Journal of Marital and Family Therapy

doi: 10.1111/jmft.12415
© 2019 American Association for Marriage and Family Therapy

WHAT DOES “COUPLE” MEAN IN COUPLE THERAPY

OUTCOME RESEARCH? A SYSTEMATIC REVIEW OF THE
IMPLICIT AND EXPLICIT, INCLUSION AND EXCLUSION
OF GENDER AND SEXUAL MINORITY INDIVIDUALS AND
IDENTITIES
Elliot S. Spengler and Elliott N. DeVore
University of Tennessee Knoxville

Paul M. Spengler
Ball State University

Nicholas A. Lee
Radford University

This study systematically reviewed extant couple therapy outcome studies (k = 111)
through December 2018 to evaluate for implicit or explicit, inclusion or exclusion of gender
and/or sexual minority individuals and identities. We evaluated sampling, participant demo-
graphic reporting, and language used in each manuscript for any reference or consideration
given to participants’ sexual and/or gender identity. Results indicate that couples have been
historically presumed to be heterosexual and cisgender male or female without reported
assessment. More recent inclusion and consideration of sexual minority individuals is limited
and absent for nonmonosexual and gender minority individuals. These findings are contextu-
alized in supplementary analyses of other sociocultural characteristics (e.g., race, age,
length together). Suggestions are provided for affirmative consideration of the plurality of
individuals’ sexual and gender identities. Implications are discussed for research, training
and practice of couple therapy with sexual and/or gender minority couples.

Knowing is not enough; we must apply. Willing is not enough; we must do.
-Johann Wolfgang von Goethe

Couple and marriage therapy (hereafter referred to as couple therapy)1 is an essential health
intervention shown to work across an impressive range of client concerns and client demographics.
The field has accumulated a substantive body of outcome studies illustrating its efficacy (Snyder &
Halford, 2012), especially for traditional and integrative behavioral couple therapy (T/IBCT; Ben-
son & Christensen, 2016) and emotionally focused couple therapy (EFT; Johnson & Brubacher,
2016). Meta-analyses reflect that couple therapy produces large improvements in couple function-
ing and relationship satisfaction. A review of six previously published meta-analyses reported a
mean Cohen’s d effect size of .84 across theoretical approaches compared to waitlist or no

Elliot S. Spengler, M.A., Department of Psychology, University of Tennessee Knoxville; Elliott N. DeVore,
M.Ed., M.A., Department of Psychology, University of Tennessee Knoxville; Paul M. Spengler, Ph.D., Department
of Counseling Psychology, Social Psychology and Counseling, Ball State University; Nicholas A. Lee, Ph.D.,
Department of Psychology, Radford University.
Portions of this study were presented in March 2017 at the annual Great Lakes Regional Counseling Psychology
Conference in Muncie, IN, August 2017 at the annual meeting of the American Psychological Association in Wash-
ington, DC, and August 2019 at the annual meeting of the American Psychological Association in Chicago, IL.
Address correspondence to Elliot S. Spengler, Department of Psychology, University of Tennessee, Knoxville,
Tennessee 37996; E-mail: [email protected]

JOURNAL OF MARITAL AND FAMILY THERAPY 1

treatment control (Shadish & Baldwin, 2003). Research also demonstrates that these substantive
improvements sustain with little decline up to five years after treatment (e.g., Christensen, Atkins,
Baucom, & Yi, 2010).
Couple therapy is efficacious in the treatment of a wide range of client problems, many of
which had been historically thought to be best treated by individual therapies, including posttrau-
matic stress, depression, and anxiety (Lebow, Chambers, Christensen, & Johnson, 2012). In accor-
dance with Sexton et al.’s (2011) guidelines for assessing evidence-based treatments in couple and
family therapy, the two most widely researched couple therapies, EFT and T/IBCT, meet nearly
all categories at the highest level of evidence (i.e., level III), including evidence from efficacy and
effectiveness research, process research, and generalization across settings and populations.
Despite the breadth of empirical work and claims of generalizability as a veritable health interven-
tion, consideration and inclusion of sexual and/or gender minority (SGM)2 individuals in outcome
research and discussions remain inadequate (cf. Green & Mitchell, 2015).

Couple Functioning and Couple Therapy for all Couples

Couples who report safe and secure attachments and high relationship satisfaction experience
corresponding physical and emotional health benefits when compared to couples who are dis-
tressed. High relationship quality and functioning for (presumed) heterosexual, cisgender couples
has been shown to contribute to emotional regulation when under stress or duress (Mikulincer &
Shaver, 2015), stronger immune systems (Kiecolt-Glaser et al., 1993), and decreased mortality
(Kiecolt-Glaser & Newton, 2001). Sexual minority (SM3) couple functioning exhibits similar
health, economic, and other benefits for couples with high relationship quality (Umberson & Kroe-
ger, 2016). Research is beginning to include couple functioning for gender minority (GM3) couples,
where one or both partners are transgender or gender nonconforming, with similarly demonstrated
benefits (e.g., Platt & Bolland, 2017).
Despite an increase in research about SGM couple functioning, consideration of SGM couples
in vetted and scientifically based models of couple therapy is needed. This need is especially urgent
in light of findings indicating heightened risk for relationship dissolution, specifically within the
context of the structural stigma and oppression that SGM couples and individuals encounter
(Dierckx, Motmans, Mortelmans, & T’sjoen, 2016; Khaddouma, Norona, & Whitton, 2015).
Given the significant health benefits of positive relationship functioning, inclusive research about
the delivery of couple therapy for SGM couples is clearly an important social justice and health
equity issue. Since Ussher (1991) referenced SM as the “forgotten minority” within couple and
family research, mostly conceptual adaptations of existing couple therapies (e.g., Chapman &
Caldwell, 2012; Zuccarini & Karos, 2011) or thought pieces about the need for or importance of
couple therapy with SGM couples (e.g., Giammattei, 2015; Green & Mitchell, 2015) exist in the
scholarly literature. Not only is there minimal attention to SGM couples within outcome research,
but, as Green and Mitchell (2015) commented in the Clinical Handbook of Couple Therapy, “. . .al-
most all of the literature on couple therapy presumes a heterosexual status among couples seeking
treatment. . .” (p. 490). It is this presumption and evaluation of the current state of the field that
forms the focus of this systematic review.

