Gay Affirmative Therapy for the Straight Clinician

Many straight therapists who say they are “gay affirmative” mean that they are gay positive or gay friendly. They tell lesbian and gay clients things like, “I’m open-minded” and “People are people.” These well-intentioned therapists are, indeed, accepting and pro-gay—but they’re also uninformed. Even lesbian and gay therapists may be uninformed.

Over the years, I’ve known well-meaning gay and lesbian colleagues and students who were unaware of the specific issues that gays and lesbians face. They’ve said they didn’t realize there were stages to coming out, or that there were differences between gay and straight couples, or the typical reactions of  family members, as well as what to do with mixed orientation marriages.

To be uninformed is a form of prejudice by omission. Having a healing, affirmative stance in the therapy room does help relieve some of the distorted thinking that most clients bring in, but having an affirmative stance without being informed about the specific issues that lesbians and gays experience limits your clinical effectiveness.

Gay Affirmative Therapy (GAT) takes the position that there is nothing inherently wrong with being gay or lesbian. What’s wrong is what is done to gay men and lesbians by a homophobic, homo-ignorant society and heterosexist therapy. Living in a shame-based culture creates a variety of behavioral and psychological disorders. GAT focuses on repairing the harm done to these clients, helping them move from shame to pride. GAT does not, in itself, constitute a specific system of psychotherapy but rather is meant to provide a framework that informs psychotherapeutic work with lesbian and gay clients.

What Gay Affirmative Therapy Is Not

In general, GAT explores the trauma, shame, alienation, isolation and neglect that occur to lesbians and gays as children and how this manifests as adults. While important, this has the potential of going too far and eclipsing other issues that your clients face. GAT is not intended to de-emphasize emotional disorders and not examine any pathology. GAT is not supposed to explain all the problems facing gays and lesbians. It is supposed to be an essential inclusion.

Historically, gay-negative therapists jumped to conclusions and applied homophobic and heterosexist trauma models and theories, when in fact gay clients exhibit other individual problems.  For example, a gay male who might appear promiscuous and in stage five of the coming out process could actually be a suffering from bipolar disorder or sexual addiction. The closeted lesbian complaining of low libido may not be repressed, but have suffered sexual abuse in her childhood.

But don’t be afraid to diagnose and pathologize gay-specific problems if need be, just because homosexuality itself has been over-diagnosed and pathologized.

Does this seem confusing? Then you’re on the right track! As therapists, our responsibility is to be armed with all the up-to-date information. Knowing all the ways problems can arise, you can then assess with clients—and with their help—what applies and what doesn’t.


All gays and lesbians are touched in some way by trauma. How they are affected and how it manifests depends on the individual, his or her personality, and the family of origin. When working with gays and lesbians, it is important to assess and treat them through the lens of the effects of the trauma of homophobia and heterosexism.

My working definition of trauma is an event or episode, acute or chronic, that causes overstimulation without an outlet or release for that overstimulation. This leaves individuals feeling helpless and overwhelmed. According to this definition, any seemingly harmless event or situation can be subjectively traumatic when it leaves an individual feeling unable to cope, or fearing some ongoing threat.

Growing up gay or lesbian is incrementally traumatic. Slights happen over a period of many years, and children learn to internalize them, all the while struggling to cope with being alone and in secrecy. For those for whom heterosexuality is the “alternative lifestyle,” trying to develop an identity while role playing (or, as one of my clients calls it, “doing straight drag”) is chronically painful. And, it sets the stage for awkward identity development and difficult future functioning.

The trauma lesbian and gay children experience growing up is pervasive. However, this trauma goes even deeper, and it often falls under the radar of therapists and even gays and lesbians themselves. The trauma I’m referring to is a sexual trauma.

The assault on gays’ and lesbians’ sexuality is profound and becomes worse as they enter adolescence and adulthood. The trauma not only affects their psychological identity but also negatively influences their psychosexual formation and identity. The psychological consequences of homophobia and heterosexism parallel those of sexual abuse.

