Reimagining "Multiple Relationships" in Psychotherapy: Decolonial/Liberation Psychologies and Communal Selfhood

Lacerda-Vandenborn, E., et al. (2025).

American Psychologist, 80(4), 522–534.

https://doi.org/10.1037/amp0001441

Abstract

Promoting decolonial and liberation psychologies (DLPs) requires psychologists to critically interrogate taken-for-granted assumptions pertaining to psychotherapy relationships. One fruitful area of interrogation surrounds conceptualizations and practices concerning multiple relationships (MRs), wherein a psychologist and client share another form of relationship outside of the psychotherapy context. The prevention or minimization of MRs is widely viewed as an ethical imperative, codified within professional ethics codes and further encouraged through insurance and liability practices. From the standpoint of DLPs, the profession has not adequately grasped the extent to which psychotherapy relationships reflect individualistic selves that facilitate psychologists’ serving, however unwittingly, as “handmaidens of the status quo.” We present three practitioner testimonios from among our authors—Indigenous, Muslim, and lesbian, gay, bisexual, transgender, queer, questioning, and other sexual/gender minorities—to concretely demonstrate how the professional and ethical framing around this ubiquitous practice within psychology has served to flatten human relationships within a colonizing frame. We then discuss three problematic assumptions concerning MRs that are reflected in the American Psychological Association’s Ethics Code. We offer communal selfhood, a theoretical framework that aligns with DLPs, as a potential space for understanding and reframing MRs. We conclude with general recommendations for conceptualizing therapeutic relationships without recourse to a problematic conceptualization of MRs.

Public Significance Statement

Decolonial and liberation psychologies challenge conventional thinking concerning “multiple relationships” in psychotherapy. Discouragement of multiple relationships reflects an individualistic ideology and risk-aversive managerialism, protecting the profession more than promoting public welfare. Professional and ethical reforms, in line with a “communal selfhood” framework, would reinforce the profession’s commitments toward antiracism and anticolonialism.

Here are some thoughts:

The paper critically examines the traditional ethical stance on "multiple relationships" (MRs) in psychotherapy, arguing that the prevailing individualistic, risk-averse approach is often unsuitable for diverse communities. The article uniquely applies decolonial and liberation psychologies (DLPs) to challenge these Western-centric norms, advocating for a "communal selfhood" framework. It stands out by featuring compelling practitioner testimonios from Indigenous, Muslim, and LGBTQ+ psychologists, illustrating how rigid MR prohibitions can be detrimental in community-oriented contexts where interconnected relationships are vital for trust and healing. The article not only critiques existing guidelines but also offers recommendations for systemic reform, aiming to foster antiracism and anticolonialism within the psychology profession.

Biology is not ethics: A response to Jerry Coyne's anti-trans essay

Aaron Rabinowitz

Friendly Atheist

Originally posted 2 JAN 25

The Freedom From Religion Foundation recently faced criticism for posting and then removing an editorial by Jerry Coyne entitled “Biology is Not Bigotry,” which he wrote in response to an FFRF article by Kat Grant entitled “What is a Woman?” In his piece, Coyne used specious reasoning and flawed research to argue that transgender individuals are more likely to be sexual predators than cisgender individuals and that they should therefore be barred from some jobs and female-only spaces.

As an ethicist I’m not here to argue biology. I don’t know what the right approach is to balancing phenotypic and genotypic accounts of sex. Luckily, despite Coyne’s framing of the controversy, Coyne is also not here to argue biology. He’s here to argue ethics, and his ethics regarding trans issues consist of bigoted claims leading to discriminatory conclusions.

By making ethics claims like “transgender women… should not serve as rape counselors and workers in battered women’s shelters,” while pretending to only be arguing about biological definitions, Coyne effectively conflates biology with ethics. By conflating biology and ethics, Coyne seeks to transfer perceptions of his expertise from one to the other, so that his claims in both domains are treated with deference, rather than challenged as ill-formed and harmful. Biology is not bigotry, but conflating biology with ethics is one of the most common ways to end up doing a bigotry. Historically, that’s how you slide from genetics to genocide.

The article is here.

