Répondre au défi que posent les parents de même sexe aux psychothérapeutes psychanalytiques de couple et de famille: confronter les préjugés implicites!

Introduction

Although there have been obvious developments within society regarding same-sex couples and same-sex parenting, i.e. lesbian and gay marriage, assisted reproductive technologies involving egg donation, donor insemination, embryo donation and surrogacy which, together with fostering and adoption, increase the possibilities for same-sex couples becoming parents, there remains an enduring belief that the traditional nuclear family is generally considered the best environment in which to raise children. Moreover, efforts to dispel this belief, for instance, through years of research involving same-sex parents and their children, Golombok (2015) remind us that it is the quality of family relationships and the wider social environment that has more influence on children’s psychological development, than the number, gender, sexual orientation, or biological relatedness of their parents, or indeed the method of conception. With this argument firmly before us, this paper will examine developments within psychoanalytic thinking and practice that attend to the particular challenges posed by same-sex parents for psychoanalytic couple and family psychotherapists. At the heart of this exploration, lies implicit bias and the management of this by psychotherapists.

History repeating itself

 The year, 2019, presaged the 50^th anniversary of the Stonewall Inn riots that ushered in the era of gay pride. Month long celebrations marked this important moment, and the LGBTQ community revelled in the many rights and freedoms it had gained since Stonewall. In light of the 50^th anniversary, two remarkable events occurred. First, the NYPD Commissioner apologized for the Stonewall raids, declaring that their actions were wrong and that the laws that prompted the raids were discriminatory and oppressive. Several weeks later, the President of APsaA, Lee Jaffe, apologized for the role psychoanalysis had played in oppressing the LGBTQ community. In a statement he said: “Regrettably, much of our past understanding of homosexuality as an illness can be attributed to the American psychoanalytic establishment. While our efforts in advocating for sexual and gender diversity since are worthy of pride, it is long past time to recognize and apologize for our role in the discrimination and trauma caused by our profession and say, we are sorry”. These two public apologies were an attempt to make right the harm caused by long held policies and beliefs used to stigmatize and oppress members of the LGBTQ community, and they were nothing short of monumental as they addressed the oppression each institution had contributed.

Though the apologies are important we must not be lulled into thinking that the LGBTQ community is no longer subject to oppressive policies and discriminatory politics. Rather than a static point, they are an opening, an opportunity to shed further light on the oppressive attitudes and biases that still exist within the larger community. Though often times subtle, biases towards this minority group are powerful and often have damaging and lasting effects.

Implicit bias

One phenomenon we must examine in our work with LGBTQ patients is that of unconscious or implicit bias. Unconscious bias is characterized as stereotypes we all hold outside of our conscious awareness that originate from our need to make sense of the world by categorizing it. Unconscious bias is more prevalent than explicit bias or conscious prejudice and is often at odds with our values and morals. Unconscious bias begins to emerge in middle childhood and continue throughout our development, leaving us with well-established stereotypes, attitudes and beliefs before we are even aware of them (Navarro, 2019). In an address to the IPA regarding gender, Irene Matthis (Junkers, 2002) cautioned that analyst’s need to be “aware of the ever-present unconscious bias in thinking about issues of sex and gender arising not only within the patient but also within the analyst”. This caution should apply to our biases around same sex relationships as well as same sex parenting. LGBTQ individuals, couples and families face many challenges both within the community and in the consulting room, and our understanding of their issues and our own will go far in helping establish strong working alliances with our patients.

Many studies on implicit bias toward the LGBTQ community in criminal justice, educational and health care settings have been conducted. In one such study, Burke et al. (2015) examined implicit and explicit bias toward LGBTQ patients by medical students. In their study they noted that explicit attitudes are prone to being influenced by social desirability bias and influenced by the advancements that LGBTQ individuals have gained in recent years. So, it would appear to be socially desirable to hold positive views of LGBTQ individuals. However, implicit bias, as noted above, is ingrained and most likely not recognized by the person holding it (Dovidio et al., 2012). Results of Burke’s study indicated that 46% of heterosexual first year medical students held explicit biases while 82% held some degree of implicit bias. Therefore, while many students had positive views of their LGBTQ patients, the majority of them held beliefs that would likely negatively affect how they would approach them or manage their care.