The fact is that most children—gay and straight—learn they have to hide and modify sexual parts of themselves that are discouraged. This hiding modifies, vandalizes, and compromises their identities. The sexual oppression and terrorism experienced by those who grow up gay and lesbian—particularly during the adolescent years when sexuality and intimacy development is at a crucial stage—is profound.

For years, psychological researchers and clinicians believed that those with a homosexual orientation were unable to form close attachments, maintain relationships, and have healthy self-esteem. In other words, it was thought that these negative characteristics were innate to homosexuality. The truth is that they are the result of what is done to gays and lesbians. The effects of covert cultural sexual abuse persist into adulthood and are just as pernicious as those of sexual abuse.

The following will demonstrate how the trauma is sexualized, how it manifests, how to identify it for your clients, and how to help them heal from it.

Defining Covert Cultural Sexual Abuse

Covert cultural sexual abuse (CCSA) is the foundation for many (if not most) problems for gays and lesbians. And most therapists working with gays and lesbians miss this phenomenon. It’s not enough to simply say that gays and lesbians were permanently scarred by the homophobia and heterosexism they experienced growing up. Homophobia and heterosexism are inherent to covert cultural sexual abuse and have devastating, complicated psychological and psychosexual consequences, causing guilt and shame to run as deep as in those who have been sexually abused.

I define covert cultural sexual abuse as chronic verbal, emotional, psychological, and sometimes sexual assaults against an individual’s gender expression, sexual feelings, and behaviors. Conceptually, it is similar to sexual harassment in that it interferes with a person’s ability to function socially, psychologically, romantically, affectionately, and sexually. Its effects persist into adulthood and wreak havoc in people’s lives—as does sexual harassment.

My working definition of sexual abuse (both covert and overt) is whenever one person dominates and exploits another using sexual feelings and behavior to hurt, misuse, degrade, humiliate, or control another. The abuse comes from a person who violates a position of trust, power, and protection of the child. In other words, sex is simply a tool with which to exert power, dominance, and influence—just as in rape and sexual harassment.

Overt sexual abuse involves direct touching, fondling, and intercourse with another person against that person’s will. Covert sexual abuse is subtle and indirect. It includes inappropriate behaviors such as sexual hugs, sexual stares, or inappropriate sexual comments, as well as verbal assaults and denigration, such as punishing a child for not being the “right type” of male or female and homophobic name-calling.

Covert cultural sexual abuse involves bullying through humiliation, offensive language, sexual jokes (of antigay nature), and obscenities. These attacks can be directed at the gay or lesbian person directly or indirectly. In other words, what I define as covert cultural sexual abuse is the expression of heterosexism, a belief in mainstream society that demands that all people be—or pretend to be—heterosexual. Heterosexism uses homophobia to exploit the sexual feelings and behaviors of those who are not heterosexual. In other words, heterosexism perpetrates and violates the trust that gay and lesbian children have in those in who are in positions of trust, power, and protection of them.

To be clear, I am not saying that gays and lesbians are sexually abused. Nor am I diminishing the profound negative effects of overt sexual abuse. What I am trying to help clinicians understand is that many of the deep-seated problems gays and lesbians have come from covert cultural sexual abuse.

Children (and adults) are bombarded by messages—from the church, from politicians, from their schools, from their peers and their family—that being gay is morally wrong, sinful, and forbidden; they internalize these message on some level. The shame and guilt become profound and part of their identity.

Restrictive Socialization Messages

All kids get some social limitations from their families, schools, and communities. Many of these messages are important; they teach children how to behave appropriately in order to be accepted. But the problem with restrictive messages like “don’t think,” “don’t act,” “don’t feel,” and “don’t touch” is that they limit children and cause their core selves to remain underground. If, for example, an innately playful child is taught to curtail her playfulness, she is being forced to deny that part of herself.

