During the 1980s, the AIDS crisis unleashed a torrent of animosity against gays and lesbians. As hatred rose, so too did physical assaults. Most of the perpetrators were teenagers, who did not just torment queer adults – they also directed their anger and hatred at their peers. As a result, a substantial percentage of gay and lesbian youth dropped out of school, abused alcohol and drugs, and attempted suicide. Two types of violence consequently plagued queer life: violence from attackers and self-harm. Some advocates responded by focusing on preventing attacks on the streets. They worked with police to improve their responses and lobbied legislators to enact hate crimes protections, which helped make antiqueer violence visible. Others, typically teachers and parents of queer children, focused on creating support systems in schools, so that gay and lesbian teens would not give up hope for a better future.

Three scenarios ranging from simple to complex show how appointments with primary care clinicians can include useful conversations about stress and treatments that work.

This chapter emphasizes how therapy can be a resource for Black women in their mental health and wellness goals, including personal growth and resilience, recovery, and reinvigoration. We present therapist and client stories to illustrate the benefits of psychotherapy. We also discuss our joys working with Black female clients and how these relationships can enrich therapists’ lives.

A 35-year-old G2P1 with chronic hypertension is referred by her primary care provider to your tertiary-care center for prenatal care of a singleton intrauterine pregnancy at 8+2 weeks’ gestation by dating sonography. The patient has no obstetric complaints to date. Her last pregnancy was 10 years ago.

You are seeing a 29-year-old G2P1 with a singleton pregnancy at 34+6 weeks’ gestation for a routine prenatal visit. Pregnancy dating was confirmed by first-trimester sonography. She reports normal fetal activity and has no clinical complaints. Your colleague following her obstetric care is now on a two-month leave. Although mode of delivery was addressed early in prenatal care, your colleague left you a note to discuss a trial of vaginal birth after Cesarean delivery (VBAC) with the patient.

A 37-year-old nulligravida with a one-year history of well-controlled essential hypertension is referred to your high-risk obstetrics clinic for preconception counseling. Recent comprehensive investigations are free of end-organ dysfunction. Maintaining a healthy lifestyle, she lost weight over the past year; her body mass index (BMI) is now 31 kg/m2. She uses condoms for contraception and is adherent to long-acting nifedipine once daily; folic acid–containing prenatal vitamins were initiated last month.

A healthy 23-year-old G2P1 presents for prenatal care at 12+0 weeks’ gestation by dating ultrasound. Her last pregnancy was cared for by your colleague, who is currently away. Pregnancy was uncomplicated, and she had a spontaneous vaginal delivery at term. You learn from the antenatal notes that the patient had a flu-like illness in early pregnancy; investigations were unremarkable, and symptoms resolved with supportive care. She tells you her healthy two-year-old son has been attending daycare since six months of age and is meeting his developmental milestones.

You are seeing a new patient in consultation for transfer of care to your high-risk obstetrics unit at a tertiary center. She is a 27-year-old primigravida at 14+3 weeks’ gestation with an incidentally positive surface antigen to the hepatitis B virus (HBsAg) on routine prenatal testing. A copy of the original laboratory report has been provided to you. Although detailed serological investigations were performed, results are not available. The patient is aware of the results. Referral to a hepatologist has also been instigated. The patient’s first-trimester sonogram and aneuploidy screen were unremarkable. She has no obstetric complaints.

A 37-year-old G6P3A2 at 20+3 weeks’ gestation is referred from a community hospital center for consultation at your tertiary center’s high-risk obstetrics unit for ‘anterior placenta previa with abnormal features’ reported on ultrasound evaluation of the morphologically normal female fetus. First-trimester sonography performed in the same center, integrated with maternal serum biomarkers, revealed a low risk of fetal aneuploidy.

A 34-year-old G2P1 with long-standing multiple sclerosis (MS) is referred by her neurologist for prenatal care of a spontaneous pregnancy at 10 weeks’ gestation by dating sonography. She takes prenatal vitamins and has no obstetric complaints.

This chapter is a fictional account of several people talking about aspects of their lives that are impacted by variations in sex development at a support group meeting. In their exchanges about past, present and future medical encounters, the author draws out both the opportunities and the dilemmas presented by medicine. Through the characterizations, the author also teases out some of the most pertinent psychological themes in the field, such as how to decide about “normalizing” surgery for a child and how to talk about bodily differences in relationships. These themes are centralized in Chapters 9–14 and explored in the literature summaries and practice vignettes therein.

