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The gender affirmative lifespan approach (GALA): A framework for competent clinical care with nonbinary clients

A. What are the major themes and/or concepts discussed by the author(s)?

B. How does the author(s) frame this concept, construct, or developmental concern in a fresh or unfamiliar way? This may involve describing concepts or terms that are new to you, identifying a different methodology for examining these ideas, or how the author references a study that you were previously unfamiliar with, for example.

C. What new inference (“IF-AND-THEN”) or logical assumption can you make by applying the author’s ideas to your own existing knowledge about this topic? Elaborate on your inference. 

D. How can you apply the theory/theme/concept to an issue in family science, early education, counseling, or human development research, teaching, or practice (beyond what the author(s) has/have described)? 

E. Develop one question to pose to the class based on your reading and reflection.

Racial and Gender Identity Among Black Adolescent Males: An Intersectionality Perspective

A. What are the major themes and/or concepts discussed by the author(s)?

B. How does the author(s) frame this concept, construct, or developmental concern in a fresh or unfamiliar way? This may involve describing concepts or terms that are new to you, identifying a different methodology for examining these ideas, or how the author references a study that you were previously unfamiliar with, for example.

C. What new inference (“IF-AND-THEN”) or logical assumption can you make by applying the author’s ideas to your own existing knowledge about this topic? Elaborate on your inference. 

D. How can you apply the theory/theme/concept to an issue in family science, early education, counseling, or human development research, teaching, or practice (beyond what the author(s) has/have described)? 

E. Develop one question to pose to the class based on your reading and reflection.

The gender affirmative lifespan approach (GALA): A framework for
competent clinical care with nonbinary clients

G. Nic Ridera , Jennifer A. Vencillb , Dianne R. Berga, Rachel Becker-Warnera,
Leonardo Candelario-P?ereza and Katherine G. Spencera

aNational Center for Gender Spectrum Health, Program in Human Sexuality, Department of Family Medicine and Community Health,
University of Minnesota Medical School, Minneapolis, Minnesota, USA; bDivision of General Internal Medicine, Department of
Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA

ABSTRACT
Background: The limited research on nonbinary individuals suggests that this community
experiences significant health disparities. Compared to binary transgender individuals,
research suggests that nonbinary individuals are at elevated risk for discrimination and
negative mental health outcomes, including depression, anxiety, traumatic stress, and suici-
dality. Even mental health providers who work with binary transgender individuals often
lack knowledge of and training to work competently with nonbinary individuals.
Methods: The authors of this conceptual article present the Gender Affirmative Lifespan
Approach (GALA), a psychotherapy framework based in health disparities theory and
research, which asserts that therapeutic interventions combating internalized oppression
have the potential to improve mental health symptomatology resulting in improved overall
health and well-being for gender diverse clients. GALA’s therapeutic interventions are
designed to promote positive gender identity development through five core components:
(1) building resiliency; (2) developing gender literacy; (3) moving beyond the binary; 4) pro-
moting positive sexuality; and (5) facilitating empowering connections to medical interven-
tions (if desired).
Results: The core components of the GALA model are individualized to each client’s unique
needs, while taking into consideration age and acknowledging developmental shifts in, or
fluidity of, gender across the lifespan. This model represents an inclusive, trans-affirmative
approach to competent clinical care with nonbinary individuals.
Discussion: Application of the GALA model with nonbinary clients is discussed, including
one clinical case vignette.

KEYWORDS
Genderqueer; nonbinary;
transgender; transgender
health; LGBT health; gender
affirming psychotherapy

Transgender identities are gaining visibility in
research and scholarship; however, this scholarly
work often perpetuates a narrow view of gender
diversity by focusing primarily on binary gender
identities, which categorize people as exclusively
male/man or female/woman (Richards et al.,
2016). This binary gender framework has been
developed and reinforced over many years through
colonization and systemic oppressions, and contin-
ues to be reflected in status quo approaches to
transgender health care (Richards et al., 2016;
Webb, Matsuno, Budge, Krishnan, & Balsam,
2017). For example, a colonized understanding of
gender, derived from biological sex only referring
to male (XY) versus female (XX), means that

those assigned male at birth are socialized to
behave in culturally masculine ways and those
assigned female at birth are socialized to behave in
culturally feminine ways (Crouch & David, 2017).

