Topics in Sex Therapy for Gay Men:  Overcoming Fear of Bottoming


Topics in Sex Therapy for Gay Men:  Overcoming Fear of Bottoming
The peach emoticon is often used in apps for gay men like Grindr or Scruff to connote an ass, or bottoming.

I’ve been a specialist in therapy and coaching for gay men for over 27 years, as individuals and couples.  I work with guys on lots of issues and disorders, such as depression, bipolar disorder, OCD, ADD, substance abuse recovery, dating skills, career planning, and couples in conflict.  Lately, I’ve had more and more gay men come to me with issues more specifically about sex therapy, and currently as of this writing (June, 2019), I’m undergoing the education and supervision process to become a Certified Sex Therapist.  I’ve been helping guys with sexual issues for almost my whole career, though, because most of my clients are gay men who feel more comfortable discussing very personal sexual issues with another gay man, especially one with a lot of experience and one who doesn’t shy away from frank discussions of intimate details.  My clients seem relieved that they have someplace to go to discuss these things with a professional.

One of these topics is sexual fear.  In this two-part blog article on overcoming sexual fears, I will discuss both fear of bottoming, and actually fear of topping (see link here); I see both of these in practice.  These fears hinder gay men from a more robust quality of life, because they hinder having a more robust sex life; they go together.  Lots of material written by therapists exists for straight men, and gay men can sometimes “translate” these for a partial benefit.  There are other books about gay men and bottoming, but there is little material written by a licensed psychotherapist that addresses gay men’s bottom sexual issues in more candid detail.

In this part, we look at gay men who have a fear of bottoming.  It’s not because they just don’t like it (which is fine, by the way!), but it’s that they want to be a receptive partner in anal intercourse, perhaps even crave it as a sexual need and desire, but they have neurotic anxiety that prevents them from accessing this part of their sexual selves.  These fears, in my observation over many years in practice, are these:  1) physical pain; 2) self-consciousness or anxiety about hygiene; 3) medical issues or injury; 4) shame or stigma around the bottom role; and 5) STD/HIV transmission.  Let’s look at each of these in turn:

1) Fear of Physical Pain – For guys who haven’t bottomed yet, or haven’t done it much, and fear physical pain, we first need to differentiate between actual pain they experience, and pain they don’t actually have, but are afraid they will.  The latter is called “anticipatory anxiety”, which is fearing something that hasn’t happened yet.  The short answer to that one is, “try it and see.”  Part of sexual self-empowerment (a concept I teach often in my practice) is that you get to say no, or to slow down or change, to your top partner if you’re feeling pain.  Learning to tolerate bottoming comfortably, or even enjoyably, can be a gradual process.  Even something practical like using the right lube product can help.  I’ve helped many couples devise a strategy to gradually increase the bottom partner’s ability to be penetrated comfortably, which can employ various gradation sizes of toys, because the sphincter muscle has to be trained to relax and expand, just like any other muscle in the body (think of guys who can take very large toys, or guys into fisting).

For the former, a fear of bottoming when they have already experienced pain, is to determine the cause of the pain.  Is it something physical, such as a fissure (which is kind of like a stinging “paper cut” in the anal area), a hemorrhoid, or another medical condition that would be treated by a colorectal surgeon?  If so, the medical issues need to be ruled out first; this is always an important step before you enlist the help of a therapist.  Comfort in anal penetration is a topic that both a physician and a therapist might help the patient with, like many topics that involve the medical/physical, along with the emotional/psychological.

Once you have gotten the “all clear” from an MD, part of the pain might be a cognitive effect of resisting bottoming on another level.  If you are not really attracted to your partner penetrating you, that could be a factor.  If you resent your partner for any reason (such as you feel he’s not making an equal contribution to the relationship), even unconsciously, that could be factor.  If you’re carrying a social or religious guilt about gay sex, particularly being the bottom in gay sex, that could be a factor.  If you’re feeling guilty because you are breaking a monogamy agreement, that could be a factor.  If you are a survivor of sexual abuse, and experienced anal trauma from it, causing a body memory, that could be a factor.  If you’re bottoming because you were persuaded to, or feel that you’re obligated to, when you really are more of a top in your natural desires, that could be a factor.  With all of these, they can respond to Cognitive Therapy (which is my most frequently used therapy technique), but the issues need to be explored and discussed, and brought more from the unconscious to conscious thought and consideration.  Again, this is the purview of a psychotherapist, and less so about an MD.

