in recognition of idahobit

Today is May 17th, the International Day Against Homophobia, Biphobia, Inter-sexism, and Transphobia.

In commemoration of all those sexual and gender diverse people who advocated for and died for their sexual rights, allowing people like me to study and work as a sex therapist, I wanted to share a paper I wrote a couple of weeks ago. The first section if a personal reflective piece where I challenge my own beliefs about sexuality. The second section is research review on the unique challenges bisexuals face.

If you can, please get a rainbow to celebrate such wonderful diversity and resilience. You can learn more about IDAHOBIT here.

We need to do better when working with bisexuals: why improvements in research, education and treatment are needed.

By Aleksandra Trkulja

a.trkulja@postgrad.curtin.edu.au

Reflection Paper

During BLOCK week, the modules on language, sexual diversity and sex positivity challenged personal attitudes and beliefs for me. On the first day of BLOCK, we explored attitudes and judgments. During an exercise where the group noted words associated with varying sexual topics and body parts, I noticed a reoccurring theme arise. The way I defined ‘sex’ differed from the definitions of those around me. Words were scrawled on paper that I had never associated with certain topics. I was curious to witness the diversity in language and attitudes.

I had set a goal to journal every night as a reflective exercise. What I noticed was startling. I defined ‘sex’ as penile-vaginal intercourse between a man and woman. As a mental health counsellor working with people and discussing sexual health, I reflected on how damaging this limited definition of sex was on my practice, and my perception of sexual and romantic relationships. I frantically wrote to myself;

“I’m so confused and ashamed. Until today I believed that penetrative sex was ‘real’ sex. I’m upset because this implies any other sexual activity is invalid in comparison. I’m questioning whether losing my virginity was in fact even losing my virginity? I want to throw that word in the bin.” – excerpt from journal

Although I had always assumed I was sex-positive, upon deeper reflection, I am still burdened with the unhelpful lessons a sex-negative society has conditioned me to believe. That night I wrote a therapeutic letter to a woman where I reframe when my sexual career began. It was not defined by the moment I first experienced penetrative, heterosexual, sexual intercourse, but rather several years earlier with her, drunk and giggling. Reframing my virginity as a sexual career was therapeutic. Using language in a way that suited my experience was helpful, it allowed me to proudly acknowledge and recognise the experiences I’d had with men and women were all equally as valid.

 On day 3 of BLOCK, we explored sexual diversity. My reflections from a day or so earlier became clearer once exploring topics of homophobia and biphobia. Journaling that evening I identified I had experienced internalised biphobia until this week. I had been ashamed to be fluid in my sexuality and the way I expressed it. I had also carried that negative attitude about fluidity into intrapersonal, interpersonal, and social situations. I had worked with sexual minority people as a mental health counsellor, but failed to consider the unique challenges they face. Had these people ever been offered the opportunity to stop and reflect on the sex-negative baggage they had subconsciously absorbed from society? The module on sexual diversity and sex positivity inspired an overdue realisation; bisexuals are not homogenous to other sexual minority groups. As a somewhat fluid individual, how could I learn more about this group, and improve my clinical practice with sexual minorities to minimise projecting biphobic values onto clients?

Position Paper

The term bisexual is used to describe people who are sexually oriented and attracted to, all people (Moradi, 2016). Bisexuals are not homogenous to other sexual minority (SM) subgroups, and experience unique forms of discrimination including biphobia (Friedman et al., 2014; Grabski et al., 2019; Zivony & Lobel, 2014; Zivony & Saguy, 2018). Bisexuals are the largest population of SM subgroups, and are gradually increasing (Bostwick & Dodge, 2019; Copen et al., 2016). They are at greater risk of diagnosed anxiety, depression, suicidality and substance abuse than their heterosexual and homosexual counterparts (Björkenstam et al., 2017; Coulter et al., 2016; Flanders & Robinson, 2019; Friedman et al., 2014; Nam et al., 2019; Schuler & Collins, 2020; Star & Pachankis, 2019). Despite requiring individualised care, there is a lack of intersectionality within research and clinical practice which fosters the lack of bisexual visibility (Dyer & das Nair, 2013; Higgins et al., 2019, Owen-Pugh & Baines, 2014; Pachankis, 2018; Percat & Elmerstig, 2017; Ruben & Fullerton, 2018).

