Setting aside a chapter to explore the implications of our patient's sexual orientation on their psychotherapy suggests that the treatment of gay, lesbian, and bisexual patients differs from the work we do with our heterosexual patients. In many ways, of course, it doesn't. Much of our daily work focuses on the mitigation of mental disorders and of life challenges that transcend the categories of sexual orientation. Nevertheless, gay, lesbian, and bisexual individuals do bring to their treatments particular life experiences that are less common in the lives of heterosexual patients and that can profoundly shape the goals and the techniques of their psychotherapies.
The mental health profession has its own developmental history that also contributes to the challenges clinicians face in treating these patients. Although attitudes regarding homosexuality have changed rapidly in the last few decades, we have behind us a long history of considering homosexuality a sin, a crime, a form of degeneracy, and—our own contribution to this list—a psychiatric disorder. Despite the removal of homosexuality from the American Psychiatric Association's nosology in 1973, this legacy still casts a shadow over our efforts to understand our gay patients as clinicians and as a profession.
Perhaps what is unique about homosexual and bisexual people would disappear in an unbiased society. But in our current world, conventional judgments about gender, the necessity for hiding and secrecy, and the presumption that all children will turn out to be heterosexual make for common developmental challenges in the lives of gay and lesbian patients, which, in turn, lead to particular clinical presentations and unique technical challenges for the therapist. In this chapter we examine each of these areas to define a psychotherapeutic approach to gay, lesbian, and bisexual patients that has, at its core, the goal of promoting the healthy integration of our patients’ sexual orientation into their personality as a whole.
Conducting therapy commonly stimulates, in the mind of clinicians and patients alike, a wish for answers to questions such as, ‘How did this happen?’ or ‘Where does this come from?’ The pursuit of answers to such questions has a rich history with at least two complementary trends: one plumbing the clinical situation for information about psychological development, the other drawing on empirically derived developmental data to inform clinical work. Both practices have been roundly criticized: the former as an unreliable and unverifiable method of inquiry, the latter as incapable of capturing the most essential aspect of observable developmental events—their meaning (Auchincloss and Vaughan, 2001; Tyson, 2002).
With these cautions in mind, some authors who treat gay and lesbian adults have drawn upon commonalities in their patients’ life histories to construct developmental lines or nodes that they consider common to the experience of homosexual individuals. Others have looked to allied fields for empirically validated developmental data and have attempted to integrate those data with their clinical experience.
The result is a rich collection of observations and hypotheses, which, though they lack a common epistemological foundation, can be helpful to the clinician in a few important ways. First, as predictors of themes that may be important in the lives of gay and lesbian patients, these theories can guide the therapist's listening, helping her look for salient experiences her patients may not yet be able to articulate. And second, a familiarity with common developmental events in gay and lesbian lives can help the clinician predict the sorts of transferences that may develop over the course of a treatment and understand those that do.
The development of many gay and lesbian individuals may diverge from that of their heterosexual peers in the earliest years of life. Gay and lesbian adults in various cultures are more likely to recall gender nonconformity in childhood than heterosexual adults (Whitam and Zent, 1984; Whitam and Mathy, 1991). One notable aspect of their atypicality that has received particular attention is the common aversion to rough and tumble play among prehomosexual boys and the interest in such play among prehomosexual girls.
The gender role nonconformity of many prehomosexual boys has been found to include preference for social interactions with girls and women over boys and men, interest in doll play, cross-dressing, adornment, an aptitude for color and texture, and emotionality (Corbett, 1996; Isay, 1999). Similarly, many prehomosexual girls have been described as showing little interest in girls’ toys and clothes, a preference for boys’ company, and for typically boyish styles of dress (Whitam and Mathy, 1991).
This nonconformity has been considered to derive in part from biological influences, such as the prenatal organizing effects of sex steroids (although there is more direct evidence of steroids influencing play preference in girls than in boys) acting in concert with early experiences and identifications in childhood (Ehrhardt, 1985; Isay, 1999; Friedman, 2001).
The prehomosexual child's sense of his or her own gender identity is shaped by the unfolding of his or her temperament, play preferences, and identifications throughout the course of childhood. Unlike children with gender identity disorder, the majority of prehomosexual children do not appear to doubt that they are male or female. However, in the context of the rigid and highly conventional notions of how boys and girls should behave typical among early school-age children their nonconformity can create in prehomosexual children a troubling sense of gender defectiveness (Richardson, 1999).
For example, while a boy who feels more comfortable playing with girls and dolls and fears getting hit with the ball on the playground may not doubt that he is a boy, he may feel that he is behaving in a girlish way. Friedman (1988) has described this common experience as a sense of ‘unmasculinity’ while Corbett (1996) has referred to it as an ‘experience of gender otherness.’
The clash of prehomosexual children's gender role nonconformity with their parents’ expectations for their behavior and the mismatch between their temperament and that of their same sex parent can lead to tension and conflict in those early relationships. For example, an early school-age boy who is afraid of loud noises or being flipped upside down may find an afternoon in the backyard with his father an uncomfortable, even frightening, experience. His father, who discovers that he just can't get his son to enjoy playing with him, who sees his son hurry up back into his mother's arms when given the chance, may start to feel rejected by his boy. Father and son may withdraw from each other, each with feelings of failure, isolation, and anger (Friedman and Downey, 2002). Similarly, some gender nonconforming girls may have difficulty in their relationships with mothers who are persistently critical of or uncomfortable around their daughter's boisterous play (Vaughan, 1998).
Whether the same-sexed parent is thought of as a prehomosexual child's primary erotic object, as Isay (1987) has suggested, or as a figure whose attention and affection, while not erotic, is yearned for by the child, as Friedman and Downey (2002) believe, most authors have described the disruptions that arise in these relationships as having potentially serious negative consequences for the developing prehomosexual child (see, for example, Goldsmith, 1995, 2001). Among those commonly described are lingering damage to the individual's self esteem and a difficulty establishing love relationships in adulthood (Isay, 1999; Friedman and Downey, 2002).
Childhood experiences in the world of peers often compound these difficulties, particularly for gender nonconforming prehomosexual boys. Boys’ society has been described as a hierarchical one, with athletic prowess and boldness one of the major determinants of a boy's place in the social order. Gender nonconforming boys are typically relegated to the lowest strata of this society where they are vulnerable to being shamed and scapegoated routinely by their peers. For many adult homosexual patients, these negative experiences are crucial to their self concept and their anticipations of experiences with other men, including gay men, and persist as traumatic memories they may never have disclosed to anyone.