And so the false self begins. Gay and lesbian children learn to split off important parts of their core identities. This causes them to lose their sense of self early on. We therapists can help clients resurrect their “buried treasures,” as I call these lost parts of the self, to discover their authentic identity.

Disowning Aspects of the Self

Cutting off romantic and sexual urges becomes habitual for lesbians and gays. The individual’s sense of identity becomes fugitive, and she tends to misinterpret who she really is—not only in relation to sexuality but also in relation to her social sense of self in terms of how to act, feel, think, and experience body sensations. Straight children may disown parts of themselves that shape their identity, but gay children suppress much more of their identities.

When gay and lesbian children cut off and disown parts of themselves, they go underground. They still, however, repeatedly seek conscious expression, if only in excessive denial. But such an attempt at camouflage—being the exact opposite of what the individual hopes to hide—is often laughably recognizable.

Pretending That Nothing’s Wrong

Early on in life, almost everyone learns to present his best face to his peers and classmates—and, conversely, to minimize or deny anything that might subject him to judgments and ridicule. Many gay and lesbian children and teenagers hope that someone will see through their pretending to be straight. They long for someone to say, “I can see something is wrong; let me help you.” Unfortunately, this rarely, if ever, happens.  The “something” that is wrong is not their homosexuality but that they are pretending to be someone whom they are not.

Becoming a Master of Pretense

Just because a client comes out and seeks to integrate his sexual and romantic orientation doesn’t mean he’s vowed to embrace integrity in every other aspect of life. Becoming a master of pretense and living out of integrity is the consequence of suppressing homosexuality. Displaying a false self as a heterosexual to others—and oneself—becomes a way of life. This may explain why many gay men and lesbians don’t stop pretending and hiding even after they come out. Pretending has become a way of life, manifesting in other ways that need to be addressed. They often do not even realize they are continuing with this defense in relationships.

Therapeutic Tools For Psychosocial Information Gathering and Treatment Planning

As a clinician it is important to know the right questions to ask and terminology to use to obtain the best possible assessment and decide what direction to head in for treatment. As a straight clinician you need to watch for the negative transference of your clients, who, as you ask these questions, may feel you are coming from a pathological stance about homosexuality.

I would suggest that as you do the initial intake, you tell your clients that the questions you ask are those you ask in most every session about growing up in a minority status. Assure lesbian and gay clients that you do not believe in the pathogenic models of homosexuality. Reassure them that you want to obtain the best information to help them and that knowing about their gay and lesbian childhoods—even if they did not know they were gay or lesbian as children—is important to helping them understand the type of adult they have become.

You can tell clients that you do not want to create a victim mentality by asking these questions but that you do need to understand their experiences in order to be able to know who and what is accountable for their not having permission to explore their homosexuality. Explain that this is an important part of understanding their adult functioning as gay men and lesbians.

Following are some suggestions of what to ask your clients:

  • When do you recall knowing that something about you was different from other children of the same gender—even if you did not call it gay or lesbian?
  • When did you discover your gayness or lesbianism?
  • Did you feel different from your peers—particularly those of the same gender?
  • Did others—adults or peers—notice you were different and shame or bully you for it? If so, how?
  • Were you consciously making decisions to hide or pretend to be like everyone else?
  • Even if you don’t recall overt forms of abuse for being gay or lesbian as a child, what about the covert abuse, which includes the absence of permission to explore your homosexuality or the lack of role models? How do you feel about that?
  • Do you think that not being acknowledged by yourself or others as a gay or lesbian child affects your adult life today in terms of self-esteem and relationships?
  • Why do you think you did not tell anyone when you were young?

As a psychotherapist, your goal is to teach gay men and lesbians that they’re not responsible for any of the abuse they received as children and teenagers. Accountability rests on the guilty shoulders of those who did the abuse. Having strong and healthy therapeutic attachments helps gay men and lesbians recover the birthright of their sexuality and heal the effects of covert cultural sexual abuse.

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