The Department of Sexology believes that biphobia, and internalised biphobia is detrimental to the health of bisexual clients, and without research, education and clinical improvements, researchers and healthcare providers are fostering sex-negative, biphobic cultures that contradict their hard work. We believe that there must be improvements on both a systemic and interpersonal level to foster bisexual visibility, reduce health disparities, and provide more accurate research and ethical clinical practice.

Bisexuality

Discrimination

Heterosexual people’s attitudes and stereotypical beliefs about both bisexual men and women included viewing them as untrustworthy, confused, open to experiences, promiscuous, and unable to maintain long term monogamous relationships (Zivony & Lobel, 2014; Zivony & Saguy, 2018). These findings suggest heterosexuals carry specific social stereotypes that are deductions and assumptions about sexuality, and bisexual invisibility may exacerbate these stereotypes (Zivony & Saguy, 2018).

Further research into stereotypes shows how it affects people’s attitudes about bisexual. Bisexual are the subgroup heterosexuals believe are least entitled to adopt children and have sexuality satisfaction (Silvaggi et al., 2019). Bisexual men are stigmatised as the ‘bridge population’ for HIV transmission from homosexual men to heterosexual women, despite research indicating heterosexual men have more anal sex than non-heterosexual men (Bostwick & Dodge, 2019; Dodge et al., 2016; Friedman et al., 2014).

Biphobia, Internalised Biphobia

The binary notion of sexual orientation as being either heterosexual, or homosexual has generated a phenomenon of ‘double-discrimination’, unique to the bisexual sub-group (Boyer & Lorenz, 2020). Binary perceptions of sexual orientation result in bisexuals being viewed as indecisive or questioning, invalidating and illegitimatising their sexual orientation. Friedman et al. (2014) found that bisexuals experience discrimination from both heterosexual and homosexual populations for opposing heteronormative and monosexual expectations, making this ‘double discrimination’ different to homophobia.

Internalised biphobia is when a bisexual person carries these stereotypes and attitudes toward bisexuality and themselves. Internalised biphobia was found to significantly affect the quality of life of sexual minority men in Poland (Grabski et al., 2019).

The Effects of Biphobia

Mental Health

Biphobia directly affects the mental health of bisexuals who report higher rates of psychological distress, suicidal ideation, and diagnosed anxiety and depression compared to heterosexuals (Björkenstam et al., 2017; Friedman et al., 2014; Nam et al., 2019). Bisexual women appear to be particularly vulnerable to anxiety and depression, potentially influenced by biphobic microaggressions like dismissal, mistrust and social exclusion found to affect their mental health (Flanders & Robinson, 2019).

Star and Pachankis (2019) found amongst a Swedish sample that sexual orientation openness does not necessarily lead to lower levels of depression. Instead, this was mediated by an individual’s access to social support from friends and partners. Openness about sexual orientation led to higher levels of depression when social supports were low. Openness may also be affected by cultural and societal attitudes toward sexuality and minority tolerance (Björkenstam et al., 2017; Grabski et al., 2019; Star & Pachankis, 2019).

Substance Use

Experiences of biphobia was found to influence alcohol use in bisexual adolescents and adults (Coulter et al., 2016; Schuler & Collins, 2020). In LGBT+ affirmative school climates, everybody but bisexuals seemed to consume significantly less alcohol compared to those in LGBT+ non-affirmative climates. Bisexual adolescents appeared to drink the most, and more frequently despite being in LGBT+ affirmative climates, which implies this climate is not addressing bisexual adolescents needs.