2) Fear of Hygiene – This is one that is a common fear, because it’s not just theoretical; it can be a reality.  Products on the market such as “Pure for Men”, which are over-the-counter capsules with a combination of fiber substances designed to form the stool and help eliminate it,  appeal to the idea of bottom guys taking it with less chance of your top “striking oil”, as they say, or running into fecal debris in the middle of intercourse.  Despite its ubiquitous online reviews, many of my clients report mixed real-world results with it. The fear of not being completely “clean”, or free of any fecal remnants in the anal canal, can lead a number of guys I’ve worked with to take self-cleaning (via douching with enema bottles or shower attachment devices ) to an extreme, which can strip the anal canal of important mucosal lining.  This can almost be like an OCD-symptom, where clean is never “clean enough”.

Guys who have this fear might have experienced the socially awkward or embarrassing situation of having to stop sex “early”, or they may have just heard about it and fear it. This makes sense; gay men grow up with a constant barrage of devaluing messages that we are not “good enough” – we can hear it from parents, teachers, coaches, and certainly Republican politicians or Right-wing news pundits, in the most graphic and sadistic terms possible, calling for our systematic extermination.  Guys with a history of bullying also can have a certain “social anxiety” about this, which is defined in part as, “fear of negative evaluation by others.”  If our top has to “stop early” due to hygiene issues, they can express disgust, and we can experience embarrassment or even shame, even though these sexual accidents are no big deal (notice how they never happen in porn, which leads us to false sense of the situation; porn models fast from eating for a while before filming, etc.).  There are a number of books that discuss hygienic preparation for receptive anal sex, and most describe using a water douche, but explain ways to do that gently and safely.

Again, the cognitive reframing is important.  If we fear a sexual accident so much that it inhibits us from bottoming when we want to, that’s giving the fear too much power.  We need to reframe the message from, “This cannot ever happen or I’ll just die!”, to “I don’t want this to happen, and I will educate myself to take some preparation precautions, but if it happens, I need to accept this as a risk of a sexually active bottom man, and if my top shames me for it, that says something more about him and his lack of social graces, than anything about me.”

3)  Fear of Medical Issues – Some guys fear bottoming because they have “heard stories” about the various medical conditions that some guys have experienced in the aftermath of anal sex.  Fissures, small tears, and other less common conditions can happen.  A client recently nonchalantly told me a story of how he experienced a small injury from getting double-penetrated recently, and went to his colorectal surgeon physician, who prescribed him a corticosteroid cream to use for a few days, and he got complete relief.  While there can be “horror stories” (I’ve never heard these, in 27 years of practice), I know some unusual situations can happen regarding sexual injury.  Again, these fears can respond to cognitive therapy intervention, where we discuss overall sexual health, and discuss this anxiety in the context of how likely is it, in proportion to the sex life of your Average American (or international) Bottom.  It’s possible, but it’s not likely.  Again, a consult with a colorectal surgeon or even a very gay-savvy general practitioner (GP) MD can put the risk of “the bad stuff” in perspective, and help you feel self-empowered that you’re doing your best to prevent them.