There is also a growing body of literature demonstrating that mental health professionals have their own implicit biases toward the LGBTQ community. As well intentioned as we are, we may hold beliefs that would cause us to neglect important areas of concerns for our patients or engage in microaggressions, thereby eroding the therapeutic relationship and our ability to help the patient gain an understanding of their dilemmas. One such bias that we may hold is that of heterosexism. In the article Deconstructing Heterosexism: Becoming an LGB Affirmative Heterosexual Couple and Family Therapist, McGeorge and Carlson (2011) explore the way heterosexism can affect the lives of our LGBTQ clients and how it may negatively influence the therapy process. They urge therapists to examine three areas of implicit bias that may affect our work with LGBTQ patients in individual, couple and family therapy. The first area is that of heteronormative assumptions, which results in holding the heterosexual relationship as the ideal, with all of its traditional norms and roles. The second is institutional heterosexism, which can be used as a form of social control to maintain heterosexual dominance. Though we have seen the lessening of some of these controls with the granting of marriage rights for example, there has been an upswing in heterosexual control coming in the form of maintaining religious rights to refuse services to those from the LGBTQ community. Finally, the third area of implicit bias is heterosexual privilege. These are the unearned rights and privileges granted to individuals simply because they are of the dominant sexual orientation. McGeroge and Carlson stress the importance of the heterosexual therapist understanding the impact of heterosexism on the LGBTQ client and couple, as well as their own heterosexism, which may contribute to their own unconscious bias affecting their patients. It would be of equal importance for the LGBTQ therapist to examine their own heterosexism and how it may be influencing their approach to treatment.

Consequently, there are several areas that the couple and family analyst must be aware of in working with the LGBTQ population; their own unconscious bias as well as that of the internal state of the client. In their article Moving Counselling Forward on LGB and Transgender Issues: Speaking Queerly on Discourses and Microaggressions, Smith et al. (2012) raise the idea that the dominance of heterosexist language in our society leads to microaggressions and microinvalidations toward sexual minorities. In one instance they site how important it is to confront language that assumes a heteronormative hierarchy. Such an example can be applied to the term “LGBTQ affirming therapist”. While on the surface this seems like a harmless and even noble phrase, the authors note how it fortifies heteronormativity, placing one group of people who hold the power in the position over the group that “needs” affirmation. They explain that queer theorists would seek to deconstruct the heteronormative paradigm rather than seek affirmation and acceptance by it. What this trend demonstrates is the need for further exploration of language and how it affects individuals in the LGBTQ community, especially the language that appears positive on its face. We must continually engage in the process of gaining a deeper understanding of our attitudes and behaviours toward sexual and gender minority patients in order to confront our biases and the attitudes that may block efficacious treatment.

Finally, to demonstrate the importance of examining how language and attitudes affect the LGBTQ population, we must consider the idea of homophobia and internalized homophobia. Smith et al. (2012) discuss homophobia in the context of current thinking. The term phobia, they say, refers to a certain clinical condition with specific symptoms, placing the term within the medical model, potentially pathologizing the individual. This maintains the dominant discourse and may harm the therapeutic relationship. Internalized homophobia places the onus on the individual to manage a difficult internal state and minimizes the idea that there are external factors that foster both prejudice and discrimination, causing the individual distress. We must be aware of both the internal and external struggles individuals of the LGBTQ community face as well as the internal and external pressures we, the analyst, may feel based on our unconscious biases and participation in a heterosexist and heteronormative world. Can psychoanalytically minded therapists be agents in deconstructing current paradigms, both externally and internally, thereby freeing up our thinking and helping our patients access couple and family configurations that best serve their needs or, are we in danger of unwittingly fostering the current paradigms, cementing the status quo and furthering the oppression of this group?

