useful resources to promote
and enable critical work in this area (Brook, 2010; Feminist Webs, 2012; see
Batsleer, 2013).
Practitioners working in therapeutic and one-to-one settings have also drawn
on theoretical ideas about the disciplinary power of dominant discourses to
develop techniques that enable clients to reflect on the ways in which gen-
der power relations operate within their lives. In a critique of the field of
mainstream sex therapy, Tiefer (2012) suggests that being an ‘ethical’ therapist
also involves being a ‘social activist’: a practitioner who works collaboratively
with clients to challenge cultural norms about gender and sexuality such as
those outlined above relating to contraceptive decision-making and condom
use (Harvey, 2012). As Tiefer and others have argued, such an approach to
therapeutic practice presents a direct critique of medicalised approaches to
sex therapy that seek to understand sexual disorders or dysfunction purely
in terms of physiology. Arguing against a medical/therapeutic dualism, Moser
and Devereux (2012) call for an integrated approach to therapeutic practice
that draws on biopsychosocial understandings of human sexuality. This would
involve acknowledging any physiological conditions that can act as barriers
to good sex (such as heart conditions linked to erectile difficulties), explor-
ing psychological issues such as fears about sex or anxieties about being able
to ‘perform’ sexually, and unpicking sociocultural norms about sexual gender
roles and what counts as ‘good’ or ‘proper’ sex (Moser & Devereux, 2012;
Tiefer, 2012).
In this chapter we have noted the continuing popularity of self-help books
that set out to explain the ‘essential differences’ between men and women and
provide practical advice on how to manage the tensions and challenges arising
from these ‘hard-wired’ differences. There are, however, a number of self-help
books that offer practitioners, and the people they work with, critical tools
and resources for examining cisgender identities and practices and challeng-
ing limited or rigidly held gender norms. One example is Bornstein’s ‘gender
workbook’ (1998, 2013), which uses a series of quizzes, reflective exercises, and
critical commentary to help readers to question and define their own gender
identity, drawing on insights from queer theory and genderqueer communities.
Throughout the ‘workbook’ Bornstein plays with the concepts of ‘real man’ and
‘real woman’, suggesting that these are both ‘vital concepts’ and ‘meaningless,
useless terms’ (1998, p. 22): vital because nearly everyone believes that there
is such a thing as a ‘real man’ and a ‘real woman’ and meaningless because
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.
People experience and understand their gender in a wide range of

different ways.
Applied professionals can play a key role in creating safe spaces within
which people can explore their own gendered experiences and think
critically about gender norms.
Work with clients on cisgender needs to be conducted sensitively,
particularly given the persistent social and cultural regulation of gender.
Evidence suggests that work in this field can be creative, engag-
ing, and potentially transformative for clients of all genders, ages and
backgrounds.
Conclusions
Throughout this chapter we have explored a range of theoretical approaches

to cisgender, outlining key debates and tensions between biological and social
constructionist, discursive and more materialist approaches, as well as those
that attempt to move beyond these binaries to generate new insights into
cisgender bodies and identities. In focusing on the recent developments in
neuroscience and critical social psychology, we hope to emphasise the strengths
of interdisciplinary approaches to the study of cisgender and suggest that this
is an important area for future research, theory and practice.
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
• Psychological research on gender differences has found varying levels of

correlation between gender and the different psychological phenomena
measured.
• Recent developments in neuroscience have enabled new insights into the
relationship between gender, the body, the mind, and the social world.
Much of this work has been criticised for its inadequate methodologies and
biological essentialism and for perpetuating sexist gender stereotypes.
• Contemporary critical psychology increasingly adopts an intersectional and
interdisciplinary approach to cisgender, examining how gender intersects
with other aspects of identity.
• Research suggests that there are multiple ways of being cisgender. Although
people have choices about how to live and perform their cisgender identities,
many people experience pressure to conform to dominant cisgender and
(hetero)sexual norms.
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.
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10
Further Genders
Meg John Barker and Christina Richards
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:
• have no gender (e.g. gender neutral, non-gendered, genderless, agender,

neuter, neutrois);
• incorporate aspects of both man and woman (e.g. mixed gender, sometimes
pangender, androgynous);
• are to some extent, but not completely, one gender (e.g. demi man/boy,
demi woman/girl);
• are of a specific additional gender (either between man and woman or
otherwise additional to those genders, e.g. third gender, other gender,
sometimes pangender);
• move between genders (e.g. bigender, gender fluid, sometimes pangender);
• move between multiple genders (e.g. trigender, sometimes pangender);
• disrupt the gender binary of women and men (e.g. genderqueer, genderfuck).
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
(binary) gender as an independent variable (IV) in the vast majority of studies.

The bias towards reporting research which finds a difference over that which
does not means that such research is over-reported, reinforcing the notion that
there are two and only two genders, and that they are different in kind and not
degree.
If we assume, for the moment, that gender is, in fact, a spectrum, it might
be reasonable also to assume that it would, as with so many aspects of human
experience, be normally distributed. Relatively few people would be situated
within the tails, and the great mass would be clustered around the mean, as in
the diagram below (Figure 10.1).
However, if we consider the impact of such cultural forces as gendered modes
of dress, language use, and even such things as gendered stationery, colours,
watches, shampoos, and so on, such forces would create a bimodal distribution,
as in the diagram below. This is evidenced in an embodied sense when one picks
a ‘pink’ or ‘blue’ aisle in a children’s toy shop (Figure 10.2).
The tendency in both mainstream and popular psychology to constantly
reinforce the idea of ‘opposite’ binary genders could be regarded as very much
Population
frequency
Masculine Feminine
Figure 10.1 Gender distribution
Culture
Population
frequency
Masculine Feminine
Figure 10.2 Gender distribution with cultural impact
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).
Fitting and misfitting binary gender
Write down in two columns what it means to be feminine and what
it means to be masculine in mainstream culture (covering all aspects,
including behaviour, roles, emotions, and appearance – for example,
women care about their appearance and men don’t). Consider whether
you, or the people you know, fit only into one column.
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
Figure 10.3 Spectra of gender (adapted from Barker, 2013)
In addition to multidimensionality, it is important to note that gender is

intersectional – meaning that the way in which people’s gender manifests itself
intersects with other aspects of their identity and experience, such as class,
race, ethnicity, age, generation, and geographical location. What is considered
masculine and feminine differs across different contexts (see Barker, 2013). Fur-
thermore, how people behave often depends on the situation they are in, or
on the gender of the people they are interacting with, rather than on anything
intrinsic about their own gender. For example, single fathers behave in nurtur-
ing ways (Risman, 1987); and girls play in more independent ways when with
other girls rather than with boys (Maccoby, 1990). This fact, that gender in such
contexts is not a fixed and innate characteristic but, rather, is changeable and
culturally bound, has been termed ‘doing gender’ (West & Zimmerman, 1987).
All of these aspects make it difficult to measure the degree of masculinity or
femininity that a person possesses.
So, we have seen that psychology has overwhelmingly focused on gender

as a (natural) binary, and on demonstrating differences between women and
men. Bem’s research suggests that it is certainly possible for some people to
have a more androgynous gender (having both masculine and feminine traits)
and for gender to be more flexible and fluid. We now turn to the small body of
more recent research which has studied those whose identities and experiences
explicitly fall outside the gender binary of women and men.
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
negotiated with evident tensions. This is apparent in the limited amount of

research which has been conducted, thus far, into Western non-binary gender
experience.
In relation to the extent of non-binary identity, one UK study found that 5%
of the lesbian, gay, bisexual, trans, and questioning (LGBTQ) youth surveyed
identified as neither male or female (METRO Youth Chances, 2014). In the
United States, Harrison et al. (2012) found that 13% of trans people surveyed
were ‘a gender not listed here’ (p. 14). Finally, a Scottish study on trans mental
health, McNeil et al. (2012), found that over a quarter of survey participants
identified as non-binary or agendered. Generally speaking across such research,
non-binary-identified people were younger than trans men or women (this is
also echoed by Hansbury, 2005).
A key finding from the research is that many non-binary people do not feel
that they have specific spaces within which they fit. This often includes an
experience of not fitting into cisgender or trans spaces, analogous to many
bisexual people’s experiences of not fitting into heterosexual or lesbian/gay
spaces (see Bowes-Catton & Hayfield, Bisexuality, this volume). Some non-
binary people have created online or offline spaces for themselves (e.g. Beyond
the Binary working group, 2014), while others have found a home within
broader trans or LGBT communities (Rankin & Beemyn, 2012).
Such developments have been successful in creating a nascent sense of
community among some non-binary people, perhaps especially those who
are younger and internet literate. For those who do not have access to such
developments, the (labelled) identity may not be available to match the expe-
rience of being non-binary. This may lead to the associated psychological
sequelae of having an isolated experience. Saltzburg and Davis (2010) found
that non-binary young people often reported not knowing how to embrace
their gender identities until they found others who identified in such ways.
The participants also said that it was difficult to have a sense of authen-
ticity without any acknowledgement of their identities from the people
around them.
In terms of wider understandings of gender, most non-binary research par-
ticipants did not perceive either gender or sexuality as discrete, or mutually
exclusive, categories but, rather, stated that there was complexity and mul-
tiplicity in gender embodiment and expression (Davidson, 2007). Some felt
an inherent responsibility to challenge the gender binary, even describing
themselves as ‘gender pioneers’ and having a sense of being engaged in ‘culture-
making’ (Saltzburg & Davis, 2010, p. 105). However, of course, by no means all
non-binary people feel such political motivations, and a significant proportion
are in cultural and economic positions of marginalisation which limit their
capacity to engage in such ways.
Non-binary experience has important implications for how psychologists

measure gender in the demographics sections of their research (notwith-
standing the wider question of whether gender should be included at all,
or whether it can be regarded as an IV with discrete levels). Current good
practice would involve, at the very least, including the possibility of ‘in
another way (please state)’ and ‘prefer not to say’ options alongside ‘man’
and ‘woman’ in demography sections pertaining to how people identify
their gender (Equality and Human Rights Commission – Glen & Hurrel,
2012).
It is also important to ensure that participants are not misgendered in
any way in the reporting of research (Ansara & Hegarty, 2012) and that
anonymised names and pronouns reflect their own gender identities.
Finally, reflexivity (for both qualitative and quantitative research)
should involve reflection on researchers’ own gender assumptions and
the potential impact of this on all aspects of the research process (see
Richards et al., 2014, for an in-depth consideration of this topic).
Current debates
While research on non-binary identity and experience is very recent, theo-

retical considerations have been present in the wider academic literature for
some time, notably in the form of queer theory and Trans Studies. Prior to
this, some psychological and psychiatric writing dealt with genders that trans-
gressed a fixed binary; however, all of these tended to be subsumed within
understandings of ‘transsexualism’, as this was the only available discourse (see
Murjan & Bouman, Trans Gender; Lenihan, Kainth & Dundas, Trans Sexualities,
this volume). Within such queer and psychoanalytic literatures there have
been occasional depictions of gender as non-binary, but these have often been
deployed in problematic ways, for example in order to deny the necessity of
transition for trans people (e.g. Hakeem, 2007).
The lacuna of material on the lived experience of non-binary gender, and its
lack of visibility within wider culture, means that it can be useful to turn to
activist and community literature as well as the small number of extant studies.
For example, there have been important collections of accounts from ‘beyond
the binary’ in each of the last three decades (Bornstein & Bergman, 2010;
Nestle & Wilchins, 2002; Queen & Schimel, 1997), as well as a recent explo-
sion of non-binary websites, blogs, and social media groups. These are helpful
174 Gender
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
described themselves with percentages, for example ‘one-third male, one-third

female, one-third transgender’ (p. 2), or without labels: ‘I am me.’
Such proliferation of terms reached popular attention in 2014 due to the
decision of the social networking site Facebook to provide 58 possible gender
terms, and the possibility of choosing the pronoun ‘they’ (see Barker, 2014).
Some psychologists and other scientists have taken a stance on how many dif-
ferent versions or forms of gender there may be once non-binary genders are
included. Fausto-Sterling (2012) suggested five, but later revised this. Fontanella
et al.’s (2013) global survey divided participants into nine gender categories:
heterosexual cisgender females, non-heterosexual cisgender females, females
who identify themselves as men, fluid females, intersex persons, heterosexual
cisgender males, non-heterosexual cisgender males, males who identify them-
selves as men, fluid males. Bem (1995) similarly combined gender and sexuality
to make an initial suggestion of 18 genders to encompass all the potential
combinations of two sexes (male/female), three genders (masculine, feminine,
androgynous), and three desires (heterosexual/homosexual/bisexual), although
obviously this neglects to include diversity of biological sex or desires that
do not relate to gender of attraction (see Richards, Further Sexualities, this vol-
ume). Saltzburg and Davis (2010) certainly found that some of their non-binary
participants also employed terms which integrated identity of gender and sex-
uality, such as ‘lesbian in a male body’, and others also included elements of
spirituality, such as ‘faerie’.
This raises the question of whether gender-related theory and activism should
focus on dismantling the gender dichotomy; on expanding it; or on operating
within it. Interestingly, Bem changed her position on this towards the end of
her career. She had previously argued that gender should become an unimpor-
tant category, only considered when absolutely relevant. However, in 1995, she
suggested that the way forward was to turn the volume up on gender instead
of down:
I propose that we let a thousand categories of sex/gender/desire begin to

bloom in any and all fluid and permeable configurations and, through that
very proliferation, that we thereby undo the privileged status of the two-
and-only-two that are currently treated as normal and natural.
(Bem, 1995, p. 330)
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
as Serano (2013) have pointed to a preference of masculine-of-centre over

feminine-of-centre people in many LGBT, trans, and non-binary spaces, reflect-
ing wider cultural gender biases. It is not surprising, perhaps, that Harrison
et al. (2012) found that 73% of non-binary participants identified on the trans-
masculine spectrum, and only 27% on the transfeminine. From our clinical
experience there is also a risk of a ‘tyranny of cool’ in this area, whereby non-
binary people who are older, less educated, or without easy internet access feel
excluded from potentially supportive online and offline environments due to
quickly changing terminologies and mores and a ‘call out culture’ in relation
to those who fail to keep up (Serano, 2013).
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
be conducted, it seems likely that constant cultural priming of binary gender

(in the form of signs on toilet doors, unnecessarily gendered products, being
called sir/madam, etc.) has a similarly adverse effect on non-binary people’s
cognitions, self-esteem, and ability. However, as in other areas of LGBTQ men-
tal health, it would be valuable to balance research in this area with that on
the resiliencies of non-binary people/communities and the positive aspects of
non-binary experiences.
When working with non-binary people in an applied context, the main thing
to bear in mind is the diversity of experience. For example, psychologists must
be mindful that non-binary gender can be both a destination and a waypoint,
as, of course, binary gender may be. This is analogous to the way in which some
bisexual people can later identify as gay/straight and some gay/straight people
can later identify as bisexual (Diamond, 2009).
Similarly, physical interventions may or may not be desired or required by
non-binary people. These may include hormones, surgeries, and changes to
aspects of appearance, clothing, gait, and/or voice. Rankin and Beemyn (2012)
found that some non-binary people who were assigned female at birth took
hormones and/or had chest (top) surgery. Others did not engage in permanent
body alteration but modified some visible markers of gender in other ways, such
as breast binding, bodybuilding, having a traditionally male hairstyle, not shav-
ing their body hair, and/or packing. Those assigned male at birth similarly had
differing relationships to hormones/surgeries, and did things such as growing
their hair long, having hair removed, using make-up, and/or wearing ‘feminine’
jewellery. Some people liked to destabilise conventional markers of gender by
dressing androgynously, by combining ‘men’s’ and ‘women’s’ clothing, and/or
by dressing in clothing associated with a different gender. Some made similar
shifts in mannerisms such as gait, making eye contact, and sitting with legs
together or apart.
As with many genders and sexualities, non-binary gender might be experi-
enced as fixed or fluid, and as ‘natural’, chosen, or socially constructed. Non-
binary people may regard themselves as being cisgender or transgender (see
Harvey & McGeeney, Cisgender, and Murjan & Bouman, Trans Genders, this vol-
ume). Indeed, some may find neither term to be a good fit, as cis/trans presents
a further binary. Given that cis and trans are taken from molecular biology, it is
possible that the additional molecular terms fac and mer may be embraced
in the future to describe non-binary gender statuses (as they do molecules;
Norman, 2014). Perhaps facgender people would include those whose expe-
riences fit between, or as a third addition to, binary genders (e.g. demi boy/girl,
gender neutral, or bigender) whereas mergender people would be those with
more fluid and/or multiple genders (e.g. genderfluid and pangender).
With all these issues, ask etiquette is appropriate (Richards & Barker, 2013):
simply ask what terminology people prefer and how they experience their
178 Gender
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.
The following recommendations (adapted from Richards & Barker, 2013)

are a useful guide when working with non-binary people:
• Reflexively engage with your own assumptions about gender and

encourage all staff within a service to do the same.
• Be open to reading and learning more about gender diversity and rais-
ing questions with clients (but don’t expect them to provide you with
free education).
• Become comfortable talking about gender issues and adopting clients’
terminologies.
• Normalise genders beyond the binary for clients who are new to this.
• Don’t focus on gender when it is not relevant to the client’s presenting
issue.
• Don’t assume a gender binary or pathologise people who don’t
experience themselves within it.
• Create a space which is comfortable for people from a diverse range of
gender identities (e.g. with relevant materials, posters).
Future directions
In terms of future directions, clearly more psychological research is required

into all aspects of non-binary experience, and into applied practice with non-
binary people across different settings.
In relation to quantitative research, it would be valuable to have more
research on people who identify as non-binary, as well as on those who expe-
rience their gender in non-binary ways without necessarily identifying in
that way (see Barker & Richards, Further Genders, this volume). Kuper et al.
(2012) highlight the importance of considering sampling when undertaking
such research, as their online survey found a very different range of people,
and experiences, than past research which has focused exclusively on those
attending gender clinics. Joel et al.’s (2013) research in the general popula-
tion found that 35% of people felt to some extent as the ‘other’ gender, as
both men and women and/or as neither, which highlights the importance
of studying non-binary experience in general rather than just among specific
communities.
In relation to qualitative research, further studies could usefully explore

the diversity of non-binary experiences, and the multiplicity of meanings
that non-binary identities have for the people concerned (rather than search-
ing for one ‘explanation’ for non-binary gender; Richards & Barker, 2013).
Doan’s (2010) geographical research considered how experiences varied across
different spaces. Other people commented upon, or even touched, gender non-
normative people in public spaces and asked inappropriate questions about
genitals/surgeries, and there were specific issues around the use of public toilets
and telephones.
It is important that research in this area neither eroticises non-binary peo-
ple nor assumes that all experiences will be the same (Richards et al., 2014).
It should also accountably consider the utility of the research for the peo-
ple involved and the groups they are drawn from. For example, Rankin and
Beemyn’s (2012) study explicitly fed into higher education policy, having deter-
mined that university accommodation, bathrooms, sport teams, paperwork,
and social traditions could easily exclude non-binary people. Research could
also usefully feed into such issues as passport gender recognition (Elan-Cane,
2013) and guidelines for media representations (Trans Media Watch, 2014),
with psychologists supporting activist endeavours and educating policy makers
and practitioners about the impact of misrepresentations and discrimination
(see Carrera et al., 2012).
Summary
• Non-binary gender is a fast-evolving area which remains under-researched

within psychology.
• Many literatures from other disciplines, and from outside the academy,
have useful information on non-binary gender which can be of benefit to
psychologists.
• Research with non-binary people should be undertaken ethically and with a
view towards how it can pragmatically aid this population.
• Identity terms continue to evolve and it behoves psychologists to engage
with them.
• Gender, sex, and sexuality are complexly intertwined. A cross-cultural,
intersectional understanding of non-binary gender is vital, but should not
be undertaken from a colonialist viewpoint.
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:
Richards, C., Bouman, W. P., & Barker, M. (forthcoming). Non-binary genders. London:
Palgrave Macmillan.
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11
Intersex/DSD
Katrina Roen
Introduction
Psychologists have made significant contributions to how intersex or diverse

sex development (dsd1 ) is understood, at key historical junctures (e.g. Kessler,
1998; Money et al., 1955), while medical research has played a greater role in
defining this topic area. This chapter addresses the questions: what has psy-
chological research offered so far, and what are the key tensions and dilemmas
facing psychologists working in this field?
Intersex/dsd is often defined in ways that make it appear as an extraordinar-
ily rare medical phenomenon. Here, I seek to define it in a way that makes
it a more ordinary psychosocial phenomenon. The purpose of this is to offer
respectful space for diversity, to question normative imperatives that are known
to have negative effects on emotional well-being, and to offer a way forward
in the ongoing dialogue about what role psychology can play in relation to
intersex/dsd.
The term ‘intersex’ emerged early in the twentieth century and came to be
used as an identity term that was the basis for political claims in the 1990s.
In the early 2000s, the term ‘Disorder of Sex Development’ (DSD) was pro-
nounced as more appropriate by those attending a decisive meeting which
produced the current consensus statement (Hughes et al., 2006). Since then,
most medical publications have been using the term ‘DSD’. Historically, the
term ‘hermaphrodite’ was used, and this overlapped with the medical usage of
‘intersex’ through much of the twentieth century. All of these terms are prob-
lematic for a number of reasons. First, the people to whom these terms are
supposed to refer do not wholeheartedly claim any of these terms, with many
people considering one or more of them stigmatising and pathologising. Many
people, to whom these terms are supposed to refer, choose to use a specific
diagnostic term instead, and many would not even know that these terms are
supposed to encompass the diagnostic group to which they belong. Further,
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
development, and to avoid reliving earlier trauma experienced in the name of

healthcare.
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.
When discussing the topic of intersex/dsd in classroom contexts, it is

worth remembering that a proportion of students will have personal
experience of this, and some may not fully realise that until they hear
about it in the classroom. This calls for particular care from all par-
ties involved in classroom discussion. For students who wish to pursue
a research project in this field, it would be very worthwhile explor-
ing research approaches that involve working with a general population
sample, rather than over-researching people who identify themselves as
intersex. Questions that can be addressed using a general population sam-
ple would, for example, involve interrogating what makes intersex/dsd
stigmatising and hard to talk about, and what kinds of changes could
reduce the stigma associated with natural bodily variation.
This chapter briefly examines contributions from a range of psychologi-

cal approaches, including clinical psychology, biological psychology, critical
psychology, and feminist psychology.
Reviews and empirical studies

Recent years have seen the publication of a number of review papers in which
researchers have trawled through previous (often medical) studies to extract
information that is relevant from a psychosocial perspective (e.g. Schönbucher
Katrina Roen 187
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).
Updates and conceptual contributions

Some recent publications offer useful updates and reflections, some drawing out
the implications of the consensus statement and treatment guidelines (Hughes
et al., 2007), or giving a current overview from a clinical-psychological per-
spective (Sandberg et al., 2012), or from critical psychology and biopsychology
perspectives (Roen & Pasterski, 2014).
Some publications reflect a growth in collaboration between service user
groups and health professionals, and address issues that are relevant to psy-
chological well-being, such as information exchange (Creighton et al., 2004;
Liao & Simmonds, 2013; Liao et al., 2010).
Some authors specifically challenge the heteronormative assumptions under-
pinning a number of intersex-related medical interventions (Liao, 2007;
Roen, 2008).
Academics wishing to undertake research in this field could usefully

contribute in various ways, for example: (1) critically examining the
role that psychology has played and continues to play in relation to
intersex/dsd, (2) identifying and trialling population-level interventions
that could make it seem less shocking and upsetting to parents that
their child has been born with some naturally occurring variation in
sex development, (3) building on the research literature that supports
mental health professionals working clinically in this field, (4) iden-
tifying and trialling interventions that would appeal to young people
and raise awareness about diverse sexed embodiment, thus reducing the
imperative to seek surgically produced normative embodiment at any
cost, (5) building an intersex/dsd element into sexuality and gender
188 Gender
(Continued)
research whenever that can be done meaningfully, (6) examining research

on parent-child relationships in the face of chronic illness or disability,
and drawing out the implications for supporting parents and children
affected by intersex/dsd, and (7) examining how respectful and appro-
priate understandings about intersex/dsd can be woven into school
curricula, including, but not limited to, sex education curricula.
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.
Non-essential genital surgery on infants

The most publicly visible debate in this field relates to non-essential genital
surgery on infants. This is a psychological issue insofar as (unsupported) psy-
chological or psychosocial rationales are used as a rationale for such surgery. For
some years, clinician-researchers have been trying to amass evidence to show
that either (a) such surgery produces good enough cosmetic and psychosocial
outcomes to be worth continuing or (b) such surgery is indefensible. Many
tensions and complications have plagued this debate. Some have pointed to
a lack of clear and consistent agreement on the timing of surgery, suggesting
that spurious psychological understandings are sometimes used to justify early
surgery (Woodhouse & Christie, 2005). Studies that compare outcomes between
a treated group and an untreated group are practically impossible, as untreated
groups tend to be untreated precisely because they are in regions of the world
where clinicians (and therefore clinical researchers) do not have access. Studies
that report outcomes which are seemingly bad enough to warrant a change
in practice may be debated and soon forgotten (Woodhouse, 2004) or may
be taken up very selectively (e.g. Creighton et al., 2001). Surgeons who argue
the case for early surgery repeatedly state that current surgical approaches will
be more successful than previous ones, but there is rarely research funding
available to do follow-up studies to test this claim. Finally, qualitative stud-
ies that repeatedly show the psychosocial effects of poor treatment outcomes
are often discounted on the grounds that the methodology does not approach
the ‘gold standard’. In short, the research evidence of poor outcomes from
current treatment methods is patchy, and what evidence there is gets quickly
discounted. The latest research with a UK-based clinical sample suggests that
adolescents presenting currently have undergone vaginoplasty and/or clitoro-
plasty almost as often now as adolescents presenting 13 years ago had (Michala
et al., 2014).
Pressure to stop non-essential genital surgery on infants and children contin-
ues, with a variety of activists, surgeons and other clinicians, and researchers
contributing constructively to this debate. In response to this pressure, some
changes are underway in some parts of the world. These changes are not well
190 Gender
documented, but it is clear from presentations and discussions at medical con-

ferences that some of the more aggressive surgical approaches that are being
carried out by some clinical teams are no longer seen as acceptable by other
clinical teams. These differences can be seen between countries and within a
single country.
Public calls for a halt to non-essential genital surgery on children continue.
The United Nations has issued a clear statement aligning such surgery with tor-
ture and stating that this surgery contravenes human rights, “causing severe
mental suffering” (Méndez, 2013, p. 19). A Swiss biomedical ethics report was
also made public, stating that irreversible medical sex assignment should not
take place until the person concerned is old enough to decide on that for
themselves (Swiss National Advisory Commission on Biomedical Ethics, 2012).
These moves are setting the stage for a different level of discussion about non-
essential genital surgery on children. Whatever changes might follow, research
and applied psychologists stand to play an important role.
Researchers could ideally draw together evidence about how children cope,
and what optimises resilience, in the face of growing up with a body that
is different. Such evidence could come from research concerning disabilities
and chronic illnesses, for instance. Psychologists could also be involved in the
change processes that healthcare systems will need to embark on if there is
a significant shift in practice: this will require education of a wide range of
healthcare professionals to work appropriately with and support, in the long
term, families raising one or more children with dsd. Whether or not there
is a significant change in surgical practice, any psychological work that helps
to reduce the level of stigma associated with sex diversity, sexual anatomy,
sex development, and the medical diagnosis of DSDs would make a useful
contribution.
Prenatal treatment and psychological outcomes

Recent years have seen the development and testing of dexamethasone, which
has been administered to some women at risk of carrying a child who will
develop congenital adrenal hyperplasia (CAH). Psychologists have now con-
ducted a small number of follow-up studies examining the cognitive and
developmental effects of prenatal dexamethasone treatment (e.g. Hirvikoski
et al., 2007, 2008; Meyer-Bahlburg et al., 2009).
Gender identity and transition

Some psychologists have focused particular attention on the question of how
to support people who, while in treatment following a DSD-related diagnosis,
develop a gender identity that is not consistent with their assigned sex (Cohen-
Kettenis, 2010). (See Sarah Murjan’s chapter, in this Handbook, for more on
gender identity and transition.)
Katrina Roen 191
For health professionals, trust is a crucial issue, as is sensitivity to lan-

guage. People who have non-normative experiences of sex development
may use a variety of terminology to refer to their experience, and may
have built up substantial feelings of mistrust in relation to health pro-
fessionals. Many examples of non-normative sex development will not
be perceived by the person concerned (or their parents, in the case of
children) to come under the intersex/DSD umbrellas. Instead, some peo-
ple will use a specific diagnostic term to refer to their particular variation
in development, and some will not have any terminology for describ-
ing their sex development. They may be unaware that it is atypical, or
they may not have been given a diagnosis, for example. The fact that
disclosure is not always achieved during childhood or adolescence means
that health professionals may encounter people (of any age) who are not
yet aware that their sex development falls into a medicalised category.
This makes it imperative for health professionals to be informed about
the appropriate terminology and sensitive ways to talk about dsd. Some
people, on the other hand, may identify themselves with a term such
as ‘intersex’, and may actively choose to refuse the terminology of diag-
nosis and disorder. Those who are actively refusing medical terminology
may also be refusing healthcare due to negative experiences with health
professionals in the past. Health professionals could usefully (1) work to
regain the trust of people who have distanced themselves from healthcare
and (2) work with immediate colleagues to ensure that the health service
is explicitly and visibly respectful and welcoming to all people, including
those with experience of intersex/dsd.
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
Psychological research in this field is helping to articulate frameworks of

understanding that can underpin future work. This includes, for example,
contributing to health professionals’ training (Leidolf et al., 2008), and build-
ing understanding about the potential for giving parents less medicalised
explanations for their child’s atypical appearance (Streuli et al., 2013).
Since the publication of the Consensus Statement (Hughes et al., 2006),
applied psychologists have been placed more squarely within multidisciplinary
teams specialising in working with intersex/dsd. This is a positive move, but it
places an onus on psychologists to engage critically with the biomedical models
that dominate, and to articulate psychological understandings that engage with
the concerns expressed by service users, among others. Liao and Simmonds
(2013) offer a vision of how psychologists can proceed with a values-driven
and evidence-based approach to providing care in this highly medicalised
context.
Summary
• Defining intersex/dsd in a way that makes it a relatively ordinary

psychosocial phenomenon could offer respectful space for diversity, help to
question normative imperatives, and contribute to thinking about the role
of psychology in relation to intersex/dsd.
• Sex development naturally produces a wide range of diversity, and that
diversity can relate to all or any of the following: chromosomal make-
up, hormonal production and response, gonadal development, and genital
appearance. Differences in sex development can be noticed in infancy, in
adolescence or later in life, or may remain unnoticed.
• The fact that dsd is often addressed as a medical issue is anomalous: most
instances of diversity do not have direct health implications. The main
health implications that are shared across many people are psychosocial: all
who vary from sex development norms potentially face shame and stigma.
• The silence and shame that can be associated with dsd, and with the asso-
ciated medical interventions, mean that many who experience dsd do not
share this information with anyone.
• Some psychologists researching in this field collaborate with biomedical sci-
entists to improve the accuracy of gender predictions and sex assignment.
Katrina Roen 193
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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12
Transgender – Living in a Gender
Different from That Assigned
at Birth
Sarah Murjan and Walter Pierre Bouman
Introduction
Transgender is a broad term, coined by Virginia Prince, an activist (King &

Ekins, 2000), and used to refer to a diverse group of individuals who cross or
transcend culturally defined categories of gender, including transsexual people;
people who cross-dress, drag queens and kings; non-binary people; and gender-
variant or transgender people (Bockting, 2009). Non-binary gender identities –
those that identify outside the binary gender of male or female – may include
genderqueer, bigender, pangender, genderless, agender, neutrois, third gender,
and gender-fluid people (see Barker & Richards, Further Genders, this volume).
The term trans is a self-identifying label that is commonly used and will
therefore be used here.
The assignment of a baby as male or female is generally referred to as birth-
assigned sex, or sex. This is to be distinguished from gender, which usually
refers to the social and psychological development that interplays with sex to
form gender identity. Consequently, an individual may have a gender which
either conforms or does not conform to socially expected social roles or gender
expression. Although informed by both sex and gender role, gender identity
is generally understood to be the internal sense of one’s gender. When there
is discrepancy between an individual’s sex and gender role and their expected
expression or identity, this may be termed gender non-conformity,1 but if it
causes significant discomfort or distress it may be termed gender dysphoria.
Readers should note that the term ‘gender dysphoria’ is used variously, here
and elsewhere, as both a descriptive and a diagnostic term.
Birth-assigned females who alleviate their gender dysphoria through transi-
tion to a male role are generally referred to as trans men or trans males where
it is pertinent that they are trans – otherwise simply ‘male’ is, of course, pre-
ferred. Similarly, birth-assigned males should be referred to as trans women or
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
Descriptions of the adoption of varying gender roles have been described

throughout history and across cultures. As early as the fifth century BCE,
Herodotus described the disease of the Scythians (morbus feminarium), which
was thought to be divine retribution for pillaging of the temple, in line with
his view of diseases as being from divine causes (Thomas, 2000). The sufferers
were described as follows:
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
Benjamin involved psychiatrists, electrologists, and surgeons and formed the

Harry Benjamin International Gender Dysphoria Association, which published
its first treatment guidelines in 1979. The organisation is now termed the World
Professional Association for Transgender Health (WPATH) and introduced Stan-
dards of Care (SOC) version 7 in 2012 (Coleman et al., 2012). More recently,
the first standards of care in the United Kingdom were published, which are
more applicable to a socialised healthcare system like the United Kingdom’s
National Health Service (NHS) (Wylie et al., 2014). Throughout the standards
of care, the role of the mental health practitioner, that is, the psychologist or
psychiatrist, is firmly embedded. The role now focuses on the assessment of
gender dysphoria; exploring options for gender identity and expression; giving
information about and preparing for available treatments, such as cross-sex hor-
mones and surgery; as well as addressing any concomitant mental health issues.
Thus, the role is to support decision-making and facilitate treatment as appro-
priate rather than any attempt to ‘cure’ people of being trans. There are fierce
debates around the medicalisation and psychologisation of gender identity.
However, in light of the distress which may accompany the feeling of hav-
ing been assigned the wrong sex at birth – and in order to obtain treatments –
there are currently diagnoses associated with feeling that one has been assigned
the wrong gender. It should not be assumed, however, that trans is necessarily
psychopathological, as, aside from the distress associated with marginalisa-
tion (called minority or marginalisation stress), there are no higher rates of
psychopathology in trans people than in the general population (Hoshai et al.,
2010). In particular, there is no evidence to suggest that major mental illness,
such as schizophrenia or severe depression, is more common than in similar
cisgender4 populations (Cole et al., 1997; Mustanski et al., 2010; Simon et al.,
2011). This is important, as there has been a view in the past that something as
drastic as wanting to undergo sex reassignment surgeries must be indicative of
some severe psychopathology. This is clearly not the case.
Being trans is considered to be a consequence of a multifactorial developmental

process in which biological as well as psychological, social, and cultural factors
play a role. There is a growing body of evidence which shows that key biolog-
ical factors are involved in the development of a gender identity which differs
from that assigned at birth (Garcia-Falgueras & Swaab, 2008; Gómez-Gil et al.,
2011; Hare et al., 2009; Kruijver et al., 2000; Rametti et al., 2011; Simon et al.,
2013; Zhou et al., 1995). It is also well established that psychological, social,
and cultural factors play a role in the expression of gender, and likely in many
instances in its formation (e.g. Cohen-Kettenis & Gooren, 1999; Veale et al.,
2010a, b).
202 Gender
Some of the biologically based research has focused on the neuroanatomy

of the brain. Post-mortem anatomical studies have shown that some subcor-
tical structures are feminised in trans females. The volume and the number
of neurones of the central part of the bed nucleus of the stria terminalis
(BSTc) and the third interstitial nucleus of the anterior hypothalamus (INAH3)
of trans females are typical for the size and neuron numbers found gen-
erally in cisgender females (Garcia-Falgueras & Swaab, 2008; Kruijver et al.,
2000; Zhou et al., 1995). These differences have been found to occur in trans
women irrespective of sexual orientation and cross-sex hormone treatment
(Garcia-Falgueras & Swaab, 2008; Kruijver et al., 2000; Zhou et al., 1995).
Structural imaging studies have shown that certain brain regions and struc-
tures in trans people are closer to those of cisgender people with the same
gender identity than to those of people with the same birth-assigned sex
(Simon et al., 2013). Chung et al. (2002) looked at evidence from a wide age
range of people and showed that the difference in the volume of the BSTc
between genders is not apparent until adulthood, which could be seen to be
at odds with the evidence that gender identity develops in childhood and
adolescence. However, there is wide support for the organisation-activation
theory, which has developed from mammalian studies, the first landmark
study by Phoenix et al. (1959) suggesting that prenatal androgen exposure
has an initial impact on the developing brain, which is then activated in
puberty under the influence of sex hormones. The model has been updated
by Arnold (2009) to recognise the important contribution of genetic factors
providing a unified theory of sexual differentiation. It can be seen, therefore,
that both intersex conditions (see Roen, Chapter 11, Intersex, this volume) and
gender dysphoria represent conditions of atypical sexual development due to
genetic and hormonal influences that affect the developing foetus at different
developmental stages, with some overlap between the two (Andreazza et al.,
2014).
While to some extent it is irrelevant how people come to be trans (as we don’t
spend a great deal of time considering why people are cisgender), it is clear that
our developing understanding of hormones and neurobiology has shaped our
understanding of gender and trans issues, and perhaps shaped the narratives
of trans people. It was in this context, as well as in the context of significant
work done by trans movements, that trans people gained access to physical
treatments such as hormones and surgery and that damaging psychological
and psychiatric treatments were discredited.
There is little evidence that psychosocial factors play a significant causative
role in the development of gender dysphoria, but they may interact with
biological aetiological factors. Indeed, being trans may be causative for
psychosocial factors, as, for example, transgender children may experience
lack of warmth or even rejection from their parents (Koken, 2009). There is
evidence that a poor or absent parental relationship, being an adoptee, hav-

ing older brothers, childhood abuse, and parental encouragement to express
a child’s desired gender rather than their assigned gender at birth are more
common among people with gender dysphoria (Veale et al., 2010a, b). There
are also cultural factors which come into play, as societies differ in terms of
their acceptance of trans people, which can impact on well-being and levels of
minority/marginalisation stress.
• Research into psychological aspects and psychological theories in rela-

tion to trans is controversial. Trans people show the whole range of
psychosocial diversity, as do cisgender people.
• It is extremely important that any research that is done is care-
fully considered and with thought to any potentially stigmatising
consequences.
• The continuing political need to distinguish between nature and nur-
ture only serves to obscure the well-accepted scientific notion that
psychosexual development involves a biopsychosocial process.
• It remains difficult, on scientific grounds, to avoid the conclusion that
the uniquely human phenomenon that is currently classified as Gen-
der Dysphoria in the DSM-5 and as Transsexualism in the ICD-10 is
a consequence of a multifactorial developmental process in which
biological factors play a role, but in which psychological, social, and
cultural factors remain crucially important.
• Trans people, if given appropriate gender-related care, do not have
higher rates of psychopathology than the general population.
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 approaches to assisting people with gender dysphoria

The current WPATH-recommended treatments for people with gender
dysphoria who seek physical alteration of their bodies consist of a triadic
approach, which may include psychological, hormonal, and surgical assess-
ment and treatment. Of course, there is no assumption that trans individuals
will have treatment in all, or indeed any, areas, and significant numbers of
people do not, for a variety of reasons. Generally, treatment follows the prin-
ciple of more reversible treatment followed by progressively more irreversible
treatments, and thus one would usually start with living in the desired gender
role before starting hormones to effect the secondary sex characteristics of the
preferred sex, and only after that considering sex reassignment surgeries such
as breast removal (chest reconstructive surgery); breast enlargement (augmen-
tation mammoplasty); the removal of reproductive capability (hysterectomy;
salpingo-oophorectomy; orchidectomy); and the creation of a penis or vagina
through genital reconstructive surgeries (GRS – phalloplasty; vaginoplasty).
The roles of the mental health professional, such as the applied psychologist
or psychiatrist, are outlined in the WPATH standards of care (Coleman et al.,
2012). The assessment of the person who seeks assistance for gender dysphoria
requires careful gathering of information relating to gender and sexual devel-
opment as well as exclusion of major mental illness that might be presenting
as gender dysphoria. The latter is uncommon, but might include someone
with a psychotic disorder such as schizophrenia who holds delusional beliefs
about their gender or body. Other examples might be someone with a severe
personality disorder in which there is severe disturbance of identity; or dysmor-
phophobia, which can be directed towards the genitals. There is no evidence
to suggest that these conditions are any more common in trans people than in
cisgender people, but, nonetheless, they are important to identify in order to
avoid mistreatment. Issues relating to gender identity and gender dysphoria
should be distinguished from ‘cross-dressing’5 by men or women for other
purposes, such as performance, comfort, or sexual pleasure (see Lenihan, Kainth

