from Clinical/Therapeutic Issues

The treatment of ego-dystonic homosexuality in men poses many therapeutic challenges. From a technical standpoint, the patient typically presents with many conscious and unconscious resistances to growth. There are fears of heterosexual functioning that manifest themselves through sexual acting out, suicidal gestures, passivity, threatened premature termination, avoidance, rationalization, and so on.

The therapist must prepare for these and many other hurdles and readily ally himself with the side of the patient's personality that strives for change. Such an alliance requires that the patient feel safe, understood, and hopeful that change is possible. If these conditions are not met, or if ruptures in the alliance are not sufficiently repaired, the patient will not experience the therapist as "being on his side" and the outcome will be seriously undermined.

In the several years that I have been treating men with this condition they have taught me a great deal about themselves --about their internal turmoil and their efforts to cover up their secret lives; about their interpersonal sensitivities; and especially, about their deep sense of masculine inadequacy.

In my way of thinking, masculine inadequacy is a feeling state arrived at after years and years of wounds to a boy's developing masculine self-image. My experience has taught me that the overriding therapeutic aim in working with these men is to reverse this damage and ensure the integrity of masculine self-image. The evolution into this "phallic being" creates a safer context for these men to overcome their fears and feel more hopeful about growth because they can identify behavioral changes. Therapy provides the patient a second chance to receive the masculine mirroring via the therapist which is so vital to treatment outcome.

With this backdrop I will now enumerate the specific circumstances that spur the growth of this masculine self. Along the way I will anticipate the resistances that inevitably arise and pose specific interventions to address them.

The patient's success in this effort is directly related to his acceptance and recognition of the various factors that have interfered and continue to interfere with an adequate masculine self-image. Therefore, the therapist guides the patient in revisiting the significant situations of childhood, linking them up with past and present feeling states, and labeling the patterns. Once this is accomplished the groundwork is laid for leading the patient towards masculinization. Laying the groundwork involves using the patient's personal history to demonstrate how childhood situations left him with a sense of exclusion from the "masculine club" and produced deep feelings of "not measuring up."

The persistence of these scenarios led to strongly engrained patterns of submission and self-exclusion. Submissive behavior became a tool for temporary, albeit humiliating, entry into the male world, and self-exclusion was relied upon for protection from further wounding to the boy's fragile sense of masculinity.

The reconstruction of this boyhood disenchantment with masculinity provides reference points for the therapist to refer back to when the patient discusses the failures and disappointments of life today. A common language that incorporates the terms used by the patient, the specific circumstances surrounding damage to the masculine self, and the therapist's syncretizing comments provide the patient with verbal mechanisms to endure the surfacing of adverse feelings. In one case, a man's easily evoked feelings of victimization were lessened by telling himself that he was not helpless in the face of bullying by his cruel older brother and that he retained certain powers and choices to change circumstances if he so desired.

The Importance of Risk-Taking

In the same patient referred to earlier, workplace scenarios regularly evoked feelings of submission that he felt powerless to overcome. Analysis of these situations led to identification of specific actions or comments that he had avoided making which could have stemmed the tide of his feelings. For example, he could have given a superior direct feedback about the tone of voice used when addressing him, informed a co-worker that he would no longer take responsibility for the other's work, and he could have apologized after an overreaction as a way of providing closure to an awkward interaction. When this patient protested that such actions would have futile or humiliating, I suggested that many actions do not produce the "right" results but nevertheless would have restored his sense of masculine dignity in the situation.

I have suggested that a man's masculinity is judged via the means he uses to interact with the world, rather than the outcome of those means. This intervention attempts to alter the "yardstick" of masculinity from a child's focus upon the external results, to an adult's internal set of standards and priorities. Although the boy had no choice other than to measure himself by the arbitrary standards and circumstances around him, as a man, he is free to develop his own "measuring stick."