In considering how to rectify the narrow view
of the gender binary, it is critically important to
consider how historical subjugation and oppression
affect our own conceptualization and engagement
in research and clinical work (Bouman et al.,
2017). The more dominant cisnormative and patri-
archal binary gender framework is situated within
a social hierarchy in which men, European race/
ethnicity, and heterosexuality are often considered
superior (Crouch & David, 2017; Hwahng & Lin,
2009; Martins, 2016). The impact of this

CONTACT G. Nic Rider, PhD [email protected] National Center for Gender Spectrum Health, Program in Human Sexuality, Department of Family
Medicine and Community Health, University of Minnesota Medical School, 1300 S. 2nd St., Suite 180, Minneapolis, MN 55454, USA.
? 2018 Taylor & Francis Group, LLC

INTERNATIONAL JOURNAL OF TRANSGENDERISM
2019, VOL. 20, NOS. 2–3, 275–288
https://doi.org/10.1080/15532739.2018.1485069

framework has been upheld and reinforced
through systemic hierarchies, including in health
care settings. For example, historical discrimination
and silencing of transgender and gender diverse
people in research and health care settings has led
to mistrust and a reluctance to engage in such
services, resulting in delayed access to both phys-
ical and mental health care for many transgender
people (Rider, McMorris, Gower, Coleman, &
Eisenberg, 2018; Spencer & Vencill, 2017).

Further, cisgender perspectives tend to domin-
ate research (Galupo, 2017), which may, and often
do, exclude and erase transgender and gender
diverse voices. When representing transgender and
gender diverse individuals, it is crucial to work
alongside while uplifting the voices of those who
identify within this community (Erickson-Schroth,
2014; Galupo, 2017). Clinicians are in a unique
position to invite and welcome input from their
clients (e.g., asking about name, pronouns, and
gender-related terminology clients use and would
like avoided in discussions) in order to provide
affirming services. Discussions about how a client
defines particular identity labels or experiences
their gender may be warranted; however, this is
not the same as asking a client to educate their
clinician on transgender and gender diverse issues,
which should be avoided (American Psychological
Association, 2015).

Using resources created and maintained by
transgender and gender diverse individuals is
another way of centering this community in clin-
ical contexts while obtaining information for edu-
cational purposes (American Psychological
Association, 2015; Erickson-Schroth, 2014). For
example, the Trans Student Education Resources
(TSER), a national organization led by transgender
and gender diverse youth whose mission is to edu-
cate the public, provides materials including a list
of LGBTQþ terms and definitions. According to
TSER (n.d.), nonbinary is an umbrella term for
individuals who express their gender or identify
with a gender other than (or not exclusively as)
female/woman or male/man and who may or may
not also identify as part of the transgender com-
munity. Genderqueer individuals are those who
identify as neither, both, somewhere between, or
outside a spectrum of masculine and feminine
(TSER, n.d.). While some individuals use the terms

nonbinary and genderqueer interchangeably, others
who identify as genderqueer may not consider
themselves transgender or nonbinary. Some people
may also choose other labels such as third- and
fourth-gender, which are terms that create overlap
between non-Western and non-white indigenous
conceptualizations of sex and gender systems, as
opposed to the European American paradigm of
sexual orientation and gender as distinct categories
(Hwahng & Lin, 2009). For the purposes of this
article, authors primarily use the term nonbinary;
however, the term genderqueer is incorporated at
times to be consistent with the language research-
ers have used in prior publications.