Here are some thoughts:

In this essay, Rabinowitz critiques Coyne's conflation of biological arguments with ethical judgments concerning transgender individuals. Rabinowitz contends that Coyne's assertions—such as barring transgender women from roles like rape counselors or access to female-only spaces—are ethically unsound and stem from misinterpreted data. He emphasizes that ethical decisions should not be solely based on biological considerations and warns against using flawed research to justify discriminatory practices.

Rabinowitz highlights that Coyne's approach exemplifies how misapplying biological concepts to ethical discussions can lead to bigotry and discrimination. He argues that such reasoning has historically been used to marginalize groups by labeling them as morally deficient based on misinterpreted or selective data. Rabinowitz calls for a clear distinction between biological facts and ethical values, advocating for inclusive and non-discriminatory practices that respect human rights.

This critique underscores the importance of separating scientific observations from ethical prescriptions, cautioning against the misuse of biology to justify exclusionary or harmful policies toward marginalized communities.

3% of US high schoolers identify as transgender, CDC survey shows

Kiara Alfonseca

abcnews.go.com

Originally posted 8 OCT 24

A first-of-its-kind survey has found that 3.3% of U.S. high school students identified as transgender in 2023, with another 2.2% identified as questioning.

The first nationally representative survey from the U.S. Centers for Disease Control and Prevention also highlights the multiple health disparities faced by transgender students who may experience gender dysphoria, stigma, discrimination, social marginalization or violence because they do not conform to social expectations of gender, the CDC reports.

These stressors increase the likelihood transgender youth and those who are questioning may experience mental health challenges, leading to disparities in health and well-being, according to the health agency.

Here are some of the findings:

More than a quarter (26%) of transgender and questioning students attempted suicide in the past year, compared to 5% of cisgender male and 11% of cisgender female students. The CDC urged schools to "create safer and more supportive environments for transgender and questioning students" to address these disparities, including inclusive activities, mental health and other health service referrals, and implementing policies that are LGBTQ-inclusive.

The info is here.

The CDC study is here.

Here are some thoughts:

Recent national data reveals that 3.3% of U.S. high school students identify as transgender, with an additional 2.2% questioning their gender identity. This groundbreaking study highlights significant disparities in the experiences of transgender and questioning youth compared to their cisgender peers. These students face higher rates of violence, discrimination, and mental health challenges, with approximately 25% skipping school due to safety concerns and 40% experiencing bullying. Alarmingly, 69-72% of transgender and questioning students report persistent feelings of sadness or hopelessness, and about 26% have attempted suicide in the past year. Additionally, transgender students are more likely to experience unstable housing, with 10.7% facing this challenge.

These disparities can be understood through the lens of Minority Stress Theory and the Gender Minority Stress Framework, which highlight how stigma, discrimination, and social marginalization contribute to poor outcomes. However, protective factors such as supportive families and peers, school connectedness, affirmed name and pronoun use, and a sense of pride in identity can buffer against these stressors and promote better mental health.

Given these findings, it is crucial for psychologists to develop multicultural competence to effectively support transgender and questioning youth. This includes enhancing knowledge about the unique challenges faced by this population, developing awareness of personal biases and societal stigma, and honing skills to create affirming environments and use appropriate interventions. Psychologists should also advocate for inclusive policies, consider intersectionality, engage with families, provide trauma-informed care, and collaborate with schools and community organizations. By enhancing multicultural competence, psychologists can play a vital role in improving outcomes and promoting resilience among transgender and questioning youth, addressing the urgent need for culturally sensitive and effective mental health support for this vulnerable population.

Moving Beyond Statements to Protect Transgender Youth

Santos, M., Zempsky, W. T., & Shmerling, J. (2024).

JAMA.

https://doi.org/10.1001/jama.2024.10196

The care of transgender and nonbinary youth (aged 18 years or younger) has been scrutinized and politicized, heightening stress for lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ+) youth. These external forces have led to increased mental health concerns for this group. The statistics for LGBTQ+ youth from the Trevor Project’s 2023 US National Survey on the Mental Health of LGBTQ Young People,1 which included more than 28 000 respondents, is startling: more than 40% of respondents considered attempting suicide over the past year, less than 40% reported their homes to be LGBTQ+ affirming, and 53% reported verbal harassment at school. In addition, 67% and 54% of respondents reported symptoms of anxiety and depression, respectively. The statistics focused specifically on transgender and nonbinary youth are even more disheartening: more than 50% of respondents considered suicide over the past year and 75% and 60% reported increased symptoms of anxiety and depression, respectively. Notably, more than half of LGBTQ+ youth who wanted counseling from a mental health professional did not receive it.