Prevalence of SGM Couples

When discussing couples, overtly or covertly presuming heterosexual and/or cisgender identi-
ties obviates consideration and inclusion of an important portion of couples. Obtaining accurate
prevalence rates of SGM couples is difficult, however, due to factors such as inadequate wording
of survey questions and failure to inquire about nonmonosexual or gender minority couples. While
4.5% of adults in the United States (i.e., 11,000,000) identified as SGM in a 2017 Gallup Poll
(LGBT Demographic Data Interactive, 2019), 8.2% of millennials identified as SGM. With chang-
ing societal attitudes, millennials may be more comfortable coming out and, therefore, provide
more accurate self-reports. Estimating how many SGM individuals are in committed relationships
is more difficult. The US Census Bureau (2017) identified 935,229 same-sex couples, while the
Gallup Poll reported that 3,190,000 SGM individuals (i.e., 29%) are raising children, suggesting
that there are likely far more SGM couples than generally reported.

2 JOURNAL OF MARITAL AND FAMILY THERAPY

Unique Experiences of SGM Couples
The minority stress model posits complex interactions of distal and proximal stigma are
responsible for increased risk of psychological distress and decreased quality of life in SGM indi-
viduals beyond mental health factors experienced by cisgender heterosexual people (Meyer, 1995).
Research suggests that minority stress related to heterosexism and discrimination is negatively
related to relationship quality, couple satisfaction, and quality of life for individuals in SGM rela-
tionships (Otis, Rostosky, Riggle, & Hamrin, 2006). Doyle and Molix’s (2015) meta-analysis on
SM couple functioning found a significant negative relation between structural stigma and couple
functioning. These findings reinforce an overarching characteristic that distinguishes SGM couples
from cisgender heterosexual couples: All SGM couples are “vulnerable to similar kinds of prejudice,
discrimination, and marginalization by persons and institutions outside of their relationship” (Green
& Mitchell, 2008, p. 664; italics original).
Within the psychological mediation framework (Hatzenbuehler, 2009), the relation between
minority stress and psychopathology is mediated by social support, emotion regulation, and cogni-
tive components. Through this lens, research on social support suggests that couple therapy pro-
vides an avenue to co-create resilience and strengthen buffers through safe and secure connection.
Research has shown that SM couples, on average, have a relative lack of social support from
friends and family (Khaddouma et al., 2015) and SM individuals attribute the strongest experi-
ences of heterosexism to their family (Szymanski, 2009). In facing minority stress, couple connec-
tion may be an essential survival mechanism. The American Association of Marriage and Family
Therapy (2004) Core Competencies recognizes the importance of strengthening SGM couple and
family relationships, by emphasizing the need to “deliver interventions in a way that is sensitive to
special needs of clients” (p. 4) that “recognize contextual and systemic dynamics” (p. 2), including
clients’ sexual orientation and gender identity.
Given that relationship satisfaction is shown to buffer against minority stress, research on
SGM relationships through couple therapy outcome research is an intuitive avenue to pursue.
Because research and theoretical writings do not occur inside of a vacuum away from the guise of
society’s values, struggles, and political taboos, we provide a historical context that honestly exam-
ines examples of mental health professionals’ and society’s mixture of resistance against and per-
petuation of cissexism and heterosexism (see Table S1). Seeing that research is perpetually
encapsulated by surrounding culture and systems, it is instrumental to the purpose of this system-
atic review to overtly recognize the varying roles by psychology, psychiatry, CFT, and society that
have both enabled (e.g., decades-long pathologizing of gender variant identities and expressions by
the Diagnostic and Statistical Manual) and addressed minority stress for SGM individuals and cou-
ples (e.g., American Association for Marriage and Familt Therapy (AAMFT) amicus brief submit-
ted for the same-sex marriage Supreme Court ruling).

