Viewpoint

Queer Affirmative Approach in Mental Journal of Psychosexual Health

5(2) 114–118, 2023
© The Author(s) 2023
Health: A Need of the Hour in Article reuse guidelines:
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Indian Mental Health Care DOI: 10.1177/26318318231181697
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Jithin T. Joseph1

Abstract
The mental health needs of LGBTQIA+ individuals and the roles of mental health professionals (MHPs) in queer mental health
are gaining importance in health care. Queer individuals have specific mental health needs, and the current mental health
training and practice are often inadequate to handle these needs. This often leads to conflict between the queer community
and MHPs, causing queer people to avoid the necessary mental health care that they need; this will lead to long-lasting
consequences. The social stigma related to queer people, the mental health professional’s own cis and heteronormative
assumptions, and privilege often lead to these conflicts and non-inclusive care. The queer affirmative approach is a mental
health approach, which had shown effectiveness in dealing with the mental health needs of queer individuals. In this viewpoint,
we will discuss about the basic concept of the queer affirmative approach, its differences with the usual mental health care,
and the process involved in becoming a queer affirmative mental health professional. This will help more MHPs expand their
knowledge of LGBTQIA+ mental health and provide inclusive care for queer people.

Keywords
LGBT Issues, LGBT affirmative practice, queer affirmative practice, queer affirmative mental health professional

Received 14 March 2023; accepted 30 April 2023

Introduction Mental health professionals (MHPs) and queer people

LGBTQIA+ is an umbrella term used to denote people whose
sexual orientation or gender identity does not conform to
society’s cis-hetero binary concept. They are also known as
queer, used as a derogatory term in the past, but many
LGBTQIA+ individuals today embrace the label neutrally or
positively.1 Nowadays, a better terminology is SOGIESC―
Sexual Orientation, Gender Identity Expression, Sex
Characteristics2―as it describes any person’s sexual orienta-
tion or gender identity than differentiating people based on
sexuality or gender characteristics. The latest research found
that around 1%–4% of the population identify as LGBTQIA+,
which is a significant number.3 It was also found that queer
individuals are more likely to develop mental health issues
because of the stigma and discrimination they face from a
cis-heteronormative society.4–7 They have specific mental
health needs when coming out to the family and community
while preparing for gender affirmative care. However, due to
the discrimination they face from health care institutions and
professionals, they are more reluctant to seek help and sup-
port, which adds to the morbidity and burden.
have a controversial past because, until recently, being homo-
sexual was considered a mental illness, and they were subjected
to different harmful treatments.8 Homosexuality was removed
from DSM 2 in 1973 after a long struggle, followed by the
removal of ego-dystonic homosexuality (EDS) from DSM 3
TR in 1987.8 ICD 10 removed homosexuality as a diagnosis
in 1992 but continued to include a session on Ego-Dystonic
Sexual Orientation. The most recent ICD 11 completely
removed the diagnosis of homosexuality. Regarding gender
identity, DSM 3 had it as a disorder for the first time under
psychosexual disorders as gender identity disorder. Currently,
in DSM 5, it is renamed gender dysphoria. In ICD 11, it is
1
Clinical Research Centre for Neuromodulation, Department of Psychiatry,
Kasturba Medical College, Manipal Academy of Higher Education, Manipal,
Karnataka, India
Corresponding author:
Jithin T. Joseph, Clinical Research Centre for Neuromodulation,
Department of Psychiatry, Kasturba Medical College, Manipal Academy of
Higher Education, Manipal, Karnataka 576104, India.
E-mail: jtjthekkel1@gmail.com