& Dundas Trans Sexualities Chapter 8, this volume). However, while many do
not, some people who cross-dress may go on to wish to change their body and
so seek physical treatments to that end.
The mental health professional should assess for co-morbid mental health
issues, and, indeed, high rates of anxiety and depression, deliberate self-harm,
and suicidality have been reported (Haas et al., 2010; Mathy, 2003), which have
been linked to gender-based discrimination and victimisation (Clements-Nolle
et al., 2006). Autistic spectrum presentations have been found to be over-
represented among children and adolescents with gender dysphoria (De Vries
et al., 2010), although the relationship is far from clear. It is also important
to recognise that trans people can, like cisgender people, present with a whole
range of mental and physical health problems which may be coincidental and
may need treatment as with any other person. When assessing a trans per-
son with significant issues such as schizophrenia, bipolar affective disorder, or
even learning difficulties, issues to consider might be the stability of the gender
identity and gender expression and the individual’s ability to understand any
treatment and give informed consent.
The role of the mental health professional, such as the applied psychologist,
is, therefore, to consider these issues as well as to gain an understanding of what
the individual hopes to achieve and what difficulties may need to be overcome.
People presenting to mental health professionals with gender dysphoria will
have varying degrees of experience of living in a gender role which is congruent
with their identity. Some individuals may have considerable anxiety regard-
ing the social transition to another gender role, and may need some support
and information as well as counselling/psychotherapy regarding the potential
gains and losses they may experience by making such a change. Exploring the
options for gender expression as well as the potential risks and benefits of tran-
sition can be some of the tasks of such psychotherapy, although it is important
to note that mandatory psychotherapy (rather than supportive assessment) for
trans people has been shown to be harmful (Lawrence, 2003). Psychotherapists
may discuss some of the challenges and negotiations that occur in relation-
ships and may explore the impact of stigma and both external and internalised
transphobia. The mental health practitioner may provide information, prepa-
ration and support regarding hormonal and surgical treatments if these are
requested.
For those people who are carefully evaluated, and who have lived in their
preferred gender role, hormones appear to be beneficial (Colizzi et al., 2014), as,
indeed do surgeries (Gijs & Brewaeys, 2007) – with good outcome after surgical
reconstruction linked to good pre-surgical psychological adjustment and family
support as well as at least one year of living in the desired gender role (Carroll,
1999).
206 Gender
• Diagnosis is mainly useful to obtain services for trans people, but

it is not particularly useful in everyday practice and does not
guide the individual or clinician in terms of physical treatments or
psychosocial approaches. It is more important to get an understanding
of the individual trans person’s life and the issues that are pertinent
to them.
• Careful and collaborative consideration of their life choices can be
important to help the person make thoughtful and considered deci-
sions to maximise the possibility of good psychosocial outcomes.
• The transition period can be particularly associated with anxiety, and
cognitive behavioural approaches with a positive stance towards trans
can be a useful approach.
• If physical treatment options are to be considered, the individual
needs to consider all the possible consequences, such as loss of
reproductive potential, which need to be planned for.
• Transition is often associated with renegotiation in relationships, and
couples and families may present for therapy.
• A significant proportion of couple relationships are unproblematic or
can be successfully renegotiated, but, for some, the task may be to
work through separation.
• Transition needs to be worked through with children, and, as in any
other change, such as parental separation or divorce, it is the ability of
parents to work together and work through the change with children
that is most important and most likely to affect outcomes; again, a
trans-positive approach is needed.
Current debates
There are complex debates and many community perspectives of importance

in this field, as well as academic ones, including those from Social psychology,
cognitive psychology, sociology, queer studies, english and comparative litera-
ture, and the like – and there are often fierce debates between them. Tensions
arise around issues such as the medicalisation of gender dysphoria, diagnosis,
and access to treatments such as cross-sex hormones and surgery, as well as
issues relating to identity and the place of marginalised communities within
contemporary and historical spaces. Consequently, some key terms are intro-
duced and the debate around (medical) classification will be considered below
as an effort towards reflecting one aspect of these debates.
Classification of gender dysphoria

Gender dysphoria has become a diagnostic term that has been adopted for both
adults and children by the American Psychiatric Association (APA) in the fifth
edition of their Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
(APA, 2013a). Gender incongruence is an alternative term which is likely to
be adopted by the forthcoming International Classification of Diseases (ICD)
version 11 of the World Health Organization (WHO) (Drescher et al., 2012).
Transsexualism is the current diagnostic term in ICD version 10 (WHO, 1992),
and Gender Identity Disorder of childhood the diagnostic term for children.
The term ‘transsexualism’ is generally not favoured, and is seen as stigmatising
by many trans communities and a significant proportion of clinicians in the
field. Gender Identity Disorder was the term used in the DSM-4 (APA, 1994);
however, the word ‘Disorder’ was deliberately removed and replaced with
‘Dysphoria’ in recognition that it was no longer seen as a disorder (APA, 2013b).
There has been enormous debate as to how trans-related issues should be
classified, with most people, including psychologists and psychiatrists, agree-
ing that such states are not indicative of mental illness. Many trans people do
not wish to be stigmatised with a mental health diagnosis, and trans activists
have long called for the removal of gender dysphoria as a psychiatric or psy-
chological diagnosis, arguing that it is harmful and stigmatising and does not
fit current aetiological evidence. Parallels have been made with the declassi-
fication of homosexuality in the 1970s (Drescher, 2010). However, there was
also concern expressed in the run up to the most recent revision of DSM – the
DSM-5 – that declassifying trans from the manual might negatively impact on
the provision of services such as medicine and surgery by health insurance and
taxpayer-funded treatment. There was considerable support for the category
of Gender Incongruence, which would have been inclusive of wide varieties
of gender identity and expression and does not imply a particular treatment
pathway – thereby encompassing those individuals who would not wish to
pursue physical treatments. Concerns were raised that, while inclusive, it would
encompass individuals for whom no diagnosis was needed, and that some sort
of criterion for the distress that individuals experience was needed. The WPATH
and APA favoured the diagnostic category Gender Dysphoria (De Cuypere et al.,
2010), and Bouman and Richards (2013) have given a critical analysis of the use
of the distress criterion in this context.
The APA have acknowledged that non-conformity to birth-assigned gender
is not in and of itself a mental disorder, but have retained the concept of dis-
tress as a core criterion for the diagnosis of Gender Dysphoria, which is the
term used in DSM-5 (APA, 2013). They have broadened the diagnostic crite-
ria to recognise those individuals who identify as genders other than male or
female. The WHO Working Group on the Classification of Sexual Disorders and
208 Gender
Sexual Health has recommended a diagnostic change from Transsexualism to

Gender Incongruence and removal from the section on mental and behavioural
disorders in the forthcoming ICD-11 (Drescher et al., 2012). A separate chapter
for Gender Incongruence has been recommended. These are clearly important
issues to be resolved, as current health insurance and tax-funded healthcare
require a diagnosis to allow access to treatment.
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.
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).
• Understandings of trans issues have developed enormously within

the last hundred years. It is important to recognise the legacy of the
medicalisation and pathologisation of trans people.
• It is extremely important that any research that is done is care-
fully considered and with thought to any potentially stigmatising
consequences.
• It is important to read literature critically, understanding that language
and understandings have changed and developed and not all litera-
ture is positive towards trans. Particular care needs to be taken when
reading some of the older literature.
• There are still therapists who believe that trans is something to
be cured, akin to reparative therapy for gay, lesbian, and bisexual
people, which has been found to be damaging and is without an
evidence base.
• There is a good evidence base for the psychosocial benefits to trans
people of physical treatments such as cross-sex hormones and surgery.
210 Gender
(Continued)
• Trans people should be referred sooner rather than later to a spe-

cialist who can consider these options with the person and refer for
treatment if appropriate.
• It is important to remember that gender and sexuality are different
concepts and that trans people display the whole range of human
sexual diversity, as do cisgender people.
• There has been much focus on sexuality and gender expression in
trans people which has not been to the benefit of trans people.
Future directions
The role of mental health practitioners, including applied psychologists, has

evolved in the treatment of trans people and will likely continue to evolve;
indeed, there may well be further changes in the requirements made of
trans people requesting treatments such as hormones and surgery – and,
consequently, of the applied professionals who see them.
For example, there is no other surgical procedure aside from GRS which rou-
tinely necessitates two mental health opinions to support surgery, and one
could ask whether this is justifiable in relation to the risks and is ethical. One
could also ask whether the risk of denying treatment to some outweighs the risk
of regret in a very small minority. There has been little research with regard to
regret, and further work is needed to look at long-term psychosocial outcomes
following treatment.
Perhaps because of this lack of an encompassing established evidence base
in trans care, there are wide variations in healthcare systems across the world,
with vastly different availability of treatments such as hormones and surgery.
In Thailand, for example, it is easy to buy over-the-counter hormones. The
advent of internet pharmacies has seen an increase in self-prescribing across
the world, but is not without its pitfalls, as people are not always aware of
the risks or of implications for matters such as fertility (Mepham et al., 2014).
Some trans people may be able to access treatment which is free at the point of
delivery (albeit with restrictions such as waiting lists), such as in the NHS in the
United Kingdom, while others may be covered by private insurance, and some
may only be able to access private healthcare at great personal expense, if they
can afford to do so at all. Again, there are debates to be had around the risks
and benefits of more restrictive or more freely available treatments.
Beyond the provision of healthcare, different countries have different laws
with regard to the process by which a trans person can legally change their
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.
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Part III
Relationships
13
Monogamy
Ali Ziegler, Terri D. Conley, Amy C. Moors, Jes L. Matsick,
and Jennifer D. Rubin
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
monogamous behaviour through official policies as well as widely endorsed

notions of morality (Anderson, 2010). For example, monogamous marriage
(and, in some cases, domestic partnerships) offers individuals economic ben-
efits in countries like the United Kingdom and the United States. Some of these
benefits include reduced taxes, social security benefits, and discounts for health
or car insurance (e.g. DePaulo & Morris, 2005). At the interpersonal level, those
who deviate from the monogamy norm may be stigmatised, lose their primary
romantic partners, and be viewed by others as having flawed character traits or
personality disorders (Conley et al., 2012a; Moors et al., 2013; see also chapter
on Non-Monogamies in this volume). At the psychological level, individuals
who are sexually unfaithful (i.e. cheat on their monogamous partners) rumi-
nate about their behaviours, resulting in increased levels of guilt and shame
about their extradyadic encounters (Anderson, 2010).
Definitions of monogamy across biological and social sciences

Interestingly, despite monogamy being essential to the culturally dominant
romantic relationship script, it is actually a challenging word to define.
Although monogamy is treated as a monolithic term by most people in the gen-
eral public, definitions often vary depending on the disciplinary background of
the speakers and whether monogamy is being used to describe public, social
behaviours or whether it is based purely on sexual encounters. Thus, those
who study monogamy often make a distinction between social monogamy and
sexual monogamy.
Among humans, social monogamy refers to how much a person wishes to
be labelled and perceived as monogamous within a social context (Anderson,
2010). For instance, social monogamy emphasises people’s desire to maintain
an image of monogamy to others, even if they are not sexually exclusive
with one person. One motivation for maintaining the appearance of social
monogamy is to help individuals protect themselves and their relationship
from prejudice and stigma (Anderson, 2010; Conley et al., 2012, 2012a; Moors
et al., 2013).
Biologists also use the term ‘social monogamy’, often to refer to animals that
form enduring pair bonds. Within this context, social monogamy describes
behaviour within species in which one male and one female form pair bonds
for more than one breeding season, regardless of whether the members of the
pair have sexual encounters with others (Lukas & Clutton-Brock, 2013).
The term sexual monogamy is notably different when used in a biological
context than in a psychological or public health framework. Biologists and
zoologists define sexual monogamy as having one and only one sexual part-
ner across the lifespan (Gubernick & Teferi, 2000; Kleiman, 1977; Pinkerton &
Ali Ziegler et al. 221
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.
Public health definition of monogamy

Due to the lack of consistency regarding the definition of monogamy across
fields, we prefer to rely on a more accessible conceptualisation put forth by
the Centers for Disease Control: “mutual monogamy means that you agree to be
sexually active with only one person, who has agreed to be sexually active only
with you” (United States Centers for Disease Control and Prevention (CDC),
2009). This definition likely became familiar in the United States as a result
of the AIDS crisis in the early 1980s, when public health officials routinely
advocated for changes in sexual behaviours to curb the spread of HIV (Koop,
1987). The CDC definition is particularly fitting because most people informally
use the term ‘monogamy’ to denote sexual exclusivity.
Lay definitions of monogamy

Finally, lay people have different (and more idiosyncratic) definitions of
monogamy than those in either the social or biological sciences or public
health. Monogamy can be more fluid, indicated by such descriptions as “I’m
monogamous with whomever I’m with” (Stevens, 1994, p. 13), such that a per-
son is always monogamous, so long as she or he has only one partner at a time.
By this definition, monogamy is a fleeting, momentary commitment. Likewise,
some sex workers may define themselves as monogamous as long as they have
only one partner who is not paying for sex (Warr & Pyett, 1999). In addition,
we have informally seen that individuals often define themselves as monoga-
mous even if they are engaging in threesomes with their partner (Conley et al.,
2012b). Another type of monogamy, serial monogamy, occurs among individ-
uals who have one partner at a time, but transition, often quite quickly, from
one partner to another (Britton et al., 1998). Thus, it is important to realise that,
when both academics and lay people talk about monogamy, the exact meaning
of that phrase is far from clear. More research is needed on how people define
222 Relationships
the terms of their relationships surrounding sexual exclusivity, especially since

definitions of monogamy are currently idiosyncratic, contradictory, or in flux.
Why do people engage in monogamy?

Although monogamy is inconsistently defined across and within disciplines, as
well as by people who engage in it, we know that it is a common relationship
practice. Presumably, this type of relationship is common because it affords
people a multitude of benefits. However, despite the popularity of monogamy,
we could not find any study that could directly answer: “What are the benefits
of monogamy?” Given that we were unable to find clear answers, we conducted
our own study and asked people to list the benefits of monogamy. People fre-
quently mentioned eight major benefits that monogamy affords: commitment
(dependability, long-term), health (minimal sexual risk, no physical violence),
trust (no jealousy, faithfulness, honesty), meaningfulness (respect, feeling valued,
deepness), passion (passionate love, true love), sex (frequent sex, exciting sex),
morality (moral, natural, what God wants), and family (financial gain, appropri-
ate environment to raise children; Conley et al., 2012a). Interestingly, despite
the lack of consensus as to how monogamy is defined, people did not seem to
have problems agreeing on specific benefits of monogamy.
Taken together, people perceive monogamy to afford them a range of ben-
efits, including commitment, passionate love, trust, minimal sexual risk, and
great sex (Conley et al., 2012a). But do people believe that these benefits only
exist in monogamous relationships, or might they exist in other relational
agreements, as well? In a series of experiments, we asked people to evalu-
ate one of two relationships: monogamy (romantically and sexually exclusive
with one person) and consensual non-monogamy (romantically and/or sexu-
ally non-exclusive, but agreed on; Conley et al., 2012a; Moors et al., 2013).
People rated individuals in monogamous relationships as higher on all of these
relationship qualities (listed above) than individuals engaged in consensual
non-monogamy (Conley et al., 2012a; Moors et al., 2013). Thus, people believe
that relationship benefits, such as trust, morality, commitment, and sexual
safety, apply to monogamy and not consensual non-monogamy. People may
engage in monogamy because they believe it is the only type of relationship
that provides them with great relationship outcomes.
Important Points for Students
Although most people think of monogamy in simplistic terms, such as

“are you two together?”, understanding the specifics of monogamy is
a complex matter. Scientists between disciplines and within disciplines
use different definitions and do not necessarily agree on the answer to
“what is monogamy?” Subsequently, defining monogamy varies between

researchers and the general public, from person to person, and relation-
ship to relationship. The construct of monogamy is far more complex, we
would argue, than most people assume. Moreover, people may engage in
monogamy because they perceive this type of relationship uniquely pro-
duces positive outcomes (such as trust, commitment, and love) whereas
people do not perceive other types of relationships as affording the same
benefits.
History
Researchers have typically assumed that, if someone indicates “yes” to the

question “are you in a relationship?”, that person is in a monogamous relation-
ship. However, as discussed in the previous section, researchers and the general
public have varied definitions of what is monogamy. Within the field of psy-
chology, there appears to be an assumption that love, pair bonds, and romance
are synonymous with monogamy. In other words, monogamy is a premise that
underlies the study of romantic relationships in the field of psychology.
Additionally, the way psychologists typically assess and measure healthy
functioning in romantic relationships assumes that people are monogamous.
For example, psychologists are often interested in how satisfied people are with
their romantic relationship. One popular way to measure relationship satis-
faction is a scale that includes the item: “How well does your partner meet
your needs?” (Hendrick, 1988). Answering this question seems very straight-
forward – if a person is in a monogamous relationship. However, some people
practice consensual non-monogamy and are likely to believe that is not reason-
able to expect that one person would meet your needs (Barker, 2005). Another
example of this assumption of the universality of monogamy in psychological
research comes from the Passionate Love Scale (Hatfield & Sprecher, 1986). This
measure is used to assess how passionately in love people are with their roman-
tic partner, and includes an item: “I would rather be with [partner’s name] than
anyone else.” What if someone has two equally strong partnerships? Again, this
statement seems difficult to agree or disagree with for someone who is dating
more than one person.
In addition to the ways psychologists think about and measure romantic
relationship functioning, psychologists often discuss monogamy favourably
in undergraduate textbooks. For instance, in a popular textbook on roman-
tic relationships, Miller and Perlman (2012) at one point bemusedly note that
some people stay on the relationship market “even after they are married!”
(p. 183), clearly presuming monogamy. Later, based on prior research, they
advise readers to “Seek a social network that will support your faithfulness
224 Relationships
instead of undermining your monogamy and handle attractive alternatives

with caution” (p. 430). Again, this is relevant advice for monogamous read-
ers, but the possibility of managing a non-monogamous configuration is not
addressed.
Thus, psychologists who study romantic relationships appear to have

determined that monogamy is the best way to approach sex, love, and
romance. However, evidence to support monogamy as the optimal form
of romantic relationship is notably lacking (Conley et al., 2012). There
are various types of romantic relationships that people can engage in, or,
of course, people can choose singlehood. It seems that the field of psy-
chology has a bias towards assuming people are monogamous – and that
monogamy is the only form of romantic partnering.
Monogamy and sexual health

One burgeoning area of research on monogamy addresses the utility of
monogamy for sexual health, especially the prevention of sexually transmit-
ted infections (STIs). Most research has assumed that monogamy is the most
effective means of preventing STIs (Conley et al., 2012). Of course, monogamy
would be very effective if it were implemented perfectly, but we know that
monogamy is not implemented perfectly (Britton et al., 1998; Pinkerton &
Abramson, 1993). More recent research suggests that, instead of providing
security surrounding STIs, an agreement of monogamy may actually add an
extra layer of risk: people may presume that their partner is being faithful
(and simultaneously poses little threat to their sexual health) and, correspond-
ingly, use no protection to prevent STIs when engaging in sex with this partner
(Conley & Rabinowitz, 2004; Conley et al., 2012). A recent study compared
the safer sex behaviours of ostensibly monogamous people (i.e. people who
are committed to a monogamous relationship but reported cheating on their
partners) and consensually non-monogamous people (i.e. people who have
mutually agreed with their partners that they will have other sexual partners;
Conley et al., 2012) in order to examine the safer sex behaviours of these
two groups of individuals both within their primary dyadic relationship and
also during their most recent extradyadic sexual encounter. Individuals who
were sexually unfaithful were less likely to use barriers during their extradyadic
encounter, less likely to tell their partner about the encounter, and less likely to
be tested for STIs than individuals in consensually non-monogamous relation-
ships (Conley et al., 2012). Moreover, individuals who were sexually unfaithful
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
There is ample evidence to support that an unwritten, yet well-known, script

for coupling exists in countries such as the United States and the United King-
dom. DePaulo and Morris (2005) have suggested that marriage is not only seen
as normative and expected, but is also viewed as an achievement worthy of
celebration (e.g. weddings and commitment ceremonies). Despite progressive
changes in attitudes towards how people should date, these attitude changes
have not affected ways of thinking about monogamy (Petersen & Hyde, 2010;
Thornton & Young-DeMarco, 2001). For example, premarital sex and unmar-
ried cohabitation no longer carry the stigma that they once did; however,
the societal expectation remains that these premarital relations are monoga-
mous in nature. Furthermore, while there is less stigmatisation of premarital
sex and cohabitation, there is still an implicit understanding that one will
‘settle down’ and strive for monogamous marriage later in life. Exceptions
to lifetime monogamy (i.e. one sexual/romantic partner across the lifespan)
appear to be allowable, as long as one seeks monogamous marriage. Search-
ing for a monogamous marriage partner offers societal redemption from a
promiscuous past.
In addition to societal expectations regarding monogamy and ‘settling
down’, a steadily growing multi-billion dollar online dating industry has
formed to help individuals ‘find the one’, most often emphasising the singular
and defining nature of a monogamous relationship in one’s life. The num-
ber of users signed up for online dating sources are far from trivial; according
to popular dating sites, estimates of active online daters are in the millions
(eHarmony.com, 2010). Moreover, within the United States, 37% of single
Internet users looking for a romantic partner had visited an online dating
site (Madden & Lenhart, 2006). Slogans as well as the webpage layout for
226 Relationships
popular commercial dating sites echo the expectation of monogamous cou-

ples. For instance, Match.com tells its potential customers: “Love starts here”,
eHarmony.com states you should sign up because “Love is out there. We can
help you find it”, and plentyoffish.com declares: “Sign-up now and find your
soulmate!” In terms of webpage layout, when describing what you are seeking
in a partner, these sites make it impossible to describe more than one ideal
partner.
Isn’t everyone monogamous?

Although monogamy is believed to be a hallmark of human mating, sexual
monogamy may not always have been the preferred relationship configura-
tion among humans, and possibly originated only within the last 10,000 years.
Specifically, sexual monogamy may be an adaptation to social conditions, such
as the advent of agriculture (Ryan & Jethå, 2010). Further evidence for the
impact of agriculture on monogamy can be found in present-day foraging
societies where monogamy is not the norm (Beckerman & Valentine, 2002).
These deviations suggest that one’s proximate social environment may be
largely influencing romantic relationship dynamics and indicates that, perhaps,
perceptions of monogamy as ideal are related to current social and ecological
factors and not because of its inherent superiority.
In addition to temporal variations in the practice of monogamy, there are
also significant cultural variations. In one of the largest cross-culture studies,
Schmitt (2005) found that, worldwide, both women and men engage in non-
monogamous behaviours. Schmitt argued that the dominant sexual approach
of a particular culture varies based on a number of ecological factors, including
the proportion of men to women (sex ratio), mortality rates and availabil-
ity of resources. Moreover, across cultures, people tend to fall somewhere on
a monogamy continuum between ‘completely monogamous’ and ‘completely
non-monogamous’ (as measured by the Sociosexuality Orientation Inventory,
SOI; Simpson & Gangestad, 1991). Thus, it seems likely that monogamy is not
a stable and static norm among all humans; instead, most people – across the
world – engage in non-monogamous behaviours and relationships. This is evi-
dence that non-monogamous mating patterns are common among humans,
and potentially the preferred sexual strategy.
Even more recently, scholars have identified variations in the practice
of monogamy in Western societies. In an attempt to distinguish between
monogamy in theory and monogamy in practice, Pinkerton and Abramson
(1993) identified and explained three different types of sexual activity pat-
terns related to monogamy: lifelong monogamy (one sexual partner across
the lifespan), complete promiscuity (one sex act per partner and several part-
ners across the lifespan), and serial monogamy (several mutually monogamous
non-current partners across the lifespan). Although lifelong monogamy may
be particularly desirable from a risk reduction perspective (e.g. less likely to

contract HIV), this form of monogamy is far too often unattainable. Instead, a
more realistic assumption of monogamy is serial monogamy – in actual prac-
tice, monogamy typically does not mean that a partner is and always will be
one’s only sex partner. Thus, researchers may not be consistently making dis-
tinctions between how people are actually practising monogamy versus what is
implied in the term ‘monogamy’.
Departures from monogamy

As we have discussed, monogamy is perceived overwhelmingly positively
within the Western world; and, consequently, deviations from the monogamy
norm are perceived negatively (Conley et al., 2012, 2012a; Moors et al.,
2013; see also chapter on Non-monogamies). Due to the limited research
explicitly examining monogamy, we turn to research that examines depar-
tures from monogamy in order to better understand controversies surrounding
monogamy. Two specific deviations that we will discuss further in this chapter
are singles (or people not in romantic relationships) and extradyadic affairs.
You’re still single? Repercussions for not ‘settling down’

One way in which people can deviate from monogamy is by having no part-
ners (i.e. being single). Generally, individuals who are not engaged in romantic
relationships (even if they are involved in sexual relationships independent
of commitment) are categorised as singles. Researchers have begun investi-
gating singles and the ways that they are perceived compared with people in
(presumed monogamous) romantic relationships.
• Interestingly, research related to when one should ‘settle’ down suggests

that the mid-twenties is the cultural norm (Morris et al., 2006). Moreover,
individuals who were 25 years old (and older) were viewed negatively for
being single compared with their married 25-year-old counterparts (Morris
et al., 2006). Both 25-year-old single men and women were more likely to
be described as less socially mature, less well-adjusted, more self-centred,
and more envious than those who were married. Moreover, these differences
between single and married individuals became larger as age increased, such
that 40-year-old singles were judged more harshly than 25-year-old singles
(Morris et al., 2006).
• Ironically, the majority of women and men are not married by the age of 25
(Information Please Database, 2009; Morris et al., 2006; US Census Bureau,
2012), yet there is an apparent established cultural norm that people should
be married by 25. Consequently, women and men receive social stigma for
their single and presumed non-monogamous status (e.g. DePaulo & Morris,
2005).
228 Relationships
Monogamy and infidelity

If we know that monogamy is so pervasive and widely endorsed, then why
might individuals cheat even when they claim to be monogamous? Anderson
(2010) suggests that some men cheat because they cannot live up to the
excessive and unrealistic standards outlined by monogamy. For instance, 68%
of undergraduate heterosexual men have cheated on a partner by kissing a
person outside the relationship, and 49% have cheated on a partner by hav-
ing intercourse with another person while in a ‘monogamous’ relationship
(Wiederman & Hurd, 1999). As further evidence of the prevalence of infidelity,
roughly half of a large sample of online respondents (N > 70, 000) reported that
they had been unfaithful in their relationships at least once (Weaver, 2007, as
cited in Emmers-Sommer et al., 2010).
Contrary to popular belief, cheating does not always result from a person
falling out of love with a partner or from her or his desires to find a new roman-
tic relationship partner; instead, motivation to cheat is often fuelled by the
desire for recreational sex (Anderson, 2010). In fact, a majority of undergraduate
men reported satisfaction with their current relationships, yet dissatisfaction
with their sexual lives. Cheating, then, may provide an outlet to satisfy one’s
desires for casual sex, while maintaining the image of monogamy (Anderson,
2010; Treas & Giesen, 2000). Simply put, individuals may secretly have physi-
cal affairs with others because they fear the consequences of having an honest
discussion with their partners about opening the relationship to extradyadic
encounters. Correspondingly, women who have been cheated on are pressured
to break up with their boyfriends in order to protect their image of having
a monogamous identity (DeSteno et al., 2002). Notably, not all cheaters are
men, and romantic relationships have a wide range of dynamics that vary
based on each individual relationship. However, as we will discuss below, mar-
riage (between a man and a woman) has historically disadvantaged women to a
greater extent than men. And, accordingly, normative gendered scripts within
monogamous romantic relationships between one man and one woman more
often prescribe men the role of the cheater and women the role of the cheated
on. In sum, most Western societies provide little flexibility regarding the rules
of monogamy and also administer consequences for violations of monogamy
that affect both people in the relationship.
Despite high rates of cheating, there are clearly people who remain faithful
to their monogamous partners. Although it is likely that different people have
different motivations for upholding a monogamous agreement, one potential
explanation is to avoid the undesirable consequences of engaging in infidelity
(Emmers-Sommer et al., 2010). Emmers-Sommer and colleagues outline such
consequences as sanctions that are social (disappointing one’s family), legal
(experiencing divorce complications), relational (hurting one’s partner and
possibly terminating the relationship), and personal (feeling shame or guilt for
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).
Gender and monogamy

Though we believe it is important to question monogamy’s status as the
ideal human relationship configuration, we also find it important to ques-
tion how monogamy may be differentially advantageous (or disadvantageous)
for women versus men (see also Ziegler et al., 2014). Historically, the institu-
tion of monogamy has not promoted gender equality, especially given that
marriage previously allowed the ownership of wife by husband (Weadock,
2004). And, although relationship dynamics have changed and greater gender
equality has been established (Rayside, 2007), certain components of con-
ventional monogamy still exist in a way that restricts women’s agency and
autonomy. In monogamous relationships, sexual scripts have strict and specific
rules for how women and men enact their gender roles (Gagnon & Simon,
1973; Sanchez et al., 2012). Of course, not all monogamous relationships
oppress women; however, the established institution of monogamy may make
it challenging to question normative gendered scripts (Barker, 2005; Barker &
Langdridge, 2010).
Despite monogamy’s disenfranchisement of women, the pressures and
excitement surrounding ‘settling down’ are actually greater for women than
for men (Krueger et al., 1995). And, accordingly, research continues to find that
women, compared with men, are more committed to monogamy and hold less
positive attitudes towards consensually non-monogamous relationships (e.g.
polyamory; Moors & Conley, in preparation; Moors et al., 2014). Women’s
greater investment in monogamy may seem puzzling given its oppressive foun-
dations; however, from a sociocultural perspective, it may actually be quite
practical, because women are taught that their success and subsequent value are
reliant on their romantic relationships. This ensures women’s dependence on
men (Rudman & Heppen, 2003), thus further increasing women’s investment
in monogamy (Kilianski & Rudman, 1998). Women are not only socialised to
believe that marriage is an important lifetime achievement, but, arguably, they
are also taught that their identity as a woman is dependent on their ability to
fulfil these relational roles. Thus, by not engaging in traditional monogamous
relationships, women fail to fulfil essential components associated with their
role as women.
230 Relationships
Despite monogamy’s status as the ideal romantic relationship, people engage

in relationships that depart from this normative standard (Conley et al., 2012a;
Conley et al., under review). For example, a 2002 representative sample of
adults from the National Survey of Family Growth (NSFG) found that approx-
imately 18% of women and 23% of men were engaged in non-monogamous
relationships – though it is not clear whether these non-monogamous rela-
tionships are undertaken with the consent of both partners (Aral & Leichliter,
2010). Given this diversity, clinicians and counsellors should be knowledge-
able about all relationship configurations in order to avoid making assump-
tions about the status of clients’ relationships and, in turn, to better serve
their clients. This awareness can help clinicians and clients discuss a range
of sexual and romantic partnerships that may define people’s intimate lives
(Shernoff, 2006).
Increased awareness about the diversity of relationships is beneficial across
all healthcare settings. Given that an agreement of monogamy may actually
add a layer of risk for STI prevention (i.e. whenever monogamy agreements are
not perfectly upheld; Conley et al., 2013), physicians and health professionals
should explicitly ask about the patient’s sexual behaviours, rather than iden-
tity or relationship status. For example, a couple may have an agreement to be
mutually monogamous, but may fail to live up to this agreement (e.g. extramar-
ital affairs), or a spouse who is in a long-term, committed relationship may be
assumed by her care provider to be sexually monogamous, even though she has
an agreement with her partner to be sexually non-monogamous. Subsequently,
using categories such as ‘partnered’ or ‘monogamous’ to screen patients for
STI risk may be ineffective due to departures from monogamy agreements (Choi
et al., 1994), or, for that matter, lack of explicit monogamy agreements in
a dyad.
In general, the assumptions that healthcare providers make about roman-

tic relationships and their own biases in favour of monogamy are similar
to assumptions that providers may make about a client’s presumed
heterosexuality (e.g. O’Hanlan & Isler, 2007). Similarly to the call for
increased awareness about sexual orientation and gender identity in med-
ical fields, it is important for both providers and clients to communicate
openly about not only the client’s current relationship configuration but,
more importantly, the romantic and sexual behaviours that contribute
to her or his mental health, risk for STIs, and overall experiences of
relationships in order to provide the best and most thorough care.
Future directions
As previously discussed, research that exclusively investigates monogamy is

limited, and there is little empirical evidence that directly addresses the unique
benefits of monogamy. The little research that does exist has found comparable
relationship satisfaction and functioning among gay men in monogamous ver-
sus consensually non-monogamous romantic relationships (Blasband & Peplau,
1985; Kurdek & Schmitt, 1985; Wagner et al., 2000). These findings primarily
come from gay male samples, but we argue that it is not unreasonable to expect
similar results in heterosexual samples. We are also aware of extensive amounts
of research that have been conducted on the topic of marriage, romantic
relationships, and heterosexual relationships; but, to our knowledge, no pub-
lished research has considered the implications of the presence or absence of a
monogamy agreement as it relates to satisfaction, longevity, or other markers
of dyadic adjustment. The question of whether monogamy is the most psycho-
logically, socially, and culturally advantageous relationship configuration is, in
fact, an empirical one.
In addition to factors related to relationship functioning, we are also inter-
ested in better understanding other components of monogamy. For example,
we previously reviewed the inconsistencies in definitions of monogamy; there-
fore, it would be helpful to conduct research to better understand how individ-
uals personally define monogamy and the implications this has for the types of
relationship agreements that they have with their partners. We have also sug-
gested that monogamy may be more advantageous for men than for women,
yet we lack the empirical evidence to confirm this theory. This is a pressing issue
for future research on the benefits and liabilities of monogamy. Evidence is also
lacking regarding the potential benefits of monogamy for children, and, there-
fore, this is clearly an area that would benefit from more extensive empirical
research (Conley et al., 2012).
In sum, we have identified gaps in the current literature on monogamy
and conclude that there is no definitive empirical evidence to indicate that
monogamy is the optimal relationship configuration. Although we believe
that monogamy can and does provide certain benefits, it is currently unclear
whether or not these benefits are unique to monogamous romantic relation-
ships. Therefore, at this point, it is necessary to re-examine cultural assumptions
about monogamy using empirical approaches. We hope the current review
demonstrates the necessity for research on monogamy as well as alternatives
to monogamy.
Summary
• Most people in the general public treat monogamy as a monolithic term,

yet definitions vary depending on the discipline and whether monogamy is
232 Relationships
being used to describe public, social behaviours or whether it is based purely

on sexual encounters.
• Monogamy is perceived overwhelmingly positively; thus, deviations from
the monogamy norm, including singlehood and extradyadic affairs, are
perceived negatively (Conley et al., 2012, 2012a; Moors et al., 2013).
• Despite monogamy’s status as the ideal romantic relationship, current
research does not support the cultural truism that monogamy is supe-
rior across multiple domains, including sexual health (Conley et al.,
2012a).
• Monogamy is a premise that underlies the study of romantic relationships
in the field of psychology. Accordingly, psychology researchers have often
equated love, pair bonds, and romance with monogamy.
• It is challenging to interrogate normative gendered scripts within the con-
fines of the monogamy script, and thus monogamy may reinforce oppressive
gendered structures (Barker, 2005; Barker & Langdridge, 2010).
• It is important for clinicians and counsellors to be knowledgeable about all
relationship configurations in order to avoid making assumptions about the
status of clients’ relationships and, in turn, better serve their clients.
• There is a lack of empirical evidence regarding the unique benefits of
monogamy; therefore, this is clearly an area that would benefit from more
extensive empirical research (Conley et al., 2012).
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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14
Open Non-monogamies
Nathan Rambukkana
Introduction
This chapter discusses the recent literature1 on open non-monogamies, or

non-monogamous arrangements that are known about by, at the very least,
all the involved intimate partners. (This specifically excludes a consideration of
the growing parallel literature on secret non-monogamies (e.g. infidelity, adul-
tery, and cheating) addressed in relation to monogamy and marriage in Ziegler,
Conley, Moors, Matsick, & Rubin, Monogamy, this volume.)
This growing field comprises work on polyamory (discursively ethical or
consensual non-monogamy); on polygamy (plural marriage, usually – but not
exclusively – polygynous: Muslim, Christian, and other); on swinging (some-
times known as The Lifestyle, a subculture devoted to casual open sex); and
on non-monogamies outside these three major formulations. This last category
includes open marriages and relationships; alternative marital arrangements,
sometimes referred to as swapping2 or co-marital sex; friends with benefits;
group sex (e.g. threesomes, orgies); open-sex commune experiments (e.g. the
Oneida intentional community); and otherwise-unnamed non-monogamous
intimate practices such as those that can occur in some lesbian, gay, bisex-
ual, and kink subcultures. Finally, it also includes work that considers non-
monogamies broadly across these categories. These practices have different
histories, etymologies, facets, and politics. Some of these practices are thou-
sands of years old, some are merely decades old and some are just being fleshed
out; some have their origins in religion or spirituality, others in a staunch
and iconoclastic secularism. Taken together, however, they form a present and
undeniable facet of contemporary intimacy that has been growing in promi-
nence and significance in the public sphere and public culture since at least the
early 1990s (Rambukkana, 2015). Engaging with open non-monogamies is no
longer something relegated to societal margins in the life of Western societies; it
has shifted to be a part of the centre – albeit a part that sits somewhat uneasily
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
There is a burgeoning presence of work on non-monogamies in academia.

