texto em 
Inglês (pdf)
Artigo em XML
Referências do artigo
Curriculum ScienTI
Tradução automática
Permalink
Marital problems, particularly separation and divorce, are among the most stressful conditions people face during the course of personal growth and development, often affecting physical and emotional well-being (Carr, 2019; Snyder et al., 2006). Partners in troubled relationships are more likely to suffer from anxiety, depression, substance abuse, acute and chronic health problems and debilitating conditions like impaired immunological functioning and high blood pressure. They are also more susceptible to accident-proneness and sexually transmitted infections (Gurman, 2015; Johnson, 2019). Amid the profound changes in loving relationships that have accompanied the dynamics of social transformation, couple therapy is one of the therapeutic modalities that has grown most during the recent history of psychosocial interventions (Lebow & Snyder, 2022).
Roughly speaking, there are two distinct categories of couple therapy. The first encompasses models that developed early on in the history of the broad field of family therapy. Although the central attributes of these therapeutic methods have endured various generations of systemic therapists, they have been considerably revised and refined. Examples of such approaches include structural, strategic and psychoanalytic therapies, especially those based on object relations theory and inspired by Bowen's theory (Gurman, 2015; Scharff & Scharff, 2014; Snyder et al., 2006).
Couple therapy also includes a second wave of approaches that have developed over recent decades and had a major influence on practice, training and research, such as cognitive behavioral therapy (CBT) and integrative behavioral therapies, narrative and solution-focused therapies, emotion-focused therapy and Gottman method therapy, as well as integrative approaches (Gurman, 2015; Snyder et al., 2006). Evidently the therapist’s role in couple therapy acquires different contours, nuances and specificities according to the theoretical and clinical approach applied to the marital situation (Lebow & Snyder, 2022).
More than a simple technique, psychotherapy is part and parcel of Western culture. Integrated into contemporary customs and worldviews, it constitutes a rich source of meaning about who we are and what we do with our lives (Gurman, 2015). By appropriating psychotherapy and its array of modalities and typologies as a cultural object, couple therapy helps engender meanings that extend far beyond therapist-client interaction, while at the same time being seen as a thermometer of the relational customs and perspectives underpinning the interpretative repertoire of couple relationships in our culture. There is therefore a reciprocally influencing relationship between culture and couple therapy (Johnson, 2019).
Given that most of the literature on couple therapy presumes a heterosexual status among couples seeking “treatment” (Spengler et al., 2020), many therapists have doubts about how to conceptualize and actively intervene in the clinical problems of couples who deviate from heteronormative norms. This can encourage a tendency among psychotherapists to generalize therapeutic intervention tactics employed for heteronormative couples to non-heteronormative couples (Grafsky & Nguyen, 2019; Heiden-Rootes et al., 2020).
One of the most unique features that distinguishes non-heteronormative couples – a group with their own particularities and frame of reference – from other couples is that partners (lesbian, gay, bisexual, transsexual, queer, intersex, asexual, pansexual, non-binary, and other identities and orientations not explicitly represented in the acronym – LGBTQIAPN+) are exposed to different types of prejudice, discrimination and segregation perpetrated by people and institutions who function under a heterosexist-heteronormative- and cis-centered logic of relationships (Alexandre & Santos, 2019; Coolhart, 2023). This hegemonic logic deliberately excludes the existence of other types of affective-sexual relationship, failing to recognize the legitimacy of the plurality of love, affection and marital bonds that make up the spectrum of human relations (Alexandre & Santos, 2019; Grove & Blasby, 2009; Tombolato et al., 2018).
A pioneer in gender studies, Rich (1980) argues that discourses that oppress lesbians attempt to normalize the assumption that heterosexuality is the basis for a harmonious society. This exclusionary and oppressive rhetoric, which the author calls “compulsory heterosexuality”, is defined in terms of gender and sexual norms that are imposed as normal, concealing their real origin in the political sphere and relations of power – and therefore relations of domination. One of the most efficient ways of reinforcing heteronormativity is to veil lesbian existence under a cloak of invisibility, making it out to be an unthinkable possibility or suggesting that it is an intermittent and volatile sexuality that comes and goes (Rich, 1980; Toledo & Teixeira Filho, 2010; Wittig, 1992).
Lesbophobia is the reaction to the possibility of a woman moving outside the matrix of gender intelligibility, which, according to Butler (2003), is the idea of a supposedly linear continuity among sex, gender, desire and sexual orientation. It includes various forms of negativity directed towards lesbians, their affective relationships and expressions of sexuality, which are viewed as threatening because they escape male control and domination.
Professionals who work with lesbian and female bisexual couples often come across specific issues that this group has to deal with in everyday life (Green & Mitchell, 2015; Wahlig & Long, 2019). Many of these couples initiate psychotherapy to deal with challenges that are specific to being lesbian or bisexual, such as how to handle prejudice in one or both partners’ families of origin, how “out” they should be at work and in the community and being ashamed of showing affection in public (Green & Mitchell, 2015).