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Joseph
renamed as Gender Incongruence and entirely removed from
the session of mental and behavioral disorders and moved to
conditions related to sexual health. These changes were made
based on increasing evidence about the normality of various
sexual orientations and gender identities and to reduce the
stigma and discrimination faced by the queer individuals.8,9
Even though DSM had removed homosexuality entirely
as a diagnosis in 1987, in many countries, queer people still
get diagnosed and treated for homosexuality by MHPs, using
very harmful conversion therapy, aversion treatment, medi-
cines, and even ECT.10 Until recently, no professional mental
health bodies in India came up with a position statement
regarding their stand on issues related to queer mental health.
In 2018, a few days before the historic supreme court decision
of decriminalizing IPC-section 377, the Indian Psychiatric
Society (IPS) came up with a position statement against
pathologizing homosexuality and discrediting conversion
treatment11. Following this, the Indian association of Clinical
Psychologists and the Association of Psychiatric social work
Professionals came up with similar position statements. Even
today, our medical or psychological textbooks contain queer-
phobic materials, and the curriculum has no actual training in
the health care needs of queer clients and they do not teach
an affirmative approach. The national medical commission
recently included conversion therapy under professional
misconduct, which was a welcome step.12
Each mental health professional must clearly understand
this history because this will help them understand the injus-
tice and cruelty inflicted in the name of treatment to the queer
community. It will also help each mental health professional
self-reflect on their cis-hetero privileges and biases and serve
as the first step to becoming a queer affirmative mental health
professional.
What Is Queer Affirmative
Mental Health Care (QAMHC)?
Queer affirmative mental health care is an approach where
the MHPs recognize the historical wrongdoings towards queer
people by mental health systems, understand how MHPs had
caused harm and distress to queer persons, acknowledge, and
take responsibility for the cis-heteronormative biases and
privileges that are with us knowingly and unknowingly, ready
to make reflective feedback on these privileges and to make
amends.13 A queer affirmative MHP (QAMHP) understands
the negativity, discrimination, and stigma the queer people had
faced as well as their struggle to overcome those challenges.
Further, it is important for QAMHP to acknowledge these chal-
lenges when they come for care.13 They also understand the
particularity of queer struggles that are often not similar to the
others and how they can contribute to mental, physical, and
social issues in queer people’s lives. Along with understanding
these issues, an affirmative practitioner is willing to be involved
in the process of queer struggles and improve their lives.13
In short, a QAMHP should be able to see the queer clients’
115
problems from the point of view of the queer person rather than
just showing empathy or sympathy to them. The queer affirm-
ative approach is not a stand-alone treatment, but it can be
incorporated into any medical and mental health practice set-
ting. An affirmative practitioner does not see their clients’ gen-
der identity or sexual orientation as a problem, but try to affirm
the normality of any sexual orientation and gender identity
from the first point of contact.13
While dealing with queer clients, MHPs often use
different techniques.13
Classic Neutral Practitioner
They genuinely accept that people’s gender and sexuality are
personal and that the MHP should have no say in the matter.
They don’t consider queer people mentally ill but don’t want
to provide special care for them or try to understand the spe-
cific problems queer individuals face. This approach fails to
recognize the social and political issues faced by queer people
and how that can contribute to mental health issues among
queer people.
The Queer-Friendly/Sensitive Practitioner
They are often empathetic and want to help queer people gen-
uinely, and they might know a few queer individuals from their
family or friend circle. They might have superficial knowledge
about the specific issues and needs of queer people.
The Queer Affirmative Practitioner
They claim, and are committed to, the identity of a queer affirm-
ative practitioner and communicate it to clients and fellow pro-
fessionals. They are self-reflective about their social location,
personal beliefs, and professional training and practice. They
work to deconstruct the influence of heterosexism and cisgen-
derism in mental health disciplines, practice, and the lives of
queer and trans clients. They educate themselves about standards
of care, protocols, and guidelines for working with LGBTQIA+
clients. They adopt a critical psychosocial approach that views
individual distress as systemic and structural, not intrapsychic.
