Sexual and Relationship Therapy

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Sex therapy with gay male couples using

affirmative therapy

Philip A. Rutter

To cite this article: Philip A. Rutter (2012) Sex therapy with gay male couples using affirmative
therapy, Sexual and Relationship Therapy, 27:1, 35-45, DOI: 10.1080/14681994.2011.633078

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Sexual and Relationship Therapy
Vol. 27, No. 1, February 2012, 35–45

Sex therapy with gay male couples using affirmative therapy

Philip A. Rutter*

Widener University, Center for Education, Chester PA, USA

(Received June 2011; final version received October 2011)

This manuscript explores the benefits of applying the Gay Affirmative Therapy
approach to sex therapy with gay male couples. The tenets of this empathic,
empowering and strength-based integrative approach are presented and tied to
sex therapy and more specifically to dynamics within gay male dyads. A case
presentation integrates both the individual and systemic constructs of Affirmative
Therapy while modeling assessment and treatment of sexual dysfunction within a
gay male couple.
Keywords: sex therapy; gay male couples; affirmative therapy; strength-based
approach

The foundation of sex therapy

Though the arena of sex therapy and relevant literature has its foundation in mostly
psychodynamic concepts and psychoanalytic bases (Leiblum, 2006), more recent
clinical sexology has moved to more strength-based and post-modern theories as
proposed by Affirmative Psychotherapy (Bieschke, Perez, & DeBord, 2007). While
the past decade has seen improvements to the approach in sex therapy to be more
inclusive of diverse couples, much is to be gained by incorporating concepts and
strategies of the Gay Affirmative Therapy model (Firth & Mohamad, 2007;
Langdridge, 2007). It deconstructs dominant paradigms, confronts gender stereo-
types and patriarchy and broadens the lens of potential socioeconomic status and
ethnic/cultural groups who may benefit. Further, this approach fits well with the
oppressed and marginalized status frequently accompanying the experience of same-
sex clients (Davies, 1996; Ritter & Terndrup, 2002).
Leiblum and Rosen (2000), along with other leading clinical sexologist, urge the
use of systemic strategies to treating dysfunctions and/or desire to guide a sex
therapist’s work with a couple presenting with sexual dysfunction or desire disorders
(Hertlein, Weeks, & Sendek, 2009; Leiblum & Rosen, 2000). Gay affirmative therapy
promotes exploring the contextual and systemic influences on lesbian, gay and
transsexual (LGB) clients’ functioning, suggesting integrating systemic theories as
crucial to effective couples work (Coyle & Kitzinger, 2004; Davies, 1996; Tunnell &
Greenan, 2004).
As mentioned above, the vast majority of sex and relationship counseling with
both heterosexual and homosexual clients had a historical grounding in

*Email: [email protected]

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36 P.A. Rutter

psychodynamic (and often psychoanalytic) perspectives (Leiblum & Rosen, 2000;

Long, Burnett, & Thomas, 2006). Prior models explored the symbolic content and
utility of the symptoms or exploration of defenses and the ego’s unconscious as it
related to desire disorders (Scharff & Scharff, 1987). These psychodynamic or
psychoanalytic models appear, however, to be a ‘‘poor fit’’ when conducting sex
therapy with same-sex couples (Hertlein, Weeks, & Sendak, 2009). Further, Milton
and Coyle (1998) reported deficient practice among some psychodynamic therapists,
who viewed homosexuality as pathological. More concerning was their discovery of
clinical training programs in which psychoanalytic and psychodynamic training
programs, when discussing homosexual patients, described this population as
‘‘perverse or disturbed’’ (Milton & Coyle, 1998, p. 74).

