Paul, a slim, attractive, 29-year-old white man who owns a landscaping company, was referred to me by his therapist (with whom he was making no progress) shortly after he attempted suicide. He told me that eight months previously, Julie, his fiancée, had discovered that he'd been having unprotected anal sex with men. When she confronted him, he denied it, but soon broke down and confessed. Devastated and angry, she broke off their engagement, accusing him of being duplicitous (she believed they were monogamous) and secretive. Worst of all, she felt frightened that he'd put her at risk for HIV and other sexually transmitted diseases.
Paul loved Julie and said he knew she was the woman for him. They'd dated for three years and been engaged for one. He hadn't told her about his homoerotic tendencies, nor had he confessed his suspicions that he might be bisexual. Then again, he thought every guy had some homoerotic thoughts that he probably kept private. He couldn't understand why Julie was so angry with him or why she didn't try to understand what he was going through.
Instead, Julie had rebuffed all his desperate and obsessive attempts to win her back. Ultimately, she'd had a restraining order issued against him. Shortly after this, Paul engaged in a binge of sexual acting-out with both men and women, culminating in the suicide attempt that brought him to my office.
This has happened many times: a man comes into my office, referred by his own therapist and clutching coming-out literature the therapist has given him. He explains that his therapist has tried, unsuccessfully, to help him come out as a gay or bisexual man. But even though he's had sex with other men or gone to gay male Internet porn sites, he insists he isn't gay. He says he isn't homophobic, either; if it turns out that he is gay or bisexual, he'll accept it and move on with his life—but it just doesn't feel right to him.
Historically, psychotherapy assumed homosexuality was a psychological disorder. Therapists focused on helping clients "recover" and find their innate heterosexuality, much to the harm of many gays and lesbians. During the last three decades, in reaction to these prejudiced and destructive attitudes, we've seen the pendulum swing so far the other way that it's now become almost a therapeutic credo, not to mention a requirement of political correctness, to assume that men who have sex with men are "in denial," and that the clinician's job was to help them recognize and accept their "true" homosexual orientation. In fact, neither extreme represents the experience of many men.
The truth is that many men who have sex with men aren't gay or bisexual. Although their confused mental and emotional state resembles that of the initial stages of coming out, gay men go on to develop a gay identity, whereas these men don't.
Therapists who treat such men need to realize that just because a client is sexual with the same gender doesn't necessarily reflect his sexual or romantic orientation. While we may believe we've accurately assessed whether a client is gay, it isn't up to us as therapists to make this judgment. Countertransference, cultural stereotypes, and personal feelings too often enter the therapy room and complicate our work—particularly with these clients. Therapists need to help such clients discover for themselves whether they're acting out a gay or bisexual identity by asking the right questions and by agreeing on a shared vocabulary.
Understanding Straight Men Who Have Sex with Men
There's growing evidence that many men who have sex with men aren't all gay or bisexual. According to the Centers for Disease Control, more than 3 million men who self-identify as straight secretly have sex with other men—putting their wives or girlfriends at risk for HIV infection and other sexually transmitted diseases. A recent New York City survey that appeared in the September 19, 2006, issue of the Annals of Internal Medicine found that nearly 1 in 10 men say they're straight and have occasional sex with men. In addition, 70 percent of these men are heterosexually married. In fact, 10 percent of all married men in this survey reported engaging in same-sex behavior during the previous year.
To best treat these men, therapists and clients need to be able to differentiate four terms that are often confused: sexual identity and orientation; sexual preferences; sexual fantasies; and sexual behavior. Contrary to common usage, they aren't always in alignment.
Sexual identity and orientation encompasses one's sexual and romantic identity, in which thoughts, fantasies, and behaviors work together in concert. It's the alignment of affectional, romantic, psychological, spiritual, and sexual feelings and desires for those of the same or opposite gender. Sexual orientation doesn't change over time. One's sexual behaviors and preferences might change, but like one's temperament, one's orientation remains mostly stable. The term also refers to how someone self-identifies, not how others may categorize him or her. Some people self-identify as straight, while others self-identify as gay or lesbian, bisexual, or questioning. It's important as therapists to ask your clients how they self-identify, regardless of with whom they have sex.
