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The Six Principles of Sexual Health as Applied to Gay Men: A Guide

I’ve been enjoying my recent completion of the Certified Sex Therapist credential from AASECT, the American Association of Sex Educators, Counselors, and Therapists.  I achieved this not only from my long experience as a gay men’s specialist therapist (29 years in 2021), but also through completing an 18-month continuing education program for therapists provided by the Sexual Health Alliance, where my mentor was David Ley, PhD, the inspiring and wise author of The Myth of Sex Addiction and Ethical Porn for Dicks, two very important books on sexual health.

That idea – sexual health – has been a long-held interest of mine, as I help gay men who are both single and in relationships achieve that for themselves.  Somewhat recently, Doug Braun-Harvey, LMFT, of San Diego, California, and Michael Vigorito, LMFT, of Washington, DC, identified and discussed Six Principles of Sexual Health as a part of their book, Treating Out of Control Sexual Behavior, which was an alternative to the exploitive, poorly-researched, and sex-negative “sex addiction treatment” fad of recent years, which is quickly falling out of favor despite its media hype and lucrative commercialization.  Like many other psychotherapist/theorist/authors (such as Marsha Linehan, PhD, who invented Dialectical Behavioral Therapy (DBT), initially to reduce the number of patients committing suicide with Borderline Personality Disorder), Braun-Harvey and Vigorito looked at the prevailing treatment models for people who thought their sexual behavior “felt” out of control (whether it really was, or not), and asked, “Can we do better?”  Their groundbreaking book answered this in the affirmative.

In a recent AASECT-approved continuing education seminar with the Sexual Health Alliance (which I’m also a certified graduate from), again led by Dr. Ley, he discussed these “Six Principles” again, and how therapists can use them to help clients in therapy with sexual concerns. I decided to take this a step further, and discuss how these can apply more specifically to gay men, of all ages.

World Health Organization and Sexual Health

According to the World Health Organization (which, Trump, in a usual fit of anger, got the United States out of, and Biden recently restored), “sexual health” is defined as “the state of physical, emotional, mental, and social well-being related to sexuality; it is not merely the absence of disease, dysfunction, and infirmity.  Sexual health requires a positive, respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence.  For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected, and fulfilled” (World Health Organization).

That last word – “fulfilled” – is one that I think is important.  It’s perhaps somewhat easier to think in terms of “disease prevention” such as PrEP, condoms, etc., but WHO makes a good point in that sexual health also involves the quest for all concerned to also be fulfilled, and a lot of guys I work with as clients are not currently feeling fulfilled in their sexual selves, either single or partnered (with one or more), and want to be, which can form the basis of their work with me through my help as a gay men’s specialist Certified Sex Therapist.

Six Principles of Sexual Health

The six principles identified by Braun-Harvey and Vigorito (both gay men, by the way) were identified as: 1) Consent; 2) Non-Exploitation; 3) Protection from HIV, STIs, and Unwanted Pregnancy; 4) Honesty; 5) Shared Values; and 6) Mutually Pleasurable.

Again, that last one – “mutually pleasurable” – is a more nuanced discussion than merely the absence of “disease, dysfunction, or infirmity.”  Dr. Ley points out that so much in sexuality is about “stop signs.”  We want to stop “out of control behavior,” we want to stop “offending our religion of upbringing,” we want to stop anything that makes us feel bad.  And those can be important, to varying degrees, for different people.  But he wisely makes the point of asking where the “go” signs are in our sexuality.  What do we enjoy?  What do we currently do, that we want to keep doing, or do even more of?  What makes us attain that “fulfillment” that WHO mentions?

A Closer Look at The Six Principles

Let’s take a closer look at each of the Six Principles, and what might be different in sexual play among gay men (versus straight people). For each of these, I will offer a discussion of “as applied to gay men” in particular:

#1: Consent

Recently with the #MeToo discussion in media and journalism, there has been a welcome increase in social awareness and sensitivity to societal ills such as date rape, rape-within-marriage, sexual harassment in the workplace (which goes way beyond “Hollywood”), sexual assault (including in the military), and an increased understanding of just what constitutes “consent” (which can be withdrawn at any point in the sexual encounter).

