Therapising queerness: navigating the mental health system in Singapore

Natasha Tan was 23 when she came out to her parents, who promptly booked her an appointment with a psychiatrist at a private clinic within Mount Elizabeth Hospital. (All patient/survivor names in this essay have been changed.) Requesting to speak to Natasha alone, he asked if she wanted to “change the fact that [she] was gay”, and offered two options: one was talk therapy, the other electroshock therapy; which while legal, is typically used for severe psychiatric disorders such as schizophrenia and mania. Appalled but unshaken, Natasha told him that homosexuality had been removed from the American Journal of Medicine as an illness in the 1970s. The psychiatrist pulled out the book, flipped through its pages, and Natasha was proven right.

“I felt somewhat numb, because it was a very intense and overwhelming time—less than 48 hours before the appointment I had come out to my mum—but I remember feeling a bit indignant at the way the doctor couldn’t even look me in the eye, as if I was something shameful.” That was in 2009. Natasha never returned.

For those whose family and social circles have rejected them, the discrimination meted out by mental health providers can form a retraumatising cycle, a wound that digs deeper each time. In the concept of queer time, timelines don’t inch forward in a linear line, but unspool in the complexities of loops, zig-zags, and pauses. Built upon the work of American theorists, such as Jack Halberstam and Elizabeth Freeman, the term rejects what is called “chrononormativity,” mainstream societal expectations of how we spend our time, and instead embraces a separate logic for queer people. This clash with conventional life is situated in alterity, and often from childhood. As such, many queer people take decades to articulate the nuances of their identity, their sense of self having been repressed, making for a complex mental health journey. What does it look like for these queer lives to rise through the cracks of a system that doesn’t cater to them?

A couple of years later, in a bid to better support her colleagues who were undergoing personal hardships, Ash signed up for a five-day introductory counselling course offered by a training academy. When asked about their reasons for participating in the course, many of the participants cited their involvement with church. It created an odd in-group, in which the majority assumed that they were free to talk in whatever way they wished. At one point, one of the participants asked, giggling, “What if someone is gay?” The others laughed along. The instructor, who was also clearly Christian, replied sympathetically, “I know it may be uncomfortable or difficult for you, but we must remain neutral.” It was a pivotal moment that revealed their biases; their empathies were not centred on the queer person’s experience, but on the receiver. “Mocking people and their sexuality in class is not okay,” Ash said. Aside from noting that it was a subsidiary of a Christian community service organisation on its website, the academy had neither advertised itself as Christian, nor mentioned Christianity on its other public channels.

Mental health providers also exist outside of institutions as independent workers. Accountability is rare, if at all.

Melissa Ng, a physical education teacher, had considered fitness to be an anchor to her life. When she got diagnosed with rheumatoid arthritis, an incurable condition, she fell into depression and anxiety at the frailty of her body. In 2017, Melissa, who was not out to many, sought the help of a counsellor, one who had once declared in a lecture that she was an “ally”. When Melissa asked the counsellor over text if she was queer-friendly, she replied: “I do work with people with homosexual preferences, if that is what you mean when you say ‘queer’.” Although “preferences” as a term has been disputed when talking about queerness—it has the connotation of an easy choice—Melissa was not in the right state of mind to bring this up, and booked a session.

Melissa attended sessions at the counsellor’s HDB (Housing Development Board) flat, paying in cash, for what appeared to be a side-gig. Melissa hadn’t checked this counsellor’s qualifications. She once told Melissa that she believed “queer relationships do not last long,” and that queer people should not come out to their family. Eventually, Melissa stopped attending.

For transgender people, the issue of seeking help is more complex. While gender dysphoria is recognised as a clinically diagnosed condition, the way institutions, medical or otherwise, treat transgender people continues to spark debate. Hormone therapy, especially for youth, has polarised opinions globally.

In Singapore, obtaining medical help for transitioning requires multiple consultation sessions with psychiatrists before medication from endocrinologists can be granted. When Alex Chan, a trans man, asked his psychiatrist at a hospital to recommend an endocrinologist, she questioned him. “You say you’re bisexual. How does that impact your gender?” she asked, conflating sexual attraction and gender identity. “Generally, men like this don’t want to be with other men because they don’t want to play the woman’s role in bed.” Alex subsequently went into “lockdown mode,” only wanting to give answers that would enable him to get out of the room.

