The health sciences, particularly psychiatry, have had a long history of using the biomedical paradigm to pathologize queerness, in both Western and Indian contexts. Recently, some Indian MH community members have developed and implemented alternative, affirmative counseling approaches to working with queer clients, including a course(1), manuals(2) and group therapy modules(3)– indicating a shift in how queerness is viewed by MH practitioners, towards a more postmodern understanding of gender and sexuality.
Such efforts notwithstanding, the Indian context is widely homo-negative, with queer identities not included in counselor training. How, then, have counselors working with queer individuals adapted their practice? A research study I conducted for my Master’s aimed to explore such experiences. Here, I analyze the shift from a top-down biomedical approach that locates the distress within the queer client, to a psychosocial approach that looks critically at power hierarchies and locates such distress within the societal fabric.
The biomedical approach as a tool to pathologize queerness
Toward the end of the 18th century, medicine was no longer solely a system of knowledges and methodologies to cure illnesses, but had assumed a normative posture. It was used as a disciplinary power over people’s social lives by decreeing what was moral and amoral, or “normal” and pathological.(4)
Sexual diversity was first pathologized by the Viennese psychiatrist, Kraft Ebbing. In his ‘Psychopathia Sexualis’ (1894), he ruled that any non-procreative sexual behaviour was abnormal; non-normative sexuality was ‘a collection of loathsome diseases’.(5) This trend continued in the MH community. Homosexuality was described as a mental illness in the first and second Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association.(6)
“Conversion therapy”, considered a human rights violation by most international guidelines, is still widely practised in India. Apart from the fact that research has repeatedly shown its impossibility, the very intent to “cure” is a devaluing and pathologizing proposal.
Stepping away from labels and diagnoses
In queer theory and feminist studies, gender and sexuality are now recognized as constructed categories that have been naturalized and reified to establish and maintain power hierarchies. These approaches critically examine the dominant discourses that reproduce these categories. Queer theory sees sexuality and gender as inherently fluid, socially constructed, and unstable.(7)
‘Queer affirmative practice’ – developed in the West and being implemented in India – is an approach to counseling rooted in the poststructuralist assumptions of queer theory, that calls for the counselor's self-work, attitudes, knowledge, ethics, and process skills.(8) Most counselors in my study subscribed to this approach, integrating it with their primary theoretical orientations. I outline in this article three key components of their practice that underscore the shift from a biomedical to a psychosocial paradigm when working with queer clients.
Deconstructing the counselor’s “expert” position
The shift away from a clinical approach is starkly underscored by the fact that a majority of my respondents thought that the counselor needed to work on their own biases and pre-conceived notions about queer people; that becoming an affirmative counselor would require effort, introspection, and constantly learning and updating themselves on queer issues. Relying on clinical knowledge to play the “expert” was not conducive to being an effective counselor.
This process of self-reflection is clearly necessary: studies conducted in the UK found that heterosexual health care providers implicitly preferred heterosexual individuals over queer individuals. Queer individuals and practitioners may themselves internalize these biases. Unlearning dominant discourses through careful reflection, training, knowledge and experiences was recommended. (9)
The counselor’s expertise is deconstructed by another practice advocated by study participants. This was the idea that the counselor be open to learning from their queer clients during therapy, which meant remaining cognizant that a client may know more than the counselor about queerness with regard to theory, culture, or their particular concerns.
“therapy does not take place in a vacuum; that the client, counselor and therapeutic process are all influenced by the socio-political fabric, including laws and media portrayals, within which they are situated.”
Using intersectionality theory
Where a bio-medical paradigm looks at MH concerns as “disorders” caused by a neuro-anatomical imbalance of chemicals in the brain, a psychosocial approach gives greater emphasis to the social context, and this applies equally to queer clients.
My findings indicate that counselors’ conceptualizations of queer client’s concerns included, besides consideration of their queer identities, other aspects of the clients’ social location as well. This perspective helped to guide counselor interventions – a client’s relatively greater social marginalization, for instance, could adversely affect their access to queer resources and spaces.
Counselors spoke about using a “queer lens” to examine their clients’ concerns, which took note of the minority stress faced by queer individuals. Using conventional (white, cis-heterosexual) psychological theory for their queer clients was problematized by these Indian counselors. For example, self-harm may be a coping mechanism for a queer client undergoing extreme distress due to their gender identity or sexuality, and should be viewed in that light. Asexuality needed be recognized as a valid identity, and not pathologized or diagnosed as “Schizoid Personality Disorder” based on some textbook definition.