Gender nonconforming prehomosexual girls seem to suffer less from teasing or exclusion by their peers during middle and late childhood perhaps in part because girls’ society during these ages appears to be more tolerant of gender role differences (Friedman and Downey, 2002). Unlike the almost always negatively viewed ‘sissy-boys,’ the bold behavior of tomboys can be seen as a desirable trait, occasionally giving these girls the status of peer leaders and making these prepubertal years a time tomboys can safely pursue and profit from close relationships with peers (Zevy, 1999).
As with all children, gay and lesbian children entering early adolescence experience the physical changes associated with puberty coupled with growing awareness of their own sexuality. Gay and lesbian adolescents may be troubled to find that they are attracted to same sex peers or that they have homosexual masturbatory fantasies. Budding sexuality may allow them for the first time to comprehend what is actually behind the life-long sense of being different than others (Floyd et al., 1999).
Parental responses to the physical changes of puberty may be especially important for homosexual youth. For example, many lesbians describe strong bonds with their fathers in childhood and time spent pursuing common interests such as sports or working on cars, but as these girls enter puberty, many find that their fathers retreat, no longer finding it acceptable to play in the same manner with a ‘young lady’ that they did with their younger daughters. Many lesbians describe a sense of loss of this important relationship and of feeling betrayed by their bodies as a consequence (Vaughan, 1998).
Typical situations of this developmental period such as sleepovers and experiences in physical education and locker rooms may prove both intensely erotic as well as disturbing as to gay and lesbian youths as these adolescents strive to prevent others from discovering the nature of their secret differences. The fact that society is organized around the presumption of heterosexuality creates a unique and distressing situation for gay and lesbian youths, who are sexually overstimulated while simultaneously feeling a strong sense of shame (that frequently accompanies self-recognition of homosexuality) and a concomitant need to hide.
Gay and lesbian adolescents are often in the awkward position of being attracted to same-gender peers without initially knowing whether their peers are attracted to them. Partly because of this uncertainty, homosexual adolescents may find themselves secretly falling in love with their same-gender, heterosexual friends. These ‘love affairs from afar’ are usually unconsummated exercises in frustration and can have a substantive developmental impact on an individual's later capacity to form and sustain loving, intimate relationships in adulthood as demonstrated in the following vignette.
Ms A, a woman in her late thirties, presented with anxiety and confusion over her relationship with K, her female partner of 8 years. Several months prior to Ms A's entering psychotherapy, K had suffered a depressive episode after being tapered off an antidepressant medication that she had taken for several years. In her irritable, depressive state, K had been withdrawn and harshly critical of Ms A and their relationship, leaving Ms A feeling emotionally battered. Eventually K recognized that she was in the midst of a depressive relapse, resumed her medication, and recovered. K was then eager to ‘forget about’ her criticisms of and withdrawal from her partner, but Ms A had been so shaken by K's attacks that she found herself unable to let go so easily of the hurt she felt. Ms A noticed at that time that she was intensely attracted to men and had masturbatory fantasies of heterosexual intercourse. Prior to this, Ms A had been monogamous and had had only fleeting thoughts about men. These secret feelings persisted and troubled Ms A and prompted her presenting for psychotherapy.
Following Ms A's first therapy session, she precipitously and tearfully ‘confessed’ to K about her recent interest in men and wondered if they should break up. During the opening phase of treatment, the therapist linked Ms A's sexual desires for men with her feeling both abandoned by and resentful of K during her irritable bout of depression. Ms A revealed that the secretive nature of her masturbatory fantasies had made her feel extremely guilty, which seemed to confirm the therapist's formulation that these fantasies were partly Ms A's retaliation against K for her critical attacks.
Ms A then revealed a similar experience had occurred during adolescence. She had developed a crush on L, her best friend in high school. At sleepovers, the two girls cuddled in physically intimate though not overtly sexual ways. Even though she realized L was interested in boys, Ms A could not stop herself from impulsively blurting out her desire to have sex with her. The friendship dissolved practically overnight and left Ms A heartbroken. The therapist was then able to show Ms A how her ‘confession’ of her heterosexual fantasies to K, which threatened shattering their long-term relationship, had recapitulated the earlier adolescent experience where the sudden revelation of sexual feelings with L had led to the loss of her first love relationship. These insights helped Ms A understand at a deeper emotional level what was at stake in her relationship with K. The heterosexual fantasies faded from importance as Ms A and K gradually rekindled their love and passion for one another.
As the homosexual youth begins high school and enters mid-adolescence, other distinctive problems arise. Social context clearly proves a powerful determinant of how gay and lesbian youths will weather these years. In those few social milieus in which being gay or lesbian tends to be seen as an alternative but equally valid developmental pathway as heterosexuality, gay and lesbian adolescents will tend to have adequate adult support and role models for how to achieve a healthy gay identity. For example, the presence of gay–straight alliances in schools that are progressive about homosexuality often helps to foster acceptance of the full range of sexual self-expression. Such programs are generally only possible in areas where adults appreciate and understand that such an approach will not result in greater numbers of homosexual children but rather better self-esteem and an earlier capacity for an integrated sense of self in those who are gay or lesbian.
As homosexual adolescents complete their high school years and leave home for work or for college, they may experience a sense of freedom to define who they are and to surround themselves with people who may be more capable of supporting their growing sense of gay identity. When they are able to enter a milieu where same-sex attraction, dating, and partnering are more acceptable, they may be able to accomplish two key developmental tasks: coming out with the sense of identity integration that it both reflects and provides and falling in love/beginning the search for a life partner.
Beginning the process of coming out is a necessary precursor to beginning the process of finding a mate, and how well the coming out process goes may determine how the gay or lesbian youth feels about himself as a potential life and sexual partner for another. The search for intimacy characteristic of young adulthood may be postponed in homosexuals. Delays in the coming out process itself or the fact that the gay or lesbian adolescent has been denied the opportunities to date those he wants to date prior to leaving home may create such developmental delays. Ready access to drugs and alcohol for late adolescents and young adults can be problematic as gay men and lesbians in their late teens and early twenties may use such substances to override their sense of discomfort with themselves, sometimes putting themselves at risk for HIV and other STDs.
While most gay men and lesbians will come out during their teens, twenties, and early thirties, a subset do not come out until later in life. Those who come out later in life seem to belong to two distinctive subgroups. Members of the first group are well aware of long-standing, if not lifelong homosexual feelings and may have grappled with internalized homophobia and feelings of shame and self-loathing that prevented the evolution and consolidation of a healthy gay identity earlier in life. Alternatively, they may have long been aware of homosexual longings but hoped that heterosexual marriage or having children would lessen the importance of these feelings or may have decided that they wanted the social acceptance and protection of a heterosexual life-style (Isay, 1996).