His later attempt to get a referral from a polyclinic to the gender clinic went smoothly: “It really depends on luck.”

We could begin by looking at the most extreme practice: conversion therapy. According to the UN, this refers to “interventions of a wide-ranging nature, all of which have in common the belief that sexual orientation or gender identity (SOGI) can and should be changed.” It is a practice that reached mainstream attention through the 2018 film, “Boy Erased” and the 2021 Netflix documentary, “Pray Away”.

International health organisations have repeatedly declared that conversion therapies have no scientific justification. Yet, the practice remains legal in many countries, including Singapore. A 2020 parliamentary question from Anthea Ong, then a nominated member of Parliament, elicited a vague government response. “MOH [Ministry of Health] expects doctors and other healthcare professionals to practise according to evidence-based best practice and clinical ethics,” it stated, steering clear of taking a definite position against conversion therapy. One of the most extreme documented cases of conversion therapy was the use of electroshock therapy at Adam Road Hospital in 1994, which, among other harms, erased four weeks of the patient’s short-term memory. This was the very same procedure suggested by Natasha’s psychiatrist 15 years later.

Although conversion therapy is generally poorly documented, it’s often associated with religious institutions. Heckin’ Unicorn, a Singapore queer-owned accessories brand, published a series on conversion therapy in 2021, listing Focus on the Family, TrueLove.Is by John 3:16 Church, and Church of Our Saviour as three examples of Christian faith-based organisations who allegedly practise conversion therapy. While the term itself is not explicitly used, their websites list counselling services that seem to suggest the aim of either changing or suppressing divergent sexual identities to that of heterosexuality or celibacy. These practices also exist in Islam, often manifesting in an exorcism ritual called, ruqyah. Although the practices vary widely, none of them affirm, celebrate or encourage an individual’s queer identity to flourish.

The beliefs that buttress these extreme interventions have also seeped into subtler modes of harm. Just like how the existence of Section 377A of the Penal Code painted men who had sex with men as less than equal and deviant in Singapore society, the continued existence of conversion therapy, and the lack of anti-discrimination regulations in counselling, therapy, and psychiatry permit the unjust treatment of LGBTQ+ people seeking help to perpetuate. (S377A was finally repealed last year, but with worrying sops to religious conservatives.)

LGBTQ+ people, and youth in particular, are a vulnerable group in society, with multiple studies pointing to a higher risk of suicide and mental health issues. But the lack of regulatory protections put them at risk of being retraumatised by the very sources that claim to support them.

In July 2022, a Hwa Chong Institution counsellor presented a slideshow to a Secondary 4 cohort. On it were claims that “a majority of homosexuals have intestinal worms” and are “paedophiles”, drawing links between homosexuality and alcoholism and sexual assault. These unscientific claims went viral on social media, not only for their content but also for the fact that Hwa Chong, a reputable school, had such a figure of authority in the first place. It eventually suspended the staff member.

It is in unsafe, unpredictable circumstances like these that queer people, especially the young, learn to diminish their sense of self, leading to repression: the slow unspooling in queer time. That incident should prompt society to reconsider who is authorised to guide young minds without the danger of harming them.

According to a Today article, The Singapore Association of Social Workers, Singapore Association for Counselling and the Singapore Psychological Society have high barriers to entry and strict guidelines, and have notably included sexual orientations and gender identities in their code of ethics. But they have no disciplinary powers to investigate complaints against counsellors and psychologists registered with them. Moreover, registration is voluntary, hence independent practitioners can run a mental health business without qualifications outside their purview. Clients, therefore, cannot assume that every counsellor and psychologist is certified and accountable.