Affirmative therapy – ethical and practice variations

Affirmative therapy has been in existence in one form or another since the late-1980s,
originally taking more of an ‘‘ethical treatment’’ or sensitivity-to-difference approach
when working with LGB clients (Langdridge, 2007; Perez, DeBord, & Bieschke,
2000). Inclusive in this approach is the clinician’s ethical duty to acknowledge and
actively work towards acceptance of difference for the lesbian, gay or bisexual
client’s experience. This ethically affirmative approach (Langdridge, 2007) offers that
any practitioner working with clients who are lesbian, gay or bisexual should be
practicing in accordance with ethical guidelines of their respective discipline. The
ethical affirmative therapy approach is separate from the practice affirmative
approach (Perez, DeBord, & Bieschke, 2000) in that it merely presents via
documented research, what was poor practice in the past while promoting what
would be best practices for future clinical work with LGBT clients (Langdridge,
2007).
The second type of Affirmative Therapy is practice driven, inclusive of what
theories are best to integrate, the personal and clinical stance of the affirmative
therapist and the general tone of the relationship from a strength-based and
ultimately LGB embracing stance (Langdridge, 2007; Long, Burnett, & Thomas,
2006; Ritter & Terndrup, 2002). Theories stated to fit well when integrated in
Affirmative Therapy practice include: cognitive therapy (Beck, 1988), structural or
multigenerational therapy, narrative therapy, feminist therapy and solution-focused
therapy (Langdridge, 2007; Ritter & Terndrup, 2002). These theories will be
expanded upon for their relevance in treating sexual dysfunction or desire disorders
for gay male couple clients. Following the description of pertinent theories and
strategies that fit the gay affirmative therapy practice model (Davies & Neal, 2000), a
case example will include application of said theories to a desire discrepancy
presented by a gay male couple seeking sex therapy.
It is important to describe another element of what Langdridge (2007) and others
describe as Affirmative Therapy practice, as it is less of a tangible strategy and more
of a way of being with the lesbian gay or bisexual client (Davies & Neal, 2000). The
therapist’s ability to understand and be sensitive to the context of the lesbian, gay or
bisexual experience (Lebolt, 1999), to view lesbian and gay sexualities as normal,
natural and healthy as any other sexual orientation (Haldeman, 2000; Fassinger,
2000) and to understand the LGB client’s sexuality is not per se the cause of
psychological difficulties presented by our lesbian and gay clients (Haslam, 2000;
Milton & Coyle, 1988). However, it is acceptable to believe that social evaluations
 Sexual and Relationship Therapy 37

and responses to lesbian and gay sexualities may cause distress – that is, the external,
interpersonal and systemic contexts related to our LGB clients sexual identity
(Dworkin, 2000).

Therapy with same-sex couples

Before strategizing sex therapy with gay male couples, it is helpful to realize the
resilience of these couples and their ability to ‘‘weather the storm’’, so to speak. As a
key marriage and family therapist/researcher phrased so eloquently: ‘‘Gay and
lesbian couples are a lot more mature, more considerate in trying to improve a
relationship and have a greater awareness of equality in a relationship than straight
couples’’ (Gottman et al., 2003, p. 70).
For these reasons, and the marginalized and oppressed status of many same-sex
client couples, a sex therapist working with gay male couples would be well served to
integrate those concepts espoused by the affirmative therapy model, namely
cognitive, solution-focused and narrative (from an individual perspective) and
multigenerational or structural theories (from a family systems perspective). These
approaches, of course, are not all integrated in tandem but, as Corey (2008) suggests,
an integrative approach includes a delineation of who, when and why questions. For
all three prompts, the theories above suggest a very good fit with sex therapy for gay
male couples. A final theory, or approach, that is part of the Affirmative
Psychotherapy model, is feminist therapy. Feminist therapy is probably one of the
most powerful frameworks or theoretical stances couples’ counselor serving same-
sex couples can hold. The significant impact of navigating internalized patriarchal
messages, exploring gender roles-inclusive of a gender role analysis and
confronting gender stereotypes can prove quite beneficial when treating a desire
disorder or dysfunction manifest for a gay male couple (Long, Burnett, &
Thomas, 2006).

