Topics in Sex Therapy for Gay Men: Overcoming Fear of Bottoming
[WARNING: CONTAINS SEX THERAPY CONTENT NOT SUITABLE FOR UNDER 18]
This article comes from my work with gay men around confidence, relationships, and sexual self-understanding.
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Clinical Perspective
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. 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, 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 often feel relieved that they have someplace to go to discuss these things with a professional.
This Two-Part Series on Sexual Fears
One of these topics is sexual fear. In this two-part blog article on overcoming sexual fears, I discuss fear of bottoming and fear of topping (see part two 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. Lots of material written by therapists exists for straight men, and gay men can sometimes “translate” these for 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.
Fear of Bottoming
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!). It’s that they want to be the 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: 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 fear they will. The latter is “anticipatory anxiety”—fearing something that hasn’t happened yet. The short answer 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, slow down, or change direction with your top partner if you feel pain. Learning to tolerate bottoming comfortably, or even enjoyably, can be gradual. 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. This can include using toys in graded sizes, because the sphincter muscle can learn to relax and expand over time (think of guys who can take very large toys, or guys into fisting).
If you’ve already experienced pain, the next step is to determine the cause. Is it something physical, such as a fissure (a stinging “paper cut” feeling), a hemorrhoid, or another medical condition that a colorectal surgeon would treat? If so, rule out medical issues first. This step matters before you enlist the help of a therapist. Comfort in anal penetration can involve both a physician and a therapist, because it can involve both the physical and the psychological.
Once you get the “all clear” from an MD, pain can still reflect psychological resistance. If you are not really attracted to your partner penetrating you, that can be a factor. If you resent your partner (even unconsciously), that can be a factor. If you carry social or religious guilt about gay sex—especially being the bottom—that can be a factor. If you feel guilty because you are breaking a monogamy agreement, that can be a factor. If you survived sexual abuse and experienced anal trauma, your body can hold that memory. If you’re bottoming because you were persuaded to, or feel obligated to, when you’re more of a top in your natural desires, that can be a factor. These issues can respond to Cognitive Therapy (my most frequently used technique), but we have to explore them, discuss them, and bring them from unconscious influence into conscious choice.
2) Fear of Hygiene
This fear is common, because it’s not just theoretical. It can happen.
Products such as Pure for Men appeal to the idea of reducing the chance of your top “striking oil,” as they say. Despite its ubiquitous online reviews, many of my clients report mixed real-world results with it.
The fear of not being completely “clean” can lead some men to take self-cleaning to an extreme (via douching with enema bottles or shower attachment devices). That can strip the anal canal of important mucosal lining. The psychology can also resemble an OCD-symptom, where clean is never “clean enough.”
Some guys have lived through the socially awkward moment of stopping sex early. Others have heard stories and fear it. Either way, the fear makes sense. Gay men also grow up with devaluing messages that we are not “good enough,” and many men carry bullying histories. Social anxiety often centers on fear of negative evaluation by others. If a top reacts with disgust, embarrassment and shame can follow—even though accidents are no big deal in real life. Porn creates a false standard because it hides the normal realities of bodies, preparation, and mess.
Again, cognitive reframing matters. If fear of an accident blocks you from bottoming when you want to, fear is running the show. A healthier frame is: “I don’t want this to happen. I will prepare in reasonable ways. If it happens anyway, I will treat it as a risk of being a sexually active bottom man. If my top shames me, that says more about him and his lack of social graces than it says about me.”
If you’re reading this and have questions about your own situation, you don’t need to have it all figured out. You’re welcome to email me at Ken@GayTherapyLA.com with a few thoughts or questions, and we can see together whether working together would be a good fit.
3) Fear of Medical Issues
Some guys fear bottoming because they have heard stories about medical conditions that can follow anal sex. Fissures, small tears, and other less common issues can happen. A client recently told me he experienced a small injury after getting double-penetrated, saw his colorectal surgeon, used a corticosteroid cream for a few days, and got complete relief.
While unusual situations can happen regarding sexual injury, fear often grows out of proportion to the actual risk. These fears can respond to cognitive therapy. We talk about sexual health and ask: how likely is this, in proportion to the sex life of your average (American or international) bottom? It’s possible, but it’s not likely. A consult with a colorectal surgeon or a gay-savvy GP can put risks in perspective and help you feel more self-empowered about prevention.
4) Fear of Shame or Stigma
This fear has come up less frequently in recent years, likely because acceptance has increased. Trans visibility and broader challenges to gender “expectations” have also helped. Still, some gay men fear bottoming because it feels denigrating to them—like it makes them less masculine.
We hear this in American English: “I really got fucked on that deal,” or “She totally fucked me over.” Those casual attitudes carry homophobic microaggressions, and they can get internalized. Cognitive work asks: whose business is it? As a consenting adult, you control your body. What you do or don’t do with another consenting adult is no one else’s business.
This is also part of the abuse recovery work I do with clients, and part of the Sexual Self-Empowerment model for “compulsive” sex (I strongly oppose the “sex addiction treatment” model, which has been debunked and often functions as anti-male and especially anti–gay male). There is also a form of LGBTQ+ Pride that extends into “bottom pride,” such as “PWR BTM” shirts you’ll see in places like West Hollywood.
5) Fear of HIV and STDs
A healthy fear—really, a healthy respect—for HIV and other STDs can be protective. HIV and STDs are “no fun at all,” and that reality should motivate education and a sexual health routine that includes regular testing and treatment when needed.
The fear of HIV is also a remnant of collective trauma from the AIDS crisis. What has frustrated me since I began HIV/AIDS education (31 years ago) is that fear often exceeds risk. At the height of AIDS, people feared contagion from air, water fountains, toilet seats, or being in the same room. That fear was never only about contagion. It also served distancing and shaming. Even within gay male culture, the “good gay” was HIV-negative and the “bad gay” was HIV-positive.
But we have known for decades how HIV transmits—and how it does not. Men who bottom need accurate education about this. With the advent of PrEP, prevention is easier than ever. For current information, see www.PrepFacts.org. For other STDs (often referenced vaguely with exaggerated dread), regular screening and treatment preserves sexual health.
Conclusion
Education and information build self-empowerment. 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, and sex problems are not what they see me for. This matters as a reality check: this isn’t rocket science, and these fears can be managed or eliminated with support, especially with cognitive therapy work.
The opposite of these fears is 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 too, when you remove the barriers between your current state of mind and the one you can build 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, Licensed Clinical Social Worker (CA LCS18290), and an AASECT Certified Sex Therapist, with additional certification in psychiatric illness and Consensual Non-Monogamy and Polyamorous Families from the Sexual Health Alliance. He is a retired Adjunct Associate Professor at the Suzanne Dworak-Peck School of Social Work at USC, and is the founder/director of GayTherapyLA.com and GayCoachingLA.com. 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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If this topic resonates, you’re not alone — and this is exactly the kind of work I do with men who want real, practical change, not just insight. I help clients turn understanding into action — improving confidence, relationships, and quality of life in a thoughtful, sex-positive, and affirming therapy space.
About the author
Ken Howard, LCSW, CST is a psychotherapist and AASECT-Certified Sex Therapist with over 30 years of experience working almost exclusively with gay men. A former USC faculty member, he is also the host of The Gay Therapy LA Podcast, where he explores the psychology, relationships, and inner lives of gay men — and he brings that same depth and practicality into his work with clients through therapy (CA) and coaching (worldwide) via telehealth.