Written by Challian Christ, B.A. (Hons), Amy Bartlett, LL.B., LL.M., Stéphanie Manoni-Millar, B.A. (Hons), and Terence H. W. Ching, Ph.D.
The chronic and cumulative identity-based stressors that queer individuals face on a daily basis (e.g., systemic discrimination, lack of constitutional protections, internalized stigma, pressure to conceal authentic identity expressions) are commonly referred to as minority stress, and can compromise the well-being of queer individuals over time. While not officially recognized as a Criterion A event for posttraumatic stress disorder (PTSD) per the DSM-5, minority stress can precipitate symptoms observed with PTSD, such as hypervigilance and impairing beliefs about personal safety. In addition to minority stress, queer individuals are more likely than cisgender heterosexual individuals to experience traumas, including sexual abuse and assault, increasing their risk for developing PTSD.
MDMA-assisted therapy holds great promise for tackling some of our most pressing mental health concerns, including PTSD. However, queer communities have a complicated history with psychological theory and practice, and the research community has yet to robustly engage with the queer experience. Further, transgender and gender-queer representation have been low in clinical trials for psychedelic-assisted therapies, raising the question of whether these therapies can address the mental health needs of gender minorities in the same way it may for the wider population.
It is essential that we continue to deepen our understanding of the potential MDMA-assisted therapy holds for everyone. This involves understanding how to provide MDMA-assisted therapy in ways that are non-(re)traumatizing, accessible, and adaptable to multiple lived realities. Developing and validating queer-affirming MDMA-assisted therapy that can effectively address minority stress is thus necessary. In the following overview, we imagine what queer-affirming MDMA-assisted therapy could look like, with a focus on cultivating a queer-affirming set and setting. We are attempting to be as non-prescriptive as possible, acknowledging the limits and blind spots in our collective perspective. We aim to contribute to conversations around queering MDMA-assisted therapy and provide actionable suggestions for readers, especially principal investigators and study therapists in ongoing MDMA-assisted therapy trials.
Set and Setting in Queer-Affirming MDMA-Assisted Therapy
“Set” refers to the frame of mind participants enter a psychedelic experience with, including their lived experiences as beings with multiple intersecting identities, or as members of a particular community or communities, and beliefs surrounding trust, control, safety, etc. “Setting” refers to the context in which the psychedelic experience occurs, including the time of day, location of the dosing session, others in attendance, etc. These extra-pharmacological factors reliably and profoundly impact the outcomes of psychedelic-assisted therapy, and are consistently considered in preparatory, dosing, and integration sessions in MDMA-assisted therapy.
In the context of queer-affirming MDMA-assisted therapy, we think that minority stress can be an integral component of queer participants’ set as they enter the psychedelic space. Therapists can create a more conducive therapeutic alliance and atmosphere by addressing queer participants’ particular needs for safety and support. If clinicians neglect to create a therapeutic space that outwardly affirms participants’ queer identities, participants may feel less safe, seen, and accepted. This may perpetuate the “closet-ing” of participants’ authentic identities and diminish the healing potential of MDMA-assisted therapy. So, what concrete actions can clinicians take to cultivate a queer-affirming set and setting in queer-affirming psychedelic therapy?
Queer people experience considerable mental health disparities and report below-average healthcare satisfaction due to clinician discomfort, poor clinician communication, and distrust in the therapeutic relationship (Valdiserri et al., 2018). This shows a lack of sensitivity among professionals working with queer individuals and often leaves queer individuals feeling responsible for educating their provider about their healthcare needs.
Therapists can work to empathically understand the multifaceted ways in which queer individuals face prejudice and discrimination. A good starting point is getting educated on the historical, social, political, and cultural contexts from which heterosexism and cisnormativity have emerged. Therapists can also study the ways in which these sociopolitical factors permeate modern healthcare and begin cultivating self-awareness and working to address their unseen prejudices and biases which impede their ability to effectively serve their queer clients.
In the pursuit of ethical, equitable, and culturally responsive provision of care, clinicians can familiarize themselves with and adhere to established professional guidelines for psychiatric practice with gender and sexual minorities (e.g., APA, 2012, 2015). Clinicians should also seek ongoing professional development. Queer-specific cultural humility training is regularly available through trusted organizations (e.g., the National Coalition of Anti-Violence Programs; World Professional Association for Transgender Health; GLMA: Health Professionals Advancing LGBTQ Equality). Valuable resources on the intersection between queer-lived experiences and the use of psychedelics for healing can also be found through Chacruna Institute’s Queering Psychedelics chronicles.