Present Study
In response to these concerns, and in light of the known health benefits of empirically sup-
ported couple therapies for (presumed) cisgender heterosexual couples, we conducted a systematic
review of extant couple therapy outcome studies. The first order objective of this review was to
assess rates of recruitment of SGM couples in outcome research. The second order, and more
important, intent was to provide a deeper and historical structural evaluation to assess whether or
not researchers consider the sexual and gender identity of couples, or, by contrast, if heterosexual
and gender binary assumptions have been made when referring to “couple” or “marriage.” That is,
when researchers have referenced couples, which sexual and gender identities are they referencing?
Who is being explicitly or implicitly included or excluded? And how is language, or lack thereof,
used within couple therapy outcome research? We expected to observe growth and development in
the field, with evolving public and professional attitudes, reflected by greater consideration of cou-
ples’ sexual orientation and gender identity in more recent couple therapy outcome studies.
Unlike a meta-analysis, which has the goal of summarizing statistical results from a body of
studies, the intention of a systematic review is to provide a summary of descriptive factors within
relevant studies centered around a certain topic (Petticrew & Roberts, 2006). To date, no study has
systematically reviewed the generalizability or representativeness of couple therapy outcome
research in regard to couples’ sexual orientation and gender identity. This systematic review differs

JOURNAL OF MARITAL AND FAMILY THERAPY 3

from other reviews of SGM issues in CFT journals that focused on publications that explicitly
address SGM issues (e.g., sampling and generalizability regarding GLB issues, Hartwell et al.,
2017; content analysis of GLB studies, Hartwell et al., 2012). Our portal of entry is unique in that
we sought not to just count inclusion of SGM couples but, at a deeper more structural level, to
assess consideration of all couples’ sexual and gender identities. Beyond issues of recruitment and
inclusion in research, we asked the basic question: Were couples considered as cisgender and
heterosexual, or where they assessed or considered on continua of sexual and gender identity? We
contextualize these findings in supplementary analyses of attention by researchers to other partici-
pant (e.g., race, ethnicity, age) and couple characteristics (e.g., length together).
Studies selected for inclusion had to reflect couple therapy treatments at level II (promising
research, perhaps one study) or level III (evidence-based, accumulated research) using Sexton
et al.’s (2011) guidelines for classifying CFT research. We chose this framework as this would
reflect the mainstream of couple therapy outcome research for the best researched models of cou-
ple therapy. Level II models are promising interventions with a clear treatment package and pre-
liminary outcome research. Level III models have at least two randomized control trial studies.
Gurman (2011) identified six couple therapy modalities with either preliminary research or at mini-
mum one randomized control trial study: Behavioral Couples Therapy (BCT) in its three forms,
Traditional (TBCT), Integrative (IBCT), and Cognitive (CBCT); Emotionally Focused Couple
Therapy (EFT); insight-oriented couple therapy (IO); and structural-strategic couple therapy (SS).
Benson and Christensen (2016) similarly assessed the first five modalities as having relevant out-
come research. Based on recent developments (e.g., Garanzini et al., 2017), we also included Gott-
man’s (1999) couple therapy as a level II model.
As per the AAMFT Core Competencies (2004), the present evaluation is necessary in order to
critique the rigor and application of research to practice and ensure contextual and systemic
dynamics are taken into account for evidence-based practice in a culturally sensitive manner. This
study also falls in accordance with the U.S. Department of Health and Human Services’ Healthy
People 2020 goals to eradicate mental health inequities and ensure access to quality mental health
care for SGM individuals. Because the CFT field has long emphasized the confluence of research
and clinical practice (Sexton & LaFollette, 2016) and the importance of systemic dynamics (Addi-
son & Colhart, 2015), our hope is to bring attention to a forward moving equitable and balanced
consideration of all peoples’ sexual and gender identities in couple therapy research, training and
practice.

METHOD

In keeping with the ethos of this manuscript, we advocate for the use of feminist standpoint
epistemology to engage a dialectic between the epistemologies of the authors during the research
process. Else-Quest and Hyde (2015) noted that such a reflection is imperative to intersectional
research in psychology:
Standpoints are not random or spontaneous but are grounded in history and culture, con-
ferring a particular vantage point. Moreover, because the scientist operates from a privi-
leged standpoint, the standpoint of the oppressed or disadvantaged is crucial. The role of
power is explicit here, insofar as it systematically biases how knowledge is created and
organized (p. 160).
As such, we felt it important to provide insight and context for what brought us to this work.
Being that all four authors were assigned male at birth and White, our standpoint as scientist-prac-
titioner-advocates is inextricably bound to and limited by our racialized and gendered experiences.
The first author identifies as a White, cisgender, heterosexual man who has provided couple ther-
apy, has formal training in EFT, and has published research on EFT and sexual minorities. The
second author identifies as a White, Queer man with fluid gender expression who has provided cou-
ple therapy, has introductory training in multiple couple therapy modalities, and has published
about SGM experiences. The third and fourth authors are White, cisgender, heterosexual, part-
nered men with families. They both have extensive knowledge of the science and practice of couple
and family therapy, have published research on EFT and couple therapy, and the third author has

4 JOURNAL OF MARITAL AND FAMILY THERAPY

published research about sexual minorities. The first, second, and third authors are engaged in
advocacy with and for SGM people. The fourth author has provided clinical services to SGM indi-
viduals and couples. We include all of this to encourage the reader to ask, “How might the lived
experiences of the researchers influence their research and who they think about studying?”, which
brings us to this systematic review.
The origin of the idea for this study was years of dialogue by the research team. The catalyst
arose when the third author was supervising a doctoral student providing EFT for a couple that
initially identified as cisgender and heterosexual. During the process of therapy, the previously
self-identified husband came out as a transgender woman. The supervisee was tasked with
researching the literature on couple therapy that encapsulated one partner transitioning and found
only a small number of thought pieces. This absence of research, and our own observations of ref-
erences to couples reflecting a presumption they are cisgender and heterosexual, crystallized our
interest in assessing how SGM couples are considered in couple therapy outcome studies. We
engaged a feminist process of reflexivity in our synthesis to ensure that we were responsive to
minority experiences of SGM couples. To this end, we sought dialogue and consultation with
SGM individuals and scholars for input and feedback throughout the review and writing process
so that the voice of the “oppressed or disadvantaged” was considered and heard. This input
included suggestions, for example, for search terms for coding articles, and an overall process of
reflexivity regarding balancing a tone of advocacy with a reflective stance supportive of growth
and development of a positive future for the field of CFT.