While the histories of scholarship in this area stretch back to early legal, crit-
ical, and sexological engagements – as well as social, biological, evolutionary,
cross-cultural, and even some experimental and psychoanalytic approaches in
psychology – massive multidisciplinarity of formal discourse on open non-
monogamies (let alone monogamy and non-monogamy as a whole6 ) makes it
238 Relationships
difficult to summarise in a survey chapter. It is easier, perhaps, to highlight work

that explores open non-monogamies in the immediate historical moment of
the past 50 years. The period of the 1970s–1980s introduced notions of swing-
ing and open marriages to sustained academic study. Then, the late 1980s and
early 1990s saw the birth of queer theory and the growth of modern sexual-
ity studies from niche subdisciplines (and an at-times marginalised major field
of sexology) to full-fledged and increasingly mainstreamed disciplines and pro-
grammes that brought with them a concomitant tide of new work. Finally,
the period from the mid-1990s to the present introduced polyamory discourse
into academic study, catalysing a renewed interest in open non-monogamies
that combined with current socio-political happenings to bring new scrutiny
to polygamy as well.
The exploration of polyamory (or poly) is particularly on the rise in the
current period. From the mid-1990s to mid-2000s, edited collections such as
Kevin Lano and Claire Parry’s Breaking the Barriers of Desire: Polyamory, Poly-
fidelity and Non-monogamy – New Approaches to Multiple Relationships (1995);
Marcia Munson and Judith Stelboum’s The Lesbian Polyamory Reader: Open
Relationships, Non-monogamy, and Casual Sex (1999), and Serena Anderlini-
D’Onofrio’s Plural Loves: Designs for Bi and Poly Living (2004) – some of which
were simultaneously published as special issues in LGBT* and queer academic
journals – broke ground in bringing a largely positive (though occasionally
critical) discussion of polyamory into academia. A watershed moment was
Jin Haritaworn et al.’s (2006) Sexualities special issue on polyamory, which
brought a more critical thread into the discussion, questioning how issues of
power and privilege intersect with polyamory specifically and non-monogamy
broadly. As Meg Barker and Darren Langdridge’s collection Understanding Non-
monogamies (2010) explores, the study of non-monogamy and its discussion
in multiple spheres, from the theoretical to the applied, was on the rise.
Evidence of this can be seen in the spate of doctoral and MA projects that
have been (or are being) produced on polyamory and non-monogamies, an
early example being Christian Klesse’s dissertation on polyamory and non-
monogamy within UK gay male and bisexual communities, published as
Spectres of Promiscuity: Gay Male and Bisexual Non-monogamies and Polyamories
(2007), the first monograph on poly issues. Thinner early on (Noel, 2006),
more of this later work engages with broader issues of power, some even
including a burgeoning critical academic response to polyamory that, while
supporting many of its general principles, mounts a constructive critique of the
shortcomings of the discourse itself. More recent major works include Maria
Pallotta-Chiarolli’s Border Sexualities, Border Families in Schools (2010), Elizabeth
Sheff’s The Polyamorists Next Door: Inside Multiple Partner Relationships and Fam-
ilies (2013b) and my own Fraught Intimacies: Non/Monogamy in the Public Sphere
(2015).
In addition, there is a healthy discussion of polyamory in academic jour-

nals and book chapters, addressing the relationship of polyamory to multiple
topics, such as: anarchist theory (e.g. Heckert, 2010; Shannon & Willis, 2010);
feminism and women’s issues (e.g. Aguilar, 2013; Pallotta-Chiarolli, 2013);
LGBT* and queer issues (e.g. Moss, 2012), and bisexuality specifically (e.g.
Anderlini-D’Onofrio, 2011; Estep, 2006); race issues and diaspora (e.g. Williams,
2010); class issues and privilege broadly (Haritaworn et al., 2006; Klesse, 2013);
neoliberalism (Woltersdorff, 2011); therapy issues and alternative approaches
(e.g. Barker, 2011; Keppel, 2006; Weitzman, 2006); communal living (Aguilar,
2013); the criminalisation of plural unions (Barnett, 2013); and kink (Sheff &
Hammers, 2011). There is also some work devoted to general discussions of the
dynamics of open non-monogamies (e.g. McLean, 2004; Robinson, 2013; Sheff,
2015).
Finally, there is a profusion of writing on polyamory in the self-help and
activist vein, much of which is written by counselling and therapy profession-
als and/or academics. Older, more foundation titles include Dossie Easton and
Janet Hardy’s [Catherine Liszt’s] The Ethical Slut: A Guide to Infinite Sexual Pos-
sibilities (1997, 2009) and Deborah Anapol’s Polyamory: The New Love without
Limits, Secrets of Sustainable Intimate Relationships (1997). Newer work includes
Anapol’s Polyamory in the Twenty-First Century: Love and Intimacy with Multiple
Partners (2010), Anthony Ravenscroft’s Polyamory: Roadmaps for the clueless and
hopeful (2004), Peter J. Benson’s The polyamory handbook: A user’s guide (2008),
Tristan Taormino’s Opening up: A guide to creating & sustaining open relationships
(2008), and Jenny Block’s Open: Love, sex and life in an open marriage (2008).
The discourse of polygamy,7 on the other hand, occupies a different tem-
porality, with a different timeline in public and academic spheres.8 While with
polyamory the resources most significant to psychology and cognate disciplines
(extrapolating from work that is categorised by PsycINFO and contained within
scholarly journals) yield at the time of writing only 39 sources, stretching back
to an earliest contribution in 2004, with traces of earlier work from 1992 at
the earliest (Fox, 2004), the same search on polygamy yields 360 articles, with
an earliest English-language text appearing in 1976 (Kitahara, 1976). As such, a
more significant time range to explore polygamy discourse is the time clustered
around recent significant events in North American polygamy. Specifically,
I will address here the period stretching from the 2007 trial and conviction
of Fundamentalist Church of Latter-day Saints (FLDS) prophet Warren Jeffs,
which also contains the 2008 Texas raids, the 2009 attempted conviction of
two FLDS sect leaders in Bountiful, BC, as well as the subsequent 2011 refer-
ence case on Canadian polygamy legislation and its aftermath. Together, this
span is the most significant period for this second open non-monogamy dis-
course (Rambukkana, 2015). But even this shorter seven-year period still yields
128 sources, over a third of the total catalogued since 1976.
240 Relationships
Table 14.1 Content analysis of titles of PsycINFO-indexed articles

on polygamy, 2008–2013
Animal and insect 39

African polygamy/African American polygamy 26
Polyandry 4
Monogamy/serial monogamy 12
Polygamy and health/health education 32
US polygamy 4
Pacific Islander/Caribbean polygamy 2
Women’s and gender issues 19
Mental health 13
Historical polygamy 4
Psychoanalysis 1
Arab/Middle Eastern polygamy 9
South Asian/Southeast Asian polygamy 5
Consensual non-monogamy and therapy 1
Cyber polygamy 1
Relation to LGBT∗ and queer issues 5
Polygamy and children/adolescents 15
Polygamy and HIV/AIDS/STIs 15
Marriage and family studies 26
Polygamy and Muslims/Islam 4
Polygamy and counselling/relationship therapy 4
Polygamy and conflict 1
Polygamy and religion 5
Central Asian/Eurasian/European polygamy 5
Polygamy and sexuality 16
Canadian polygamy 2
Evolutionary psychology/sociobiology/behavioural 20
ecology/behavioural science
Polygamy and men 5
Polygamy and marketing/economics 6
FLDS/Christian polygamy 6
Polyamory 2
Polygamy and law 4
Polygamy and sexual predation/sexual and gender 3
violence
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
polygamy in relation to Evolutionary psychology/sociobiology/behavioural

ecology/behavioural science.10 The focuses of these studies speak to the sig-
nificant concerns of polygamy research among the social sciences (notably:
effects on women, children, and adolescents; particular dynamics of polygamy
among African nations and diasporas; concerns around health and, in partic-
ular, HIV/AIDS prevention; and changes to – or, as it is more often framed,
deviance from – normative sexuality and family forms). Also of note, however,
is which topics are rarely taken up in this research sample.
While work on Mental health has a modest showing (n = 13), research on
Polygamy and counselling/relationship therapy is slim (n = 4) – especially con-
sidering that it is a more prominent subfield of research on polyamory (see
below). There are also a surprisingly low number of studies foregrounding
Polygamy and men (n = 5) and polygamy and Sexual predation/sexual and
gender violence (n = 3), though these subjects appear as articulations of other
problematics. Also surprisingly low is the number of articles on Polygamy and
law (n = 4) and on North American polygamy broadly (n = 4 for US, n = 2 for
Canadian, and n = 6 total for FLDS/Christian polygamy), speaking both to how
this work appears more in other disciplinary journals (e.g. law journals) and
to how, in research on the effects of polygamy, the preponderance of evidence
is not about North American cases. Finally, the slim tally of discussions cen-
tring on religion, conflict, polyamory, or polyandry seems to indicate that these
key issues, while explored elsewhere in work on non-monogamies, are only
marginally discussed in conjunction with polygamy in the journals most sig-
nificant to psychology as a discipline. This indicates that polygamous relation-
ships are considered in a categorically different way than polyamorous ones:
the latter a viable lifestyle choice whose boundaries and constraints are worthy
of discussion; the former a societal problem or even a present health concern.
Research on swinging, swapping, open marriages, open relationships, and
other varieties of open non-monogamies is also very broad. Since many of
the terms are discussed in conjunction in the literature, they are considered
together. It is also worth noting that this research often bleeds into work on
polyamory and polygamy as well, making an interpenetrated field of study.
Possibly the first reference to such work to appear in PsycINFO is a 1956
article by Robert M. Frumkin discussing Early American sex customs, which
included a discussion of the Oneida commune’s practice of complex marriage,11
a thread of discussion that recurs in the 1970s in analyses of the new com-
munes of the hippie movement (e.g. Smith and Sternfield, 1970). Graduate
work and conferences on these new communities of practice in the late 1960s
gained prominence as a area of study in 1970 with a cluster of papers on the
topic of group sex in the Journal of Sex Research (and based, in part, on a panel
at the 12th Annual Conference of the Society for the Scientific Study of Sex
on 1 November 1969 in New York) (Bartell, 1970; Denfeld & Gordon, 1970;
242 Relationships
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).
Open non-monogamies and normative social and

counselling psychology
Early work considered the personal attitudes and biases of counsellors and
therapists (family, couple, and individual) about the topic of swinging or gen-
erally open relationships, exploring themes such as how this population might
be better served – for example, encouraging clients to ask counsellors about
their sexual histories to weed out ones with more normative frames (Knapp,
1975); and worked on modelling the swinger psyche – for example, identi-
fying a link between open marriage and ego development that could inform
clinical practice (Ryals & Foster, 1976). Some work also drew from practition-
ers’ experience with swingers and ex-swingers to determine current issues in
those populations, such as fear of discovery, jealousy, and (for some) disap-
pointment and marital conflict (Denfeld, 1974). More recent work has explored
how polyamory can be a challenge to family and relationship counsellors – or
even to the nomenclature of couples counselling in general – with articles dis-
cussing the mental health field’s slow response to accepting polyamory, even
as it moves generally to embrace sexual diversity (Weitzman, 2006), as well as
strategies for supporting polyamorous clients (e.g. Anapol, 2013; Easton, 2010;
Labriola, 2013), openly non-monogamous clients generally (e.g. Barker, 2011;
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).
Academics need to break out of the disciplinary boundaries that have

sequestered so many of considerations of, and discourses on, open non-
monogamies. In particular, work in social sciences disciplines such as
psychology, sociology, marriage and family studies, education studies,
and law needs to come into deeper and more sustained contact with
work coming out of humanities disciplines such as women’s and gen-
der studies, sexuality studies, LGBT∗ and queer studies, communication
studies, and cultural studies. Finally, it is of supreme importance to have
academic and scholarly conversations about various non-monogamies in
tandem, including (although the constraints of form did not permit it
in this chapter) on infidelity and cheating – indeed, on monogamies as
well – as all of these forms and formulations of relationships are part of
the same societal articulations of normativities and privileged intimacies.
The theoretical questioning/exploration of extra-dyadic

romantic love
Early forms of this research include engagements with LGBT* and queer sub-
jects, for example in relation to the positive experiences of bisexual men (D.
Dixon, 1985; Wolf, 1985) and women (J. Dixon, 1985) in open marriages,
and the use of open marriages by married gay men as a compromise solution
(Nugent, 1983). Other work looks at swing culture, attempting to model what
(if any) factors swingers share as group (e.g. Jenks, 1985a, b), at ex-swingers
and issues that led them to leave the lifestyle, such as disillusionment and
emotional difficulties (Denfeld, 1974), and at swinging groups broadly (e.g.
Denfeld & Gordon, 1970; Duckworth & Levitt, 1985). While from the begin-
ning there was both supportive (e.g. Denfeld & Gordon, 1970), critical (e.g.
244 Relationships
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).
The effects of non-monogamies on women

In early work on swinging and open relationships in general, there is some
focus on bisexual women, and how open non-monogamies could afford mar-
ried bisexual women possibilities of expressing concurrent same-sex desires (e.g.
J. Dixon, 1985). The effects of polygamy on women, as noted above, are one
of the major sites of analysis, with the majority of work discussing (and some-
times presuming) wholly negative effects (e.g. Bove & Valeggia, 2009; Shepard,
2013), but with some work challenging this viewpoint (e.g. Bennion, 1998;
Calder & Beaman, 2014; Cook, 2007), though usually to argue the existence of
both positives and negatives.
The evidence for negative effects on women’s mental health is particularly
compelling, with Shepard (2013) noting that a systematic review of women on
mental health among polygamous women reveals ‘moderate confidence [of]
more significant prevalence of mental-health issues in polygynous women as
compared to monogamous women’ (p. 47), with a ‘higher prevalence of soma-
tisation, depression, anxiety, hostility, psychoticism and psychiatric disorder in
polygynous wives as well as reduced life and marital satisfaction, problematic
family functioning and low self-esteem’ (p. 47). In addition, the vast litera-
ture on polygamy evidences multiple other problematics concerning women,
such as reasons for (and ways of coping in) polygamy (Tabi et al., 2010);
women’s attitudes to polygamy (Negy et al., 2013); polygamy and misogyny
(Gleditsch et al., 2011); sexual, physical, and psychological abuse (Elbedour
et al., 2006); and issues surrounding women’s family function, marital life, and
life satisfaction under polygamy (Al-Krenawi, 2012).
Other work on polygamy seeks to complicate some of these narratives,
looking for forms of women’s agency within polygamous arrangements (e.g.
Bennion, 1998; Campbell, 2014), while at the same time acknowledging and
engaging with negative aspects. A crucial point, and one emphasised by Lori
G. Beaman in her introduction to the collection Polygamy Rights and Wrongs

(2014), is that a criticism of conventional polygamy as wholly negative because
of its patriarchal basis ‘relies on an underlying assumption that the ideal, alter-
native model of monogamy is not patriarchal’ (p. 4). The privileges and abuses
inherent in both polygamy and monogamy, then, are a crucial backdrop for
considering polygamy’s effects on women.
With respect to polyamory and more recent formulations of open relation-
ships, it is worthy of note that the vast majority of authors writing about these
topics with respect to self-help and activist works are women, and, indeed, some
genealogies trace this form of relationship work to lesbian feminist perspec-
tives on romance and relationships, and especially the structural critique of
monogamy (Munson & Stelboum, 1999).
The effects of multiple-partner parenting on children,

communities, and society
As noted by Harrison (2013), there is little work in polyamory self-help books
about how to raise children in polyamorous families. The newness and icon-
oclastic nature of intentional non-monogamies makes promoting the practice
while acknowledging one has children a tricky and dangerous prospect. For
example, Janet Hardy, co-author of The Ethical Slut (1996), initially published it
under the pseudonym Catherine A. Liszt to protect her family and school-aged
children. Moreover, it can even be challenging doing academic work on non-
monogamies that involves children; Elizabeth Sheff, author of The Polyamorists
Next Door (2013b), found that she was unable to get ethics approval for col-
lecting contact information during a study of the effects of non-monogamous
families on children, making some aspects of research, such as longitudinal
work with the same subjects, challenging (2013a). Some studies, however, do
exist on topics such as addressing myths about children in polyamorous fam-
ilies (Goldfeder & Sheff, 2013), and on the advantages and disadvantages of
being from poly families (Sheff, 2013a, 2013b).
Sheff notes that with mainly white samples from the Bay area, children
from poly families are in ‘amazingly good shape’12 – given the expectation
or presumption of critics that they would lead lives of stigma and confusion
(e.g. see Herrmann, 2006) – and report experiences that share features with
those of other blended families (where having multiple parents simultaneously,
and families of different shapes and sizes, is becoming increasingly common)
(Sheff, 2013a, 2013b). In particular, she notes that children in poly families
face numerous advantages (attention, money, role-models, help with home-
work, rides, honesty, freedom to think, empowered to construct own chosen
family) and disadvantages (stigma from peers, peers’ parents, or teachers; fear
of stigma generally; hardships of co-parents leaving poly relationships; being
exposed to adult drama; too much supervision to get away with lies) (2013a,
2013b).
246 Relationships
As open non-monogamies become more common and understood, and non-

monogamous populations more established, further work in this vein is likely.
While there is some earlier discussion of the effects of swinging, open marriages,
or open families on children (e.g. the debate between de Lissovoy (1977) and
Constantine (1977) over the extent to which child development is neglected in
open families), its dearth is possibly due to the same societal mores, but even
more pronounced.
With respect to polygamy, studies involving children are more common,
and address multiple issues, generally focusing on the negative effects of
polygamy on children and adolescents. For example, Omariba and Boyle
(2007) found that polygyny in Sub-Saharan Africa correlated positively with
higher child mortality, Kermani et al. (2008) found that Tehranian children
from polygamous families had decreased social capital, and Gesinde (2011)
found that Nigerian youth from polygamous families had an increased like-
lihood of receiving emotional mistreatment. Other studies offer positive or
mixed findings. Dreher and Hudgins (2010), for example, found that mater-
nal conjugal multiplicity among rural Jamaican women ‘does not necessarily
result in poorer developmental outcomes for preschool-aged children’ (p. 495),
and, in fact, can be a strategic adaptation to poverty. In addition, Elbedour
et al. (2007) found similar overall mental health levels between Bedouin Arab
adolescents in monogamous and polygamous families, though there was a
higher incidence of psychopathological symptoms among polygamous fam-
ilies. Similarly, Hamdan et al. (2009) found that there were no differences
on measures of competence, behavioural problems, anxiety, and depression
between adolescents from monogamous and polygamous families in similar
Bedouin populations. Attitudes of young people towards polygamy have also
been studied. Khasawneh et al. (2011) found that Jordanian children from
polygamous families generally supported it, said they felt their fathers treated
them normally, and saw it as a solution to spinsterhood, a common issue in
Jordanian society. With respect to young people outside polygamy, Negy et al.
(2013) found an overall neutral attitude towards it among US young adults,
with higher negative attitudes coming from young women, those opposed
to same-sex marriage and those with higher scores on an authoritarianism
scale.
Education is also a focus of research, both with respect to polygamy, split
between discussions of children with behaviour issues in polygamous com-
munities (e.g. Elbedour et al., 2003) and HIV/AIDS education broadly (e.g.
Waldrop-Valverde et al., 2013), and with respect to polyamory, where multiple
issues are considered, such as difficulties children from poly families may face
in schools (e.g. Pallotta-Chiarolli, 2010a, b) and the adaptability of children to
changed familial compositions broadly (Sheff, 2013b).
The psychological exploration of the minutiae

of non-monogamous living
The most radical fact often observed about practitioners of open non-
monogamies is that when their lives are put under a microscope, as they so
often are, they share a preponderance of similarities with the monogamous.
Elizabeth Sheff notes in her introduction to The Polyamorists Next Door (2013b)
that the polyamorists you will meet in her book are like (or indeed are) the
people who already populate your life: ‘your bankers, information technology
specialists, teachers, and dentists. Like your other neighbours, they love their
children, still owe on their student loans, forget to floss, and could probably
stand to lose a few pounds’ (p. 1). Similar notes have been made, however coun-
terintuitively, about polygamists (e.g. Campbell, 2014) and, indeed, swingers
(e.g. Gould, 1999).
But, despite these similarities, there are unique dynamics that emerge
from open non-monogamies that have become objects of specific study, for
example negotiation practices (McLean, 2004), identity politics (Robinson,
2013), relationship termination (Sheff, 2015), the power relationships and
dynamics of jealousy (Easton, 2010; Mint, 2010), compersion (Ballard, 2013),
non-dyadic relationship models (Labriola, 1999), raising children in non-
monogamous families (Pallotta-Chiarolli, 2010a, 2010b; Sheff, 2010), and
whether ‘polyamorous’ is a sexual orientation (Robinson, 2013). One key
trend is the ‘move towards academic theory and research which acknowledges
the existence of openly non-monogamous relationships without pathologising
them’ (Barker and Langdridge, 2010b, p. 4). A major facet of this move is
that in the consultations for DSM-5, active participation and contribution
from polyamory researchers was sought by those revising it in conjunction
with the proposed, but not adopted, ‘Hypersexual Disorder’13 (Moser, 2013;
Wagner, 2010).
Current debates
The divide between a mononormative perspective and its challengers tracks

closely to the divide between those who endorse normative sexualities in gen-
eral and those who challenge them. A preponderance of the writing and work
on polygamy falls into the former camp, most of the work on polyamory
falls into the latter, and work on swinging contains examples of both – at
times with trends leaning in both directions (e.g. more positive, supportive
work at the outset in the 1970s, somewhat more critical work a decade later
when swinging was seen as being in decline, with a new trend for positive
work starting in the 2000s). The one major exemption to this admittedly
broad generalisation is with respect to feminists, who are more sharply divided
248 Relationships
over polygamy especially, with some cleaving to an anti-polygamy stance (e.g.

Starr & Brilmayer, 2003; West Coast LEAF’s14 role as intervener in the 2011
reference case (Bauman, 2011)), while some argue that such a stance needs
to be complicated (e.g. Calder & Beaman, 2014; Campbell, 2008, 2010, 2014;
Okhamafe, 1989).15
This last debate is also articulated strongly to the debate between “pro-
criminalization and pro-legalizing” approaches to polygamy and plural mar-
riage broadly (Rambukkana, 2015), in ways that exceed internal femi-
nist disagreement. This, again, has strong links to a mononormative/anti-
mononormative divide, though it is grounded more specifically in state and
international jurisprudence and policy.
Debates between activist and critical approaches to polyamory (and con-
sensual non-monogamies in general) are well summarised by Barker and
Langdridge:
The academic work on consensual non-monogamies has tended to be rather

polarised in the sense that it reads as overwhelmingly celebratory, or criti-
cal, of the non-monogamies it considers. In the former category would be
[ . . . ] feminist and/or Marxist works [ . . . ] which put non-monogamies for-
ward as potentially radical ways of managing relationships. Also, most of the
‘self-help’ style texts on polyamory suggest that it is a superior way of relat-
ing in that it enables and requires more personal autonomy, self-awareness
and responsibility, and more mutuality, equality and negotiation within rela-
tionships [ . . . ] [While, including,] and since, the special issue [of Sexualities]
(Haritaworn et al., 2006) there has been a body of research that has analysed
and strongly challenged polyamory ‘self-help’ texts. Such research argues
that these books set up new regimes of normativity, endorsing individualism
at the expense of critiquing structural power relations around race/ethnicity,
gender, class and sexuality. They also claim that the books put forward a uni-
versalising model that ties easily with an imperialist narrative of the West as
sexually and emotionally advanced and superior.
(2010a, p. 753)
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
case,16 partly due to members of the Canadian Polyamory Advocacy Asso-

ciation acting as interveners and arguing not only that consensual non-
monogamy could be a valid lifestyle choice, but also that polyamory
was qualitatively and constitutionally different from conventional polygamy
and therefore should not be caught by the Canadian anti-polygamy laws
(Bauman, 2011).
The field of non-monogamy scholarship is a growing one, not held

concurrently or cohesively within any one discipline. For the stu-
dent researcher of non-monogamies, this means that study of non-
monogamies may start within one discipline, but serious work will need
to incorporate a broader engagement. For students working within aca-
demic disciplines and interested in how the growing societal recognition
of open non-monogamies affects their discipline, it would be useful to
focus on issues with which open non-monogamy might have signifi-
cant intersections. For example, women and gender studies students can
centre issues surrounding women’s agency, consent, and false conscious-
ness; communication and cultural studies students can study how sexual
minority groups have been represented in literature, journalism, or pop-
ular culture; law students can dig into the precedent law mobilised in
major cases and the history of sexual regulation; and psychology or soci-
ology students can explore social-scientific models of non-monogamous
behaviour.
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
is growing too prominent to be swept under the rug, ignored, or relegated to

hyper-observed enclaves.
With respect to both psychological research and applied psychology, open
non-monogamies present particular challenges, and ones that are not eas-
ily addressed from within the psychological canon alone. Movement outside
purely psychological or even purely social-scientific work is essential to under-
stand the complex problematics at play here. A further challenge is to consider
them together, and in conjunction with work on monogamy and adultery,
same-sex marriage and intimacy broadly, to truly track the extent of the
scholarly conversation occurring around these issues. For counsellors and
therapists, this broader reading could even extend into considerations of non-
monogamous writing outside academic strictures, from periodicals and websites
to written, televisual, and filmic fictions and documentaries. Understanding
these new dynamics and how to engage with individuals encountering them
(both those openly non-monogamous and those affected by it tangentially,
such as parents, former partners, or children) is a comprehensive task that
requires a similarly comprehensive engagement.
The most significant point for psychologists, psychiatrists, counsel-

lors/therapists, and medical professionals is that actions related to open
non-monogamy (as a subtype of proposed ‘Hypersexual Disorder’) were
not included in the recently released DSM-V. The rejection of patholo-
gised multi-partner sexuality has profound consequences for the framing
of knowledge and practice in multiple applied fields. As an arbiter of
both clinical and societal knowledge, the revised DSM will also affect
legal professionals and those in education when they interact with
non-monogamy issues, as will more proximate changes (such as legal
decisions both in specific cases and in higher courts, and educational
encounters at the levels of boards and schools). Other professional
cultures (such as those around journalism and other forms of media
production, those surrounding members of government/governmental
employees, and members of interested NGOs or lobby groups) will also be
affected by such changes, similarly to how the mainstreaming of LGBT∗
and queer cultures continues to have a sociocultural ripple effect. As open
non-monogamies become more prominent in Western societies, profes-
sionals will need to educate themselves to their subtleties and complex
dynamics.
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
across their different categories and discursive divisions, something that is

only apparent so far in some writing (e.g. Klesse, 2006; Rambukkana, 2015;
Willey, 2006). This work is needed to match and meet the slow collision of
these discourses, brought on by the twin engines of digital convergence and
globalising diasporas – both forces that connect flows of information and peo-
ple, catalysing new and complicated engagements with open non-monogamies.
Summary
• Open non-monogamies are on the rise in terms of societal prominence and

significance, affecting areas such as counselling and therapy, law, media
and representation, social planning, and politics; and 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.
• With respect to psychology, non-monogamies have been an object of study
since at least the 1950s, and a discernible subfield since the 1970s, with
studies focused around specific discourses of commune sexuality, swing-
ing/swapping/open relationships, polygamy, and, most recently, polyamory.
• Collectively, such studies address: (a) the status of open non-monogamies in
relation to normativity; (b) the theoretical questioning of healthy romantic
love with multiple partners; (c) the effects of non-monogamy on women;
(d) youth and non-monogamy; and (e) the psychology of non-monogamous
living.
• Debates contest divides between mononormative and anti-mononormative
perspectives, between activist and critical approaches, on the legalisation of
polygamy, and between various forms of open non-monogamy.
• Implications are discussed for multiple fields, theoretical and applied.
• The future of work on open non-monogamies is discussed, including
emergent categories such as: polygamy legalisation, non-monogamous as
identification, poly children growing up, further impacts of marriage legisla-
tion, cross-cultural and cross-categorical work, and the impact of changing
demographics.
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
the convention of using a ‘*’ as a wild-card in digital searching. Finally, I include

‘queer’ as a separate, non-capitalised additional positionality to respect the notion
that some have of queer as an anti-identity identification.
4. ‘Compersion’ is an affect akin to reverse-jealousy, or a feeling of enjoyment derived
from one of your partners deriving pleasure from another partner, and is more com-
mon among US polyamorists (or polys), with UK polys preferring the cognate term
‘frubbly’ (Ritchie & Barker, 2006); ‘sisterwives’ refers to co-wives in Fundamentalist
Church of Jesus Christ of Latter-day Saints (FLDS) nomenclature; ‘triads’ are sta-
ble three-person equilateral partnerships; and ‘New Relationship Energy’ (NRE) is
a state of excitement and energy brought about by a new relationship in polyamory
nomenclature (Barker et al., 2013).
5. ‘Mononormative’ is a term coined by Pieper and Bauer to denote a normative invest-
ment in monogamy as solely central to the structures of life and society (e.g. see
Ritchie & Barker, 2006), based in structure on a combination of ‘monogamy’ and
‘normativity’, on the model of the notion of ‘heteronormativity’ as formulated by
Berlant & Warner (1998) to denote a similar structural investment in heterosexuality.
An ‘anti-mononormative’ perspective would challenge this centrality.
6. Though I will make slim use of it here due to the constrained scope of this
chapter, my belief is that monogamies and non-monogamies need to be considered
together as a combined discursive formation I refer to, after Angela Willey (2006), as
‘non/monogamy’ (Rambukkana, 2010, 2015).
7. Elsewhere, I make a distinction between definitional polygamy and conventional
polygamy. Similarly to how monogamy technically and etymologically denotes a
relationship comprising a single ‘marriage’, while conventionally connoting a rela-
tionship consisting of a single ‘committed relationship’, polygamy technically and
etymologically denotes a relationship consisting of multiple marriages of any com-
position, while conventionally being used to refer to polygynous polygamy only
(Rambukkana, 2015). In this chapter, when I refer to polygamy I will use its broader
definition that comprises polygyny (a person with multiple wives), polyandry (a per-
son with multiple husbands) and polygynandry (marital combinations involving
multiple husbands and wives).
8. This chapter will treat only its most recent history as a discourse. See Gordon
(2002) and Carter (2008) for two exemplary studies of early polygamy legislation
and debate, focusing on the United States and Canada, respectively. See also the rul-
ing in Reference re: Section 293 of the Criminal Code of Canada (Bauman, 2011) for a
further historical gloss stretching back to antiquity.
9. These figures are from a top-level content analysis factoring in only article and jour-
nal titles. For example, a positive result for ‘Relation to LGBT* and queer Issues’ could
be gleaned from either a title indicating this connection, or the article appearing in,
for example, the Journal of Bisexuality. A deeper analysis (of abstracts or whole arti-
cles) would no doubt yield further cross-connections and a finer grain of categories.
As one example, though only 12 articles from this sample specifically referenced
‘monogamy’ as a top-level subject, Beaman notes that debates about polygamy
keep circling back to considerations of ‘the family’ as form, with monogamy and
its defence deeply implicated in connected issues such as polygamy criminalisation
(Beaman, 2014, p. 3).
10. This last cluster, which also includes some animal studies, is grouped in this
way because studies of the biological and evolutionary mechanisms underwrit-
ing or leading to polygamous behaviour (and, in particular, polygyny) are notably
privileged in anti-polygamy discourse, despite their sometimes questionable big
254 Relationships
data methodologies, theoretical models, or assumptions. For an example of this

privileging see Bauman (2011); for an argument deconstructing the weight given
to these arguments, particularly in legal cases, see Rambukkana (2015).
11. In Oneida complex marriage, all the men were considered married to all the women
in the commune and multiple sexual pairings could occur (Sheff, 2013b, p. 56).
12. She notes that the demographics of her participants may skew the results favourably,
but also that such demographics are an underlying issue in poly community broadly,
in that it tends to favour upwardly mobile (or at least comfortable) and overwhelm-
ingly white populations (Sheff, 2013a). This enclaved nature of polyamory as a
discourse and community has also been identified as a factor limiting its spread and
growth (e.g. Haritaworn et al., 2006; Rambukkana, 2015).
13. Of special concern to polyamorists and poly-friendly therapists was that one of
the specifying criteria of the proposed disorder would have been ‘Sexual Behaviour
with Consenting Adults’ (Wagner, 2010), opening the possibility that polyamory
could be pathologised as a subvariety of hypersexual obsession in a manner akin to
‘compulsive masturbation’ or ‘cybersex’.
14. West Coast Legal Education and Action Fund, retrieved from http://www.
westcoastleaf.org.
15. While, as noted above, polygamy and ‘Women’s and Gender Issues’ had a signif-
icant showing in the highlighted sample, in the entire PSYCInfo search archive
only six articles contained references to ‘feminism’ or ‘feminist’ and ‘polygamy’ or
‘polygyny’, indicating that, while women are considered important to discussions
about polygamy in social science literature, feminist theory is a less significant site
of engagement.
16. In the decision, The Honourable Chief Justice Bauman ruled that non-formalised
polyamorous partnerships were not captured by s. 293 (the major anti-polygamy
statute of the Criminal Code of Canada, the constitutionality of which was the object
of the reference case) (2011, p. 1037). However, he also ruled that the provision
would still capture formalised multiple unions (i.e. ones celebrated through marriage
or marriage-like ceremonies), as well as the celebrants of such events (Bauman, 2011,
p. 1036; Rambukkana, in 2015). Another facet of this societal recognition is how, as
part of this process, a formal definition of ‘polyamory’ was written into Canadian
case law (see Bauman, 2011, p. 138).
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
Two essential elements of clinical psychological practice are, first, the

identification that something in a person’s psychological well-being or
behaviour is causing distress and then, second, delivering an intervention to
ameliorate that distress. Within clinical psychology, societal understandings of
gender and sexuality have been both reflected in and influenced by the profes-
sional positioning of the discipline, changing over time, with the defining gaze
of distress moving from the imposition of a largely restrictive and medically
orientated set of beliefs to more individual, self-defining representations of plu-
ralistic identities. This chapter will chart this journey, making reference to the
changing nature of the profession arising from the changes in the frameworks
of understanding (ontology) in which psychology has been contextualised and,
with it, the shifting offerings in terms of therapeutic intervention.
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
search for the contents of the unconscious. As a consequence, we started to

see the development of psychological practitioners, psychoanalysts following
in the footsteps of Freud, but also hypnotherapists following the earlier work
of Franz Mesmer and Jean-Martin Charcot. Within the psychology labs other
forms of applied psychology were developing, and one with a lasting legacy
and specific applications within the field of sexuality was behaviourism. This
school of thought developed partly in opposition to ‘mentalist psychology’
(i.e. psychology which concentrated on unobservable mental processes such
as cognition) and espoused the belief that psychology should only focus on the
observable, that is, behaviour, which can be studied scientifically to understand
the causal relationships behind conditioned responses to identified stimuli.
Psychology as an emerging discipline was highly successful, resulting in a
proliferation of psychologists as expert practitioners. With this came concern
with being able to regulate and govern what could and could not be counted as
legitimate psychological practice, that is, that which is based on ‘true science’,
and, hence, who were legitimate practitioners of psychology. Within clinical
psychology this resulted in the famous Boulder1 Conference of 1949, which
drew together experts across the discipline to give their rounding endorsement
that the profession of clinical psychology should be based upon the scientist-
practitioner model and a common curriculum for training should be developed
based on these principles, involving research, theory, and practice, located very
much within a medical model of psychological ill-health.
As the dominant research paradigm at this time was positivism, the develop-
ment within the field of clinical psychology in terms of approaches to problems
of sexuality was based on the establishment of ‘facts’ produced from logically
determined questions, followed by the application of scientific principles used
to define, measure, and operationalise relationships between discrete variables,
resulting in causal, deterministic, generalisable theories. The embodiment of
these views was the first edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM I)2 in 1952 by the American Psychiatric Association. As clinical
psychology at that time was heavily tied to the medical model, the DSM became
the major guide to assessment, delineating the ‘normal’ from the ‘abnormal’
and hence which behaviours required treatment and which did not. The DSM
became the accepted taxonomy through which treatment practices and men-
tal health services were organised in both the United States and the United
Kingdom. A parallel system is that of the International Classification of Diseases
and Related Health Problems (ICD), authored by the World Health Organization
(WHO), the aim of which is wider than DSM, endeavouring to be the ‘standard
diagnostic tool for epidemiology, health management and clinical purposes’
(WHO, 1992). Now in its tenth edition (ICD-10), it is the health classification
system used by many countries, including the National Health Service (NHS)
in the United Kingdom, and has a specific chapter on ‘Mental Health and
Behavioural Disorders’.
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
to a challenge to the dominant discourse of positivism and psychology itself

coming under the gaze of critical observers. One clear root of criticism came
from feminists, and, with more women coming into psychology through the
academic door, as opposed to just the clinical door, they started to ask ques-
tions about how women had been positioned in psychology, especially with
regard to their mental and physical health, and to critique the perspective of
a largely androcentric profession. Feminist psychologists challenged not only
how research questions were answered but also the very questions being asked
and who was asking them.
With the enthusiasm shown towards psychology by the general public, the
discipline flourished, and with this growth came an increasing pluralism, in
terms of both the epistemological coverage of the discipline and the clini-
cal areas it now addressed. Clinical psychology as a profession had pivoted
from a male-dominated profession to one with more equal numbers of men
and women, and would go on to be female-dominated3 – bringing with it
different types of challenges (Nicolson, 1992). Within clinical psychology the
medical model was increasingly being challenged, and with the emergence of
critical and community psychology the profession became confident enough
to reposition itself as independent and distinct from psychiatry. While the
‘scientist-practitioner’ model remained central, what was deemed ‘science’
widened and the focus of interest became the person in the social, cultural, and
economic context, not always the individual per se. Evidence such as the Black
Report (Inequalities in health, 1980) in the United Kingdom served to clearly
demonstrate that individual health trajectories were dependent upon the eco-
nomic and social context of the individual, including mental health, and that
certain environmental contexts were particularly toxic for less economically
powerful groups such as women and children. Such evidence provided the gen-
esis for clinical psychology to also concern itself with the ‘community’ and not
just the individual.
With these changes came a rejection of medical diagnosis and an affirma-
tion of ‘formulation’ as being the starting point for all interventions in clinical
psychology. Formulation, as opposed to diagnosis, does not try to fit a set of
identifiable clinical symptoms to a predefined disorder, but to understand the
feelings and/or behaviours of the person within the context of that individual
and their history, and to use psychological theory to explain the interactions
and outcomes within that person’s world. Hence, in terms of clinical psychol-
ogy and working with sexual issues, the point of referral was no longer the
type of sexual behaviour displayed, but whether the person was experiencing
distress in terms of the expression of their sexuality. This change in orienta-
tion meant that it was legitimate to address not just what might be seen as
statistically ‘deviant’ behaviours which caused distress to self or others, but
also the promotion of pleasurable sexuality. Changing values were also being
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).
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
(Crenshaw, 1989), originally outlining that single-axis frameworks which try

to explain oppression and inequality of minority gender or racial groups ren-
der certain experiences invisible. For example, Crenshaw argued that black
women’s experiences were compounded by sexism and racism, and, as such,
were in many ways different from white women’s experience. Yet early femi-
nist discourses did not account for these differences and hence rendered the
particularities of black women’s experiences invisible. Intersectionality can be
seen as a multi-axial approach which explores how different social and identity
categories, such as gender, sexuality, class, ethnicity, religion, ability, and so on,
interweave and create unique experiences for individuals in terms of the effects
of power, inequality, oppression, and access to privilege. It thus transcends sin-
gular and presumed homogeneous categories of identities. When applied to
therapeutic work, intersectionality can offer a richer understanding of a per-
son’s particular experiences within wider social contexts and makes relevant
the clinical psychologist’s own positioning, and hence their understanding and
assumed knowledge.
Know your history

Clinical psychology’s take on gender and sexuality cannot be disentan-
gled from the history of how the discipline, and then the profession,
developed and the paradigms of understanding that existed at that time.
As clinical psychology has become well established and distinctive from
the medical model and psychiatry, its approach to these topics has also
become more enlightened and responsive to current perspectives.
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,
and so on interrelate and position individuals in unique, and sometimes

concurrent, multiple positions of oppression and/or privilege. Hence,
individuals with non-heterosexual and/or non-cisgender identifications
or practices are not a homogeneous group of people and may have
different experiences of inequalities.
Both perspectives of marginalisation and intersectionality thus have particular
relevance when assessing, formulating, and creating collaborative interven-
tions with gender or sexual minority individuals. In the therapeutic work
with gender-minority clients, for example, a formulation which does not take
account of wider social factors of discrimination and how these impact on
the person’s distress would be at best severely limited and at worst unethi-
cal. A case formulation should not only locate the intra-personal distress of a
gender and/or sexuality-variant person, but also consider any relational experi-
ences and effects of disparaging stereotypes, threats of violence and oppressive
social structures, which may well compound this distress.5 Furthermore, a for-
mulation will consider how the particularities of different identity and social
categories such as class, ethnicity, religion, locality and so on will give rise to
idiosyncratic experiences of oppression or privilege, and identify how these
positions may concurrently locate people within, and outside, liminal realms
of a dominant culture (Fisher, 2003). Equally, a society which is to a large extent
organised around binary notions of gender and heterosexuality (assigning male
or female genders at birth, signifying male or female, married or unmarried,
commonly depicting couples as male and female, etc.) will not only compound
stress for sexual and/or gender-diverse people through prejudice, discrimina-
tion or general invisibility, but affect how such individuals can actively engage
in all aspects of society (Butler, 2004). Thus, to practise ethically, the impact of
marginalising and oppressive social structures and the respondent discourses of
those affected need to be incorporated in any psychological formulations which
try to understand and make sense of distress in relation to gender and/or sexual
identity.
Know your history

Clinical psychology has not developed in isolation, but has emerged from
the spaces between established disciplines, such as medicine, psychology,
sociology, and, more latterly, cultural studies. Hence, it is important when
studying topics within clinical psychology to look without, as well as
(Continued)
within, the discipline, to get a richer understanding but also to continue

to enrich the discipline itself.
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.
Clinical psychologists often work as part of a multidisciplinary team offering

interventions addressing psychosocial aspects of care, while working together
with medical professionals, social workers, support workers, advocacy agencies,
and so on. For example, when working with individuals with a disorder or
diversity of sex development (DSD) such as congenital adrenal hyperplasia (lack
of a certain enzyme which affects hormone production and, hence, physical
development), the clinical psychologist will likely work with endocrinologists,
surgeons, and important people in that person’s life such as parents/guardians,
as hormone treatment and/or surgical intervention may be recommended dur-
ing childhood. Or, for example, when working with trans*6 individuals clinical
psychologists may deliver affirmative therapeutic interventions for trans*
children and adolescents, and their families. The therapeutic aims of such
approaches may be to foster non-judgemental acceptance of a person’s gen-
der identity; alleviate associated emotional, relational difficulties; break cycles
of secrecy; allow mourning to occur; manage uncertainty about gender; and
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
Training of clinical psychologists in the United Kingdom is now governed by

guidance from the Department of Health (DoH), the BPS and, more recently,
by the Health and Care Professions Council (HCPC). In line with wider politi-
cal debates and legislative changes, notably the Equality Act (2010) making it
unlawful for services and educational institutions to discriminate on grounds
of sexual orientation, the DoH introduced sexual orientation as a core training
standard as part of its equality and diversity training in the United Kingdom’s
NHS. Thus, clinical psychology training programmes are required to include
training on gender and sexuality (among ethnicity, culture, and age) as a core
competency in the curriculum (HCPC, 2012, p. 26).
The guidelines also reflected a shift within the profession towards a more
critical and reflective stance, including more service user-led perspectives, high-
lighting the need to practice in a non-discriminatory manner and to have an
awareness of approaches such as community, critical, and social constructionist
perspectives (HCPC, 2012, p. 27). This stance endorses an explicit move
away from expert-driven epistemologies towards more inclusive and collabo-
rative practices, which take account of power imbalances within therapeutic
relationships. In the United States, the APA Practice Guidelines for lesbian,
gay and bisexual (LGB) clients (2000, 2011) similarly emphasise the need
for psychologists to increase their understanding of issues relevant to LGB
individuals through continuous professional development. Interestingly, most
of these guidelines in the United Kingdom and the United States address
concerns around sexualities other than heterosexuality, but do not explicitly
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.
Know your history