Implicit bias and same-sex parenting

When working with LGBTQ couples an important challenge to these ideas occurs when couples are making the transition to parenthood. Heterosexism, heteronormativity and unconscious bias can greatly affect the couple, the couple as parents, and the manner in which the couple transitions to parenthood as the individuals adjust to all of the stresses and demands of parenting within the context of a heteronormative society. Couples, and individuals, in the LGBTQ community come to parenthood through many avenues: having been in a heterosexual relationship; as a committed choice between two same sex partners; through adoption; through insemination with a known donor who may or may not have some degree of participation in the child’s life; and insemination with an anonymous donor who the child may likely never know. Considering all of these scenarios, and understanding the specific challenges LGBTQ parents face in a heteronormative world, internally and externally, will help us gain an understanding of the specific challenges posed to the therapist treating this population. For example, how do we think of parenting roles? Do we hold them along tightly held gender lines or are we free to think of them as more flexible and fluid? Is the role of father, in the traditional sense, a reaffirmation of heteronormative values and roles or does a traditional father role fit for some LGBTQ families, implying choice? How can we deconstruct this role and that of mother in an effort to bring more access and freedom to the relationships lived out on a daily basis? Do the roles of mother and father need to fall along gender lines or can each member of the same-sex couple be free to adopt whatever function fits for them, constructing new roles and ways to explore and live them out that best fits the family, maximizing the idea of a creative couple. What if the couple unconsciously holds the heteronormative paradigm even though it may not fit for them and is reaffirmed by microaggressions and microinvalidations from society and the therapist? We must explore what we hold internally and what we communicate, unwittingly to the couple and each individual. As well, we must help our patients explore the beliefs and values they hold within themselves with regard to the couple and the role of parenting and what this may communicate to the child.

The impact of implicit bias on same-sex parenting research

 Golombok (2015), reminds us that it was once argued that children who grew up with lesbian mothers would be inadequately parented because it was believed that lesbian mothers were less nurturing than heterosexual mothers, that they would be ostracized by their peers and, most troubling of all to the courts, that «the children would show atypical gender development such that boys would be less masculine in their identity and behaviour, and girls less feminine, relative to boys and girls from heterosexual homes» (p. 34). This thinking, to a large extent, provided the impetus for researchers conducting studies into the lives, experiences and outcomes of children raised by same-sex parents. Begun in the late 1970s, primarily to support lesbian mothers fighting for custody of their children following the mother’s disclosure of her lesbianism within marriage, these early studies sought to reassure the courts that the wellbeing and development of these children would not be harmed if the judge allowed the children to remain with their mothers. Although a number of early studies, (Kirkpatrick, Smith, Roy, 1981; Golombok, Spencer, Rutter, 1983) did much to reassure the courts, concerns continued to persist since, because school age children provided the focus of this research, questions were raised about the development of older age adolescents. To answer these concerns, longitudinal studies, i.e. Tasker and Golombok (1997), attempted to follow a group of children originally recruited to their lesbian mother study into their teens and again in their twenties. When compared with the control group, i.e. children raised by divorced mothers, they found that the children and young adults from the lesbian mother households had just as good relationships with their mothers and even better relationships with their mother’s partner than did children growing up in a heterosexual family with their mother’s new male partner.

The shift in focus towards researching children raised from birth in planned lesbian households produced further positive results, showing, for example, that children born through donor insemination showed no difference in terms of psychological adjustment or gender development from children born through donor insemination in two-parent heterosexual families. Yet, despite these positive findings, further questions were raised of the research alleging sample bias. For instance, it was suggested that those families in which children were experiencing problems would be less motivated to take part in the research. Mobilising their efforts to counter these concerns, researchers in the UK (Avon Study) and the US (Gartrell Study) set about conducting large-scale, longitudinal, epidemiological studies. Consistent with previous findings these representative samples showed that children in lesbian mother households did not differ in terms of psychological adjustment or gender development from children growing up in heterosexual female households.