Study Search and Inclusion

Published studies and unpublished dissertations assessing the efficacy (e.g., laboratory con-
trolled RCTs), effectiveness (e.g., naturalistic studies), and the absolute (treatment only or treat-
ment-control group) or relative strength (treatment compared with a viable alternative treatment)
of couple therapy dated through December 2018 were included (see Data S1 References).4 The first
two authors conducted electronic searches to identify English language journal articles and disser-
tations in PsycINFO and PubMed databases. The search terms included the name of each modal-
ity or an alternative (e.g., affective-reconstructive for insight-oriented, behavioral for behavioral)
and variations of the terms couple (e.g., conjoint, marital, relationship) and therapy (e.g., coun-
selling). Our search strategy was iterative in nature and meant to balance sensitivity (conducting a
wide range search that garnered many irrelevant articles) with specificity (limiting irrelevant arti-
cles but possibly missing relevant ones intermittently). In order to ensure an exhaustive review, we
administered forward (articles citing a publication) and backward (references) searches from stud-
ies retrieved paying special attention to meta-analyses and other reviews until no new studies were
identified.

Sample
We identified 174 studies through the initial search criteria: 26 Cognitive BCT, 45 EFT, 12
Gottman, 86 Integrative/Traditional BCT, four Insight Oriented (IO), and two Structural Strate-
gic (SS).5 Original outcome research was included. In instances where data were reanalyzed or lon-
gitudinal follow-up data were analyzed, such subsequent publications were excluded from
summaries of participant characteristics but were analyzed for use of language in the article (e.g.,
the need for generalizability of findings to SGM couples). Excluded from review were process stud-
ies, family therapy studies, and when an intervention was not assessed. Two publications
(Emmelkamp, van der Helm, Macgillavry, va Zanten, 1984; Everaerd, 1977)5 included two sepa-
rate outcome studies with independent samples. These steps resulted in 109 outcome studies with
111 unique samples (53 IBCT/TBCT, 31 EFT, 17 CBCT studies, seven Gottman, two IO, two SS).

Coding
Descriptive statistics were coded for each of the following participant characteristics in the
experimental, control, or comparison groups: sample size, age, race/ethnicity, education, SES, rela-
tionship status, length together, number of children, individuals who identify (or researchers iden-
tified) as a sexual minority, individuals who identify (or researchers identified) as a gender
minority, and number of SGM couples. It is important to note that we were unable to disentangle

JOURNAL OF MARITAL AND FAMILY THERAPY 5

race and ethnicity within this research. Only one study allowed participants to describe both their
race and ethnicity (Walker, 2013). Participants’ sexual and gender identity were coded for if partic-
ipants could self-identify their sexual orientation and gender identity or if the authors presumed
participants to be heterosexual and cisgender/binary. Coding also included therapy modality and
contextual area of study (e.g., one partner with OCD diagnosis).
We coded the use of language (a) in the methods that assumed a heterosexual identity when
participants did not explicitly self-identify their sexual orientation, (b) in the manuscript for inclu-
sion or exclusion criteria pertinent to SGM individuals explicitly or implicitly (e.g., authors state
married prior to 2015 Supreme Court ruling), and (c) in the introductions or discussions pertinent
to SGM individuals explicitly or implicitly. We carefully read and searched for relevant terms (i.e.,
gay, lesbian, hetero*, homo*, trans*, sex*, queer, straight, and gender). Two authors coded each
study and consulted a third for unresolved discrepancies. Kappa coefficients for a priori estab-
lished codes (e.g., sexual orientation, gender binary, presumed heterosexual) ranged from .65 to
1.0 (M = 0.928), indicating substantial to perfect agreement. For variables with no a priori agreed
upon subcategories (e.g., participant age, race/ethnicity) percent agreement ranged from 82.86 to
100 (M = 97.42). Coding language was relatively straight forward. Discrepancies in coding mostly
occurred in relation to subtle language usage, for example “both sex” and “both genders” were
coded as an assumption of binary gender.

RESULTS

Contextual Overview of Couple Therapy Outcome Studies

A total of 10,238 individuals participated in 111 couple therapy outcome studies (99 publica-
tions, 12 dissertations). Participant sample sizes ranged from eight to 877 with a median of 64
(M = 92.23, SD = 108.59). There were 48 studies with 5,626 participants reported after the
AAMFT (2004) Core Competencies. There were 14 studies with over 180 participants or 39.73% of
all participants. Review of Figure 1 shows the majority of couple therapy studies reported partici-
pants’ age, education, length of relationship, and number of children. Over 40% of studies
reported participants’ socioeconomic status and race/ethnicity. Zero studies allowed participants

Figure 1. Percentages of studies reporting non-GSM and GSM participant demographics.

GM = gender minority. k of studies = 111.