Sexual preferences refer to sexual acts, positions, and erotic scenarios that someone prefers to have while engaging in sexual activity. The term takes into account what individuals like to do and get into sexually, not necessarily with whom they like to do it. Preferences and erotic interests can change over time, as one becomes more open or closed to certain thoughts and behaviors.
Sexual fantasies are any thoughts that one finds arousing. They can encompass anything—sexual positions, romantic encounters, body parts, clothing and shoe fetishes, even rape. Sexual fantasies aren't necessarily acted out. In fact, in many cases, they aren't.
Sexual behavior is any behavior intended to pleasure oneself and/or one's sexual partner. It doesn't necessarily reflect one's orientation. For example, men who are imprisoned engage in sexual behaviors with other men, but do so out of sexual necessity, not because of erotic interest in another man. They desire the behavior and the sexual release it achieves, and the gender of the partner is secondary.
Why Men Have Sex with Men
For straight men who have sex with men, same-sex encounters aren't about romance or sexual attraction and desire, but about sexual and physiological arousal—"getting off" with another who's male and accessible. They don't sexually desire or get aroused by looking at other men, only by the sexual act. But if they don't actively desire other men, how do they get to the point of having sex with them? These men typically want to bond with and get affection from other men. Their behavior may reflect a desire to experiment, to engage in something that's taboo, or to express inner psychological conflicts involving their sexual feelings and desires that have nothing to do with having a gay or bisexual identity.
Straight men who have sex with men do so for a variety of reasons. Some have been sexually abused and are compulsively reenacting childhood sexual trauma by male perpetrators; some find sexual release with another man more accessible; some have sex with men because it's easier and requires fewer social skills than those required to have sex with women; some are "gay for pay" and get financial rewards; some like the attention they receive from other men; some like anal sex, which they're otherwise too ashamed to talk about or engage in with their female partners.
When doing an intake with straight men, it's important to ask them if they have been—or are—sexual with men, even if they tell you they're straight. If they want to know why you'd ask, you can say that it's a standard question for all your new clients to get a complete profile of them, and that you ask gay clients about heterosexual sex as well.
When I learn that a straight client is having sex with men, I ask a series of questions: What is your interest in men? Do you prefer one type over another? Do you feel drawn and compelled to satisfy your sexual urges with men? Do you care about the physical appearance of the man? Do women play any role in the fantasy? Is it different for you if they aren't? I also try to listen for the themes running through their sexual interests and fantasies, which often decode aspects of their personal identity and histories.
I used this approach with Paul. When I asked him to describe his situation, he told me he was sexually aroused only by women, and that his fantasies mostly were about women and brought him to orgasm. I asked him what the men who were occasionally included in his fantasies looked like, and he told me that they were faceless; even their physiques didn't matter to him. Paul also told me that he always had sexual fantasies about men "controlling him" by telling him to please them. His most common and peak erotic fantasies included being "hypnotized or drugged" by the man whose spell he was under.
Meeting guys online didn't satisfy him because they'd immediately begin talking about oral and anal sex. He'd discovered that all he really wanted was to make an intimate connection with them through talk and nonsexual touch, and dreaded having an encounter turn sexual. It was more erotic online and in his fantasies than it was in reality. Reporting that he didn't enjoy sex with men as much as he did with women, he often allowed the men to penetrate him through unprotected anal intercourse without inquiring about their HIV status, although he always went prepared with condoms. This satisfied his fantasies of letting the men have full control over him.
Paul admitted to me that the men he'd met online had introduced him to crystal meth. He said the drug helped him enjoy the experience: he would have had gay sex without it, but the drug heightened his interest.