The narrative for gay male couples

One of the larger stressors for the current generation of gay male couples (assuming
client base of 25–55-year-old clients) is the debate around same-sex marriage and the
impact on of the HIV-AIDS pandemic (though its prevalence among gay men has
dropped dramatically in the last decade). These groups are indeed impacted by both
as they relate to fidelity, monogamy and the sanctity of their commitment. These two
significant social issues are indeed part of the gay male couples’ ‘‘script’’. Drawing
from Narrative concepts, clinicians working with gay male couples ought be aware
of the messages each individual partner carries into their sexual relationship.
A sexual dysfunction or desire discrepancy is indeed discouraging and potentially
devastating for the gay male couple. Particularly stressful is the paradigm of two
men that may have moved quickly to the physical attraction/sexual activity realm
early in their relationship with less foundation on emotional and psychological
connectedness (Bettinger, 2004). So when the sexual relationship has concerns, the
gay male couple finds this wholly distracting and challenging and may not have the
emotional or interdependent resources navigate the current dilemma. Sex therapists
serving gay male couples could serve clients well by exploring the emotional and
intellectual attractions to buoy the couple above the current sexual disconnect. It is
important to recognize some comorbidity concerns relevant to gay male couple’s sex
38 P.A. Rutter

therapy provision. One arena is a client’s potential HIV-positive status and the other
is use of recreational drugs. Firstly, a client’s HIV status can cause depression,
which, while understandable, can coincide with anti-depressant medications (SSRI’s)
that contribute to erectile dysfunction or the HIV-positive partner may be prescribed
anabolic steroids when their t-cell count reaches a critical number and may have a
coincide with onset of hypoactive sexual arousal disorder (Purcell Wolitski, Hoff,
Parsons, Woods, & Halkitis, 2005).
An important set of questions to include in clinical sexology intake interviews
and assessments would be potential use of recreational or illicit psychoactive
substances. Purcell and colleagues (2005) examined the use of MDMA (ecstasy)
among gay men who were sero-positive and found a high comorbidity with erectile
dysfunction, ejaculatory incompetence and potential desire decline (Zeshamlany,
Aizenberg, & Weizman, 2001). The confusing element here is that MDMA use, in
the moment, can actually cause sexual stimulation and feelings of attractiveness. It is
the actual ‘‘mechanics’’ that suffer once physically engaged with a partner, i.e.,
erection may be partial or absent, ejaculate minimal or absent (Purcell et al., 2005).

Affirming the resiliency of gay male couples

While some scripts for the gay male population are laden with stereotypes and
misogyny, many more gay men confront gender stereotypes and create their own
templates for ‘‘normal’’ sexual play and creativity. Beyond the typical encounters all
couples engage in, heterosexual or homosexual, gay men are vastly creative! If one
area of desire or dysfunction crops up for a gay male couple, these same clients are
wonderfully resilient in creating other alternative behaviors to express their
attraction and get their sexual needs met (Tunnell, 2009). One vivid example is the
allowance gay male couples give to broaden their monogamy or commitment lenses.
Traditional sex therapy and couples work would potentially assume open relation-
ships or polyamorous systems were fragile, but in the experience of two men in
romantic and sexual connection, these variations on monogamy may be less of an
indication of fragility for the gay male couple (Bettinger, 2004). The ability of gay
male couples to engage or broaden their sexual repertoire through non-primary
partners is fodder for sex therapy conversations, as a way they have discovered and
negotiated the parameters of their dyadic system (Bettinger, 2004; Tunnell, 2006).
Sex therapists working with gay (or lesbian for that matter) couples, would be well
served by asking how the couple defines the open or closed nature of their dyad, how
they came to that decision and so forth.