The second group seems to be a distinctive set of women in their forties and beyond who are often completely unaware of homosexual feelings earlier in life and do not feel that they have struggled with their identities but who suddenly, in midlife and perhaps in the context of a heterosexual marriage that lacks intimacy, find themselves in love with a woman with whom they have developed a close relationship (Notman, 2002). They are often startled to find that there is an erotic component to such a relationship but often describe themselves as curious to explore this added dimension of what originally began as a friendship with a confidante.
Many gay men and lesbians find that having accomplished important developmental tasks such as coming out, forming bonds and relationships within the gay and lesbian community, forging a positive gay identity and finding a partner, their concerns—and their developmental pathways—once again converge with those of their heterosexual cohorts (Kertzner, 2001). Their strong homosexual identity is gradually subsumed into a wider set of identities (and to an overall sense of being human) as they become increasingly integrated into the larger community. Having children may speed this process as many gay men and lesbians find that this gives strong common ties to other parents regardless of their sexual orientation of those parents. Concerns about caring for aging parents, maintaining a strong primary relationship over time, and aging itself are examples of mid and late life issues that are universal.
In the 30 years since American psychiatry accepted homosexuality as a potentially healthy form of loving and sexuality, clinicians—freed from seeing their patients’ orientation as their pathology—have identified a wide range of needs in their gay, lesbian, and bisexual patients. Accordingly, a literature has grown up in which psychotherapists have described the most common clinical presentations they've faced with their homosexual patients and shared the results of their innovative efforts to respond to them.
In the following pages we summarize some of the most useful of these insights to have emerged. Most of these contributions come from the consulting rooms of psychodynamic psychotherapists and psychoanalysts, and as with other similarly derived theories of technique, the question of their validity remains empirically unanswered. Instead, we consider the following to be provisional yet, nevertheless, well supported findings in so far as they capture a clinical consensus among those most experienced in treating homosexual patients. Where outcome data are available, as is the case with some cognitive-behavioral interventions, we report it.
Many gay and lesbian patients bring to their psychotherapy a persistent pattern of conscious and unconscious shame and self-hate organized around the knowledge that they are gay. Some will arrive describing their struggle with internalized homophobia as the reason they have sought out treatment. Others may only discover their difficulties with it as a result of years of treatment. For most, however, the mitigation of sexual orientation-associated shame will be an important therapeutic goal.
Adolescents and adults vary widely in the complexity of the underpinnings of their homophobia. Some patients may come to the recognition that they are gay after a healthy childhood in which they received the necessary support to achieve a solid foundation of self-worth. Having absorbed their culture's prevailing negative views towards gay people, the discovery of same-sex attractions in adolescence may activate anxiety, depression, and a subsequent struggle to revise their notions of themselves or of gay and lesbian people. But they will be bolstered in this process by a basic conviction in their own goodness and lovability.
Cognitive-behavioral approaches may be well suited for these patients as their internalized homophobia can be framed as a pervasive negative schema toward homosexuality. Some cognitive-behavioral therapists consider such homophobia to be a conditioned emotional response that can be treated with cognitive restructuring (Spencer and Hemmer, 1993; Purcell et al., 1996, pp. 401–2). Various cognitive-behavioral approaches such as identifying thinking errors, cognitive restructuring, and behavioral experiments can help patients confront their self-blaming cognitions and pathological core beliefs while relaxation techniques and stress reduction may decrease distress and increase their quality of life (Safren et al., 2001a).
For other patients, internalized homophobia will be a more layered phenomenon, built up over the course of childhood and adolescent development. Their feeling that being gay renders them defective typically condenses early experiences of gender difference, rejection by the same sex parent, harassment by peers in grade school, and shame over homosexual attractions in early and middle adolescence. In some cases, other experiences of trauma and neglect originally unrelated to the patient's sexual orientation may retrospectively become organized into this constellation of self-hate for being gay.
Among the commonest ramifications of internalized homophobia are difficulty maintaining a love relationship; difficulty integrating sexual pleasure with love; and self-consciousness about the masculinity or femininity of one's speech, behavior, and body. In those with more severe developmental traumas and unconscious guilt, internalized homophobia may manifest itself through self-destructive behavior, including drug and alcohol abuse and unsafe sex. Healthier patients may, by contrast, be well adjusted to the demands of work and successful in love, but may harbor unconscious negative self-evaluations that result in a gnawing sense of inadequacy.
The treatment of internalized homophobia combines supportive and insight-oriented interventions in a balance titrated to the immediate needs of the particular patient. Supportive maneuvers include the facilitation of the coming out process (described below), the therapist's expression of an accepting view of the patient's past and present gender nonconformity (Isay, 1999) and homosexuality (Frommer, 1994), psychoeducation about sexual orientation and its development, and empathic support as the patient describes possibly for the first time to anyone some of the shaming and frightening experiences of her development. These techniques will play a relatively greater role in work with patients whose treatment is less complicated by early and marked developmental injuries.
Insight-oriented approaches (whether psychodynamic or cognitive) focus on helping the patient unravel the various strands of shame and guilt that have come together to form his homophobia (Downey and Friedman, 1995; Friedman and Downey, 1995). In this process, the unconscious beliefs that may underlie the patient's shame (‘My father withdrew from me, because I was overly emotional. Being overly emotional is gay and wrong.’) can be made conscious, challenged, and gradually modified by the patient and therapist. This treatment approach, also conducted in the context of the therapist's affirming stance, will constitute the greater portion of the work with patients whose homophobia condenses earlier traumatic experiences.
The following vignette demonstrates the mitigation of shame related to homosexuality in a psychoanalytic treatment:
When Mr B first presented for analysis at 24 years of age, he described conscious, romantic, and erotic attraction to and arousal for male peers since early adolescence. He deeply desired a loving, intimate relationship with a man, yet he reported having fled good prospects for reasons he did not fully understand. He felt chronically unhappy about this. In the sixth year of an 8-year analysis the patient described his childhood ‘obsession’ with seeing his handsome father's muscular body. He reported numerous episodes of trying to catch glimpses of his father's getting in or out of the shower. Over the ensuing weeks, he told his analyst in detail—alternating with protests of intense shame—of a conscious, erotic fantasy he recalled from childhood and adolescence. His fantasy was that he would be in the shower with his father who would lift him face-to-face and press him up against his soapy, hairy, muscular chest, gradually sliding him down to enter him anally with his erect penis.