In an adult population, Schuler and Collins (2020) found that both female and male sexual minority people had significantly greater substance use compared to heterosexuals. Within the sexual minority subgroups, bisexual women appeared to be at greater risk for multiple substance use behaviours, which suggests there are unique risk factors for substance use experience by bisexual individuals, particularly bisexual women (Schuler & Collins, 2020).

Barriers to Healthcare

Despite being at risk of health disparities, bisexuals may not disclose their SO due to the individual situations, provider, location, or the nature of disclosure (Ruben & Fullerton, 2018). Without adequate support systems in place, SO disclosure can lead to increased depression (Star & Pachankis, 2019). It has been reported that only 14% of patients have been asked about their SO by healthcare providers (Ruben & Fullerton, 2018), making it an easier topic to avoid. SM people may want the historical context of their SO acknowledged, but the provider may not do this, which affects assessment and treatment (Higgins et al., 2019).

Healthcare workers report not prompting discussions around sexuality because they lack managerial support, and training (Dyer & das Nair, 2013; Owen-Pugh & Baines, 2014; Percat & Elmerstig, 2017). Healthcare workers are hesitant to work with sexual minority groups due to increased discomfort, limited time, resources, training, knowledge, abilities, counselling tools, and the fear of making mistakes (Dyer & das Nair, 2013; Owen-Pugh & Baines, 2014; Percat & Elmerstig, 2017).

Suggestions for Future Research, Education, and Practice

There are three main approaches to accommodating to bisexual individual’s needs; through research, education and clinical practice (Pachankis, 2018).

Research

·      Researchers can refrain from merging bisexual research with other SO subgroups to maintain intersectionality (Copen et al., 2016). This could include consulting bisexuals to develop flexibility in language and terms used to identify the variety of people who fall under the umbrella term ‘bisexual’ to create greater visibility for the bisexual subgroup as a distinct SO (Bostwick & Dodge, 2016)

·      Researchers can use tools like the Bisexual Microaggression and Microaffirmation Scale for Women (BMMS-W; Flanders & Robinson, 2019) to improve the quality of insight into how biphobia affects mental health to further inform safe and ethical clinical practice. And develop an equivalent for men considering they experience more discrimination than bisexual women (Bostwick & Dodge, 2019).

·      Further research into what needs bisexual adolescents have, considering LGBT+ affirmative school climates are not enough to influence alcohol use (Coulter et al., 2016).

Education

·      Education on bisexuality for monosexual communities can combat stereotypes, discrimination and biphobia (Dodge et al., 2016). A decrease in discrimination indirectly affects support seeking behaviours, and may lead to a reduction in health disparities in bisexual populations (Friedman et al., 2014).

·      Education for adolescents of all SO in schools. The creation of safe spaces, increased intersectionality when writing policies to protect adolescents, improving sex and relationship education and access to resources may help to reduce the number of bisexual adolescents using alcohol (Coulter et al., 2016).

·      Education and training for healthcare workers who work with SM individuals, including access to mentors who can facilitate working with sexual issues (Dyer & das Nair, 2013; Ruben & Fullerton, 2018; Owen-Pugh & Baines, 2014)

Practice

·      Clinicians can seek training, and follow SM informed ethical guidelines of practice (Moradi, 2016). Training can provide understanding on the above mentioned unique challenges bisexuals face, and improve clinician’s intersectionality in practice, assessment and treatment of bisexual clients Higgins et al., 2019).

·      Clinicians can be the first to prompt discussion about sexuality issues by using micro-affirmations or the BMMS-W (Flanders & Robinson, 2019) to encourage disclosure, whilst being aware disclosure may not happen and may not be helpful (Björkenstam et al., 2017; Star & Pachankis, 2019).

·      Empowering clinicians with the resources they need to refer clients onto more appropriate clinicians if they comfortable supporting bisexual clients (Friedman et al., 2014).

