Copyright Sociological Research Online, 2003


Stephen Hicks and Katherine Watson (2003) 'Desire Lines: 'Queering' Health and Social Welfare'
Sociological Research Online, vol. 8, no. 1, <>

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Received: 5/12/2001      Accepted: 26/2/2003      Published: 28/2/2003


This article considers how knowledge about lesbians and gay men is produced in health and social welfare texts. It looks at the consequences of a reliance upon the liberal 'ethnic model' of sexuality. The authors provide a critique of 'anti-discriminatory practice' versions of sexuality categories which, in their view, assert the liberal model at the expense of ideas found in the sociological traditions of gay liberation, lesbian feminist, interactionist and queer/postmodern theories. Through a queer reading of health and social welfare texts specifically addressed to sexuality, the article considers the hierarchy of sexual knowledges which promote heteronormativity; the reliance upon fixed identity models of sexuality; the functionalist view of a "gay culture"; the silencing of lesbian feminism; and the traditionally gendered and fetishistic versions of 'the lesbian' produced. The authors argue against merely 'adding in' lesbians and gay men, and in terms of practice, encourage a reflexive engagement by all practitioners with the ways in which these dominant discourses concerning sexuality populate and discipline knowledges within health and social welfare.

lesbians; gay men; sexuality; health; nursing; social welfare; social work; anti-discriminatory practice; queer; education


This article is concerned with the forms of knowledge about lesbians and gay men that exist within the disciplines of health and social welfare. Our aim is to examine the production of knowledge about sexuality that occurs in mainstream health and social welfare texts and, in doing so, demonstrate that this is an active epistemological process, and crucially one that influences practice within these applied disciplines. The examination of this process is, we feel, important because certain claims as to how things are 'out there' in the world become naturalised, and thus accepted as representing the 'truth' of lesbian and gay lives.

As discursive regimes which legitimate and assert ideas about the categories 'lesbian' and 'gay', we believe the texts themselves are practices and therefore worthy of study in their own right. We say this because we want to avoid the notion that health and welfare texts are simply examples of theory which may or may not influence something called practice. It is our view that, within our disciplines, textual 'descriptions' of lesbians and gay men are often taken as factual. In addition, the texts themselves divert attention from their production of the categories 'lesbian' and 'gay'. These texts "construct the description as independent of the agent doing the production" (Potter 1996:150), so that lesbians and gay men appear to simply be. In our view, these are both practical matters with important consequences.

One such consequence is that texts which offer guidance to health and welfare practitioners actually promote some versions of 'lesbian' and 'gay' over others. These versions we will characterise as the liberal "ethnic model" of sexuality (Epstein 1987), in that they see lesbians and gay men as an essentially different group with particular lifestyles and special needs. The result is that practitioners believe that, if only they meet these needs, then lesbians and gay men will not be discriminated against and can be offered equality with heterosexuals. Elsewhere, however, lesbian and gay theorists have been highly critical of the liberal model, characterising it as assimilationism and mere "virtual equality" (Goldstein 2002; Kitzinger 1987; Vaid 1995; Warner 1999). For these authors, such belief systems actually obstruct a more dynamic project of transformation, one that would seek to problematise the notion of heterosexuality as a given. As Urvashi Vaid states:

A mainstream civil rights strategy cannot deliver genuine freedom or full equality for one fundamental reason: the goal of winning mainstream tolerance...differs from the goal of winning liberation or changing social institutions in lasting, long-term ways (Vaid 1995:3).

Mainstream Approaches and 'Anti- discriminatory Practice'

Whilst there has been a visible drive towards addressing issues of inequality in both health and social welfare, we think that lesbian and gay issues are still largely absent (Logan et al. 1996; Wilton 2000), and standard texts give them scant attention (Adams et al 1998; Brandt & Rozin 1997; Gould 1990; Jones 1994; Nettleton 1995; Payne 1991,1997)[1]. This means that, for most students, the very idea of having to think about lesbians and gay men is not raised when they read texts on how to become a health or social welfare practitioner. However, even where lesbian and gay issues are addressed, we detect an approach that we call "adding in"[2]. This represents the mere insertion of lesbians and gay men into existing models of health and social welfare, without any attention being given to the ways in which these models promote certain views of sexuality over others.

It is evident, therefore, that whilst there is critical work being done, the ideas from lesbian feminist, gay liberation or queer theories have hardly impacted at all upon our disciplines of health and social welfare. As mentioned above, they are virtually absent from texts and, we predict, from teaching, which makes it all the more frustrating when we hear colleagues suggesting that 'queer theory is over' or has been 'done to death' in disciplines like women's and cultural studies. Regardless of whether this is the case, generally within the practice and teaching of health and social welfare, queer theory has yet to arrive. This reminds us of the debate within sociology about the study of sexuality, where it has also been strongly argued that it remains marginal (Nardi 2002; Roseneil 2002; Stein & Plummer 1996). Peter Nardi, for example, argues that where issues of sexuality are theorised within mainstream sociology this tends to be in such a way as to be "absent of any threat that the social, political, sexual, or moral order will become transformed" (Nardi 2002:45). This can be viewed as a form of assimilationism, in which lesbians and gay men are just added into an otherwise unchanged approach.

