Issues for Same-Sex Couples
Richard Niolon, Ph.D. 02/05

Therapy work with gay and lesbian couples requires additional expertise beyond that normally required for heterosexual couples, as gay and lesbian couples face a number of additional stressors, different developmental processes, and more developed skills from the therapist.

Areas of Expertise
Green and Mitchell discuss five areas of knowledge you'll need to know about to provide services for same-sex couples.

1) Homophobia -- This relates to the experiences of most gays and lesbians that there is considerable prejudice in society. Sometimes the term heterosexism is used instead to describe this, but both terms relate to experiences of prejudice, or of comparing gay and lesbian couples to standards based on heterosexual couples and finding the gay and lesbian couples are lacking. This typically comes into play in a number of areas:

• legal discrimination -- This can relate to housing choices, employment, and medical rights of access and decision-making. Kotulski (2004) highlights 1,049 federal rights awarded to straight people when they marry that are denied to gay and lesbian couples. Even when individual states decide to support civil unions, only about 300 of these rights are awarded. However, there are still extra hoops gay and lesbian couples have to jump through to get them, and these rights do not transfer across state lines. She includes examples, such as:
• a gay couple pays extra to allow both to drive the car they rent on vacation, whereas a straight married couple pays for one driver and the spouse is included free
• gay and lesbian couples can still be discriminated against in housing and business in most of the US
• even when gay and lesbian couples do receive "spousal benefits" equal to those of straight people they have to pay extra taxes on them (they are "imputed income")
• "Loss of Consortium" allows married heterosexuals to collect damages against someone who injures their married partner. Gay and lesbian couples do not have this right Copied from the web.
• whereas a straight parent can marry and easily arrange for their new spouse to adopt their child, ("second parent adoption"), a gay or lesbian parent can not, denying their children equal access to health and life insurance, and even Social Security benefits
• Kotulski does some math regarding Social Security benefits. She shows that a straight man born in 1960 who dies in 2003 after making $50,000 a year could expect benefits of $1,430 a month would be paid to his wife at retirement, but not to his gay partner. Kotulski cites the National Gay and Lesbian Task force as calculating this to mean a loss of $124 million dollars a year in denied benefits to the elder gay and lesbian community
• while a home owned by a married couple would automatically revert to the surviving partner if one spouse dies, for a gay or lesbian couple the family of the deceased partner could sue to own half or all the home

Even when only one member of the couple experiences discrimination (and 40% of GLB individuals report direct experiences of discrimination), or the minority stress that results, both members of the couple suffer. Medical discrimination is even more serious, based upon results from 1994 study of gay and lesbian physicians and medical students:

• 59% of the physicians and medical students surveyed reported having experienced some sort of discrimination themselves
• 91% reported knowing of an anti-gay bias toward GLB patients
• 64% believed that GLB patients were at risk of receiving substandard care if they were open about their sexual orientation

The court system does little better, with a 2001 study by the Judicial Counsel of California indicating at 56% of gay men and lesbians surveyed reported experiencing discrimination in the court system, such as anti-gay comments, and pressure to reveal their sexual orientation. Riggle and Rostosky recommended that effective therapists should be aware of the number of "soft spots" that increase stress and discrimination with same-sex couples. They recommend advance planning for emergencies, including financial and medical problems. This entails a will, which is common and 53% of married people but only 37% of same-sex couples. This also requires a power of attorney for both financial as well as medical decisions, which is common in 45% of heterosexual couples but only 32% of same-sex couples. Of particular importance is a living will and hospital visitation authorization; 100% of heterosexual married couples obtain this automatically, but same-sex couples must create is, and only 11% of them have. Copied from the web.

• religious discrimination -- This can range from a simple refusal to recognize or bless the relationship, to denial of the same support services provided to heterosexual relationships (think religious-based conversion therapy), to active political rallying efforts to deny rights to gays and lesbians (think Pat Robertson blaming 911 on gays and lesbians, along with the abortionists and secularists).
  
  
• relationship boundary support -- Waite and Gallagher argue that the external recognition of marriage protects the boundaries around the relationship, and is part of why marriages succeed or fail. Consider for example announcements in the newspaper of engagements and marriages, laws to support the family, and clear status allowing others to quickly understand and respect the relationship.... All combine to put pressure on the couple to maintain the relationship, and on the community to respect that relationship. Interestingly, Waite has withheld judgment on whether or not the same structures for gay marriage would support same-sex couples, while Gallagher is very opposed to same-sex marriage.