Advocating an affirmative therapeutic approach to interventions with LGBTQIAPN+ couples and families, Grafsky and Nguyen (2015) highlight that it is important to remember that the therapist’s first task is to assess the extent to which the couple’s problems are related to specific challenges faced by the LGBTQIAPN+ community, or whether they are linked to other general issues of marital life, such as interaction styles, patterns of communication or conflict management processes. The therapist needs to remain open to the possibility that some crucial problems that weaken the marital bond may have little or nothing to do with the fact that the partners are LGBTQIAPN+.
When formulating their hypothesis, therapists face the double risk of overestimating or underestimating the importance of the influence of factors relating to the everyday life of LGBTQIAPN+ people on the origin of the problematic situation (Ackbar & Senn, 2010; Grafsky & Nguyen, 2019; Green & Mitchell, 2015). Together with their LGBTQIAPN+ clients, therapists should explore how partners internalize traditional gender norms and how they perceive the prejudice – veiled or open, internal and external – and discrimination constantly faced in their support networks, including family, neighbors, workmates, health and education professionals (Coolhart, 2023; Grove & Blasby, 2009).
Research has pointed to certain aspects that are specific to lesbian couples, revealing that these relationships cannot be reduced to common understandings of heterosexual configurations (Biaggio et al., 2002; Wahlig & Long, 2019). Irrespective of sexual orientation and relationship status, couples come up against a series of problems throughout the life cycle and dynamics of the relationship, facing dilemmas that are inherent to the process of growth and development of the love bond. However, relationships of lesbian dyads are unique and peculiar in a number of manners. While certain issues may appear similar for all types of couples, same-sex couples have distinct experiences and concerns that affect relational and mental health in specific ways (Hartwell et al., 2017).
As singular beings and persons in a couple relationship, women who choose to share their emotional and sexual intimacy with other women are confronted with heterosexism and lesbophobia on a daily basis (Auad & Lahni, 2013; Biaggio et al., 2002; Wahlig & Long, 2019). Thus the impact of ongoing exposure to adverse situations resulting from deeply embedded prejudice should also be considered, as shown by studies exploring discrimination against lesbians who adopt and raise children (Tombolato et al., 2018, 2019). This discussion is increasingly necessary and opportune, especially considering the impact of laws criminalizing homosexuality in various parts of the globe, such as southern Africa and countries under far-right populist rule. Not to mention the numerous countries where resistance to LGBTQIAPN+ inclusion prevails, for example in the form of legal barriers to the approval of same-sex marriage and adoption (Human Dignity Trust, 2023; The International Lesbian, Gay, Bisexual, Trans and Intersex Association, 2023).
There is a line of thinking in the literature that suggests that most of the therapeutic techniques used to treat heterosexual couples can also be employed with lesbian couples, provided that the therapist has the sensitivity to consider how each spouse responds to specific interventions, understanding that it is the clients themselves who should say what is problematic in the relationship. However, this does not exempt professionals from the ethical responsibility of addressing the challenge of creating new forms of collaborative inquiry to strengthen theoretical frameworks, extend the repertoire of resources available to couple therapists and invent more LGBTQIAPN+ inclusive treatment practices (Ackbar & Senn, 2010; Grafsky & Nguyen, 2019). It is acknowledged that both the therapeutic approach and gender or sexual orientation of the therapist may also be of importance, as some lesbian couples prefer to work with a female or openly lesbian therapist. Lesbians engaged in political activism may request an “out” lesbian therapist or a professional who is a self-declared feminist (Biaggio et al., 2002). However, the literature from the last four decades is permeated by heterocentrism and neglects issues of class, race, and gender (Hartwell et al., 2017).
Studies about lesbian couple therapy published over recent decades show that favorable outcomes are related to high client satisfaction with couple interventions and perception of progress against a range of indicators, such as improvement in the relationship and relationships in general and in behaviors related to health or alcohol and drug abuse (Fals-Stewart et al., 2009; Kousteni & Anagnostopoulos, 2020). In light of these considerations, it is imperative to explore the literature on this topic and identify gaps and directions for future research in order to strengthen theoretical bases and practices in this field (Spengler et al., 2020).
In addition, the analysis of research findings in this area allows us to identify variations between theoretical models and clinical approaches and the demands that influence the psychotherapeutic process. The aim of this study was therefore to analyze existing evidence in the literature on lesbian couple therapy, understand current approaches and identify gaps in knowledge about the specificities of therapy with this group.
Method
We conducted a systematic literature review, which is a structured and organized method used to provide a synthesis of the results of research extracted from peer-reviewed publications. This type of review is based on a clearly formulated question and uses rigorous and explicit methods to identify, select, and critically appraise the results of relevant research. Systematic reviews are descriptive and seek to provide a critical analysis of the collected material that is reported in a clear, coherent and replicable manner with the aim of integrating and describing existing evidence, highlighting consensus and divergences, and proposing directions for future research (Carvalho et al., 2019).