Within social work and welfare, this 'adding in' approach is termed "anti-discriminatory practice" (Thompson 1993). This theory is concerned that social welfare should not reproduce discrimination on the grounds of race, gender, age, disability, sexuality, and this we think is a good thing. However, it is also an extremely complex thing, and our concern is with the ideas about lesbians and gay men that currently pass for 'truth' in anti- discriminatory practice models. This is a dominant model for social welfare because anti-discriminatory practice is widely taught on social work courses, is a requirement for passing professional courses such as the Diploma in Social Work (DipSW) and BA Social Work[3], and Thompson's text (1993), now in its third edition (2001), has become the standard and most recommended reading (a "classic bestselling text," according to the publisher[4]).

Anti-discriminatory practice arose within the discipline of social work and welfare for a number of reasons in our view. First, it was a response to challenges from the margins made by various social-political movements including women's, black, disabled, lesbian and gay liberation groups (Taylor 1993). These activist movements were largely critical of social work and welfare for perpetuating, rather than challenging, oppression, and this resulted in the tradition of radical social work, to which we will return. Second, social work has had to respond to postmodern, feminist and other critical theories which have pointed out that its knowledge cannot be innocent (Flax 1993), but is instead always implicated in the process of formulating the very things it pretends only to describe (Chambon et al. 1999; Fawcett et al. 2000; Fook 2002; Healy 2000; Pease & Fook 1999; Rojek et al. 1988).

Third, however, anti-discriminatory practice can be seen as an attempt to assimilate these ideas into existing social welfare theories, whilst concomitantly defending and legitimating the profession as a whole[5]. What we mean by this is that anti- discriminatory versions of challenges to social welfare are very watered down, and we intend to show that they leave dominant discourses, such as "heteronormativity" (Warner 1993)[6], intact. Social welfare literature regulates ideas about sexuality so that the dominant discourse of the liberal model is foregrounded, and so that other more challenging models are silenced (Philp 1979).

Within social welfare, for example, there was actually an earlier tradition of radical social work thought which addressed sexuality in very different ways (Charing et al. 1975; Hart 1980; Milligan 1975). The Case Con collective was a radical social work group, some of whom were influenced by and involved in the lesbian feminist and gay liberation movements in the 1970s[7]. The collective argued that gay men and lesbians were oppressed by ignorance, hatred and prejudice, as well as sexism, and that the role of social welfare practitioners was or should be to oppose such discrimination.

Such ideas have now all but disappeared from view and memory in social welfare. 'Radical Social Work Today', published in 1989 (Langan & Lee 1989), for example, does not address lesbian and gay issues at all (but talks about class, race, gender, disability, age, economics). Thompson's (1993) text has separate chapters on race, gender, disability, and age but not on lesbians and gay men. Don Milligan's chapter in 'Radical Social Work' (Milligan 1975), talked about "rejection of the ideas of heterosexual superiority that permeate our culture" (p96), and argued that models of integration actually result in the "cultural submission of the minority to the majority" (p100). Now, Neil Thompson argues that social workers need a "greater understanding of homosexuality" (Thompson 1997:138), that whilst "a sympathetic approach" is inadequate, it is still "a worthwhile start," and that homosexuality is not "deficient" but just "different" (1997:139). In addition, the ideas of assimilation and integration are key to some social welfare texts on lesbians and gay men (Appleby & Anastas 1998; Mallon 1999).

Ideas about lesbians and gay men are shaped differently in health than they are in social welfare, mainly due to the disciplinary locations and histories specific to each. Nevertheless, with the increasing closeness of health and social welfare professionals through a series of government directives since the 1970s, the issues raised by anti-discriminatory practice are starting to impact upon nurse training (Vigars 1995), and thus critical discussion about the ways in which social work constructs ideas about anti- discriminatory practice are extremely pertinent.

Within nursing and health studies, the notion of anti-discriminatory practice is not as formalised as it is in social welfare. The idea of 'equality of care', however, appears in Royal College of Nursing mandates, and more generally these themes echo in the copious literature addressing the ethics of caring as central to nursing practice (Kemp & Richardson 1994; Seedhouse 1998; Slevin 1999). In addition, a plethora of texts devoted to the issue of communication in practice (Crawford et al. 1998; Halldorsdottir 1997; Morrison & Burnard 1997; Tourish 1999) also nod towards issues of identity and equality.

However, as with the social welfare examples above, core teaching texts that address the sociopolitical aspects of sexuality are few and far between (but see, for example, Wilton 2000). Whilst there is a vibrant critical tradition associated with nursing research, particularly around gender and mental health (Khuse 1997), this does not tend to be reflected in primary teaching texts. Particularly when issues of sexuality are addressed, there is a tendency to construct lesbians and gay men as in need of different and special attention. This is especially the case in texts dealing with nursing care and sexuality (Van Ooijen & Charnock 1994; Wells 2000).