In the session, the patient yelled out in angry distress how humiliated he felt to admit that he liked anal sex: ‘I like to get fucked—okay?! Are you happy now, you fucker?’ It was rare for him speak so frankly. The therapist replied within the transference: ‘You experience me as the humiliating fucker, penetrating you with my interpretations.’ ‘Yes,’ he said, though calmer now, ‘maybe you really get off on being top dog here.’ It took many more months of analysis of his shame—touching on themes such as top/bottom, big/little, adult/child, ‘dirty’ anal sex/‘clean’ vaginal sex—for this analysand to acknowledge to himself and to his analyst with some semblance of acceptance how passionately aroused in so many variations he was by other men's bodies.
Many patients who seek therapy in pain over their sexual orientation have (consciously or not) chosen to come to treatment as a part of the larger process of coming out. For them, therapy can play an important part by helping them move through this crucial developmental process.
The phrase ‘coming out’ has come to mean the social and psychological process of acquiring a gay identity. Often conceptualized as a developmental line or a sequence of stages, coming out is generally considered to include realizing that one is gay, disclosing that fact to others, establishing social relationships with other gay people, coming to value positively one's homosexuality, subsuming that identity to a wider set of identities (and to an overall sense of being human), and integrating oneself into the larger community (Coleman, 1982; Cass, 1989).
For many gay and lesbian individuals who do not seek out treatment for their fear or shame about being gay, coming out will be psychotherapy enough. Dramatic and lasting improvement in their self-esteem and self-expression as well as their ability to love and work often result. For those individuals who encounter obstacles along the way to self-disclosure and creating a community of gay friends and supports, psychotherapy can be helpful by identifying and removing those barriers.
The individual therapist can explore with the patient the possible implications of talking openly with parents, siblings, children, friends, and coworkers about the patient's orientation. Where such disclosures would not endanger the patient, they can be gently encouraged and the resistances to making them explored. The therapist can also help the patient find a way into friendships with gay peers. A gay or lesbian group psychotherapy may be especially helpful for those who have difficulty creating their own peer group.
Occasionally, a parent will seek treatment for a child—most commonly a boy—whose gender nonconformity has become a focus of worry in the family. Some of these parents ask that their child's behavior be rendered more typical; some, considering it an indication of future homosexuality, will want the therapist to prevent that outcome; and others seek therapy as a way to protect their child from harassment. In all cases the first task of the clinician is to assess the child's behavior and the nature of the family system of which it is a part.
A small group of gender nonconforming children will meet the diagnostic criteria for gender identity disorder (GID). Their nonconformity, which may consist of inflexible, repetitive, and insistent cross-gendered behavior suffused with anxiety or aggression, has been understood as an effort to defend against extreme anxiety in the face of a felt separation from the opposite sex parent and merits clinical attention in the form of individual and family therapy (Coates and Woolfe, 1995). Most gender nonconformity in childhood, however, is not pathological and presents, instead, as pleasurable self-expression and flexible play. This distinction, which can be difficult to make, has been the subject of some controversy (Richardson, 1999; Zucker, 1999).
In cases of healthy gender nonconformity, many parents will benefit from expressing their fears and learning from a sympathetic expert about the development of sexual orientation. Other parents will require more extended therapeutic interventions exploring the meaning to them of their child's atypicality (Friedman and Downey, 2002).
Therapists can also help nonconforming children resist the damaging effects of peer harassment. The clinician can help counter the attitudes of peers with open support of the child's interests and help the child develop new ways of responding to peers. Gender nonconforming children face a difficult choice between proudly pursuing their interests and changing their behavior to decrease negative attention. The sensitive clinician can help a child craft a well-considered response to this dilemma. In the case of severe harassment, the clinician may advocate for a change in the child's social milieu (Friedman, 1997).
The parent or parents of a homosexual adolescent who has just come out or whose homosexuality has just been discovered by his family may also seek treatment. As with gender nonconformity, it is essential to delineate the reason for seeking treatment, to educate the parents, and to focus the treatment appropriately. For example, the family of the homosexual adolescent may be seeking treatment for the adolescent with the goal of making sure he or she turns out to be heterosexual. In this case, it is the clinician's job to educate the family, pointing out that most professional associations condemn such attempts as unethical because of the lack of evidence that such change from homosexual to heterosexual is actually possible and the risk that such attempts at change will increase depression and anxiety while decreasing self-esteem (Bernstein and Miller, 1995; Shidlo et al., 2001). Allowing the parents to mourn their lost image of who their child is and will become can be crucially important in helping them to begin to accept and support their homosexual adolescent. Support groups such as Parents, Families, and Friends of Lesbians and Gays (PFLAG) can provide a helpful forum for families struggling to accept homosexuality in a loved one and can encourage them to begin to fight the homophobia and heterosexism in society that adversely affects their child.
One essential principle to keep in mind when a child has just come out to his or her parents is the inherent mismatch in phase of development that is likely to result in hurt and frustration on both sides. The adolescent telling his parents he is homosexual has most likely known and dealt with this aspect of himself for some time and is disclosing it at a point where he feels it is more important to be authentic, whatever the interpersonal risks, than to continue to hide such a key aspect of his identity. In other words, the telling itself is the end result of an internal process that represents a step toward psychological integrity and wholeness. Parents, in contrast, may have little or no inkling of their child's homosexuality and may be caught off guard as they quickly try to formulate a response to a disclosure that shatters their image of who the child is. Many parents recall reacting with dismay, disappointment, and despair, reactions that they later wish they could undo as they see their hurtful impact on their child. Highlighting this disparity between coming out and finding out may help to mitigate this situation and improve relations between parent and child.
It is possible that parents, upon hearing of their child's homosexuality for the first time, may become abusive and punitive or may withdraw support from the adolescent, sometimes kicking them out of the house or refusing to pay for schooling. As shifts in society's acceptance of homosexuality have helped to move the average age of coming out in a younger and younger direction, more adolescents are at risk as they may come out before they are actually psychologically or fiscally capable of living independently. In situations of such extreme parental reactions, clinicians must be prepared to involve social services to ensure that the adolescent is safe and living in an abuse-free environment. In this case, the clinician's perspective that the parents’ reaction is homophobic in nature and that one can live an equally fulfilling, valid, and valuable life as a gay man or lesbian will be key in psychologically protecting the adolescent. Cognitive-behavioral interventions that target coping with chronic stress such as problem-solving techniques can also be helpful in these situations (Safren et al., 2001a, p. 220).
The heterosexually married homosexual adult may seek treatment at a point of crisis in the marriage, perhaps after a homosexual affair or encounter has come to light, or may seek treatment as the result of an ongoing inner psychological process when the conflict between inner desires and the reality of the heterosexual relationship become too much to bear. The question of ‘why now?’ is especially important in understanding the factors that lead a homosexual adult in a long-standing marriage to seek treatment at a given time. When a third, same-sex sexual partner of the heterosexual married individual is also involved, evaluating the qualities of this tie and attempting to understand the pressures being exerted by the same-sex partner may also be clinically relevant.