The patient's passage through these masculine rites offers the therapist an opportunity to demonstrate visible pride and satisfaction at his phallic conquests. The therapist must feel free to offer admiring comments balanced by sensitivity to the fragile state of his patient's masculinity. This gentle affirming or mirroring of the patient's phallic assertiveness promotes internalization of the therapist's pride, and thereby, the patient's confidence that his masculinity is enhanced. In may respects, these therapeutic exchanges parallel the normal developmental dance between a proud and attuned father and an idealizing and vulnerable boy passing through the phallic-narcissistic phase.

The therapist's reinforcement of the patient' phallic assertiveness inevitably triggers some core childhood fears that stand in the way of sustained progress. For example, it is typical for these men to feel paralyzed by the fear of disappointing the therapist. They may become overwhelmed with shame and confusion about "what really is expected," as if a secret agenda is being used to measure them. They may angrily insist upon the unfairness of it all, since so much is upon them to do, or they may simply find one "logical" reason or another to avoid taking such risks.

These resistances must be viewed as windows of opportunity to speak directly to the boy within, and to provide the emotional supplies so scarce during childhood. The therapist's ability to empathically immerse himself in the patient's experience, much the way a "good enough" father can recall his own fears and insecurities as a boy, will determine whether these core fears become roadblocks or simply way stations for refueling.

In the same way that a boy who is filled with disappointment in himself needs his father to make it better, the patient needs reassurance, affection and containment from the therapist. Initially, the therapist must put himself in the patient's experience and communicate from there. Examples might include, "This is scary stuff...It probably looks pretty hopeless at this point...It is unfair that no one else is suffering but you...You're worried that each step you take will be the wrong one..." Such understanding is essential but not sufficient, since the "good enough" father/therapist must do more.

Broadening perspective, instilling objectivity, or offering concrete and specific handling of situations can build confidence where it is most needed. For instance, "You need to know that I'm proud that you've made it this far and that doesn't disappoint me, but tells me that we need to put our heads together and prepare you better next time...Of course it seems like a foreign land because you've never really been settled there before, but I will help you learn the terrain and before long, you'll feel like a native...The only thing expected is that you'll keep telling me about your feelings and confusion so that I can help you manage them and guide you to where you want to go...It's important to realize that your fear makes it easy for you to find excuses not to follow through, such as when you jump to conclusions about the entire female population based upon the experiences you've had with only a few...Now, let's talk about what you can realistically expect to happen and how you might want to handle it so you feel better prepared...I think that you'll feel less like you're submitting if you made those conditions clear and explain why you neglected to tell them earlier..."

Breaking Out of the Entrenched Pattern

The therapist's ability to soothe some of the patient's fears often produces an interest in goal-setting on the part of the patient. Dynamically, the patient is now ready to risk further disappointment in return for the prospect of self-satisfaction because he knows the therapist will be there to offer solace if he should stumble. In essence, the therapist's empathic attunement provides a "safety net" to ensure that when the patient is let down, his feelings can be contained rather than subjected to a downward spiral.

Goal-setting must be handled with much caution and delicacy since it spurs action in one director or another. First it must be understood as both a catalyst for growth, and a potential resistance to growth. From a positive standpoint, defined and measurable goals are critical at certain points because men often need to see themselves as moving forward and "acquiring the masculinity" inherent in attaining each benchmark on their own "measuring stick." But from a negative standpoint, goal-setting can function as fertile ground for self-defeating patterns and provide further evidence of not "measuring up." Therefore, the therapist must anticipate how failure to meet one's goal at any given point will be experienced as a general failure in the man's quest for a masculine self.

For instance, one man with a history of childhood obesity recalled many painful memories of being teased for his ineptitude in sports and his weight. Food became a ready source of comfort when he was beleaguered by self-hatred and peer ridicule. Although he was no longer obese when he began therapy, the symbolic value of food remained the same: it comforted him when he felt unmanly. Due to his childhood experiences he saw a soft, uncontoured body and self-indulgent eating habits as less than manly.

