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A Gay Therapist’s Tips for Gay to Men Improve Sexual Functioning: The Mind/Body Connection

istock-gay-couple-bedHow Gay Men Improve Sexual Functioning:  The Mind/Body Connection


Sexual Satisfaction as Personal Right

As I’ve learned over 25 years providing gay-affirmative therapy and coaching for gay men and gay male couples all over the world, a robust mental health is made up of certain core components.  A part of good mental health is good physical health:  getting good sleep, food, drink, having comfortable temperature control in your environment, feeling safe and relaxed where you live/work, having a digestive system that works well, being free of pain, and having sexual expression/fulfillment.

Mental health can also include having social support in our environment, from our Families of Origin or our Families of Choice.  It can mean having access to the resources you need to alleviate problems that get in the way of our well-being.

So, recently, when I began work with several guys who entered therapy or coaching with me with concerns about their sexual functioning, together we immediately looked at ways to cope with this, and to identify resources that would help.

In my book, Self-Empowerment: Have the Life You Want!, I talk about how dealing with your problems involves both internal and external resources.  Internal resources include courage, determination, focus, resilience, confidence, and hope.  External resources are anything outside you, like other people, information, or products you can buy or use.  So when guys complain that their sexual functioning is not fulfilling for them, we need to look at why this is.  Unlike some problems in therapy/coaching that are very psychological, sexual dysfunctions are challenges that often have both a psychological and a physical/medical component.  It’s one of those times when a psychotherapist/coach like me might collaborate closely with my client’s physicians or other health care providers.

In solving these problems, we have to start with recognizing that sexual expression and fulfillment (among consenting adults, or peer consenting adolescents) is a basic human right.  This is also social and political issue, because we have a lot of forces in our country/world who believe that sex is only for a certain privileged few, or that there is a prescribed, “right” way for sexual expression and that anyone who deviates from that must be punished (anti-gay religious forces, the “sex addiction” industry, misogynists who believe only straight men have sexual rights, people who believe that only the perfectly-abled have sexual rights, people who believe that adolescents, the elderly, the mentally ill, or the differently-abled shouldn’t have sex, people who believe only the “pretty” can be sexual, etc.).  When a guy is having sexual functioning difficulties, I start with validating his feelings and agreeing that we should work to try to change the situation for the better if we can.

Types of Sexual Difficulties

These difficulties can include (most commonly) difficulty having strong erections (especially those firm enough to penetrate the natural “resistance” of the anal sphincter muscle), delayed ejaculation (often a side-effect of the SSRI-family of antidepressant medications), loss of libido (which can have all kinds of causes: testosterone deficiency, hormone imbalance, stress, psychological guilt, fatigue, poor physical fitness, poor circulation, illness, etc.), or physical structure challenges such as a curved penis or an unusually constricted anus.  In relationships, sexual problems can take the form of differences in libido (and desired sexual frequency) with a partner/spouse, sexual stalemate (boredom), and a sex life impacted by emotional states between partners such as guilt, anger, resentment, ambivalence, fatigue, stress, or prior trauma (such as accidents/injuries/surgeries, or with sexual abuse survivors).

Since the first step toward solving a problem is identifying it, having an assessment from a therapist/coach (from a mental health point of view) and having an assessment from a physician (general practitioner, urologist, endocrinologist, or “men’s health specialist”) are the places to start.

Online Resources

Knowing what’s going on with your physical system can help shed light on why your sexual functioning is impacted.  Laboratory blood tests can test markers like your free and total testosterone, estradiol (estrogen), follicle-stimulating hormone, prolactin, and others.  You can do this with your doctor, or, you can order blood tests for yourself by paying privately at a service like, which has “packages” for testing men’s hormonal levels and other specific medical aims; you order their requisition form, take it to a local blood-drawing facility (I use LabCorp facilities in Los Angeles) and then you can take these results to your various physicians and have them interpret them and make recommendations for what to prescribe you medically.  I’ve used the physicians at in Florida for this, using telehealth phone consultations, and they have been a big help, but there are other resources.  For a treasure-trove of articles about men’s sexual health, testosterone, the hormonal system, and many treatment options, based in solid scientific research, visit Nelson Vergel’s  (Vergel is a renowned expert, researcher, and advocate in men’s sexual, hormonal, and athletic health, and is the author of “Built to Survive”, a book which helped so many guys living with HIV/AIDS combat wasting syndrome.)