6 JOURNAL OF MARITAL AND FAMILY THERAPY

to self-identify or overtly assessed their sexual identity and all studies inferred participants’ sexual
identity based on the gender of their partner.6

SGM Participant Demographics

Review of Figure 2 shows zero couple therapy outcome studies assessed for transgender and
gender nonconforming identities (e.g., nonbinary, gender fluid, agender). The only gender variant
choices for participants were binary male or female, which inherently presumes cisgender. Of the
10,238 couple therapy participants, 470 individuals (4.6%) were (by presumption) in SM relation-
ships and all other individuals were presumed to be heterosexual.
Sexual orientation. Participants’ sexual orientation was presumed in 100% of studies appar-
ently based upon the gender appearance of their partner. For example, a female partner and male
partner were both presumed to identify as heterosexual and talked about as such throughout each
study rather than explicitly giving participants the opportunity to self-identify their sexual orienta-
tion. In one study (Ussher, 1990), all 20 male participants were partnered with a male and pre-
sumed to identify as gay. Zero studies provided participants an option to self-identify as any SM
identity other than gay or lesbian (e.g., bisexual, asexual, pansexual). Zero studies assessed partici-
pants sexual orientation along a continuum (e.g., The Kinsey Scale; Kinsey, Pomeroy, & Martin,
1948), thereby assuming sexual identity as a monosexist and categorical variable.
Sexual minority identity. Five studies reported SM identity where participants were partnered
with someone of the same gender (Fals-Stewart, O’Farrell, & Lam, 2009; Garanzini et al., 2017;
Hewison, Casey, & Mwamba, 2016; Monson et al., 2012; Ussher, 1990). Three studies purposefully
sampled “same-sex” couples. We do not reference these couples as gay or lesbian, as individuals
were not overtly provided the option to identify their sexual orientation. Ussher (1990) assessed
CBCT with 10 male couples where one partner was diagnosed with HIV. Fals-Stewart et al. (2009)
assessed BCT with same-gender couples (48 female, 52 male) where one partner was diagnosed
with an alcohol use disorder. In this study, counselors who identified as gay or lesbian were
matched by gender to the couple. Garanzini et al. (2017) examined the effectiveness of Gottman
therapy with same-gender couples (18 female, 88 male) at the Gay Couples Institute in San Fran-
cisco. Two studies included partial samples of same-gender male and female couples (16 of 439
couples; Hewison et al., 2016) or female couples (three of 40 couples, Monson et al., 2012). Hewi-
son et al. examined the effectiveness of psychodynamic couple therapy (i.e., IOCT) in a naturalistic
treatment setting in the United Kingdom. Monson et al. examined CBCT where one individual
was diagnosed with posttraumatic stress disorder (PTSD). In total, there were 470 individuals in
SM relationships representing 4.6% of all participants (see Figure 2). Removing Fals-Stewart
et al.’s and Garanzini et al.’s large samples, only 0.6% of the remaining participants were in SM
relationships. Reflecting historical changes, in studies after the AAMFT Core Competencies (2004)
8.0% of participants (n = 450) in four studies were in SM relationships.

Figure 2. Participant frequencies identified by gender identity and sexual orientation.

N = 10,238.

JOURNAL OF MARITAL AND FAMILY THERAPY 7

SGM Conceptualization in Studies
SGM identity inclusion and exclusion criteria. Researchers explicitly or implicitly excluded
SM individuals in 26.1% (k = 29) of studies. Greater attention is found in studies after the
AAMFT Core Competencies (2004), where 43.8% (k = 21) referenced SM identities as inclusion or
exclusion criteria. GM identities were not mentioned in any inclusion or exclusion criteria (see
Table S3). Given that same-sex marriage was legalized in 2015, there were 15 studies published
prior to 2015 which stated that couples must be married to participate, thereby implicitly excluding
SM couples. Two studies (Fals-Stewart et al., 2009; Garanzini et al., 2017) explicitly stated that
participants had to be in a SM relationship. In 12 studies, researchers a priori stated that partici-
pants had to identify as heterosexual. One study (McCrady, Epstein, Hallgren, Cook, & Jensen,
2016) reported this criterion excluded 12 SM couples. Denton, Wittenborn & Golden, (2012) was
the only study to provide a rationale for this exclusion, stating there would be “insufficient statisti-
cal power to evaluate gender differences" (p. 26). Two studies did not include identifying as hetero-
sexual in their inclusion criteria but post hoc excluded same-gender couples. Fischer, Bhatia,
Baddeley, Al-Jabari, and Libet (2017) excluded four same-gender couples from analysis because
differences “could not be meaningfully analyzed due to the small number of same-sex couples” (p.
528). Schumm, O’Farrell, Kahler, Murphy, and Muchowski (2014) excluded two female couples
without rationale, although they noted they were “referred to couple therapy outside the study
protocol” (p. 994). Researchers had an explicit inclusion criterion (e.g., all couples welcome) in
4.5% (k = 5) of studies, although only Hewison et al. included SM individuals.
SGM in introduction or discussion. Authors referenced or mentioned SM identities in 13.5%
(k = 15) of original studies and 9.6% (k = 5) of follow-up studies in the introduction or discussion.
After removing the five studies that included SM couples, 9.4% of remaining studies included some
form of reference to SM identities. In the studies published after AAMFT Core Competencies
(2004), 25% (k = 12) included a reference to SM identity in the introduction or discussion. Zero of
the twelve studies where researchers overtly stated that participants had to identify as heterosexual
addressed SM considerations. There was zero mention of any GM identity or expression in discus-
sions or introductions across all couple outcome research.
Of the 10 studies that did not include SM participants but did mention SM identities in the
introduction or discussion, all consisted of only one sentence pertaining to SM identities. Each dis-
cussed the lack of inclusion of SM individuals as limiting generalizability or a need to replicate the
results beyond heterosexual couples. Leff et al. (2000) put it bluntly when they wrote, “Clearly (the
results) cannot be extrapolated beyond those living with a heterosexual partner” (p. 99). Other
than Ussher’s (1990) study of male couples, Shaprio and Gottman’s (2005) was the first mention of
any language geared towards SM couples. Christensen et al. (2004) discussed the lack of generaliz-
ability and heterosexist nature of verbiage in a footnote: "The change from ‘marital therapy’ to
‘couple therapy’ reflects a broadening of the emphasis from heterosexual married couples to all
romantically involved couples" (p. 176).
For five studies that included SM participants, they discussed the dearth of research for practi-
tioners to use with SM couples. Ussher (1990) wrote, “one of the difficulties facing practitioners is
that there is, as yet, little information in the research literature regarding the efficacy of couples
therapy developed for heterosexual client groups, when used with gay couples” (p. 2). Fals-Stewart
et al. (2009) remarked, “rigorous clinical trials in the empirical literature are scarce (with SM cou-
ples)” (p. 379). Garanzini et al. (2017) wrote, “There is a need for basic research about the special
needs of same-sex couples” (p. 674). Ussher remarked, “If therapists acknowledge the unique
issues facing gay couples and incorporate these into couple therapy, there is every reason to predict
that couple interventions will be effective and valued in improving quality of life for gay couples”
(p. 10).