Standard texts, even when addressing lesbians and gay men, add these issues into an already existing heteronormative framework. Texts that encourage nursing students to be reflexive discuss a range of scenarios which are unremarkably heterosexual, highlighted by the odd reference to the 'special needs' of the lesbian and gay client (Gould 1990). Moreover, a focus on an ethics of care or communication could, if not placed within a broader sociopolitical project, diminish the importance of challenging normative structures of representation and discrimination. For example, the notion of caring is based in principles such as 'enhancement of dignity', 'protection', 'regard for patients' and 'compassionate competence', but these general points can often obscure the dynamics of power and fail to mount a challenge at the level of beliefs and values, much less discourse or knowledge. As Halldorsdottir states:

If we content ourselves with a basically warmhearted, commonsense approach to caring as an essence of nursing, we may end up with idiosyncratic attitudes being accepted as legitimate answers to nursing problems (Halldorsdottir 1997:107).

'Queering' Mainstream Approaches

Whilst both of us are involved in teaching students on professional health and social welfare courses, we do not teach them 'how to work with lesbians and gay men'. Instead we prefer to ask difficult questions about what the categories 'lesbian', 'gay' and 'heterosexual' actually mean, and to encourage students to see that there are many competing versions. That is, we think it far better that health and social welfare practitioners, students and academics are reflexive about their use of, or assumptions that inform, 'lesbian' and 'gay' (Taylor & White 2000).

In this article, therefore, we engage in 'queering' the assumptions of some standard and anti-discriminatory texts. What, then, do we mean by the concept of 'queering'? We are borrowing here from ideas that have emerged within lesbian feminist, social constructionist, interactive and queer theories (Harne & Miller 1996; Kitzinger 1987; Plummer 1975, 1981; Seidman 1996). Clearly there is much disagreement amongst those within each of these traditions, and even more so between them all, and so it is important here that we outline the ideas from these theories that we have found most useful. All of them can be characterised by a concern to show that sexuality categories are neither natural nor inevitable, and crucially that the terms used (such as 'lesbian' or 'gay') do not describe but actually construct and make claims about the status of sexual knowledge.

Lesbian feminism, for example, challenged the idea that heterosexuality was normal and actually argued that it is a political institution designed to control the sexuality of women and silence the very idea of the 'lesbian' (Rich 1980). Celia Kitzinger points out that, within the framework of radical feminism, "heterosexuality, far from existing as a 'natural state', 'personal choice' or 'sexual orientation', is described as a socially constructed and institutionalised structure" (Kitzinger 1987:64). In a very different way, Ken Plummer's interactionist account of sexual stigma argued that "nobody becomes deviant 'all at once'..." (Plummer 1975:27), and that sexual meanings must be socially constructed and negotiated within interactions. Thus, rather than being a condition or description of a type of person, homosexuality refers to a social role which a person takes on over a period of time. This cannot exist without the reactions of others (and indeed the reactions of the self), and so the homosexual is defined as deviant by those who are not. Homosexuality is achieved and enacted, rather than something one simply is.

Queer theory has extended and developed some of these points, but with an explicit commitment to what are sometimes termed postmodern and Foucaultian ideas concerning knowledge (Halperin 1995; Seidman 1997; Spargo 1999; Turner 2000). We intend to use some of the concepts from queer theory and lesbian feminism in order to outline what we think are some problems with standard approaches to questions of sexuality in health and social welfare. This is a process of reading against the grain that we are calling 'queering'. Steven Seidman (1997) argues that the process of queering knowledge involves a desire to disturb the dominant paradigm within any discipline, to question its forms of knowledge rather than just 'adding in' lesbians and gay men (1997:99). Further, queering is a deconstructive process which questions foundational assumptions, and, by so doing, make queer what is known (Seidman 1997:xi). Finally queering will require asking questions about how the disciplines of health and social welfare have contributed to dominant discourses of heteronormativity (Seidman 1997:95).

Through a number of themes concerning knowledge, identity and gender, we intend to show how anti-discriminatory texts make foundational assumptions about sexuality categories which are heteronormative. In order to do this, we have chosen examples from some key health and social welfare texts. First, we have chosen texts which attempt to give an anti-discriminatory perspective in each discipline, namely Thompson's (1993) 'Anti- discriminatory Practice' for social welfare, and a series of linked articles on 'The ABC of Sexual Health' which appeared in the British Medical Journal (BMJ) from 1998-99 for health. In addition, we also consider some texts which are devoted explicitly to lesbian and gay issues in social work (Appleby & Anastas 1998; Hunter et al. 1998; Mallon 1999), and nursing (Wells 2000).

Who Knows?

What both lesbian feminist and queer theories have suggested, albeit in different ways, is that sexuality itself is a system of knowledge. While lesbian feminism pointed out that heterosexuality was a system used to restrict and control women's sexual choices (Rich 1980), queer theory has argued that the very categories of the 'homosexual/heterosexual' are used to frame ideas about sexuality into moral and political hierarchies (Seidman 1997; Stein & Plummer 1996). This means that claims about sexuality made within various disciplines, such as those of health and social welfare, are in fact the operations of power resulting in the establishment of normative frameworks. Social work, for example, is a key area in which knowledge claims about sexuality are routinely made via the operations of an expert or professional discourse.