The review protocol was registered in PROSPERO (International Prospective Register of Systematic Reviews – registration number omitted). The review involved the following stages recommended for systematic reviews (Carvalho et al., 2019; Silva et al., 2017): (1) identification of the topic and formulation of the guiding question; (2) definition of search strategies and study inclusion and exclusion criteria; (3) database search to select articles from the areas of human sciences and health; (4) exclusion of duplicate studies; (5) selection, description and categorization of information of interest extracted from the eligible studies (author(s), year of publication, country, objectives, results and conclusions); and (6) assessment, interpretation and synthesis of the studies, including a descriptive analysis and critical discussion of their main contributions and identification of gaps in the literature.
The following guiding question was used: “What is the status of national and international literature on lesbian couple therapy?” The question was formulated using the PICOS mnemonic (Carvalho et al., 2019): Participants/patients (lesbians), Intervention (couple therapy), Control or comparison (standard or most used intervention, no intervention), Outcome/results (benefits of therapy), and Study design (observational, cross-sectional, longitudinal, clinical, field study and case study).
The search procedures were carefully defined. Searches were performed for journals indexed in the following bibliographic databases: PubMed, LILACS, PsycInfo® and Web of Science. The search terms were defined according to each database using Health Sciences Descriptors (DeCS, acronym in Portuguese) from the Virtual Health Library (BVS, acronym in Portuguese), Medical Subject Headings (MeSH) and Thesaurus of Psychological Index Terms (APA Thesaurus). Uniterms were used in the following search string: (Lesbian Couples) OR (Homosexuality, Female) AND (Marital Therapy) OR (Couples Therapy). The Boolean operators AND and OR were used to limit search results and standardize search strategies.
The following inclusion criteria were adopted: (1) articles written in English, Portuguese and Spanish; (2) primary studies addressing lesbian couple therapy; (3) articles reporting empirical results and theoretical studies; (4) articles with a full version of the abstract available in the database; and (5) articles published between January 2011 and October 2023. This period was used due to the rapid growth in couple therapy over the last decade, considering that this modality of therapy reached maturity at the end of the last century, with the strengthening of firmly established empirical bases, thus enhancing the effectiveness of interventions. According to Kousteni and Anagnostopoulos (2020), couple therapy became the treatment of choice for marital problems during this period.
The exclusion criteria were as follows: (1) dissertations, theses, chapters of books, books, monographs, manuals, editorials, book reviews, letters to the editor, comments or critiques; (2) literature reviews, meta-analyses and meta-syntheses; and (3) articles that only touch on the topic and when examined in detail are far removed from the review objective, such as studies focusing on individual therapy and counselling, and psychoeducation for the management of difficulties coping with chronic diseases and mental disorders, including the abuse of alcohol and other substances.
The searches were performed in October 2023. The article search, screening and analysis stages were performed by two reviewers (initials omitted), who were members of the research team and have expertise in couple and family psychotherapy and gender and sexuality studies. Following standardized procedures proposed by the literature, the reviewers examined the material independently, permitting the comparison of results and determination of level of agreement.
The reference management tool Rayyan for Systematic Reviews® (Ouzzani et al., 2016) was used by the two reviewers to organize the eligible studies, removing duplicate articles (Stage 2). The “Advanced Search” option was used to limit the search fields (titles, topics, abstracts and keywords), applying the “language” filter when available on the database. The article titles and abstracts were then screened by the reviewers to select studies meeting the inclusion criteria. Where the information in the titles and abstracts was not sufficient to select the study, the full-text version of the article was read.
After screening of the titles and abstracts to assess eligibility, the full-text versions of the articles were assessed thoroughly according to the inclusion and exclusion criteria and the lists produced by the reviewers were compared to determine level of agreement. Any disagreements were resolved by a third reviewer. This systematic refinement process resulted in the final selection of studies included in the review corpus.
After reading the full-text versions of the publications, the data of interest were extracted (Stage 3) into a specially designed form using the following analysis categories: author(s), year of publication, country where the study was conducted, study objectives, study design, number of participants, theoretical perspective, main results and conclusions. The content was exported to a Microsoft Excel (version 2016) spreadsheet containing these pre-established categories. The data were then synthesized and compiled in chronological order in tables and figures.
After further meticulous reading by reviewers, a thematic analysis of the non-quantitative results of the review corpus was performed using NVivo to identify the core themes addressed by the publications. The themes were organized into categories adopting the technique proposed by Braun and Clarke (2013) for this type of analysis. This procedure is particularly useful for organizing thick descriptions of a topic using the creation of themes. The core themes were considered emerging themes by the researchers rather than theoretical categories per se, being induced by the study objective and discussed with the Health Psychology Teaching and Research Laboratory (LEPPS-USP). The thematic analysis involved the following stages:
(1) Initial coding – the study results and conclusions were grouped, read exhaustively and coded by the two reviewers focusing on general aspects related to the study objectives, resulting in 16 agreed codes; (2) Code refinement and selection – a new reading was performed to refine the codes, focusing on specific aspects related to the objective in order to identify key results, resulting in eight codes; and (3) Thematic analysis of the selected codes – the codes were then categorized inductively, resulting in four core themes (Braun & Clarke, 2013).