There is also the role of “consensual non-consent” in BDSM and kink play that needs its own consideration. Consent is a legal, ethical, social, interpersonal, and emotional concept, and the increased attention relatively lately just goes to show how much magnitude of exploitation there has been throughout history, often against cisgender or trans women, but against others, too (I was sexually harassed by a male supervisor at a non-profit organization right as I was getting licensed as an LCSW in California.  Since then, I have worked with many men, straight and gay, who have faced this same issue.  It’s not about gender, but about power imbalance, such as an aggressive supervisor (of any gender) who holds the power of continued livelihood, housing, and access to health insurance/medical care over their victim (of any gender).  Violations about consent are all too frequent when we’re talking about people with Narcissistic Personality Disorder who believe that power is something they, and they alone, are entitled to, selfishly holding someone else’s well-being hostage to it.  People with disabilities (such as the developmentally disabled or the mentally ill) as well as the elderly and the intoxicated (such as the “drunk girl at a frat party passed out”) can be especially vulnerable to the Narcissist “helping themselves” (as Supreme Court justices, Presidents, actors, and other famous figures have been accused of).  In true consent, the questions need to be asked and answered about “yes” or “no” clearly.

As Applied to Gay Men

People shouldn’t assume that somehow consent doesn’t apply to gay men because it’s “just guys” and they “want it all the time anyway.”  I have worked with plenty of gay men who have been victims of the same crimes we hear about against women.  Even in “consensual non-consent”, that involves a specific kind of BDSM/kink play, which has its own rules to be considered “mutually beneficial”.  Guys who are straight, bisexual, or “in the closet” might be especially vulnerable to exploitation when there is alcohol, drugs, or some kind of power imbalance involved.  We need to challenge this idea that only women are victims of sexual crimes, even if they are in the majority of those victimized (by straight men who have been brought up to exploit others as part of being a man).  Male rape and sexual assault survivors of all sexual orientations face the double trauma of being both assaulted and stigmatized/disbelieved.  Gay men who have had consent violated are experiencing yet-one-more way that gay men’s sexuality is invalidated, as if they didn’t have the same rights as everyone else. For everyone, healthy sex has an aspect that both (or more) partners are engaging in the sexual act(s) on a level playing field and with equal social power.

#2: Non-Exploitative

Important questions to ask include what, if any, are the power imbalances between or among the parties having sex? Is there any information being withheld from one partner (such as portraying oneself as being single when they are partnered/married)?  Is there some kind of “secondary gain” involved, such as workplace harassment?  See above, again, on what true “consent” means; sex without it is inherently exploitative.  Sex that has a primarily commercial function is often seen as exploitative (such as “human trafficking,” exploitation of children, and other acts made famous recently by Trump, Epstein, et. al. in the news) but truly autonomous adult sex workers would debate this as their right to a livelihood on their own terms, regardless of the “legislation of conservative religious morality coded into law.”  Someone having sex with someone to “get back at their ex” or merely to satisfy a curiosity to “see if a deaf person still moans in sex like a hearing person” would also be considered exploitative (that was a true story from my high school days with a straight “friend”, which I thought was creepy).  Sex to gain some kind of favor, or to prevent the levying of some kind of punishment (such as teacher/student, boss/employee, cop/citizen, vendor/client, etc.) would also fall into this category, and doesn’t imply sound sexual health.

As Applied to Gay Men

One could argue that an older gay guy having sex with a younger gay guy who is being objectified for his youth and beauty could be exploitative in a “twink/sugar daddy” arrangement, or even a younger gay guy who is having sex with an older gay guy to manipulate him into monetary or commercial gains would be, too.  Same with objectification of someone by having sex with them because they are rich/famous (“star f—er”) or a racial or ethnic stereotype (the Black “bull”), or merely because of a physical attribute (my article on avoiding the pitfalls of dating in “cash, connections, or cock” is here).  Healthy sex has to pass a certain “two civilians” test, and be reasonably free of some kind of power imbalance that one participant has “over” the other.