Stigma and mental health

Nonbinary individuals face stigma and discrimin-
ation both from the larger society and within the
transgender community, as stereotypes exist that a
lack of binary gender identification means that one
is not “really” transgender (National LGBT Health
Education Center, 2017). For example, Wyss (2004)
documented numerous experiences of physical and
sexual violence faced by genderqueer and gender
nonconforming youth in their American high
schools; data that have been supported by add-
itional work on perceived safety in schools for
gender diverse youth (e.g., Toomey, McGuire, &
Russell, 2012). Results from the 2015 U.S.
Transgender Survey (USTS; N¼ 27,715, 35% iden-
tified as nonbinary) indicated that a majority of
nonbinary participants reported that they tend not
to tell others about identifying as nonbinary or cor-
rect assumptions about their gender, particularly
because others historically did not understand and
it felt “easier” not to mention it. Forty-three per-
cent of nonbinary participants reported fear of vio-
lence if they were to tell others about their gender
(James et al., 2016). Similarly, the European Union
Agency for Fundamental Rights (2014) conducted
an internet-based, quantitative study with 6,579
transgender people from 28 countries in the
European Union and found that their sample of
gender variant individuals (11% of total sample)
tended not to be “out” or to disclose their identities
to others in settings such as work or school. Forty-
two percent of gender variant participants in this
study reported harassment or discrimination in the

276 G. N. RIDER ET AL.

past year, ranging from name calling and ridiculing
to isolation and physical assault. Almost two-thirds
of the gender variant sample reported avoiding
expressions of their gender or going to certain pla-
ces for fear of threat or assault (European Union
Agency for Fundamental Rights, 2014).

Research also suggests that although trans-
gender individuals experience health disparities
compared to their cisgender peers, nonbinary
youth and adults experience elevated disparities
including negative mental health outcomes com-
pared to both binary transgender and cisgender
people (Harrison, Grant, & Herman, 2012; James
et al., 2016; Tabaac, Perrin, & Benotsch, 2017;
Toomey et al., 2012; Veale, Watson, Peter, &
Saewyc, 2017; Wyss, 2004). In a quantitative study
using a convenience sample of 64 genderqueer-
identified adults who completed an online survey,
over half of participants endorsed clinical level
depressive symptoms, and another one third of
participants reported anxiety symptoms that
reached a clinically significant level (Budge,
Rossman, & Howard, 2014). Results from the
2015 USTS indicated that 49% of nonbinary par-
ticipants reported current psychological distress,
compared to 35% of transgender men and women
and 5% of the overall U.S. population (James
et al., 2016). Clark, Veale, Townsend, Frohard-
Dourlent, and Saewyc (2018) found that nonbi-
nary transgender Canadian youth demonstrated
lower rates of overall mental health and higher
rates of nonsuicidal self-harm than binary youth.
Nonbinary youth assigned male at birth reported
greater use of marijuana and tobacco than other
groups. This study replicated findings that
nonbinary Canadian youth reported lower levels
of mental health and greater incidence of self-
harm than their binary peers (Veale et al., 2017).

Despite these risks documented in U.S. and
Canadian samples, European gender variant par-
ticipants were among the most likely to report
that they did not want or need psychological or
medical care related to gender (European Union
Agency for Fundamental Rights, 2014). In an
online quantitative study using a convenience
sample of 677 binary and nonbinary transgender
youth in the United Kingdom, Rimes, Goodship,
Ussher, Baker, and West (2017) found that nonbi-
nary participants assigned male at birth were less

likely than binary and nonbinary youth assigned
female at birth to seek mental health services.
Unexpectedly, nonbinary participants reported
higher levels of life satisfaction than binary partici-
pants, though the researchers note that life satis-
faction ratings across all transgender groups were
significantly lower than those found in general
population research. Clark et al. (2018) found that
nonbinary transgender Canadian youth were less
likely than their binary peers to desire hormone
therapy, however, were more likely to report bar-
riers to accessing such gender affirming care when
hormone therapy was needed.