Clinical psychology is a relatively new discipline and profession. As such,
perspectives have changed rapidly, and approaches to gender and
sexuality in clinical psychology are reflective of the prevailing values
and understandings of the time. These have developed considerably,
particularly over the last 20 years, and continue to change; hence,

keeping abreast of the current literature is vital to practice in this area.
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 &
Hegarty, 2012), in addition to lacking reliability and validity. Proponents, on

the other hand, argue that diagnosis helps people to access medical interven-
tions and gives trans* people legal status to protect them from discrimination.
They also argue that the change in the DSM from Gender Identity Disorder
to Gender Dysphoria no longer classifies it as a ‘disorder’, but emphasises dis-
tress. Hence, one of the clinical challenges can involve managing this tension
of a supposedly expert, gatekeeping position versus a more uncertain, imperfect
perspective (Wren, 2014).
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.
Summary
• The positioning of sexuality and gender in clinical psychology has been

heavily influenced by the evolving and changing nature of the discipline
and profession.
• The conceptualisation of these topics has shifted from one of considering
them as fixed, human entities (essentialism) to fluid, co-constructed, and
contested understandings (social constructionist).
• Clinical psychologists try to understand issues presented around sexuality
and gender through collaboratively developing a formulation which makes
sense of a client’s experience, informed by historical and culturally specific
socio-political contexts.
• Training clinical psychologists in theories and awareness of sexualities and
genders has become a core competency at training institutions across a
range of Western countries, with professional psychological bodies taking
an affirmative stance in relation to diverse sexual and gender practices and
identities.
• A clinical psychologist’s position may extend from a purely therapeutic role
to a consultancy role, when intervening at an institutional or organisational
level, to potentially the role of a political activist.
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.
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.
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.
References
disorders (2nd ed., text revision). Washington, DC: American Psychiatric Association.
disorders (3rd ed.). Washington, DC: American Psychiatric Association.
American Psychological Association (2000). Guidelines for psychotherapy with lesbian, gay,
and bisexual clients. Washington, DC: APA.
disorders (4th ed., text revision). Washington, DC: American Psychiatric Association.
American Psychological Association (2011). Practice guidelines for LGB clients: Guidelines
for psychological practice with lesbian, gay, and bisexual clients. Washington, DC: APA.
APA (American Psychological Association) Task Force on Appropriate Therapeutic
Responses to Sexual Orientation (2009). Report of the task force on appropriate therapeutic
responses to sexual orientation. Washington, DC: APA.
Ansara, Y. G. & Hegarty, P. (2012). Cisgenderism in psychology: Pathologising and mis-
gendering children from 1999 to 2008. Psychology & Sexuality, 3(2), 137–160. doi:
10.1080/19419899.2011.576696.
APS (2013). Ethical guidelines for working with sex and/or gender diverse clients.
Melbourne: APS.
Ben-Zeev, D., Young, M. A., & Corrigan, P.W. (2010). DSM-V and the stigma of mental
illness. Journal of Mental Health, 19(4), 318–327.
BPS (2011). Response to the American Psychiatric Association: DSM-5 development.
Leicester: BPS.
BPS (2012). Guidelines and literature review for psychologists working therapeutically with
sexual and gender minority clients. Leicester: BPS.
Butler, J. (2004). Undoing gender. Abingdon: Routledge.
Crenshaw, K. (1989). Demarginalizing the intersection of race and sex: A black femi-
nist critique of antidiscrimination doctrine, feminist theory and antiracist politics. The
University of Chicago Legal Forum, 140, 139–167.
DCP (2011). Good practice guidelines on the use of psychological formulation. Leicester: BPS.
DHSS (Black Report). (1980). Inequalities in Health: Report of a Research Working Group,
London: Department of Health and Social Security .
Di Ceglie, D. (1998). Management and therapeutic aims with children and adolescents
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(Eds.) A stranger in my own body: Atypical gender identity development and mental health.
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Fisher, D. (2003). Immigrant closets: Tactical-micro-practices-in-the-hyphen. Journal of
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Gilbert, P. (2009). Moving beyond cognitive therapy. The Psychologist, 22, 400–403.
Great Britain. Parliament. Equality Act. (2010). Elizabeth II. Chapter 15. London:
Stationery Office.
HCPC (2012). Standards of proficiency: Practitioner psychologists. London: HCPC.
Holt, V., Skagerberg, E., & Dunsford, M. (2014). Young people with features of gen-
der dysphoria: Demographics and associated difficulties. Clinical Child Psychology and
Psychiatry, doi: 10.1177/1359104514558431.
Johnstone, L. & Dallos, R. (Eds.) (2014). Formulation in psychology and psychotherapy:
Making sense of people’s problems (2nd ed.). East Sussex: Routledge.
King, M., Semlyen, J., Tai, S.S., Killaspy, H., Osborn, D., Popelyuk, D., & Nazareth,
I. (2008). A systematic review of mental disorder, suicide, and deliberate self-harm in
lesbian, gay and bisexual people. BMC Psychiatry, 8(70). doi: 10.1186/1471-244X-8-70.
Krafft-Ebing, R. V. (1886/1901). Psychopathia Sexualis (trans. F. J. Rebman). London: The
Aberdeen University Press. (Original work published 1886.)
Lindquist, N. & Hirabayashi, G. (1979). Coping with marginal situations: The case of gay
males. Canadian Journal of Sociology, 4, 87–104.
Masters, W. H. & Johnson, V. E. (1970). Human sexual inadequacy. Boston, MA: Little,
Brown.
Pilgrim, D. & Treacher, A. (1992). Clinical psychology observed. London: Routledge.
RCP (2013). Good practice guidelines for the assessment and treatment of adults with gender
dysphoria. London: RCP.
Nicolson, P. (1992). Gender issues in the organisation of clinical psychology. In P.
Nicolson & J. Ussher, (Eds.), Gender issues in clinical psychology. (pp 8–38), London:
Routledge.
Psychology, 24(2), 248–258.
Ruel, E. & Campbell, R. T. (2006). Homophobia and HIV/AIDS: Attitude change in the
face of an epidemic. Social Forces, 84, 2167–2178.
Smith, G., Bartlett, A., & King, M. (2004). Treatments of homosexuality in Britain since
the 1950s – an oral history: The experience of patients. British Medical Journal, 328, 427.
doi: http://dx.doi.org/10.1136/bmj.328.427.37984.442419.EE.
Strickland, B. R. (1988). Clinical psychology comes of age. American Psychologist, 43,
104–107.
disorders: Clinical descriptions and diagnostic guidelines. Geneva: WHO.
World Professional Association for Transgender (2011). Standards of care for the health of
transsexual, transgender, and gender nonconforming people. 7th Version. Minneapolis, MN:
WPATH.
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.
16
Counselling Psychology
Dawn Clark and Del Loewenthal
Once a body-world relationship is recognised, there is a ramification
of my body and a ramification of the world and a correspondence
between its inside and my outside and my inside and its outside.
(Merleau-Ponty, 1968, p. 136)
History
Before exploring counselling psychology ‘approaches’ to sexuality or gender, it

is important to clarify that we are writing from a stance that considers identi-
ties and selves as multiple and dynamic, and contingent on relational factors,
socio-historical contexts, and the political climate for recognition or constraint.
Therefore, the professional identity of the counselling psychologist should be
considered no more fixed, predetermined, or universally agreed upon than any
sexual or gender identity we may encounter in a clinical context. As a result
of this, counselling psychology may be interpreted very differently by individ-
ual psychologists. Textbooks which attempt to define our discipline are often
replete with constructions of counselling psychology’s difference from or simi-
larity to other applied professions, most commonly clinical psychology (Pugh &
Coyle, 2000). Oversimplifications of this difference once suggested that clini-
cal psychologists tend to look at what may be ‘wrong’ and how to ‘treat’ it,
while counselling psychologists tend to look for what may be ‘right’ and how
to ‘use’ it (Super, 1977). However, such simple comparisons bring forth ques-
tions concerning how we might decide what may be ‘right’ or ‘wrong’ in the
problematic notion of formulation, and do not sit comfortably within the val-
ues of a pluralist discipline such as ours. These notions of ‘right’ and ‘wrong’
may also be somewhat more pronounced in the areas of sex, sexuality, and
gender, and perhaps our first ‘approach’ in counselling psychology should be
asking ourselves why. From that starting point, we will take the opportunity in
this chapter to present some very brief and broad theoretical perspectives which
280
Dawn Clark and Del Loewenthal 281
may be considered as an introduction to our discipline with regard to sexual-

ity and gender. However, we acknowledge that practitioners and academics will
differ on this. Thus, many perspectives cannot be covered. Our intention is to
open up the ‘broad church’ that is said to be counselling psychology theory
(Strawbridge & Woolfe, 2010, p. 4) and research, with reference to philosoph-
ical perspectives and critical stances which may have broad relevance to the
areas of sexuality and gender, without attempting to create a new ‘dogma’ in
understanding or approach.
Applied counselling psychologists bring together the existential, human-
istic, and phenomenological traditions, alongside psychodynamic, cognitive
behavioural, social constructionist, narrative, and systemic approaches. We also
develop phenomenological models of practice while attempting to incorporate
traditional scientific perspectives, although this often raises tensions within
the notion of the ‘scientist-practitioner’ in counselling psychology, as our
ontological, relational, and professional values sit rather uncomfortably with
mainstream psychological sciences (see BPS, 2005; Strawbridge and Woolfe
2010) and many current organisational contexts (Thorne, 1994). Despite these
tensions, which are by no means exhaustive, some counselling psychologists
assert that the discipline’s foundations in intellectual traditions tangential to
mainstream psychological perspectives are what gives counselling psychol-
ogy a ‘critical edge’ over other applied psychology disciplines (Strawbridge &
Woolfe, 2010). Moreover, those who subscribe to this notion of a ‘critical
edge’ believe influencing social change is the primary focus of the disci-
pline (Rostosky & Riggle, 2011). Indeed, this assumed ‘critical edge’ is often
presented as integral to the identity of the profession or as indicating an inher-
ent capacity for incorporating diversity (Rubel & Ratts, 2011). However, as
Parker (1995) argues, there may not actually be a place inside psychology for
a truly critical psychology to start, and this assertion appears to have more
and more resonance for our discipline due to the current political climate in
psychology. As counselling psychologists proliferate in public services in a cli-
mate of ethically and epistemologically debatable ‘evidence-based practice’ (see
Proctor, 2005) while being socialised in training to nosological categorisations
of psychopathology (Strawbridge & James, 2001) and standardised outcome
measurement (which conflicts with our value base), counselling psychology
may well be in danger of losing its ‘critical edge’, if indeed it ever really
had one.
Broadly speaking, our discipline has been theoretically influenced by

postmodern thinking and pluralism. Postmodernism may provide counselling
psychologists with ways to inform their work in a time of radically changing
cultural conditions while challenging the ‘modernist’ egocentric/person-

centred approaches of psychoanalysis and humanism (Loewenthal & Snell,
2003). Postmodern philosophers would posit that our gendered and sexual
selves are subject to language (Jacques Lacan, 1901–1981), to discourses, and to
power/knowledge relationships (Michel Foucault, 1926–1984). Postmodernism
reminds us that we are also subject to the other (Emmanuel Levinas, 1906–
1995), to difference and deferral of meaning (Jacques Derrida, 1930–2004),
and so forth. Postmodern perspectives encourage us to distance ourselves
somewhat from ‘grand theory’ while moving nearer to the subjective experi-
ence of our clients (Lyotard, 1987). Pluralism in philosophy means ‘doctrine
of multiplicity’ and stands in opposition to monism and dualism. Pluralist
influences in applied counselling psychology are perhaps best exemplified
by our questioning of hegemony in theory, or what counts as ‘evidence’.
This also extends to our awareness of the politics within diagnostic nomen-
clature, critical approach to the medical model, and a mindful awareness
of the social construction of psychopathology and multiplicity of meaning
in categorisation. The strongest influence of pluralism in counselling psy-
chology is perhaps best exemplified in our tendency towards integrative
therapies (see Lapworth et al., 2001). Many counselling psychology perspec-
tives are as frequently drawn from philosophy and sociology as they are
from mainstream psychological sciences, and some of these may be particu-
larly helpful in devising an approach to studying and working with sexuality
and gender. Some of these perspectives, which are central to the founda-
tions of counselling psychology and to this area of inquiry, are those of
self and other, identity, subjectivity, intersubjectivity, relationship (or the
‘relational’), and the phenomenological experience of embodiment or being-
in-the-world.
The links between gender, sexuality, self, and identity have a long history,
dating back to the eighteenth century (see Foucault, 1979). When Locke’s
(1997) modernist notion of self was replaced by James’s (2007[1890]) ‘social
self’ and Cooley’s (1902) ‘looking glass self’, these brought about the idea that
one’s self-evaluation could be derived from the observations of others. Fur-
ther to this, George Herbert Mead’s (1934) distinction between ‘I’ and ‘Me’
introduced the idea that the self was positioned by language and brought
forth the concept of being self-reflexive and Goffman’s (1959) emphasis on the
human capacity to take the role of the other, rendering them self-conscious
to judgement and highlighting pressure to conform to social expectations.
These developments, which saw the self (ego) become a central concept in
psychology, are also central to the foundations of work in Gender/Sexuality
Studies. The subsequent influence of Carl Rogers’s (a predominant figure in
both humanistic and counselling psychology) strengthening of the ‘authentic’
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).
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
To explore some current counselling psychology debates in the areas of gender,

sex, and sexuality, we will do so in context (rather than as decontextualised
ideas) by presenting a case study and discussing it with reference to relatively
new research in the field. This is intended to encourage a non-defensive interro-
gation of potential issues in clinical work which may be connected to sexuality
and gender.
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.
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
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
and gender-oppressive paradigms altogether (Carroll et al., 2002). Though this

may seem a tall order, Kirsten could begin by making a commitment to con-
fronting her own internalised biases and denials before focusing on Leon’s.
Kirsten might also wish to reconsider the way she appears to view her work
with Leon as connected to her ‘liberating’ him. This notion of gay liberation
by heterosexual therapists reveals deep power imbalances in privileged het-
erosexual ideologies (see Moon, 2005). Interestingly, we might locate some
of Kirsten’s misguided thoughts about the dominant majority somehow ‘lib-
erating’ the minority in the central principle of gay-affirmative therapy, which
“affirms a lesbian, gay or bisexual identity as an equally positive experience
and expression to heterosexual identity” (Davies, 1996, p. 25). Such assertions
infer that heterosexual identities, relationships, and experiences are inherently
positive – which is not a given. These assumptions and the power relations
within them are often produced and reproduced by well-meaning therapists
like Kirsten (Asta & Vacha-Hasse, 2013). Kirsten’s beliefs about her not being
‘homophobic’ or Leon’s ‘internalised homophobia’ illustrate well the poten-
tial here of a counselling psychology stance which questions the validity of
standardised tests in psychology. Homophobic scales may allow us an indi-
vidually low score on very overt behaviours, while denying the more covert
homophobia in society (Kitzinger, 1999). Similarly, ‘Internalised Homophobia’
scales allow misguided locating of cause and effect inside the person, who,
through some kind of ‘faulty processes’, has internalised thoughts which are
so deeply ingrained that they permeate psychological testing, perspectives,
constructs, and our lives. As Kenneth Plummer (1981) argues, once it was
the homosexual who was sick, now it is the homophobe who is sick; soci-
ety, however, has never been sick. We will never have a standardised test for
heterosexism in our society.
Leon also conformed to gender-role stereotypes, which led to Kirsten’s micro-
invalidations (Sue & Sue, 2008) when she asked about his girlfriend and
demonstrated gender-role expectation/bias drawn from cultural interpretations
of biology (Rogers, 1999) when she couldn’t understand why a woman might
not like children (Sue, 2010). Kirsten’s knowledge of same-sex relationships
also appeared to demonstrate a lack of awareness of how intersecting identities
might affect experience (Huang et al., 2010), and she overlooked the heterosex-
ualisation of emotion when confronted with Leon’s aggression (Moon, 2008).
There may be some racial stereotypes playing out here for Kirsten (Chantler,
2003, 2004), as research indicates white practitioner bias towards diagnoses
indicating higher risk of violence in black males (Adebimpe, 1981). Many of
Kirsten’s assumptions are led by particularly dominant or hegemonic repre-
sentations of men and women or gay, lesbian, and bisexual people, and she
does not consider how power and ideology may reside within these representa-
tions. Kirsten might also want to consider ideology and power with recourse to
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,
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).
A relational approach in counselling psychology prioritises the therapeutic

relationship (Loewenthal & Samuels, 2014). However, psychologists and their
patients/clients are also in relationship with society and power. Power and ide-
ology drawn from the social structure affect client presentations, as illustrated
in the case study above (Proctor, 2002). Thus, a broader conceptualisation
of the ‘relational approach’ and of subjective client distress, which aims to
incorporate the relationship an individual client and their psychologist have
with wider society, may be helpful in formulation. One way applied profes-
sionals can explore for themselves social beliefs, expectations, and processes
is with an exercise called the gender-role analysis (see Evans et al., 2011).
We believe this may also be helpful to explore issues of ideology (Althusser,
1971) and role expectations connected to sex, sexuality, and sexual/gender
minorities. This could be used with clients, in supervisory sessions, or as a
reflexive tool by individual psychologists. Alongside this, we might also wish
to explore how power circulates in society, in knowledge, in communication,
and in the clinical context (see Evans et al., 2011; French & Raven, 1959).
The gender/sexuality role analysis may be therapeutic, as it raises awareness
of internalised social messages and can aid processes of ‘re-socialisation’ by
restructuring gender/sexuality expectations and re-examining those beliefs in
context with reference to power in society (Foucault, 1979). Worrell and Remer
(2003) outlined six steps for a gender-role analysis, which have been recently
adapted by (Evans et al., 2011), and we suggest this can be further adapted,
adjusted, and expanded to incorporate and explore sex, sexual relationships,
sexuality, and sexual minorities.
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”
(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).
Future directions
As mentioned previously, counselling psychology has historically attempted to

privilege a social justice agenda, and researchers are currently asking where the
discipline may need to re-address these aims and treat them not as a given, but
as requiring re-evaluation and reform (Baluch et al., 2004). Research indicates
that this should extend to counselling psychology faculties, as those training
the next generation in areas of diversity and difference rarely have any training
in such topics themselves (Asta & Vacha-Hasse, 2013). Becoming more inclu-
sive and social justice-focused as a discipline will likely require considerably
more academic engagement with the politics of the organisational context,
of ‘evidence-based practice’ and, with respect to this, a re-interrogation of
claims that counselling psychology professionals are predominantly agents for
social change as opposed to agents of social control (Cohen, 1975; Rose, 1989;
Rostosky & Riggle, 2011; Loewenthal, 2015). Our approach to sex, sexuality,
and gender in comparison to other disciplines will be dependent on this.
Gender-focused work in counselling psychology is going someway to better
engage with heterosexual identity development, questioning taken-for-granted
beliefs about heterosexual identities (Worthington et al., 2002), and there is
increasing interest in hegemonic masculinities and male gender-role conflict
(Wester, 2008). Masculinity research in counselling psychology is also begin-
ning to engage with issues of power in multiculturalism for the male (Wester,
2007). Feminist perspectives also continue to influence the research field
(Brown, 1994; Gyler, 2010), and work on multiple feminist identities broad-
ens the approach (Enns & Fischer, 2012) to applied practices (Burnes, 2013;
Evans et al., 2011). However, feminist perspectives are rarely taught explicitly
on training courses (see Tindall et al., 2010) despite an influential expansion of
feminist methodologies (Szymanski et al., 2011). Work on sex and sexual rela-
tionships is not explicitly taught on training courses. Research and perspectives
connected to experiences of sex and relationships in a rapidly changing techno-
logical world and instant internet access to pornography with respect to gender
roles/expectations also require further development (see Clark, 2013). Research
on gender-specific discourses in diagnoses is promising (Clark, 2013), whereas
class perspectives, which have particular relevance for gender, sexuality, and
sexual minority work, are distinctly lacking.
Sexual minority research concerning heterosexual therapist development and
new directions in affirmative therapy is asking whether current commitments
from counselling psychologists are enough (Asta & Vacha-Hasse, 2013). Some
are questioning whether concepts of internalised heterosexism, with respect
to clients rather than society in general, may be misguided (Biesche et al.,
2008), and others are questioning how use of this concept may negatively
affect sexual minorities (Croteau et al., 2008). Further studies are beginning to
question our very understanding of heterosexism altogether (Szymanski et al.,

2008) alongside those who question the standardised testing of such elusive
society-bound concepts which cannot really be located inside the individual
at all (Kashubeck-West et al., 2008). This is beginning to advance counselling
psychology perspectives on internalised heterosexism in clinical practice and
training, which will hopefully shift the focus away from our clients and towards
psychology and psychologists instead (O’Shaunessy & Spokane, 2012).
In many cases, counselling psychology research is beginning to ask some
very difficult questions about our approach to sexuality and gender, and cer-
tain ‘answers’ we are receiving may be a challenge for a number of counselling
psychologists, not least those who have assumed their discipline might have an
inherently ‘critical edge’ over other applied disciplines. Whether counselling
psychology can continue to claim that it privileges a ‘social justice’ agenda, or
has a broader capacity for incorporating diversities in the current climate, is
debatable. However, working towards ‘ethical justice’ by reflexive questioning
of our own socialisation processes, ideologies, and power in individual con-
sulting rooms could be a step in the right direction (Derrida, 1972). Perhaps
when counselling psychologists begin to question notions of our profession
as being critically attuned to ‘social justice’ aims or ‘non-judgemental’ prac-
tice and we begin to interrogate power and ideology (Althusser, 1971) as we
reflect on the ways our assumptions, socialisations, or ‘affirmative’ actions may
become micro-aggressions or micro-invalidations of subjective experience, per-
haps then, when we are sitting a little less comfortably on the ‘critical edge’
of psychology, the real work in the counselling psychology of sexuality and
gender can actually begin.
Summary
• The ‘critical edge’ or commitment to social justice in counselling psychology

is not a given. This is dependent on the individual psychologist’s interro-
gation of their own positions on gender and sexualities, and requires an
engagement with the power relations and ideological assumptions within
that positioning and the discipline itself.
• Postmodern perspectives may remind us that our knowledge and experi-
ences of sexuality and gender are subject to history, culture, and political
climate. They are also subject to language, subject to the other, and subject
to power/knowledge and to difference and deferral of meaning.
• A pluralist stance may help facilitate a better capacity for recognition and
understanding of within-group differences in research and practice.
• Focus on decontextualised constructs such as homophobia or sexism may
function in ways that lead to overlooking social privilege, heterosexism,
and heteronormativity and result in the re-production of sexual or gender
inequalities. Counselling psychology perspectives would suggest it might be

more productive to engage with the micro-aggressions, micro-assaults, and
micro-invalidations which may be more likely to unconsciously affect our
practice and our research.
• This area requires awareness of socialisation processes and analyses of power
which highlight the importance of the relational and reflexive stance in
counselling psychology.
Further reading
Foucault, M. (1979 [1976]). The history of sexuality Volume 1: An introduction. London:
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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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17
Health Psychology
Joanna Semlyen
Introduction
Health psychology is a new and developing topic within psychology with a

growing and broadening focus and application. This chapter will look at health
psychology and its intersection with sexuality and gender, offering current,
contemporary, and critical theoretical aspects of the topic; explain and outline
the main objectives of this field; and provide an overview of the theoretical
approaches. Gender will be looked at both from a mainstream health psychol-
ogy approach and from a critical, social constructionist view, showing how
considerations of normative and non-normative gender identity have shaped
our understanding of the importance of its intersection with health practice
and promotion.
Sexualities will be examined within a health psychology context, exploring
lesbian, gay, bisexual, and heterosexual identities and their intersection with
health. The material covered will include mental and physical health issues
both within and between sexualities. The chapter will summarise the evidence,
looking at heterosexism and homophobia and their relationship with health
inequalities in this group.
To offer both development and understanding, the chapter will conclude by
highlighting problematic research and practice resistant to understanding of
sexuality and gender and make recommendations for development of practice
and research in the field.
History
Health psychology is a relatively newly developed area within psychology,

evolving as a separate field around 30 years ago and emerging as a division
within the British Psychological Society in 1997; since then gaining in popular-
ity, and becoming the fastest-growing area in psychology. Health psychology is
300
Joanna Semlyen 301
the application of psychological theory and practice to the domains of health,

healthcare, and illness. These domains include both promoting and maintain-
ing health, and preventing ill-health, in addition to interventions to ameliorate
the impact of illness. Health psychologists also work to improve and influence
the healthcare system and health policy. With the increasing rise in preventable
deaths due to lifestyle (Mokdad et al., 2004), a large research base has developed
on a range of topics, with increasing involvement in the growing prevalence
of and interest in chronic diseases such as diabetes and cardiovascular heart
disease that can be, to a great extent, attributed to patterns of behaviour.
Principles of health psychology are based on the biopsychosocial model, a
term, and concept, coined by Engel (1977), with the aim of considering the psy-
chological determinants of health and the contribution of behaviour to health,
illness, and healthcare experience within a framework that draws on biolog-
ical, psychological, and social contexts and influences (Marks et al., 2011).
Applying the principles of social cognition models, both health behaviour and
behavioural intention can be determined by cognitions and attitudes such as
risk perception and attitudes towards and beliefs about health. See Conner and
Norman (2005) for a clear summary of research evidence.
Critical health psychology

A critical health psychology acknowledges the importance of the broader
socio-political, historical, economic, and geographical determinants of health
(Chamberlain & Murray, 2009). This approach recognises the very real health
inequalities experienced by groups in society who lack equity of access to
healthcare, such as minority groups. Objectives for critical health psychol-
ogy include activist approaches, challenging (and, where possible, subverting)
oppression, and focusing specifically on health inequalities and the disparity
created by dominant discourses in society. For an excellent overview of critical
health psychology, see Murray (2004).
The ultimate position of the critical health approach argues that illness
and health are indistinct from the intersectional influence of gender, class,
ethnicity, and sexuality (Hepworth, 2006).
LGBT health psychology is a growing topic within an already developing

field. There are numerous possibilities for students to develop knowl-
edge and expertise in this field and become academics, researchers, or
practitioners specialising in one or more topic areas.
Current debates, key theory, and research
We know from evidence that health inequalities occur as a result of being

in a sexual or gender minority and that there are observable physical health
disparities in lesbian, gay, bisexual, and transgender (LGBT) people compared
with the general population. This inequity can be directly experienced, such
as increased smoking (Hagger-Johnson et al., 2013), or indirectly experienced,
such as through discrimination (Herek et al., 2009). Strong evidence indicates
that LGBT are less likely to go for routine health screenings and are at higher
risk of smoking, alcohol and drug use (Hagger-Johnson et al., 2013) and men-
tal health problems (King et al., 2008). Yet LGBT health research and practice
is understudied, under-researched, and underfunded. This section will outline
these issues in more detail.
Gender, sex, and health

We know that there is a significant health gap between men and women in
their experience of health. For example, men and women vary in their knowl-
edge about health, their recognition of symptoms, and their willingness to seek
help. Hormonal influences and genetic factors associated with biological sex are
recognised as important factors in disease risk and prevalence and in the ways
in which health and ill-health are experienced. Gender, on the other hand,
refers to the socially constructed role and behaviours that are seen as ‘appro-
priate’ for and are adopted by men and women, which then relate closely to
health (Doyal, 1995). These socially constructed health behaviours and roles
vary across societies and history, and are open to change, but will always impact
in some way on health. Gender is useful to help us understand the way society’s
expectations of us can shape how we behave in a health context. Biological sex
and socially constructed gender interact, producing different risk and suscepti-
bility to ill-health, as well as disparity in health-seeking behaviour and health
outcomes.
Gender and health psychology

The commonly held assumption is that men die quicker while women get sicker,
conveying that men are more likely to die younger than women. Men use
health services less than and differently from women, who attend regularly
throughout their lives, and men carry out fewer preventative health behaviours
(Bertakis et al., 2000; Hayes & Prior, 2003). Moreover, gender functions as a
social determinant of health, with women occupying different social positions
from men and experiencing more ill-health that is less life threatening (Lee,
1998). Conversely, men are at higher risk of experiencing violence or accidental
injury, and they drink more alcohol, more heavily, accounting for a large part
of the observed gender difference in life expectancy (McCartney et al., 2011).
Joanna Semlyen 303
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).
Trans health psychology
Trans health knowledge is usually centred on the impact of surgical and
hormonal procedures; however, we should look at the health inequalities in
this group. There may be a health impact of hormone-related cancer. Moreover,
we know that transgender people are screened less often. Health vulnerabil-
ity could be experienced through denial of primary care, such as cervical or
prostate screening, especially for cancer in reproductive organs (Spicer, 2010),
and delayed screening can lead to more severe cancer outcomes (Richards et al.,
1999).
A particular health issue that affects trans women is HIV. In a recent review
of evidence from 15 countries, Baral et al. (2013) found that trans women have
49 times higher odds of infection than adults in the general population. For
trans men, in addition to experiencing discrimination and the side effects of
treatments, their health may be negatively affected by the adoption of a mas-
culine (health promotion-averse) health style, although the protective effects
of testosterone on bone density may be advantageous.
Trans health has gained almost no attention within health psychology, or,
indeed, most disciplines in psychology, where any focus on gender has been
wholly cisgender in focus. We do know that trans people experience signifi-
cant discrimination in society, and this is mirrored in the health sector, where
transgender people report harassment in medical settings, being denied medi-
cal care, and delaying or avoiding health prevention interventions (Grant et al.,
2011).
Trans people experience very high levels of anxiety and depression when
compared with both the general population and sexual minorities (Budge et al.,
2013). Indeed, mental health problems are so prevalent and significant in this
group that research indicates as many as one in three transgender individu-
als, especially younger trans people, have made one or more suicide attempts
(Grossman & D’Augelli, 2007). We know little about trans experience of mental
health services, but trans people do use psychotherapy and counselling services,
and not just to address issues around their gender identity (King et al., 2007).
Trans people can feel they do not fit in to either heterosexual or LGBT spaces,
and, as such, report feeling marginalised. Moreover, trans people’s experience
of health is shaped by society’s expectation of cisgender normativity. This pre-
sumption of cisgender allows no room for sexes that are outside the binary,
and this is likely to render trans people marginalised and vulnerable, which, in
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.
Sexuality and health psychology

Health psychology, like most mainstream domains of psychology, is histori-
cally and contemporaneously heteronormative in its positioning. Regarding
health research and practice, Wilton (2000) stated that, with heterosexuality
as the assumed norm, the health of the lesbian, gay, and bisexual (LGB) popu-
lation is not considered. Indeed, sexuality has rarely featured in public health
or psychology research. A search of a 20-year span of public health research in
Medline revealed fewer than 0.1% of articles with an explicit inclusion of les-
bian, gay, and/or bisexual populations (Boehmer, 2002). Moreover, in Lee and
Crawford’s (2007) similar consideration of PsycInfo, fewer than 1% of papers
included non-heterosexuals in recorded psychological research over a 27-year
span. Indeed, health psychology almost never places LGB as a topic of sole
focus; instead, when included, it usually forms a comparative sample. In main-
stream psychology textbooks and other similar material, aside from a small,
tokenistic paragraph or small section on homosexuality, heterosexuality is the
assumed norm throughout the rest (Barker, 2007). The coverage of sexuality
within health psychology textbooks is even more minimal, despite extensive
coverage of the impact of disadvantage on health (Rohleder, 2012).
Smoking and LGB

There is a well-established relationship between sexual orientation identity and
increased smoking rates. Much of the research has been carried out in the
United States and indicates that this relationship is stronger in sexual minor-
ity women (Corliss et al., 2013; Lee et al., 2009), with smoking prevalence
being up to twice that of adult heterosexuals (Bontempo & D’Augelli, 2002).
Joanna Semlyen 305
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).
Cancer and LGB

The relationship between sexuality and health is an understudied area in can-
cer care (Semlyen & Hulbert-Williams, 2013), but there is growing evidence to
suggest that lesbians and gay men may have higher cancer risks and differing
cancer care needs and experiences (Boehmer et al., 2011); for example, lesbians
are less likely to attend for cervical screening (Fish & Anthony, 2005). Fear of
experiencing homophobia in the health setting may lead this group to delay
in gaining a diagnosis (Trippet & Bain, 1992) and, as such, show poorer cancer
outcomes (Richards et al., 1999). The Cancer Patient Experience Survey (PES)
reported that non-heterosexual respondents visited their GP significantly fewer
times prior to diagnosis (Department of Health, 2012). Communication with
health professionals was experienced less well by the LGB respondents in the
survey. Delayed presentation may also be associated with concern about the
stigma associated with cancers of higher prevalence in LGB groups, for example
anal cancer in gay men (Grulich et al., 2012).
More positively, a recently published study on US oncology trial participation
rates found that LGB cancer patients were more than twice as likely to take part
as heterosexuals (Jabson & Blosnich, 2012).
Discrimination, disclosure, and health

LGB people often experience heteronormativity, heterosexism (Irwin, 2007;
Röndahl et al., 2006), and homophobia in their healthcare experience
(O’Hanlan & Isler, 2007) and frequently report poorer communication with
healthcare practitioners (Klitzman & Greenberg, 2002). Heteronormative
assumptions are common within health services, and, because this assumption
renders the LGB individual invisible, it is fair to say that heterosexuality, by
being an assumed norm, acts as a form of discrimination (King & McKeown,

2004).
LGB people also report experiencing direct prejudice and discrimination
in health service use. Fearing discrimination from one’s healthcare provider
may lead to non-disclosure of sexuality or gender identity, which in itself
could impact upon diagnosis, health information, and a lack of social sup-
port whereby, for instance, a partner may be excluded from that person’s
healthcare. Indeed, disclosure may be associated with better communication
with the healthcare professionals, and greater satisfaction with care received
(Eliason & Schope, 2001). Importantly, fear of disclosure renders LGB identity
neither recorded nor researched, leading to wrong assumptions about LGBT
health issues, health needs, and presence in the health system.
Fear of discrimination is closely linked to fear of disclosing one’s sexuality
or gender identity. We can think of disclosure in a number of ways: coming
out to oneself and coming out to others (family, friends or work, and health
professionals). Coming out to others has been reported to increase mental well-
being in a wide range of health outcomes (lower anxiety, less depression, and
greater well-being). Being able to disclose one’s sexuality to a mental/healthcare
professional is likely to increase the likelihood of seeking and gaining help for
mental health problems (Meckler et al., 2006), although not all LGB people will
necessarily be able to do so. LGB people are also diverse and intersectional. The
impact of also being a member of an ethnic minority, or having a particular
religious or other identity, will also impact on disclosure and, therefore, health.
Older LGB people are likely to experience their sexuality in relation to health
differently. They are more likely to be anxious about coming out, having expe-
rienced a history of homophobia and living in a time when there were legal
restrictions on homosexuality.1 LGB people may also initially struggle to dis-
close their sexuality to themselves. Early identity formation includes a level of
self-acceptance, leading to identity resolution (Mayer et al., 2012); this, too, can
impact on health and healthcare.
Disclosure of sexuality to a healthcare professional is known to result in better
communication and greater care-related satisfaction (Eliason & Schope, 2001);
conversely, LGB people who are not already ‘out’ to their healthcare team may
experience increased disclosure anxiety (Van Dam et al., 2001), resulting in
delay-related health behaviours. For example, of the 50 women interviewed in
Wilton and Kaufmann’s (2001) study of lesbian experience of midwifery, the
single overriding shared issue was anxiety about disclosure and particularly any
negative impact.
Research tells us that it is this very real experience of discrimination that leads
to an increase in mental health problems. The relationship between discrimina-
tion and mental health has been studied broadly and is referred to as minority
stress (Meyer, 2003). The theory states that the experience of chronic stress
Joanna Semlyen 307
brought about by experiencing stigmatisation of their sexuality can lead to LGB

people experiencing poorer mental health and well-being. Meyer proposes that
negative experiences such as prejudice, social exclusion, and victimisation asso-
ciated with a stigmatised status such as being a sexual or gender minority lead
to poorer mental and physical health (Lick et al., 2013).
Health psychologists working with diverse populations need both knowl-

edge and awareness to avoid discrimination against this already excluded
group (Goldberg, 2006). Wider literature has shown that heteronormative
ideology affects both access to healthcare and healthcare professionals
(Irwin, 2007). Promoting awareness of sexuality among health psychol-
ogy academics and, in turn, facilitating education of sexuality issues
through the teaching of sexuality and gender-minority health will help
achieve a more inclusive health psychology programme and bring about
increased awareness of the intersection between gender, sexuality, and
health.
LGBT and mental health

Physical and mental health are closely connected. Good mental health is associ-
ated with an increase in life expectancy and improved recovery from ill-health.
We also know that health risk behaviours, such as alcohol, drug, and tobacco
use, are increased in people with mental health problems. People with men-
tal health conditions consume 42% of all tobacco in England (McManus et al.,
2010). Moreover, smoking itself increases the risk of having a mental health
problem (Cuijpers et al., 2007).
The most significant health issue within the LGB population is mental
health. We know that LGB people experience higher rates of depression, anxi-
ety, suicidal ideation, suicide attempts, and substance misuse (drugs, alcohol,
and smoking). A recent meta-analysis found that depression, anxiety disor-
ders, and substance use disorders were more prevalent in LGB people than in
heterosexuals. More specifically, gay and bisexual men were at higher risk of
anxiety and depression, they were twice as likely to have attempted suicide in
the preceding 12 months and were found to be more than four times as likely to
have attempted suicide in their lifetime when compared with heterosexual men
(King et al., 2008). Lesbian and bisexual women had especially high rates of
substance dependence, more than three times the rate for heterosexual women,
and were found to have lifetime suicide attempt rates almost twice those of
heterosexual women.
In addition to experiencing poorer mental health, there is evidence to indi-

cate that LGB people seek mental health services more (King et al., 2003).
Research tells us that experiences of mental health services are poor, especially
when disclosing their sexuality with mental health professionals (MHP), who
then link their mental health problem to their sexuality (King et al., 2003).
There are still a great many practitioners, particularly those working in the
mental health sector, who erroneously believe that to be lesbian, gay, or bisex-
ual is an illness or perversion (King et al., 2007). Indeed, a recent study showed
that 17% of the 1,328 MHP2 survey respondents had attempted to ‘cure’ LGB
people of their sexuality (Bartlett et al., 2009). If sexual and gender minority
groups fear they will not be accepted or, worse still, are going to be discrim-
inated against for their identity, they may delay or, indeed, never approach
mental health services for help or treatment at all.
LGBT people frequently experience homophobic hate crime, which may lead
to the development of mental health problems (King et al., 2008; Meyer, 2003).
Homophobic bullying (deliberate victimisation) of young LGB individuals is all
too frequently reported, and this has been experienced across the life course,
including at school (Rivers, 2001) and university (Ellis, 2009). At worst, such
victimisation appears predictive of suicide attempts (Bontempo and D’Augelli,
2002). Early discrimination can lead to poor resilience and coping in later years.
It can also lead to early choices about misuse of drugs and other substances
(McCabe et al., 2010).
While you are providing health psychology practice, interventions, and

assessments, a number of your clients are likely to be lesbian, gay, bisex-
ual, or trans in identity. Asking people directly allows them to know you
are interested and facilitates your awareness of their identity. As a popula-
tion, LGBT people may have specific health needs, but most often simply
need to be included. Reaching out to the LGBT population by providing
an inclusive and LGBT-aware service will encourage LGBT engagement
and reduce possible health inequalities.
Future directions
Understanding LGBT health

How we understand health can determine our relationship to our own health
and to how we use health services. The meaning of health for LGBT people may
not be the same as for the general population. For some, being healthy may be
Joanna Semlyen 309
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.
Researching LGBT health

There is a significant lack of research focusing on LGBT in health psychol-
ogy. The research that is available has often come from the non-profit sector,
using community samples and snowball sampling. Research focus is very
much on LGBT as different. This positioning can continue to pathologise
these populations as ‘other’ to the (heterosexual, cis-gendered) norm. Indeed,
heterosexuality itself only appears in health psychology as a comparator against
which LGB and/or T health is compared.
UK mainstream health surveys have started to collect data on LGB, but trans
is not yet routinely collected (Hagger-Johnson et al., 2013). Significantly, we
have only minimal population data available on the health of LGBT people.
People may refuse to select from one of the predetermined LGBT categories or
to disclose at all; therefore, there is no clear picture of how many people in
the United Kingdom identify as gay, lesbian, bisexual, or transgender, nor an
agreed way to measure, and we end up (under-)estimating prevalence.
What is published often forms part of sexual minority-specific journals with
lower impact factors and smaller readerships. Minority health psychology
research may be considered less fundable and a lower priority because of low
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.
Teaching LGBT health

A lack of comprehensive coverage in health psychology journals, textbooks,
and conference proceedings, in addition to a lack of research and reporting of
LGBT issues in health psychology course materials, would arguably compro-
mise awareness of sexuality and gender issues in health psychology. Moreover,
health psychologists working with these populations need the knowledge and
awareness to prevent discrimination against a community who already expe-
rience social exclusion (Goldberg, 2006). Training is key in addressing lack
of knowledge and lack of awareness and preventing discriminatory practice.
Health staff, health psychologists, and academics should be trained to be sensi-
tive and aware of differing sexualities and remain non-judgemental. Promoting
awareness of sexuality among health psychologists, and, in turn, facilitating
education of sexuality issues through the teaching of sexuality to trainees and
practitioners, would help achieve a more inclusive health psychology and bring
about increased awareness of the intersection between sexuality and health.
LGBT health should be included along with other topics frequently addressed
as minority topics.
Addressing LGBT health

Where LGBT health has been included in mainstream health psychology, it
is invariably the topic of HIV/AIDS, in a section on sexual health. This has
meant, effectively, a conflation of non-heterosexual health with gay, male sex-
ual health. Where health psychology has had a lesbian/bisexual female focus,
the emphasis has remained specific to the intersectionality of gender and
sexuality – namely, breast and cervical cancer. Such a focus on sexuality-specific
conditions could very well eclipse the importance of other health issues in these
populations and, furthermore, make ‘lesbian and gay health’ synonymous with
risk and disease.
A psychology of sexualities has been emerging, but this has been largely
(if not wholly, and maybe unsurprisingly) driven by LGBT health psychologists.
For more on this, see Peel and Thomson (2009) and Flowers (2009). More-
over, although the research base is growing, lesbians and bisexual men and
women remain less likely to be studied than gay men (Barker et al., 2012; Lee &
Crawford, 2007).
Joanna Semlyen 311
Future directions for health psychology should include developing health

psychology interventions and resources, focusing on diversity and heterogene-
ity within LGBT health. The approach should be two-fold, ensuring, on the one
hand, mainstream inclusion of LGBT, warranting the development of a broader
health psychology discipline, and, on the other, the further development of an
LGBT health psychology ensuring the development of UK-based research and
practice, maximising the expertise currently available.
Summary
• Sexuality and gender intersect with health, commonly resulting in health

differences. These differences reflect higher health risks.
• LGBT may experience health-related discrimination. Inequalities that are
experienced can be direct or indirect. LGBT people may be excluded
from healthcare through presumed heterosexuality (heterosexism) or actual
prejudice.
• Real and perceived discrimination leads to delayed and reduced engagement
with preventive health and increased health risk behaviours in this popula-
tion. LGBT people experience poorer mental health and are at risk of poorer
physical health.
• Lesbian, gay, bisexual, and trans health psychology is a developing area but
needs to be developed with further research and practice focusing on these
as diverse and interrelated identities.
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. & 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.
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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
The foundations of gender studies can be linked to early feminist studies

such as Simone de Beauvoir’s book The Second Sex, which unpacked the ‘oth-
erness’ of women in a sexist and patriarchal Western culture where women
became defined in relation to men (Jarviluoma et al., 2003). A key thrust of
early research was to problematise the ‘natural’ differences between the binary
categories of sex outlined in much early work on sex differences and to fight
for equality. Second-wave feminists of the 1970s began to form consciousness-
raising groups focusing on women’s experiences and were more concerned
about viewing gender differences as positive. At the same time, men’s stud-
ies and the study of masculinity began to take on board feminist concerns
about sexism but also began to theorise the plurality of masculinities and the
hierarchical nature of such relations (Connell, 1987). Connell’s (1987) book
Gender and Power considered how the hegemonic ideal of masculinity cre-
ated marginalisation between men (with gay men being at the bottom), yet
all men benefited from patriarchy, whether or not they fitted the dominant
construction.
Similarly, early research in the field of sexuality began to problematise the
assumption that heterosexuality should be the yardstick against which all
other forms of sexuality should be ‘measured’. Alfred Kinsey and colleagues
(1948, 1953) collected sexual histories of over 100,000 people, found that many
people had same-sex experiences and noted the fluidity of sexuality across
the life course. However, this did not deter the American Psychiatric Associ-
ation from including homosexuality as a mental disorder in 1952. Thus, early
homosexuality research focused on the mental health, diagnosis, and ‘causes’
of homosexuality, resulting in psychologists and psychotherapists attempting
to ‘cure’ lesbian, gay, and bisexual people (Clarke et al., 2010). Gay-affirmative
psychologists challenged such assumptions, and, in turn, lesbian, gay, bisexual,
and queer (LGBTQ) psychologists began to explore the lives and experiences
of LGBTQ people. Celia Kitzinger’s (1987) ground-breaking book The Social
Construction of Lesbianism presented findings based on 120 interviews with
lesbians. Kitzinger’s work is important as it critiqued gay-affirmative research
for marginalising the lesbian experience in a similar fashion to mainstream
psychology’s focus on heterosexual men (Clarke & Peel, 2004).
The heterosexual questionnaire: Reversing the gaze
If you are struggling to understand the concept of deconstruction,

consider the following selected questions taken from the activist quiz
developed by Rochlin (1972):
1. What do you think caused your heterosexuality?