DISCUSSION

This study represents the first systematic review of the implicit or explicit, inclusion or exclu-
sion of SGM couples and the broader issue of consideration of all participants’ sexual and gender
identities in couple therapy outcome research. Results indicate that in the vast majority of studies
couples are presumed without reported assessment to be heterosexual, and cisgender male and

8 JOURNAL OF MARITAL AND FAMILY THERAPY

female. Consideration of, and inclusion is limited for same-gender couples and altogether absent
for nonmonosexual sexual identities (e.g., bisexual, asexual, pansexual) and gender minority indi-
viduals. Since the 2004 AAMFT Core Competencies about 25% of studies discuss limits of general-
izability to SM couples, albeit usually only by brief mention (e.g., sentence or partial sentence).
These findings reflect positive change in the field of CFT however much more is needed. No study
reported having participants self-identify their sexual or gender identity; and no study assessed
participants using measures sensitive to (a) the plurality and continua of sexual identity, or (b) the
plurality of gender identity. Without further change, persistence of a dominant heteronormative
cisgender view of who is a couple will obviate inclusion of the lived experiences of all individuals’
sexual and gender identities.
Our review goes beyond inclusion and exclusion criteria and recruitment numbers into deeper
structural considerations of SGM couples and the sexual and gender identities of all individuals in
couple therapy outcome research. As Grzanka and Miles (2016) note, “. . .we express concern that
if multiculturalism in applied psychology is organized foremost around a politics of visibility and
inclusion, this may likewise engender new forms of subjection and marginalization even as such
discourse is motivated explicitly by a ‘social justice’ imperative” (p. 385). While recruitment and
inclusion of SGM in couple therapy outcome research is much needed, a structural issue that con-
cerns us is the use of language in the majority of this research that presumes when we speak of cou-
ples the reference is to heterosexual and cisgender male and female couples. Essentially, how we
talk about people matters – language defines and confines reality (cf. social construction theory;
postmodern and poststructural philosophies). We urge couple therapy researchers, educators, and
practitioners to shed heteronormative language for inclusive and thoughtful consideration of cou-
ples’ and individuals’ sexual and gender identities. As a field, we have neglected the varied experi-
ences of couples’ sexual and gender identities for long enough and, surely, we can do better.
These findings should also be considered and contextualized in relation to their contrast to the
Publication Manual of the American Psychological Association (2010):
Detail the sample’s major demographic characteristics, such as age; sex; ethnic and/or
racial group; level of education; socioeconomic, generational, or immigrant status; dis-
ability status; sexual orientation; gender identity. . .As a rule, describe the groups as
specifically as possible, with particular emphasis on characteristics that may have bearing
on the interpretation of results. Often, participant characteristics can be important for
understanding the nature of the sample and the degree to which results can be generalized
(pp. 29–30).
Accordingly, we provided supplementary analyses to contextualize attention to SGM individ-
uals and issues in couple therapy outcome research. There was a stark contrast between reporting
SGM identities and other sociocultural [e.g., age, socioeconomic status (SES)] and couple charac-
teristics (e.g., children). We wish to note that race and ethnicity were not reported in 57.7% of the
studies and conflated in 99% of studies. Akin to a presumption of heterosexuality, the lack of con-
sideration or a presumption of racial and ethnic identities also limits understanding of how these
lived experiences shape and inform a couple’s life.