These practitioner engage with queer and trans communities to
build knowledge from their lived experiences and to build soli-
darities and friendships, thereby diversifying their social circle.
They advocate for the rights of queer and trans persons in and
outside the mental health system.
Process of Becoming a Queer
Affirmative Mental Health Professional
This process aims to modify MHP’s existing practice to be
more inclusive and responsive to queer persons and their
116
specific needs, demonstrate the MHPs alliance with queer
persons, and help create a safe space where clients experience
affirmative care.14,15 The process involved is explained below.
Recognizing and Understanding the
Barriers to Queer Affirmative Practice
These include heterosexist and cis-gendered beliefs, assump-
tions, and practices that have existed in the society for a long
time and still exist among all of us knowingly or unknow-
ingly. Heterosexism is a systemic process that marginalizes
LGB individuals based on beliefs and assumptions that
heterosexuality is the only valid way of living, and therefore,
the preferred norm.14 Cisgenderism refers to the cultural and
systemic ideology that denies, denigrates, or pathologizes
self-identified gender identities that do not align with assigned
gender at birth and resulting behavior, expression, and com-
munity.15 We often fail to recognize these factors and their
implications for queer persons. The common barriers to queer
affirmative care are briefly explained below, and a detailed
description can be found in references.13–15
Hetero and Cisnormative Assumptions
Hetero and cisnormative assumptions refer to automatic,
unconscious beliefs, and expectations that reinforce hetero-
sexuality, heterosexual relationships, and cisgenders as the
ideal norm. It creates a society where only heterosexual and
cisgender lives are visible and fails to recognize queer people.
Hetero and cisnormative assumptions in MHP can lead to the
belief that everyone seeking therapy from them is heterosex-
ual or cisgender.14,15
Figure 1. Three-step Process of Becoming Queer Affirmative MHP.
Journal of Psychosexual Health 5(2)
Institutional Heterosexism and
Cisgenderism
Institutional heterosexism and cisgenderism are defined as
the societal policies and actions by institutions (e.g., govern-
ments, health care systems, and educational systems) that
promote a heterosexual/cisgender lifestyle above all others,
exclude or discriminate against LGBTQIA+ people as indi-
viduals and as a group, and privilege and grant benefits to
heterosexuals and cisgenders.14,15 Affirmative MHPs need to
identify such issues and understand the impact they can cre-
ate on queer lives.
Heterosexual and Cisgender Privilege
Heterosexual and cisgender privilege refers to unearned civil
rights, societal benefits, and advantages granted to individu-
als based solely on their heterosexual orientation or cisgender
identity, making them superior and powerful. These privi-
leges operate on an unconscious level and increase the indi-
vidual’s sense of worth and belonging. At the same time, they
can lead to self-stigma and internalized homo/transphobia
among queer individuals because they may think of them-
selves as inferior because of their identity or sexual
orientation.14,15
Three-step Model of Becoming a Queer
Affirmative Therapist (Figure 1)
Once the MHPs understand how heterosexism and cisgenderism
influence people and the impact they create on queer lives, they
Joseph
need to critically re-examine themselves to understand how
cis-heterosexism influenced themselves and their practices. It is
a three-step critical exploration process that each MHP must
undergo before projecting themselves as a QAMHP. A brief
description of the three-step process is given here. Detailed
descriptions and a list of self-reflective questions used in each
step are available in the references.14,15
Exploring Cisgender/Heterosexual
Normative Assumptions
• This step includes exploring the cis-heteronormative
assumptions we may hold unconsciously, which may
also reflect in our practice.
• Because of this, we may falsely assume the gender
identity or orientation of the people who comes for
service and fail to recognize the needs of queer clients,
thus becoming less inclusive.
• This also includes acknowledging that we hold
cis-heteronormative assumptions like others in our
society, and this self-acceptance is the crucial step in
changing ourselves to become affirmative.
Exploring Cisgender/Heterosexual Privileges
• They are the privileges and advantages we unknowingly
enjoy because we belong to a cis-hetero identity.
• Often, these are invisible to us and need a critical
self-reflection to understand how these privileges
give us advantages and cause disadvantages to queer
individuals. Active work is needed to acknowledge
this and dismantle these unearned benefits.
Exploring Cisgender/Heterosexual
Identity Development
• This step is one of the most crucial parts of becoming
a queer affirmative mental health professional.