2. When did you decide to become a heterosexual?
(Continued)
3. Is it possible this is just a phase you will grow out of?

4. If you have ever slept with a person of the same sex, is it possible that
all you need is a good gay lover?
5. Why do you insist on flaunting your heterosexuality, can’t you just be
who you are and keep quiet about it?
6. Just what do men and women do in bed together? How can you truly
know how to please each other being so anatomically different?
7. Have you considered trying aversion therapy?
Questions such as these raise awareness of the patronising and routine

comments made to members of LBGTQ communities on an often daily
basis. Pause for thought for those of us belonging to the ‘normative’
status.
Key theory, research, and current debates
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
interactions) and stake claims to an ‘unmotivated stance’, need to optimise

their chances of producing research of value to others by thinking through
issues of data collection and analysis. Therefore, before conducting any qual-
itative research, serious consideration needs to be given to the design of the
study to ensure that the researcher is able to collect and analyse data that will
enable the exploration of something in an open-ended and exploratory fash-
ion, which is key to good qualitative research. One of my current postgraduate
students recently told me that her participants said everything that she wanted
them to say. I think that she meant that they discussed topics that she was
interested in exploring and that resonated with her background reading, but,
ideally, we want at least the possibility of being surprised by our data in order to
forge new understandings to push the field forward. What follows is an explo-
ration of a few key approaches from both experiential and critical camps in
order to highlight what these methods look like in practice.
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)
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
observations. This resulted in early affirmative researchers not disclosing their

personal connections. However, seeking to represent the voices of others runs
the risk of pathologising the Other (Wilkinson & Kitzinger, 1996); thus, recent
studies of LGBTQ issues, for example, have claimed an ‘insider advantage’ in
studying sexuality and warned outsiders to be reflective about their position in
order to conduct sensitive research (Clarke et al., 2010). This move is also not
without critique, as the insider status does not necessarily translate to an under-
standing of shared experience (Allen, 2010; Clarke et al., 2010). Guidelines for
researching sexuality are useful resources for anybody new to the field (see, for
example, Barker et al., 2012; Shaw et al., 2012).
When studying men’s health, I normally contextualise my interest by dis-
closing that my research in this area is a consequence of my past relationship
with a man who had testicular cancer. The research project that I am currently
involved in is about understanding the poor prognostic outcomes for prostate
cancer in the African Caribbean and African community. In order to overcome
problems of my outsider status with this ‘hard to reach’ population, I have fol-
lowed guidelines for good practice (Kong et al., 2003; Wheeler, 2003), which
include: familiarising myself with the issues around the marginalisation of the
participants in this context; carefully outlining the motivations behind the
study and stipulating how the findings will be used; including public participa-
tion in the grant application; and consultations about the design of the research
with key black and ethnic minority community members such as doctors, and
others leading the field at a grass roots level. It is hoped that conducting the
research in this way will aid recruitment and result in meaningful outcomes for
the members.
Students who choose to undertake a qualitative project on gender and

sexuality should ideally try to work with a supervisor who is a qualitative
researcher, as their guidance is extremely useful for novices. Often the
qualitative research training at universities is not equivalent to the time
and emphasis placed on quantitative method training (due to the dom-
inance of quantitative research in psychology), so the extra support of a
‘safe pair of hands’ is extremely useful.
Often students have some excellent ideas about gender and sexuality
projects that are hard to study due to accessing appropriate partici-
pants/data. This is especially difficult if qualitative research is equated
with conducting interview or focus group studies. However, if you think
creatively about the question or topic you wish to examine, it is nearly
(Continued)
always possible to gain access to some really interesting alternatives, such

as online support groups or YouTube videos, for example. These data raise
some important ethical issues, but the British Psychological Society has
been developing some useful advice in this area that is essential reading
if you choose this route.
I became interested in how men who have testicular cancer choose
whether or not to have a prosthetic testicle, and wanted to explore modes
of support for this decision (Seymour-Smith, 2013). While I could have
explored this through retrospective accounts in interviews, I wanted to
capture the actual practices of men in situ. One place where men can
gain support in their decision-making is through online support groups.
It is typically argued that men search for medical information, whereas
women tend to seek social and emotional support (Seale et al., 2006,
p. 2577), and Seale et al. (2006, p. 2588) argued that women enact greater
emotional expressivity. Taking a discursive approach (see later section on
this approach) allowed an examination of the support mechanisms that
men employed in practice in an everyday setting. A sequential analy-
sis demonstrated how members ‘did support’ by attending to concerns
raised in initial posts: something that might be missed in analyses that
do not focus on the interactive nature of such groups. The mechanics
of support are displayed through the collective practices of these men.
It was possible to consider how masculine identities were invoked, and
how members played close attention to such nuances and designed their
responses accordingly. Others have urged that strategies must be found
to help men express ‘emotions’ (Lieberman, 2008). However, from this
study, perhaps it is possible to argue that concerns about men’s emotional
presentations are not as problematic as once was thought.
The middle ground: Experiential and critical

Another approach that takes the perspective of the participant seriously is nar-
rative analysis. However, the term ‘narrative analysis’ incorporates a whole
variety of interdisciplinary perspectives united in an interest in narrative as the
organising principle for human action (Bruner, 1987), ranging from the experi-
ential to the more critical. Narrating the self into being is of central importance,
life stories being sites where individuals construct and negotiate their sense of
self and memberships of groups (Linde, 1993). As individuals, we continually
employ narratives in our everyday lives to help make sense of ourselves and oth-
ers and the events that we encounter. The topic of investigation for narrative
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 the level of the individual construction of sentences, through the

form of narratives and the social negotiation of narratives, up to the social
level of belief systems and their history, and finally to their effect on the
construction of narratives.
(Linde, 1993, p. 1)
From this broader perspective, narrative analysis explores the relationship

between both private and public accounts. Individual narratives are often
couched in ways that are socially, culturally, and historically appropriate and
exemplify the norms and moral standards of their era. Bruner’s (1987) notion of
canonical narratives suggests that culture speaks through individual narratives
and demonstrates how lives should be lived. Linde suggested that we continu-
ally revise our life story so that it is coherent, and only when this is achieved do
we feel comfortable in society, as we display an identity that is “good, socially
proper and stable” (Linde, 1993, p. 1). This has a particular relevance to narra-
tives of illness, and Crossley (2000) has argued that the study of illness stories
offer a way of examining how health and illness are experienced, given mean-
ing and reflexively constructed by individuals. This is particularly the case as
illness can represent a ‘biographic disruption’ forcing the reconstruction of
a coherent life story (Crossley, 2000; Frank, 1995; Riessman, 1993). In effect,
illness creates “narrative wreckage” (Frank, 1995), and formulation of new nar-
ratives is a chance to reclaim identity. Finally, it is worth noting that illness
narratives are dialogical. They are threaded through with voices of others and
are produced for and with friends, family, and beyond. As Arthur Frank has
argued,
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
rhetorical expectations are reinforced in some ways, changed in others, and

passed on to affect other’s stories.
(Frank, 1995, p. 3)
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.
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).
Kitzinger and Frith’s work employed focus groups as a means of exploring

such issues with women, whereas the work of O’Byrne et al. explored this
understanding in focus groups with men. Although mediated in some instances
by a performance around ‘macho’ claims that they would never turn down sex,
the men were cognisant of the normative ways in which non-verbal and verbal
sexual refusals are accomplished. When exploring whether or not the men also
understood women’s sexual refusals, similar knowledge was evidenced. Thus,
both Kitzinger and Frith (1999) and O’Byrne et al. (2006) were able to critique
the taken-for-granted understanding that a clear ‘no’ should be delivered in
order to effectively refuse sex. The subtleties of communicating sexual refusals,
then, are understood by both men and women alike; thus, the responsibility for
hearing sexual refusals should no longer be dismissed on the grounds of mis-
communication. Indeed, appeals to misunderstanding sexual refusals in rape
cases should be treated with suspicion.
The above discussion of experiential and critical research raises an impor-
tant consideration for qualitative researchers of gender and sexuality. Should
the goal of research be to give voice to marginalised groups, or should we
prioritise research that interrogates dominant understandings? The merits of
both approaches have hopefully been demonstrated – thus affording space for
both types of research. We should be able to continue investigations into the
marginalisation of LGBT lives and dominant constructions of gender and sex-
uality. We should also consider the intersections of sexuality and gender with
other ‘variables’ such as ethnicity and class.
Teaching qualitative research methods to students can be tough as there

is a lot to cover, typically in a small proportion of the degree. How do
we cover the key information in a way that engages students? Some
suggestions are highlighted below:
• Try not to set up divisions between quantitative and qualitative

research. Carefully highlighting the benefits of quantitative research in
a particular area before presenting the benefits of a qualitative frame-
work might be one route to take. We are interested in different research
questions so this is not a competition!
• Try, as much as possible, to guide students through each aspect of
the process of qualitative research in a way that highlights good prac-
tice. Hands-on experience of data collection, ethical considerations,
transcription, analysis, and writing up is a sure way of dispelling any
myths that qualitative research is the easy option.
• Try to illustrate points with reference to your own work,and that of

other key qualitative researchers, as this really highlights the variety
of approaches and grounds the discussion in worked examples.
• ‘Hands-on’ help with data analysis is crucial. If students have to write
a report, encourage them to bring in analysis of one data extract
and work through their ideas highlighting over-interpretation versus
overly descriptive issues of analysis.
• Try to support training with exemplar papers of the method.
• If you team teach, try to collectively agree on a programme of study
that works with the experience of the team.
• To raise the profile of issues of sexuality and gender, try to incorpo-
rate examples of this body of work so that it is integrated into the
psychology curriculum.
• I only supervise qualitative projects and am thus able to offer group
supervision (in addition to individual support) so that we can discuss
aspects of the project that are unfamiliar to students. These sessions
include data sessions with the students’ own data. This might be worth
exploring in your own practice.
• Share teaching resources with other academics.
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
like sluts” as a precaution against unwanted sexual attention. The movement

caused considerable debate about the appropriateness of women dressing as
‘sluts’ in order to make their point. However, SlutWalk protests have strong
links to the work that academics have conducted around dispelling rape myths.
Older, milder forms of protests about women’s right to feel safe on the street at
night, such as Reclaim the Night, are making a resurgence, and these protests
seem to be more heavily influenced by feminist academic work. Ringrose and
Reynold (2012) argued that the SlutWalk movement illustrates how it is possi-
ble to generate awareness and form political resistance. Indeed, Ringrose and
Reynold considered SlutWalk protests to be a significant form of feminist polit-
ical action that can lead to re-signification, whereby “an injurious term is
re-worked in the cultural domain from one of maligning to one of celebration”
(Ringrose & Reynold, 2012, p. 334).
Future directions
It is an exciting time for qualitative researchers as new debates and ways of

analysing gender and sexuality are highlighted. The critique of interview data
stemming from discursive psychology (Potter & Hepburn, 2005) has high-
lighted the benefits of working with ‘naturalistic’ data. Space restrictions do
not allow a full discussion of this, but Potter and Hepburn (2005) argued that
it is hard to disentangle social science agendas from the way that interview
research is set up and presented to participants (or other researchers). The ben-
efits of working with naturalistic data are that: it avoids imposing researcher
categories onto the data; it allows us to situate research in everyday settings, so
that we can study people’s practices in situ rather than reflexively at a distance;
it allows the researcher to focus on the issues that are at stake for the partici-
pants rather than imposing their own concerns, often resulting in novel topics;
and it captures the complexity of often mundane situations (Potter & Wiggins,
2007, pp. 78–79). This discussion is not intended to argue against the use of
interviews or focus groups, but the critiques do raise some important points for
consideration.
Linked to this discussion about naturalistic data, conversation analysts (CA)
are keen to ground their studies of sexuality and gender in participants’ ori-
entations. A key argument from CA is that we should only analyse gender or
sexuality if we can see that they are live concerns for interlocutors (Speer &
Stokoe, 2011). Such an approach is illustrated in Susan Speer’s (2001, 2011)
work on third party compliments in passing as a ‘real woman/man’. Speer
(2001, 2011) examined the reported use of third party compliments in con-
sultations with trans patients at a gender identity clinic. Although physical
appearance and success in passing as ‘real’ men or women is not a formal crite-
rion of assessment at the clinic, it is a mundane reality for patients outside
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
• Early qualitative psychological research on gender and sexuality focused

on problematising the perceived ‘natural’ differences between ‘the sexes’,
explicating the pluralities of femininities and masculinities, and challenging
heteronormativity.
• Experiential qualitative research prioritises participants’ descriptions of their
lived experience, giving voice to their lives and practices. More critical
approaches focus on how gender and sexuality-related phenomena are con-
structed in wider discourse. There are also approaches which bring together
both experiential and critical perspectives.
• 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
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identity and anti-normative knowledge. Feminism & Psychology, 20, 147–164.
Barker, M. & Langdridge, D. (2008). Bisexuality: Working with a silenced sexuality.
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
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Clarke, V., Ellis, S. J., Peel, E., & Riggs, D. (2010). Lesbian, gay, bisexual, trans and queer
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19
Quantitative Methods
Gareth Hagger-Johnson
Introduction
This chapter provides an introduction and review of quantitative approaches

to researching sexuality and gender. Sexuality is considered a broad term
encompassing several topics that might be amenable to quantitative methods,
including sexual behaviour and sexual orientation. The chapter first considers
the brief history of quantitative approaches to studying behaviour and orien-
tation. Next, major quantitative studies of sexual behaviour are introduced
and current debates outlined. Implications for applied professionals are then
discussed, ending with a brief overview of current debates.
Defining key terms

In this section, we begin by defining key terms in sexuality and gender
research. The definitions used by different researchers often vary, so bear in
mind that research you might read could be using a different definition from
that presented here.
Sexual orientation – Sexual orientation is defined as sexual identity in terms
of the gender to which the person is attracted (OED Online, 2004). In popu-
lar culture, it is often taken to mean whether a person is either heterosexual (or
‘straight’), lesbian (a woman who is attracted to women), gay (a person attracted
to the same sex), or bisexual (a person attracted to both sexes). In recent years,
the term ‘queer’ has been reclaimed by activists. It was previously a derogatory
term referring to gay men but is now sometimes used to challenge traditional
notions of heterosexuality and/or gender. In psychological research, however,
sexual orientation may refer to identity, behaviour or attraction. These three
components may overlap, but are not the same thing. Many people who iden-
tify as lesbian or gay engage in sexual behaviour with those of the same sex,
and are clearly attracted to members of the same sex – but not all. Similarly,
there are people who are attracted to the same sex and may even engage in
same-sex behaviour, but do not identity with the labels ‘gay’, ‘lesbian’, or even
333
‘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
Figure 19.1 Three overlapping components of sexual orientation
Gareth Hagger-Johnson 335
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.
The Kinsey studies

The Kinsey studies were the largest studies of sexual behaviour and are often
credited with demonstrating that homosexual and bisexual behaviour were
widespread in the population, suggesting that same-sex behaviour was normal
(Gathorne-Hardy, 2005). The Kinsey Scale is a seven-point scale ranging from
0 to 6, where 0 is exclusively heterosexual, 6 is exclusively heterosexual and
other responses are considered bisexual (Kinsey et al., 1948). Kinsey referred
to experience or response, rather than to sexual orientation identity. It is often
forgotten that an additional category ‘X’ was used in the original Kinsey studies
to record asexuality.
The Masters and Johnson studies

Drawing on the Kinsey studies, Masters and Johnson conducted a series of
research studies into sexual functioning and sexual performance. Such work
was still relatively unusual at the time, and they were among the first to
Table 19.1 Klein Sexual Orientation Grid (Klein, 1993; Klein et al., 1985)
Letter Variable/component Past Present Ideal
A Sexual attraction
B Sexual behaviour
C Sexual fantasies
D Emotional preference
E Social preference
F Het/Homo lifestyle
G Self-identification
consider sexuality in relation to ageing. Their research is often considered a

precursor to the ‘sex therapy’ industry and as establishing sexuality as an impor-
tant aspect of quality of life. The chapter on sex therapy discusses this in more
depth.
The Klein Sexual Orientation Grid

Klein’s Sexual Orientation Grid (Fritz Klein, 1993; Klein et al., 1985) distin-
guishes between attraction, behaviour, fantasies, emotional preference and
variables which are arguably more social than individual: social preference,
het/homo lifestyle, and self-identification. The response options echo the
Kinsey Scale in that they range on a continuum from 1 to 7, but respondents
rate themselves on each of the seven components separately, and then three
times for the past, present, and ideal (future). This allows for perceived change
over time, acknowledging that any one of the components might have been dif-
ferent in the past. There is also an implicit acknowledgement that people may
not be comfortable with their present position on a component, and would
ideally like this to change in the future (Table 19.1).
People rate themselves on a seven-point scale from 1 to 7 (Table 19.2).
Table 19.2 Klein Sexual Orientation Grid rating guide
A to D E to G
1. Other sex only 1. Hetero only

2. Other sex mostly 2. Hetero mostly
3. Other sex somewhat more 3. Hetero somewhat more
4. Both sexes equally 4. Hetero/gay-Lesbian equally
5. Same sex somewhat more 5. Gay-Lesbian somewhat more
6. Same sex mostly 6. Gay-Lesbian mostly
7. Same sex only 7. Gay-Lesbian only
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.
Gender identity: The Bem Sex Role Inventory (BSRI)

The Bem Sex Role Inventory (BSRI) is a self-report questionnaire which pur-
ports to measure masculine and feminine traits, on separate ‘dimensions’
(Bem, 1974). The original aim was to identify benefits of having more
androgynous personality traits, defined as falling between masculine and fem-
inine dimensions. This raises several problems: traditional roles may have
changed, and should US college students’ perceived norms be accepted as
norms for the whole population and for other countries? As commentators
have argued, however, the BSRI actually measures traditional sex role char-
acteristics as defined in relation to the norms of the original sample on
which the study was based (Hegarty, 2003b). Participants were US college stu-
dents from Stanford University and Foothill Junior College. Masculine traits
were defined as characteristics of what men said they were like, and femi-
nine traits were defined as characteristics of what women said they were like.
This reasoning becomes circular. There are also more general questions to be
raised about accepting mean scores for one population group as a standard
for other people. In individual differences psychology, which studies varia-
tion in personality traits, the variation between people is considered more
important than the average score on a trait for particular groups (e.g. men
and women). The chapter on non-binary gender discusses the BSRI in some
depth.
Having introduced some of the historical quantitative work, we now consider

contemporary quantitative research in relation to sexuality and gender. This
tends to consist of large population surveys, designed to have large sample sizes
and to generalise to the wider population.
National Survey of Sexual Attitudes and Lifestyles (NATSAL)

NATSAL-2013 and NATSAL-2000 were conducted as follow-ups to NATSAL-
1990, both of which were used to inform the design of government policy
and public health interventions for Human Immunodeficiency Virus (HIV)
and sexually transmitted infections (STIs). NATSAL-2000 was used for the
Teenage Pregnancy Strategy, the National Sexual Health and HIV Strategy, and
the Chlamydia Screening Programme. It is noteworthy that the government
vetoed the 1990 survey, which was subsequently funded by Wellcome. The
Medical Research Council (MRC) funded NATSAL-2013 and 2011. They were
essentially conceptual replications, but there were important methodological
differences from the original. NATSAL-2000 involved computer-assisted inter-
viewing (CAI), which in some studies has been shown to increase reporting of
‘sensitive’ behaviours such as drug use. However, CAI has become the norm
in recent years. The response rate, following adjustment for over-sampling in
London, was high at 65.4%. This is similar to the response rate of 66.8% in
NATSAL-1990.
The principal findings emerging from NATSAL have been published in The
Lancet (Johnson et al., 2001; Mercer et al., 2013). The authors of the 2011
report observed, since 1990, increases in every key behaviour except for inject-
ing drug use: the proportion of respondents co-habiting rather than marrying;
number of casual sexual partners (heterosexual and homosexual); incidence
of unprotected sexual intercourse; concurrent (simultaneous) partnerships for
females, where individuals have more than one partner in the same time period
(important in STI epidemiology); paying for sex in the past five years; and
heterosexual anal sex. The largest increases were in lifetime heterosexual part-
ners for women, homosexual partnerships for women, reported heterosexual
intercourse for men and women, and prevalence of first intercourse before
age 16. Younger partners were more likely to report new partners, but this
effect is partly explained by the higher proportion of unmarried respondents
at younger ages. In 2013, the report showed that the frequency of reported
sexual behaviour had actually declined, particularly vaginal intercourse. The
proportion of women describing themselves as bisexual had increased (Mercer
et al., 2013).
Behaviours that are particularly relevant for understanding HIV transmission
were studied in NATSAL-2000. Crucially, consistent condom use was more fre-
quent in men and women who reported two or more partners in the previous
year. This illustrates that ‘number of partners’ and ‘condom use’ have to be
evaluated separately or controlled for. Individuals may moderate the risk asso-
ciated with additional partners by using condoms consistently. In total, 15.4%
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.
Longitudinal Study of Young People in England (LSYPE)

Whereas NATSAL was focused on adults, the Longitudinal Survey of Young Peo-
ple in England (LSYPE; see Hagger-Johnson et al., 2013) is a prospective cohort
study of pupils in England born between 1 September 1989 and 31 August 1990
and their parents or carers (hereafter, parents), with intended annual follow-
ups planned until 2015. The data set is unique in that it studies the same
pupils over time and includes a wide variety of variables. Furthermore, the
LSYPE data are fully representative of the population of English pupils. Sample
boosts were performed to obtain N = 1, 000 for the ethnic categories Indian,
Pakistani, Bangladeshi, Black African, Black Caribbean, and Mixed. Areas of
socio-economic deprivation were over-sampled by a factor of 1.5, meaning that
additional people from these groups were recruited into the study, to address
the problem that these groups are traditionally under-represented. At wave 6
and wave 7, LSYPE collected information about sexual identity and behaviour.
For example:
• 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)?
LSYPE has become an important data set, because it is longitudinal (future

follow-ups are planned) and it is representative of the population of pupils born
in 1990/1991. Several researchers have already published analyses using the

data, showing, for example, that LGB young people are more likely to smoke
and drink alcohol hazardously (Hagger-Johnson et al., 2013), and are more
likely to experience symptoms of common mental disorder (Robinson et al.,
2013). You can even access the data from the UK Data Service (see web links)
without a charge. Increasingly, data are being provided in ‘open access’ form,
meaning that anyone can conduct analyses on them. This should have the
effect of making better use of existing data. Much of the LSYPE data described
above, for example, has not been analysed.
National Health and Nutrition Examination Survey

(NHANES, 2007–2008)
Whereas NATSAL and LSYPE are UK studies, NHANES are cross-sectional sur-
veys, conducted on a random sample of US (non-institutionalised) respondents.
There is some over-sampling of ethnic minority groups, but this can be
taken into account during analysis so that results generalise to the US non-
institutionalised population. From 1999, NHANES has been repeated with little
change to the survey content. Therefore, it is particularly useful for examining
trends in the population over time, or for estimating prevalence of diseases.
However, the data are not longitudinal and are limited by possible cohort
effects.
NHANES has available data on sexual behaviour at four time points (in the
years 2000, 2002, 2004, and 2006). Although the data are North American,
the scope and variety of other variables available makes NHANES a viable
tool for secondary analysis. Many of the questions could be calibrated against
equivalent questions in UK studies for comparison. These include:
• ever had sexual intercourse;

• age when first had sexual intercourse;
• number of partners;
• condom use;
• STI diagnoses;
• sexual orientation;
• oral sex;
• sexual partners who were five years older, or five years younger.
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
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.
English Longitudinal Study of Ageing (ELSA)

Although we have data on adults, from NATSAL and NHANES for example,
there is relatively little research on sexuality in relation to ageing, particularly
longitudinal work. It is, therefore, encouraging that ELSA has data available on
sexual orientation, attraction, and behaviour, although not identity. Note that
these two questions allow bisexual and asexual responses:
1. Which statement best describes your sexual experiences over your lifetime?
Please include all sexual experiences including sexual intercourse, fondling
and petting.
• Entirely with women

• Mostly with women, but some experience with men
• Equally with women and men
• Mostly with men, but some experience with women
• Entirely with men
• No sexual experiences in lifetime
2. Which statement best describes your sexual desires over your lifetime?
• Entirely for women

• Mostly for women, but some desires for men
• Equally for women and men
• Mostly for men, but some desire for women
• Entirely for men
• No sexual desires in lifetime
The following questions are sexual behaviour questions available in ELSA:
• 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.
If you record self-reported sexual behaviours in your research, you will

get different proportions of people with same-sex sexual orientation than
if you record sexual identities (or attraction).
If the focus is on sexual behaviour (e.g. in Health Psychology
or public health research), make sure your questions ask about
behaviour. The example below shows how you might ask about sex-
ual behaviours in a way that is non-threatening. It does not make
any assumptions that respondents are heterosexual, lesbian, gay, or
bisexual. It does, however, allow people to report same-sex behaviour
(Table 19.3):
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.
The importance of longitudinal data

There is currently a relative scarcity of longitudinal data in quantitative sexual-
ity research, which needs to be addressed in the future. NATSAL-III (2010/2012),
for example, has shown that sexual behaviour (at least, in the United Kingdom)
has changed, in terms of age of first sexual experience, number of partners,
and attitudes (Mercer et al., 2013). For example, women now report more sex-
ual partners than they did in previous surveys. Does this reflect a change in
behaviour, or a change in how willing women are to self-report their number
of sexual partners? Vaginal intercourse between men and women was reported
to be less frequent, which commentators in the popular media took to reflect
increases in long working hours and ‘screen time’ that have reduced the time
available for sexual activity (Dent, 2013)! When data from the three surveys are
put together, it becomes possible to look at ‘period’ and ‘cohort’ effects. Cohort
effects refer to changes that occur across successive birth years, or generations.
Period effects refer to changes that occur at or across a particular time. These
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.
Psychobiology of sexual orientation

In this section we consider some of the psychobiological work, which differs
from the surveys described above. It differs because it considers the role of biol-
ogy in sexuality and gender, rather than simply looking at behaviour, identity,
or attraction in and of themselves, for example.
Studies regularly report minor but significant differences between same
sex-oriented and heterosexually oriented adults in relation to biological vari-
ables, ranging from pupil dilation patterns (Rieger & Savin-Williams, 2012),
to birth order (Rahman & Wilson, 2003), to the relative lengths of the sec-
ond and fourth finger (2D:4D ratio) (Kraemer et al., 2006). These studies
originate from the psychobiological set of theories (or paradigm) attempting to

explain homosexual behaviour and also to describe ‘group differences’ between
heterosexuals and non-heterosexuals. Psychobiological approaches draw on
evolutionary theory. Homosexuality and bisexuality are, at first glance, prob-
lematic for evolutionary theories of sexual behaviour because they depart from
the expected focus on sexual reproduction (McKnight, 1997). Both show strong
genetic components (heritability), initially thought to be 100% concordant
for monozygotic twins (from the same egg), suggesting no role for the envi-
ronment at all (Kallmann, 1952). Later studies suggested that both genes and
the environment were involved, but there is consistent evidence for a heri-
tability of same-sex attraction (which may or may not translate to same-sex
behaviour, depending on the sociocultural environment and sanctions in a
particular country) (Rahman & Wilson, 2003).
The need to explain the ‘problem’ of non-heterosexual behaviour has gen-
erated several theories which attempt to provide at least partial ‘explana-
tions’. These are briefly introduced below. Interested readers are referred to
the landmark review article published in Personality and Individual Differences
(Rahman & Wilson, 2003) to learn more, and a book devoted to the topic,
called Straight science, which is worth reading in full (McKnight, 1997). Perhaps
unsurprisingly, commentators have argued that homosexuality and bisexuality
should not be approached as ‘problems’ in need of ‘explanations’, because this
reinforces heteronormativity (the belief that heterosexuality is more desirable
than other sexualities). Devoting scarce resources to researching the ‘causes’ of
homosexuality, as if it were a problem that could be ‘solved’, is rather worry-
ing, in my view. Although it might be scientifically interesting to know why
sexual orientation can vary, the implication might be that, once we know
the cause, we can prevent it from happening. Similar concerns are frequently
raised by disability activists, who worry that genetic research has the ulti-
mate aim of removing variation (e.g. deafness) that those at the top of a
social hierarchy have the power to stigmatise (Shakespeare, 1999). Activists,
however, have often used biological and genetic evidence to support greater
acceptance of non-heterosexuality because the alternative views (that factors
in the environment such as upbringing or personal choice are the cause) are
used by people who support heteronormativity (Falomir-Pichastor & Hegarty,
2013).
Psychopathology. Historically, homosexuality was considered a form of
psychopathology and was listed in forensic psychology textbooks as a dis-
order and in psychiatric diagnostic manuals (De Block & Adriaens, 2013).
Psychometric tests were developed in military settings in order to detect
homosexuality in men, and to detect men claiming to be homosexual in
order to get discharged (Hegarty, 2003a). Departures from heterosexuality were
seen as illnesses, which were referred to psychiatrists for treatment. This view
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’
because they both offer advantages in terms of reproduction. Limitations of this

theory include its silent treatment of lesbian women, and it makes assumptions
that gay/bisexual men are innately more sexually active than heterosexual
men – this might simply be due to greater opportunity to find sexual partners
(Rahman & Wilson, 2003).
Psychobiological theories of homosexuality and bisexuality are contro-

versial because they imply a deficit or a problem that needs explaining.
Studies have shown that homosexuality is correlated with proposed
markers of developmental instability, such as facial asymmetry, but find-
ings are mixed and study quality is variable (e.g. how participants were
recruited and selected could lead to bias).
It is, arguably, scientifically interesting to explain variation in gen-
der and sexuality of many kinds (not just ‘homosexuality’ but identity,
desire, asexuality, ‘fetish’, etc.), but this kind of research should involve
dialogue with concerned communities and critical reflection on pub-
lic policy implications (compare to, for example, debates on disability
activism and genetic testing for disability).
The extent to which same-sex and other kinds of attractions,
behaviours, and identities are considered pathological by scientists has
changed over time.
Researchers interested in psychobiological theories of sexuality should
familiarise themselves with the history of research in this area and critical
accounts of the literature, particularly those which identify questionable
assumptions about groups and group differences in experimental settings.
Future directions: Implications for applied psychology

and the wider world
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.
Towards wider measurement of gender identities

The Equality and Human Rights Commission report included recommendations
on how to measure gender identities in quantitative surveys and interviews.
The research, conducted by NatCen, involved qualitative interviews and focus
groups which informed the development of provisional questions. These were
cognitively tested for acceptability among the participants. The final set of five
questions appears below.
Q1. At birth were you described as:
• 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.)
• Yes (please go to Q4) [transgender individuals are routed to question 4]

• No
Q4. Continuing to think about these examples, which of the following options
best applies to you?
• I am thinking about going through this process

• I am currently going through this process
• I have already been through this process

• I have been through this process, then changed back
• None of the above
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:
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.
Quantitative measures of sexual orientation and gender identity are

available.
No measure is perfect, but it is preferable to administer an imperfect
measure than nothing at all.
Public bodies have a responsibility to promote equality in everything
they do, which includes recording sexual and gender identities.
People should have the opportunity to record their sexual orientation
identity and gender identity in the same way that other demographic
variables are recorded routinely.
Traditionally, transgender people have had few opportunities to be
counted in quantitative research, because questionnaires usually pro-
vide only two options: male or female. This might cause distress for
individuals who do not identity as male or female, have changed
(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.
References
Balarajan, M., Gray, M., & Mitchell, M. (2013). Monitoring equality: Developing a gender
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,
N., Reid, S., Conacher, M., Douglas, J., & Swerdlow, A.J. (2006). A cohort study among
university students: Identification of risk factors for Epstein-Barr virus seroconversion
and infectious mononucleosis. Clinical Infectious Diseases: An Official Publication of the
Infectious Diseases Society of America, 43(3), 276–282.
De Block, A. & Adriaens, P. R. (2013). Pathologizing sexual deviance: A history. Journal of
Sex Research, 50(3–4), 276–298.
Dent, G. (2013). Want to have more sex? Leave your smartphones out of the bedroom.
Independent. Retrieved from http://www.independent.co.uk/voices/comment/want-to
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Falomir-Pichastor, J. & Hegarty, P. (2013). Maintaining distinctions under threat: Hetero-
sexual men endorse the biological theory of sexuality when equality is the norm. British
Journal of Social Psychology, 53(4), 731–751.
Forhan, S. E., Gottlieb, S. L., Sternberg, M. R., Xu, F., Datta, S. D., McQuillan, G. M.,
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Klein, F. (1993). The bisexual option (2nd ed.). New York/London: Haworth Press.
Gathorne-Hardy, J. (2005). Kinsey: A biography. London: Pimlico.
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Hagger-Johnson, G., Taibjee, R., Semlyen, J., Fitchie, I., Fish, J., Meads, C., & Varney,
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Hegarty, P. (2003b). ‘More feminine than 999 men out of 1,000:’ The construction
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.
Kallmann, F. J. (1952). Twin and sibship study of overt male homosexuality. American
Journal of Human Genetics, 4(2), 136–146.
Kanazawa, S. (2012). Intelligence and homosexuality. Journal of Biosocial Science, 44,
595–623.
Philadelphia: W.B. Saunders Co.
Klein, F., Sepekoff, B., & Wolf, T. J. (1985). Sexual orientation: A multi-variable dynamic
process. Journal of Homosexuality, 11(1–2), 35–49.
Kraemer, B., Noll, T., Delsignore, A., Milos, G., Schnyder, U., & Hepp, U. (2006). Finger
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210–214.
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substance use in lesbian, gay and bisexual youth and heterosexual youth. Addiction,
104(6), 974–981.
McKnight, J. (1997). Straight science?: Homosexuality, evolution and adaptation. London:
Routledge.
Mercer, C., Tanton, C., Prah, P., Erens, B., Sonnenberg, P., Clifton, S., Macdowell, 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.
OED Online (2004). Sexual orientation, n. (entry 261213) (3rd ed.). Oxford: Oxford
University Press.
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.
Rieger, G. & Savin-Williams, R. C. (2012). The eyes have it: Sex and sexual orientation
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20
Sex Therapy
Michael Berry and Meg John Barker
Introduction
It is difficult to pinpoint an exact moment when sex therapy began. While

the use of psychology and psychotherapy, as they are currently understood,
in treating sexual issues is a relatively recent phenomenon, human interest
in sexual satisfaction is a timeless issue and ancient civilisations had a wide
variety of strategies for dealing with sexual problems. Historical research sug-
gests that the ancient Greeks and Romans, for instance, used a panoply of
herbal remedies, magical devices such as amulets and charms, and prayer to
gods as means of dealing with sexual difficulties (McLaren, 2007). During the
Middle Ages, Western Europeans used similar methods (Taberner, 1985) as
well as attributing sexual problems to suspected ‘witches’: usually poor, eccen-
tric, or socially marginal women who were thought to have robbed people
of their sexual ‘potency’ (Rider, 2006). Clearly, while our interest in sexual
health and functioning can be traced back through the millennia, accepted
treatment methods have changed dramatically since the days of witch-burning
and Spanish fly.1 Nevertheless, our understanding of sexual therapies can still
benefit greatly from being considered within a socio-historical context, given
that accepted treatments continue to reflect and perpetuate prevailing cultural
understandings of sex, gender, and selfhood.
In this chapter, we take account of key sociocultural factors as we outline
some of the core principles of sex therapy and illustrate the key psycho-
logical bases of current concepts and debates. First, we describe the recent
history of sex therapy, tracing the trajectory of the discipline from Freud to the
present day, and identifying some of the principal psychological theories and
psychotherapeutic models used in the field. We then present a number of the
current debates in sex therapy, describing the critical views of psychologists and
therapists who have challenged traditional notions of sexual behaviour, gender
roles, and diagnostic categories. Finally, we identify some of the implications
353
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
that seemingly non-sexual factors may have underlying sexual dimensions

(Hawton, 1985; Wincze & Carey, 2001). Third, the inverse view is also shared
by many sex therapists and sexologists, who hold that sexual problems in an
individual’s life are often highly influenced by non-sexual factors, especially
relationship issues and physical illness (Denman, 2004). In short, sex therapists
tend to see sex in a contextual way – as inherently interwoven with the rest of
an individual’s life.
During the latter half of the twentieth century, a significant shift occurred
towards more cognitive and behavioural models of sexual behaviour and forms
of intervention. Alfred Kinsey, an American sexologist, particularly influenced
the understanding of human sexuality through a series of behaviourally focused
studies (Gathorne-Hardy, 1998). Between 1938 and 1956, Kinsey and his asso-
ciates conducted 18,000 personal interviews which aimed to uncover the sexual
behaviours of average American citizens. The research focused on the quantita-
tive measurement of sexual behaviour, and the two key works, Sexual Behavior
in the Human Male (Kinsey et al., 1948) and Sexual Behavior in the Human Female
(Kinsey et al., 1953), presented a highly statistical picture of Americans’ sex-
ual activities. Alongside their research interviews, Kinsey and his colleagues
conducted a series of controversial studies that involved direct observation of
research participants engaged in sexual acts (something for which it would now
be very difficult to get ethical approval). The focus in these was on a sequence of
sexual behaviour, from arousal through orgasm, and, indeed, Kinsey’s research
was highly focused on the role of the orgasm, as a measure of normal or healthy
sexual behaviour (Gathorne-Hardy, 1998). Many later sex therapists and psy-
chologists have adopted a similar standard, using orgasm – or its absence – as a
primary criterion of sexual well-being. However, we will see later in the chapter
that this model has been challenged.
After Kinsey’s work in the 1940s and 1950s came two of the most important
pioneers in the field of sex therapy – William Masters and Virginia Johnson,
whose work contributed to a psychological understanding of sexual behaviour
and a psychotherapeutic model for the treatment of sexual problems (Mas-
ters & Johnson, 1966, 1970). As with Kinsey, in Masters and Johnson’s model,
human sexual behaviour was seen as following a predictable and essentially
universal course, based on the attainment of orgasm. Masters and Johnson
also based their sexual response cycle model on observational laboratory data,
and defined four distinct phases: (1) the excitement phase; (2) the plateau
(stimulation) phase; (3) orgasm; and (4) resolution (a return to the pre-excited
state). Within this system, sexual dysfunction was seen as a non-response, or
inappropriate response, during any stage of this cycle (for instance premature
ejaculation, or pain resulting from sexual stimulation). In this respect, Masters
and Johnson’s work has been highly influential in terms of both the ways in
which sexual problems have been defined and the accepted techniques of sex
therapy practice.
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.
Key theory and current research
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
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:
• 302.71 Male hypoactive sexual desire disorder

• 302.72 Female sexual interest/arousal disorder
• 302.72 Erectile disorder
• 302.74 Delayed ejaculation
• 302.75 Premature (early) ejaculation
• 302.73 Female orgasmic disorder
• 302.76 Genito-pelvic pain/penetration disorder
• 302.79/70 Other specified/unspecified
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:
Criterion B – persistence of symptoms for at least six months.