The need for the Gender Affirmative Lifespan
Approach (GALA) as a psychotherapy framework

Arguments of biological sex have been used to
pathologize and undermine gender diversity and
nonconformity, as well as maintain and reinforce
binary gender norms, stereotypes, power differen-
tials, and disparities in access to resources
(Crouch & David, 2017; Serano, 2007; TSER,
n.d.). This perpetuation of oppression has also
contributed to silencing, discrimination, margin-
alization, and erasure of transgender and gender
diverse individuals and radically changed under-
standing of gender identity and expression
(Martins, 2016). Given that research often
informs clinical work, it is important to under-
stand the cultural ramifications and implications
of historically published empirical work, particu-
larly as health-related studies are often informed
by European American LGBTQ frameworks
(Hwahng & Lin, 2009).

While there has been increased attention to
mental health concerns, stigma, and minority
stress related to the larger transgender commu-
nity, there remains little awareness of or know-
ledge about nonbinary identities and experiences
(Matsuno & Budge, 2017), including how to
competently and affirmatively work with this
community in clinical settings. Notably, mental
health clinicians are tasked with the responsibility
to assess readiness for gender affirming interven-
tions and make referrals for access to medically
necessary treatments (Coleman et al., 2012).
Mental health clinicians thus are often in a gate-
keeper role when helping transgender and

INTERNATIONAL JOURNAL OF TRANSGENDERISM 277

nonbinary clients with the process of medical
transition (Budge, 2015). Transgender clients par-
ticipate in therapy services for multiple reasons,
including personal growth, gender transition
assistance, and coping with stigma, prejudice, and
discrimination (Bess & Stabb, 2009 ; Budge, 2015;
Rachlin, 2002). For those who are seeking therapy,
the gatekeeper model can undermine the mean-
ingful and transformational role that psychother-
apy can play in transgender people’s lives due to
fear that they will be denied access to medically
necessary gender affirming treatments (Budge,
2015). Competent and affirmative clinical work
involves explicitly addressing and countering the
gatekeeper model in therapeutic work, and
acknowledging the unique challenges, barriers, and
supports of those who identify within sub-com-
munities of the transgender population.

Even clinicians who work with binary trans-
gender individuals may lack knowledge of and
training to work competently with nonbinary and
genderqueer individuals (Budge et al., 2016;
Hendricks & Testa, 2012). For example, although
there are now several professional documents that
guide mental health practice with transgender cli-
ents, few mention clinical care for nonbinary peo-
ple. The American Psychological Association’s
(2015) Guidelines for Psychological Practice with
Transgender and Gender Nonconforming People
notes that a “nonbinary understanding of gender
is fundamental to the provision of affirmative
care,” highlighting the potential for gender to be
fluid and widely diverse (p. 835). Unfortunately,
this set of guidelines does not address differences
that may arise when working with binary and
nonbinary clients, or the unique needs of nonbi-
nary clients. Likewise, both the American
Counseling Association’s (2010) list of clinical
competencies and the World Professional
Association for Transgender Health’s (WPATH)
Standards of Care for the Health of Transsexual,
Transgender, and Gender-Nonconforming People
(Coleman et al., 2012) acknowledge a lack of (but
need for) differentiation between the many diverse
gender identities, including nonbinary and gender-
queer-identified people. Lack of training and
experience in transgender health in general, and
with nonbinary clients in particular, put clinicians

at a distinct disadvantage in their ability to fully
assist gender diverse clients.