Queer theory has also turned its gaze upon the ways that various institutional practices and discourses in fact produce sexual knowledges, since they bring into being and characterise sexual subjects. Carol-Anne O'Brien (1999), for example, has shown that social work literature pathologizes or marginalizes lesbians and gay men, and that it equates the very notion of 'sex' with heterosexuality (O'Brien 1999:141-3). That is, dominant discourses concerning sexuality within social work establish and maintain heterosexuality as a norm. Whilst neither we nor O'Brien deny that there is social work knowledge on lesbians and gay men[8], O'Brien argues that social work as a whole maintains these as specialised and subordinate areas of knowledge (O'Brien 1999). She argues that "social work and social welfare literature and practice are far from being socially neutral or limited to technical interventions; they are deeply implicated in the construction of power relations in sexuality" (O'Brien 1999:151).

Queer theory is, then, interested in how and why heterosexuality is an organising principle of knowledge, how it is 'natural' and taken-for-granted. Gayle Rubin (1993) has pointed out that sexual knowledge maintains heterosexuality (and even particular forms of heterosexuality) at the top of a hierarchy, and these operations queer has labelled 'heteronormativity' (Warner 1993). It is therefore the job of queer theory to work against this, to question and throw a critical spotlight onto heteronormativity.

One of queer theory's main arguments here, borrowing from a postmodern concern with hierarchical binaries which structure systems of knowledge, is to point out that heterosexuality depends upon an abject homosexuality for its very security:

...homosexuality and heterosexuality do not represent a true pair, two mutually referential contraries, but a hierarchical opposition in which heterosexuality defines itself implicitly by constituting itself as the negation of homosexuality. Heterosexuality defines itself without problematising itself, it elevates itself as a privileged and unmarked term, by abjecting and problematising homosexuality. Heterosexuality, then, depends on homosexuality to lend it substance - and to enable it to acquire by default its status as a default, as a lack of difference or an absence of abnormality" (Halperin 1995:44, emphasis in original).

We think that taken- for-granted heterosexuality is evident in many ways within health and social welfare texts. The BMJ series, for example, features pictures of white heterosexuals almost exclusively, even though the text often uses non-gendered terms to describe sexual partners. Thus 'male' and 'female', unless prefixed with the word 'homosexual', mean heterosexual (Butcher 1999; Gregoire 1999). In addition, we think that the BMJ series presents ideas about lesbian and gay sex as special 'kinky' sex. For example, bondage, cottaging, cruising, fisting and rimming (to name a few) are listed as part of a gay sex vocabulary (Bell 1999:453) that sets lesbian and gay sex apart from heterosex. On a very basic level, we must ask whether such things as bondage, cottaging, cruising, rimming, fisting or sadomasochism are exclusively lesbian and gay sexual practices.

One of the symptoms of heterosexuality's dependence on an abject or even kinky homosexuality is that it must always be positioned as a privileged subjectivity, as the position from which knowledge is derived. Professional discourses, therefore, operate to define lesbians and gay men as that which can be known, as the object of study. Queer theory explicitly attempts to "shift heterosexuality from the position of a universal subject of discourse to an object of interrogation and critique, and to shift homosexuality from the position of an object of power/knowledge to a position of legitimate agency - from the status of that which is spoken about while remaining silent to the status of that which speaks" (Halperin 1995:57).

In anti- discriminatory practice texts, however, homosexuals are something to be understood or known about. Gerald P. Mallon's text on child welfare, for example, provides his readers with a list of questions to ask themselves how much they really know about lesbians and gay men (Mallon 1999:33). Thompson also argues for awareness training and consciousness-raising for practitioners (Thompson 1997:158), Hunter et al. argue for greater knowledge of lesbian and gay populations (Hunter et al. 1998:4), while Appleby & Anastas' text offers itself as a "comprehensive, up-to-date textbook [which] helps social workers understand and meet the needs of lesbian, gay, and bisexual people" (Appleby & Anastas 1998:back cover). Finally, Wells et al. (2000) offer their readers a proposed aetiology of the homosexual. All of these texts are written from the perspective of the heterosexual knower, a position which confers epistemological authority and the power to define lesbians and gay men as having a set of identifiable characteristics.

Identity Crisis

The 1990s and after has seen the emergence of a whole series of critiques of the very idea of lesbian and gay identities (Archer 2002; Doan 1994; Queen & Schimel 1997; Roseneil 2002; Simpson 1996; Sinfield 1998; Smyth 1992; Stein 1997; Vaid 1995). This was also preceded by black lesbian and gay writers who pointed out that gay identities were almost always imagined or represented as white (Beam 1986; Lorde 1984; Shah 1993). In fact, it is highly debatable that there has ever been a period of 'fixed' or 'essential' lesbian or gay identity either within academic theorising or local communities and activisms. While queer theory may like to claim that its challenge to the very idea of a unified homosexual identity is new, in fact most of lesbian and gay theory questions identities in some way or another. Lesbian feminist and gay liberation theories, for example, were built upon the idea of identities as socially constructed, political and therefore changeable, but even within these traditions they were contested.

What queer theory has done, however, is to argue strongly against what may be termed a liberal "ethnic model" of lesbian and gay identities which prevailed through the 1980s (Epstein 1987). This ethnic model can be understood as having emerged from claims to equality based upon the idea of a common-interest but minority group. The problem with this position is that it tended to reify the idea of the homosexual, so that she or he became a distinct type of person. The ethnic model of lesbian and gay identities is therefore problematic because it tends to homogenise those categories, not least in terms of race (Lorde 1984). This leads to the idea that lesbians and gay men have a fixed identity, that they are particular types, and that they have special needs which differ from those of the population as a whole. Instead queer theories have pointed out that, whilst lesbian and gay identities may persist and have some political uses, they can never be adopted innocently or without consequence (Butler 1991; Seidman 1996). That is, identity categories are not descriptive referents, but ways of thinking and making claims about sexuality.