Additionally, clinicians need to recognize that queerness is not isolable from other identity parameters such as race, ethnicity, disability, religion, and socioeconomic and immigration status. These identity factors are often accompanied by nuanced stressors and can compound with and exacerbate minority stress in queer individuals. Training in cultural humility pertaining to these other identity parameters may prepare therapists to work with queer individuals from various backgrounds more holistically.
Psychedelic researchers and clinicians should familiarize themselves with examples of past injustices in psychedelic therapy. This means reckoning with the fact that one of the early uses of psychedelics involved explicit attempts to “cure” homosexuality and “transvestitism” (Cavnar, 2018). This practice took place in and out of hospitals in England, Canada, and the United States, and spanned three decades, being ostensibly discontinued shortly after the international prohibition of psychedelics in 1971.
“Homosexuality” and “gender identity disorder” have since been delegitimized as mental illnesses in the DSM, but the legacy of pathologizing queer identities persists. Today, “conversion therapy” (i.e., systematized attempts to alter an individual’s sexual orientation or gender identity to hetero- and cis-normative standards) is still openly practiced by licensed therapists in Canada and the United States. It is important that these practices are universally denounced by psychedelic researchers and clinicians to dissuade the revival of the archaic and harmful practice of psychedelic-assisted “conversion therapy”.
Terminology and Language Mirroring
Language is an effective tool for building trust between the clinician and patient. As clinicians align themselves with queer clients’ lived experiences, they may become more comfortable with the terminology queer individuals use to self-identify. This helps them avoid the conflation of distinct concepts (e.g., sex/gender), and precipitates fewer instances of inadvertently making clients feel unseen or misunderstood. It is important that clinicians working with queer individuals listen attentively to the language they use when describing their own sexual and gender identity and mirror it carefully. This language is constantly changing on both social and individual levels. Clinicians should stay up-to-date on evolving terminology and accommodate clients if their self-identifiers change.
Queer-Affirming Intake Protocols
Patients pursuing mental health services tend to see value in having clinicians ask about their sexual orientation and gender identity as part of the intake process, but intake forms commonly give prospective patients insufficient or no opportunity to fully describe their gender and sexual identity. This can have a lasting negative impact on the therapeutic alliance, as it signals to gender and sexual minorities that the clinic or clinicians may not recognize nuanced queer identities beyond the historical hegemonic standards of Western healthcare. Providing a greater number of options for sexual orientation and gender identities on intake forms, as well as “not listed above” options with areas for specification are an effective tool for building trust between clinician and client.
Debinarizing the Therapist Dyad
In previous trials of MDMA-assisted therapy for PTSD, male-female therapist dyads were standard. While this may promote a sense of safety for many participants by echoing the support provided by heteronormative mother-father archetypes, this practice reflects assumptions about gender that do not apply to many people. This is particularly true of gender-diverse participants, and/or those who were raised in households with single, same-sex, or gender-diverse parents. It is important that researchers work to make various gender pairings available to participants and collaborate with them prior to the dosing session to select a therapist team that is of greatest comfort to them.
Queering the Dosing Space
Many queer individuals associate medical spaces with invalidation and gatekeeping, so creating healing spaces that appear less overtly clinical and more comfortable through thoughtful design is of particular importance. While this is standard for MDMA-assisted therapy, efforts to overtly affirm queer identities may be rare in these clinical spaces. Displaying safe space indicators and pride flags, hanging queer-affirming art, employing queer office staff, and ensuring access to single-stall gender-neutral bathrooms are just a few examples of creating progressive and responsive queer-friendly healing spaces.
Idiosyncratic meaning-making processes involving cultural symbolism and metaphor are also common features of psychedelic healing processes in MDMA-assisted therapy (Ching, 2020; Williams et al., 2020). Therefore, clinicians may encourage participants to bring personally significant objects that symbolize self-acceptance to the dosing sessions. Clinicians may similarly consider working collaboratively with participants regarding the music used during dosing sessions to further affirm queer identities. For example, given the invalidating and potentially traumatic experiences many queer individuals have with religious institutions, the overtly religious music sometimes used in psychedelic dosing sessions can be triggering and undo the safe container. Having queer participants hear and vet samples of intended music playlists may be a queer-affirming means of therapeutic collaboration.