The theoretical framework used for the analysis was the gender perspective, drawing on the contributions of Adrienne Rich (1980) and her theory of “lesbian existence” and compulsory heterosexuality, and Monique Wittig’s (1992) concept of the “straight mind”, which view gender as a field of forces in which power relations are historically organized and socially constructed by male domination. We also drew on the literature on couple therapy with LGBTQIAPN+ people.
Results
Twelve of the 789 studies retrieved by the searches met the inclusion criteria and were included in the review corpus. The reviewer agreement rate was 100%. The corpus selection process is summarized in a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram (Moher et al., 2009) (Figure 1).
Table 1 presents a synthesis of the key features of the studies reviewed.
Table 1 Characterization of the articles by author, year of publication, country of origin of the lead author, type of study, main results and conclusions.
| Nº | Author(s) | Year | Country | Type of study | Results and conclusions |
|---|---|---|---|---|---|
| 1 | McGeorge & Carlson | 2011 | United States | Theoretical | Heterosexual therapists need to be aware that not all LGB clients perceive heterosexism as influencing their presenting problem. However, it is important that therapists explore the possibility that heterosexism may influence LGB clients’ experiences of their presenting problem. This can be key to understanding and interpreting the cry for help. |
| 2 | Powell & Neustifter | 2012 | United States | Theoretical | Therapists should be aware of the special considerations of elder LGB couples and potential situations of intimate partner violence; know where to find medical and housing resources to be able to provide advice; be prepared to address sexual concerns in old age and to discuss the benefits and drawbacks of disclosing the relationship to family members. |
| 3 | Reibstein & Sherbersky | 2012 | United Kingdom | Single case study | Strategies were introduced collaboratively, that is, by inviting, rather than directing, the couple to use them. The strategies were employed within a wide contextual lens. Circularities and interactional patterns were noted. Some strategies were demonstrably behavioral while others strengthened the couple’s empathic base. |
| 4 | Grove, Peel, & Owen-Pugh | 2013 | United Kingdom | Qualitative | The ways in which the couples positioned themselves as part of a ‘minority group’, or part of a generic group of couples struggling with relationship issues impacted how they discussed seeking professional help. |
| 5 | Pepping & Halford | 2014 | Australia | Theoretical | The authors describe distinctive challenges for same-sex couples (for example, homophobic discrimination, internalized homophobia, and low family support). These distinctive challenges suggest that some adaptation of existing approaches to couple counselling and therapy could enhance their effectiveness and relevance to same sex couples. |
| 6 | Belous | 2015 | United States | Single case study | While the couple still had difficulty socializing within the LGBT community, they expressed interest in attending certain LGBT-themed establishments. In addition, both women enjoyed more positive interactions with their families as a result of a more solid identity, as well as increased self-esteem. |
| 7 | McGeorge, Carlson, & Toomey | 2015 | United States | Quantitative | The results indicated a positive association between the inclusion of LGB affirmative therapy in the classroom and faculty members’ beliefs about LGB individuals and relationships. Faculty members who reported more positive beliefs about LGB clients appeared to be more likely to include LGB affirmative therapy content in the courses they teach. |
| 8 | McGeorge & Carlson | 2016 | United States | Mixed (quantitative and qualitative) | Participants who underwent couple and family therapy training reported holding positive beliefs about LGB individuals, that their training programs had affirmative program environments, and that LGB affirmative course content was included in their program curriculum. |
| 9 | Blount, Peterson, & Monson | 2017 | United States | Single case study | Having the opportunity to address posttraumatic stress disorder (PTSD) within a conjoint framework helped the spouse with the symptoms challenge maladaptive beliefs about herself and her relationships, playing a pivotal role in the outcome of the treatment. Overall, the couple reported high satisfaction with Cognitive-Behavioral Conjoint Therapy (CBCT) and expressed gratitude for the opportunity to participate in treatment. |
| 10 | Garanzini, Yee, Gottman, Gottman, Cole, Preciado, & Jasculca | 2017 | United States | Quantitative | There were significant improvements in relationship satisfaction following eleven sessions of therapy for both gay male and lesbian couples. Effect sizes suggest that this therapy was highly effective. Initial co-morbidities did not affect the size of the changes; in fact, some changes were significantly larger for certain initial co-morbidities. |
| 11 | Gottman, Gottman, Cole, & Preciado | 2020 | United States | Quantitative | Couples entering therapy are likely to be more distressed and have more co-morbidities than expected in the previous literature. Same-sex couples present a particular set of both strengths and challenges compared to heterosexual couples. Gay male and lesbian couples were different on trust and monogamy, as were heterosexual and lesbian couples. |
| 12 | Tadros & Smithee | 2021 | United States | Single case study | Social supports are seen as a protective factor in relationships between incarcerated lesbians; however, if there is a lack of those supports due to coming out as LGBTQ, symptoms of depression will gradually continue to increase. Therapists are advised to be mindful of the multiple stigmas associated with identifying as a lesbian, as well as being incarcerated. |
Source: the authors
Four of the studies were case studies (33%), three were quantitative (25%), three were theoretical (25%), one was qualitativwe (8%) and one used mixed methods (8%). Two articles were published in each of the years 2012, 2015 and 2017, accounting for 54.5% of the studies. One article was published in each of the following years: 2011, 2013, 2014, 2016, 2020 and 2021. No articles were found in 2018, 2019, 2022 and 2023. The selection did not include articles published in 2018, 2019, 2022 and 2023.