Within the social welfare literature, however, we detect a fixed identity or "ethnic" approach. Mallon's text, for example, argues that a foundational component for practitioners is "knowledge of the history, culture, traditions and customs, value orientation, religious and spiritual orientations, art, and music, of gay and lesbian communities" (Mallon 1999:23). While he is keen to point out that there are differences amongst lesbians and gay men, Mallon's approach suggests to us an easily assimilated gay culture and identity. This is also promoted in Thompson's text on anti-discriminatory practice, which uses a model of 'sexual identity' and, as we have already pointed out, argues that homosexuality is not deficient but just different (Thompson 1997:139).

Diane Wells et al. (2000), in a recent textbook dealing with sexuality in health and illness, also construct homosexuality in terms of a fixed identity. The text assumes a heterosexual stance as neutral, based on the assertion that "heterosexuality is, statistically speaking, so obviously the 'norm'..." (Wells et al. 2000:155), and offers only a small subsection in one chapter entitled 'Homosexuality'. Whilst the authors do state that in clinical practice "each case needs, in the usual way, to be assessed on its merits rather than on the basis of personal or societal stigma" (156), a checklist of causal factors leading to homosexuality is provided. So, for example, "homosexuality may arise through fears and anxieties over interacting with the opposite sex", or "may reflect a response to social isolation or alienation" and that "traumatic sexual experiences" and "poor relationships with parents" may have contributed to the emergence of a homosexual identity (155-156). The authors also state that it is important, however, to appreciate "that sometimes the person's own behaviour (in terms of unusually marked feminine or masculine traits) may have elicited the parental reactions" (156).

There are plenty of other examples of the "ethnic" model of sexuality: the text by Appleby & Anastas argues that "there is no need to develop a new model or theory of social work practice with lesbians, gays and bisexuals," but rather simply the need for "lesbian/gay-affirmative practice" (Appleby & Anastas 1998:396). Mallon's text echoes this in adopting a "gay- and lesbian-affirming perspective," and he even provides a set of questions for the reader which are designed to aid "an honest assessment of one's level of functioning with 'different' others" (Mallon 1999:33). The text by Hunter et al. argues that the "lesbian and gay community is represented by a national culture. This is symbolised by Pride Day parades..." (Hunter et al. 1998:37), and Bell's (1999) BMJ article echoes this through the pictorial representation of 'gay culture' in terms of club scenes and the inclusion of a 'gay sex vocabulary'.

We think that such ideas have two important consequences for an understanding of lesbians and gay men within health and social welfare. First, these are seen merely as a natural variation of sexuality, but within a system that promotes and enforces heterosexuality they can only ever be a deviation from the standard. Second, 'lesbian' and 'gay' are seen as referring to embodied selves or identities which can be easily known by health and social welfare. We imagine a tour-bus taking practitioners to view the national culture, music, art and customs of lesbians and gays: gay discotheques, k.d. lang concerts, finely crafted dildos, drag shows. All of this personalises or individualises the idea of lesbians and gay men, but much of lesbian and gay theory has suggested these are, in fact, epistemological categories. Some lesbian feminist theorists, for example, have argued for a different way of interpreting the world which rejects the ways that lesbians and gay men are only assessed by their variation from a heterosexual norm.

A further point that has been made, especially within lesbian feminist, black and queer theories, is that identities are multiple, since they must take account of race, gender or disability as much as sexuality (Lorde 1984; Shakespeare et al. 1996; Smith 2000). Queer theory has taken this concern with the fracturing of identities to show that they are not essences, but rather actions or what Stuart Hall has called "a 'production', which is never complete, always in process, and always constituted within, not outside, representation" (Hall 1990:222). Queer theory is, then, not interested in identities as essences describing sexualities, but rather in how such forms of knowledge operate.

Within anti- discriminatory practice texts, however, we think that identity aspects are treated as wholly discrete. This is especially true of issues of race and ethnicity. In fact, the very ideas of race and ethnicity are applied as belonging only to black people. Hunter et al., for example, apply the phrase "racial and ethnic lesbian, gay, and bisexual persons" in just this way (Hunter et al. 1998:10), and their book proceeds to outline how different black communities regard questions of sexuality. For example, we are told that "Asian American lesbians and gay men... generally identify more strongly with their lesbian and gay identity than with their Asian American identity...," or that, within "African American groups, there are Black-identified lesbian, gay, and bisexual persons and lesbian, gay, and bisexual-identified Black persons" (Hunter et al. 1998:47). Our objection, here, is that black lesbian, gay and bisexual people are being compartmentalised into 'types', either by racial origin or by identification, being asked to prioritise one aspect over others (Lorde 1984). Whilst these texts do acknowledge that lesbians and gay men are not solely white, they also set up a series of racial types and cultures and their attendant attitudes towards questions of sexuality[9].