Building a Queer Psychedelic Community
The importance of post-dosing integration sessions is widely recognized among psychedelic researchers, but this process can often take months or years—far beyond the timelines of clinical trials. Because of this, it may be helpful for researchers to work collaboratively with queer-affirmative practitioners to arrange appropriate aftercare if needed. Queer-affirming resources should be shared, and researchers may consider linking participants with local psychedelic societies and public queer-friendly integration circles. Since researchers and clinicians are predominantly white, heterosexual, and cisgender, we must work to amplify queer and non-white voices at every level in psychedelic spaces. The involvement of queer researchers and clinicians should also be a priority for future clinical trials involving queer participants.
These recommendations in no way constitute an exhaustive list of efforts researchers and clinicians can make to better address the needs of queer individuals in MDMA-assisted therapy. Additionally, queer people have been, are, and continue to be resilient in the face of minority stress. Whether it is Ching describing his own psychedelic experience which helped him accept and affirm his intersectional queer identity (2020), or Dallas Denny describing her use of psychedelics to successfully overcome her internalized transphobia (2006), we believe psychedelics hold great potential to unlock queer individuals’ ability to heal from the effects of trauma and minority stress. We hope researchers and clinicians will seek out more expansive resources and pursue formal education on cultural humility as part of developing queer-affirming MDMA-assisted therapy and exploring the unique potential these substances hold for helping queer people heal.
Challian Christ’s research aims to facilitate the development of spiritual literacy in the rapidly growing field of psychedelic-assisted psychotherapy. Challian’s thesis project involves a phenomenology-focused comparative analysis of psychedelic-induced mystical-type experiences and mystical-type experiences occasioned through traditional yogic practices such as fasting and meditation. Challian’s aim is to determine to what degree spiritual teachings in Hinduism, Buddhism, and Jainism can be repurposed to develop more nuanced and effective treatment plans in the field of psychedelic-assisted psychotherapy.
Amy Bartlett began a Ph.D. adventure at the University of Ottawa in September 2020, diving into the wonderful world of psychedelics, spirituality, and human connection. Amy is working with Dr. Anne Vallely and Dr. Monnica Williams at uOttawa, and also contributing to a variety of projects in Dr. Williams’ Laboratory for Culture and Mental Health Disparities. Amy is curious about exploring the role that mystical psychedelic experiences play in individual and communal healing. Amy is passionate about psychedelic integration, community building, harm reduction, psychedelics for healing, diversity and inclusion in the psychedelic space, decriminalization, psychedelic ethics, and building pathways for safe, accessible and well-supported access to psychedelic substances and non-ordinary states of consciousness. Amy is also interested in psychedelics for navigating end-of-life issues and psychedelic chaplaincy.
Stéphanie Manoni-Millar, B.A., is a Community Researcher at the Center for Research on Educational and Community Services and is currently completing her PhD Psychology at the University of Ottawa. Her research utilises both qualitative and quantitative methodology and her primary focus is on youth, resilience, and marginalized populations. She values interdisciplinary research and collaboration. Stephanie aims to use research to inspire community growth and amplify the voices of marginalized members of the community in order to support access to services and basic necessities.
Terence Ching is a postdoctoral associate at the Yale OCD Research Clinic. Terence received his Ph.D. in clinical psychology from the University of Connecticut. Prior to moving to the United States, Terence received his Bachelor’s and Master’s degrees in psychology from the National University of Singapore. His research and clinical interests are at the intersections of: (1) fear-/trauma-based disorders (OCD, anxiety disorders, PTSD); (2) cultural diversity; and (3) psychedelic-assisted psychotherapy. Terence has completed clinical training in a variety of settings, including the University of Connecticut, the Institute of Living, as well as Dartmouth-Hitchcock Medical Center. Terence approaches psychotherapy from an evidence-based and culturally attuned perspective, and specializes in cognitive-behavior therapy (CBT) for fear-/trauma-based disorders. Terence has also received training in functional analytic psychotherapy (FAP), as well as MDMA-assisted psychotherapy.
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