2) Internalized Homophobia -- This basically relates to the internalization of negative societal views about homosexuality. This typically comes into play when same-sex couples report unhealthy views about their relationship that are in-line with societal views. This may include beliefs that men in a gay couples are distant and so the relationship is unstable, or that women in a lesbian relationship are too close and so the relationship is enmeshed. It may also influence beliefs about monogamy, as well as family and community support that are relevant to the long-term chances of success for the relationship.

Riggle and Rostosky suggests several ways to deal with internalized homophobia, including direct efforts to "dispute, deconstruct, and subvert" homophobic views and place them in a social context; support for social activism and personal power through activism; and connection with mentors and role models.

3) Outness -- This relates to the degree of openness that gay or lesbian individuals or couples show regarding their lives to their family, co-workers and employers, peers, and community. It is not uncommon to be more "out" in one setting than in another, or for one member of the relationship to be more "out" than the other.

4) Intimacy -- Green and Mitchell use the term "ambiguous commitment" to describe same-sex couples. Personally, I don't like this term, as an "ambiguous commitment" seems focused on internal and unstable aspects of the relationship, and does not capture the different social external reality for gay and lesbian couples. While gay and lesbian couples experience the same level of intimacy that heterosexual couples do (see for example Kurdek's and Gottman's work), there are a number of complicating factors to consider:

• internalized homophobia -- Green and Mitchell suggest this can be seen when there are arguments, sexual problems, and depression. This makes sense from what we've read, as a lack of rituals of connection, templates for the relationship, a social focus on what's wrong with same-sex couples, and appropriate gender roles can all increase and maintain conflict in the relationship. Irrational beliefs about monogamy and long-term satisfaction in monogamous relationships can create more anxiety and difficulty when discussing sexual desire, frequency, and needs for intimacy. As a result, a great deal of stress can arise within the relationship, especially if the relationship is hidden, leading to more depression and anxiety...
  
  
• media depictions -- There is a long history of negative representations of gays and lesbians in the media regarding their ability to find love, offer love in return, and form satisfying relationships. Often gay men are depicted as being predators, flighty, shallow, and unable to form committed relationships, all of which support internalized homophobia (think "Just Jack" from Will & Grace)
  
  
• rituals of connection -- This can relate to how the couple spends its free time; specific legal steps taken to protect the relationship; the words they use to describe each other to family, friends, and others; and even commitment ceremonies Copied from the web.
  
  
• negotiation -- Green and Mitchell list several areas that heterosexual couples can generally take for granted. These include:
• monogamy
• pooled finances
• caring for each other during periods of illness ("till death to us part")
• moving for one another due to career advancements
• care and concern for each other's family
• mutual inheritance
• coordinated health care benefits and power of attorney rights
  
  To this I would add several other areas:
• acceptance into the in-law family (at least during the holidays)
• joint property ownership, especially of a home
• retirement planning
• compatible gender roles with regards to sex, housework, career, love...
• respect for the relationship by employers (for example, family and medical, maternity, and bereavement leave)
• ongoing connection to the family of origin
• whether or not marriage is an option

Gay and lesbian couples have to engage in additional negotiation and planning in order to assure smooth functioning in these areas. 5) Internal and external boundaries -- External boundaries are not reinforced by the community, and so are harder to maintain. Boundaries internal to the community may be difficult as well, as same-sex couples typically maintain connections to friends and ex-lovers, and have more dense social networks, which may appear enmeshed to outsiders.

Family Structure
Related to outness and intimacy is the issue of "family." Green and Mitchell recommend conducting a Sociogram to diagram the "family of choice," or the family connections gays and lesbians construct. This includes concentric circles, with a couple at the center, two or three very close friends around that, other support systems around that, and community and extended sources of support after that. This support network is evaluated based upon several factors, including:

• size and composition
• frequency, length, and type of contact
• type of activities together
• multiplexity of roles
• type and quality of support
• reciprocity
• density
• stability

They expect that 8 to 12 people in the "family of choice" is adequate. Efforts to add additional people may take a year or more, and require an active role in adding people, increasing the functions they serve, and developing new connections between them. This also means distancing from family of origin at times, so that you can spend holidays and such with the family of choice.

LaSala (2000) argues from a Bowenian perspective that gay and lesbian couples who are not "out" to their families of origin should be open about their relationships with their family. Otherwise, they risk poor differentiation and fusion, emotional cutoffs, and poorer adjustment.

Green (2000), however, harshly criticizes this approach, arguing that most gay and lesbian couples derive support primarily from their "family of choice" as opposed to their biological family. Further, pressuring a couple to be open to their biological family may expose them to rejection and emotional trauma unnecessarily. Given how easy it is to expect acceptance from the family for heterosexual couples, it is not as difficult for heterosexual couples to be open about their relationship to their family. Assuming the same for same-sex couples is heterocentric. Green offers that same-sex couples are able to make solid decisions regarding the benefits and risks of being open with family, and that therapists can trust the couples judgment.