The article is paywalled here.

Here is my summary:

The care of transgender and nonbinary youth has become a highly politicized and scrutinized issue, leading to increased stress and mental health concerns for this vulnerable population. Recent statistics from the Trevor Project's 2023 US National Survey on the Mental Health of LGBTQ Young People reveal alarming rates of suicide ideation, anxiety, and depression among LGBTQ+ youth, with even higher rates among transgender and nonbinary individuals. Despite the controversy surrounding gender-affirming care, major medical organizations and research confirm its lifesaving necessity.

Children's hospitals are uniquely positioned to make a positive impact on the lives of transgender and nonbinary youth and their families. However, simply offering statements of support is no longer sufficient. Families are fearful about accessing care, particularly in states that have banned gender-affirming services. Children's hospitals must take action to counteract the harm caused by this cultural war. This includes establishing resource centers to connect families with care, providing evidence-based education to counter misinformation, increasing care capacity to reduce waiting lists, ensuring safety and support for LGBTQ+ healthcare workers, and convening legal experts to protect staff and maintain care access.

By taking these steps, children's hospitals can help address the medical and psychological needs of transgender and nonbinary youth, ultimately saving lives. The article concludes with a call to action, emphasizing the need for collaborative efforts to support vulnerable families and healthcare workers. As the situation remains critical, with a transgender youth attempting suicide every few minutes, it is imperative that children's hospitals take immediate action to provide comprehensive support and care.

Spain passes law allowing anyone over 16 to change registered gender

Sam Jones

The Irish Times

Originally posted 16 Feb 23

Spain’s parliament has approved new legislation that will allow anyone over 16 to change their legally registered gender, ease abortion limits for those aged 16 and 17 and make the country the first in Europe to introduce paid menstrual leave.

The new transgender law – which was passed despite protests from feminist groups, warnings from opposition parties, and amid tensions between different wings of the Socialist-led coalition government – means that anyone aged over 16 will be able to change their gender on official documents without medical supervision.

However, a judge will need to authorise the change for minors aged 12-14, while those aged 14-16 will need the consent of their parents or guardians. No such changes will be available to those under the age of 12.

The law will also see a ban on conversion therapy – punishable by hefty fines – and an end to public subsidies for groups that “incite or promote LGBTIphobia”.

The information is here.

Some thoughts:

Spain's transgender laws are important to know from a multicultural competence perspective.

Familiarity with such laws enhances our cultural competence, allowing us to better serve diverse populations, including transgender individuals from various backgrounds. Moreover, knowledge of pioneering laws like Spain's enables us to advocate for similar reforms in our own country, promoting inclusivity and human rights. Furthermore, understanding the legal recognition of transgender rights in countries like Spain encourages us to reflect on our own ethical practices, ensuring respect, empathy, and non-discrimination in our work.

Doctors’ union will ‘critique’ Cass Review after criticising puberty blocker ban

Aine Fox

Independent

Originally posted 1August 24

The doctors’ union is to “critique” the Cass Review into children’s gender services and make recommendations to improve a healthcare system which it said has “failed transgender patients”.

The British Medical Association (BMA) said its evaluation of the review will “pay particular attention” to the methodology used to underpin the report’s recommendations.

Published in April and first commissioned in 2020, the report concluded that gender care is currently an area of “remarkably weak evidence” and young people have been caught up in a “stormy social discourse”.

Research by the University of York, carried out alongside the report, found evidence to be severely lacking on the impact of puberty blockers and hormone treatments, while the majority of clinical guidelines were found not to have followed international standards.

The review made 32 recommendations on how to ensure young people get a high standard of care which meets their needs in a way that is “safe, holistic and effective”.

The info is here.