Recently, two resources were published that
begin to highlight the unique needs of, and clin-
ical recommendations for working with, nonbi-
nary and genderqueer clients. The American
Psychological Association’s Society for the
Psychology of Sexual Orientation and Gender
Diversity produced the first fact sheet on nonbi-
nary gender identity, including clinical recom-
mendations for mental health providers (Webb
et al., 2017). Additionally, the National LGBT
Health Education Center (2017) published an
introductory guide to providing affirmative health
care to nonbinary individuals. Comprehensive
models for clinical work that are inclusive of
nonbinary and genderqueer individuals are lack-
ing and are critical for developing appropriate,
culturally competent intervention strategies with
this population. The Gender Affirmative Lifespan
Approach (GALA; Berg et al., 2017, described in
Spencer & Vencill, 2017) was developed as a
trans-affirmative psychotherapy framework that is
explicitly inclusive of nonbinary people and val-
ues nonbinary identities as central to the overall
approach. The authors aimed to create an
evidenced-based, integrative psychotherapy
approach to challenge the historical binary cis-
and heteronormative models of transgender
health care.

Methods

Brief overview of the GALA model

The authors of this conceptual article present
GALA, a psychotherapy framework based in
health disparities theory and research, which
asserts that therapeutic interventions combating
internalized oppression have the potential to
improve mental health symptomatology resulting
in improved overall health and well-being for
gender diverse clients. The GALA model is com-
prised of five philosophical foundations, as well
as five core components. In promoting healthy
gender development, the five core components of
GALA are defined as the practical application
areas in which clinical interventions are focused.
These interventions are tailored to the develop-
mental phase of each client to create an

278 G. N. RIDER ET AL.

individualized treatment approach. The five
philosophical foundations are the main concep-
tual values on which these interventions
are based.

The five GALA philosophical foundations

The philosophical foundations of GALA include
the values of: (1) trans-affirmative care; (2) inter-
sectionality; (3) transparency; (4) developmental
differences in care across the lifespan; and (5) an
interdisciplinary approach (Berg et al., 2017;
Spencer & Vencill, 2017).

GALA counters gatekeeping models of trans-
gender care through a trans-affirmative approach
that centers transgender voices and experiences,
and asserts that being transgender is an identity,
not a disorder (Carroll & Mizock, 2017; Hidalgo
et al., 2013). The value of intersectionality
requires that, when addressing an individual’s
gender, clinicians recognize and acknowledge that
the cultural contexts of race, class, sexual orienta-
tion, ability status, and other important identities
are inextricably linked and interwoven into a per-
son’s lived experience (Crenshaw, 1991; Nadal,
2013). Additionally, GALA promotes transpar-
ency (Brown, 1994) as a critical practice to sub-
vert processes of oppression in gender health
care. Specifically, this involves intentional infor-
mation sharing between clinician and client, and
breaking down difficult-to-access or -interpret
concepts and procedures (Singh & Burnes, 2010).
Transparency is important in countering the opa-
city of systems of power (e.g., accessing health
care in a historically transphobic culture and
environment) that serve to perpetuate pathologiz-
ing narratives of gender diverse, nonbinary, and
transgender bodies and sexualities (Spencer &
Vencill, 2017). The GALA model emphasizes
attention to generational and developmental dif-
ferences across the lifespan with regard to gender
identity and expression over time (Berg et al.,
2017). Therapeutic approaches are tailored based
on whether the client is a child, adolescent,
emerging adult, elder, and so on, and incorporate
attention to generational differences that shape
gender exploration and identity development.
Finally, interdisciplinary approaches are central to
GALA and critical to informing competent

practice with gender diverse clients, who often
interact with multiple providers from a range of
disciplines (Ettner, Monstrey, & Coleman, 2016).
These philosophical foundations are the frame-
work of GALA and inform the process of apply-
ing the five core components of the model in
clinical work.