The first thing I told Paul was that he must stop having sex with other men while he was in treatment with me, addressing the dangers of risking HIV. I also told him to stop his experimentation with crystal meth, which he'd recently begun to enjoy.
He agreed, but added, laughing, "I can't believe I'm paying my gay shrink to tell me to stop having sex with men!"
Links with the Past
In subsequent sessions, I asked Paul about sexual abuse because it can lead to homosexual behavior (not homosexual orientation), but he denied it. His father, he told me, was an alcoholic who frequently physically abused and humiliated him. Because Paul wasn't good at sports, his father taunted him, calling him a "girly" man. To test his mettle as a fighter, his father once initiated a fist fight that left Paul bruised and bleeding from his mouth. He longed to have his father's love and acceptance, but didn't know how to get it. His mother never intervened; instead, she'd comfort her son after these abusive episodes.
Paul was sympathetic to his mother. He saw how his father humiliated and intimidated her. Although she was never beaten, she lived under the threat of violence. He recalled that, as a child, he hated his father and wished him dead, so that he and his mother could have a nice life together.
I consider sexual fantasies and erotic interests—whether expressed in healthy or unhealthy ways—as inseparable extensions of our core identity. They're clues to the past. Often they're unsuccessful attempts to resolve problems from childhood that are somehow eased in the erotic realm.
I began to see Paul's sexual contacts with men as an attempt to resolve the conflictual relationship with his father. As he attempted, unconsciously, to master the abuse and humiliation he received from his father as a child, he placed himself in sexual situations where he was at risk and felt humiliated all over again. With the other man in control, Paul was "helpless." He was under the spell of the other man, who was intoxicated, just as his father had been.
Unfortunately, like so many attempts to master past trauma by repeating it, this wasn't an effective strategy for healing. By placing himself with these drugged men, Paul's psyche was attempting to recreate the situation with his alcoholic father, but to have a different outcome. What Paul really wanted was for these men to hold him and affirm him and connect to him in an affectionate way. As some researchers in the field of trauma explain, "the fantasy thoughts are prompted by fear more than desire, by anxiety more than pleasure." In other words, fantasies become a way of managing fear and anxiety. In Paul's case, his fantasy and sexual issues with men eroticized the pain that he'd suffered in childhood with his father and attempted to convert trauma into triumph. Unfortunately, the reality was that this behavior kept him feeling like a little boy, preventing him from both taking responsibility for his life and trying to actually resolve his issues with his parents.
Many males who were physically and/or sexually abused as boys or teenagers may reenact that trauma by engaging in homosexual behaviors as adults. At first glance, they may appear to be in early denial about their homosexuality. I think of these men as being homosexually imprinted—they're innately heterosexual boys who were molested or physically abused by another male and keep "returning to the scene of the crime" to defuse and desensitize their emotional pain and trauma. When the original trauma is resolved, they stop having sex with men, if they're straight. If they're really gay, they continue having sex with men, which is an expression of their core identity. After the haze of trauma is lifted, they discover that they're romantically interested in men and want to make an intimate connection with other men.
Paul soon began to understand that he was "returning to the scene of the crime" for several reasons. First, he realized that he was not only angry at his father, but also "hungry" for the father he'd never had. He'd sought sex with men as a way of finding the nurturance and male acceptance he never received from his father. He tried to talk to his father about all the anger he'd accumulated since his childhood, but his father—still an active drinker—just laughed and called him weak.
Fortunately, he was able to feel my empathy for him and my sorrow for what he'd been through. He allowed me to "father" him in appropriate therapeutic ways. For example, he didn't have a lot of money, so he couldn't come more than once weekly, but I thought he needed more frequent sessions. So I allowed him to call me outside the therapy hour on my cell phone if he felt like going out and having sex with a man, so I could help him withstand the urge. He needed to feel that I was there for him when he experienced anxiety and traumatic feelings, and was overwhelmed with what he felt was my sincere interest in being available to him. His calls never lasted more than 15 minutes and were never more frequent than twice weekly for several months. He brought in his journal and left it with me to read, and I didn't charge him for my time. I provided what he'd needed from his father—closeness and availability. Ultimately, he was able to father himself. He learned to manage his anxiety on his own and no longer needed to call me outside of the therapy hour. He was able to stop himself from acting on his sexual impulses, knowing that they weren't in his best interest and that they were all about trauma reenactment.