#3: Protection from HIV, STIs, and Unwanted Pregnancy

There has been a lot of discussion about this. Throughout the AIDS crisis, proper (key word) use of condoms was a reliable means of HIV prevention, even if some sexual conservatives (such as the Catholic Church) tried to challenge or undermine this message.  The advent of PrEP was controversial (such as it being labeled a “party drug” or “unreliable”, both of which concepts were disproven; my article on the mental health aspects of PrEP is here), but we now see either Truvada or Descovy as everyday use for many (most?) gay men.  While critics of PrEP argue that it “doesn’t protect against everything” such as syphilis, gonorrhea, or HPV, that doesn’t constitute a reason not to use it.  It has been shown with very reliable data to be highly effective when used daily, or even less than daily.  STI management for sexually active people (of all kinds, not just gay men) involves regular testing, and treatment if any are found.

As Applied to Gay Men

Gay men have had recorded higher prevalence of syphilis at times, so gay men are encouraged to have regular screenings, although this is not limited to them.  Gay men used to make a joke out of “preventing unwanted pregnancy,” but since we can now often find cisgender gay men sexually involved with trans masculine individuals, pregnancy at times can be considered a possible risk.  Guys who are more fluid in sexual identity might also be having some vaginal sex, and considerations to prevent unwanted pregnancy still apply with bisexual men or even gay-identified men who are not exclusive to MSM (“men who have sex with men”) play.  The idea of talking about and discussing these issues can be considered a part of sexual health, and even of consent.  As the saying goes, with all of these, “an ounce of prevention is worth a pound of cure,” and part of being “sexually skilled” at pleasing yourself and a partner includes a knowledge of how to keep unwanted outcomes at bay.  Rationally managing these risks can be a part of the gay men’s specialty therapy I provide, in what’s called “psychoeducation” (education with a psychological aspect to it) and a part of Cognitive-Behavioral Therapy to manage actual risk, or to manage irrational fears about the risks of contagion (which many gay men still have about HIV).

#4: Honesty

Dr. Ley discussed a challenging question of how transparent one is with their partner.  Are you “good at” expressing your needs, desires, preferences, and anti-preferences (things you specifically don’t like in sex)?  Do you keep your agreements about a monogamy agreement with your partner, or do you keep agreements about the “ground rules” of your open relationship in Consensual Non-Monogamy?  How honest have you been lately with others?  With yourself?  Honesty is not only “not doing something naughty,” but also being validating to yourself of what you like.  Honest sex is healthy sex.

As Applied to Gay Men

Gay men can, like others, have, uh, occasional “problems” with honesty.  I hear this a lot in my practice.  We get away from practicing honesty when shame gets in the way of proudly “owning,” discussing, and asserting what we feel with others.  As gay men, we know all about shame from the minority stress of a generally homophobic society, and the creation of the “false self.”  So, with increased shaming, it’s a short trip to increased lying.  Validating ourselves, being our authentic self, and speaking our truth, even if we have to negotiate and navigate areas of disagreement with others, is a part of sexual health.

#5: Shared Values

Dr. Ley calls this “the other safe sex talk,” meaning that what having sex means to you and everyone involved needs some discussion. Is this sexual act a one-time thing, like a hookup?  Is it a part of dating?  Is there any kind of implied commitment, such as to exclusivity (some gay men only forego condoms with steady partners or domestic partners)? Do you both (or more) share an interest in what this sex is (private, public, duo, group, vanilla, kink, etc.)?  Are you essentially “on the same page” here?  Is sex a recreational sport f—k, or is it an intimate expression of lovemaking?  Ideally, the partners participating in sex make it all healthier by having a reasonable congruence of shared values in what they’re doing.

As Applied to Gay Men

Just like with straight people (and I’ve learned in my trainings that straight people can be every bit as kinky as gay men, if not more so because their sex of all kinds is generally more socially supported as the majority), gay men can have many varied values.  The same gay man might have lovemaking-style sex with a long-time partner early in the day, and have a casual hookup with an outside partner later that same day or week.  But in both cases, hopefully the man and his respective partners understand the nature of the sexual encounters for what they are.  When there are not shared values, there needs to be a candid discussion, sometimes in the moment, and sometimes as a topic for partners in sex therapy sessions.  Many times, gay domestic partners or spouses can slowly erode eroticism in favor of “comfort” and “familiarity,” which on the one hand implies intimacy and bond in a long-term relationship, and on the other hand, can be a damper on the exciting aspects of eroticism.  Candid discussions and negotiations can help identify which values each partner wants to assert, with whom, and when/where.