·      Clinicians can facilitate a sex-positive culture within practice to minimise biphobia, foster safe therapeutic alliances, encourage disclosure, and build bisexual client’s support systems to reduce health disparities and unhealthy coping (Bostwick & Dodge, 2019; Owen-Pugh & Baines, 2014).

Bisexuals are not homogenous to other sexual minority (SM) subgroups, and experience unique forms of discrimination like biphobia (Friedman et al., 2014). As a growing SM population, we believe it is important to consider these unique challenges and integrate the knowledge into research development, education and clinical practice. This will help to prevent bisexual population health disparities (Björkenstam et al., 2017; Coulter et al., 2016; Flanders & Robinson, 2019; Friedman et al., 2014; Nam et al., 2019; Schuler & Collins, 2020; Star & Pachankis, 2019), and foster greater bisexuality visibility (Dyer & das Nair, 2013; Higgins et al., 2019; Owen-Pugh & Baines, 2014; Pachankis, 2018; Percat & Elmerstig, 2017; Ruben & Fullerton, 2018).

References

Björkenstam, C., Björkenstam, E., Andersson, G., Cochran, S., & Kosidou, K. (2017). Anxiety and Depression Among Sexual Minority Women and Men in Sweden: Is the Risk Equally Spread Within the Sexual Minority Population? The Journal of Sexual Medicine, 14, 396-403. http://doi.org/10.1016/j.jsxm.2017.01.012

Bostwick, W. B., & Dodge, B. (2019). Introduction to the Special Section on Bisexual Health: Can You See Us Now? The Archives of Sexual Behavior, 48, 79–87. https://doi.org/10.1007/s10508-018-1370-9

Boyer, S. J., & Lorenz, T. K. (2020). The Impact of Heteronormative Ideals Imposition on Sexual Orientation Questioning Distress. Psychology of Sexual Orientation and Gender Diversity, 7(1), 91–100. http://doi.org/10.1037/sgd0000352

Copen, C. E., Chandra, A., Febo-Vazquez I. (2016). Sexual behavior, sexual attraction, and sexual orientation among adults aged 18–44 in the United States: Data from the 2011–2013 National Survey of Family Growth. National health statistics reports; no 88.

Coulter R. W. S., Birkett, M., Corliss, H. L., Hatzenbuehler, M. L., Mustanski, B., & Stall R. D. (2016). Associations between LGBTQ-affirmative school climate and adolescent drinking behaviors. Drug and Alcohol Dependence. 1(161), 340-7. http://doi.org/10.1016/j.drugalcdep.2016.02.022

Dodge, B., Herbenick, D., Friedman, M. R., Schick, V., Fu, T-C(Jane), Bostwick, W., Bartelt, E., Muñoz-Laboy, M., Pletta, D., Reece, M., Theo G. M., & Sandfort, T. G. M. (2016). Attitudes toward Bisexual Men and Women among a Nationally Representative Probability Sample of Adults in the United States. PLoS ONE, 11(10), e0164430. http://doi.org/10.3886/E100265V1

Dyer, K., & das Nair, R. (2013). Why don’t healthcare professionals talk about sex? A systematic review of recent qualitative studies conducted in the United Kingdom. The Journal of Sexual Medicine, 10, 2658–2670. http://doi.org/10.1111/j.1743-6109.2012.02856.x

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Pachankis, J. E. (2018). The Scientific Pursuit of Sexual and Gender Minority Mental Health Treatments: Toward Evidence-Based Affirmative Practice. American Psychological Association, 73(9), 1207–1219. http://doi.org/10.1037/amp0000357

Percat, A., & Elmerstig, E. (2017). ‘‘We should be experts, but we’re not”
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Zivony, A., & Saguy, T (2018). Stereotype Deduction About Bisexual Women. The Journal of Sex Research, 55(4-5), 666-678, http://doi.org/10.1080/00224499.2018.1437116