Despite the many attempts by researchers to reassure those with concerns about the wellbeing of children growing up in lesbian mother households, it seems that the very same questions are now being asked about the children of gay fathers. These questions not only reflect the dominance of heteronormative thinking, i.e. that families that deviate from the norm of the traditional two-parent heterosexual family are believed to pose particular risks to the psychological wellbeing of the children (Golombok, 2015), but also questions about gay men’s suitability for parenthood. Thankfully, we have moved away from the notion that same sex children of gay fathers are likely to be molested sexually by their fathers, their father’s lovers and gay friends, but Bigner (1996), draws our attention to the fact that gay fathers must reconcile the two polar extremes of what it means to be both gay and a father. Gay father studies, such as those conducted by Farr et al. (2010) and Golombok et al. (2014) – of adoptive children raised by gay fathers – convincingly report positive parent child relationships as well as positive outcomes in regard to children’s adjustment and wellbeing. It is telling, however, that data on children of parents identifying as bisexual remains woefully under-represented in the research to date, suggesting perhaps another kind of implicit bias at work within the field.

Taken as a whole, the body of same-sex parenting research demonstrates that children growing up with lesbian and gay parents are no different from children growing up with heterosexual parents in terms of psychological adjustment or gender development (Patterson, 2004). It would seem, therefore, that the gender and sexual orientation of the parent is much less important for children’s psychological wellbeing than the quality of the family relationships themselves. Golombok (2015) pushing the point further, suggests that neither parent’s sexual orientation or their gender make a difference to children’s own gender identity, gender role behaviour or indeed their sexual orientation and, if anything, it seems that children growing up with same-sex parents are more open-minded and appear to be more confident in expressing their sexual orientation whatever it may be.

Managing implicit bias in same-sex parenting

Despite the positive outcomes contained in decades of research, same-sex parents continue to encounter a host of challenges specific to their gender and sexuality. For instance, Bos et al. (2007) suggest that lesbian mothers have concerns about rearing their children in a homophobic society and feel more pressure in justifying the quality of their parenting than their heterosexual counterparts; a particular aspect of the negative outside world scrutinizing the worth of same-sex parents. Attention has also been drawn to the absence of support from families of origin (Oswald, 2002), as well as the paucity of positive role models for same-sex couples, although the increased visibility of same-sex parenting within the wider community must surely be lessening this particular concern. Additional considerations concerning the internalized impact of implicit bias for lesbians and gay men themselves will be examined through a number of clinical examples.

In regard to same-sex parenting, so much emphasis seems to be placed on the conscious decision to have children; a consequence perhaps of the complexities and choices same-sex couples face in actually deciding to have a child. Yet, unsurprisingly, a number of lesbian and gay male couples present for therapy precisely because of unconscious motivations and arrangements regarding the decision to have a child and the actual care of that child coming to exert a destabilising impact on the couple relationship itself and hence their presentation in therapy. D’Ercole (2008) emphasises the importance in clinical work with samesex couples of attending to internalised experiences relating to feelings of difference. This is because, as has already been discussed, negative social attitudes are believed to produce internal conflicts within the individual, manifest in feelings of guilt, alienation, confusion and hostility, etc. that may then become activated and enacted within the couple relationship. It is therefore suggested that these internalized homophobic feelings and attitudes need careful “working through” in order to help the partners in same-sex couple relationships achieve integration.

