CLINICAL ISSUES IN WORKING WITH BISEXUAL WOMEN

Clinically, the issue of bisexuality is potentially important with three types of clients: (1) women who label themselves as bisexual; (2) women who are unsure about their sexual orientation; and (3) women who identify themselves as lesbian or heterosexual, but for whom bisexual fantasies, attractions, or behavior may be distressing or ego-dystonic.

Successful therapy, even with women who identify themselves as bisexual, must begin with an examination of whether the bisexuality is indeed a clinical issue. Just as there has often been a tendency for heterosexually biased therapists to assume that homosexuality is a therapeutic issue for all gay and lesbian clients, many therapists may assume that bisexuality is an issue for all clients who exhibit bisexual behavior, attractions, or self-identity. Many such clients enter treatment with no internal conflict about their orientation; the first order of business for the therapist is to determine whether the client herself considers her sexual orientation in any way worthy of discussion. For example, I have experienced both heterosexually identified clients with significant lesbian experiences and lesbian clients with significant heterosexual contact whose behavior did not apparently cause them to experience personal conflict. It is not my business to start to create conflict for them.

Sexual and Romantic History

For those women who report a need to work on issues of sexual identity, a detailed sexual and romantic relationship history is essential. This should include a history of the emergence and expression of both heterosexual and homoerotic fantasy, attractions, and behavior, including masturbation fantasies.

In addition, the clinician should obtain a relative weighting of the power of heteroerotic versus homoerotic attractions. Does one type of attraction seem primary (i.e., more satisfying, more romantically compelling, or more erotically charged)? How much variation is there over time? Probably most important are the recent experiences of the client, as they are most likely to predict a future direction.

Next, the therapist should assess the degree to which these experiences are ego-dystonic or ego-syntonic, and the likelihood that the client could compartmentalize the ego-dystonic component of her sexuality should she desire to do so. Notice that this is an acceptable alternative for me, if it appears practical. I do not take the political or therapeutic stance that all bisexuals must identify themselves as such; I help many lesbians compartmentalize their bisexuality if it seems practical and that is what they want to do, just as I have helped some heterosexual women compartmentalize theirs.

The clinician must also ascertain the social supports a client has for bisexuality and her potential ability to maintain a bisexual identity without support, or the social supports she has for maintaining a lesbian identity if that is how she labels herself or if she decides to do so.

Next, the therapist needs to help the client explore her self-identity and what this means to her. It can be especially revealing to determine how she labels herself in different situations. Some such labels, if they are discrepant with her personal identity, may reveal internalized biphobia or homophobia. For example, the client may consider herself bisexual, but may identify herself as lesbian with lesbians and heterosexual with heterosexuals.

Finally, it is important to understand the degree to which, in general, the client is motivated and prepared to deal with upheavals in her life chat would be created by a change either in personal self-identity or in self-disclosure to others. It is also important to explore specific issues and difficulties that may realistically be expected. For example, a previously heterosexually identified mother who is grappling with potential bisexuality may make choices in behavior or disclosure according to their possible repercussions for child custody.

Identity Formation

Probably the single most common issue the clinician will encounter in work with potentially bisexual clients is the very issue of identity formation: "Am I bisexual, lesbian, or straight? If so, what does this mean? How do I figure it out? How do I handle it if I am?" Clinicians not experienced in dealing with gay and lesbian clients might consult the writings of gay and lesbian therapists on identity formation, as many of the same principles hold for bisexual identity formation (Cass, 1979, 1990). In a culture that repudiates both homosexuality and bisexuality, most individuals will find it both imperative to come to terms with the despised and denigrated elements of identity and exceedingly difficult to do so. The journey to self-integration will be time-consuming and conflict-laden for most, and will include information-seeking, behavioral exploration, the need for social supports, and some degree of self-disclosure to others. Moreover, this odyssey invariably includes periods of defensive strategies that seek to deny, compartmentalize, or repress certain aspects of self. It is most important that this journey be self-determined. In clinical issues, the policy of "outing" is destructive; the therapist's most useful role may be to support partial denial of identity, while planting the idea that continued evolution of identity may take place in the future.