The intersection of religion and sexuality has long been a thorny topic in public conversation. Rachel Goh recounted their experiences from 2014-17 attending deliverance ministry sessions, which, according to various churches’ websites, span counselling to chasing out demons and evil spirits. While at Trinity Christian Centre, of which the ministry is an integral part, Rachel was handed a workbook, in which they were asked to list down sexual sins. Alongside premarital sex, bestiality, sexual abuse, and pornography were homosexuality and transexuality. “Homosexuality”, it stated, “is a consequence of perverting the image of God.” Participants were taught that sexual sin had consequences such as “demonic intrusion”, “ungodly soul ties”, and, ironically, “guilt and shame.” (Trinity Christian Centre did not reply to a request for comment.)

One of the trickiest aspects of queer people’s experiences in religious institutions is that they are not binary, i.e. good or bad. “The strange thing about being in church is that some parts were alright,” Goh said. “For example, she [the ministry worker] was very gentle. She helped me to process other things I was struggling with, with my family.” Regardless, Rachel could not be their full self. Later on, they tried another talk therapist, who likened their sexual identity to people who cheat on their marriages. “Everybody sins” was the approach. Rachel cited their “internalised homophobia” as a reason for their inability to insist on affirming services. It took them many years of processing before they were able to do so: queer time. Before seeing their current therapist, they had e-mailed to ask if the medical professional was queer-affirming. Otherwise, “we don’t even engage.”

Similarly, Ash, who was disappointed with earlier help from a Christian counsellor and the five-day counselling course she attended, eventually sought therapy at a private hospital. This therapist was also Christian, but was more well-versed on issues of depression and anxiety, including appropriate medications. “She has never made me feel like it’s wrong to be gay. She said that God has a lot to say about many things and nothing to say about many other things. It makes me feel comfortable,” explained Ash.

“There is research and professional experience to show that faith and spirituality can be an important resource for maintaining and improving mental health, especially for minority groups,” said Leow Yangfa, a registered social worker and executive director of Oogachaga, “a community-based nonprofit organisation working with LGBTQ+ individuals, couples and families.” Leow continued: “When such religious counselling crosses into the realm of pseudoscience and scientifically unproven practices, it becomes harmful and unethical. For example, when mental health practitioners choose to incorporate their religious beliefs into their professional practice, especially in their attempts to change the sexual orientation and/or gender identity of their LGBTQ+ clients.”

While mental health is clearly political, the answer isn’t in regulation alone.

“There’s a lot of self-reading and learning that can be done, and that should fall on the onus of the healthcare professional. If they’re not willing, they really shouldn’t be working with the community,” said Eleanor Ong, a therapist with The Relational. “That being said, courses can only take a person so far, a lot that has informed my work has been through lived experience, personal reading and case discussions with other therapists; also being open-minded to continuously learn.”

There has been progress: in a landmark moment in 2021, the Singapore Psychological Society denounced conversion therapy, making them the first professional organisation to take a stance on the issue. They also recommended affirmative approaches.

There is still much to be done, and several initiatives led by queer communities aim to plug these gaps. In 2019, the Inter-University LGBT Network produced a guide to LGBTQ+ friendly spaces in Singapore. The informal group Queer Women SG and support platform Prout have been collating affirmative therapy and counselling service providers.

Let us, for a moment, consider time as elastic. If we think of trauma as a reliving of time, and depression as a halting, then the theory of queer time is not far-fetched. With overarching systems that relegate queer people’s experiences to the sidelines, it might take queer people a longer while to celebrate their full selves. Let us hope that it isn’t too long to wait for some.

Oogachaga’s recommendations:

All professionals working to support the mental health of LGBTQ+ persons should consider the following—the 3 As—in their practice.

1) ACKNOWLEDGE that Minority Stress (Meyer, 2003) and discrimination against LGBTQ+ people exist, and they impact the mental health of LGBTQ+ persons (reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2072932/)

2) AVOID subscribing to any practices that seek to impose “change” on one’s sexual orientation and/or gender identity (SOGI) to becoming cisheteronormative. This is different from acknowledging that some people may experience their identity in a more fluid or transitional way, as part of their exploration and questioning process.

3) AFFIRM LGBTQ+ and other sexual and gender minority clients’ identities, experiences and resilience. This is aligned with many conventional therapeutic principles and modalities that focus on the client, eg: recognising client’s self-determination, the practice of person-centred therapy, strength-based therapy etc.

Charmaine Poh is Jom’s head of visual culture and media.

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