The five GALA core components

As previously mentioned, the GALA core compo-
nents are the main overarching topics for clinical
application and intervention. The five core com-
ponents of GALA include: (1) developing gender
literacy; (2) building resiliency; (3) moving
beyond the binary; (4) exploring pleasure-ori-
ented positive sexuality; and (5) making positive
connections to medical interventions (Berg et al.,
2017; Spencer & Vencill, 2017). Developing gender
literacy is the process of identifying and naming
oppressive practices within a society shaped by
the binary gender paradigm. Gender literacy also
involves understanding that one’s body does not
define their gender identity or expression (Berg
& Edwards-Leeper, 2018). Building resiliency
involves learning how to overcome adversity and
effectively cope with challenging situations in life
(Jew, Green, & Kroger, 1999; Singh, Hays, &
Watson, 2011). Resiliency building also involves
finding and creating safe places (e.g., with family,
friends, community groups) to share these diffi-
culties and to gain support (Bockting, Miner,
Swinburne Romine, Hamilton, & Coleman, 2013;
McCann & Brown, 2017; Singh et al., 2011;
Testa, Jimenez, & Rankin, 2014). Gender and sex-
ual binaries pathologize nonconformity and can
limit healthy gender and sexual expression
(Burdge, 2007; Saewyc, 2017). Thus, moving
beyond the binary allows for the inclusion and
affirmation of all gender identities and expres-
sions (Berg et al., 2017; Burdge, 2007). Research
and practice in the past have focused largely on
negative sexual outcomes for transgender and
gender diverse people (Spencer & Vencill, 2017),
and little attention has been paid to how dys-
phoria, stigma, and relational experiences shape
sexual and gender health (Glynn et al., 2016).
Since gender identity and affirmation can play
such a critical role in healthy sexuality (Hill-

INTERNATIONAL JOURNAL OF TRANSGENDERISM 279

Meyer & Scarborough, 2014; Spencer, Iantaffi,&
Bockting, 2017), developmentally appropriate
psychotherapy aimed at exploring pleasure-ori-
ented positive sexuality is extremely important to
fostering healthy gender and sexual development
(Spencer & Vencill, 2017; Spencer et al., 2017).
Lastly, gender competent clinicians need to facili-
tate referrals for appropriate medical interventions,
including knowledge of the full spectrum of gen-
der care, not just binary-focused interventions
(Coleman et al., 2012; Lev, 2004; National LGBT
Health Education Center, 2017).

The GALA model was developed to assist with
facilitating gender health as well as improving
overall health and well-being for gender diverse
clients. As previously mentioned, professional
education and training opportunities for working
with nonbinary individuals are lacking (Budge
et al., 2016; Hendricks & Testa, 2012; Matsuno &
Budge, 2017). Furthermore, there is limited pub-
lished guidance for facilitating affirming interven-
tions with nonbinary individuals at different
developmental stages in clinical settings. As such,
the authors of this article have provided key rec-
ommendations for clinical work with nonbinary
clients using GALA. These recommendations are
based both on existing scholarly work as well as
on the work of the authors, who are all mental
health providers and gender specialists with
experience providing clinical services to nonbi-
nary clients. Note: two of the authors also iden-
tify as nonbinary people of color.

Results

Key GALA recommendations for clinical work with
nonbinary clients

Developing Gender Literacy
In applying GALA with nonbinary clients, the first
core component, gender literacy, is highly useful in
disrupting binary gender assumptions. Gender lit-
eracy involves identifying and externalizing
oppressive gender narratives that have become
invisible (Berg & Edwards-Leeper, 2018). A key
role clinicians can play is to validate the client’s
gendered experience and support them in develop-
ing an ability to critique and externalize the
embedded binary messaging pervasive in

dominant culture (Berg et al., 2017). Many nonbi-
nary clients are apprehensive about accessing clin-
ical services, anticipating clinicians’ lack of
knowledge about nonbinary identities and a med-
ical system that is based in reinforcing a binary
gender paradigm (National LGBT Health
Education Center, 2017). Clinicians have the
opportunity to be transparent about the binary
medical system while also serving as an advocate
for nonbinary clients within the system.

