This Pride month, cities around the globe celebrate the wide expanse of sexual identity. People honor the labels many use to identify themselves. Identities like gay, lesbian, bisexual, or queer are written on posters and floats, indicating the long hard-earned rights to declare who they are to the world. Beyond the hardships many of these folks are now facing in America, the therapy world needs more insightful education to help clients explore nuanced experiences in their sexual lives. Research suggests that difficulties in defining and categorizing sexual orientation can have negative implications for many individuals and/or partners in general. Psychotherapists, couples counselors, and medical professionals are in need of deeper knowledge to better serve their patients.

Sexual Identity Labels Often Don’t Fit

A 2010 study by the National Defense Research Institute states that the research on sexual orientation often relies on three main categories of definition –  sexual/romantic attraction, sexual behavior, and sexual identity (self-labeling) – which frequently do not align into one clear label. This puts people into labels that don’t fit exactly right, which runs the risk of ignoring the diversity that plays a huge part in sexual identity development.

Lisa Diamond, a renowned psychologist working in sexuality, gender, and intimate relationships, discusses the differentiation between labels, thoughts, and actions. She states in her 2016 study in Current Sexual Health Reports that rates for same-sex orientation are highest when measured by attraction, followed by behavior, and lowest when based on self-identity. ​​In a separate study in 2019 by the Journal of Official Statistics looking at these intersections, 9.1% of self-identified gay women, 3.9% of bisexual women, 8.4% of gay men, and 14.3% of bisexual men report being exclusively attracted to the opposite gender, which contradicts their sexual identity.

Clinicians must recognize that their clients’ sexual identity cannot be exclusively described in simple labels. Therapists who quickly place clients in prescriptive identities may show unconscious assumptions which can cause harm.

For some time now, sexuality researchers have been identifying men through their sexual behaviors versus labeling their identities. They label men who have sex with men as “MSM” versus “gay” or “bi”. This began most likely in the late 1980s by HIV and AIDS researchers, as many men who identified as heterosexual shared sexual encounters and behaviors with other men but did NOT identify as gay or bisexual. Separating the sexual behaviors from identities let researchers glean information as part of their battle against an epidemic crisis which at that time was causing a large number of men to die and the medical providers without an effective cure.

The Impact of Therapists Misusing Labels

This lack of clear categorization and the non-alignment of attraction, behavior, and identity among people can create internal conflict. In the article Sexuality and Gender: Findings From the Biological, Psychological, and Social Sciences, researchers Mayer and McHugh state that there can be a pressure to be “sure” about one’s identity and to adhere to the “born that way” hypothesis, creating a fixed biological basis for sexual orientation. If a client feels unsure about their sexual orientation, they may feel pressure to identify themselves with one exclusive label in order to feel accepted and supported by their community.

This pressure to conform is linked to mental health challenges. The article Sexuality and Gender by Lawrence S. Mayer et. al. discusses higher rates of poor mental health for LGBTQ+ individuals generally and explores the adverse consequences of concealing aspects of one’s identity. While labeling can have negative mental health effects, expressing thoughts and feelings is linked to improved well-being. If a clinician assumes and uses labels with which a client does not align, it contributes to the client feeling less open to sharing more complex feelings and attractions to their therapist. 

Comfort Discussing Sexual Material in Sessions

The Journal of Marital and Family Therapy in 2008 published a study of 175 clinicians assessing how their training, education, perceived sexual knowledge, and comfort with sexual material influenced their willingness to engage in sexuality-related discussions with their clients. The findings stated that Marriage and Family Therapists who perceive themselves as having higher levels of sex knowledge were not more likely to initiate sexuality-related discussions. In fact, perceived sexual knowledge did not have a significant effect on sexual discussions in the path model. 

Their results indicate that the combination of sexuality education AND supervision experiences are the cornerstone for a therapist’s base level of comfort. This is how sexuality knowledge is gained. When therapists I teach and/or supervise tell me they consider themselves sexuality-educated based on their lived experiences or having volunteered for a college peer program, I know that this isn’t enough to have productive, comfortable therapeutically effective sessions with clients around their sex lives within their clinical exchanges. It requires supervision that teaches the deeper understanding of the biological, medical and sexual health issues that intersect with therapy clients’ lives whether they are no matter their relationship status or identity. 

Using Label-Free Language

I encourage the therapists I train and supervise to use neutral words or phrases to describe sexual behaviors with clients and emphasize that they understand it might be difficult to share these sensitive subjects. Using terms that aren’t labeled allows more openness for the client to discuss and explore often conflicting and overlapping fantasies, behaviors, and identity. Instead of asking: “Have you had any gay/lesbian/queer relationships?”, I encourage my therapists to ask: “Have you ever had any same gender emotional, sexual or erotic experiences growing up?” or “Have you had fantasies about a person that presents as a transgender?”. These gender descriptions of the person with whom they shared a sexual behavior or fantasies does not make assumptions about the client’s self-identity or orientation.  

Therapists must get more didactic education and supervision to learn neutral language to use with their clients about sexual fantasies and experiences. It is through in depth training that all therapists and medical professionals can allow clients to feel more authentic with themselves in their psychotherapy journey and within the therapeutic relationship.