Chapter 6 summarizes the changes to medical care in recent years. There is now a greater recognition that the projected social and psychological challenges of genital variations cannot be fixed by surgery. The first international consensus statement on intersex was published in 2006. The statement makes a number of recommendations to improve care. Controversially however, a new term disorders of sex development (and, later, differences in sex development, or DSD) was introduced to replace intersex and hermaphroditism. Biotechnological developments have been advancing rapidly. More has been learned about “normal” and “abnormal” sex development. However, parents still struggle to talk to children about their bodily variations, young people still worry about getting into relationships, childhood genital surgery is still considered the only way out of stigmatization, psychological expertise is still a low priority in specialist services and the huge potential of peer support is not fully realized.

How to talk about variations in sex development is a major theme for impacted individuals and families. This is the topic of Chapter 12. The author summarizes the research literature with caretakers and with adults about the difficulties of disclosure. Considerable criticism has been levied at health professionals for failing to role model affirming communication. For sure there are gaps in health professionals’ talk, but the biggest contributor to the difficulties is to do with the widespread misunderstanding about the biological variations. Psychological care providers are not there to put a cheerful gloss over clients’ negative expressions. However, they can be part of the favorable social condition in which a wider range of meanings about bodily differences are negotiated. In the practice vignette, the author highlights how tentative and uncertain the enabling process is, where a negative view of sex variations is still widely endorsed in the social context.

Chapter 8 begins by pointing out the current lack of collective clarity about the role of psychological care providers (PCPs) and suggests that researchers and practitioners make collective effort to develop the role of PCPs in sex development in future. Meanwhile it outlines the psychological consultation process that is generic and familiar to most PCPs. The author provides an initial assessment template and summarizes the popular psychotherapeutic interventions. The template is visible in several of the practice vignettes in the ensuing chapters of the book. The author ends the chapter by arguing that the tertiary environment is set up for diagnostic workup and treatment and unsuitable for the kind of ongoing psychosocial input that is needed by individuals and families living in their communities. The author makes a case for PCPs in DSD centers to collaborate with peer support workers to enable nonspecialist providers in the community to contribute to ongoing support for individuals and families.

Chapter 11 of the book reviews potential psychological contributions in the highly charged process of assigning legal gender to a newborn with genital variations. Although a number of psychological theories exist for understanding gender development, it is the brain gender framework that has been singularly privileged in intersex and DSD medicine. However, the decades of research cannot contribute to the certainty professionals and caretakers seek. Psychological care providers (PCPs) have other frameworks to draw from in order to work ethically and pragmatically with families. In the practice vignette, the author envisions how a highly skilled PCP in a high-functioning DSD team could work substantially to help caretakers to cope with uncertainty and minimize the need for psychosocially motivated medical interventions. In the vignette, the psychological care path is in position before medical investigations begin. It remains highly active long after the medical and legal processes are completed. Although the vignette is built around a child diagnosed with 17β-hydroxysteroid dehydrogenase-3 deficiency, the care principles are relevant to legal binary gender assignment for children born with a range of sex development variations.

Difficulties with communication about bodily differences are strongly linked to sexual experiences. In Chapter 13, the author critiques the dominant ways of talking about sexuality in the wider society. These oppressive ideas can give rise to insecurities, self-objectification and body shame for people in general. Adults who have been medically managed are particularly vulnerable to the effects of objectification and shame. The author outlines typical components of sex therapy programs. However, rather than fix sexual problems, which can perpetuate people’s sense of inadequacy, the author suggests that psychological care providers support clients to process any trauma and develop a more relaxed and appreciative relationship with the body. This work, which requires generic therapy knowledge and skills, can be integrated with a range of specific sex therapy techniques and resources to reimagine a sexual future that focuses on bodily pleasure rather than gender performance. Although the practice vignette is built around a female couple, one of whom has partial androgen insensitivity syndrome, the care principles have wide applications for people with variations more generally.

Inconsolable distress is neither a universal nor inevitable response to inability to have biological children. In Chapter 14, the author criticizes research with clinic samples that has produced a problem-saturated account of childlessness that obscures a wide range of alternative responses. The author examines the influence of pronatalist ideology on people who are impacted by infertility including many people with sex variations. Away from the treatment context, psychological input can guide individuals, couples and groups to explore personal meaning of nonparenthood. It can facilitate service users to grieve for what is not possible, challenge feelings of deviance and shame, reengage with a range of life goals and, perhaps most important of all, recast adult identities. Through the practice vignette built around a heterosexual couple, one of whom has a late diagnosis of Klinefelter syndrome, the author teases out the difficulties of working psychologically in a treatment context, where complex existential issues and relational dynamics are compressed into the frame of pressurized treatment decisions.