In transposing the model of gay and lesbian identity formation to bisexual identity, the picture gets more complicated because many more variations are possible. Some women move from a heterosexual to a bisexual identity and comfortably remain there, whereas for others bisexuality is a way station toward lesbianism. Still others perceive themselves as lesbian and then as bisexual. When a woman is undergoing a second major transformation of sexual identity, it is advantageous for her to build upon the strengths gained during the first transformation, and it may be clinically helpful for the therapist to point this out to the client. A woman who has previously identified herself as a lesbian and is currently struggling to come to terms with attractions to men can be reminded of the process she went through in "coming out" as a lesbian. As she notices the similarities in process, she can access past experiences and skills to help her with her current situation.

Therapeutic Validation

I find it very useful to help women make clear distinctions among the following: aspects of internal experience (feelings, fantasies, attractions) behavior self-labeling, and self-disclosure. I validate apparent dissonance among these elements if the dissonance is comfortable for the client, at the same time as I point out possible disadvantages of maintaining this dissonance. In effect, I do recognize an "essential" nature of sexual orientation, at least as determined by internal experience, but make that separate from all other elements. For example, I may say to a client,

"You may indeed be bisexual internally—be capable of attractions to some degree or another to both men and women. But you may choose whether to act upon these feelings. Moreover, you can choose what you want to call yourself and to whom you want to reveal any of these aspects of yourself. You can be internally bisexual and call yourself a lesbian (or heterosexual). You can "come out" as a lesbian to others, or you can choose not to disclose anything. This is perfectly okay, but there is some potential for problems. You may eventually find that you feel a need to act upon both sets of feelings, and you may feel phony or superficial with others if you do not disclose your bisexuality. You can do whatever is comfortable for you now, recognizing that you may or may not decide differently in the future."

Perhaps the single most important thing a therapist can do for female clients who have any degree of bisexuality is to validate the concept of bisexuality and give information. This can be important even for women whose bisexual component seems insignificant at the time. Validating lesbian fantasies in a presumably heterosexual woman, for example, may not seem important at the time it is done; however, given the fluidity of sexual orientation, it can have great future significance. The "heterosexual" woman of today may choose to actualize her lesbian fantasies tomorrow. And for the woman whose bisexuality is more than incidental, validation and information from the therapist are even more important. The therapist may be the only person in the client's social system who even corroborates the existence of bisexuality, so the therapist must be able to provide unwavering support, as well as information that includes reading material and (most importantly) referrals to bisexual organizations and support groups. Fortunately, these days such literature and support groups can usually be accessed through local lesbian and gay hotlines, organizations, and bookstores.

Although identity is the most common issue the clinician will confront regarding bisexuality, other problems may present themselves. The book by Klein and Wolf (1985) includes a chapter on counseling bisexuals that describes many of these issues (Lourea, 1985). Some of the problems bisexuals may encounter include the following: dealing with partners who cannot handle their bisexuality; grappling with the issue of monogamy-nonmonogarny; and coping with the reactions of others to whom they have disclosed their bisexuality. Women who have previously identified themselves as heterosexual face many of the same issues confronted by lesbians in "coming out." Women who have previously identified themselves as lesbians have additional conflicts. They may include guilt and a sense of betraying their community, as well as "culture shock" when they find themselves relating to men again and having to confront sexism, which they thought they had left behind forever.

Case Vignettes

It may be useful to conclude this section with several vignettes of my own clients in recent clinical practice.

Lee is a 33-year-old self-identified bisexual married woman. She lives with her husband and her female lover, both of whom accept her dual relationships/but who are not romantically or sexually involved with each other. She entered therapy on the premise that these relationships would not be challenged. Although some other clinical issues involve the complexities that managing these relationships entail, her situation has remained stable for several years, as has her identity. She feels no need to participate in the bisexual community, although she does not conceal her identity from others.