I told Paul that I thought he'd suppressed his anger toward his mother, who'd never protected or rescued him. I explained the concept of eroticized rage—acting out one's anger through sexual issues. Perhaps his sexual acting-out, especially putting Julia in harm's way, represented an attempt to take out his anger at his mother on his girlfriend. This insight resonated strongly with Paul, and he began to sob uncontrollably. "How could I have done this to Julia?" he cried. For the first time, he began to understand why she was so upset and angry.
In time, he was able to direct his anger at his mother for not being there for him. He even met with her after writing a respectful letter of anger to her. She apologized, recognizing that her passivity was neglectful, and that she was responsible for much of what had happened to him.
Ultimately, Paul was able to hold his mother and father accountable for their negative behavior toward him in childhood. Having had an abusive father and neglectful mother, he came into treatment letting them off the hook and reenacting the trauma by displacing the anger and shame on himself and his fiancОe. He needed a safe place to explore his sexual behavior without being labeled gay, bisexual, or even questioning. This wasn't a case that revolved around whether he was gay, but rather what his original trauma was and how it could be resolved. Had Paul not been heterosexual, his gay identity would have surfaced during treatment.
Coming Out Straight
When our work was finished, I again asked Paul how he self-identified in terms of his sexual orientation. He said that he believed he was heterosexual and was consistently sexually attracted to women, and desired to be sexual and have emotional relationships with them. But this didn't mean that his interest in sexual behavior and fantasies with men had disappeared. He still enjoyed seeing and masturbating to gay-male pornography, and continued to have infrequent encounters with men. He didn't identify as bisexual because he didn't desire other men. Instead, he saw himself as heterosexual with homoerotic interests. He no longer struggled with compulsions to be sexual with men, as so many gay men who are trying to fight their orientation do.
Paul realized that his underlying problem wasn't his interest in having sex with men; it was the secrecy and compulsivity with which he engaged in this behavior—the fact that he couldn't tell his fiancОe. He promised himself that all of his future female partners would know about his sexual interests in men.
I know I'm walking on thin ice in my therapy with straight men who have sex with men because it resembles the type of work psychotherapists did in the past with gays and lesbians, as well as "conversion" or "reparative therapy" pushed today by conservative religious groups. According to these now widely discredited forms of therapy, geared to "curing" homosexuals, men who acted out homosexually did so because they weren't fathered or mothered well; their hunger for same-gendered parenting caused their homosexuality. Once this hunger was satisfied, homosexuality would disappear and clients' innate heterosexuality would surface. It's my judgment that these men who have sex with men aren't gay to begin with, but are using homosexual sex to resolve past issues.
While, on some level, my work with Paul may seem to resemble this archaic approach, it's different. First, we now understand that not all men who have sex with men are gay or bisexual. In addition, I don't see straight men's interest in sex with males as pathological. Rather, I think their sexual behaviors and fantasies need to be understood in the context of their personal histories and family-of-origin issues. Therapy with straight men who have sex with men isn't about the impossible task of changing orientation; it's about helping them discover their orientation and their sexual preferences, feel positive about their discovery, and experience their sexuality without shame.
Therapists who work with this population have to follow their clients' leads. The work is as much about education as psychotherapy. It's crucial to give each man who has sex with men information about homosexuality and the coming-out process, sexual abuse, sexual addiction, family-of-origin issues, and mood disorders that could contribute to the desire to have sex with males. However, as the work evolves, it's up to the client himself to decide if this is the beginning of the coming-out process, a sign of early sexual abuse, a sexual addiction, or some other form of acting out. It could also just be that once-in-a-while sex with men is something that a man might want, and means nothing more than that. As Freud is often said to have remarked, "Sometimes a cigar is just a cigar!"