It is important in the initial evaluation of such a patient to decide whether a couples-oriented focus or an individual approach is more appropriate and for the clinician to resist the patient's (or spouse's) sense of urgency that the situation be quickly resolved but to press for adequate time for psychological exploration before taking definitive action. One important factor in the evaluation process is whether the spouse of the heterosexually married homosexual has known or suspected his or her partner's homosexuality and whether there is any potential for compromise within the partnership regarding the issue of the homosexuality. For many, such a revelation triggers a desire for an immediate divorce while others may be willing or able to tolerate a transition period while the issues are sorted out or even a restructuring of the marital agreement, which allows for the expression of same-sex sexual relationships alongside the preservation of the marital bond. The decision to divorce generally involves moving from many years of denial of one's sexuality and requires giving up the social respectability provided by marriage and eventually coming out to those—often including children—who know the homosexual individual as heterosexual and who are likely to feel unsettled or betrayed by the revelation. If divorce seems likely, it is important for the clinician to help the patient limit the extent to which the patient's guilt and the spouse's anger lead to legal and financial concessions that are not in the patient's best long-term interests.
Although many gay men and lesbians will form partnerships and start families without seeking clinical assistance, occasionally a couple or individual will come to treatment to explore concerns about having children. A couple seeking to start a family often present with concerns about the state of their current relationship and the potential emotional, sexual, and financial impact of children on their union. In these cases, work with the couple will be similar to that of a heterosexual couple seeking assistance at such a transition point, with the caveat that a gay or lesbian couple may lack the societal approbations, ranging from familial encouragement to legal protections, that a heterosexual couple takes for granted.
Gay and lesbian couples may also present with issues specific to their homosexuality. The de facto infertility of a homosexual couple—their inability to conceive and bear a child together as a couple—is often a hidden reason for mourning and may be helpful to elucidate in treatment. Decisions such as who will carry a child in the case of a lesbian couple or who will father a child in the case of a gay male couple as well as struggles over whether to involve a known sperm or egg donor or whether to adopt. Modern reproductive technologies allow potential creative answers to these issues once the couple has dealt with the underlying psychological issues (such as mixing the sperm of two gay men during artificial insemination or in vitro fertilization with a surrogate or having a lesbian serve as an egg donor for her partner), but dealing with the underlying issues may also make such questions recede in importance in the minds of the couple. Seemingly practical questions about how to conceive or what a child will call each partner frequently hide deeper concerns about competition within the pair or unresolved tensions about gender.
Having children demands of gay men and lesbians that they achieve an even greater level of resolution of their own internalized homophobia than coming out and forming a partnership did earlier in life. For example, wondering whether having gay or lesbian parents is fair to the child or attempting to create parenting scenarios that involve a third, opposite-sex parental figure on the grounds that two same-sex parents are inadequate to the task of raising a child are common lingering expressions of internalized homophobia that can be usefully explored in couples or individual psychotherapy. Having children also often precipitates another round of coming out and working through within the families of gay men and lesbians as, for example, the parents and siblings of the couple decide whom to tell about their new grandchild or nephew. Addressing these vestiges of homophobia within the couple and the family system may allow the couple to deal more effectively with the very real issues of gay and lesbian parenting, including the antihomosexual bias that parents and children can be faced with in the school or community.
While the patient with HIV may or may not come to treatment to focus on issues specifically related to his HIV-positive status, living with HIV/AIDS creates the stress typical of living with any chronic life-threatening illness as well as the stigma associated with homosexuality and sexually transmitted disease. Fear of suffering and death, the diminution of expectations of longevity and accomplishment in life, the fear of rejection by family and friends, and dealing with the loathing and prejudice of society are common themes in the HIV-positive patient in treatment (Blechner, 1997).
Being HIV positive can also create a sense of being damaged, bad, or sick that resonates powerfully with the patient's original responses to his own homosexuality. Gay men who are HIV positive and seeking a partner frequently view themselves as ‘damaged goods’ when it comes to forming an intimate long-term relationship, assuming no partner would want to contend with their HIV disease and the specter of AIDS. Becoming involved with an HIV-positive partner may ameliorate fears of infecting—and thereby potentially killing—the loved other but creates different concerns such as facing illness and mortality and threat of loss of the partner.
Negative core beliefs about the self—such as an HIV-positive patient's conception of himself as defective and unlovable—can usefully be targets of cognitive approaches to case conceptualization and treatment. The labeling of inaccurate inferences or distortions may help the patient become aware of the unreasonableness of such automatic patterns of thought (Beck and Freeman, 1990, p. 80). Cognitive probes and questioning may be used to elicit such automatic thoughts (p. 81). As an example, when John expresses reluctance to invite a man out on a date, the cognitive therapist might ask the patient to imagine out loud here and now in the session how his prospective date would react. ‘Oh, I know what he would say’. He'd say ‘I don't want to be involved with someone who is going to die. I'm out of here.’ Here the therapist has identified an automatic thought: ‘HIV-infected people will all die.’ Such automatic thoughts can then be tested with the therapist who carefully attends to the possibility of exaggeration and catastrophizing. Relaxation techniques can also be useful with patients who are anxiously worried about the impact of their diagnosis on various aspects of their lives (Beck and Freeman, 1990, pp. 79–94). Outcome studies demonstrate the efficacy of cognitive therapy for depressed patients with HIV (Lee et al., 1999; Safren et al., 2001b; Blanch et al., 2002; Molassiotis et al., 2002).
Interpersonal psychotherapy has been shown to have particular advantages for HIV patients (Markowitz et al., 1998). Interpersonal therapy relates mood changes to environmental events and resultant changes in social roles. For example, the interpersonal therapist defines depression as a medical illness and then assigns the patient both the diagnosis and the sick role. She then ‘engages the patient on affectively laden current life issues, and frames the patient's difficulties within an interpersonal problem area: grief, role dispute, role transition, or interpersonal deficits. Strategies then address these problem areas, focusing in the present on what the patients want and what options exist to achieve this’ (Markowitz et al., 1998).
Exploratory psychodynamic treatments, including psychoanalysis may be usefully employed with the HIV-positive patient grappling with these issues. In patients with frank AIDS, evaluation and treatment should focus on helping patients receive life-enhancing medical care, resolving troubling psychological issues and making the best use of whatever time is left.