The integrative approach of affirmative therapy

Current approaches to couples and relationship therapy with gay male couples
would have at their core several threads of commonality. Theories that affirm the
struggle, that openly accept the unique sex lives of gay men and that offer an
empathic yet operational perspective on the presenting problem are best received and
most effective (Long et al., 2006; Tunnell, 2006).
Couples’ counseling, by its nature, is systemic, but current theorist and applied
researchers offer a subset of family systems models that fit well with gay men.
Structural therapy (Minuchin) and Multigenerational (Bowen) Family systems
theories can be integrated with other postmodern theories to challenge historically
 Sexual and Relationship Therapy 39

dysfunctional patterns of relating that are less functional but ingrained (Bettinger,
2004), while offering an explanation of repeating patterns that could be curtailed or
modified to be curative. One example from Multigenerational work conducted by
McGoldrick is the use of sexual genograms. These generational diagrams are
impactful ways for gay partners to see the patterns of sexual expression, dysfunction
and secrets across generations. This can often empower clients to acknowledge the
pattern and stem it (ending what McGoldrick coins as generational transmission).
Those using the Multigenerational approach suggest it is both illuminating and
empowering for clients served (Long et al., 2006). Structural therapy is currently
integrated into same-sex relationship counseling via the clinicians use of techniques
including family mapping, enactments and unbalancing rigid structures/roles (Long
et al., 2006). These techniques and their benefit will be explored in a later segment of
this chapter via case presentation.
Other theories that fit well with sex therapy provision for gay couples include
cognitive therapy and solution-focused therapy. Both have significant efficacy study
data, as well as both theories fitting what would be considered a brief-treatment
model. What may come as a surprise is a change in the visibility of Rational Emotive
Behavior Therapy (REBT) in its application to same-sex couples. This may have to do
with the high expert power inherent in REBT not fitting well with sexual minority
clients. My experience in serving lesbian and gay individuals and couples suggests a
more collaborative, coach like role (as in cognitive therapy or solution-focused
therapy).

Gay couples strengths

Gottman (1999) elaborates on a difference in communication style that may buoy
gay and lesbian couples above their heterosexual peers. It seems gay and lesbian
couples ‘‘where positive emotions seem to have a lot more power or influence’’
(Gottman et al., 2003). Gottman and colleagues (2003), offer the ways gays and
lesbians resolve conflict may be the glue that maintains stability, allowing these same-
sex couples to focus on positive communication, allowing quicker problem solving
and conflict resolution.
Gay male couples (and lesbian couples for that matter) can get quite adamant in
their defense to secure and bolster ‘‘the couple’’. If it means new behaviors or
deleting old ones, or potentially closing the relationship or opening it to other
partners, gay clients are ultimately willing to be creative and purposeful in
maintaining the couple through difficult times (Bigner & Wetchler, 2004).
Finally, it needs mention that humor and resilience for this population go
hand in hand. Confronting stereotypes together, working collaboratively to
present themselves to the broader population as a health loving couple and
navigating the day-to-day stressor often found in all couples, is most usually
accompanied by a rapier wit, a sardonic commentary style or a playful ability to
laugh at the problem/stressor in tandem. This allows sex therapy with gay men to
include this strength – to use humor to confront the issue and to band together
to ‘‘poke fun’’ at it. My clinical work with gay men and couples has often
included highly resilient humorous anecdotes related to their sexual lives and
encounters. This ability to ‘‘laugh’’ through it without being self-deprecating or
hurtful is, in my opinion, one of the healthier coping mechanisms gay couples
bring to sex therapy.
40 P.A. Rutter