Within the BMJ series, questions of disability emerge only in a discrete article on "sexual problems of disabled patients" (Glass & Soni 1999). Here we see that the issue of disability is raised to question an otherwise assumed discourse of heterosexual penetrative intercourse, but only for those deemed to be 'impaired'. Glass & Soni comment that "defining sexuality as wider than just physical function is particularly important for people with disabilities" (Glass & Soni 1999:518), yet physical ability is clearly regarded as a defining feature of sex in the BMJ series as a whole.

This has two important consequences in our view. First, the notion of 'sexual dysfunction' is linked to any form of sex which is not heteronormative penetrative intercourse. Second, this is seen as some kind of automatic problem for disabled people, dealt with in a separate article even though others in the series also raise potential sexual problems. We cannot see, for example, why Glass & Soni's list of common sexual difficulties - "erectile difficulties", "difficulties with ejaculation" or "fertility problems" (1999:520) - are in any way specific to disabled people. Our point here is that disabled people are treated as deficient, but also that they are constructed as particular types identified by their difference from the able bodied norm. As with race or ethnicity, disability is reified and further treated as wholly separate from sexuality categories (Shakespeare et al. 1996).

Finally, queer theory has also been at pains to point out that all such fixed versions of identity are regulatory and disciplinary, since they are forms of knowledge which define lesbians and gay men in certain forms over others. This point was also made in a different way by Ken Plummer using labelling theory in the early 1980s (Plummer 1981). We need to develop categories about ourselves in order to make sense of our experiences, but these may also restrict us and can even serve to dominate and control. We may feel relaxed out on the gay scene, but this may also serve to segregate us, a point also forcefully made by the Gay Liberation Front's command to "come out everywhere," not just in gay spaces (Blasius & Phelan 1997).

We detect such regulatory practices in the ideas about gay identities and communities promoted within social welfare literature. The gay scene (a commercial collection of bars, clubs and even products promoted as 'gay') is frequently regarded as a gay community in these texts. Texts like those of Appleby & Anastas or Mallon take a functionalist view of what they see as the gay community, which they regard as a haven and a coping strategy for lesbians and gay men who experience stress in the heterosexual world. Appleby & Anastas, for example, see the lesbian and gay community as a "social, political, and psychological buffer... to the hostility of the dominant culture" (Appleby & Anastas 1998:81). Mallon, too, argues that lesbians and gay men have to find some "goodness of fit" with their surroundings (Mallon 1999:56), and this is because both texts adopt an ecological or systems approach in which lesbians and gay men are ultimately expected to assimilate into the wider society.

We would like to highlight just two examples of this assimilationism. Appleby & Anastas adopt a 'Minority Identity Development Model', proposed by Atkinson et al. (1979:198), which is concerned with the assimilation of all 'minorities' into the dominant culture:

The cultural ideal of the United States is assimilation, or the process of diverse racial and ethnic groups coming to share a common mainstream culture. Lesbian, gay, or bisexual clients may fall on any point along the continuum of acculturation, may or may not be assimilated in all aspects of their lives, and may or may not experience the anomie that results from cultural dissonance (Appleby & Anastas 1998:102).

Under this model, those agitating for change and resisting the norms of both whiteness and heterosexuality are regarded as experiencing dissonance, something that has to be resolved. The Atkinson et al. model proposes a move from initial conformity, through a stage of resistance, towards a final point of 'synergetic articulation'. At this final stage, the person experiences self fulfilment and individual control, having resolved the conflicts and discomfort associated with the middle-stage of resistance, which is seen as being "too narrow and rigid" (Appleby & Anastas 1998:105). This suggests that lesbian and gay political activism, or indeed seeing the categories as being about challenges to heterosexual privilege, is exactly just a passing phase to be negotiated and resolved.

In Mallon's text, a case study of Lonnie, an African-American nine-year-old boy, is discussed as Lonnie is being treated for 'gender identity disorder'. Lonnie shows no concerns about his being a boy, but Mallon suggests that there are some potential indications that he might be gay - he is artistic, wants to be a dress- designer, hates sports and does not want to marry. Lonnie's adoptive parents continue to see him as gender disordered because he is effeminate and acts 'like a girl' (Mallon 1999:6). Aged 12, Lonnie thinks that he might be gay, and Mallon suggests that his diagnosis be changed to a Post-Traumatic Stress Disorder due to his history of physical abuse as a child (1999:5). His adoptive parents agree to help him with his sexuality, but what strikes us the most is the way that Lonnie's atypical gender behaviour is a problem, and one that must be resolved either through an explanation of disorder or through the notion that gays are artistic, good at dress design or bad at sports. Not once is the idea raised that it is the gender system that is wrong.

These fixed identity models have at least two important consequences for our argument here: first, in adopting any form of identity to represent lesbians and gay men as a whole, inevitably there will be many who will be deemed outside of this. This can result in distinctions of the 'good homosexual' versus the 'bad queer' (Hicks 2000; Rubin 1993; Smith 1994; Warner 1999), particularly of the sort made by the gay conservatives or mainstreamers (Bawer 1993; Sullivan 1995). Second, adopting any kind of lesbian or gay position will always have consequences or social effects. Thus 'coming out' as lesbian or gay will never result in the liberation of our true selves, since we are actually entering into discourses which define us as we live through them. We do not have a pre-existing 'sexuality' to be freed, instead we enter into a web of sexual meanings. As David M. Halperin puts it, if " come out is to release oneself from a state of unfreedom, that is not because coming out constitutes an escape from the reach of power to a place outside of power: rather, coming out puts into play a different set of power relations and alters the dynamics of personal and political struggle" (Halperin 1995:30). Following Foucault (1978), then, queer theory is interested to understand how discourses of sexuality emerge and operate, how they work to legitimate some ideas and delegitimate others.