A clinical vignette illustrates the psychodynamic approach with a patient with end-stage AIDS:
A 33-year-old successful business executive with a year-long history of Kaposi's sarcoma, Mr C presented with complaints of anxiety a few weeks after being discharged from the hospital after his first bout of pneumocystis pneumonia. The bout had been serious, requiring endotracheal intubation and forced ventilation of his lungs while he recovered. There was much material, seemingly as scattered and diffuse as his anxiety: not feeling close to his lover since the hospitalization; the lover's positive HIV antibody test; his law suit against his company, which had fired him while he was in the intensive care unit; and so on. There were questions about which ‘new age crystal’ to use today, which relaxation tape to listen to, and how many times to visit his acupuncturist. All of this was spoken of in a chatty way and was woven in and out of discussion of his traditional medical treatment. Two dynamic themes permeated his speech, though neither was directly mentioned: (1) intense guilt and shame about his homosexuality for which AIDS seemed (to the patient) to be the punishment, and (2) enormous anxiety about death. Both were taken up and explored psychotherapeutically in some depth. This vignette focuses on the latter theme.
The prognosis at the time of Mr C's treatment was gloomy for patients with Kaposi's sarcoma and pneumocystis pneumonia and he was well aware of this. Natural enough, one might think, to be anxious about death while living with a potentially fatal illness. The therapist asked him to describe his fears in as great detail as he could. Mr C began, somewhat to the therapist's surprise, to depict his inner landscape. There was a figure—not human, maybe animal—hooded in formless darkness except for glowing eyes. This is what came to mind when he became anxious about his own death.
The material wandered to his sixth year. He had pet hamsters that he kept in a cage on the back porch. He returned home one day to find no hamsters present in the screened-in porch where he had let them roam. There was a hole in the screen leading into the backyard. He followed the trail to the bloody remnant of one furry, dismembered limb. He ran back into the house screaming in terror and sobbing inconsolably. ‘Why terror?’ the therapist inquired. He did not know.
Then yet another story from the patient's childhood emerged. At age 2 years, he went to a store with his parents. A colorful neon light in the front window attracted his attention. He grabbed on to the nearby electrical cord that had exposed wires and received a massive electrical shock for several seconds until he was forcibly knocked away from the cord. Consciously he remembered nothing of this incident, though he had been told about the time he ‘almost died’ and had seen photographs of himself with bandaged, badly burned hand. The therapist and Mr C then spoke in detail of the connections between these three experiences.
They began to consider that, though amnesic for the electrocution, Mr C seemed to carry forward some mental representation of this near-death trauma, which may then have informed his terrified reaction to his hamsters’ death (perhaps via the homology from burned hand to dismembered limb). The childhood terror carried forward yet again and infiltrated his natural concerns and fear of dying from his present illness. The therapist and patient together reconstructed the dark, formless animal with glowing eyes (of neon?) as the unseen, fantasied predator who ate his hamsters, a childhood embodiment of death that haunted him still, invoking fears of a violent, abrupt, and painful death. Having analyzed the unconscious roots of his fears about death in this way, Mr C was able to think and speak more freely about his own death with his therapist, his lover, and his family. This led to his experiencing much greater self-control over the way he lived his life and to a marked reduction in his anxiety.
Given the prevalence of antihomosexual bias in society at large and of internalized homophobia among gay men and lesbians, it should not be surprising that some homosexual adults seek out therapy with a wish to become heterosexual. The treatment of choice in these cases takes the patient's wish to change rather than his homosexuality as the target of therapeutic attention. Patients seeking to change the direction of their sexual attractions should be informed that attempting to do so is unlikely to be successful (particularly in males) and may further compound the patient's distress. Instead, the clinician can explain, psychotherapy may offer the patient help in the form of a deeper understanding of his sexual feelings, his attitudes towards them, and the choices before him about disclosing or acting on his attractions.
The therapy may then proceed as a treatment of internalized homophobia and a facilitation of the coming out process as described above. Not all patients will choose to pursue these goals or be able to achieve them. Particularly among patients whose acceptance of their homosexuality implies a departure from deeply held religious beliefs or the loss of a crucial relationship (as may be the case with some heterosexually married patients), the open acceptance of one's orientation may entail such sacrifice that a patient will choose to continue efforts to suppress his desires. Even in these cases, however, a supportive therapist empathic to the patient's conflicts may help ease the pain inherent in what will inevitably be experienced as a compromised life.
The psychodynamic psychotherapist's attitude toward homosexuality in general and homosexual individuals in particular may well be determinative in whether an insight-oriented psychotherapy can be effective. While blatant prejudice against gay and lesbian people would certainly be an obvious contraindication for a therapist to work with this population, subtler forms of conscious and unconscious homophobia are often present within a therapist regardless of his or her sexual orientation. Mitchell (1996) observes that a therapist's pursuit of being bias-free is a futile and disingenuous ideal. He suggests that we serve our patients better by remaining open to discovering and rediscovering our prejudices and affinities as inevitable aspects of the therapeutic inquiry (p. 71). Neutrality is a fundamental principle of psychoanalytic treatment that asserts that the therapist should resist imposing his or her own values on the patient. This principle is meant to protect patients from therapists’ using their authority and influence deliberately to shape or guide patients’ beliefs, choices, or actions.
In reaction to decades of biased treatment approaches for homosexual individuals, a group of therapists—influenced culturally both by the gay liberation movement and the antihomosexual bias within psychoanalysis—decided that dynamic psychotherapy had never been conducted under the principle of neutrality with regard to sexual orientation. They proposed an alternative principle—gay affirmative psychotherapy. Gay affirmative psychotherapy categorically rejected any effort to change a person's sexual orientation from heterosexual to homosexual and established an affirmative psychotherapeutic stance that emotionally communicates to the patient the therapist's belief that homosexuality is a natural developmental end point for some individuals (Frommer, 1994, p. 215).
In reaction to gay affirmative psychotherapy, a contemporary version of the earlier directive-suggestive approach (also known as ‘conversion therapy’) has emerged. This approach is known as reparative therapy (see Nicolosi, 1991, 1993) and is based on the assumption that homosexuality is a mental disorder that can be changed through treatment. These approaches are controversial because they require the patient to regard core aspects of the self—i.e., homosexual desires—as pathological. For a detailed account of the extremely problematic nature of sexual conversion therapy, see Bernstein and Miller (1995), Roughton (1999), and Shidlo et al. (2001).