Criterion C – symptoms cause clinically significant distress.
Criterion D – the symptoms are not better explained by another disorder,
or by relationship or other stress, and are not due to the effects of a
substance/medication.
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).
During the development phase of DSM-5, a substantial number of researchers

argued for the importance of sociocultural and relational factors, alongside
psychological variables, in the assessment, diagnosis, and treatment of sexual
problems. Consequently, DSM-5 stresses that relevant social factors must be
taken into account in assessment and diagnosis, including:
(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)
Though DSM-5 has retained a categorical model of diagnosis, the develop-

ment of the manual was marked by debates about the use of categorical versus
dimensional diagnostic paradigms (Balon, 2008; Balon et al., 2007; Mitchell &
Graham, 2008). Within a categorical model of diagnosis, sexual dysfunctions are
seen to differ from normal/healthy sexual functioning in kind, rather than
in degree. By contrast, within the dimensional model of diagnosis, sexual dys-
functions are seen to differ from normal/healthy sexual functioning in degree,
rather than in kind (Krueger & Piasecki, 2002). As Widiger and Samuel (2005)
suggest, the categorical model sees diagnostic categories as reflecting “discrete-
clinical conditions”, whereas the dimensional model takes diagnostic categories
as reflecting “arbitrary distinctions along dimensions of functioning” (2005,
p. 494). Overall, the DSM-5 sexual dysfunction diagnoses reflect a shift towards
a more quantitative set of diagnostic criteria.
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
Name of Technique Key References

Intervention
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
359
techniques.
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
While standardised diagnostic categories provide a general view of how applied

psychologists conceive of their clients’ and patients’ sexual problems, the con-
ventional diagnostic categories outlined in standard psychiatric manuals are
contested by many people working in this area (Kleinplatz, 2012b). Leiblum
(2007), for example, summarises some key challenges:
What constitutes a sexual disorder? [ . . . ] How important is the degree or

existence of personal distress as a diagnostic criterion? [ . . . ] Who deter-
mines treatment success: the clinician or the patient? How do we eval-
uate treatment success? Greater sexual frequency? Increased feelings of
satisfaction? (p. 4)
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
from getting an erection on a number of future occasions. Frustrated by these

problems, the patient develops an avoidant, disinterested attitude towards sex.
While such a client might fit the criteria for three diagnoses – early ejaculation,
erectile dysfunction, and hypoactive sexual desire disorder – the value of using
multiple diagnoses to describe a clearly interrelated set of psychological and
behavioural factors is questionable. Consequently, as Levine et al. (2009) argue,
“when desire, arousal, and orgasmic problems coexist in the same patient, the
decision about the most basic dysfunction is arbitrary” (Levine et al., 2009,
p. 164). Some argue that, rather than distinct diagnoses, sexual disorders are in
fact symptomatologies resulting from other underlying psychological factors.
This argument is in part supported by substantial research indicating a strong
correlation between sexual problems, depression and anxiety, relationship fac-
tors, and life stress (Barlow, 1986; McCabe et al., 2010; Stevenson & Elliott,
2009).
Another set of issues cohere around the underlying assumption, within
several diagnostic categories and in much sex therapy as a whole, that a
normal or healthy person will possess a strong psychological motivation for
sex – that is, a relatively high baseline level of sexual desire (Risen, 2010).
Based on this assumption, in the DSM-5, low or absent desire for sex is the
basis for the categories of ‘desire disorder’. Additionally, the category of ‘sex
addiction’ – which is commonly used by clinical practitioners, but does not
appear in DSM-5 – suggests that healthy sexuality involves a Goldilocks ‘just
right’ amount of sexual desire. However, a growing number of researchers have
examined asexuality, finding that this does not constitute any kind of sexual
dysfunction (see Carrigan, this volume). Thanks to such research, distinctions
between asexuality and ‘disordered’ low/absent sexual desire are now reflected
in the DSM-5, although the pathologisation of asexuality in the past, and its
continued marginalisation in wider society, may well contribute to distress
experienced by asexual people (Richards & Barker, 2013). Critical psycholo-
gists have similarly questioned the construct of sex addition, and the way in
which this may serve to pathologise certain groups, such as gay men or kink
practitioners (e.g. Irvine, 2005).
Consequently, normative models of gender and sexual behaviour, pervasive
in much of the sex therapy literature, are important areas of contempo-
rary debate and critical analysis. Critical sexologists and psychologists high-
light the fact that homosexuality was classified as a mental illness in the
DSM until 1973, and in the ICD until 1992 (see Riggs, this volume). The
relatively recent declassification of homosexuality, and the controversy sur-
rounding this, indicates the important influence that political discourses and
social norms exert on the way sexual health problems are defined. Today,
gender dysphoria, the ‘paraphilic disorders’ and the sexual dysfunction diag-
noses outlined above are continuing frontiers of this ongoing debate (see also
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:
Sexual health is the experience of the ongoing process of physical, psycho-

logical, and socio-cultural well-being related to sexuality. Sexual health is
evidenced in the free and responsible expressions of sexual capabilities that
foster harmonious personal and social wellness, enriching individual and
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.
For students, critical engagement with psychological research is particu-

larly important when considering sexual issues. Human sexual behaviour
is extraordinarily diverse and implicates our political, moral, and per-
sonal views of the world. Consequently, the study or treatment of sexual
(Continued)
problems often (and likely always) involves the student’s or researcher’s

system of morality and ethics. It is particularly important to maintain
a critical orientation to the complex social values and discourses that
surround sexuality and, by implication, sex therapy practices. This type
of critical engagement may reduce the risk of biased, aspecific, or unduly
narrow definitions of sexual health and well-being. Students may find it
useful to access the resources on www.sexualitygender.wordpress.com to
help consider their existing ideas about sex.
In recent years, the critical psychological approach of social constructionism

has become a key element in critical sex therapy research and practice (see
Seymour-Smith, this volume). In addition to subjective lived experience, high-
lighted above, emphasis is placed on the wider social world in which the
client’s experience occurs. This requires a contextual approach to practice, in
which the sex therapist works with the client to interpret the sexual scripts that
inform their sexual life and sexual problems, and analyse the social norms –
or discourses – that have influenced such scripts. Here, apparently ‘objective’
measures of sexual performance – as are often represented in conventional
diagnostic systems or sex advice media (Barker et al., forthcoming) – are de-
emphasised. Instead, the subjective meaning of the client’s sexual experiences,
within the context of the world in which they live out this sexuality, is the
focus of the therapy process (Aanstoos, 2012; Kleinplatz, 2012b).
Such work acknowledges that both the client and the psychologist or thera-
pist bring preconceptions, social scripts, values, and norms into the consulting
room. At times it can be challenging to identify and manage one’s own assump-
tions about normality, and strategies are needed to help psychologists work
with clients whose range of experience may be unfamiliar, or even uncom-
fortable (see Richards & Barker, 2013). Consequently, in our work we have
recommended reflexive critical approaches to categories of sexual health and
well-being, gender and sexual behaviour (Barker & Langdridge, 2010; Berry &
Barker, 2013).
As part of the social constructionist approach, an increasing number of sex
therapists work to deconstruct the dominant notions of sexuality and gen-
der that infuse clients’ sexual experiences (Barker, 2005; Kleinplatz, 2012b;
Schilt, 2009; Tiefer, 2006). This often includes analysis of social discourses about
gender – for instance, the notion that women should look a certain way, or
that men should be able to live up to certain standards of sexual performance.
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,
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).
Research indicates that general medical and psychological practitioners

often neglect to inquire about clients’ and patients’ sexual problems
(Temple-Smith et al., 1996). Such reticence is due to cultural sensi-
tivity about sexual issues, personal discomfort with discussing clients’
sexualities, and lack of specialised training in sexual areas (Athanadiasis
et al., 2006; Tsimitsiou et al., 2006). Many sex therapists stress the value of
including questions about sexuality in standardised assessment practices,
especially for those clients presenting with relationship issues (Giraldi
et al., 2013; McCabe et al., 2010; McCarthy & McDonald, 2009b). One
of the important contributions that sex therapy and related research
may have for applied psychology is its emphasis on sexual issues as
a core aspect of clients’ lives. Many advocate the need for specialised
training in sexuality and sex therapy for therapists, psychologists, and
counsellors who wish to work in this area specifically, both to increase
biopsychosocial knowledge and to reflect on their own assumptions
around sex and sexuality.
A number of professional organisations support the work of sex thera-
pists and researchers. These include the College of Sexual and Relation-
ship Therapists (COSRT) in the United Kingdom and the Society for the
Scientific Study of Sexuality (SSSS) in North America. Such organisations
serve as professional networking bodies, hosting conferences and train-
ing events for sex therapists and their research-oriented colleagues, and
publishing research journals, including the journal Sex and Relationship
Therapy and the Journal of Sex Research, respectively.
Future directions
In her updated collection of new perspectives in sex therapy, Kleinplatz (2012b)

puts forward a list of future goals for sex therapy, which we have summarised
below. These are grounded in the kind of idiographic and constructionist
approach which we have argued for throughout this chapter. Many of these
could also be usefully adapted for academic research in this area.
1. Focus on the ability to be present rather than trying to enable a certain

kind of sexual performance (erections, penetration, orgasm, etc.) through
understanding clients’ subjective meanings and experiences.
2. Appreciate the uniqueness of each client and the huge variety of possible
sexual practices and experiences that may work for them, rather than pro-
moting a one-size-fits-all goal for therapy. Here, Kleinplatz provocatively
(and usefully, we think) suggests that sex therapists could learn a lot from
professional dominatrices who make it their business to learn exactly what
gets their clients off.
3. Promote social change through sex education and activism rather than con-
tinuing to reinforce a problematic normative sexual script (e.g. measuring
men’s worth by their last erection, buying into cultural ideas about ageing
bodies and the value of maintaining youth, or assuming that women must
be penetrated in order to maintain their relationships).
4. Be guided by clients rather than by categories of functioning and dysfunc-
tioning. For example, rather than trying to get penises to penetrate or
vaginas to be penetrated, attend to the whole person and to the sensible
reasons why this might not be a safe or desirable thing to do (e.g. because
they want to be valued for more than their sexual performance, because past
relationships have left them fearful of letting people in, or because sex
has become all about pleasing others with no attention to what turns
them on).
5. Get to the core of clients’ pain and joy, hopes and despair, and aim at
transformation rather than simply safely promoting mediocre sex.
6. Foster deep-seated change in the ways clients relate to themselves, others and
sex, rather than just aiming to contain problematic (e.g. non-consensual)
sexual behaviours.
7. Offer multiple options to clients. They may choose to just do what works to
enable erections, penetration, or orgasms, and we should honour that choice
if so, but if we offer other alternatives alongside this they may choose, for
example, to deepen their relationship, to transform their thinking about sex,
or to address their lives more widely.
8. Aim higher than returning clients to adequate sexual functioning and
work with them towards ‘sex worth wanting’ though being vulnerable and
authentic, and through tuning into their bodies and their engagement with
others.
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
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
• The development of sex therapy as a distinct clinical specialisation is a rela-

tively recent phenomenon with its roots in the work of Kinsey and Masters
and Johnson, and an emphasis on diagnosis and cognitive behavioural
treatment.
• The diagnostic categories for sexual dysfunctions in the DSM relate to desire,
arousal, and orgasm, as well as to penis-in-vagina penetration.
• Such an approach has been criticised for being universalising,
heteronormative, rigid, and goal-focused, as well as for failing to cap-
ture diversities of sexual experience and relational aspects of sex, and
pathologising or stigmatising certain people, groups, and practices, causing
unnecessary harm to clients and to wider communities.
• Critical and social constructionist approaches work with the sexual scripts
and values that influence clients and emphasise meanings of sexuality
within the client’s subjective experience.
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.
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.
Retrieved from http://www.ted.com/talks/al_vernacchio_sex_needs_a_new_metaphor
_here_s_one.html.
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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
and post-industrial societies. A common trajectory in Britain might involve

school – further/higher education – work – marriage/children – retirement –
death. Such models pivot around the changing economic fortunes of individ-
uals, who at different stages experience greater or lesser involvement in waged
work and childcare. But this model reflects heteronormative thinking (which
takes heterosexuality as the norm) and presumes cisgendered status (of peo-
ple content with the gender assigned at birth). It cannot serve LGBTQI people
well (or childless/childfree heterosexual people and the increasing number of
singletons). For instance, it cannot accommodate ageing as a gay man, which,
in more commercialised gay cultures, is distinct, in that men can experience
ageing as ‘accelerated’ (Bennett & Thompson, 1991). They report feeling judged
as old(er) before their time on ‘gay scenes’ where athletic youthful bodies are
prized over ageing ones (Heaphy et al., 2004). But life-stage definitions are being
eclipsed in Western societies by open-ended life courses that are much less pre-
dictable and depend on a range of influences. Following Arber and Ginn (1995),
ageing in ‘Western’ contexts is defined as the outcome of relations between
physiology, that is, material changes to the body, chronology, and the passing
of time, which includes the symbolism of being 18, 40, or 65. Both influences
are embedded in social relationships where differently aged bodies are imbued
with different meanings.
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
Necessary withdrawal vs. continuity?

While contemporary theorists contest the idea that ageing is predominantly
about loss, decline, and decrepitude (see Gilleard & Higgs, 2000), 1950s func-
tionalist sociology (in the United States) explained ageing as involving gradual,
inevitable withdrawal from society and civic participation. This was deemed
necessary for the continuation of society (Cumming & Henry, 1961). With-
drawal from the labour market and positions in public life are functional in
that it creates socio-economic opportunities for younger people and enables
transfers of resources, power, and responsibility across the generations. Old(er)
people’s increasingly marginal(ised) status is thought to prepare them psycho-
logically for the ultimate disengagement – death. This bleak view has been
supplanted by the idea that continuing social participation is actually more
functional for society and better for the individual. The ‘third age’ can be
a period of creativity (Laslett, 1989), involving freedom from waged labour
and greater resources of time to apply skills and knowledge – what I call
‘ageing capital’ (Simpson, 2013a, b) – for the collective benefit through famil-
ial, social, political, and community activities. Indeed, theories of ‘successful
ageing’ (Baltes and Baltes, 1990), which have come largely from social psychol-
ogy, have argued for the need to support individuals in the management of the
ageing process and the challenges this presents. Individuals need to adapt to
changes in circumstances, given physical, cognitive, or other loss, but there is
continued focus on what individuals can do independently.
Although successful ageing represents an improvement over functionalist
theory, as a mirror image of the latter, it has its own problems. It relies on a
utilitarian view of old(er) people as valuable when providing (unwaged) labour
Paul Simpson 379
or supporting social reproduction in their role as grandparents. Such think-

ing offers little room for the pleasures of indolence and struggles to appreciate
later life as valuable in itself. While the theory can help old(er) people remain
independent (Flood, 2005), it could also risk stigmatising individuals consid-
ered to be ‘ageing badly’ because of hidden, structural factors beyond their
control (Estes et al., 2003). This can reinforce inequalities of gender, sexual-
ity, class, and race that can widen with age. In my research on middle-aged
gay men (Simpson, 2013b), stories of successful ageing, indicating how men
had adapted to loss of physical capacity, still worked with the assumption that
ageing is something to be avoided or denied. At face value, adapting to physical
loss represents positive thinking, but it comes perilously close to reinforcing the
defeatist view from functionalism that individuals should resign themselves to
a diminished social role in later life as a natural, inevitable fact of life.
Ageing as a product of societal arrangements

The dominance of functionalist explanations of social phenomena was eclipsed
in British social science/sociology from the 1970s by structuralist theories stress-
ing how the organisation of society causes disadvantages. On this account, ‘old
age’ is thought to represent a form of ‘structured dependency’ – resulting from
the capitalist system of production that marginalises old people (particularly
working-class old people) as surplus to requirements in societies where status is
organised around production and consumption (Vincent, 1999). Recognising
disadvantage in later life as structurally induced avoids blaming individuals for
forces beyond their control. This theorising also draws attention to how old
people are devalued if no longer involved in (or made marginal to) production,
consumption, and reproduction. But it also assumes a life-stage model of ageing
and over-relies on socio-economic explanations of old age, which can miss loss
of status that works independently of class position. Further, it risks homogenis-
ing old(er) people as socially excluded, and thus overlooks the opportunities
that they have/create to avoid complying with dominant social expectations
and constraints (Hockey & James, 1993). Such thinking can ignore diversity in
later life and risks reinforcing the stereotype of dependency that theorists and
practitioners might want to avoid (Bury, 1995).
• Be creative about how you convey messages about ageing processes,

drawing attention to the diversity of experience at different points in
the life course. These are not the same for all: For example gay men
generally move towards more domestic-based kinship or ‘families of
choice’ in midlife.
380 Intersections
(Continued)
• Teaching/learning methods will be more effective when they involve

students empathising with others across lines of difference. You could
involve older people in devising/delivering courses and setting assign-
ments that involve students engaging with organisations supporting
older people.
• Encourage students/readers to engage critically with stereotypes of
ageing (as well as gender, sexuality, class, and race) and intersectional
theories of ageing.
Current debates
Different cultures of ageing

While structured dependency theories remain influential, there has been a
shift since the 1980s away from analysis of class towards analysis of the cul-
tural or symbolic influences on ageing and later life. If structuralist approaches
can downplay the diversity of old(er) people’s lived experience, theorising on
differentiated, individualised ‘cultures of ageing’ in complex late modern soci-
eties (Gilleard & Higgs, 2000) addresses this head-on. This theory is inspired by
British sociologist Anthony Giddens (1991) and draws on humanistic psychol-
ogy. It argues that various cultural, political, legal, moral, and demographic
changes (i.e. longevity), as well as increasing affluence in a globalising world
since the 1950s, have ushered in pluralised cultures of ageing. Life courses are
now much more heterogeneous, and later life is being recuperated by the ‘baby
boomer’ generation (born post-World War II). Silver surfers can now draw on
images and ideas from globalising media and consumer culture, including the
abundant self-help therapy culture, to reconstruct identities in ways that blur the
boundaries between youth and age. Growing older can involve youth-coded
leisure activity and fulfilment, such as global travel, rather than decline, loss,
and dependency.
This thinking challenges theories that homogenise later life as descent into
misery, constraint, and passivity. As such, it offers individuals resources with
which to contest ageism. But, while it focuses on the diversity of ageing expe-
riences, it pays scant attention to (and thus renders invisible) those in the
fourth age – the oldest in society. It also understates inequalities attached to
differences of class, gender, and race. The autonomy presumed in this theory
foregrounds and falsely universalises the experiences of more culturally and
economically resourced older people. Besides, one might ask why older people’s
choices in relation to consumer culture should be prized over other choices
Paul Simpson 381
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 as radically socially constructed

Another challenge to structuralist theories of (ageing) subjectivity has come
from poststructuralism, which follows the thought of late twentieth-century
French historian and philosopher, Michel Foucault. This school of thought,
which emerged in Britain in the 1980s, would emphasise the role of culture
and ideas rather than structure and economy in constructing our notions of
later life. On this account, age, gender, and sexuality have nothing to do with
biology but are the products of social and cultural processes (Foucault, 1979).
Individuals are thought to internalise historically shaped discourses, which reg-
ulate how ageing identities are thought and enacted. Theorists working with
this worldview have drawn attention to how an ‘ageing industry’ or ‘grey
market’, which can include rejuvenating tourist experiences as well as cos-
metic surgery, has helped women in particular to reclaim value by defying
chronology and perpetuating their relative youth (Heyes, 2007). Within this
paradigm, age has been theorised as no more than simulation – a product of
human-made culture – and the older body surface is thought to operate as a
‘mask’ covering an interior, youthful self (Featherstone & Hepworth, 1993). For
instance, old people might claim to be 65, 70, etc., but ‘inside still feel 25,
30 etc.’
Poststructuralist theorising highlights the workings of age/ageist discourses,
which operate at a symbolic level independently of socio-economic influences.
Like late modernist approaches, this theory seeks to denaturalise ageing – to
challenge the view that it is a purely biological phenomenon, essential to
human beings across time and place. However, it ignores, and risks reinforc-
ing, material inequalities relating to gender, race, and class over the life course
(Estes et al., 2003). We might ask just how blurred age divisions have become
and who has the economic, cultural, and psychological resources to blur them
through cosmetic surgery or travelling experiences. It has also been questioned
whether these technologies are death-denying or reinforce the medicalisation
of old age (Marshall, 2006). Besides, emphasis on regulation risks downplaying
382 Intersections
how individuals resist pressures of ageism and consumer culture. Featherstone

and Hepworth’s theory also sees ageing subjects as validated mainly through
consumption, and the idea of the ‘mask of ageing’ reinforces essentialist and
ageist thinking that old(er) people can only be recuperated when they invoke
qualities associated with youth or a younger, interior self.
Newer currents – ambivalent resources of ageing
The two theories just discussed illuminate or close down consideration of dif-
ferent aspects of ageing that occur at material and symbolic levels. However,
despite Arber’s and Ginn’s exhortation in 1995 that we should avoid theorising
ageing in a vacuum as if separate from other differences (class, race, gender,
and sexuality), much remains to be done to advance this intersectional project.
Many theorists have still failed to do this, or have attempted it with insufficient
rigour, simply ‘adding and stirring in’ a new factor/ingredient in ways that miss
the complexity and effects that various influences have on identity and relating
(Cronin & King, 2010).
The problems identified in the foregoing discussion are being addressed
by an emerging body of work attuned to intersectionality, where ageing is
conceived as the unpredictable outcome of the messy dialogue between struc-
tural, discursive and biographical influences. For Silver (2003), the marginalised
positioning of old(er) people is thoroughly contradictory. Although it entails
cultural, economic, social, and political exclusion, simultaneously it invites
critical reflection on ageism (and more besides) courtesy of the intellec-
tual and political resources garnered through the ageing process. Silver’s
empirical work involving older Jewish-American women theorised that they
approach age as a challenge rather than as something to be avoided. She
also observed (in a Jewish-American context) women’s cultural and reflexive
advantages over men courtesy of gendered socialisation. Women generally
are better equipped to maintain social networks in later life, and conse-
quently are less likely to experience isolation and mental health difficulties.
The same research noted the relative de-gendering and democratisation of
old age, where age eclipses gender as a marker of identity. Men’s withdrawal
from waged work can sometimes result in household chores becoming less
gender-defined.
The ambivalences of ageing have also been explored in studies of ageing as an
LGBTQI individual, which connects gender and sexuality with other influences.
For gay men, ageing is particularly context-dependent. They report feeling
their ageing as ‘accelerated’ mainly when on the ‘gay scene’ (Heaphy, 2007).
Further, Heaphy draws attention to the class-based resources of ageing which
gendered individuals draw on when responding to ageism within LGBTQI cul-
tures. Ageing, gender, sexuality, biography, and class – cultural and material
factors – enmesh to shape how people negotiate later life. Gendered sexuality
Paul Simpson 383
and class can be simultaneously a barrier and a reflexive resource. Heaphy

notes how some gay men might have been attracted to lower-paid, ‘feminised’
occupations (hairdressing, nursing, etc.) and some lesbian-identified, childfree
women might be attracted to and benefit from better-paying ‘masculine’ ones.
Such career ‘choices’ affect not only individuals’ worldviews and what they con-
sider themselves capable of but also the material resources they can mobilise
to make later life more convivial. In terms of kinship, older lesbian-identified
women might benefit earlier from a ‘family of choice’ than gay men, who were
usually involved during their youth in the individualised, commercialised gay
scene (Heaphy, 2007). My work has challenged the stereotype of the lonely
old queen, arguing that friendship families help middle-aged gay men avoid
isolation (Simpson, 2013a, b).
Moreover, my work on middle-aged gay men’s narratives of ageing in
Manchester draws attention to the differential socio-economic, cultural, and
narrative resources that reflect men’s ‘ageing capital’ in different contexts that
can involve capitulation to, ambivalent negotiation with and resistance to (gay)
ageism (Simpson, 2013a, b). Indeed, this work points up how middle-aged
men’s claims to represent a more ‘authentic’ form of gayness (because they
are less concerned with fashion and physique) can contradict their claims to
embody a more mature way of being and relating that involves a smooth, linear
path to greater acceptance of self and others. Indeed, ageism is multidirectional
(Bytheway, 1995), and the middle-aged can express reverse ageism that rein-
forces stereotypes of younger gay men as selfish, ‘superficial’, and irresponsible
(Simpson, 2013a, b).
Although less is known about ageing as bisexual, this process can involve
double invisibility, on the grounds of age and sexual difference and fear of, if
not actual, exclusion from both gay and straight fields of existence, including
social/support groups and kinship formations. Older bisexual men might expe-
rience cultural ageism if venturing out on the gay scene, and (ageing) bisexual
women could face rejection by lesbian-identified women and ageism and sex-
ism combined if venturing into heterosexualised leisure spaces. However, while
acknowledging these possibilities (albeit based on a small convenience sample
of culturally resourced younger bisexual people), Jones (2011) has observed how
normative and non-normative futures are envisioned. Indeed, being defined as
non-normative can prompt critical questioning, and positive futures involv-
ing ethical polyamory (emotional involvement by consent with more than one
partner) were commonly imagined. They contest the idea of bisexual ageing
as being all about misery and double exclusion. Jones notes that it was older
(women) bisexuals who appeared more likely to envision or adopt a norma-
tive or monogamous lifestyle. I would speculate that this is connected with
pressures of ageism (and sexism) and, perhaps, class that together motivate
individuals to seek emotional and socio-economic security as they grow older.
384 Intersections
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:
• happening at all stages of life;

• differentiated by how it intersects with gender, sexuality, class, and
race. This complex of factors influences whether later life is experi-
enced as more or less secure and satisfying. The idea of the more
open-ended life course is more able to accommodate these differences;
• historically and culturally variable – our Western capitalist experiences
of it are not typical, representative, or universal.
Implications for applied psychology and the wider

world: Future directions
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
In practice, this will entail understanding of the differential cultural, biograph-

ical, reputational, and socio-economic resources available to individuals and
how the structure of society and dominant expectations constrain or enable
very different old(er) people to live more or less authentic, fulfilling, and
connected lives. It is important that professionals and society generally think
creatively about how to maintain and develop services for older people, and
particularly LGBTQI individuals, in times of austerity (King, 2014), when their
rights and needs might be viewed as dispensable.
Old people in particular are discounted as sexual beings (Gott, 2005). Social
policy and the care system itself largely ignore older people’s needs for inti-
macy (Hafford-Letchfield, 2008). The problems of expressing sexuality in care
homes are multiplied for older LGBTQI residents, who might find their sex-
ual histories denied and face pressure to go “back into the closet” (Stein &
Almack, 2012). This is attributable to homo-, lesbo-, bi-, and transphobia (fear
of gender and sexual difference that can animate prejudice and discrimination)
and pervasive heteronormative attitudes. Despite liberalisation around sexual-
ity since the 1960s, there have been no national campaigns to raise awareness
of older people’s sexual rights. Further, despite more than 30 years of holis-
tic needs assessment, academic, professional, and governmental concern with
biopsychological functioning still overshadows consideration of residents’ sex-
ual needs. Yet there has been an increase in sexually transmitted infections
among old/er people (Gott et al., 2003), and the National Survey on Sexual
Attitudes and Lifestyles (Mercer et al., 2013) shows that many people remain
sexually active well into later life. In 2012, 42% of women and 60% of men aged
65–74 reported having had at least one opposite-sex partner. The sexualities of
old(er) people are, therefore, in need of public recognition, and professionals
should be encouraged to embed into their practice recognition of residents as
‘sexual’ or ‘intimate citizens’ – sexual beings with rights to autonomy “over
their relationships, bodies and erotic experiences” (Plummer, 1995). Think-
ing along these lines could contribute to making care homes more inclusive.
They could work as communities rather than being seen as spaces for the
warehousing of old people in Heaven’s waiting room.
This chapter has addressed non-normative forms of gender and sexuality as
they affect and are in turn affected by ageing, though, reflecting the litera-
ture itself, it has collapsed discussion of sexual difference under the general
rubric ‘gay’. While LGBTQI people experience certain forms of oppression in
common, scholarship has tended to erase the specifics of lesbian, bisexual,
trans, and intersex experiences of ageing. Growing older as a lesbian-identified
woman has been given some attention, though mainly in American scholar-
ship, where it appears that ageing is considered little barrier to being valued
in cultures that regard attractiveness in more holistic terms (Barker, 2004;
Kehoe, 1986). While we can accept that lesbian cultures might yield many
opportunities for support, we might question the romanticised assumptions
386 Intersections
that underpin the idea of a community largely untainted by ageism in soci-

eties where it is endemic. Ageism may operate differently and less acutely
within Western lesbian cultures, but these cultures are not immune to ageism
(Cruikshank, 1991). There are signs that, like young gay men, younger les-
bians are beginning to reject intimacy and friendship with their ageing peers
on the ‘aesthetic’ grounds of whether they embody the appropriate youthful
‘look’ (Slevin & Mowery, 2012). Further, ageing bisexual, trans, or intersex
individuals can find themselves even more isolated in later life as they are
at greater risk of rejection or marginalisation by gay and straight cisgen-
dered people (Clarke & Peel, 2007). The trans challenge to normative gender
seems less acceptable than lesbian, gay, and bisexual people’s crossing of the
line of normative sexuality (Weiss, 2008). Older bisexual people might find
themselves excluded from social and intimate relations on account of stereo-
types of them as unreliable, duplicitous, self-deluding, and hypersexual (Rust,
2003).
Finally, it is worth bearing in mind work being pursued by Kathy Almack
and Andrew King, which questions stereotypes of ageing/later life. Acknowl-
edging scope for cross-generational transfers of knowledge and care within
LGBTQI cultures, this policy-oriented project challenges views of old people
that reduce them to mere objects of care (which results in their being patro-
nised). Older people – whether LGBTQI or straight – can be embedded in a
complex of reciprocal relationships as both recipients and providers of care.
• Consider practically how differences intersect, but also avoid stereo-

typing. One size does not fit all. Equality needs to be secured by
differentiating services in line with individual choice.
• To meet individual and collective needs, consult with individuals,
significant others, and voluntary and advocacy groups (general and
specific).
• Think creatively about how to develop services for older LGBT peo-
ple, especially those living in care homes, who can find themselves a
minority within a minority.
Summary
• Ageing is a highly differentiated process both within developed nations and

between the more and less developed parts of the globe. It is historically and
culturally variable.
Paul Simpson 387
• 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.
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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”.
History, key theory, and research
Given the contemporary dominance of social cognition in the discipline

(Augoustinos, 1999), it is perhaps unsurprising that the majority of psy-
chological research has been mainly interested in the relationship between
‘socio-economic status’ and health (risk)-related behaviours, prompted by the
large body of research which points to gross health inequalities across the class
spectrum (e.g. Graham & Kelly, 2004). This research typically applies social
cognition models in attempts to link attitudes, beliefs, and perceptions to
health behaviours (Mielewczyk & Willig, 2007). Congruent with mainstream,
Western psychological research in general, such models focus on the individual
(e.g. beliefs, attitudes) at the expense of examining the wider socio-political,
cultural, and economic contexts within which ‘health behaviours’ take place
(Mielewczyk & Willig, 2007). Consequently, class-related health disparities are
commonly regarded as resulting from individual (poor) choices (see Day et al.,
2014, for a critique of the treatment of class within psychology), ignorance of
health-promoting activities, and faulty cognitions (e.g. Malson, 1998).
An example of the above are Wardle and Steptoe’s (2003) findings that those
from ‘lower’ SES groups were less ‘health conscious’, held stronger beliefs about
the role of chance in health, and spent less time thinking about the future,
all of which were associated with “unhealthy behavioural choices” (ibid., p.
440). However, as those such as Day et al. (2014) have argued, the notion of
‘choice’ in relation to health has been invoked as part of the neo-liberal agenda,
promoted as if we could all have healthful lives if only we would take personal
responsibility for health and make the ‘right’ choices, something which those
such as Walkerdine (2002) argue to be a myth.
Aside from ‘mainstream’ psychological research on class, there exists a body
of work informed by more ‘critical’ perspectives which, rather than reducing
classed practices to the level of the individual (e.g. attitudes, cognitions), aim
to understand these through a lens of ideology and structural positionings.
For example, in the context of the United States, Lott (2012) notes the
myriad ways in which poor people are disadvantaged in most aspects of life
Bridgette Rickett and Maxine Woolhouse 393
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
are denied an important pathway towards political mobilization” (Power et al.,

2011, p. 191).
Contemporary ‘mainstream’ psychology is dominated by social cogni-
tive theories which tend to reduce understandings of ‘ways of being’ to
individual ‘choices’ structured by an individual’s cognitions. This has
the effect of obscuring the wider socio-economic, political, and social
conditions that structure people’s lives and therefore justifies the status
quo by failing to acknowledge the privileges and disadvantages that are
(re)produced through social inequalities. As such, it is crucial to:
• recognise our own class positioning (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;
• adopt a critical and ‘class-focused’ lens when considering psychologi-
cal theories by, for example, asking questions such as “To what extent
is social class acknowledged?”; “How is social class conceptualised?”;
“What might be the implications of this theory for different social
groups?”;
• take social class into account when engaged in our own work as either
students of psychology, practitioners, or academics.
Gender and class

A tendency in psychology to both focus heavily on ‘sex difference’ and ignore
or minimise social class, while simultaneously constructing these two cate-
gories as separate and ‘fixed’, has led to little attention being paid to the
theoretical accounting of the intersection between gender and class. However,
there has been interest in developing a cohesive theoretical account of the
intersecting constructs such as class, with assumptions of identity as being
constructed by fluctuating and fluid discourses/meanings from the world an
individual inhabits (e.g. McDowell, 2009) rather than ‘fixed’ in time and space.
In this section we will consider ‘gender’ in terms of research that has focused
on cisgender experiences, masculinities and femininities, and class. In our
last section we look at research around the intersection of gender, sexuality,
and class to enable a focus on the ‘T’ (in ‘LGBT’ – commonly used to refer
to lesbian, gay, bisexual, and transgender sexual minorities) while allowing
an examination of the crucial dimension of gender for trans experience and

identity.
For many theorists, the understanding and analysis of intersectionality
between gender and class coincides with poststructuralist argument (Butler,
1999). Poststructuralism is a term used to denote the ideas of mid-twentieth-
century French philosophers/theorists who focus on the complexity of humans
themselves and the impossibility of escaping structures in order to study them.
This body of research also tends to follow Foucauldian understandings of
power, where discourse is the medium through which power is transformed
into knowledge and understanding of ourselves and others (see the chapter on
ageing for more detail on poststructuralism, power, and identity). This small
body of research falls roughly into the three applied areas of education, health,
and counselling.
Our first example is a study with mothers that explores the psychological
impact of social class on involvement with their children’s schooling. In this
research Reay (1998) found that, although both working- and middle-class
mothers were significantly emotionally invested in their children’s education,
the mothers’ differing class positions were very apparent. For example, middle-
class mothers conveyed a sense of entitlement and belonging in relation to the
education system, assuming their children would academically achieve, enter
the higher education system, and pursue prestigious careers. In contrast, the
working-class mothers expressed uncertainty, a sense of inadequacy in terms of
their ability to support their children through the system, and assumptions that
their children would not be welcome in middle-class (e.g. grammar) schools.
For example, talking of her daughter’s possible entry to grammar school, one
working-class mother commented:
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)
Further research by Ringrose and Walkerdine (2008) explores intersections

of femininity and class through analysis of British ‘make-over’ reality TV
shows such as ‘Honey We’re Killing the Kids!’ (BBC3) and ‘The House of
Tiny Tearaways’ (BBC3). Here it is argued that such shows serve to produce
and transform ‘failing’ working-class mothers into idealised, neo-liberal, bour-
geois (feminine) subjects. Typically, primarily working-class parents’ putative
faulty parenting practices and dysfunctional lifestyles are monitored, scruti-
nised, and held responsible for sabotaging the future health and life chances
of their children. Underpinned by the question: “Is the transformation of
abject subjects possible?” (ibid., p. 227), the goal of such shows is to re-educate
396 Intersections
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
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
Gendered identities and experiences are always constructed and

shaped through class ideologies. For example, different versions of
masculinities/femininities are privileged or marginalised and may carry
different meanings according to the particular class context. This implies
that gender and class intersect to produce various forms of subjectivity,
and therefore attempts to understand gendered or classed ‘ways of being’
in isolation from one another will result in impoverished accounts. For
example, working-class women’s experiences are likely to differ signifi-
cantly from those of middle-class women given their different material,
structural, and discursive positionings and differential access to social,
cultural, and economic forms of power.
Sexualities and class