Implications for Future Couple Therapy Outcome Research

Measurement and use of language. Participants in couple therapy outcome research should be
provided the opportunity to self-identify their sexual and gender identities. In all reviewed studies
sexual identity was treated as a categorical and not a continuous variable (cf. Beaulieu-Prevost &
Fortin, 2015). Such erasure of identity and experience, thereby intentionally or unintentionally
enabling heterocentrism, is concerning considering 84% of individuals who identify as bisexual are
in a relationship that others could deem heterosexual (Pew Research Center, 2013). Simply put,
this grouping of individuals based only on the presumed gender of their partner runs the risk of
rendering nonmonosexual identities of partners invisible. Furthermore, there was zero mention of
any gender variant identity (e.g., transgender, gender fluid, agender). At all junctures, only binary
gender terms of presumed cisgender male and female partners were used. Imagine how many par-
ticipants in this research base were categorically portrayed as cisgender or heterosexual but self-
identify elsewhere along a continuum of sexual and/or gender identity. These omissions point to

JOURNAL OF MARITAL AND FAMILY THERAPY 9

the ever-increasing need for recognition of sexual orientation and gender identity as distinct and
nuanced experiences.
For measurement there are over 200 scales that measure sexual orientation, of which the path
breaker in the study of human sexuality is The Kinsey Scale (Kinsey et al., 1948). Fraser (2018)
also provides guidance with inclusive assessment of gender identity. The Marriage and Family
Therapy Practice Research Network (Johnson, Miller, Bradford & Anderson, 2017) is a naturalis-
tic database informed by practitioners and is on the leading edge of inclusiveness not seen in effi-
cacy studies on couple therapy. Following best practices for assessing sexual and gender identity in
survey research, they ask couples about their biological sex, gender identity, sexual attraction, and
sexual orientation (S. R. Anderson, personal communication, May 24, 2019). We call on couple
therapy researchers to adhere to similar standards. Continuous versus categorical measures of sex-
ual and gender identity should be used for all couple participants.
Consideration and inclusion of SGM couples. Culturally modified and scientifically vetted
models are needed to help SGM partners conjointly buffer the detrimental effects of minority stress
(Green & Mitchell, 2015). While presumed active ingredients from various couple therapy modali-
ties likely translate to working with all couples (e.g., focus on attachment, emotional regulation,
cognitive restructuring), other aspects may not be applicable to SGM couples (e.g., gender differ-
ences in communication styles) and the unique needs of SGM couples are not adequately
addressed within extant couple therapy outcome research (e.g., minority stress, internalized hetero-
sexism, role ambiguity, insufficient social support). The need is further amplified by a recent con-
sumer survey where 87% of SM individuals say couple interventions should be tailored to meet
their specific needs (Pepping et al., 2017). Gary Diamond and colleagues’ research on Attachment-
Based Family Therapy with self-identified lesbian, gay, and bisexual teenagers who are suicidal
(Diamond et al., 2012) and SM young adults with persistently rejecting parents (Diamond & Shpi-
gel, 2014) serves as a model for culturally adapted SGM couple therapy outcome research (e.g., see
recruitment strategies, treatment modifications). Some argue that recruitment of SGM couples or
institutional funding constraints hinder recruitment of SGM couples, whereas these and other
examples (e.g., Garanzini et al., 2017) suggest otherwise. Couple therapy researchers might also
consider the community-based participatory research model (Collins et al., 2018) which centers the
experience of individuals from a community and collaborates with them through the process of
creating and evaluating health interventions. To this end, participatory research has shown pro-
mise for relationship education interventions informed by SM couples (e.g., female couples; Whit-
ton et al., 2017).

Implications for Training and Practice

The intent of this review is not to convey that couple therapists and scholars are wholesale
ignoring issues related to sexual and gender identities and practitioners are left with no guidance.
To the contrary, as is often the case, developments in practice and training precede research. In lieu
of an absence of couple therapy outcome research one implication of these findings is that practi-
tioners should be tentative when generalizing extant findings to SGM couples and, instead, use
alternative resources for guidance. In recent decades, scholars have engaged in theoretical modifi-
cations of couple therapy modalities for SM couples (e.g., male couples, Allan & Johnson, 2017;
bisexual couples, Deacon, Reinke, & Viers, 1996) and GM couples (e.g., Chapman & Caldwell,
2012). A sizable body of research exists on SM couple functioning (e.g., 12-year longitudinal study
of SM couples, Gottman et al., 2003) used to inform proposed modifications of couple therapies
and training resources, including the production of high-quality training tapes (e.g., EFT, John-
son, 2012; IBCT, Tullos & Martell, 2015). Practitioners who identify as SGM and allies are using
their inherent community cultural wealth (Yosso, 2005) and knowledge to inform couple therapy
practice. Such instrumental work occurs in many centers and organizations around the United
States.7 Garanzini et al. (2017) published out of the Gay Couple Institute the first study of the
Gottman method with SM couples (88 male, 18 female couples) receiving treatment as usual. These
centers illustrate a movement across the country of SGM identified and allied practitioners who
are actively recognizing and addressing the nuanced therapeutic needs of SGM couples. Indeed,
the field of couple therapy may be on the move with inclusive signs, notably AAMFT filing an ami-
cus brief for the Obergefell vs. Hodges (2015) Supreme Court ruling. Other ongoing projects