Medical and Psychological Assessment

A physician who is qualified to address these issues might prescribe you supplemental Testosterone (in either intramuscular injection form, topical gel, or time-release pellets injected under your skin), an estrogen blocker like Anastrozole, a medicine to stimulate your testes like HCG (human chorionic gonadotropin), or others that he/she recommends in reviewing your lab tests and reported symptoms.  Or, an erectile dysfunction drug like Viagra, Levitra, Cialis (all pills) or one with a penile injection (like Trimix) can help.  That’s the physical/medical side.

On the psychological side, a therapist/coach might help you to identify any underlying thoughts, beliefs, or feelings that you might have that are impacting sexual functioning.  For example, guys who feel “guilty” about being gay after a lifetime of anti-gay messages growing up might feel that they are “undeserving” of sexual satisfaction as a gay man.  Partners in a relationship with unresolved anger or conflict (even unconsciously!) might have sexual difficulties.  HIV-positive men, even those who are not infectious due to being undetectable on meds, might have a lingering irrational fear of infecting a negative partner (top or bottom).  Some guys might like being bottoms, but they have guilt about being in a “subservient” role to another guy.  Survivors of sexual abuse might feel guilty about having/enjoying sex after their victimization, or many sex acts might be triggers for flashbacks to the abuse (which requires treatment for Post-traumatic Stress Disorder (PTSD)).  Even sexual boredom, where a guy craves a different kind of sex, or sex with a different person (for novel stimulation with a different guy’s body, hair, ethnicity, personality, etc.) can cause problems.  With so many possible “roots” to a guy’s sexual dysfunction, the assessment of what’s influencing it is especially important to explore, identify, evaluate, and clarify.


The interventions to resolve the problem(s) can be many, and may be used in combination.  The medical ones involve changing the body’s chemistry through medications that affect the hormonal system, and these can sometimes help resolve the whole problem altogether (I’ve seen testosterone supplementation work wonders in short time).  These require monitoring with your doctor, including monitoring your hematocrit and hemoglobin levels, because Testosterone supplementation can cause “polycythemia” (or, many red blood cells) that can make your blood thick and prone to clot.  I, for example, need to have “therapeutic phlebotomy” for this about once a month (which is unusually frequently, by the way) where my hematologist has me “donate” about 500 cc’s of blood and take in 500 cc’s of saline (water) to thin it back out. Without this, “thick blood” could be a heart attack or stroke risk, among others.  Guys who use Testosterone supplementation (or other anabolics, such as in bodybuilding) should always be carefully monitored by a physician.

Other interventions that a therapist might use could be Cognitive Therapy, where we explore what core thoughts, beliefs, and assumptions you might be telling yourself that impede your sexual functioning.  Cognitive Therapy is a process of identifying, challenging, and re-writing these thoughts into something more positive and useful.  Behavioral Therapy might involve “homework assignments” where you try different things with your partner in your next sexual situation.  More traditional or “psychodynamic” therapy might involve exploring how experiences in your childhood are influencing your experience of yourself as a sexually-mature adult now, or exploring how you might have unconscious feelings that are undermining your sexual functioning in ways you’re not aware of, such as ways that you resent your partner for something (they make more money than you, you’re jealous of their recent success, etc.).  We might explore any feelings you have about sexual guilt, and conflicts about wanting to do a certain kind of sex, but on the other hand, feeling like that would be “too kinky” or “gross”, or something “normal guys” wouldn’t do (such as fetishes).  We might also use journaling exercises, mindfulness meditation, or stress reduction.

Books that educate guys on the issues can be very helpful adjuncts to therapy/coaching sessions.  Some favorites are How to Top Like a Stud, How to Bottom Like a Porn Star, The Gay Man’s Kama Sutra, Mating in Captivity: Reconciling the Erotic with the Domestic, The Joy of Gay Sex, and Sex Outside the Lines, among others.  Reading books between sessions, and then discussing them in session, can help you consolidate the information you read/learn and apply it to your life for your best benefit.

These interventions can be a trial-and-error process.  Often, sexual dysfunction results from more than one cause, or has at least more than one factor/influence, so overcoming it can take time and patience, and experimentation.  There is no one solution that helps every guy.  Also, needs might change over the course of your lifetime or over the course of a relationship.  Guys that have no interest in kink play early on might become drawn to it later.  Guys who like one kind of guy, or one kind of sex at one point, evolve to like other guys or activities later.  Our sexual selves, interests, priorities, and likes/dislikes can evolve over a lifetime.


Validating your feelings that you are entitled (with another consenting adult, of course) to a sexual functioning that is fun, satisfying, and rewarding is a great place to start.  Taking care of yourself sexually is part of an overall plan of self-care that protects and enhances your quality of life in many areas, over the long term.  Make a commitment to yourself that you will allow yourself to get the help you need, for the sex life you want.  For more information on my sex therapy services for gay men, visit this link here.


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