Here is a summary:

The British Medical Association (BMA) has announced plans to "critique" the Cass Review, a report on children's gender services, and make recommendations to improve healthcare for transgender patients. The BMA has expressed concerns about the report's methodology and is calling for the implementation of its recommendations to be paused while the union carries out its evaluation, which is expected to take the rest of the year to complete. However, the NHS has rejected this suggestion, stating that it has "full confidence" in the report and will soon publish a plan to bring in its recommendations.

The BMA's evaluation will focus on several key areas, including the methodology used to underpin the report's recommendations, the impact of puberty blockers and hormone treatments (which was found to have severely lacking evidence), and clinical guidelines (most of which were found not to follow international standards). The union is also advocating for transgender patients to continue receiving specialist healthcare regardless of age and is calling for more research to form a solid evidence base for children's care. The BMA's critique will be shared with its UK council in January 2025.

The decision to evaluate the Cass Review comes after the report concluded that gender care is currently an area of "remarkably weak evidence" and that young people have been caught up in a "stormy social discourse". The report made 32 recommendations on how to ensure young people get a high standard of care that meets their needs in a way that is "safe, holistic and effective". The BMA's chairman of council, Professor Philip Banfield, emphasized the importance of getting this work right, stating that it is a highly specialized area of healthcare for children and young adults with complex needs.

Why the largest transgender survey ever could be a powerful rebuke to myths, misinformation

Susan Miller

USAToday.com

Originally posted 23 Feb 24

Here is an excerpt:

Laura Hoge, a clinical social worker in New Jersey who works with transgender people and their families, said the survey results underscore what she sees in her daily practice: that lives improve when access to something as basic as gender-affirming care is not restricted.

“I see children who come here sometimes not able to go to school or are completely distanced from their friends,” she said. “And when they have access to care, they can go from not going to school to trying out for their school play.”

Every time misinformation about transgender people surfaces, Hoge says she is flooded with phone calls.

The survey now gives real-world data on the lived experiences of transgender people and how their lives are flourishing, she said. “I can tell you that when I talk to families I am able to say to them: This is what other people in your child’s situation or in your situation are saying.”

Gender-affirming care has been a target of state bills

Gender-affirming care, which can involve everything from talk sessions to hormone therapy, in many ways has been ground zero in recent legislative debates over the rights of transgender people.

A poll by the Trevor Project, which provides crisis and suicide prevention services to LGBTQ+ people under 25, found that 85% of trans and nonbinary youths say even the debates about these laws have negatively impacted their mental health.

In January, the Ohio Senate overrode the governor’s veto of legislation that restricted medical care for transgender young people.

The bill prohibits doctors from prescribing hormones, puberty blockers, or gender reassignment surgery before patients turn 18 and requires mental health providers to get parental permission to diagnose and treat gender dysphoria.

The info is here.

Here are my thoughts:

A landmark study is underway: the largest survey of transgender individuals in the United States. This comprehensive data collection holds the potential to be a powerful weapon against harmful myths and misinformation surrounding the transgender community. By providing a clear picture of their experiences, the survey can challenge misconceptions, inform policy, and ultimately improve the lives of transgender individuals. This data-driven approach has the potential to foster greater understanding and acceptance, paving the way for a more inclusive society.

Gender-Affirming Care for Cisgender People

Theodore E. Schall and Jacob D. Moses

Hastings Center Report 53, no. 3 (2023): 15-24.

DOI: 10.1002/hast.1486 

Abstract

Gender-affirming care is almost exclusively discussed in connection with transgender medicine. However, this article argues that such care predominates among cisgender patients, people whose gender identity matches their sex assigned at birth. To advance this argument, we trace historical shifts in transgender medicine since the 1950s to identify central components of "gender-affirming care" that distinguish it from previous therapeutic models, such as "sex reassignment." Next, we sketch two historical cases-reconstructive mammoplasty and testicular implants-to show how cisgender patients offered justifications grounded in authenticity and gender affirmation that closely mirror rationales supporting gender-affirming care for transgender people. The comparison exposes significant disparities in contemporary health policy regarding care for cis and trans patients. We consider two possible objections to the analogy we draw, but ultimately argue that these disparities are rooted in "trans exceptionalism" that produces demonstrable harm.

The info is paywalled here.