4) Fear of Shame/Stigma – This fear has been less frequently expressed in my practice in recent years, I think due to a general increase in societal acceptance of same-sex marriages in particular and gay/lesbian people in general, especially among the younger generation.  With increased trans visibility in recent years, and much more challenges to gender “expectations”, the fear of bottoming due to it appearing “feminine” has lessened.  But there are some gay men who fear bottoming not because of any pain or anxiety other than feeling like if they do, they will be somehow denigrated.  We hear this in the vernacular of American English: “Oh, man, I really got fucked on that sales deal,” or “She totally fucked me over in choosing Brad for that promotion instead of me.”  Those casual social attitudes (which are more than a little homophobic as microaggressions) can be internalized and mess with our desires versus what we feel is our “duty” to protect our masculinity or something.  Again, with cognitive intervention, we apply the reality-testing of “whose business is it?”  It’s asserting that as a consenting adult, you have dominion and control over your body, and what you do, or do not do, with it, with another consenting adult, is no one’s business.  This is also part of the abuse recovery work I do with clients, as well as the Sexual Self-Empowerment model for “compulsive” sex (I’m very much against this “sex addiction treatment” model, as it has been debunked as both charlatanism and vehemently anti-male, especially anti gay male).  There is a part of overall LGBTQ+ Pride that extends quite frankly into “bottom pride”, such as t-shirts that say, “PWR BTM” that I saw for sale recently at a gay-friendly store in West Hollywood (although there is a band with that name, also).

5)  Fear of HIV/STD’s – Having a healthy “fear”, or at least respect for, the risk of HIV transmission and other sexually-transmitted diseases (pretty much limited to gonorrhea, chlamydia, and syphilis in practical reality, although others (such as Hepatitis C) are possible) is a healthy thing.  A recognition that HIV and STD’s are “no fun at all” is a powerful motivator to educate ourselves about what is sexual health, and how do we get/keep a regimen that keeps us safe, including regular screening testing, and, if necessary, treatment.  The fear of HIV is really a remnant of the collective trauma that we all experienced as a society in general, and gay men in particular, of the horrors of the illnesses and deaths of people we lost to the height of the AIDS crisis.  But what has frustrated me ever since I began in HIV/AIDS education (um, 31 years ago!) is that the fear has been out of proportion to risk.  People at the height of AIDS feared getting AIDS from breathing the same air, drinking from the same water fountain, using the same toilet seat, or just being in the same room as someone with HIV.  It wasn’t just about fear of actual contagion; it was about a cognitive “distancing” and shaming; I’ve written before that even in the gay male community, the “good gay” was HIV-negative and the “bad gay” was HIV-positive.  But we have known for decades now (!) how HIV is transmitted – and perhaps more importantly, how it’s not.  So it’s important for a guy who is bottoming to know this.  With the advent of PrEP, it’s easier now than ever to have a strong sense of security about HIV prevention; see for information.  In terms of the “other STD’s” that are so often vaguely referred to with an exaggerated trepidation, regular screening, and, if necessary, treatment, will preserve a guy’s sexual health in these areas.


One theme to managing these fears is education/information, and the self-empowerment that comes with those, and realizing that many guys bottom frequently and let’s say “luxuriously”.  Many of my clients (particularly younger, single ones) are quite sexually active, and enjoy themselves immensely (sex problems are not what they are seeing me for; it’s other topics they need help with).  And this is an important lesson:  that this is not rocket science and all of these fears are things that can be managed or eliminated with some support, particularly doing the cognitive therapy work to move past them.

The opposite of these fears and anxieties are relaxation, comfort, confidence, and even abandon.  Ask any gay bottom how he likes his “job”, and you’ll likely get a satisfied grin in response.  That kind of delight can be yours to enjoy, as well, if we remove the barriers that stand between your current state of mind and another state you could achieve with some work on yourself.

If having some support for this is something you’re interested in, call/text 310-339-5778 for more information on having a session in my office (near San Vicente and Sixth in LA), or we can discuss my telehealth coaching services available anywhere in the world via webcam.

[Ken Howard, LCSW, is a licensed psychotherapist in California, CA LCS18290, and is a Licensed Clinical Social Worker, with additional certification in psychiatric illness and currently undergoing the process to be Certified Sex Therapist under the supervision of David Ley, Ph.D.  He is also an Adjunct Associate Professor at the Suzanne Dworak-Peck School of Social Work at USC, and is the founder/director of GayTherapyLA, where he supervises three associate clinicians.  He is also an organizational consultant, conference speaker, and expert witness on LGBT, HIV/AIDS, and Diversity issues, and hosts the podcast, “Gay Therapy LA with Ken Howard, LCSW”.]


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