When gay men usually think of sex therapy, or therapy for sexual issues, their first thought is probably that that’s something to work on in couple’s therapy with a partner or spouse. For the most part, they would be right; when I work with gay couples, assessing the current status of their sex life is part of the work, and then discussing strategies and ways to improve it if either partner, or both, has complaints about their sex life.
What you might be overlooking is the role, value, and purpose of therapy for sexual issues, topics, and challenges that affect you that might be a part of individual therapy. In my practice, I work with gay couples, but the majority of my work is with adult gay male individuals, and has been for over 23 years now. That’s my specialty and “niche” of expertise that sets me apart from most licensed psychotherapists in my local community (West Hollywood, Los Angeles, Beverly Hills). You might not be aware of some of the sexual topics that might apply to you, that I help a lot of individuals with.
Below are some of the areas about sex and sexuality that can be part of the work in individual therapy. Think about which of these might apply to you, and consider if it might be time for you to talk to someone about these or similar issues:
- Validation for a Gay Male Identity – One of the things my clients always tell me is that they enjoy working with a gay male therapist because they feel especially comfortable talking to therapist who “gets it” on gay sexual content, as opposed to the awkwardness that might come from trying to talk about sexual issues to even the most well-meaning (straight or lesbian) female therapist, straight male therapist, or even to another gay male therapist who doesn’t specialize in working with gay men almost exclusively. They report less fear of judgment, but also just a vast body of experience working with so many gay men due to both specialization and length of experience. There are almost no sexual issues that a client can report to me that I haven’t heard before and helped the client with the situation.
- Dating and Sexual Choices – What “feels right” for one client about how to approach dating and/or sex might not work for another client. Some clients only want to have sex under certain circumstances (like active dating), while some “hook up” through fuck buddies, bars, clubs, websites, apps, sex clubs, or bathhouses. Sometimes clients need support to talk freely about what works for them, and what doesn’t. Sometimes it’s about having less or different sex, and sometimes it’s about finding ways to have more sex, but with the guys and circumstances they want. Therapy about sex is what I call “Sexual Self-Empowerment”, which is saying “yes” when you want to say “yes”, and saying “no” when you want to say “no”. This is about having dominion and control over your own body, and about the choices you make as an adult, consenting man. For clients who are survivors of sexual abuse, incest, or sexual assault, much of their therapy can be about a healthy “reclaiming” of the integrity and control of their own bodies. For others, it can be about honoring what your particular body (and mind) long for, discussing ways that you can get fantasies and desires fulfilled in ways that are both safe and satisfying, or even thrilling.
- Sexual Performance and Other Anxiety – Some guys have quite a bit of anxiety around sex, and therapy can help overcome this. “Performance anxiety” about being able to penetrate as a top, or to be a “good” bottom, or the ability to reach climax can all be areas of concern. Sometimes, a discussion of alcohol and drug issues is part of this, because some guys can over-rely on alcohol (or even drugs like crystal meth, marijuana, ecstasy/molly, cocaine, GHB, etc.) to get to the point where they can “relax enough” to have the sex they want, or even sex at all. Developing the ability, over time in treatment, to have the sex you want without having to rely on substances is common goal in sex therapy.
- PrEP, Condoms, and HIV Prevention – As a therapist who has been open about being HIV-positive for 25 years, I know a lot about HIV, its transmission, and how to live with it successfully (I was the Chair of the LA County HIV Mental Health Task Force for 9 years, and co-coordinated its annual mental health conference in LA, “Coping with Hope”). I also know a lot about risk management and HIV prevention. This information changes frequently; just last year, we had more highly-compelling research come out about the effectiveness of Truvada, an HIV treatment medication, being taken by HIV-negative guys (and women) as an HIV prevention medication, called “Pre-Exposure Prophylaxis”. While some guys use this in addition to condoms, some guys use it in place of, and have stayed HIV-negative. Public health opinions can vary on this, but the reality is that some guys use PrEP as an alternative to condoms and enjoy enhanced pleasure from it. But it’s important to learn about the educational resources about PrEP, and where to go to get solid information, as well as being referred to an HIV-savvy physician who can enroll someone in PrEP care, which is more than just taking a pill every day; it’s also about regular HIV testing and other STD screening for comprehensive sexual health. Often my HIV-negative clients have anxiety about HIV transmission risk and prevention, and my clients who are newly-diagnosed with HIV (although there aren’t many anymore, thanks to PrEP), want emotional and practical support for living with HIV for the long term, including around disclosure, dating, and getting good medical care.
- STD Prevention and Management – If you’re on PrEP, that effectively takes care of HIV transmission risk (with good adherence), but “other” sexually-transmitted diseases are still “out there” and need their own kind of attention. These aren’t life-threatening, but can be annoying. Mostly this is a medical issue, but my clients in therapy might discuss their feelings about if they contract a non-HIV STD, or need support for how to disclose to recent partners, and also about reducing risk. The fact is, if you’re a sexually active adult, you might have to get treatment for an STD once in a while, and there is no shame in this. Sometimes discussing anxieties in a way that separates the HIV issue from the issue of other STD’s is a topic in sex therapy.
- Coping with Erectile Dysfunction – It’s hard (ahem, no pun intended) to talk about erectile dysfunction except with another guy. ED can have both psychological and/or physical origins, and coping with ED is a frequent topic in sex therapy. Issues like poor self-care (diet, exercise, sleep, stress management) can contribute to ED, and so can unconscious conflict with a primary partner – conflict you weren’t even aware you had. Or, issues like low Testosterone can contribute to ED, easily, even if guys who aren’t “all that old” yet. Often, I refer guys to information that educates men on hormone issues, especially in the context of midlife and aging. I also disclose my own experience having treatment for hormonal issues, and make referrals when necessary for these kinds of resources. Low Testosterone has implications for ED, but also for mood, stamina, fatigue, identity, and overall outlook. This is where both the medical and the psychological often overlap.