Here is my summary:

The authors cite several examples of gender-affirming care for cisgender people, such as breast reconstruction following mastectomy, penile implants following testicular cancer, hormone replacement therapy, and hair removal. They argue that these interventions can be just as important for cisgender people's mental and physical health as they are for transgender people.

The authors also note that gender-affirming care for cisgender people is often less scrutinized and less stigmatized than such care for transgender people. Cisgender people do not need special letters of permission from mental health providers to access care whose primary purpose is to affirm their gender identity. And insurance companies are less likely to exclude gender-affirming care for cisgender people from their coverage.

The authors argue that the differences in the conceptualization and treatment of gender-affirming care for cisgender and transgender people reflect broad anti-trans bias in society and health care. They call for a more inclusive view of gender-affirming care that recognizes the needs of all people, regardless of their gender identity.

Final thoughts:

1. Gender-affirming care can be lifesaving. It can help reduce anxiety, depression, and suicidal thoughts.  Gender-affirming care can be framed as suicide prevention.
2. Gender-affirming care is not experimental. It has been studied extensively and is safe and effective. See other posts on this site for more comprehensive examples.
3. All people deserve access to gender-affirming care, regardless of their gender identity. This is basic equality and fairness in terms of access to medical care.

Gender-Affirming Care for Trans Youth Is Neither New nor Experimental: A Timeline and Compilation of Studies

Julia Serano

Medium.com

Originally posted 16 May 23

Trans and gender-diverse people are a pancultural and transhistorical phenomenon. It is widely understood that we, like LGBTQ+ people more generally, arise due to natural variation rather than the result of pathology, modernity, or the latest conspiracy theory.

Gender-affirming healthcare has a long history. The first trans-related surgeries were carried out in the 1910s–1930s (Meyerowitz, 2002, pp. 16–21). While some doctors were supportive early on, most were wary. Throughout the mid-twentieth century, these skeptical doctors subjected trans people to all sorts of alternate treatments — from perpetual psychoanalysis, to aversion and electroshock therapies, to administering assigned-sex-consistent hormones (e.g., testosterone for trans female/feminine people), and so on — but none of them worked. The only treatment that reliably allowed trans people to live happy and healthy lives was allowing them to transition. While doctors were initially worried that many would eventually come to regret that decision, study after study has shown that gender-affirming care has a far lower regret rate (typically around 1 or 2 percent) than virtually any other medical procedure. Given all this, plus the fact that there is no test for being trans (medical, psychological, or otherwise), around the turn of the century, doctors began moving away from strict gatekeeping and toward an informed consent model for trans adults to attain gender-affirming care.

Trans children have always existed — indeed most trans adults can tell you about their trans childhoods. During the twentieth century, while some trans kids did socially transition (Gill-Peterson, 2018), most had their gender identities disaffirmed, either by parents who disbelieved them or by doctors who subjected them to “gender reparative” or “conversion” therapies. The rationale behind the latter was a belief at that time that gender identity was flexible and subject to change during early childhood, but we now know that this is not true (see e.g., Diamond & Sigmundson, 1997; Reiner & Gearhart, 2004). Over the years, it became clear that these conversion efforts were not only ineffective, but they caused real harm — this is why most health professional organizations oppose them today.

Given the harm caused by gender-disaffirming approaches, around the turn of the century, doctors and gender clinics began moving toward what has come to be known as the gender affirmative model — here’s how I briefly described this approach in my 2016 essay Detransition, Desistance, and Disinformation: A Guide for Understanding Transgender Children Debates:

Rather than being shamed by their families and coerced into gender conformity, these children are given the space to explore their genders. If they consistently, persistently, and insistently identify as a gender other than the one they were assigned at birth, then their identity is respected, and they are given the opportunity to live as a member of that gender. If they remain happy in their identified gender, then they may later be placed on puberty blockers to stave off unwanted bodily changes until they are old enough (often at age sixteen) to make an informed decision about whether or not to hormonally transition. If they change their minds at any point along the way, then they are free to make the appropriate life changes and/or seek out other identities.

The info is here.

Transgender and Intersex Kids Must Have a Voice in Health Care Decisions

Scott Nass
thenation.com
Originally posted 13 Feb 20

Here is an excerpt:

We physicians are not allowed to take critical care away from patients, nor to force interventions on them, just because their bodies and needs don’t fit our personal expectations of “normal.” That’s not a part of our oath. Prioritizing patients means focusing on what they say they need, supporting each patient and their family in age-appropriate ways. The answer is very simple: Individuals must take the lead in making decisions about their own bodies.