Recommendations for assessment

The clinical literature suggests two levels of assessment, which intertwine with the
actual processes of couples counseling. Initial sessions include clinical impressions,
communication styles, perspectives on the problem and previous strategies (Hertlein
et al., 2009). This model also suggests the second and third sessions are separate
individual consultations with each member of the system (therapy session with an
individual session where problem exploration and relationship dynamics are
explored without their partner present).
This is inclusive of a thorough biopsychosocial intake, essentially assessing the
broader perspective on the issue at hand. One reason why the affirmative
psychotherapy integrated approach works so well here is that it is, by its very
nature, biopsychosocial, exploring individual, dyadic and systemic arenas in context
(Firth & Mohamad, 2007; Hertlein et al., 2009).
The second realm of assessment in sex therapy is often referred to as ‘‘paper/
pencil’’ methods. These include use of a sexual history interview, either shorter
versions (Kingsberg, 2006) or more elaborate versions (LoPiccolo & Heiman, 1978).
The former may be considered cursory and supplemented with additional assessment
protocols described below, the latter is quite extensive, but offers much richer
elaboration on historical, developmental, relational and contextual information.
Gottman’s (1999) approach to assessing couples functioning, while systematic
and somewhat linear, is invaluable in gaining quick perspective on the couples
interaction style, blockages and potential for positive change. Surveys of note
include: the Locke Wallace Marital Adjustment Scale (modified for same-sex
couples), the Four Horsemen and The Repair Attempt Checklist (Gottman, 1999).
While there are multitudes of surveys that can be used, these three offer a decent
perspective of relational patterns, communication styles and previous problem
resolution strategies.

Case presentation
A client couple, Tim (age 23) and Jeffrey (age 22), described their presenting
problems as a ‘‘change in sexual frequency’’ and an apparently sudden desire
discrepancy. In asking the timeline for same, Tim disclosed his HIV-positive status
that had been diagnosed two months prior (Jeffrey is HIV-negative). Prior to this
diagnosis, the couple had enjoyed a vibrant and open sexual relationship. Tim and
Jeffrey had plans to move in together and to become partners inclusive of a
commitment ceremony.
While these plans remained a focus, as it was part of their narrative, the
decimation (couples’ word here) of their sex life due to the dwindling desire of the
HIV-negative partner (Jeffrey) was in discord with their emotionally and socially
constructed reality of ‘‘getting married’’ as a young gay couple. Doing sex therapy
with this couple focused solely on the desire disorder would be fruitless. Rather, this
clinician heard their ‘‘sex story’’ and socially constructed narrative and worked to
deconstruct those chapters or scripts no longer helpful to the dyad. This new
construction of their respective individual and systemic narratives was an imperative,
given the change in HIV status and their current navigation as a sero-discordant
couple. Conversations included exploring fears, hopes, expectations and wants/needs
for each other and for themselves. Using Narrative questions (Shapiro & Ross,
 Sexual and Relationship Therapy 41

2002), both in couples and individual break-out sessions, we were able to gather data
about how and what impact this diagnosis meant for the relationship and the
partners moving forward. The couple held to the script of wanting to move in
together as this allowed a ‘‘test’’ of their capacity to share space. Upon exploration
of their story and script, we learned the step of getting engaged or committed to each
other was a familial message both partners were receiving from their parents – quite
consistently and frequently actually. Jeffery offered the insight that though they had
always wanted to live together, his mother looked at the wedding or ceremony as a
‘‘validation’’ of the couple. Both he and Tim assumed this was a good narrative to
follow. Only upon pointed conversations and questions did they concurrently realize
the ceremony concept was externally imposed.
This male couple also expressed urgency in wanting to restore their sex life and
asked for specific strategies each of the first three sessions. While sensate focus was
indeed useful in slowing them down from session one to two, the dynamics suggested
cognitive behavioral constructs might help more. Inherent in individual break outs
with both partners was fear of contagion, diminished hope for the relationship,
desire decline in HIV-negative partner (previously receptive partner), shame and self-
esteem issues with Tim (due to HIV-positive status) and distorted assumptions
individually and systemically. One pivotal discussion included a cognitive distortion
Tim held that Jeffrey no longer found him sexually attractive. When disclosed to
Jeffrey, the response was a resounding ‘‘yes’’ to still being ‘‘very attracted’’ to Tim.
They had become caught up in defining their intimate connection and attraction to
mere sexual/physical parameters.
Pertinent to this point in the clinical dialogue was the depiction of their ‘‘sex
story’’ (Bettinger, 2004), in which both had become set in a particular sexual role or
position. Jeffrey was historically the receptive partner with Tim being the insertive
partner. While they had been sexually versatile in prior relationships, they had
remained in these ‘‘bottom’’ (Jeffrey) and ‘‘top’’ (Tim) roles. Utilizing feminist
therapy concepts, sessions explored a gender role analysis as it folded into sexual
positions/preferences. Upon discussion, it became apparent that the bedroom was not
the only ‘‘gendered’’ activity occurring in this couple. Expectations for Jeffrey to
make meals, clean and generally present as more nurturing were complimented/
contrasted by Tim’s role to provide more expendable income, work on yard etc. While
these may be more shared activities across genders, the gender role analysis suggested
this couple had presumed much from each other and fallen into distinct patterns that
were now impacting their sex lives in palpable ways.
A behavioral suggestion included trying sex toys/dildos to explore role reversals
or versatility in anal sex positions. Initially not sure of this activity’s purpose, the
couple left the third session with mixed responses as to whether they could
accomplish the task. Upon returning to the fourth session, not only had they
successful switched roles/positions, they had created a replica dildo of each other’s
penis using a plastic cast process. The description presented that week, of the couple
creating the ‘‘cast’’ from each other’s erect penis, of making the new dildo from
plastic form kit and the actual giddy presentation of ‘‘trying them on for size’’ was
the happiest interaction and mood since Tim and Jeffrey started sex therapy.
Once we had some successes in sessions, it seemed important to return to the
systemic messages they received from parents and family of origin about coupling
and intimate relationships. And the couple’s previous rigid role status suggested a
sexual genogram could be helpful (Hertlein et al., 2009). Both described a generally
42 P.A. Rutter