Rostosky and colleagues (2004) conducted a qualitative study of 14 same-sex couples regarding how "open" they were with their families. While the 11 described positive support from at least one family member, 11 also recounted negative experiences with at least one family member, with eight describing anger and hurt. Six specifically said that the lack of family support had a negative impact on their relationship. Six reported accepting the lack of support, but six reported hiding aspects of their relationship to avoid it.

Green and Mitchell still recommend conducting a traditional Genogram of both members' family of origin. This support network is evaluated based upon several factors, including: Copied from the web.

• if, and how long, the family has known about the gay or lesbian individual
• the impact of this on the family
• how decisions are made to disclose the relationship to the family, and to which members
• how the family has responded to accept the new partner

Therapist Skill
Many have argued for and against gays and lesbians only receiving services from other gays and lesbians. It's not that being gay includes the necessary and sufficient knowledge to provide effective services, but rather that it provides a cultural frame of reference that is very hard to duplicate otherwise, especially as prejudice comes up frequently even in modern research. Bowers and Bieschke (2005) published a study that found, consistent with previous research, that heterosexual male therapists were more likely to view gay and lesbian individuals in negative terms, and even to rate them as being at a greater risk for violence and aggression.

Riggle and Rostosky suggest that for heterosexual therapists, if you would be uncomfortable seeing a GLBT couples therapist for your own relationship then you're probably not ready to see gay and lesbian couples for therapy for their relationships. They also mentioned the American Psychological Association Guidelines for Psychotherapy with the Lesbian, Gay, and Bisexual Clients as a good resource to guide your work.

For many therapists, the issue of non-monogamy is most difficult. Recall though that 25-50% of heterosexual couples, depending on the sample, are non-monogamous. Green and Mitchell point out that problems develop not because of the non-monogamy, but rather because of problems with rules around the non-monogamy. If this is the case, there are few clear areas they can be discussed:

• How are acceptable sexual partners obtained?
• Where do sexual encounters occur? And when?
• How many times will sexual encounters with a particular individual be allowed?
• Will details of the sexual encounters be shared with a partner? To what degree?
• How will risk of HIV be handled?
• How will risk of STD be handled?
• How will accidental future contacts with the sexual partner be handled?
• How will revisions be made to this decision process?

Other Areas
There are of course a number of additional areas that Green and Mitchell did not discuss:

• domestic violence (which we discussed) where gay and lesbian couples often receive few services
• violence and hate crimes--Alabama was chosen by Out magazine as the worst state in American for gay people to live, and hate crimes rate in Chicago against gays and lesbians doubled compared to the previous year's rates in the six months after the Massachusetts ' supreme court ruled "separate is not equal"
• the link between substance abuse and HIV spread through unsafe sexual behaviors
• prejudice within the community
• coming out to same-sex couples, whether as straight or gay
• the impact of "small town dynamics" for therapists in the gay or lesbian community

For more information, see
Green, R. J., & Mitchell, V. Gay and lesbian couples in therapy: Homophobia, relational ambiguity, and social support. In Alan S. Gurman and Neil S. Jacobson (eds), Clinical Handbook of Couple Therapy (3rd Edition) 2002. New York: Guildford Press.

Murphy, J.A., Rawlings, E. I., & Howe, S. R. (2002). A survey of clinical psychologists on treating lesbian, gay, and bisexual clients. Professional Psychology: Research and Practice, 33(2), 183-189.

LaSala, M. C. (2000). Lesbians, Gay Men, and Their Parents: Family Therapy for the Coming-Out Crisis. Family Process, 39 (1) 67-81.

Green, R. J. (2000). Lesbians, gay men, and their parents: A critique of LaSala and the prevailing clinical "wisdom." Family Process, 39(2), 257-266.

Rostosky, S. S., Korfhage, B. A., Duhigg, J. M., Stern, A. J., Bennet, L., & Riggle, E. D. B. (2004). Same-sex couple perceptions of family support: A consensual qualitative survey. Family Process, 43(1), 43-57.

Bowers, A. M. V., & Bieschke, K. J. (2005). Psychologists' Clinical Evaluations and Attitudes: An Examination of the Influence of Gender and Sexual Orientation. Professional Psychology: Research and Practice, 36(1), 97-103.

Riggle, E. D. B, & Rostosky, S. S. (2005). For better or for worse: Psycholegal soft spots and advance planning for same-sex couples. Professional Psychology: Research and Practice, 36(1), 90-96.