Just because individuals are minors now does not mean they won’t have wishes for their bodies in the future. Transgender and intersex youth grow up. When they are denied their own choices, families bear the resulting stress and trauma.

If you don’t know any transgender or intersex kids, it may feel easy to shrug this off. But this is about more than just a few bad bills. Intersex and transgender children’s bodies are being used to uphold regressive ideas about gender’s being based on anatomy and fixed at birth, with medicine used to enforce rather than affirm.

It’s clear to me, as a physician who helps intersex and transgender children live healthy lives, that those who supported the South Dakota bill are putting youth at risk. Nearly 45 percent of transgender youth considered suicide in 2017, according to the Trevor Project. Those numbers are highest when children are not allowed to affirm their gender. Of intersex children who had infant clitoral surgery, 39 percent could not achieve orgasm as adults, compared to 0 percent in a control group. Many families are never told about these types of risks.

The info is here.

Gender, identity, and bioethics

Elizabeth A. Dietz
The Hastings Center Report
First published: 15 July 2016

Abstract

Transgender people and issues have come to the forefront of public consciousness over the last year. Caitlyn Jenner' very public transition, heightened media coverage of the murders of transgender women of color, and the panicked passage of North Carolina's “bathroom bill” (House Bill 2), mean that conversations about transgender health and well-being are no longer happening only within small communities. The idea that transgender issues are bioethical issues is not new, but I think that increased public awareness of transgender people and the ways that their health is affected by systems that bioethics already engages with offers an opportunity for scholarship that works to improve transgender health in meaningful ways.

The article is here.

Bathroom Bills, Bigotry, and Bioethics

Elizabeth Dietz
The Hastings Center Bioethics Forum blog
March 31, 2016

Here is an excerpt:

HB 2 should incite the worry, and the anger, of bioethicists on several fronts. It is unclear how transgender people could even comply with the letter of the law, let alone its spirit. When transgender men who are read as men – but whose birth certificates say “female”–- are compelled to use the women’s restroom, this creates precisely the “problem,”- i.e., the idea of men invading a women’s only space, that the law purports to protect against. The law’s defenders have invented an imaginary threat to shore up support for the legislation, insisting that women are endangered if transgender women, who are routinely misgendered as “men” in this rhetoric, are allowed to share these spaces. While a 2013 survey by the Williams Institute of UCLA School of Law found that “roughly 70% of trans people have reported being denied entrance, assaulted or harassed while trying to use a restroom,” there is no evidence of violence perpetrated by transgender people in restrooms.

The article is here.

Born this way? How high-tech conversion therapy could undermine gay rights

By Andrew Vierra and Brian Earp
The Conversation
Originally published on April 21, 2015

Here is an excerpt:

We fully agree with the President and believe that this is a step in the right direction. Of course, in addition to being unsafe as well as ethically unsound, current conversion therapy approaches aren’t actually effective at doing what they claim to do – changing sexual orientation.

But we also worry that this may be a short-term legislative solution to what is really a conceptual problem.

The question we ought to be asking is “what will happen if and when scientists do end up developing safe and effective technologies that can alter sexual orientation?”

Based on current scientific research, it is not unlikely that medical researchers – in the not-too-distant future – will know enough about the genetic, epigenetic, neurochemical and other brain-level factors that are involved in shaping sexual orientation that these variables could in fact be successfully modified.

The entire article is here.

Treatment of Gender Identity Disorder: Guidelines from the ApA

by Mary Elizabeth Dallas
MedicineNet.com
Originally published on July 6, 2012

Psychiatrists who see transgender patients need specific guidelines to help determine the best course of treatment, according to new report from the American Psychiatric Association.

The American Psychiatric Association Task Force on Treatment of Gender Identity Disorder also calls for the psychiatrists' group to clarify its position on the health care and civil rights of people who are transgender or transitioning gender, meaning they are in the process of changing their gender through hormones and surgery.

The entire story is here.

The guidelines from the American Psychiatric Association are here.