Nine of the articles were written by researchers from the United States, two by researchers from the United Kingdom and one by a researcher from Australia, revealing an overwhelming predominance of authors from developed countries in North America and Europe. No studies from Latin America were found, suggesting a possible gap in knowledge and the need for investment and policies to promote research on this topic in the region, including Brazil.
With regard to the training of therapists, only Garanzini et al. (2017) reported that the interventions with couples were undertaken by psychotherapists. None of the other articles specified whether the professionals who treated the couples were psychologists. Belous (2015) reported that the couple who participated in the study attended 69 psychotherapy sessions, Blount et al. (2017) mentioned that psychometric and psychoeducational assessments were carried out with the couple and Reibstein and Sherbersky (2012) used psychodynamic interventions.
All the selected articles were written in English and published in reputable journals with high editorial standards. The Journal of Marital and Family Therapy accounted for five articles. The thematic analysis resulted in the identification of four categories: (a) Reasons that led couples to seek couple therapy (articles 1, 2, 3, 4, 5, 9, 11, 12); (b) Perceived changes in couples after therapy (articles 2, 3, 5, 6, 9, 10, 12); (c) Therapeutic approaches (articles 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12); and (d) Recommendations for couple therapists (articles 1, 2, 4, 5, 7, 8, 12).
3.1 Reasons that led couples to seek couple therapy
Seven studies addressed the reasons or complaints that led couples to seek couple therapy. The couple Karen and Rebecca sought therapy to address how to come out to Rebecca’s family, setting this goal as part of their plan to have a baby (Reibstein & Sherbersky, 2012). Another case study illustrates that couples may seek therapy to help treat a mental disorder suffered by one of the spouses, in this case an American army officer diagnosed with posttraumatic stress disorder (PTSD) (Blount et al., 2017). Another article presented the case of Anna and Barbara, who had conflicting feelings about belonging to “mainstream” or LGBTQIAPN+ “minority” couples, which led them to seek therapy to help rethink their feelings about belonging to the LGBTQIAPN+ community (Grove et al., 2013).
Other couple problems, such as coping with stress, comorbidities and alcohol and substance abuse (Gottman et al., 2020; Pepping & Halford, 2014; Powell & Neustifter, 2012) and lack of balance and commitment to the relationship (McGeorge & Carlson, 2011) were also the focus of psychotherapy. The couple involved in the study conducted by Tadros and Smithee (2021) sought help to adjust to their new relationship when one of the spouses was incarcerated and address sexual issues that existed before incarceration.
3.2 Perceived changes in couples after therapy
The lesbians who participated in the studies reported perceiving a reduction in symptoms of depression (Blount et al., 2017; Reibstein & Sherbersky, 2012) and improvements in communication and the relationship after completing the therapeutic process (Belous, 2015; Blount et al., 2017; Garanzini et al., 2017; Reibstein & Sherbersky, 2012; Tadros & Smithee, 2021). They also mentioned that they felt more comfortable in their identity and talking openly with others about their sexual orientation (Belous, 2015; Pepping & Halford, 2014). Others said they were able to better plan their future and reorganize their lives (Powell & Neustifter, 2012; Reibstein & Sherbersky, 2012) or that they had a better understanding of their partner’s position and were able to glimpse healthy ways of managing difficulties and differences (Belous, 2015; Blount et al., 2017; Garanzini et al., 2017; Reibstein & Sherbersky, 2012; Tadros & Smithee, 2021). Some denied suicidal ideation or intent at posttreatment and follow-up (Blount et al., 2017), while others perceived an improvement in their relationship and enjoyed more positive interactions with their families than before (Belous, 2015; Reibstein & Sherbersky, 2012), as well as increased self-esteem (Belous, 2015), a reduction in the abuse of alcohol and other drugs (Garanzini et al., 2017) and better sex life (Tadros & Smithee, 2021).