Bea, a lesbian mother and her female partner, Jess, sought therapy two years after the birth of their son, Jack. The reason they sought help was that Elliott, the gay donor father and friend of Bea’s sister, had apparently “betrayed” the couple by his failure to have any contact with Jack. The women were incandescent, complaining bitterly about how Elliott had let them down, although they were hopeful that he might be willing to join them in the therapy. When the couple were seen with Elliott, Bea accused him of abandoning her and their son. Elliott was equally indignant, pointing out that he had never agreed to be an active father in Jack’s life and questioned Bea’s memory of events. The therapist queried the importance of Elliott being actively involved in Jack’s life, especially as the two women constituted a parental pair, although it was clear that they did not feel complete without the presence of a father for Jack. When questioned, Bea spoke of the importance of children having both a mother and father in their lives, possibly the consequence of her own parents divorcing when she was seven years old. Whilst directly referencing the impact of Bea’s internal parental couple on her, the therapist also felt the need to examine Bea’s insistence on the presence of a father for Jack, especially as Jack had other important male influences in his life, and felt that it was a cloaked reference to her own internalized heteronormative assumption that same-sex parents are not in themselves enough for a child, simply because they fail to offer that child a cross-gendered pairing that is felt to be so important for their wellbeing and development. Yet, in situations of donor insemination, the procreative act does not mirror that of the majority of heterosexual couples nor does it map neatly onto a straight couple’s transition to parenthood since, in truth, it is more akin to separated and post-divorce couples living in separate abodes and negotiating contact arrangements across the divide. For Bea and Jess, the therapy was focused on helping them to embrace the value of what they were offering Jack and to create a space for Elliott to be part of his son’s life if he so wanted. Interestingly, as the mothers stepped back, Elliott began to show an interest in Jack and, at the point where the therapy ended, Elliott was establishing a routine of seeing him on a weekly basis.

Adam and Martin are a gay male couple in their late twenties who were advised by their social worker to seek an initial consultation from a couple-based specialist adoption service. Although, at one level, we see a couple that are consciously onboard with the idea of having a child, at another level, they were completely unprepared for the havoc it would unleash in both their external and internal worlds. At the time of the referral, the couple had been caring for Max, a ten-month old boy who had been placed with them with a view to adopt. Adam and Martin are a couple who met online and who described a strong bond between them with many shared interests and a good network of friends. Influenced by the increasing number of gay men within their circle having children, the couple decided to adopt. Goldberg (2010) suggests that the decision concerning the route to parenthood is often related to the importance of having a biogenetic relationship to one’s child, i.e. passing on one’s genes or physically resembling one’s child. She suggests that where this is not of consideration, then couples are more likely to adopt, although she also highlights the fact that gay men become parents amidst institutional discourses that privilege heternormativity and thus present challenges to their parenting pursuits. Additionally, same-sex couples themselves may grapple with these normative assumptions and this is exactly what Adam and Martin reported to their therapist. For instance, following the decision to adopt, Max had come too soon and Adam was forced to relinquish his much-loved job in order to care for Max; a decision based solely on Martin’s earning potential and which Adam was struggling to accept. Adam immediately felt cast in the role of “housewife”, an identity he completely eschewed, whilst in Adam’s mind, Martin became the man of the house.

At the point that the couple sought therapy, Adam was acutely in touch with a longing to be free of the constraints and responsibilities of childcare and Martin was busily trying to avert a crisis in their relationship by reconfiguring his work schedule to care for Max. However, although admirable in itself, this attempted solution failed to address Adam’s internal discomfort in terms of his masculinity feeling compromised by assuming the primary caregiving role for Max, and, at the same time, it averted Adam’s rivalry with Martin for a more equitable arrangement concerning Max’s care. The clue to Adam’s deep discomfort at being a gay dad was evident in the various references to him feeling judged by others, especially when he and Martin were out together with Max. For instance, Adam expressed deep resentment in regard to the scrutiny he and Martin felt under, for instance, in passing through border control when the guard seemed to question the fact that they could be Max’s parents; an obvious example of a micro-aggression that has the effect of invalidating the couple and their right to parent. To some extent, this resonates with Bigner’s (1996), thinking about boundary controls for the children of gay fathers, who attempt to control the disclosure of their father’s sexual orientation, for example, by refusing to be seen in public with their father and his lover, or in controlling one’s behaviour with peers by refusing to bring them to the family home. Hence, we see the importance of patrolling the border between what is private and what is public, in order to afford some modicum of protection from the negative gaze of the outside world.