During the rest of the chapter we will attempt to examine the way in which
LGBT groups have been researched and understood in terms of the social class
they are categorised, or categorise themselves, as belonging to. However, as
McDermott has previously argued (2006), LGBT psychology has conducted
important research, but there remains little work on social class in LGBT
psychology’s wider academic thinking, with much research generated from
samples that are usually white and middle-class. This has led to a conclusion
that “The exclusion of social class from sexualities research and theory raises
epistemological questions about whose experiences are being used to generalise
understandings of sexual and intimate life” (McDermott, 2011, p. 64).
McDermott has carried out a body of research that aims to illuminate some
of the processes involved in the regulation of sexuality and class inequities
that often result in negative outcomes for women who identify as ‘sexual
other’. For example, using interviews with 24 women (living a variety of loca-
tions across the United Kingdom and employed in various types of work)
and drawing on feminist interpretations of Bourdieu’s work (1984) to under-
stand sexuality and class (e.g. Skeggs, 1997) resulted in a number of findings.
First, the women reported a heavy regulation of their sexuality in the places
where they were employed and recounted multiple experiences of their sexu-
ality being derogated. Indeed, many reported leaving their places of work as
result of the homophobia they experienced. In addition, the women reported
that the performance of a lesbian identity in their working environments
was a serious risk for them that resulted in psychologically demanding ‘prac-
tices of survival’ (p. 202) such as ‘acting straight’. The important feature of
these findings is that these experiences were heavily classed. For middle-class
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)
similar sexual identities will have similar experiences and outcomes

when, in fact, their class positionings may impact these greatly. This
points to the need for examining how class and sexuality may intersect
to produce very different experiences, practices, and outcomes.
Intersections of gender, class, and sexualities

Lynn Weber’s (2001) early work suggests that the psychological dimensions
of everyday life are intertwined and mutually dependent, as are systems of
inequality that both limit and restrict some people while privileging others.
Weber’s arguments go on to map out a theory of gender, sexuality, and class
hierarchies that are not static or fixed but are located within space and time.
Therefore, to understand the intersections of these multiple identities we must
understand the specific historical and political context they exist in. Weber
uses the illuminating example of the term ‘mothers’ to argue the importance
of such a focus. For example, if we compare how we understand ‘traditional
mothers’, ‘lesbian mothers’, ‘social mothers’ (and, we would add, ‘single moth-
ers’), we can see that meanings are hierarchical in that they serve to prescribe
the morality, the legitimacy, and, indeed, the legal rights of these mothers to
rear their children. In addition, these meanings are located within multiple
understandings of gender, sexualities (and, indeed, race), and class.
As such, other authors have argued (e.g. Clarke & Braun, 2009) that it is
vital to examine the hierarchical gendered, classed (and raced) positions that
LGBT people occupy in order to examine the multiple categories of identity
and the impact these have on experience. Research carried out by Gibson
and Macleod (2012) has used such a focus to look at how South African
female university students who identify as lesbians talk about their experi-
ences. Here, women reported experiencing differing levels of ‘heterosexism’
(a term commonly used to describe an ideology that denies and denigrates
anything non-heterosexual) depending upon which socio-economic space they
occupied. For example, while white, middle-class spaces (such as university)
were constructed as ‘safer’ for middle-class women, more traditional working-
class spaces (such as townships) were represented as ‘dangerous’ for them as
lesbians. However, heterosexism ensured that even while in ‘safer’ spaces the
women still felt ‘strange’. For working-class women, the otherness associated
with their sexuality was compounded by the otherness of their class, with
homosexuality constructed as a being derogated as ‘other’ which reflected
their association with the ‘other’ of lower social classes, and they therefore
feared being associated with either. In sum, LGBTQ (generally referring to
Lesbian, Gay, Bisexual, Trans, and Queer or Questioning) people’s experiences

of what is considered to be safe are shaped by intersecting positions of class and
sexualities.
Further research has examined how culturally valued discourses around
gender, heterosexuality, and class articulate through workplace practice. For
example, in Rickett and Roman’s (2013) work on female door supervisors,
the authors identify a discourse of ‘playing the hero’. This discourse illumi-
nates and troubles notions of heterosexuality. For male colleagues, ‘playing
the hero’ appears to be a powerful means of gaining sexual success through
a heterosexual, hegemonic masculinity whose inherent ‘hero’ status is gained
through the capacity to protect woman. Women, in turn, are presented as
being helpless in the face of such displays, turning from sensible womanhood
to ‘throwing themselves’ at the ‘hero’, an unruly and hypersexual femininity
that draws on heavily gendered, classed, and morally imbued understand-
ings of acceptable and unacceptable sexual practice (Skeggs, 1997). Here, then,
notions of the working-class hero bolster powerful ideals around masculinity
and heterosexuality that position men and women in firmly divided roles. It is
argued that it is through heterosexuality that working-class masculinities can
be invested with notions of strength and bravery. In addition, it is the use of
‘playing the hero’ that reiterates ideology around ‘the hero’ as being knowing,
strong, powerful, physically and sexually agentic, and in control of the space
he inhabits and the occupants of it. On the other hand, normative expecta-
tions of femininities in the same space are associated with a lack of autonomy
and agency, having potentially ungovernable sexual practices, and being vul-
nerable to physical harm. Indeed, it appears for many working-class women in
this workspace that any social and political inequalities can only be overcome
by securing a heterosexual relationship with a man who embodies this ‘hero
position’.
Current debates and future directions
A recent example of research in psychology has purposefully focused on the

cultural and social meanings associated with gender, transsexualities, and class.
Using media text, Rickett et al. (2013) analysed the reporting of a UK media
‘story’. In January 2013, the UK media were dominated by an article/thread
written by newspaper writers and feminists Julie Burchill and Susanne Moore.
The resulting explosion of online and print content preoccupied itself with
defining feminism, feminists, ‘real women’, transgender, and the trans commu-
nity. Using feminist-informed poststructuralist discourse analysis, this research
interrogated constructions of what is a woman and/or a feminist and how these
ideas can be shaped by a gendered and classed ideology around who and what
we see to be genuine, legitimate, worthy, and respectable.
402 Intersections
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?
As a number of academics and practitioners have already brought to our atten-

tion (e.g. Liu et al., 2012; Maracek & Hare-Mustin, 2009), psychological research
and theorising around social class and classism has important implications for
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.
Implications for theory and research

At the height of this recent interest in how gender is classed, a number of
debates and issues have emerged. For example, there are growing calls for work
on the intersection of gender and class to take the role of emotions more seri-
ously (e.g. ‘class disgust’; Tyler, 2008). The clear conclusion from reading the
stories told in the research reviewed in this chapter is the constant reiteration of
the emotional pain and distress that often accompanies experiences of deroga-
tion and subjugation. Any future research will need to take these highly charged
stories of emotional life seriously.
All in all, there is a clear need for more psychological research on gender,
sexuality, and class, and, further, research that takes a holistic and contextu-
alised approach to this (e.g. Walkerdine, 1996). In addition, this focus 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.
However, while we firmly argue for class to be at the centre of analysis in
psychology, we do echo Linda McDowell’s (2009) concerns that, 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.
404 Intersections
Summary
• Social class can be thought of as both a social construction and as being

structured through unequal access to material resources and social, eco-
nomic, and political power.
• As students, we can adopt a critical and ‘class-focused’ lens when considering
psychological theories by, for example, asking questions such as “To what
extent is social class acknowledged?”; “How is social class conceptualised?”;
“What might be the implications of this theory for different social groups?”
• Mainstream psychology tends to both focus heavily on ‘sex difference’ and
ignore or minimise social class while simultaneously constructing these two
categories as separate and ‘fixed’.
• Alternatively, gender and class can be seen to intersect to produce various
forms of identities, practices, and experiences, and, therefore, attempts to
understand gendered or classed ‘ways of being’ in isolation from one another
can be critiqued as being impoverished.
• As with gender, sexuality intersects with class in ways which shape our iden-
tities, practices, and experiences and may produce very different outcomes
depending on the marginalised or privileged status of our sexuality and class
location.
• As students of psychology, we can start to recognise the privileging of
heterosexuality and the persistent homophobic cultural climate that may
shape psychological research and theory.
• It is important that we do not treat anyone we work with as ‘helpless’;
instead, we should be aware of the gendered, sexual, and classed world in
which they have lived, do live, and hope to live.
• Poor and working-class groups can suffer most with mental health problems
but may also receive poorer-quality ‘treatment’ than their more privileged
counterparts.
• A classed, gendered, and sexual collision of identities can force dilemmas
or splits that may be a helpful way to start to understand differentials in
attainment and ‘successes’ and ‘failures’.
• Interrogating the wider classed, gendered, and sexual dimensions of valued
ideas around being ‘psychologically healthy’ and a ‘good client’ may help us
to avoid these values being unwittingly used to derogate and disadvantage
quality of intervention.
• As applied professionals, reflecting on our own class positioning, personal
histories, and any experiences of classism allows us to consider that issues
underpinning ‘problems’ presented to us differ across the class spectrum, as
do understandings of them and the values attached to them.
• Exploring with clients how social class is understood and how it is ‘played
out’ in interpersonal relations and social interactions, including the practice
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
Writing about disability presents an immediate challenge around definitions,

given that these might change depending on the theoretical framework that is
being used. In this chapter we strive to address this and other challenges that
arise when writing about disability and sexuality. We will first tackle the above-
mentioned task of defining disability by providing an overview of the medical,
social, and feminist models of disability. Those models will be framed within
their historical and geographical contexts and later discussed in relationship to
the field of psychology. Key theories and research on disability and sexuality
will then be introduced before we address current debates and implications for
practice.
Throughout this chapter, we will adopt an intersectional lens as a way to
acknowledge the complexity of all our bodies, identities, and lives. For example,
one of the authors (Alex) is white, is an immigrant, identifies as trans masculine,
experiences chronic illness, and is a parent. These are just some of his identi-
ties that might be in the foreground or the background depending on context,
defined here as a combination of place and time. Privileging an intersectional
lens does trouble the waters of easy discourse and traditional knowledge con-
struction, yet we believe this lens to be apt for tackling a topic that does the
same, namely that of disability and sexuality.
While we will strive to be as comprehensive as possible in our overview, we
acknowledge that this chapter cannot be exhaustive and that we are from a
minority Western culture, which informs many of our views and experiences.
Both disability and sexuality are complex topics that have been addressed
from multiple theoretical perspectives in a range of disciplines. We strongly
encourage our readers to see this chapter as a possible guiding thread and
introduction to this vast intersection that still has so much territory left
unexplored.
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).
These three models of disability have emerged at slightly different times

and in a range of places, but co-exist to this day, and understanding them
is essential if we are to be conscious of which definitions of disability peo-
ple might be using in a specific context. The medical model of disability
has been around as long as the idea of a medical science, even though
it was only in 1980 that it became crystallised into a specific framework
through the World Health Organization’s definition of disability and its
publication of the International Classification of Impairments, Disabilities
and Handicaps (WHO, 1980; Wood, 1980). A few years earlier, the Union
of the Physically Impaired Against Segregation (UPIAS), an organisation
in the United Kingdom, had claimed that societal and systemic barriers
created disability (Barnes, 1996; UPIAS, 1975). Later, in 1984, Mike Oliver,
a British academic, author, and activist, coined the term ‘social model of
disability’ (Oliver, 1984), which then spread beyond the United Kingdom
to a more global audience. The 1990s and the beginning of this millen-
nium saw the rise of a feminist model of disability that sought to build
on the social model of disability while also embracing the physical reality
of bodily limitations and pain that many people with disabilities might
also experience (Begum, 1992; Garland-Thomson, 2003; Gerschick, 2000;
Lloyd, 1992; Morris, 1992).
One practical framework clinicians can employ is a narrative ther-
apy approach, which helps clients consider their relationship with their
disability from multiple standpoints (White & Epston, 1990).
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.
Disability and sexuality in psychology

There is no unified perspective on disability and sexuality in psychology. As a
discipline, psychology is closely connected to a number of other fields, such
as neuroscience, sociology, and anthropology, to name but a few, and it is
rich with a range of perspectives (Hergenhahn, 2013). Even when looking
at psychology as a stand-alone discipline, several theoretical lenses can be
applied: from more cognitive behavioural ones to developmental ones to social
constructionist ones, to mention only a few theoretical schools.
The psychological theory adopted impacts how disability and sexuality are
viewed, both independently and in relationship with one another. From a
cognitive behavioural perspective, solution-focused approaches might be priv-
ileged to address the impact of disability on mental health and body image.
Within this framework, there will be an emphasis on problem areas. Those
problem areas could be internal and embodied: mental health, either as the root
of disability or as the result of dealing with a disability; developmental capac-

ity; sexual identity development; sexual and reproductive functioning. The
problem areas could also be external: dealing with stigma and discrimination;
systemic barriers to accessing sexual and reproductive healthcare; relational
issues following the onset of a disability; or dealing with sexual abuse, as
rates tend to be higher in this population (Plummer & Findley, 2012). Problem
areas will then be tackled through specific interventions and therapies, includ-
ing sex therapy, psychoeducation, and family or couple therapy. Interventions
will usually be focused and time-limited, and clinical emphasis will be on the
problem(s) and potential solution(s) rather than on interpersonal processing,
although this might also sometimes be included if deemed to be part of the
clinical intervention.
Developmental psychologists are likely to emphasise how disability might
have impacted people’s attachment style, if its onset was at birth or in
childhood. They might then be interested in how this might impact a per-
son’s psychosexual development and relational capacity. The developmental
approach specifically, and the psychological outlook in general, would also
pay attention to the type of disability – sensory, physical, or mental. This
would potentially privilege a more medical model of disability, in which the
individual and the location of the impairment in the body are seen as the
focus of inquiry, from both research and clinical standpoints. For example, in
a recent study of military veterans in the United States (Breyer et al., 2014),
the authors focused on potential association between mental health issues
and sexual dysfunction. The study team measured sexual dysfunction based
on the common medical model and through the diagnostic codes used by
healthcare providers to indicate issues such as the incapacity to achieve an
erection or have an orgasm. Similarly, mental health issues were categorised
according to diagnostic labels, such as post-traumatic stress disorder. Another
area that could have been addressed from a different perspective was the
quality of intimacy and partnership after exposure to traumatic events and
long periods of separation. A developmental approach would also focus on
the timing of disability onset and differentiate approach to sexuality issues
by age and developmental stage, given the importance placed on develop-
ment being a mostly linear process of growth across the lifespan. Within
this approach, there could also be a tendency to reinforce some identities
and behaviours as normative and others as deviant from the norm, given
the focus on commonality of experiences as people go through development.
People with disabilities could easily be seen as outsiders to those common
experiences and the norms regulating developmental theories, especially if
their sexual identities and practices might also be seen outside those norms
(e.g. queer or trans∗ identities; non-mainstream sexual practices) (Iantaffi,
2009).
414 Intersections
A social constructionist psychological perspective, on the other hand, would

tend to be more akin to the social and feminist models of disability. Within this
framework, disability and sexuality are seen as constructs further influenced
by systemic constellations of other constructs, such as race, ethnicity, gender,
and class. The complexities and interactions of these constructs would be con-
sidered within geographical, historical, and socio-political contexts. This lens
would see disability and sexuality not as a fixed, singular issue but as a situated,
multifaceted construct or complex of constructs. Social constructionist psy-
chologists might pay particular attention to issues such as how the sexualities
of people with disabilities are constructed in a specific cultural context. For
example, within Anglo-American contexts, they might address how people
with disabilities are usually infantilised and therefore desexualised (Bonnie,
2004; Esmail et al., 2010; Tepper, 2000). From a clinical perspective, they might
then consider how this could impact someone’s self-construct as well as all
the systems around them, such as family, school, religion, and law. From this
standpoint, the body is not a biological artefact; rather, it is continuously and
relationally being constructed, and so are desire and pleasure.
Historically, disability and sexuality have not been central to psychology
as a field of study and/or clinical practice. The main ways in which the field
has engaged with disability and sexuality have been two-fold: addressing how
sexual functioning and reproductive health are impacted by disability, and
investigating the intersections of disability and sexual identity development,
especially when this relates to sexual and gender minorities (Olkin & Pledger,
2003). Other unrelated psychological research might also inform the field of
disability and sexuality. The increasing bodies of evidence on the positive
impact of social support on physical and mental well-being (Eisenberger & Cole,
2012; Taylor et al., 2012) and the neurological benefits of touch across the lifes-
pan (Burleson & Davis, 2014) strengthen arguments about the importance of
seeing people with disabilities as sexual beings for whom touch, pleasure and
connection are important and might often be pain-relieving. Growing interest
in mindfulness might benefit the field of disability and sexuality by empha-
sising the importance of being fully present in the now without judgement
(Dimidjian & Kleiber, 2013). This approach from a clinical standpoint can help
clients to be more accepting of their bodies, identities and pleasure and more
fully engaged with them as they are.
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,
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
as ‘acting out’ and become pathologised, especially in people with intellectual

disabilities.
This highlights the second fundamental concept mentioned earlier: citizen-
ship. As discussed above, the sexual and reproductive citizenship of people with
disabilities is not a simple matter. For example, researchers (Esmail et al., 2010)
carried out focus groups with service providers, people with visible and invisible
disabilities, people with intellectual disabilities, and the general public. Viewing
a documentary on sexuality and disability was used as a stimulus for conversa-
tion midway through the focus group session. They found that individuals with
disabilities were commonly viewed as asexual. A lack of representation, infor-
mation, and education contributed both to the stigma attached to disability
and sexuality and to negative self-concept for people with disabilities. Another
author (Tepper, 2000) illustrates the historical roots of ignoring the existence
of sexual pleasure for people with disabilities. Tepper argues that not including
a discourse of pleasure for this population perpetuates people with disabilities
as asexual and victimised. The author found in their dissertation research that
people who became disabled after an accident/injury experienced low sexual
self-esteem and intrusive thoughts about things ‘not being the same’ as before
the accident/injury, due to the “absence of quality sex education combined
with learning about sex primarily from having genital intercourse” (Tepper,
2000, p. 288).
Stereotypes of people with disabilities often collude with other cultural
discourses such as gender, race, class, and sexual orientation. Women with dis-
abilities are more likely to be portrayed as victims, given that this colludes with
the minority Western cultural script of femininity and sexuality. Men of colour
who also have a disability are more likely to be represented as threats, given that
this too colludes with our cultural script of sexually dangerous and predatory
black masculinity. Neither of these portrayals is likely to enhance, promote,
or even imply sexual citizenship or, indeed, any kind of citizenship for people
with disabilities.
Whether or not citizenship is something to aspire to is also a topic that has
recently been debated (Shildrick, 2013). For example, Shildrick (2013) wonders
whether the very concept of citizenship as a category relies on excluding those
who do not fit into predetermined categories, and, as such, limits a broader
range of possibilities for human experiences and identities. Nevertheless, for
many people with disabilities, not having full citizenship, including sexual
and reproductive citizenship within the broader community, has significant
repercussions on the ability for self-determination and choice.
Choice is definitely a part of the third fundamental concept introduced ear-
lier: access. People with disabilities have historically needed to fight to have
access in a multitude of ways, and even when access is provided it is often
within very limited and restricted parameters, transforming choice into an
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).
History and current debates
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
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?
Like clinicians, applied professionals and students, clients are influenced

by mainstream minority Western cultural scripts, beliefs, and myths,
whether those exclude them or not. This also means that you need to be
prepared to explore your own beliefs, myths, and scripts around disability
and sexuality. Sharing information on self-pleasuring, using medication
to reduce pain and increase mobility during sex, prop use to enable dif-
ferent positions, fatigue and spasticity management, and dealing with
bowel and bladder concerns is most definitely useful. It is, however, not
enough if it is not supported by a self-exploration of our own inner land-
scapes around the areas of disability and sexuality. Whether you are a
scholar, student, or applied professional, it is worth noting which mod-
els you resonated with so far and which you found challenging. Some of
the books listed in the Further reading section will provide more detailed
information on some of the practical issues listed above (e.g. mobility
and position management, timing medication to reduce pain during sex,
dealing with spasticity and sex), but further personal reflection is needed
if we want to avoid perpetuating the narrower cultural and societal scripts
around disability and sexuality.
Future directions
Disability and sexuality is the intersection of two multidisciplinary fields and,

as such, the possibilities for future directions are numerous and challenging to
define. One of the exciting developments in recent years has been the increased
visibility of this whole arena, which had previously been taboo. The body, citi-
zenship, and access will probably remain central in future studies and debates.
For example, one area that has been increasingly debated is who can give con-
sent to sexual relationships and how the capacity for consent can be assessed,
especially in people with intellectual disabilities, who, until fairly recently, had
not been seen as sexual agents (Brady, 2001; Greenwood & Wilkinson, 2013;
Human Rights, 2011). Whose bodies are viable agents for consent? If some peo-
ple are not able to give consent, can they still have sexual access and, if so, what
does this mean? What is the impact on citizenship for people with disabilities,
including those with sexual and gender-minority identities whose bodies and
relationships might be more closely monitored and regulated?
These debates and the entire field of inquiry need to be broadened to
ensure addressing the many areas still left fairly untouched by research. Too
many people are systematically excluded from data collection because of
normative expectations, which do not include the bodies of people with dis-
abilities and/or sexual and gender minorities. Qualitative research has provided
valuable insights into this area (Iantaffi, 2006), but data collected in this man-
ner are not often seen as valid underpinning for policy changes. There is
also a need to go beyond the purely descriptive level of research towards
more critical and applied studies if health disparities in this area are to be
addressed.
Education, as well as research, is much needed. An intersectional lens in
clinical education in particular would be helpful to broaden applied profes-
sionals’ understanding of the range of human experience and better prepare
future providers to address disability and sexuality competently. Neither topic
is addressed in much depth in most programmes, and the combination of dis-
ability and sexuality is even more rarely addressed (Coleman et al., 2013). The
disability and sexuality movements already know how to do many of those
things: research, educate, and provide culturally competent care. Building part-
nerships within and across those movements surely seems a positive trajectory
for future endeavours in this area.
Summary
• Definitions of disability depend on the theoretical model used.

• A common medical model of disability posits that it is a deficiency (physical,
sensory, or mental) affecting ability to carry out tasks necessary to everyday
422 Intersections
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
One of the challenges of writing a chapter on intersectionality, with a specific

emphasis on sexuality and ethnicity, is that specificity distorts the ideal of
intersectionality, which seeks to see people as multiple composites of identities,
not simply two or three of these. However, the pragmatics of understanding
some of these intersections in depth does require us to develop a focus. This
chapter, therefore, seeks to investigate the experiences, dilemmas, challenges
and triumphs of being a sexual and ethnic minority. Using case studies and nar-
ratives from clinical encounters, research studies, web-blogs, and mass media,
I chronicle these accounts to understand the complex psychological and polit-
ical journeys people caught between seemingly conflicting identities have to
make on a daily basis.
In this chapter, I focus on the importance of seeing people as being greater
than the sum of their parts, but, in so doing, not forgetting the parts. This can
be a challenge for the individual and the psychologist. I bring into focus how
other aspects of life (i.e. other intersections, e.g. ageing, religion, and so on)
can affect gender and sexual minorities differently from those lesbian, gay,
bisexual, and trans (LGBT) people who are not ethnic minorities. I document
the problems encountered when negotiating minority identities within major-
ity cultures, and also highlight how people in such circumstances have found
ways not only to deal with these issues but also to celebrate their multiple
selves, individually and collectively. Finally, I discuss how intersectionality can
be taken from a theoretical domain to a practical one.
Intersecting identities are a dance all of us have to perform. For some, the
partners, the pace, the framework, are all well charted and rehearsed; for others,
less so. Like tangos, they can be complicated, but if performed well they have
the potential to be exhilarating.
Intersectionality, sometimes, has a bad reputation. Recently, as reported in
the New Statesman (2012), Rhiannon Lucy Cosslett and Holly Baxter of The
427
428 Intersections
Vagenda magazine suggested that “anyone with an interest in genuine equality

for all adapt [the] phrase . . . ‘my feminism will be comprehensible or it will be
bullshit’ ”.1 This is a critique of writer and media analyst Flavia Dzodan’s (2011)
slogan “my feminism will be intersectional or it will be bullshit”. The term has
been contested and detested by some. Rose George, author and journalist, for
instance, tweeted: “For the record, intersectionality is a crap word. Perfectly
good concept, crap and alienating and self-defeating word” (@rosegeorge3;
https://twitter.com/rosegeorge3/status/323759102088077314).
One of the issues relates to the word ‘intersectionality’: it is long, has sev-
eral syllables, and until recently was not a buzzword, and so is somewhat alien
to most people. A word being long or unfamiliar does not make it a ‘crap
word’, and, as the history of language has taught us and continues to tell us,
words come into and out of collective lexicons, mutating and merging with
other words, all the time. With the word ‘intersectionality’ itself, if the suf-
fix ‘ality’ is removed, the word ‘intersection’ is clear enough for most people
to conceptualise a crossroads or matrix. Therefore, just because a word is long
and unfamiliar, this does not make it a pretentious or unhelpful term. The
process of vocabulary development can facilitate communication of nuanced
emotions or experiences. This is evident from one of the commentator’s posts
in response to an article in the New Statesman (“ ‘Intersectionality’, let me
Google that for you”; Filar, 2013), stating: “Great article! I hadn’t heard the
term intersectionality until a couple of weeks ago but quickly realised it was
just a term for what I already believed in (and then was happy to have a handy
term).”
One of the early uses of the term ‘intersectionality’ was to describe vari-
ations of experiences related to (female) gender and (Black) race/ethnicity2
(Crenshaw, 1993). Since then, the term has been variously used to incorporate
other ‘marked’ identities (such as homo/bisexuality, disability). The concept of
intersectionality only made its way to psychology relatively recently. Even in
psychology, it is still finding its way into certain subspecialties, such as Clinical
Psychology, with much of the psychological work on intersectionality having
come from social-psychological perspectives.
There may be several reasons for the slow uptake of intersectionality among
applied psychologists and other practitioners,3 but I suspect three of the reasons
are as follows. (i) The obscurity caused by the term itself. Davis (2008) has out-
lined the confusions caused by the various ways in which intersectionality has
been conceptualised and defined. However, Cole (2009) has helped by provid-
ing us with the basic ‘ingredients’ that help us understand intersectionality.4 (ii)
The lack of research into intersectionality has meant that the process of translat-
ing research into practice as a vehicle for change has not occurred. An excellent
article by Cole (2009), however, outlined ways in which intersectionality could
be incorporated into psychological research. (iii) Some practitioners would
Roshan das Nair 429
argue that ‘intersectionality’ as a concept is surplus to requirement because,

as practitioners, they take an ideographic approach anyway. Even so, what
intersectionality has to offer, if not anything else, is an aide memoire to assess
power differentials, within the clients’ life stories and within the therapeutic
encounter also.5
History
Stainton-Rogers and Stainton-Rogers (2001), in their preface to The Psychology

of Gender and Sexuality: An Introduction, state: “In terms of psychology text-
books, ‘gender’ and ‘sexuality’ are comparatively new kinds of language” (p. 1).
In fact, the detailed examination and interaction between these terms and
other identity markers is not just new to textbooks of psychology, but to wider
psychological literature also.
Historically, gender or ‘sex’ was conceptualised by the medical professions
as a biological construct that was considered independent of social, historical,
or political contexts. To some extent, psychological thinking has retained this
ideology. Take, for instance, psychological research that records gender as a
demographic variable. What does this variable mean? In most cases, it is used
as a marker to differentiate it from another gender, thereby assuming that in
some way each gender category provides the true ‘essence’ of that gender and
is uniquely different from other genders. Interestingly, when race and ethnicity
are documented in psychology, these tend to be categorical variables that also
assume homogeneity of each category. Both gender and ethnicity categories are
treated as fixed points; there is no continuum of femaleness or Blackness, there
is only female or Black, or, more accurately, the average of female or Black.
Therefore, there is no recognition of the psychological processes involved in
becoming female or Black. For French existentialist Simone de Beauvoir, for
instance, “One is not born, but rather becomes, a woman” (1973, p. 301).
Similarly, US psychologist William E. Cross (who proposed some of the most
popular nigrescence models6 ) describes his own transition that included “shifts,
pulls and conflicts from ‘Negro-to-Black’ conversion experience” (1995, p. 32;
see also 1971, 1991). Similarly, when it comes to sexuality, we also see models
describing a trajectory of sexual identity development (e.g. Cass, 1979; Troiden,
1989).
Therefore, all these ‘categories’ of sexuality, gender, and ethnicity to some
extent are not natal or static, and there is a process of developing into the roles
and performances that are expected of each of these categories. By conceptu-
alising these categories as fluid, we also reduce the risk of seeing identities as
dichotomies. This means that male is not seen as the opposite of female, and
similarly with distinctions between Black/White, gay/straight. This is impor-
tant, because in making such dichotomies some people (indeed, groups of
430 Intersections
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.
When considering sexuality, also consider other aspects of the individual,

as these other factors will give meaning to the sexual identity label and
experiences people have.
Ethnicity, like sexuality and gender, is not a homogeneous construct,
and must be viewed in relation to other aspects of personhood, such as
class, religion, and their position in society.
Always look out for what is not said in a text and consider what these
‘silences’ mean.
Do some media-watching through an ethnicity/sexuality lens: How vis-
ible are different groups? Are intersections represented at all? If they are
represented, which intersections are in the foreground and background?
Key theory and research with implications for applied

psychology and the wider world
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, while the absence of sexuality is an intriguing silence in research

on race and mental health, the absence of ethnicity is an intriguing silence
in research on sexuality and mental health. As Foucault (1980) reminds us in
The History of Sexuality, “There is not one but many silences, and they are an
integral part of the strategies that underlie and permeate discourses” (p. 27).
There are various reasons that could explain these silences, and I propose three.
(i) It could be argued that these variables or factors could have been considered
‘not relevant’ to be included or commented on for these reviews, which were
specific to race and sexuality, respectively. (ii) It could be that these data were
not available in the primary studies included, but the reviewers could have
commented on this absence. (iii) It could also possibly be that these two factors
(race and sexuality) fall into areas unknown to researchers examining one or
the other of these aspects in isolation.
Notwithstanding the problems identified above related to essentialism and
categorisation, studies have continued to reveal that Black and Minority Ethnic
(BME) LGBT people are at higher risk for having mental health problems. For
instance, Hahm et al. (2013) found that Asian American lesbian and bisexual
women had significantly higher odds of reporting fair or poor health, severe
depression, and mental health diagnosis (after controlling for covariates) com-
pared with their heterosexual counterparts. They were also more likely to be
treated in in-patient mental hospitals compared with their White counterparts.
The reasons for higher rates of such mental health problems among such
groups have been related to poorer access among both LGBT and BME groups to
healthcare in general, and the impact of the racism and homophobia that these
groups experience. This latter assertion was assessed by Choi et al. (2013), who
examined the associations between specific types and sources of discrimination
and mental health outcomes among BME men who have sex with men (MSM)
in the United States, and how these associations varied by race/ethnicity. Their
sample included African American, Asian and Pacific Islander (API), and Latino
men. They found that, irrespective of racial/ethnic group, experiences of racism
within the general community and perceived homophobia were positively asso-
ciated with depression and anxiety. Past-year homophobia experienced within
the general community was also positively associated with anxiety. The posi-
tive association of perceived racism within the gay community with anxiety,
however, was statistically significant only for the API group. This selective dis-
crimination based on race is something that has been reported elsewhere (e.g.
Butler et al., 2010; das Nair & Thomas, 2012a, 2012b). What is important to
note here is that, while discrimination can be obvious in some instances, there
are other, subtler forms of discrimination that may be as pernicious to the
minority group(s). This includes the way ethnic minorities feel when access-
ing not only physical LGBT spaces, but also cyberspaces, and the experiences
they have there.7
Roshan das Nair 433
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.
• When considering research into sexuality, attempt to get an under-

standing of the other identities of participants. These may have
a bearing on your findings and make any recommendations more
nuanced.
436 Intersections
(Continued)
• It may not be possible (especially in quantitative research) to assess,

control for, or report all identities of participants. However, some of
these identities may have a significant influence on the variables under
study; therefore, these identities may need to be accounted for.
• Intersectionality offers an aide memoire to consider hierarchies of
power and domination in different strands of society.
Coming out from a race/ethnicity perspective

There are two forms of racial ‘groups’ I will consider here: one relates to people
in the Global South (the nations of Africa, Central and Latin America, and most
of Asia), and the other relates to BME people in the West. I am conscious, even
in making this distinction between groups, that there are as many similarities as
there are differences between the groups. However, given some of the cultural,
legal, and societal differences, I have chosen to explore these groups separately.
Same-sex sexuality in the Global South

One of the criticisms of stage models of same-sex identity development
(in which coming out plays a major role) is that most of the research has
been done using White, gay male samples from Europe, North America, and
Australia (Kaufman & Johnson, 2004). However, in our recent study on Indian
same-sex sexual identity development (Pandya et al., 2013), a similar trajec-
tory to those proposed by Cass (1979) was observed. This is not surprising,
given the sampling strategy used in this study, and the cultural awareness of
the ‘global gay’ among the sample. Therefore, along with the notion of the
‘gay’ identity, blueprints of such identity formation have also been culturally
incorporated among those who can/could integrate the stages, and associated
feelings, within their cultural milieu. The problem with these theories and mod-
els is that those who do not follow this set trajectory are considered ‘stuck’ or
untrue to the (gay) ‘community’.
Interestingly enough, in our study, of the 12 men interviewed, eight of them
were heterosexually married, but only two of them identified as ‘bisexual’
and only two identified as ‘gay’. Although all our participants used a sexual
identity label to mark their sexuality, this only reflected their same-sex sexual
orientation. This is pertinent on two counts. First, it demonstrates the split
between sexual desire/activity and sexual identity. Therefore, from a research
or healthcare perspective, it suggests that we need to explore people’s sexual
desires/activities and their sexual identity (perhaps especially with BME people,
Roshan das Nair 437
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.
BME same-sex sexuality in the West

BME LGBT individuals in the West have to negotiate their gender and sexual
identities and performances in line with the normative expectations of their
ethnic communities and those of the dominant ethnic majority and LGBT peer
438 Intersections
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):
(i) Is coming out necessary in the first place?

(ii) If yes, who does the BME individual come out to, and
(iii) Where does he/she come out (in)to?
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
be opposed to their children adopting such identities and practices. Goldberg

(2010) refers to the experiences of a British Arab woman’s coming out to her
parents, and the negative consequences that ensued. Forced marriages11 have
become common when parents suspect that their children, because of their
sexuality, will bring disgrace to their families (Hill & McVeigh, 2010). There-
fore, rejection by their own families and communities, excommunication from
their religious institutions, homelessness, forced marriage, and even murder
and ‘assisted’ suicide are some of the negative outcomes of coming out.
(iii) When BME LGBT people do come out, there is the hope or the expec-
tation that, if there are negative consequences from their families of origin or
ethnic communities, they will have the support of the majority LGBT commu-
nity. Alas, for some people, there is no such community that welcomes them.
LGBT communities are not immune to racism. Surveys, reports and case studies
have documented the experience of exclusion that BME non-heterosexuals face
from mainstream LGBT venues (e.g. Buttoo, 2010; das Nair & Thomas, 2012a;
McKeown et al., 2010). das Nair and Thomas (2012b) have discussed the com-
plexities of such racism for BME LGBT people. While legislation provides some
security for overt forms of racism, more covert forms of racism go unchallenged.
Support groups that allow people who share an ethnic or religious background
have been useful for BME LGBT people in helping them identify safe spaces
where they can negotiate their own way of being without compromising any
of their identities.
These issues of categorising people into groups based on gender, ethnicity,
and sexuality cause dilemmas for researchers and mental health professionals
working with people who are LGBT and belonging to BME communities. There
are clear reasons, good political and social reasons, to club categories to generate
a critical mass, particularly when fighting for rights and for claiming protection
from social prejudice and discrimination. There are also pragmatic reasons, par-
ticularly when using quantitative research methods, to club categories together.
And yet, they end up looking like one-size-fits-all t-shirts that in actual fact fit
nobody!
In therapy with BME non-heterosexual people, it is worthwhile consider-

ing how the individual labels themselves sexually, and whether Western
LGBT terms and cultural practices are relevant and appropriate for them.
Attempt to understand their sexuality in their own terms, even if this
may be discrepant from your own or the dominant society’s view on what
sexuality is/should be.
Intersectionality helps to remind us of the power differentials in ther-
apy and of the social hierarchies clients may find/situate themselves in.
440 Intersections
Current debates
As mentioned at the start of this chapter, a major debate about intersectionality

relates to the word and the concept itself, with some people believing that
it is merely a navel-gazing exercise that only academics can afford, while
others believe that it has the power to make a real difference on the
ground.
There is a growing awareness of the importance of intersectionality within
the economic and political sphere, and even the European Union (EU) has
begun to embrace intersectionality in its policies related to inequality (e.g.
Kantola & Nousiainen, 2009; Lombardo & Verloo, 2009). Even outside the
EU, other governments are considering ways in which they can conceptu-
alise issues of inequality through intersectionality. The Norwegian Equality
and Anti-discriminatory Ombud (n.d.) for instance, according to the Gender
in Norway website (n.d.), uses an intersectional perspective such that “the
Ombud shall view the various discriminatory grounds in conjunction with one
another, and develop cross-sectoral expertise and an ability to deal with mul-
tiple discrimination at the interface between gender and other discriminatory
grounds”. This is an interesting development.
Another issue I have not touched upon here, but which is of significant
import, is that of immigration and sexual citizenship. There are two aspects
of immigration that are relevant here: (i) how nation states decide who is wor-
thy of asylum based on their sexuality and how they ‘assess’ sexuality (see,
for example, Simmons, 2008), and (ii) how immigrants are assessed as citizens
based on their attitudes towards sexuality (Mack, 2012). It is beyond the scope
of the chapter to elaborate on these issues. However, the preceding discussions
on the pitfalls of viewing people and identities as dichotomies and the appli-
cation of intersectionality to multiple identities may provide a more nuanced
approach to immigration policy.
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
• Intersectionality is a helpful theory and concept to remind us of the multiple

identities that people have, and the power differences that exist between
individuals because of the unique ways in which different identities interact
with each other vis-à-vis the dominant identities in society.
442 Intersections
• 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
7. A good way to appreciate the impact of being a member of a minority sexu-

ality or ethnicity group is to consider White or heterosexual privilege question-
naires (e.g. The White Privilege Pop Quiz, http://www.mollysecours.com/index.php?
option=com_content&view=article&id=19:pop-quiz&catid=9:blog&Itemid=13; Het-
erosexual privilege checklist, http://sap.mit.edu/content/pdf/heterosexual_privilege
.pdf).
8. The Chakraborty et al. (2011) study flanks the categories ‘Mostly heterosexual,
some homosexual feelings’ and ‘Mostly homosexual, some heterosexual feelings’
on either side of the category ‘Bisexual (equally attracted to men and women)’.
The implication is that if bisexuals have ‘some homosexual feelings’ they are
‘mostly heterosexual’ and if they have ‘some heterosexual feelings’ they are ‘mostly
homosexual’.
9. I also direct the interested reader to Moore, L. (2009). Does your mama know:
An anthology of Black lesbian coming out stories. Washington, DC: RedBone Press.
10. http://www.gaylesbianmoc.com.
11. A distinction needs to be made between ‘forced’ and ‘arranged’ marriages. The latter
is a practice that is common in homosocial societies where there is little opportunity
for adults of different sexes to mix. Therefore, the families take responsibility for
matching their adult children with suitable brides or grooms on the basis of caste,
social class, education, horoscopes, and so on. In some respects, they arrange for the
couple to meet, but force is not intended. In forced marriages, there is coercion, and
the person has no choice.
Further reading
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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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
equate to antipathy towards non-heterosexual people. The situation is more

complex than this. Homosexuality and homosexual life were not constituted
(Foucault, 1980, p. 43; McIntosh, 1996, p. 38) until relatively recently. Our cur-
rent understandings of non-heterosexual identities, relationships, and practices
cannot be mapped on to ancient same-sex acts (see Groves, 2008, especially
pp. 117–126; Kugle, 2003, p. 197).
Boswell (1980) argues that intolerance in the Christian Church is not founda-
tional, but arose in the Middle Ages. Religious fundamentalism or foundation-
alism, which often presents itself as holding to the true (literal, conservative)
interpretation of (verbally inerrant) scripture, is in fact a late nineteenth-
century phenomenon in American Christianity with a resurgence in the 1970s
(Marsden, 2006, p. vii). Anti-modernist movements are also found in Judaism,
Islam, and elsewhere.
At the other end of the spectrum, the Religious Society of Friends (Quakers)
is reputed to be one of the most LGBT-accepting of religious groups. How-
ever, Munt draws attention to a more complex picture in the experience of
her research participants (2010, pp. 63–66).
Psychology has been and is still allied to socially conservative religion, in
the form of conversion or reparative therapy that seeks to change a person’s
sexual orientation. Some Christian voices (Core Issues Trust, 2014; Doyle, 2014)
continue to speak in favour of the reduction in homosexual feelings through
therapy (an exception is Exodus: Bailey, 2013), despite the opposition of major
therapy professional bodies (Consensus Statement, 2014; see also Haldeman,
1994; Serovich et al., 2008).
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
viewpoint is referred to as ‘complementarity’ (see Beardsley, 2013; Cornwall,