• Becoming a QAMHP involves more than simply
learning about LGBTQIA+ topics; it requires the
cisgender and heterosexual MHPs to also know how
they developed a heterosexual sexual orientation and
cisgender identity.
• This process will help the MHP understand that they
have a gender identity and sexual orientation, and the
processes involved in the development of the same will
help them become queerer affirmative in their practice.
Basic Principles of Queer Affirmative
Mental Health Care
The basic principles are described very briefly here, and for
a detailed description, the reader can refer to the book
117
published by the Mariwala Health Initiatives on queer affirm-
ative counseling practices.13
Principle 1: Knowing and Using Queer
Affirmative Language in Practice
Affirmative language eliminates cis-hetero biases, is non-stig-
matizing, non-pathologizing, and non-derogatory towards
queer individuals, and it refers to verbal and nonverbal com-
munication. Affirmative language should also be reflected in
socio-demographic forms, rating scales, therapy materials,
and posters stuck in your clinic.
Principle 2: Having and Publicizing a
Queer Affirmative Practice Set Up
Usually, the practice setups tend to be cis-heteronormative
regarding space setups, materials, and exhibits, which can
make queer clients uncomfortable. The physical space of
practice should be inclusive and free from cis-heteronorma-
tive language or displays. The staff should also be trained to
use a queer affirmative stance from the point of contact.
Principle 3: Avoid Assumptions and Respect Diversity
An affirmative practitioner should not make assumptions about
clients’ gender identity, sexual orientation, relationships, or sexual
practices. While asking about such details, they should use affirm-
ative language. For example: instead of asking about husband/
wife, MHP could ask about partner; instead of married/unmarried,
use relationship status; instead of using he/she, MHP can ask about
their preferred pronouns and use them in conversations.
Principle 4: Challenging the Clients’ Misinformation
Often, the clients might have much misinformation about
gender identity, sexual orientation, queer lives, and so on, as
they live in a society surrounded by cis-heteronormative indi-
viduals. An affirmative MHP should be able to identify such
misinformation and educate the clients.
Principle 5: Facilitating Self-acceptance
This principle is one of the essential principles and aims of
affirmative practice. MHP can facilitate self-acceptance by
providing a safe environment where clients can discuss their
identity or orientation without fear, guilt, shame, or judgment.
Principle 6: Knowing About and Engaging
with Resources and the Community
Engaging with resources and queer community help the MHP
to widen their understanding of specific issues faced by queer
individuals and to understand their strength.
118
Principle 7: Maintaining Confidentiality
As a marginalized and stigmatized population, any breach of
confidentiality can lead to violence against them. Therefore,
affirmative MHP should have utmost care while dealing with
personal information.
Principle 8: Self-awareness and
Enhancing Competence
Affirmative MHP must be aware of their biases and inade-
quacies and open to correction, change, and growth. MHP
should use all the opportunities and resources to update their
knowledge on queer issues.
Principle 9: Affirmative Practitioners as
Advocates of Queer Rights
The role of an affirmative practitioner is not just limited to
providing treatment for a queer client. They must support the
community in their struggle for equality and acceptance and
advocate for changes in the cis-heteronormative biases and
practices in community and health care systems, including
mental health care.
The above article briefly describes becoming and estab-
lishing as a queer affirmative mental health professional. It
is a long and continuing journey where the MHP had to step
outside the comforts of neutral practice, challenge themselves
of their cis-heteronormative assumptions and privileges, be
open to corrections and changes, and become an advocate of
queer persons. Through self-reflection and self-transforma-
tion, you will be able to understand the struggles of queer
individuals from a socio-political perspective, apart from the
usual bio-psychological model, and thus, they can provide
non-discriminating and affirmative care for queer clients. Our
mental health and medical training must need significant revi-
sion to include an affirmative approach.
Acknowledgments
I acknowledge Akash Mohan (He/Him) who is a queer affirmative
psychologist who helped me with finding resources, references, and
also helped in the editing of manuscript.
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, author-
ship, and/or publication of this article.
Statement of Informed Consent and
Ethical Approval
Not applicable.
Journal of Psychosexual Health 5(2)
ORCID iD
Jithin T. Joseph https://orcid.org/0000-0001-6559-9497
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