By David Treadway
What touched me most about Joe Kort's superb case description was his loving treatment of Paul. He engaged Paul without agenda or judgment, extending himself with both time and care as a kind and limit-setting father figure.
Kort was profoundly accepting of Paul, while also being quite firm and parental by telling him to stop having sex with men and using drugs. (As someone who treats many addicts, I did wonder about Paul's easy acquiescence and what Kort would have done if he'd either refused the prohibition or simply begun to lie while continuing the behaviors.) Fortunately, Paul was able to accept the limits, and Kort was able to create a nurturing, safe therapeutic sanctuary in which Paul could explore his deepest vulnerabilities.
Like Kort, I believe that our early erotic imagery is often a fingerprint of our most complicated, ambivalent fears and yearnings. Exploring these images and fantasies can reveal the heart of a client's emotional conflicts. Last month, a young client of mine who has some erectile difficulties described his earliest sexual fantasy of a scene in which a beautiful young woman is tied to the mainmast of a pirate ship and surrounded by leering pirates about to ravish her. As he recalled the scene, he remembered it as being intensely arousing, but that nothing ever happened because he couldn't allow the imagined gang rape to take place. I asked him gently, "And who were you in this scene, Jonathan?" He paused and then his shoulders began to shake and his eyes filled with tears. "Well, of course, I wasn't the girl, but I couldn't stand the idea of being one of the pirates." Then he began to cry hard. "I remember sneaking peeks at my sister when I was about 11 and she was 14. I felt so dirty." He paused, looked away, and said haltingly, "I guess, maybe, I've been afraid that I was one of the pirates all along."
Kort was able to help Paul discover the underlying meaning in his sexual engagements with men in light of his early life experience of having an abusive dad and an unprotective mom. It was particularly powerful that it was through identifying his underlying anger at his mom that Paul was able to understand more profoundly his cavalier and destructive behavior toward his girlfriend.
The key to Kort's work is that he doesn't approach Paul's sexuality as a label but an expression of his personhood. Too often in our attempts to be scientific and precise, we're reduced to seeing people as diagnostic categories, but labeling people can be inherently limiting, particularly in the extraordinary, unique, and fluid areas of sexual desire, identity, and behavior.
Kort dares to challenge conventional wisdom and politically-correct thinking in exploring the possibility that straight men may engage in homosexual behavior without being in denial about their own truly gay or bisexual nature. He not only asserts that there may be classically psychodynamic and situational reasons for heterosexual men to engage in gay behavior, but that occasional sex with men may simply be a normal variant of heterosexual male sexuality.
Kort and his client seem to agree that a simple desire for homosexual sex doesn't constitute bisexuality, because the sexuality seems to be so focused on the sexual experience, rather than on any interest in or possibility of a same-sex personal relationship. In other words, just because one might like an occasional cigar doesn't mean one wants to date the cigar maker.
Ultimately, the therapeutic challenge in Kort's case is the same as that in all of our cases: to help our clients find their way home to their true natures, with compassion for themselves and carefulness toward others.
I appreciate David Treadway's understanding of the subtleties of this case. This client's behavior was homosexual, but, in this case, his orientation wasn't.
My approach is different from the reparative therapies or sexual reorientation models, which state that there's nothing "gay" about homosexuality, and that any gay or lesbian identity is heterosexuality gone wrong. It's also different from those that presume that any homosexual act signifies gay identity. Therapists sometimes rush in to make these types of judgments, with negative consequences for the client at times. I feel that this case underscores the need for psychotherapists to approach these cases with an open mind and a framework that allows for the wide spectrum and broad possibilities of sexuality and sexual orientation.
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