Yet, it is clear that the discomfort Adam experienced in the outside world, referenced Adam’s deep internal discomfort with being a gay dad, something he was able to admit during the course of therapy. He had already said that he couldn’t bear the judgmental eyes on him and admitted that when out together as a couple with Max he felt anxious about Max playing-up, since it would draw attention to him being a gay dad. He went on to explain that it was a very different feeling being out with Max on his own where he could pass as a straight dad, an identity for which he could feel proud and comfortable. This helped the therapist see more clearly Adam’s internal conflict concerning the integration of his masculine self with his gay identity. For both men Max had come too soon, but the therapist came to see that this was an unconscious reference to Adam and Martin’s prolonged struggle to settle things between them and of finding a more comfortable home within their couple relationship in which to welcome Max. Perhaps the decision to adopt was a shared unconscious attempt to force a resolution rather than allowing a careful “working through” of the couple’s complex issues relating to being gay and to being gay fathers. By speaking directly to these issues, regarding the internal and external conflicts associated with their separate and shared gay identities, it was noticeable how the men began to reclaim their couple relationship from the grip of external forces that were felt to be threatening their connection.

A final case scenario raises some additional considerations. For instance, how do we think about the position of the non-biological parent in same-sex parental couple arrangements involving a known gay donor? It seems that these parental arrangements raise fundamental questions concerning the meaning and construction of family particularly given that there are three potential couples: the biological paring; the gay donor dad and his partner; and the biological lesbian mother and her partner; all of which need consideration within same-sex parenting networks. Bowen (2008) suggests that interesting family dynamics arise in regard to those who are able to claim their status as parent based both on their legal understanding of parenthood and their interaction with the dominant culture. In other words, such arrangements as that outlined above, create particular dynamics for the partners, the children, and the family as a whole.

James seeks therapy because of issues relating to his longstanding partner, Neil. James explains to the therapist that he has a seven-year old daughter named Ellen, born through donor insemination using his sperm to impregnate Amy, one of the legal partners in his firm. He described Amy as a formidable character coming from a well-heeled family and who was determined to ensure the best for her daughter. Although James and Neil had regular contact with Ellen during the week, Amy put pressure on the men to join her and her partner Helen, with Ellen on weekend retreats to her country home. James experienced difficulty refusing the invitation, since he loved spending time with Ellen but could see that the arrangement did not suit Neil so well. Although committed to Ellen, Neil felt less secure of his place within the wider parental arrangements and was concerned about Ellen monopolising their couple relationship. James, who struggled to say no, felt between a rock and a hard place, as he tried to keep Amy, Ellen and Kevin happy. He also noticed that during the weekend visits, Kevin and Helen seemed to pair off, suggesting a particular reading of the complex workings of the couple and family relationships within the system as a whole. Essentially, the focus of the work was in helping James establish more appropriate boundaries for his relationship with Neil, separate from his co-parenting relationship with Amy, and one that included Ellen but which also allowed a protected space for James and Neil.

This case scenario draws particular attention to the varying and complex needs of same-sex partners, as the parties navigate the transition to parenthood with its myriad expectations and fantasies about how it will be and the types of challenges these parental couples might face. Glazer (2004) believes that «societal definitions of family are changing, in part due to advances in reproductive technologies, increased availability of adoptions and advances in gay and lesbian civil rights» (p. 104). She also believes that «contemporary psychoanalysis… finds itself moving away from a belief in the causal links between gender, object choice and maternal strivings» (p. 104). This suggests that perhaps in this new era, it is not only samesex parents who are facing the challenges of parenting their children, in an uncertain and, to some extent, unfriendly and hostile external environment, but that psychoanalytically informed practitioners are also being forced to renegotiate these new relational networks in regard to their theory and practice.

Conclusion

This paper has examined developments in thinking about same-sex parents and couples. It uses implicit bias as a central and organising principle in understanding the ways in which, despite advances within society and within psychoanalysis, these families of difference continue to suffer from heteronormative thinking and practice. Not surprisingly, as the numbers increase, psychoanalytic couple and family psychotherapists are increasingly meeting and working with these parents and children in their consulting rooms. The extent to which they feel open and equipped to challenge the dominance of the cross-gendered pairing as the highest context marker for the parenting of children, remains to be seen, especially when same-sex parents may feel freer to construct parenting differently and not necessarily along prescribed gendered roles.

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