This is in line with existing literature that holds that counseling has always been influenced by dominant white heterosexual male culture. A ‘sexual orientation blind’ or a “neutral” perspective in counseling ignores and denies the culturally unique experiences of queer clients, and is likely to perpetuate heterosexism.(10)
Recognizing dominant discourses in the therapy room
Another shift from conventional therapeutic practice is recognizing that therapy does not take place in a vacuum; that the client, counselor and therapeutic process are all influenced by the socio-political fabric, including laws and media portrayals, within which they are situated.
Several counselors spoke of how the existing political climate caused distress for their queer clients, who often brought to therapy the homonegative and problematic comments made by politicians. The processing of the client’s feelings about wider political discourses was done within the therapy room.
With regard to the law, many clients spoke of wanting to settle in some other country, with more progressive laws, where they could live with less secrecy and shame. Counselors themselves brought up laws that could affect a client’s life (such as Section 377 of the Indian Penal Code, when it was still in place) within therapy, so that clients were aware of potential repercussions. They also sometimes touched upon uplifting news reports for their clients, such as Taiwan’s legalizing of gay marriage.
Many participants spoke of how, though theoretical knowledge was important, a working familiarity with queer pop culture and TV shows was also relevant to therapy. They spoke of having recommended shows, and so on, to clients, so that the latter might have more points of identification and understanding with respect to their sexuality or gender. Queer media seemed to provide alternative scripts to the widely prevalent hegemonic cis-heterosexual discourses.
It is clear from the practices and ideas of counselors working with queer clients that (at least some members of) the MH community have moved beyond the biomedical paradigm in their approach to therapy, in order to critically examine the power hierarchy implicit in their own “expert” positions, to recognize the role of minority stress in their conceptualization of queerness, and to acknowledge that therapy is not insulated from the surrounding media landscape and politico-legal rhetoric.
While several of the participants ascribed to this approach, it’s relevant to note that there was some divergence in my results- not all the counselors I interviewed engaged in all three key components, or consistently engaged in them in a manner that was beyond reproach.
 Mariwala Health Initiative (2020). Retrieved from https://mhi.org.in/voice/details/queer-affirmativecounselling- practice-bombay/
 Ranade, K., & Chakravarty, S. (2013). Gay-Affirmative Counselling Practice Resource and Training Manual (1st ed.). Mumbai: Saksham.
 Wandrekar, J., & Nigudkar, A. (2019). Learnings From SAAHAS—A Queer Affirmative CBT-Based Group Therapy Intervention for LGBTQIA+ Individuals in Mumbai, India. Journal Of Psychosexual Health, 1(2), pp. 164-173. doi: 10.1177/2631831819862414
 Spurlin, W. (2018). Queer Theory and Biomedical Practice: The Biomedicalization of Sexuality/The Cultural Politics of Biomedicine. Journal Of Medical Humanities, 40(1), pp. 7-20. doi: 10.1007/s10912-018-9526-0
 Narrain, A., & Chandran, V. (2016). Nothing to Fix: Medicalisation of Sexual Orientation and Gender Identity (1st ed.). California: Sage.
 Ranade, K. (2018). Growing Up Gay in Urban India (1st ed.). Singapore: Springer Nature.
Callis, A. (2009). Playing with Butler and Foucault: Bisexuality and Queer Theory. Journal Of Bisexuality, 9(3- 4), pp. 213-233. doi: 10.1080/15299710903316513
 Ranade, K., & Chakravarty, S. (2013). Conceptualising gay affirmative counselling practice in India building on local experiences of counselling with sexual minority clients. The Indian Journal Of Social Work, 74(2), pp. 335-352.
 King, M., Semlyen, J., Killapsy, H., Nazareth, I., Osborn D. (2007). A systematic review of research on counselling and psychotherapy for lesbian, gay, bisexual & transgender people. Lutterworth, UK: British Association for Counselling & Psychotherapy.
 American Psychological Association (2017). Multicultural Guidelines: An Ecological Approach to Context, Identity, and Intersectionality. Retrieved from http://www.