Marion was a middle-aged suburban housewife with three children at the time she entered treatment for what she reported as sexual identity confusion. Although her behavior was bisexual, her attractions since adolescence had been exclusively lesbian, and her marriage was strictly a pretense. Her primary clinical issue was considerable internalized homophobia, reinforced by a lifetime of being a "good girl" who lived the lifestyle her parents chose for her. This was complicated by the losses she feared she would suffer should she actualize her lesbian potential: the loss of child custody, and the loss of substantial income from her husband. Marion eventually left her husband and has been a self-identified lesbian for a number of years. She learned to cope with the altered lifestyle necessitated by an income decrease. While she did not lose custody of her children, the two older boys were troubled by her lesbian lifestyle and one eventually left to live with his father.

Lily is a 28-year-old self-identified lesbian who sometimes sleeps with men but considers these encounters purely sexual. Although she accepts the term "bisexual" as a behavioral description, she rejects it as an identity and experiences no conflict over the discontinuity between her label and her behavior.

Diane is 28 and thinks she may be lesbian. She is behaviorally and romantically bisexual, but has recognized her lesbian attractions only recently. She has never sustained a long relationship with anyone of either sex. For now, a bisexual self-identity is the most comfortable alternative for her, as she continues to explore in therapy her internalized homophobia and her attractions to women. It is unclear both to her and to me whether her inability to sustain relationships is the result of a primary lesbian orientation or simply a conflict about commitment and intimacy.

Ann is 41, has been living for 6 years with a man, and is trying to have her first child. Eight years ago I helped her make the transition from a 12-year politically active lesbian identity and relationship to a bisexual identity. She came back to deal with her grief over miscarrying two pregnancies. She still considers herself bisexual and is very active within the bisexual movement and community.

Joanne is 39 and in the process of divorce. One other clinical issues was potential bisexuality; she had several lesbian experiences during her marriage. During the course of treatment, however, she decided that these were not emotionally significant to her, and she maintains a heterosexual identity. She recently fell in love with a man.

Terri is a 30-year-old postoperative male-to-female transsexual. Before surgery, she did not think much about her sexual orientation. Even though, as a male, she had been attracted to and married a woman, she had also had sexual fantasies about being a woman and having sex with a man. After surgery, her first sexual experiences were with men, and she found them satisfying. However, she was still attracted to her ex-wife, and this led her to question her orientation. Eventually she made contact with a bisexual S/M group through a computer bulletin board and became active with these men and women. She found that S/M was only of mild interest to her, but that she was clearly attracted to women at least as much as to men. She is now in a lesbian relationship. Affirming her bisexual identity was extraordinarily easy for her; in actualizing her female identity, she had lost so much in her life that the orientation change seemed minimal by contrast.

CONCLUSION

In our rapidly changing contemporary culture, we arc in the midst of a second revolution in our paradigm of sexual orientation. The most recent paradigm recognizes that sexual orientation is multidimensional; this conception not only includes attraction, behavior, and identity, but also allows for fluid identity over the life cycle. At the forefront of these changes are bisexual women, especially those working within the lesbian community, so it is appropriate that a book on feminist reconstruction of psychotherapy with women includes a chapter on bisexuality.

For clinicians working with sexual identity in female clients, it is no longer sufficient that they be comfortable and supportive of lesbianism. They must support and understand bisexuality as well, or they will do a disservice to all their female clients, including those who currently identify themselves as heterosexual or lesbian but may have within, them a potentially significant bisexual component of their identity, In a culture that at worst allows women only a heterosexual option, and at best acknowledges two options (heterosexual or lesbian), clinicians must be a source of information and help regarding bisexuality, because the most important function they may fulfill is that of validating its existence.

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