- “Sex Addiction” Theory and “Compulsive” Sex Theory, and Their Alternatives – I’m not a fan of the current “sex addiction” fad among certain therapists, particularly in Los Angeles (heavily influenced by the media), or in places like Salt Lake City, where the conservative sexual views of the Mormon Church find their way into therapy discussions. While extremely lucrative for therapists, “sex addiction” treatment is not an “evidence-based” treatment vetted by formal academic research on its outcomes. “Sex Addiction” (or its other name, “Hypsersexuality Disorder”) was specifically rejected by the American Psychiatric Association as a clinical diagnosis, because it doesn’t have a consistent clinical definition, and also because it is heavily influenced by varying cultural norms and religious moralism (a good article challenging this concept, by Marty Klein, Ph.D, is here, and a great book by David Ley, Ph.D., is here). Similarly, the American Psychiatric Association removed “homosexuality” from its list of diagnoses (called the Diagnostic and Statistical Manual of Mental Disorders) in 1973, because being gay is not a pathology nor a disease. “Sex Addiction” was coined by Patrick Carnes, an aggressively self-promoting addictionologist who capitalized on AIDS fear and hysteria in 1983, when, as Bette Midler once joked on a comedy album, “You gotta be careful these days. You fuck the wrong person and your arm falls off” (“Bette Midler: Mud Will Be Flung Tonight”). “Sex Addiction” expanded on Alcoholics Anonymous (AA) and added behavior issues to chemical addiction. As an alternative, I look at this a different way: In sex therapy, I explore what my client is doing sexually as a matter of course, and how he feels about that. If the client feels he is having “too much” (or, “too little”) sex, according to him (not me!), we discuss strategies for coping with that. Often, stressors like responding to social anti-gay rhetoric, over-work, not taking care of yourself, or not coping with previous traumatic experiences (such as abuse, grief, loss, bullying, etc.) can drive “compulsive” sexual behavior. Despite its popularity (and extremely aggressive marketing; there are five full-time “sex addiction” clinics in Los Angeles alone), insurance does not reimburse for this therapy. Instead, I work with the client on their depression, anxiety, trauma, impulse control, obsessive-compulsive disorder, attention deficit disorder, or others as the underlying diagnosis, and address sexual issues and behaviors as a symptom of those things. What some therapists label “sex addiction” behaviors now would have been considered normal sexual expression for the liberated gay male of the 1970’s after the Stonewall revolution, so we have to discuss and examine sexual issues not only for the individual, but also in a historical, cultural, social, and even political context.
- Working to Get Sexual Needs Met from a Primary Partner – A close colleague and I were discussion how, in general, gay male couples tend to have less sex the longer they are together. This is a common pattern. I often work with gay male couples on discussion their options, such as having “three-ways” or opening their relationship, and how that would impact their relationship. Nearly always, relationships get much better just for having a frank discussion of the issues. Sometimes, a guy can work on getting his sexual needs and desires met from a primary partner, and sometimes other options, such as the opportunity for sex with others, can be discussed in a calm, sensitive, rational way that preserves the emotional safety of each partner. Sometimes, clients in individual therapy need a place to discuss their sex life with their partner when their partner is not present, and the therapist is an objective listener that can help the client identify, implement, and evaluate their options. Other times, clients in sex therapy discuss the dilemma of how to get their sexual needs met if they are not partnered, and how “single sex” can be consistently sexually satisfying, while emotional needs might be met by close friends and other “Family of Choice” people.
- Quality of Sex: Lovemaking versus Sportfucking – Clients will sometimes discuss a need to differentiate between the kind of sex that involves a deep emotional bonding, versus the kind of sex that represents mostly physical gratification. These sometimes overlap, but not always. Clients in sex therapy might need a place to discuss “taboo” things like fetishes, kink interest, BDSM play, or even just their trepidation about trying new things, even when they want to. All of this assumes, of course, that it is sex with another consenting adult. When there are issues that involve a discussion of feelings, impulses and behaviors that are not involving consenting adults, that becomes a different kind of therapy topic. I often refer out to other therapists who specialize in working with legal “sex offenders”, as I focus on gay men who are sexually active with other gay men. While sometimes this can include gay male consenting adolescents and their adolescent gay male consenting partners, this is rare.
- Couples and Sex – While couples therapy is often very effective, focusing to improve concepts like Commitment, Communication, and Compromise, there are times in individual therapy when a client needs the opportunity to discuss his relationship with a third party clinician in privacy. Research has shown that gay male couples go through quite predictable stages of development, and each stage requires its own approach and response. Having the opportunity to sometimes has “relationship therapy with only one of the partners” can be very beneficial for some clients.
Sex therapy for the gay male individual has many advantages, but perhaps the most basic one is that it is a validating experience. Any topic is “fair game” for discussion, without moralism, stigma, or shaming. When we feel good about ourselves sexually, it has implications for other aspects of our physical health and self-care, but also for our mental health: feeling confident, satisfied, and enjoying one of the most primal pleasures that humans can experience. With so much denigration of gay men by conservative political candidates, anti-gay religious figures, a lack of full legal civil rights in the United States and certainly abroad, and with the hard-fought battles for equality, recognition, and dignity that gay men have had to fight historically, it’s nice to know that our sexual needs and desires have validity. When we feel good about our sexual selves, we feel good about our lives. Sex therapy for gay male individuals is a part of this, and I’m proud to offer this as a specialization in professional service for those in need.