10 JOURNAL OF MARITAL AND FAMILY THERAPY

tailored for SM couples, exist including pilot studies examining the effectiveness of CBCT for
female couples (K. Pentel, personal communication, August 18, 2018) and IBCT through
OurRelationship for SM couples (K. Nowlan, personal communication, March 14, 2018).
This admirable collective work by SGM scholars, practitioners, advocates and allies pro-
motes culturally sensitive and affirmative interventions with SGM couples for practitioners to
learn from and apply to their own couple therapy practice. The field of couple therapy, however,
still needs to collectively take action to address the widespread dissatisfaction with and underuti-
lization by SGM couples related to perceived insensitivity of mental health care providers (Pep-
ping et al., 2017; Spengler, Miller, & Spengler, 2016) and the associated widespread lack of
perceived self-efficacy by CFT therapists in their work with SM couples (Carlson et al., 2013).
While many researchers and institutions have called for CFT training programs to better prepare
trainees to work with SGM couples (e.g., Commission on Accreditation for Marriage & Family
Therapy Education, 2014), it remains necessary to actively evaluate if training interventions
translate to affirmative and effective work with SGM couples. Less than half of CFT students
receive any training related to SM couples and over half of AAMFT therapists report not feeling
competent to work with SM couples (Carlson et al., 2013; Rock et al., 2010). The impact of inat-
tention by scholars and educators and the associated lack of couple therapist competency can be
seen in consumer surveys of SM couples who report a lower level of satisfaction with, and
underutilization of, couple therapy relative to cisgender, heterosexual couples (Pepping et al.,
2017). Until researchers test the efficacy of couple therapy for SGM couples, we encourage train-
ers and practitioners to operate with cultural humility (Hook, Davis, Owen, & DeBlaere, 2017)
and immerse themselves in the abundant research and resources on SGM couple functioning for
indirect, albeit meaningful, support for modified couple therapies. Therefore, a direct implication
of the findings from this systematic review for training practitioners is to recognize the limits of
extant research when working with SGM couples, and to provide couple therapy with greater
tentativeness in a culturally sensitive manner (see Benish, Quintana & Wampold, 2011). Another
implication is to consider not assuming individuals’ gender and sexual identities but to inquire
as part of standard couple assessment.

Limitations
As with any systematic review this review is inherently limited by its scope and lens, including
our choice of contextual sociocultural and couple characteristics in the supplementary analyses,
and our exclusion of research outside of couple therapy outcome studies (e.g., relationship
enhancement, process research). As nearly all studies did not provide a rationale for the exclusion
of SGM participants, postulating as to what contributed consciously or subconsciously to this
decision for each study would be purely speculative without authors overtly expressing their reflex-
ivity and the ethos of their research design. On a personal level, our biases may have come through
as SGM advocates and allies. We labeled the exclusion of SGM couples and consideration of
diverse sexual and gender identities as a reflection of researchers’ cycle of socialization (Harro,
2000) in a heterosexist and cissexist society, although these are our assumptions as researchers did
not overtly justify these exclusions. Nonetheless, despite limitations, we hope this review encour-
ages a future of sensitive and inclusive couple therapy outcome research related to participants’
sexual and gender identities.

Conclusion
As it remains unclear how couple therapy works for SGM couples, we join others (e.g., Budge,
Israel, & Merrill, 2017; Hartwell et al., 2017; Lebow et al., 2012) in calling for the CFT field to
embrace a research and training agenda that is SGM inclusive and affirmative. While the field has
made recent strides in considering SGM couples, there remains room for improvement. It is essen-
tial that researchers provide participants the opportunity to self-identify along a continuum of sex-
ual and gender identities and to be more explicit about what “couples” are included and excluded.
Researchers should actively recognize the potentially wide range of committed unions of romantic
partners (e.g., intercultural, polyamorous, same gender). As Bob Dylan (1964) reflected, “The
times they are a-changin’.” Through this collective action and enhanced mutual awareness of the
power of language and presumptions, CFT researchers, educators, and practitioners can actively

JOURNAL OF MARITAL AND FAMILY THERAPY 11

and consciously choose the role they wish to play within enabling, complying with, or advocating
against minority stress for SGM couples.

NOTES
1
We use the inclusive term couple therapy to embody therapy for all committed, romantically
involved relationships, seeking to avoid exclusion based on legal status of a relationship.
2
We use the term “sexual and/or gender minority couple” to include lesbian, gay, bisexual,
transgender (LGBT), and all other individuals who do not identify as cisgender and/or heterosex-
ual. Our use of the term with couples also includes relationships where one individual does not use
this label for themselves but is partnered or married to a person with a sexual and/or gender minor-
ity identity (for example, a cisgender, heterosexual woman partnered with a bisexual, transgender
man). Our use of SGM throughout this text rather than LGBT is the acknowledgment that sexual
orientation and gender identity exist in a vastness beyond what is encapsulated by LGBT.
3
When sexual minority (SM) or gender minority (GM) are used by themselves, it is in refer-
ence to the particular population referenced in the cited research.
4
Due to space limitations, all 111 studies in this review are provided online (see Data S1 Refer-
ences for Studies Reviewed).
5
This list is not orthogonal as one study compared EFT and Gottman.
6
Due to space restrictions, a complete analysis of all non-SGM participant demographics,
including averages and percentages, is provided in Table S2 and Data S2 Supplementary Analyses.
7
This list is by no means exhaustive but includes the Mazzoni Center for LGBTQ Health and
Wellbeing in Philadelphia, The National Queer & Trans Therapists of Color Network based out of
Oakland, the Minnesota LGBTQ + Therapists’ Network, the Association for LGBT Issues in
Counseling of Alabama, and the Gay Couple Institute in San Francisco.

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 SUPPORTING INFORMATION

Additional Supporting Information may be found in the online version of this article:

Table S1. Timeline of Relevant Mental Health Professions’ Positions and Social Policies Regard-
ing GSM.
Table S2. Participant Race/Ethnicity Frequency and Reporting.
Table S3. All Sociocultural Variables Inclusion or Exclusion Details.
Data S1. Supplementary References for Studies Reviewed.
Data S2. Supplementary Analyses.

16 JOURNAL OF MARITAL AND FAMILY THERAPY