In positing goals, he placed weight lifting/working out and maintaining disciplined nutrition as especially important for his sense of masculinity. His attainment of these goals brought enhanced self-esteem due to their masculine value to him. He soon expected himself to fulfill both goals on a daily basis, and as a further condition, he allowed no "cheating" in his diet and he implicitly instituted minimums upon his workout times. This eventually led to his daily moods becoming tied to his ability to satisfy the goals. When he was unable to satisfy one he became disillusioned, depressed, and disinterested in the goals. Clearly, his sense of masculinity became dictated by meeting the goals without any consideration to his circumstances, energy level, rewards, and other issues that impacted upon goal achievement.

When goals become subverted as they did in this case, the therapist must offer comfort, interpretation, and objectivity. First, the patient needs to know that his feelings count even if they arise out of unrealistic expectations. For example, "I see how weak you feel when you eat something rich in calories or don't make it to the gym." Next, the therapist needs to make clear that the patient is doing to himself what others did to him as a boy: imposing arbitrary conditions for masculinity. For instance, "When you judge yourself so strictly you are only allowing another form of submission into your life, but this time, it's in the form of inflexible rules for masculinity."

Failures Alternate With Successes

No discussion of these problems would be complete without adequately addressing how homosexual fantasies disturb the lives of these men. The experience has taught me to treat such fantasies as very distinct from the behavior patterns and goal-setting that I have outlined thus far. My rationale is based upon the view that these fantasies grow out of the deep frustrations and unmet needs for masculine affection that occur during early childhood. Initially, these fantasies are attempts to compensate for this deprivation, and in time, other determinants reinforce their continued presence. Therefore these fantasies cannot be overcome in the same manner that these men overcome passivity and avoidance--that is, through assertiveness.

The reliance upon the fantasies subsides as the patient passes through the phallic-narcissistic phase of therapy and is rewarded by the therapists' admiring comments and a fuller sense of masculinity. Yet even with the most ideal outcomes, it is my belief that residual homosexual fantasies will emerge from time to time through the lives of these men. Therefore I believe that it is critical not to over-focus upon the presence of the fantasies in order to allow the evolution of the masculine self to take place.

By ascribing great importance to the presence or frequency of the fantasies, the therapist may inadvertently sabotage that process by communicating to the patient that no matter how masculine he behaves on the outside, he remains homosexual inside. One man who I had been treating for a few years made the following observation about he importance of realistic expectations: "I've come to accept that there is a homosexual part inside that I may never be able to get rid of. But maybe I can learn to live with it. The other day I was at the swim club with my wife and sons. A man in a very tight bathing suit walked by and I caught myself staring and beginning to have fantasies. But just as quickly, I stopped myself, told myself it was not such a big deal, and dove in the water. And it didn't ruin my day."

This man's experience captures what I see as the most realistic goal of psychotherapy of ego-dystonic homosexuality: the growth of a strong masculine self-image that provides for a satisfying heterosexual adaptation which is not jeopardized when there is a periodic intrusion of homosexual fantasies.

Yet I am aware that many men will have great difficulty embracing a goal that falls short of the total eradication of homosexuality from their inner and outer lives. In fact, I am often confronted by much disillusionment when I present this view at the beginning of therapy. Still, I believe it is a critical intervention in this type of work because it anticipates the fantasies, and attempts to demystify their meaning. If this is not accomplished, patients may easily give up hope even if they are progressing, due to the significance they have placed upon the lingering remnants of homosexual fantasy life.

Demystification begins by providing a new meaning to understand the fantasies. These men have felt stigmatized by their fantasies and have often understood them to signify their homosexuality. Yet they are typically relieved when I supply an alternate construction that weaves together the theories of early childhood development in boys, the circumstances of their early childhood, and the subsequent impact of internal and external forces.