Gender Trouble

As we have noted already, there has been a consistent questioning of the gender and racial biases of lesbian and gay theories for many years, and, in relation to queer theory, this has resurfaced in concerns that queer theory may just be the reassertion of white male versions of theory (Edwards 1998; Hammonds 2001; Jeffreys 2003; Smyth 1992; Wilkinson & Kitzinger 1996). This is by no means agreed, however. Clearly some queer theorists work from a feminist and/or anti-racist position (Butler 1990; Roseneil 2000; Somerville 2000; Turner 2000; Wilton 2000), and the notion that there is an appropriate lesbian theory distinct from queer theory is disputed (Giffney 2003; Stein 1992). However, there is certainly a problem with any queer theory which represents feminism as essentialist or based upon 'identity politics' in order to claim a more evolved position. This point is made by Lynn Segal (1999), who argues that some postmodern theorists claim to abhor all forms of binary logic and generalisation, yet themselves set up fake contrasts between a narrowly defined feminism and the more enlightened world of the postmodern[10].

In our view many of the ideas of queer theory are prefigured in lesbian feminist accounts. Lesbian feminism, for example, clearly evolved a range of critiques of the political institution of heterosexuality (Radicalesbians 1970; Rich 1980; Wittig 1992), and forms of radical feminism used social constructionist views of sexuality and gender in order to argue that such concepts were not natural but wholly political and therefore malleable. This does not mean that these earlier analyses are in fact just like queer theory, for they use quite different sets of ideas, but queer theory's assertion that sexuality categories are part of a hierarchical system of knowledge can certainly be recognised in lesbian feminism, though in a form which is much more explicitly concerned with gender and opposition to sexism.

The Radicalesbians (1970), for example, argued that 'the lesbian' emerges because women cannot and should not accept the proper place accorded to the 'female role' in society. She is "the rage of all women condensed to the point of explosion" and she is their liberation (Radicalesbians 1970/1972:396). In fact, Radicalesbians argued that the very concepts of 'lesbian' and 'gay' were only possible in "a sexist society characterised by rigid sex roles and dominated by male supremacy" (Radicalesbians 1970/1972:396). Like other lesbian feminists, Radicalesbians also argued that lesbianism was not equivalent to male homosexuality, since lesbians were oppressed because they are women, and that women were held in general contempt by a male- dominated society.

Within the health literature, however, we find a number of problems in the ways that lesbians are treated. Women are not treated as seriously as men, lesbians are subsumed within the category 'women' or they are treated in highly heterosexualised and fetishistic ways. For example, Josie Butcher's piece in the BMJ series tells us that "loss of desire for sexual activity is the commonest presenting female sexual dysfunction and often the hardest to treat" (Butcher 1999:41). Butcher names this as "hypo- sexual desire disorder", thus medicalising and pathologising women's dissatisfaction with heterosex. In addition, Gregoire actually states that "there is evidence that women are more attracted to more powerful or socially dominant men" (Gregoire 1999:247).

In her historical analysis of hysteria, Rachel Maines (1999) provides some context to understanding these ideas. Maines addresses what she calls the androcentric model of sexuality which consists of three essential steps: preparation for penetration, penetration and male orgasm. In this still popular model, women's successful sexual satisfaction is linked only to penetration and male orgasm, with the unsurprising result that the 'unorgasmic' 70% of the female population is defined as "abnormal or 'frigid', somehow derelict in their duty to reinforce the androcentric model of satisfactory sex" (Maines 1999:5). A study by Masters and Johnson (1966) which resulted in their authoritative 'bell curve' of female orgasm (and employed in Butcher's BMJ article as a guide to 'normal' female sexual response) is closely criticised by Maines. She argues that Masters and Johnson selected only women who reached orgasm regularly in coitus, and thus a minority, a fact the researchers had known at the time. She states:

Were it not for the very strong and apparently widespread bias in the direction of the androcentric norm, Masters and Johnson would have been the laughing stock of the medical community (Maines 1999:119).

In addition the BMJ series talks about women's sexual problems in a language of generality ("female sexual problems" Bell 1999:454; "problems with fertility" Glass & Soni 1999:520), whereas men's sexual problems are more specifically categorised ("erectile dysfunction" or "retarded ejaculation" Bell 1999:454). Gay men's sexual problems are also talked about in specific ways, whereas lesbians are mentioned only briefly or subsumed within the category 'women'. This illustrates the ways in which women's bodies are linked with a language of reproductive nurturance, operating outside of the sexual and positioning women very differently from men. Onto men's bodies are inscribed narratives of penetration and sexual activity.