Roughton (1999) has made a strong case for reclaiming the value of neutrality in psychodynamic psychotherapy for gay and lesbian individuals. He emphasizes the need for searching self-reflection by all psychotherapists who work with homosexual individuals to recognize currents of antihomosexual bias, cultural heterosexism, and ignorance of the norms of gay life within themselves. Thus, neutrally conducted psychoanalytic psychotherapy allows for the possibility that a patient might begin treatment thinking that he or she is homosexual (or conflicted about sexual orientation) and eventually realize heterosexuality is the orientation of his or her sexual desire (Roughton, 2001).
Given the many decades of discrimination against homosexual individuals within mainstream psychotherapy—both cognitive and psychodynamic—it is not surprising that the gay and lesbian communities are wary of insight-oriented psychotherapies. While some prospective patients have consequently avoided dynamic therapy altogether, others have tried to protect themselves from biased treatment by seeking out openly gay or lesbian therapists.
Ironically, such patients are attempting to insure that they receive the type of therapy that is authentically neutral with regard to issues of sexual orientation. It does not necessarily follow that homosexual patients could only receive competent and compassionate treatment from openly homosexual therapists, but the history of prejudice within psychoanalysis (e.g., the so-called ‘reparative therapies’) is well known in the gay and lesbian community and serves as a cautionary tale.
The patient's learning of the therapist's homosexuality seems to have a magnetizing effect on conflicts from virtually all developmental periods and thus may act as an organizing principle of transference wishes and defenses. As these conflicts realign in reaction to this discovery, some things become easier to talk about; some things harder, pointing the way to exploration of resistance. Exploration of the patient's conscious resistance to speak about the therapist's homosexuality often reveals the patient's fear of divulging old prejudices against homosexuality that he worries will offend the therapist. Such material may also lead to discovery of a wellspring of unconscious internalized homophobia that presents an opportunity for superego exploration that can yield far-reaching therapeutic effect.
For example, a 26-year-old gay man was told by a referring therapist that the psychotherapist to whom he was referred was openly gay. The patient did not mention he knew about his therapist's homosexuality until several months later in treatment. The patient acknowledged that he thought this might ‘embarrass’ the therapist as such information was ‘private and personal and none of my business.’ The therapist helped the patient to consider that what ostensibly was protecting the therapist's ‘privacy’ was actually a way to protect the patient's ‘private and personal’ fantasies about the therapist. This intervention helped to bring under psychotherapeutic scrutiny new material concerning the patient's internalized homophobia and how it restrained currents of curiosity and fantasy about the therapist.
The heart of psychodynamic or psychoanalytic psychotherapy is the psychotherapist's attention to and understanding of both the patient's transference and the therapist's inevitable reaction to it, which is known as the countertransference. By transference, we refer to the conscious and unconscious attitudes, feelings, and fantasies that the patient has about the therapist. These attitudes, feelings, and fantasies (such as sexual, affectionate, aggressive, competitive ones) about the therapist carry the pathogenic core—the conflicted wishes and fears and pathological object relations—from the patient's childhood and adolescence. In the context of a trusting and safe relationship with a judiciously frustrating, supportive psychotherapist, the ghosts of childhood conflicts, traumas, and relationships reawaken and come back to life as though they were occurring in the present in relation to the therapist. Reciprocally, the countertransference entails the therapist's conscious and unconscious attitudes, feelings, and fantasies towards the patient in reaction to the patient's transference. The transference and countertransference often bear a close relation to one another—knowledge of the countertransference, for example, often yields important and illuminating information about the patient's transference.
Patients often struggle against recognizing and admitting these intimate reactions towards their therapist. They often try to conceal these feelings and thoughts from themselves as well as their therapists. This reluctance to admit and discuss such reactions is known as the resistance to the transference. Resistance is often first detected by a shift in the free flowing associations the patient has during a session. Instead of speaking easily, the patient becomes halting about a particular subject or abruptly changes the subject altogether. Technically, the psychotherapist then focuses on precisely those feelings and thoughts that make the patient reluctant to speak what has come to mind. Such nodes of resistance are diffused throughout the material and are especially present in symptoms. Thus, psychotherapeutic exploration of these resistance nodes is often informative about the types of problems that brought the patient for treatment in the first place.
The transference and the resistance against it, then, become central to the therapeutic endeavor in psychoanalytic psychotherapy. Isay (1989), for example, has shown persuasively how resolution of diverse symptomatology during the therapy of gay men depends on their becoming conscious of, and accepting emotionally, their homoerotic, incestuous fantasies and desires for their fathers (p. 46). These homoerotic, incestuous feelings and fantasies may first come to light through discovery of erotic feelings for the therapist. Isay (1989) notes how ‘defenses against these erotic feelings may lead to a distortion of the gay man's perception of other men and to a fear of intimacy and may be the most important cause of inhibited and impoverished relations in adulthood’ (p. 39).
The reenactment in the transference of this type of overstimulation and the defensive struggles against it give rise to characteristic countertransference reactions in the therapist. The therapist may unwittingly collude with patients in their dissociative defenses against overstimulation by becoming distracted, bored, or sleepy. Or the therapist may experience a version of the sexual overstimulation itself by feeling mild sexual arousal accompanied by explicit erotic fantasies about the patient or a displacement figure. Therapists may react with shame and/or guilt to such fantasies. As the following vignette illustrates, when recognized and brought under self-analytic scrutiny by the therapist, these reactions—both the arousal and the shame and/or guilt—can prove extremely illuminating with regard to the patient's early, warded-off experiences of everyday overstimulation (see Phillips, 2001, 2002).
Mr D was a handsome, muscular, 20-year-old college student who presented for psychotherapy because of depression about his homosexuality. He felt unmanly and embarrassed that he was drawn to and aroused by other men. He thought coming out to his family would ‘cure’ him of his conflicts about his sexual orientation but paradoxically found that his family's loving and accepting reaction only worsened his dilemma. Now he had to acknowledge his conflicts about being gay were within him, and he wanted help in feeling better about himself so that he could enjoy a mutual, romantic, sexual relationship with another man.
From the beginning, the therapist noticed he was attracted to the patient's boyish good looks and diffidence. The patient usually wore a sleeveless T-shirt and short pants to therapy sessions and spoke graphically—alternating with intense expressions of shame—about his surreptitious, sexual exploits with other male college students. The therapist found himself feeling both attracted to the patient as well as uncharacteristically ashamed of such feelings. The shame was puzzling as the therapist felt in no danger of acting on any of his fantasies. The therapist silently thought this might relate to important experiences in the patient's past and resolved to see what developed.