supportive, but often directive, connection to their mothers. Jeffrey came from an
impoverished upbringing (father left when he was age 10) with a single parent
household and very close, open relationship with his mother – he came out to her at
age 9. His mother suffered from a terminal illness and Jeffrey was, in many ways, her
apparent guardian. Conversely, Tim came from a highly affluent household and had
only come out to his mother in the context of the relationship. She was, however,
accepting and was promoting the commitment ceremony along with Jeffrey’s
mother. The context of being a single parent was explored, as well as message about
intimacy, sexual expression and what commitment or marriage meant from a
generational and now dyadic perspective.

Role of the therapist

One significant benefit of the gay affirmative therapy approach is the role of the
therapist as non-expert. This matches well with marginalized or oppressed groups
(Ritter & Terndrup, 2002). To be more explicit, the post-modern social construc-
tionist theories of Feminist and Narrative both operate from a low-expert power
role. This allows the client to describe the context of their experience without
interpretation as to proper or improper functioning. A Feminist or Narrative
therapist offers the same-sex couple suggested new directions only when the
ingrained gender role or script is oppressive or antagonistic by that client’s
description (Estrada & Rutter, 2006/2007).
Additionally, and in accord with clients’ expectations of sex therapy, gay
affirmative therapy integrates slightly more directive theories, providing perspectives
to initiate more immediate change. In particular, Cognitive therapy does explore
internal and shared distorted cognitions as they impact self-image, perceptions of
partner’s behavior and negative or inaccurate assumptions. In this role, a cognitive
therapist is more of a coach, with the client again learning how to address cognitions,
both accurate and distorted. The use of Cognitive therapy along with Feminist and
Narrative, fits very well, as numerous distortions accompany gender role scripts or
socially constructed norms for which gay male couples may fall prey (Bieschke et al.,
2007).
Finally, systems theories, either Multigenerational or Structural, allow historical
perspectives for both male partners on how others operated intimately (romantically,
physically, interdependently) in their respective families of origin (Hertlein et al.,
2009). Here the clinician using either model will take more of an expert role and
guide the couple toward exploration of either sexual genogram patterns or boundary
concerns (Multigenerational) or use of enactments and unbalancing (Structural) to
add significant insight to the presenting problem of desire or dysfunction. For
example, what did the change in desire for this couple mean, moving forward – less
focused upon the actual dysfunction, rather focusing on what purpose did it serve for
the individual and the dyad (Tunnell & Greenan, 2004).