3.3 Therapeutic approaches
Systemic therapy is one of the approaches that form the basis of therapeutic interventions applied to help lesbian clients (Pepping & Halford, 2014; Reibstein & Sherbersky, 2012; Tadros & Smithee, 2021). Reibstein and Sherbersky (2012) highlighted that therapeutic strategies were introduced collaboratively by inviting, rather than directing, the couple to use them. Tadros and Smithee (2021) used an approach called the “Tadros Theory of Change”, an integrated family and couple therapy model that combines elements of structural family therapy, narrative family therapy and solution-focused family therapy.
Another approach frequently used in lesbian couple therapy is cognitive behavioral therapy (CBT), which uses different behavioral problem-solving techniques (Blount et al., 2017; Pepping & Halford, 2014; Reibstein & Sherbersky, 2012). Another approach used in the therapeutic care of couples was LGBTQIAPN+-affirmative therapy. Some participants preferred to be seen by a therapist who is understanding and, above all, accepting of same-sex relationships (Grove et al., 2013; McGeorge & Carlson, 2011, 2016; McGeorge et al., 2015).
Belous (2015) presented a case study in which contextual interventions and investigative procedures such as genograms, talk therapy, assessments, coaching and multidirected partiality were used in combination. Another approach, Gottman-Method Couples Therapy, creates a platform to help lesbian and gay couples discuss their unique preferences for equality in the relationship (Garanzini et al., 2017). A method also created by the couple John Gottman and Julie Schwartz Gottman, the “Sound Relationship House” theory, assesses the relationship in three domains: friendship and intimacy, conflict management, and shared meaning (Gottman et al., 2020).
3.4 Recommendations for couple therapists
A study with faculty members teaching on couple and family therapy training programs highlighted the importance of ensuring that these professionals receive training on LGBTQIAPN+-affirmative therapy either in their doctoral programs or through continuing education opportunities (McGeorge et al., 2015). Another article showed that faculty members from couple and family therapy training programs perceived that education is permeated by heteronormative concepts that normalize and reinforce heterosexual privileges (McGeorge & Carlson, 2016). To work effectively with lesbian clients, therapists should seek to increase their knowledge and awareness of stigma and prejudice against the LGBTQIAPN+ population and acquire necessary skills and resources through complementary training (Powel & Neustifter, 2014; Tadros & Smithee, 2021).
Two of the studies in this review illustrate the importance of initially exploring the problem within the context of living in a heterosexist society. Therapists should routinely ask lesbian couples about acceptance and support for their relationship by family and friends, encouraging the discussion of any difficulties in these areas. Studies suggest that showing openness to reflection on the impact of these issues on the everyday life of the couple can facilitate negotiation of individual differences and improve communication (McGeorge & Carlson, 2011; Pepping & Halford, 2014).
In a study with older lesbian couples, Powell and Neustifter (2012) underline that, because women are traditionally assigned the role of caregiver, therapists should be prepared to offer individual and relational support for the stresses related to caring for an intimate partner, especially when both members of the couple may be jointly caring for each other’s families. Complex grief may be a focus of therapy after the loss of a partner, especially if this grief is disenfranchised due to an oppressive and unsupportive environment.
One of the studies addressed an interesting issue that, if not brought into the open at the outset of the therapeutic process, can become a barrier to the search for continuity of treatment (Grove et al., 2013). One of the study participants suggested that all lesbian therapists are confident and prepared to listen to and work with sexual issues, and all heterosexual counsellors are not very sensitive to these issues and lacking in experience. This type of generalization should be the object of honest examination in the first therapy sessions. Finally, it is important that therapists advocate for the rights of their clients, be careful not to pathologize the relationship, validate the stressors that LGBTQIAPN+ couples face and emphasize the resilience of their patients (Tadros & Smithee, 2021).
Discussion
The literature on lesbian couple therapy is still under construction. Studies show that one of the responsibilities of the therapist at the outset of therapy is to assess the perspectives of each member of the couple as to the nature of the problems that led them to seek therapy (Lebow & Snyder, 2022). This requires that the therapist understands the general nature of the lesbian relationship, carefully considers the couple’s expectations and aspirations in relation to the therapy and does not impose, even subtly or unconsciously, heterosexual standards on the couple (Biaggio et al., 2002; Smith et al., 2019). To respect the bond between the couple and carry our an accurate assessment of the relationship, it is important that the therapist: (1) be well informed about lesbian relationships and culture; (2) respect the clients’ reports and views and conceptions of their difficulties; and (3) focus on a functional analysis of the relationship, trying to understand how it works from the experience of each member of the couple (Biaggio et al., 2002; Johnson et al., 2023).
Five of the articles reviewed by this study (McGeorge & Carlson, 2011, 2016; McGeorge et al., 2015; Pepping & Halford, 2014; Powell & Neustifter, 2012) reaffirm the idea that the couple therapist should consider aspects that are specific to lesbian relationships and understand that each couple has their own relationship dynamics. These studies also emphasize that therapists should be careful not to inadvertently reproduce heteronormative discourses, highlighting the importance of studying themes related to gender and sexuality. The literature on couple therapy with the LGBTQIAPN+ population supports these considerations and adds that many professionals still do not know how to act when treating gay couples (Grafsky & Nguyen, 2019; Spengler et al., 2020).