#6: Mutually Pleasurable

The religious conservative views of sex among some Evangelicals, Muslims, Catholics, and (Orthodox) Jews have historically tended to undermine, ignore, or aggressively invalidate the role of women’s pleasure in sex in yet-another patriarchal structure. The old-fashioned advice of mothers to newlywed daughters for their wedding night was, “just lay there and think of England.”  Part of male dominance in world cultures implied that sex was only for men’s pleasure.  But in more modern, progressive views of sexual health, the pleasure of both (or all) parties involved is seen as important, in hopefully relatively equal ways.  If both (or all) partners in the sexual act are not having pleasure (including ironic things such as sadomasochistic pleasure), then the act is probably imbalanced and lacks ideal sexual health.

As Applied to Gay Men

Even a brief conversation with many gay men will tell you that they tend to like sex – a lot.  While this is true for most (not all) humans, gay men not only take the sexual from an interpersonal act of mutual pleasure, but it extends into a cultural identity celebration (see annual Pride celebrations) as a sexual minority.  Not only is the gay male couple having mutually-pleasurable sex, but those who support them are receiving pleasure in knowing about it (perhaps up to a point).  The only people who aren’t being “pleased” with many sexual acts outside those  directly involved are the ones who have a strong investment in “policing” the sex of others by forcing their idea of morality on others (especially via religious oppression and its attempts to codify bigotry into law, such as recent “religious freedom” bills in many states who seek to oppress the broader LGBT community, and gay men in particular, because these people ‘don’t like” the sex their fellow citizens are having, or are interested in).  In this way, we could say that the sexual health principle of “mutually pleasurable” pertains to the actors involved, not the social commentary around it extraneously.  It’s nunya bizness, as the Supreme Court ruling (Lawrence v. Texas) striking down “sodomy” laws attests; in America, gay adults have an implied right to privacy when it comes to their own sexuality (in private or certain limited public spaces, such as a play space, bathhouse, or sex club).  But if the sex you’re having isn’t “mutually pleasurable,” it’s important to avoid the self-abandonment, low self-esteem, and lack of assertiveness inherent to not speaking up.  Speak up.  Assert and advocate for the kind of sexual life you want to have.  You have the right to expect a reasonable consideration of the principle of mutual pleasure in the sex you’re having.

Sex as Life-Affirming, Including Gay Men

For far too long in history, sex has been plagued (pun intended regarding the AIDS crisis) by some kind of negativity.  Oppression.  Disease.  Sexism.  Heterosexism/homophobia.  Strict moralism.  Racism.  Violations of the principles above.  Through social movement, scholarship with a clinical application (such as the work of Braun-Harvey and Vigorito), we are working to move society forward to a greater global awareness at this time in history for increased social justice by way of increased sexual health.  If we identify and apply sexual health principles, we support the individual, the conjoint (such as couples or small groups), and the macro society toward this goal.  Just like medical care, temperature and climate control, hydration, nutrition, and protection from the elements, sexuality is a part of human health, and is a life-affirming activity, even when it is not (as in the case of gay sex) a life-creating activity.  Sex for pleasure is still life-affirming, and since Stonewall (and before), gay men are included in the quest for social justice by way of healthy sexuality.  We evolve as a global society that deserves nothing less.


If you are interested in sex therapy, psychotherapy, couples therapy, coaching, or trainings/conference appearances/speaking engagements, please text/call 310-339-5778, or email

Ken Howard, LCSW, CST is (at over 29 years in 2021) the most experienced gay men’s specialist psychotherapist and life/career/relationship coach in the United States.  He is also an AASECT-Certified Sex Therapist, an Adjunct Associate Professor with the USC Suzanne Dworak-Peck School of Social Work, a person living with HIV/AIDS for 31 years in 2021, and a speaker/activist on gay-affirmative issues.  He lives in West Hollywood, California, and is married to his husband of 19 years.  He can also be found editing his upcoming New Adult novel, The Boy from Yesterday, or recording the concept album for his gay-themed original musical play, “On the Boulevard.” 


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