Helpful therapist characteristics and therapist issues

In working with same-sex couples, it would be important to explore issues of
countertransference, transference and projection. Supervision for these cases initially
would be helpful if any concerns around the sexual acts of two gay men cause you
pause or discomfort (Bettinger, 2004; Tunnell & Greenan, 2004). One item for
 Sexual and Relationship Therapy 43

consideration that relates to a theory addressed above, Feminist therapy, includes

the use of disclosure. Gay and lesbian clients are more likely than their heterosexual
peers to ask of the sex therapist’s sexual orientation or couples status. Of course,
disclosure may or may not align with your theoretical stance or personal style. It is
important, however, to realize that gay and lesbian couples will indeed ask.
Countertransference, transference and projection are relevant in all sex therapy
work and would be recommended ‘‘grist for the mill’’ in your clinical supervision. If
you also identify as gay male and are working with a gay male couple, one can surely
see the chance of countertransference or projection occurring (Phillips, 2000).
Several works cited in this chapter would be critical readings for sex therapists
wanting to serve gay male couples. Tunnell and Greenan (2004) speak candidly of
the nature of sex therapy with two gay men, that is, open discussion by gay clients of
penis to mouth or penis to anus contact. Any negative or uncomfortable reactions to
these behaviors or other potential sexual acts between two men would be an issue to
discuss in supervision before ever serving a same-sex couple. As Bettinger (2004)
offers, ‘‘gay men often have a finely tuned intuitive ability to sense a professional’s
discomfort or disapproval of their sexual choices’’ (p. 70).
Sex therapy with gay male couples also includes a unique variable that many
clinicians may bristle at, namely, a different construction of monogamy or to
defining the ‘‘couple’’. Gay male couples are sometimes mutually exclusive,
sometimes exclusive for intercourse only, other couples from a more polyamorous
stance (partner as primary with secondary and tertiary romantic relationships) and,
finally, others with a completely open relationship status. The importance of
exploring how they define their intimate relationship, monogamy and behaviors
within and outside the dyad is crucial to sex therapy with gay male couples. Our
impressions or judgments on closed or open systems are fodder for supervision, not
for the clinical room (Tunnell & Greenan, 2004).

Summary
Clinicians already in the field of sex therapy work may be operating from the
‘‘ethical’’ gay affirmative therapy model (Langdridge, 2007) acting from an LGBT
sensitivities and supportive stance. Few have yet to reach the ‘‘practice’’ of Gay
Affirmative Therapy, i.e., broad advocacy and empowerment of the client’s sexual
identity, contextual understanding and empathy for the LGBT systemic oppression
and the active integration of theories such as Feminist, Narrative or Cognitive
approaches (Coyle & Kitzinger, 2004; Lebolt, 1999). Efficacy studies, client reports
and benefits of these affirming strength-based approaches all suggest a primer on it
could help both the seasoned sex therapist and the clients they serve.
Finally, while the realm of sex therapy and the breadth of clinical background/
disciplines interested in providing sex therapy to their couples clients exist at some
degree, LGBT inclusive affirming models are mostly absent from clinical sexology
and sex therapy training literature (Long et al., 2006). Sex therapists reading this
manuscript and using affirmative psychotherapy approach in their general clinical
work could move the future of sex therapy for gay male couples by (1) affirming gay
male client couples’ strengths and coping styles, (2) validating their co-constructed
models of intimacy and monogamy and (3) exploring these gay male couples gender
scripts, historical narratives and family messages as they enhance or detract from
their intimate connections and impact sexual functioning and desire.
44 P.A. Rutter

Notes on contributor
Dr Rutter is a professor of human sexuality at Widener University, a counseling psychologist
in private practice focusing on LGBT couples, families and parents, and serves as the Clinical
Division Director for the American Association of Suicidology.

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