The danger that couple therapists reproduce their own assumptions about gender relations and sexuality is at the heart of the concept of compulsory heterosexuality (Rich, 1980; Spengler et al., 2020). Using this construct, Rich (1980) questions discourses that endorse the moral yardstick of affective and sexual behavior based on the idea that the correct and legitimate is to live life within the strict bounds of heteronormativity. The lesbian experience is commonly viewed on scale in which behavior ranges from deviant to hateful, or is simply not seen at all, becoming invisible or being summarily erased.
The main effect engendered by these discourses is the eradication of any possibility of lesbians creating their own categories and reinventing life with freedom and on their own terms (Rich, 1980; Wittig, 1992). Along the same lines, we witness the normalization of the oppression that accompanies the “straight mind”, which seeks to turn its concepts into universal laws, reaffirming the essentialist fallacy that they hold true for all societies, all epochs and all individuals (Wittig, 1992). Couple therapists need to be careful not to reproduce implicit heteronormativity during treatment so as not to run the risk of rendering lesbian relationships invisible.
To avoid these potential pitfalls of clinical practice, Benson et al. (2012) outlined five common evidenced-based principles of couple therapy: (a) working with the couple’s view of the presenting problem to be more objective, contextualized, and dyadic; (b) decreasing emotion-driven, dysfunctional behavior; (c) eliciting emotion-based, avoided, private behavior; (d) increasing constructive communication patterns; and (e) emphasizing strengths of the marital relationship and reinforcing gains. These principles were observed in several of the articles reviewed by this study (Belous, 2015; Blount et al., 2017; Garanzini et al., 2017; Reibstein & Sherbersky, 2012; Tadros & Smithee, 2021) through the examination of favorable outcomes of therapy, such a progress in couple and family communication patterns, alleviation of symptoms of depression, stopping alcohol and drug abuse, learning to better manage problems and emphasizing patient strengths.
The most cited approaches used in therapeutic processes were LGBTQIAPN+-affirmative therapy (Grove et al., 2013; McGeorge & Carlson, 2011, 2016; McGeorge et al., 2015), CBT (Blount et al., 2017; Pepping & Halford, 2014; Reibstein & Sherbersky, 2012) and systemic therapy (Pepping & Halford, 2014; Reibstein & Sherbersky, 2012; Tadros & Smithee, 2021). Costa et al. (2017) observed that the most common theoretical perspectives in studies on couple therapy were CBT and systemic therapy. Grafsky and Nguyen (2019) and Smith et al. (2019) highlighted the importance of using affirmative therapy with the LGBTQIAPN+ population to create an inclusive environment so that couples feel they belong to the therapeutic context. Coolhart (2023) observed that queer couples experienced invalidation and mistreatment in many aspects of their lives and therefore finding an affirmative therapist was a relief. Irrespective of the approach, therapists should avoid making heteronormative assumptions (Heiden-Rootes et al., 2020; Spengler et al., 2020), confronting their own stereotypical views of female relationships.
The reasons why lesbians sought couple therapy were varied and not necessarily directly related to issues of sexual orientation. The studies in this review involved couples who sought help in coming out to their families (Reibstein & Sherbersky, 2012), as well as those who were doing therapy to address a specific mental disorder (Blount et al., 2017). Grafsky and Nguyen (2019) and Heiden-Rootes et al. (2020) endorsed the idea of multiple demands not necessarily related to sexual orientation, suggesting that many LGBTQIAPN+ clients seek therapy for depression and anxiety, conflicts in the relationship or difficulties in handling life-cycle transitions. Issues such as discrimination, difficulty relating to certain family members and fear of disclosing sexual orientation may be brought up in therapy but are not necessarily the selected focus for all couples.
The influence of gender on women’s health is another relevant issue addressed by one of the studies, which critically investigates the normalization of caregiving as an exclusively female role (Powell & Neustifter, 2012). Responsibility for caring for family members is mainly assigned to women, often leading to overburdening (Renk et al., 2022). This “compulsory” caregiving role also extends to lesbians, meaning that therapy with lesbian couples should consider the contributions of feminist theory and gender studies, which seek to disessentialize historically sedimented constructions that legitimize female subjugation. It is necessary to give visibility to the in-context concerns and experiences of clients given the structural oppression stemming from the organizing principle of gender (Knudson-Martin & Wells, 2019; Wahlig & Long, 2019).