2013, pp. 45–50; Thatcher, 2012, chapter 4).
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
view religion as an endless process of probing and questioning generated

by the tensions, contradictions and tragedies in their own lives and in soci-
ety. Not necessarily aligned with any formal religious institution or creed,
they are continually raising ultimate ‘whys,’ both about the existing social
structure and about the structure of life itself.
(Batson, 1976, p. 32)
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
Communications of prejudice and discrimination expressed through seem-

ingly meaningless and unharmful tactics [that] may be delivered in the form
of snubs, dismissive looks, gestures and tones.
(Shelton & Delgado-Romero, 2011, p. 210)
In a very useful article, the authors discuss a range of sexual orientation
microaggression themes, often delivered by well-meaning individuals, ranging
from the assumption that sexual orientation is the cause of all presenting issues,
to warnings about the dangers of identifying as LGBQ, and explore the negative
impact of these microaggressions on the therapeutic process.
In a recent Australian study on trans people, higher levels of depression were
significantly associated with lower levels of perceived social support (Boza &
Perry, 2014, p. 44). This has clear implications for trans people who may lose
their religious social networks because of their gender identity, and find it
difficult to integrate into LGBT secular community because of their religious
identity. Trans persons seem to be particularly vulnerable to isolation (Gapka &
Raj, 2003, p. 13; Maguen et al., 2005, p. 481).
Attitudes towards non-heterosexual people are improved, and stereotypes
combated, by interactions between majority and minority groups (Webb &
Chonody, 2013, p. 408, in research supporting Allport’s (1979) Intergroup Con-
tact Hypothesis). Where, therefore, a particular religious environment is so
noxious to gender and sexual minority people that they must hide their gender
and/or sexual identities or leave that community, one potential for improving
attitudes diminishes. It seems likely that a group that is particularly poisonous
will reinforce its views to the point of not permitting mediating influences
through contact with LGBT people.
Current debates
No mainstream religion unequivocally accepts non-heterosexuality. For exam-

ple, although a number of Anglican provinces (The Episcopal Church (United
States); the Episcopal Anglican Church of Brazil; Anglican Church of Mexico;
Scottish Episcopal Church; Anglican Church of Southern Africa) ordain
openly non-celibate non-heterosexual clergy and bless same-sex unions, other
Anglican Communion provinces remain implacably opposed to these mea-
sures.
Differential legislative protections and entitlements seem to have an impact
on LGBT mental health: Riggle and Rostosky (2010) found that legal relation-
ship recognition is associated with greater psychological well-being (see also
das Nair & Fairbank, 2012; Hatzenbuehler et al., 2010; Newcomb & Mustanski,
2010). It seems reasonable to assume that differential institutional religious
454 Intersections
relationship recognition will also impact on LGBT mental health, though

research is needed to establish this.
With respect to legislative provision, even jurisdictions with comprehensive
pro-LGBT laws may maintain significant inequalities. For example, this is the
current picture in the United Kingdom: civil partnerships remain open to same-
sex couples only. Same-sex marriage is possible since the coming into force of
the Marriage (Same Sex Couples) Act 2013, but this legislation treats civil and
religious marriage differently. The Church of England and the Church in Wales
are prevented from offering same-sex religious marriage even where clergy and
congregation wish to do so. Clergy have no duty to solemnise same-sex mar-
riages (and individuals have no right to have a same-sex marriage performed).
A trans person, if previously married, need no longer divorce before obtaining a
full Gender Recognition Certificate (GRC) that alters legal gender. However, the
Marriage (Same Sex Couples) Act, 2013, introduces a requirement for spousal
consent in Schedule 5, which seems to permit the spouse to veto an application
for a GRC. Also, a clergyperson may refuse to solemnise the marriage of some-
one they “reasonably believe” to be a trans person, irrespective of the person’s
legal sex (Marriage Act, 1949, s 5B).
There are also a number of significant religious exceptions in Schedule
9 of the Equality Act, 2010, permitting discrimination “for the purposes
of an organised religion” on grounds of sexual orientation, civil partner-
ship or marriage, gender or being transsexual, with respect to employment,
training or promotion (see Clucas, 2012, for a full discussion, particularly
of the scope and implications of the non-conflict principle, “to avoid con-
flict with the strongly held religious convictions of a significant number of
the religion’s followers”). Probably, the average religious LGBT person will
be unacquainted with these provisions, but they may be aware of local and
national differential treatment of sexual minorities, for example the Church
of England’s repeated failure to appoint Jeffrey John as bishop (Wynne-Jones,
2010).
LGBT people are also under-represented in terms of rituals and services that
mark significant life events (for historical exceptions, see Lynch’s (1996) ref-
erences to Boswell), which may increase a sense of exclusion. Some parts of
the Anglican Communion worldwide now perform same-sex blessings (see
above), but other mainstream institutional recognition of gender and sexual
minorities is absent. Fortunate individuals may benefit from individualised
ceremonies written by supportive clergy, for example a naming service for a
trans person (author’s experience, unreported), but these instances seem to be
isolated.
Other institutional religious recognition in the United Kingdom includes
the following: the Quakers currently witness legally valid civil partnerships
and same-sex marriages (Quakers in Britain, 2010, 2013); Unitarians have
Rob Clucas 455
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)).
Applied psychologists and other practitioners need to be sensitive to the

experience of this person in their particular religious context (without assum-
ing that a particular religious context will be necessarily stigmatising).
Shelton and Delgado-Romero (2011) have drawn attention to the many
microaggressions experienced by LGB people in therapy – stereotypical assump-
tions about LGBQ clients and the inevitability of religious conflict, and warn-
ings about this, are examples of two of their microaggression themes (ibid.,
2011).
Practitioners will already be aware of the need to avoid heterosexist or cis-
sexist language. It is also important to be aware of the possibility of prejudice
against religion in general or particular religious groups/beliefs, and of the vari-
ety of attitudes and practices within any one religion/denomination/tradition.
Haldeman (2002, p. 63) warns about gay-affirmative therapists ignoring or
devaluing the spiritual aspects of clients’ identities.
Clients may receive religious guidance from clerics or other faith officials, and
from lay members of the congregation (as friends and/or as religious elders).
In some traditions of Christianity, it is normal for ‘serious’ Christians to receive
spiritual direction or companionship – a practice of ‘being with’ people on their
spiritual journey. The relationship of spiritual director/directee has certain the-
oretical parallels with the therapeutic relationship, but this varies in practice,
as does the training of spiritual directors/companions. Therapists may wish to
clarify the sources of a client’s religious guidance and the authority a client
accords to these.
A significant body of scholarly research on religiosity now exists that works
to reclaim or reinterpret texts traditionally used to condemn LGBT people – see
Yip (2010) for a comprehensive overview of the literature in this area. It may
be helpful for some clients to explore this literature.
Some clients may present with a desire to be ‘cured’ of their non-
heterosexuality (see Panozzo, 2013, for a good overview of the harm caused
456 Intersections
by conversion/reparative therapy, methodological flaws of studies claiming

the efficacy of conversion therapy, and suggestions for ways of working with
individuals with a high level of internalised homophobia; also Consensus State-
ment, 2014; Shaw et al., 2012; Shidlo & Schroeder, 2002). Practitioners without
training in dealing with clients with unwanted same-sex sexual attraction
should refer their client to an experienced clinician.
Some LGBT people may attempt to reconcile their beliefs and worldview,
perhaps with the assistance of LGB(T) faith/fellowship groups at a local or
national level, such as the Jewish Gay and Lesbian Group (www.jglg.org
.uk); Imaan, the LGBTQI Muslim group (http://www.imaan.org.uk/); the Safra
project for Muslim lesbian and bi cis and trans women (www.safraproject.org);
the Lesbian and Gay Christian Movement (www.lgcm.org.uk); Changing Atti-
tude (http://changingattitude.org.uk/); the trans Christian Spirituality group
the Sibyls (http://www.sibyls.co.uk/); and the Roman Catholic group (http://
questgaycatholic.org.uk/). LGBT Christians in particular may be able to join
affirmative worship spaces; these do not currently exist for Muslims in the
United Kingdom (das Nair & Thomas, 2012, p. 93).
Bisexual people may be particularly misunderstood – see Toft’s (2009) discus-
sion of the way the Church of England conceives of bisexuality, compared with
bisexual people’s self-understandings (see also Kugle, 2010, pp. 10–11).
Some clients may choose to live compartmentalised lives: ostensibly ortho-
dox in one arena, and openly out and activist in others (with the attending
pressures and fears of disclosure this may bring). Others may be willing to hold
their conflicting beliefs and desires or identity in tension for some time, waiting
for their deepest priorities to emerge.
In respect of all of these considerations, practitioners should bear in mind
the impact of the broader context in which their clients are situated. However
affirming a person’s immediate religious environment is, prejudice towards and
discrimination against sexual and gender minorities will be part of the wider
organism–environment field.
Discussions about coming out and the integration of religious and sex-
ual aspects of self presuppose that a client is able to acknowledge their
sexuality or gender issues in the first place. Where a practitioner suspects
that LGBT issues are out of awareness for their client, and the client’s reli-
gious and/or ethnic community is hostile to gender and sexual difference,
the practitioner will need to consider whether any recognition or acknowl-
edgement on the client’s part of their sexual or gender difference may put
them at risk of severe harm, such as enforced marriage, ‘corrective’ rape, or
honour killing, in addition to working with client defences. Practitioner strate-
gies may depend on theoretical orientation, and should be taken to clinical
supervision.
Rob Clucas 457
Read an LGBT magazine in a religious space, and/or read a religious pub-

lication in an LGBT space, if it is safe for you to do so. How does it feel?
Notice any overt prejudice and microaggressions you experience (Shelton
& Delgado-Romero, 2011), from others or from yourself.
Future directions
Conversion/reparative therapy, its permissibility and its place in the NHS is a

current political as well as applied psychological issue.
In the research arena, greater diversification is needed, to address groups out-
side the dominant mainstream religions of Christianity, Islam, and Judaism; to
provide more of a focus on groups other than gay men (often assumed to be
coincident with ‘LGBT’), especially bisexual people; and for greater understand-
ing of trans issues in religious spheres. Future investigations could include the
response of non-heterosexual non-religious therapists to religious LGBT clients
(see das Nair & Thomas, 2012, pp. 105–108); LGBT people in accepting com-
munities and their relationship with institutional religion; the religious barriers
to legal equality for non-heterosexual people; and the psychological effect of
legal regulation of the intersection between religion and LGBT matters on both
gender and sexual minorities and cis- and heterosexual communities.
Is the intersection of sexuality and gender minority concerns with reli-

gion a ‘proper’ topic for study in your discipline? Is it even visible? Are
there any ways in which your work or your discipline perpetuates the
‘irreconcilably dichotomous’ understanding of being religious and being
a gender or sexual minority person?
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
religious ideologies stigmatise sexual and gender difference to a greater or

lesser degree, and where legal protection for LGBT people against religious
discrimination is, at best, incomplete. Stereotypically, religion and sexual and
gender difference are regarded as antithetical; this creates difficulties for the
acceptance of gender and sexual minorities within religious communities,
and for the acceptance of religious belief within secular LGBT communities.
Applied psychologists and other practitioners are not immune to this ‘either/or’
thinking.
There are a number of areas likely to bear rich fruit for further study, particu-
larly the diversification of research to understand the experiences of a range of
LGBT people, not just gay and lesbian people.
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
• Research on non-mainstream religions, and an expansion of research subject

focus (especially bisexual and trans people), is sorely needed in this area.
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
A asexuality (ace), 2, 7, 8, 9, 10, 11, 12, 13,
abnormal, 26, 31, 32, 94, 95, 99, 136, 138, 14, 15, 16, 17, 19, 20, 21, 71, 130,
265, 409 132, 335, 361
abuse, 35, 83, 84, 115, 203, 244, 35, 415 ask etiquette, 177
accepting, 35, 209, 242, 286, 337, 414, autism (ASD), 205, 409
450, 451, 457 autoandrophilia, 138, 139
activism, 4, 17, 50, 53, 129, 175, 367, 458 autogynephilia, 131, 138, 139
adolescence, 61
adoption, 38, 84, 117, 199, 303, 339 B
adult, 31, 34, 61, 73, 82, 83, 84, 133, 136, baby, 61, 99, 149, 150, 198, 290, 339, 380
152, 159, 176, 186, 187, 207, 230, babyfur, 62
245, 246, 254, 264, 275, 303, 304, Barker, Meg John, 1, 3, 4, 16, 18, 19, 24,
339, 341, 344, 381, 431, 443 31, 33, 34, 35, 50, 51, 53, 63, 64, 65,
adult baby / diaper lover (AB/DL), 61, 65, 66, 68, 69, 72, 73, 96, 99, 102, 130,
73, 76 131, 133, 138, 140, 143, 166, 167,
adultery, 250 169, 170, 171, 173, 174, 175, 176,
177, 178, 179, 198, 200, 209, 223,
affirmative therapy/practice, 8, 16, 47, 48,
229, 232, 238, 239, 242, 244, 247,
49, 50, 53, 55, 70, 110, 143, 209, 273,
248, 251, 253, 254, 304, 309, 310,
277, 287, 292, 293, 317, 321, 375,
321, 329, 353, 355, 357, 360, 361,
455, 456
362, 363, 364, 365, 366, 367, 377,
age, 61, 83, 116, 121, 170, 188, 191, 193,
385, 452
200, 202, 227, 249, 274, 338, 340,
bear, 88, 177, 333, 456, 458
341, 343, 344, 353, 375, 376, 377,
Berry, Michael, D., 353, 354, 355, 357,
378, 379, 380, 381, 382, 383, 387,
360, 361, 362, 363, 364, 365, 367
413, 431, 450
bigender, 166, 171, 177, 198
ageing, 2, 54, 251, 334, 336, 341, 344, 367,
binary, 18, 43, 46, 47, 49, 82, 94, 98, 103,
375, 376, 377, 378, 379, 380, 381,
129, 130, 131, 132, 134, 136, 140,
382, 383, 384, 385, 386, 387, 395, 427
143, 149, 150, 166, 167, 168, 169,
ageplay, 60, 61, 62, 63, 64, 67, 68, 69, 75
171, 172, 173, 174, 175, 176, 177,
aggression, 151, 152, 270, 287
178, 179, 185, 186, 193, 198, 200,
alcohol, 302, 305, 307, 340 208, 272, 273, 275, 288, 303, 317,
anal, 60, 84, 86, 97, 283, 305, 319, 320, 337, 348, 365, 377, 378, 419, 448
325, 338, 342 biological, 7, 11, 30, 31, 44, 46, 80, 92, 95,
anal Sex, 60, 338 96, 97, 98, 99, 100, 101, 102, 103,
androgen, 65, 101, 187, 202 117, 134, 135, 150, 153, 157, 161,
androgynous, 129, 130, 166, 169, 171, 162, 171, 175, 186, 200, 201, 202,
175, 337 220, 221, 237, 253, 264, 283, 302,
anxiety, 66, 69, 81, 83, 84, 119, 205, 209, 335, 344, 345, 360, 376, 381, 410,
244, 246, 268, 270, 303, 304, 306, 412, 414, 429
307, 324, 360, 361, 375, 432 biopsychosocial, 140, 160, 171, 301, 360,
aromantic, 18 368, 420
arousal, 52, 131, 137, 138, 139, 266, 355, biphobia, 50, 51
356, 357, 361, 362, 368 biromantic, 8, 20
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
H 443, 448, 449, 450, 452, 453, 455,

Hagger-Johnson, Gareth, 111, 302, 305, 457, 458
309, 333, 335, 337, 339, 340, 341, hierarchy, 345, 378
343, 345, 346, 347, 349 homophobia, 77, 109, 286, 287, 293, 300,
hair, 177 305, 306, 308, 398, 432, 449
harm, 13, 27, 29, 68, 69, 119, 205, 208, homosexuality
254, 270, 368, 401, 431, 434, 449, see gay, lesbian
455, 456 hormone, 129, 185, 199, 202, 273, 303,
Harvey, Laura, 149, 151, 153, 155, 156, 346
157, 159, 160, 161, 177, 179, 212, 365 human immunodeficiency virus (HIV), 48,
hate crime, 10, 308 221, 227, 240, 241, 246, 268, 269,
303, 310, 319, 320, 327, 338, 339, 341
Hayfield, Nikki, 42, 43, 45, 47, 49, 51, 53,
humiliation, 24, 27, 61
54, 95, 101, 114, 172, 378
husband, 229
health, 2, 28, 32, 50, 54, 64, 86, 103, 112,
hysterectomy, 204
114, 117, 118, 119, 121, 122, 138,
159, 176, 177, 184, 187, 188, 191,
I
192, 193, 201, 205, 207, 208, 220,
Iantaffi, Alex, 10, 362, 363, 408, 409, 411,
221, 222, 224, 225, 230, 240, 241,
413, 415, 417, 418, 419, 421
243, 244, 265, 266, 267, 269, 274,
infantilism
275, 276, 300, 301, 302, 303, 304,
see adult baby; ageplay
305, 306, 307, 308, 309, 310, 311,
infidelity, 228, 229, 236
320, 321, 323, 324, 338, 340, 350,
informed consent, 24, 25, 27, 32, 33, 34,
356, 360, 362, 363, 384, 392, 393,
36, 37, 38, 68, 188, 193, 205, 208,
395, 396, 397, 399, 409, 410, 412,
211, 222, 223, 225, 230, 236, 240,
413, 414, 415, 419, 421, 430, 431,
248, 249, 276, 318, 325, 341, 367,
432, 434, 441, 458
383, 421, 454
health psychology, 117, 300, 301, 302, institution, 92, 93, 96, 97, 103, 134, 219,
303, 304, 305, 309, 310, 311 229, 451
hermaphroditism, 43, 44, 93 internalised homophobia, 33, 48, 111,
heteronormative, 27, 30, 70, 80, 84, 99, 284, 285, 287, 452, 456
100, 115, 116, 122, 132, 133, 136, internalised transphobia, 205
139, 140, 187, 270, 273, 286, 290, International Classification of Diseases
304, 307, 368, 377, 378, 385, 399, 448 (ICD), 26, 28, 64, 66, 71, 136, 137,
heterosexism, 98, 99, 109, 130, 219, 286, 207, 208, 265, 268, 275, 356, 361
287, 292, 293, 300, 307, 311, 316, 400 internet, 8, 9, 21, 50, 61, 65, 72, 129, 157,
heterosexual, 2, 20, 24, 26, 30, 32, 38, 42, 172, 176, 210, 225, 292, 438
43, 44, 45, 46, 47, 48, 49, 50, 51, 52, intersection, 77, 82, 155, 300, 310, 394,
60, 63, 67, 68, 72, 77, 78, 79, 80, 81, 402, 403, 408, 410, 421, 428, 447,
82, 86, 89, 92, 93, 94, 95, 96, 97, 98, 448, 449, 457
99, 100, 101, 102, 103, 109, 110, 111, intersectionality, 19, 53, 54, 55, 271, 272,
113, 116, 117, 118, 119, 120, 130, 276, 277, 304, 310, 382, 395, 417,
131, 132, 134, 140, 143, 154, 159, 427, 428, 429, 435, 440, 441, 442
172, 175, 219, 228, 229, 231, 253, intersex, 2, 171, 183, 202, 335, 348, 349,
270, 272, 274, 277, 283, 284, 285, 377, 452
286, 287, 292, 300, 303, 304, 305, see also DSD
307, 308, 309, 310, 311, 317, 320, invisibility, 136, 176, 272, 383
333, 335, 338, 345, 346, 347, 363,
375, 377, 399, 400, 401, 404, 418, J
431, 432, 433, 435, 438, 439, 442, jealousy, 222, 237, 242, 247, 253
470 Index
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
237, 252, 265, 266, 267, 269, 273, N

275, 276, 282, 303, 338, 354, 362, name, 28, 117, 174, 185, 223, 273, 318,
408, 409, 410, 412, 413, 415, 417, 348, 412
420, 421, 422, 429, 437 nappy
medication, 357 see diaper
mental health, 2, 54, 55, 119, 143, 172, natural, 13, 17, 26, 27, 30, 38, 60, 80, 93,
174, 176, 201, 204, 205, 207, 208, 95, 97, 98, 100, 102, 130, 134, 151,
209, 210, 240, 241, 242, 243, 244, 154, 171, 175, 177, 222, 317, 329,
246, 267, 270, 275, 302, 303, 304, 376, 379
306, 307, 308, 309, 311, 317, 382, negotiation, 85, 89, 157, 174, 209, 247,
403, 404, 409, 412, 413, 430, 431, 248, 322, 323, 375, 382, 383, 419,
432, 433, 434, 439, 441, 442, 452, 437, 438, 439
453, 454, 458 neuter, 166
men who have sex with men (MSM), 48, neutrois, 166, 198
66, 77, 131, 269, 432 new monogamy, 237, 251
men who have sex with men and women New Relationship Energy (NRE), 237, 253
(MSMW), 48 non-binary gender, 179, 198
minority, 12, 19, 42, 50, 53, 54, 63, 66, 95, non-gendered, 166
103, 113, 121, 133, 134, 140, 143, non-monogamy, 86, 222, 223, 225, 236,
167, 171, 201, 203, 210, 252, 266, 237, 238, 239, 240, 241, 242, 244,
269, 270, 271, 272, 274, 285, 286, 248, 249, 252, 438
287, 292, 301, 302, 304, 305, 307, normativity, 4, 10, 12, 13, 25, 26, 27, 28,
308, 310, 321, 340, 350, 375, 408, 29, 30, 31, 32, 38, 44, 68, 71, 78, 80,
410, 416, 417, 418, 419, 421, 427, 81, 83, 84, 87, 88, 89, 92, 93, 94, 95,
433, 440, 443, 447, 449, 451, 452, 97, 98, 99, 100, 102, 103, 112, 116,
453, 458 129, 130, 133, 134, 136, 137, 138,
minority stress, 203, 270, 271 140, 143, 149, 150, 151, 167, 175,
see also marginalisation stress 179, 183, 184, 185, 188, 192, 219,
mixed gender, 166 220, 225, 226, 227, 228, 229, 230,
Mize, Sara, 10, 408, 409, 411, 413, 415, 232, 237, 241, 242, 247, 248, 251,
417, 419, 421 252, 253, 263, 264, 265, 266, 300,
monogamish, 86 303, 304, 306, 309, 316, 325, 326,
monogamy, 2, 60, 103, 219, 220, 221, 222, 335, 338, 355, 361, 367, 375, 377,
223, 224, 225, 226, 227, 228, 229, 383, 385, 386, 396, 397, 401, 409,
230, 231, 232, 236, 237, 238, 240, 410, 411, 413, 418, 421, 434, 437,
245, 248, 249, 250, 253 448, 455
mononormative, 237, 247, 248, 252, 253 nuclear family, 99
Moors, Amy C, 219, 220, 222, 227, 229, nymphomania, 64
232, 236
moral, 12, 60, 69, 154, 167, 222, 323, 380, O
396 oestrogen, 153, 200
morality, 68, 219, 220, 222, 263, 264, 268, offline, 8, 9, 21, 157, 172, 176
400 older people, 376, 377, 380, 384, 385, 386,
mother, 36, 79, 94, 116, 117, 136, 154, 387
174, 346, 395 online, 8, 9, 16, 19, 20, 21, 62, 67, 157,
multidisciplinary, 192, 273, 276, 411, 421 172, 176, 178, 225, 228, 318, 330,
Murjan, Sarah, 63, 64, 72, 173, 177, 190, 333, 401, 447
198, 199, 201, 203, 205, 207, 209, open relationships
211, 362 see non-monogamy
472 Index
opposite sex/gender, 93, 137, 138 phenomenology, 30, 283, 319

oral, 31, 119, 266, 340, 342 phenotype, 171
orgasm, 137, 342, 355, 356, 357, 363, 367, physiology, 160, 377
368, 413, 419 pink, 49, 70, 166, 168
orientation, 11, 12, 13, 18, 95, 102, 226, play, 10, 30, 34, 61, 66, 72, 82, 116, 133,
267, 268, 274, 275, 333, 334, 336, 155, 170, 183, 190, 201, 202, 203,
337, 342, 350, 365, 431, 451, 453, 250, 275, 290, 291, 431, 442
454, 456 polyamory/poly, 130, 229, 236, 237,
other-gender, 114 238, 239, 240, 241, 242, 244, 245,
othering, 137, 410, 434 246, 247, 248, 249, 251, 252, 253,
otherkin, 62 254, 383
ovaries, 184 polygamy, 236, 237, 238, 239, 240, 241,
243, 244, 245, 246, 247, 248, 249,
P 251, 252, 253, 254
paedophilia, 61, 64, 68, 266 pornography, 72, 292
pain, 35, 324, 342, 355, 357, 367, 403, power, 24, 30, 33, 34, 37, 61, 62, 70, 88,
405, 410, 414 95, 97, 103, 115, 133, 134, 151, 154,
pangender, 166, 177, 198 155, 156, 157, 159, 160, 238, 247,
paraphilia, 28, 29, 64, 69, 73, 76 248, 264, 271, 274, 275, 282, 286,
parenting, 111, 112, 115, 116, 117, 121, 287, 289, 290, 291, 292, 293, 294,
122, 154, 221, 237, 245, 395 317, 325, 345, 378, 391, 393, 394,
parents, 82, 83, 84, 116, 117, 136, 188, 395, 397, 404, 429, 434, 440, 441, 447
192, 200, 202, 245, 250, 273, 339, pregnancy, 149, 338, 346
376, 393, 395, 415, 435, 439 prejudice, 98, 102, 109, 116, 122, 132,
partner, 36, 62, 86, 87, 114, 115, 116, 119, 220, 270, 272, 306, 307, 311, 385,
132, 142, 157, 189, 204, 209, 211, 434, 435, 439, 451, 452, 453, 455,
220, 221, 223, 224, 225, 226, 227, 456, 458
228, 230, 231, 236, 237, 238, 239, premature ejaculation (PE), 355
245, 250, 251, 252, 253, 254, 283,
primary care, 136, 303
285, 306, 338, 339, 340, 341, 342,
primary relationship, 219, 225
343, 347, 357, 365, 383, 385, 427,
privilege, 77, 88, 155, 219, 238, 239, 271,
435, 437, 438, 454
272, 286, 292, 293, 402, 413, 434
pass/passing, 3, 47, 113, 129, 328, 329,
377, 435 promiscuous, 50, 225
passive, 79, 88, 166, 363, 396, 437 pronoun, 174, 175
pathology, 10, 11, 13, 17, 26, 27, 29, psychiatric/psychiatrist, 3, 13, 25, 26, 28,
30, 31, 32, 33, 34, 44, 66, 70, 78, 80, 44, 47, 48, 61, 62, 63, 64, 65, 68, 78,
81, 84, 93, 109, 114, 122, 137, 138, 80, 138, 139, 173, 201, 202, 204, 207,
142, 263, 264, 266, 309, 361, 362, 208, 244, 265, 275, 288, 317, 345,
363 356, 360, 431
patriarchy, 32, 34, 96, 245, 317 psychoanalysis, 27, 78, 136, 200, 240, 264,
peers, 118, 119, 159, 203, 245, 386, 451 265, 266, 282, 294
penetrative sex, 365 psychodynamic, 65, 136, 266, 281, 354,
penis, 60, 68, 72, 94, 139, 184, 204, 357, 356
368 psychopathology, 32, 33, 47, 65, 66, 69,
perversion, 26, 27, 28, 34, 64, 93, 308 71, 99, 201, 281, 282, 345, 452
phalloplasty, 204 psychotherapy/psychotherapist, 35, 205,
phase, 17, 18, 44, 47, 51, 70, 355, 356, 211, 266, 277, 303, 311, 353, 354
435 puberty, 27, 100, 184, 202, 203
Index 473
Q Rickett, Bridgette, 391, 393, 395, 397, 399,

qualitative, 1, 2, 3, 28, 51, 179, 189, 316, 401, 403, 405
318, 319, 326, 328, 329, 330, 348, Riggs, Damien, 47, 77, 79, 81, 83, 85, 87,
421, 441 88, 89, 93, 311, 361
quantitative, 1, 2, 3, 30, 50, 51, 111, 176, risk aware consensual kink (RACK), 25
178, 333, 334, 335, 337, 343, 347, see also safe, sane and consensual (SSC)
348, 350, 363, 439, 441 Roen, Katrina, 171, 183, 185, 187, 188,
queen, 129, 173, 383 189, 191, 193, 202, 377
queer, 16, 19, 30, 50, 53, 97, 103, 131, romantic/romance, 8, 18, 19, 20, 142, 219,
132, 133, 140, 143, 154, 160, 167, 220, 223, 225, 226, 227, 228, 229,
173, 179, 206, 237, 238, 239, 240, 230, 231, 232, 243, 245, 252, 365
243, 251, 252, 253, 311, 317, 333, rubber, 62, 63, 67, 69
365, 375, 378, 401, 413, 443, 448, 452 Rubin, Jennifer D, 37, 60, 70, 96, 97, 219,
queer people of colour (qpoc), 432, 433, 236, 242
434, 435, 436, 437, 438, 439, 442 rule, 75
queer theory, 30, 50, 140, 160, 173, 179,
238
questioning, 103, 167, 172, 237, 238, 243, S
252, 275, 282, 292, 293, 365, 383, sadism, 24, 64, 68
401, 402, 411, 419, 438, 451, 452 see also BDSM; masochism;
questionnaire, 116, 334, 443 sadomasochism
sadomasochism (SM)
see BDSM; sadism; sadomasochism
R
safe, sane and consensual (SSC), 25
race, 88, 151, 155, 170, 237, 239, 248, 252,
284, 362, 375, 376, 379, 380, 381, see also risk aware consensual kink
382, 387, 400, 411, 414, 415, 416, (RACK)
417, 428, 429, 430, 431, 432, 433, safer sex, 119, 157, 224, 339
435, 436, 441, 442 same-gender, 114, 115, 120
Rambukkana, Nathan, 236, 237, 239, 241, same sex, 4, 44, 46, 67, 94, 95, 101, 102,
242, 243, 244, 245, 247, 248, 249, 103, 114, 229, 237, 242, 244, 246,
251, 252, 253, 254 249, 250, 251, 268, 283, 287, 317,
rape, 32, 68, 103, 266, 325, 326, 327, 328, 333, 335, 336, 337, 344, 345, 434,
456 435, 436, 437, 438, 449, 450, 451,
rejection, 202, 204, 209, 267, 383, 386, 453, 454, 455, 456, 458
439 scene, 88, 114, 382, 383, 452
religion, 2, 113, 236, 240, 241, 271, 272, schizophrenia, 201, 204, 205, 409
414, 427, 433, 447, 448, 449, 450, script, 95, 219, 220, 225, 232, 367, 416,
451, 452, 453, 454, 455, 456, 457, 458 417
reparative therapy scritching, 62
see conversion therapy secrecy, 36, 185, 187, 273
research methods, 51, 316, 329, 439 self-care, 402
retirement, 377 Semlyen, Joanna, 300, 305
Richards, Christina, 1, 3, 4, 16, 33, 50, 60, sensate focus, 268
61, 63, 64, 65, 66, 67, 69, 71, 73, 130, serial monogamy, 221, 226, 227, 240
131, 138, 140, 141, 142, 143, 166, sex (phenotype), 1, 3, 15, 27, 43, 44, 45,
167, 169, 171, 173, 175, 177, 178, 46, 51, 67, 78, 80, 93, 94, 95, 96, 97,
179, 198, 200, 207, 209, 266, 276, 98, 99, 100, 101, 102, 103, 114, 116,
303, 305, 315, 329, 361, 364, 365, 129, 131, 133, 134, 135, 136, 137,
377, 452 138, 139, 140, 150, 151, 154, 158,
474 Index
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
T transition, 131, 173, 190, 200, 203,

taboo, 25, 37, 60, 137, 421 204, 205, 211, 221, 335, 417,
tension, 19, 31, 136, 276, 362, 456, 457 429
terminology, 138, 166, 177, 193, 411, trans man, 334, 349
412 transsexualism, 80, 198, 199, 200, 201,
202, 203, 204, 205, 206, 207, 275,
testicles, 184
276, 361
thematic analysis, 318, 330
trans sexualities, 130, 131, 142
third gender, 43, 166, 198
transvestite/transvestism (TV), 3, 25, 64,
third sex, 43, 46, 78, 129 129, 137, 138, 204, 266, 349, 395,
tied up, 24, 94 448
time, 4, 16, 18, 31, 37, 38, 46, 49, 60, 67, trans woman, 211, 349
70, 71, 72, 73, 80, 88, 97, 98, 110, 111, trigender, 166
112, 113, 114, 131, 169, 171, 173, Turley, Emma, 24, 25, 27, 29, 31, 32, 33,
174, 200, 202, 221, 239, 244, 263, 34, 35, 37, 61, 62, 133
264, 265, 266, 281, 303, 307, 310,
317, 318, 324, 328, 335, 336, 338, U
339, 340, 343, 344, 350, 375, 376, umbrella term, 24, 335
377, 378, 381, 392, 394, 396, 400,
402, 408, 409, 413, 419, 428, 430, V
456 vagina, 60, 68, 72, 204, 342, 357, 368
toilet, 177 vaginismus, 365
tolerant, 46, 116, 288, 451 vaginoplasty, 189, 204
top, 94, 114, 155, 225, 266, 356 vanilla, 37
variation of sex development, 183, 193,
traditional, 12, 20, 34, 51, 100, 111, 281,
335
291, 333, 337, 353, 362, 363, 400,
victim, 28, 29, 115, 156
403, 408
violence, 32, 33, 36, 37, 115, 152, 222,
trans, 2, 4, 16, 19, 24, 45, 50, 54, 63, 64,
240, 241, 270, 272, 287, 302
72, 80, 86, 87, 96, 102, 109, 122, 129,
130, 131, 132, 133, 134, 136, 137,
W
138, 139, 140, 141, 142, 143, 150,
western culture, 42, 63, 113, 130, 131,
153, 166, 167, 172, 173, 174, 175,
167, 252, 317, 408, 419
176, 177, 179, 198, 199, 200, 201,
white, 46, 53, 88, 89, 97, 151, 155, 175,
202, 203, 204, 205, 207, 208, 209,
245, 254, 271, 284, 287, 320, 327,
210, 211, 212, 252, 273, 275, 276,
376, 393, 397, 398, 400, 408, 429,
286, 302, 303, 304, 309, 310, 311,
431, 432, 433, 434, 435, 436, 442,
328, 329, 334, 348, 349, 375, 384,
443
385, 386, 387, 394, 395, 401, 402,
WIFE, 229, 252, 285, 324
408, 413, 418, 427, 435, 448, 450,
wolf, 62, 242, 243
452, 453, 454, 455, 456, 457,
woman
459
see female
trans*, 54, 72, 150, 153, 252, 273, 276, 418 women who have sex with women
transfeminine, 176 (WSW), 66, 118, 119
transgender, 19, 24, 50, 86, 87, 129, 132, Woolhouse, Maxine, 391, 393, 395, 396,
134, 143, 175, 177, 198, 200, 201, 397, 399, 401, 403, 405
202, 212, 275, 286, 302, 303, 309, Work, 1, 3, 19, 20, 21, 26, 27, 30, 31, 33,
348, 394, 401 42, 44, 46, 47, 48, 50, 51, 53, 54, 55,
transgressive, 33, 37, 64, 68, 70, 72, 131, 63, 70, 77, 78, 79, 80, 81, 85, 92, 95,
133 96, 97, 101, 109, 110, 111, 113, 115,
476 Index
Work – continued 383, 384, 385, 386, 387, 391, 392,

116, 118, 120, 121, 134, 141, 149, 393, 396, 397, 398, 399, 400, 401,
151, 152, 154, 155, 156, 157, 158, 403, 404, 405, 412, 415, 428, 437,
159, 160, 161, 162, 167, 169, 184, 448, 449, 458
185, 189, 190, 192, 193, 200, 202,
210, 211, 236, 237, 238, 239, 241, Y
242, 243, 244, 245, 246, 247, 248, youth, 133, 159, 172, 188, 246, 252, 273,
250, 251, 252, 254, 263, 265, 268, 305, 367, 376, 377, 380, 381, 382, 383
271, 272, 273, 274, 275, 276, 281,
282, 284, 285, 287, 290, 291, 292, Z
293, 301, 306, 316, 317, 318, 319, Ziegler, Ali, 219, 221, 223, 225, 227, 229,
324, 325, 326, 327, 328, 329, 335, 231, 236
337, 341, 343, 344, 354, 355, 356, Zitz, Claudia, 263, 265, 267, 269, 271,
362, 364, 365, 367, 368, 377, 382, 273, 275, 277

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Meg John Barker

List of Tables and Figures xv

Notes on Contributors xvii

The history of asexuality 7

2 BDSM – Bondage and Discipline; Dominance and Submission;

BDSM and feminism 33

7 Lesbian Psychology 109

Implications for applied psychology and the wider world 120

8 Trans Sexualities 129

9 Cisgender – Living in the Gender Assigned at Birth 149

10 Further Genders 166

Key theory and research 186

12 Transgender – Living in a Gender Different from That

Part III Relationships

You’re still single? Repercussions for not ‘settling down’ 227

Part IV Psychological Areas

15 Clinical Psychology 263

16 Counselling Psychology 280

Current debates 284

18 Qualitative Methods 316

19 Quantitative Methods 333

20 Sex Therapy 353

Key theory and research 375

Key theory and research with implications for applied

5.1 Lewes’ (1988) sexual results of the Oedipus complex as

Christina Richards is an accredited psychotherapist with the British Associ-

Meg John Barker is a writer, academic, counsellor, and activist specialising

Michael Berry is a psychology researcher specialising in couple and sexual

Walter Pierre Bouman is a consultant psychiatrist-sexologist who works as

Walter is Deputy Editor of Sexual and Relationship Therapy – International Perspec-

Helen Bowes-Catton has been researching bisexual subjectivity, community,

Jan Burns is Head of the School of Psychology, Politics and Sociology at

theory, social movements, sociology of personal life, and the sociology of

Dawn Clark is a registered chartered counselling psychologist and psychother-

Rob Clucas is Lecturer-in-Law at the University of Hull. His current research

Terri D. Conley is a professor in the Psychology and Women’s Studies fac-

Roshan das Nair is Consultant Clinical Psychologist at Nottingham Univer-

Robin Dundas is Senior Specialist Psychology Associate at West London Men-

Sonja J. Ellis is Principal Lecturer in (Social) Psychology at Sheffield Hallam

Panteá Farvid is Senior Lecturer in Psychology at Auckland University of

Gareth Hagger-Johnson’s research falls between epidemiology, quantitative

Laura Harvey is Lecturer in Sociology at the University of Surrey. Her work

Nikki Hayfield is currently Senior Lecturer in Social Psychology in the Depart-

research mainly on the exploration of lesbian, gay, bisexual, and heterosexual

Alex Iantaffi is Assistant Professor with the Program in Human Sexuality,

Tony Kainth is a counselling psychologist currently working at WLMHT Gen-

Education, University of Roehampton. He is an analytic psychotherapist,

Jes L. Matsick is a doctoral candidate in the dual degree program in Psychology

Ester McGeeney is an early career researcher with a background in youth advice

Sara Mize is Assistant Professor and licensed psychologist at the Program

Body-Oriented and Mindfulness (affectionately named Da BOM!) Women’s Sex-

Amy C. Moors is a doctoral candidate in the dual-degree program in Psychol-

Sarah Murjan is a consultant psychiatrist who works as a clinician at the

Nathan Rambukkana is Assistant Professor in Communication Studies at

Damien W. Riggs is Associate Professor in Social Work at Flinders University

Katrina Roen is a professor in the Department of Psychology at the University

Jennifer D. Rubin is a doctoral candidate in the dual-degree program in Psy-

Joanna Semlyen is Senior Lecturer in Psychology at London Metropolitan

Sarah Seymour-Smith is Senior Lecturer in Psychology at Nottingham Trent

Emma L. Turley is Senior Lecturer in Psychology at Manchester Metropoli-

experience of masculinity in sexually submissive men. Emma’s other special

Ali Ziegler is Assistant Professor of Psychology at the University of Alaska