Moving Beyond the Binary
Another value of GALA is the concept of moving
beyond the binary to a gender spectrum
approach. The history of transgender health care
is mired in heteronormative, cisnormative, bin-
ary-enforcing gender assumptions (Burke, 2011;
Davy, 2015; Nieder & Richter-Appelt, 2011).
Early treatment protocols for transgender care
were deeply embedded in the colonized frame-
work of heterosexuality and accompanying gen-
der binary assumptions of patriarchal femininity
and masculinity (Butler, 2004, pp. 75–101;
Johnson, 2007). The unexamined norm guiding
transgender health care was that of compulsory
heterosexuality (Rich, 1980), with its assumption
of femaleness mapping onto stereotypical femin-
inity and maleness (when even considered, since
most of early transgender health care focused on
transgender women) assuming stereotypical mas-
culinity (Burke, 2011; Davy, 2015; Nieder &
Richter-Appelt, 2011). The enforcement of binary
genders within transgender health care served to
regulate what gender identities and expressions
were deemed “legitimate,” which further operated
to label as deviant and oppress gender expres-
sions and sexual desires that did not fit within a
heteronormative, cisnormative framework. For
example, binary transgender identities are often
seen as valid based on medicalized standards;
however, nonbinary identities are often perceived
as deviant or nonexistent and thus invalidated,
ignored, or rendered invisible. As a result, nonbi-
nary individuals who are interested in medical
interventions may present themselves as identify-
ing with singular, binary gender stereotypes in
order to access care. This process results in per-
petuation of oppression and invisibilizing of non-
binary individuals. Shifting to move beyond the

280 G. N. RIDER ET AL.

binary is essential in shattering the ties between,
and challenging frameworks centered on, transne-
gativity, misogyny, homonegativity, and coloniza-
tion (Hendricks & Testa, 2012). Applying this in
clinical work is to not only elucidate the history
of how a binary gender paradigm serves as an
underpinning to heteronormativity, cisnormativ-
ity and patriarchal gender norms, but to also
actively validate nonbinary identities and expres-
sions (Berg et al., 2017).

Building Resiliency
An important task of psychotherapy is to support
a client’s resilience to stigma, discrimination, and
stress (Hendricks & Testa, 2012). In working with
nonbinary clients, building resiliency includes
addressing the specific stressors of living as a non-
binary person in a binary world (Berg et al., 2017;
National LGBT Health Education Center, 2017).
One potential clinical intervention to utilize for
building resiliency is through supporting nonbi-
nary clients in connecting with resources online,
in communities, and via other social outlets.
Connecting to social supports and sharing experi-
ences of stigma with similar others has been
shown to improve mental health outcomes in cop-
ing with minority stress (Bockting et al., 2013;
Budge, Adelson, & Howard, 2013). Additionally,
finding role models and other nonbinary people
in the community are important components of
building resilience (Craig, McInroy, McCready, &
Alaggia, 2015). Learning how to self-advocate in
social situations, as suggested in cognitive behav-
ioral therapy models of trans-affirmative therapy
(Austin & Craig, 2015) and enrolling the support
of allies in challenging stigma (Harper &
Schneider, 2003), can be another boost to building
client resiliency.

Exploring Pleasure-Oriented Positive Sexuality
As noted above, compulsory heterosexuality and
concordant normativity in sexuality is resultant
in the rigidity of the gender binary, in that it
assumes mapping of heteronormative desire onto
binary gender categories (Butler, 2004; Rich,
1980; Serano, 2007). Nonbinary, genderqueer,
and gender nonconforming people have long
been seen as deviant in their variance from con-
formity to these sexual and gender norms

(Richards et al., 2016). Nonbinary bodies and
sexualities have been pathologized, ignored, and
misunderstood, leading to a lack of competent
resources for promoting sex positive pleasure,
satisfaction, and healthy sexual functioning (Hill-
Meyer & Scarborough, 2014; Richards et al.,
2016). As such, a core component of GALA is
pleasure-oriented positive sexuality; that is, pri-
oritizing pleasure and satisfaction for all bodies
across the gender spectrum. Existing models of
sexua