Four articles (McGeorge et al., 2015; McGeorge & Carlson, 2016; Powell & Neustifter, 2014; Tadros & Smithee, 2021) highlight the importance of addressing gender and sexuality in couple therapist training and suggest that professionals should seek to increase their knowledge and awareness of this topic. This is reinforced by the American Psychological Association (2021) Guidelines for Psychological Practice with Sexual Minority Persons, which recommend that psychologists should receive specific training on prejudice and the mental health of the LGBTQIAPN+ population, and adopt evidenced-based and culturally specific affirmative psychological practices. Maintaining the balance between recognizing differences and identifying when they need to be problematized is a key point that influences the client’s propensity to “go deep” into their problems. Fear of becoming the target of stigma and hostility is an integral part of the everyday life of lesbian couples, given the widespread structural violence and lesbophobia faced by female couples (Auad & Lahni, 2013; Souza et al., 2021).
This review analyzed existing evidence, highlighting gaps in knowledge and some “pitfalls” that family and couple therapists need to be aware of, and encourages them to create more inclusive strategies to address marital issues faced by lesbian couples. Throughout the text, we revisited the results of studies outlining the therapeutic approaches that underpin clinical practice. We addressed the key characteristics and findings of these studies, emphasizing specific aspects of interventions and care needed in the field of lesbian couple therapy.
The results of this review confirm that same-sex couple therapy remains underrepresented in the literature, despite the fact that preliminary evidence shows the potential benefits of couple interventions for this population (Kousteni & Anagnostopoulos, 2020; Spengler et al., 2020). The findings provide important insights into the strengths and weaknesses of therapeutic process with couples who live and struggle for their (re)existence on the fringes of heteronormativity, showing that much is still needed to advance scientific knowledge in this area, especially when it comes to couple therapy in Latin America. Theoretical articles and case studies predominated in this review. While these studies without doubt provide important contributions to clinical practice, it is evident that, in terms of level of evidence, research in this area remains limited. There is a lack of evidence at population level and no randomized clinical trials were found. There is also a notable lack of studies with robust samples and research designs and studies assessing process and outcomes and conflict prevention strategies for female couples.
In some of the studies analyzed by this review, couples reported that fear of being the target of discrimination was more pronounced when the issue or focus of conflict under examination in therapy was related to differences between the dyad, such as sexual problems. Some important recommendations can be extracted from the studies in this regard, given the need to build the capacity of couple therapists. The findings show that many couple therapists are ill-equipped to work with lesbian couples and that gaps in training are common. These gaps can increase the risk of professionals inadvertently reproducing beliefs that pathologize this population.
Given the vast diversity of possible family configurations, ways of living as a family have been reinvented and are constantly changing, demonstrating the vitality of the institution of family in current times. Being well informed about the huge range of possibilities and specificities of relational configurations and lesbian culture requires that the therapist understands the unique nature of these relationships and the social and cultural context in which these relational experiences are established (Rich, 1980). It is also vital that the therapist is careful when making suppositions about what constitutes a problematic relationship. An example of stereotyping that fortunately has already been dismantled, was the belief that the female relational pattern is fused. This belief was erroneously disseminated by scientific literature in the past, especially by studies inspired by systemic thinking.
Given their uniqueness, each couple relationship should be seen as a culture in itself, and the therapist should learn from the contextual experience of each process, seeking to enhance interventions in order to embrace the singularity that shapes the existence of each lesbian couple. More than adapt and reformat ready-made and stereotyped schemas, the therapist should be open to cocreate, that is, create together with the other, coevolving with the couple during the course of the therapeutic process, formulating interventions that are effective because they are embedded in dialogical contexts from an emancipatory perspective. In this aspect, this study stimulates reflection on how therapists can respect singularities using potent therapeutic interventions with transformative power, positioning themselves as LGBTQIAPN+-affirmative.
In summary, despite growing interest in exploring the differences and specificities of lesbian couple therapy, the current literature remains limited to studies that provide low quality evidence in seeking to understand experiences and challenges that are unique to this population. Further research is needed to address knowledge gaps and identify and safeguard the particularities that characterize the marital dynamics of lesbian couples in the space of couple therapy, especially given the current backdrop of visibility of family configurations that deviate from the heteronormative model. Future research should also focus on other sexual minority groups that are underrepresented in publications, such as bisexuals, transsexuals and asexuals.
This study has some limitations. By limiting the search to articles in Portuguese, English and Spanish, we ran the risk of not retrieving relevant publications in other languages. Other database and keyword combinations could also have been added to increase the chances of article retrieval. The reviewed studies were conducted by researchers from the United States, United Kingdom and Australia, meaning it is not possible to generalize findings to other regions of the world with other cultures and customs, especially countries in the Global South. Despite these limitations, the findings of this review can make valuable contributions to the definition of public health policies and indicate new directions for future research focusing on the multiple possibilities of fostering therapeutic contexts that help lesbians take ownership of their life stories and invent new narratives of possible futures.
Finally, in light of the above, it can be said that the research question “What is the status of national and international literature on lesbian couple therapy?” was answered and the study objective was met, as the review provided an analysis of current evidence in the national and international literature on lesbian couple therapy, outlining the main approaches and identifying gaps in knowledge about the specificities of this field.