As the patient spoke more about his past, he described a long-standing sexual attraction to his brother with whom he had shared a bedroom growing up. The patient described repeated experiences in childhood of feeling ‘spurned’ when his brother preferred playing with his own friends rather than with the patient. Here was one component of what was being reenacted in the transference and countertransference. In the psychotherapy, Mr D was taking the role of the athletic, attractive brother and unconsciously assigning his own childhood role to the therapist. In this way, the patient was conveying to the therapist—by inducing him actually to feel it in sessions—the past attraction, arousal, excitement towards the brother as well as the frustration, shame, disappointment, and feeling ‘spurned.’ This same interaction was being repeated in the present in Mr D's symptomatic difficulty in allowing himself a mutually enjoyable sexual and romantic relationship with a peer.
The therapist used these clues in the transference–countertransference reenactment to show the patient how he was repeating in his present love life these old conflicts from his past frustrated ‘love affair’ with his brother. As the patient became aware of this pattern, he felt freed up to permit himself openly to date and fall in love with an available, caring man.
Tactful, direct confrontation of patients who openly acknowledge unsafe sexual practices is crucial to helping some patients—heterosexual or homosexual—confront their denial of their own destructiveness through exposure to HIV or other sexually transmitted diseases. Thorough clinical evaluation of such a patient is essential so as not to miss the diagnosis of a major psychiatric illness (such as bipolar disorder or addictions). Complex characterological pathology may be present, in which case psychodynamic or cognitive psychotherapeutic exploration of symptomatic destructive behaviors may be the preferred treatment over direct confrontation and psychoeducation.
The following vignette illustrates the psychodynamic approach to a patient engaging in unprotected sex:
A 47-year-old man presented with hypochondriacal anxiety and the fear that he had contracted HIV. Concerned about his 25-year history of frequenting homosexual hustler bars and aware of the recent death of a distant acquaintance, Mr E worried that symptoms of an upper respiratory viral syndrome represented pneumocystis pneumonia or that seemingly innocuous bumps on the skin were Kaposi's sarcoma. Complete evaluations by an experienced internist and an immunologist turned up no sign of disease but were only mildly and transiently reassuring to the patient. He, thus, was referred for psychotherapeutic evaluation.
Mr E's mental status examination revealed no evidence of psychotic process, bipolar disorder, or addiction. Though he recognized there was no ‘logical’ basis for his fears, he remained anxious. Remarkably soon after the therapy began, the panic about contracting HIV began to fade and was replaced with anxiously reported material about his sexual life. Mr E reluctantly mentioned his predilection for sadomasochistic sexual activity with hustlers. When asked about those practices by his therapist, Mr E protested that it would be far too embarrassing to ever discuss such a thing with his therapist.
Mr E's practice of unprotected sex with hustlers was a secret that he controlled, usually divulging only to those who would participate fully and share in the enactment of the secret, thereby avoiding the shame and humiliation of revealing it as well as protecting him from losing control over the use of this powerful and important part of his mental life. Shame and humiliation and the need to control the secret entered the transference as forceful resistances. It became clear that he was inviting his therapist to extract the secret from him for what the patient imagined was the therapist's own voyeuristic excitement, re-creating in the transference the sadomasochistic couple of his sexual enactments, with the therapist experienced as the hustler. Over time, the therapist was able to interpret the patient's enactment as an important defense of his, to turn what made him anxious into a harmless game.
Trying to approach patients such as Mr E merely by re-educating them about safer sexual practices and reinforcing the risks of their behavior can paradoxically worsen the risk of infection rather than lowering it. The clinician's well-intentioned ‘re-education’ about his risky sexual behavior fits too seamlessly into the defensive structure of the patient's personality, a game-like inner world that seeks to turn real danger into harmless play. The unsuspecting clinician may counsel such a patient to ‘play it safe’, emphasizing ‘safe,’ and yet this type of patient hears ‘play it safe,’ emphasizing ‘play,’ as in ‘it's just a game’ or ‘nothing serious’ or ‘no real danger.’
As with Mr E. the transference–countertransference in such cases is likely to be a sadomasochistic one, including pressure to violate the psychotherapeutic frame. Consultation and/or ongoing supervision from an experienced psychotherapist will assist the therapist from foundering on the dangerous shoals of boundary violations or patient exploitation (Gabbard and Lester, 1995, p. 193). Careful attention to maintenance of boundaries and countertransference scrutiny and regulation can result in a workable therapeutic alliance that allows the patient safely to explore likely childhood traumas and deprivations that have chronically been reenacted in current symptomatology. As these patients often do not present for psychotherapeutic treatment openly reporting their sexual risk taking, they underscore the importance of tactfully eliciting a careful sexual history in all patients.
In order to deaden painful internalized homophobia, self-loathing, and shame related to homosexuality, some patients turn to illicit drugs and/or alcohol. The therapist must explicitly ask the patient about a history of drug and alcohol use and abuse both in the past and present. If a drug or alcohol problem is present and of sufficient severity that it impairs social, occupational, or interpersonal functioning, medically supervised detoxification, drug/alcohol rehabilitation, and/or relapse prevention and recovery programs (such as Alcoholics Anonymous or Narcotics Anonymous) may be necessary in the context of ongoing supportive psychotherapy.
Compulsive sexuality can put the individual at risk for contracting HIV and presents the therapist with a serious management problem. Compulsive sexuality can be used to anesthetize psychic pain, stave off emotional conflict, or stabilize a fragmenting sense of self. Formulating such behaviors as compulsions offers psychodynamic psychotherapists powerful therapeutic leverage (Dodes, 1996). The therapist helps the patient to understand that the internal moment of crisis that triggers the desperate, compulsive search for sexual partners is a sense of traumatic helplessness reawakened from the past by a similar, resonant experience in the present. Behavioral therapy has also been shown to be a helpful treatment strategy with compulsive sexuality (McConaghy et al., 1985; Konopacki and Oei, 1988). For a detailed discussion of the nature and management of sexual disorders, the reader is referred to Chapter 17 (this volume).
Perhaps more than any other encounter in clinical practice, the meeting of a therapist with a gay patient has long been configured by social forces. Those forces have shifted over the past few decades, both mercifully—as with the increased acceptance of gay people into social institutions—and disastrously, with the emergence of HIV.
As the realities that impinge on our patients continue to change, so will their needs for us evolve. Clinicians who work with homosexual patients must surely be humbled by the powerful effect of cultural factors far beyond their control on their daily work with patients. But they may also enjoy the hope that the biases that lie at the root of so many of the problems they struggle to repair may diminish, even perhaps one day, vanish.
Loewald (1960) wrote memorably of the benefit to the patient of the therapist's holding in mind a view of him as one day becoming healthier, more capable. Those who devote hours treating patients who have suffered from bigotry and rejection may find it similarly helpful to keep in mind that some day, at least in this one small area, society itself may improve.