Lesbian sex, where it is mentioned, is dealt with in ways that are both traditionally gendered and highly fetishistic (see Figure of 'the lesbian penetrator' from Bell, 1999). So the idea that "in lesbian sex either partner can be psychologically 'active' regardless of whether sex play includes penetration with a dildo" (Bell 1999) sexualises lesbians in a way that women (i.e. heterosexual women) are not in the series. That is, it is only lesbian women who, we are told, are likely to use such sex aids. Further, the turn taking inference of being either active (male) psychologically or physically, or being passive (female), and the need to insert a 'penis substitute', also has the effect of heterosexualising lesbian sex; thus lesbians here are faux heterosexuals. The ideas underpinning this stem from a version of lesbianism which, as Teresa de Lauretis states, "recasts homosexuality in the mould of normative heterosexuality, thus precluding all conceptualisation of a female sexuality autonomous from men" (de Lauretis 1998:231).


We have to reverse things a bit. Rather than saying what we said at one time, "Let's try to reintroduce homosexuality into the general norm of social relations," let's say the reverse - "No! Let's escape as much as possible from the type of relations that society proposes for us and try to create in the empty space where we are new relational possibilities."
(Foucault 2000:160).

In this paper we have analysed the ways in which a heteronormative discourse is constructed and neutralised through a number of key health and social welfare texts that, to all intents and purposes, aim to tackle issues of difference in relation to practice. Our experience of these disciplines is that non-normative sexualities and identities have been added into existing narratives and, more often than not, lesbians and gay men are presented as types with knowable characteristics. This discrete group is thus presented to health and social care workers who then only have to deal with the properties of the category itself, rather than with an individually mediated identity or indeed with the forms of knowledge responsible for such types. Succinctly, they simply need to 'understand' the homosexual client.

This is not a theory of lesbian and gay sexualities that we support. Indeed we agree with Beth Loffreda's assertion, following the violent anti-gay murder of Matt Shepard in Wyoming 1998, that "so many of us have substituted empathy for activism" (Loffreda 2000:x). Like Foucault, we argue instead to question the forms of knowledge which are dominant, and for theories of sexuality categories which retain a desire to challenge heteronormative practice, to connect with 'street theory', activist theory and anti-mainstream theory, instead of arguing for acceptance within the dominant paradigm (Stanley & Wise 2000; Vaid 1995; Weston 1998).

At the same time, however, we recognise that our own text is performing claims and establishing forms of knowledge. For this reason, we strongly hope that it will provoke debate and responses from within our disciplines of health and social welfare. We have positioned ourselves in a critical relationship with what we see as taken-for-granted constructions of sexuality within key texts, and we therefore problematise the liberal "ethnic model" as establishing a new homophobia (Smith 1994) which offers lesbians and gay men only 'virtual equality' (Vaid 1995).

In terms of practice, then, we would encourage a reflexive engagement by all practitioners (including academics, researchers and students) with the various ways in which dominant discourses concerning sexuality populate and discipline knowledges within health and social welfare. This process demands, therefore, an excavation of knowledge (Brown 1998) via the queering of texts, a form of reflexivity (Taylor & White 2000). We do not suggest a monolithic counter-theory as an antidote to such discourses, but some engagement with lesbian feminist, gay liberationist or queer theories of sexuality within health and social welfare would be a start. We would like to see this process of critique, whether in the classroom or in core texts, as a dynamic and vibrant space for exploring a multitude of subject positions and experiences.


1This does not mean that health and social welfare knowledges are monolithically 'heteronormative' - there are texts which address lesbian and gay issues (Brown 1998; Milligan 1975; O'Brien 1999; Plummer 1995; Wilton 2000), but we refer to standard or core texts recommended to students in each discipline.

2For earlier writings on the dynamics of 'adding in' see Kitzinger (1987); Stanley & Wise (1983).

3The DipSW is being phased out to be replaced by a new BA Social Work starting in 2003.

4Palgrave Publishers Ltd., 'Social Work & Social Policy' catalogue, Jan. 2002.

5The Central Council for Education & Training in Social Work (CCETSW) published its 'Paper 30' in 1989 (CCETSW 1989), but this was substantially revised (CCETSW 1995) following charges that social work had become 'politically correct' and obsessed with anti-discrimination (Pinker 1993). However, neither Paper 30 nor its successor was particularly concerned with lesbians and gay men.

6Heteronormativity can be defined as that state in which heterosexuality "thinks of itself as the elemental form of human association, as the very model of inter-gender relations, as the indivisible basis of all community, and as the means of reproduction without which society wouldn't exist" (Warner 1993: xxi).

7In an editorial to the 'gay issue' of their magazine, the group argued that social welfare had tended to view homosexuality as a problem needing treatment (remember that in the 1970s 'homosexuality' was still a classifiable mental disorder), and that lesbians and gay men were always viewed as clients but never as practitioners. Therefore the 'homosexual' was viewed as 'other' and lesbians were rarely even considered. These were "ideologies perpetuating the supremacy of heterosexual norms and the oppression of homosexuals" (Charing et al. 1975:2).

8Examples include Logan et al. 1996, Brown 1998; Wilton 2000.

9For a critique of this, and a very different perspective, see Nayan Shah (1993) or Vivien Ng (1997).

10Unfortunately Segal (1999) plays this same game herself, however, by representing only a limited version of queer theory (what we might term the 'lifestyle/diversity' version rather than one concerned with sexual discourses), in order to critique it.


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