For instance, the man most recently referred to recounted how his fantasies originated from the images of fathers and sons portrayed by such shows as "Lassie" in the early 1960's. He recalled having been five or six years old and soothing himself to sleep by imagining that he was the little boy receiving the paternal affection depicted on the TV program. Although these memories were recalled by him with great sadness and emptiness, he accepted his earlier dependency upon those fantasies due to the coldness and detachment of his father.

From this point of departure, I attempted to demystify the later homosexual fantasies through clarifications such as the following: "Deep down your fantasies serve as a security blanket in the same way they did when you were five. At that age your heart ached for your father's strong arms to hold you, but sensing his rejection, you turned away and inward in an attempt to create your own good father image. This helped you to endure his emotional detachment but laid the groundwork for your dependence upon fantasies for soothing your pain. With the onset of adolescence, you feelings of masculine inadequacy were intermixed with sexual urges, and once again you turned to your fantasies for soothing your pain. But this time, you had no choice other than to construct them in a blatantly sexual style due to the phase of life you were in. Heterosexual fantasies would not provide any type of relief and refueling, since you were still stuck in the arms of the good father, not ready to let go and too scared that you would not make it as a man."

Meaning Transformation

Yet some men are threatened by this premise because it dramatically departs from the negative view they have held for so long. In most cases, these men have tried in vain to suppress the fantasies, especially during masturbation. They may be convinced that they must overcome the fantasies, because only then will they be able to comfortably pursue heterosexual relationships. Some men go so far as to set this as a precondition and thereby enforce an intractable resistance to growth.

The therapist's success in addressing this resistance plays a pivotal role in determining the course of therapy. By referring back to the little boy's dilemma of craving fatherly affection, he can enlist the patient's acceptance of how unmet needs seek relief. It is important to stress the notion that his "boy" inside should not be blamed for what he could not control, and he cannot be expected to just abandon his dependency upon fantasy because the adult on the outside dictates it.

Such a demand only echoes the harsh treatment the boy received as a child when others demanded that he "measure up."

Rather, the boy should be allowed to indulge in his fantasies during the times his needs require it, while the adult provides gentle encouragement to grow up. This encouragement comes in the form of goals and newly formed masculine attitudes that begin to exist side by side with the older child-based homosexual fantasy life. Essentially, the patient is told that the therapy aims for the evolution of a masculine self, not just a substitution to take the place of the old homosexual feelings and images.

The demystification of the fantasies can effectively remove any preconditions that the patient's resistances put into place. In so doing, the patient is freed up to develop a strong masculine self-image at whatever pace his fears allow.

When confronted by skepticism and complaints that these ideas make it sound like I am suggesting it is acceptable to fantasize about homosexuality, I have used the following metaphor: "If we go back to the boy's experience and remember how many times he had the door slammed before him when he wanted to join the other boys, to feel accepted as a boy, or just receive some affection for making his father proud of him, we get a picture of a shaky, insecure kid locked out of masculinity. His fantasies were the emotional band aids that helped him succeed in the other areas of his life. And now you're telling him to strip off the band aids and get ready to be kicked out of the house? I think it's better to first prepare him for what it's like out there and keep the door open when he ventures out so he knows he can still return if he finds it necessary. In time, he'll get a firmer feel under his feet for what masculinity is all about and build his own house. But there still may be times when he returns to visit the old house for one reason or another."

In closing, I would like to stress that this paper presents many interventions that I have had hours to ponder over during the writing process. The written words are at best, only approximations of what I really said in sessions when I had only seconds to produce a response. Still, the gist of my approach is presented here. Yet during those occasions when my therapeutic attunement failed me and my words were insensitive or, at worst, hurtful, I looked for signs of that in my patients and tried to elicit their feelings. When I was able to elicit those hurt feelings, and they expressed their anger at me and requests for an apology, I humbly offered it and returned to gauging their progress on their own "measuring stick."

Updated: 8 February 2008

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