top of page

Homoignorance: considerations for the gay or lesbian client in therapy

This is an essay that I wrote as part of my psychotherapy training, which I have slightly re-written as an article. I’ve removed all the rather off-putting academic cross-referencing and footnotes – but I left the references that I drew on writing it. The research and writing of this piece had a big effect on my sense of myself as a gay man – and cast a lot of light on the almost invisible guilt and distortion I have felt growing up gay in a straight world. Homo-awareness: growing up gay in a straight world


This article explores the issues that arise when working with lesbian and gay clients in therapy. Fortunately, explicit homophobia is now frowned upon in almost all therapeutic circles, but I’m looking at the ways in which even ‘gay-friendly’ therapists can unconsciously damage clients by ignoring crucial differences between gay and heterosexual lives.

This unconscious ‘homo-ignorance’, as it has been called, is not limited to heterosexual therapists. I’ve been powerfully struck while I was researching this piece how much it also applies to me as an openly gay man working in a liberal, integrative training institute.

And I believe this is an important area of consideration because the figures show that we as therapists will encounter a disproportionate number of lesbian and gay clients in our work.

Statistically sophisticated research in France, the UK and US, reported 11.6% male and 7.8% female same-sex behaviour in a sample of 5,700. Even allowing for the underreporting that is natural in such a stigmatized subject matter, we can assume there is a significant minority of lesbians and gays in any given population. However, evidence compiled by the National Institute for Mental Health in England in 2003 points out that gay men are two and a half times more likely to suffer anxiety than straight men; four times more likely to attempt suicide; one and half times more likely to become alcohol or drug dependent. A 2008 report concludes that lesbian and gay people are at “significantly higher risk of mental disorder, social isolation, substance abuse and deliberate self-harm than heterosexual people”. In short, we are likely to see a lot of lesbian and gay clients in our therapy rooms and understanding how we can best help them in an informed and sensitive manner is of crucial importance.

To begin with, I would like to survey some of the theories that are relevant in thinking about this topic. The second part of the article will look at clinical considerations when working with lesbian and gay clients.

Theoretical considerations 1: homosexuality as a problem

Theory has a powerful pull on the way in which we consider our work with gay and lesbian clients. For the greater part of the 20th century psychoanalytical thinking about homosexuality was premised on the idea of “developmental arrest”. In this model, human sexuality passes through stages to attain a normalized state of heterosexual pairing. Despite his relatively enlightened view on homosexuals, Freud never deviated from this line of thinking, in 1905 he wrote: “The final outcome of the sexual development lies in what is known as the normal sexual life of the adult, in which the pursuit of pleasure comes under the sway of the reproductive function… ”

Freud, nevertheless, does return to the theme of homosexuality repeatedly in his work, indeed almost all of his major case studies are centred on it. His sometime nemesis, Carl Jung, in contrast, barely mentions this central aspect of sexuality at all in his work, and was never able to see it as more than “ a manifestation of sexual immaturity, a fixation or arrest in psychosexual development and, for this reason, disturbed.”

Historically, Freud’s psychoanalysis became much more hard-line when it travelled over to American in the Thirties and Forties. Analytical thinking towards homosexuality hardened into quite brutal homophobia. Aversion therapy, electro-shock therapy and even brain surgery were practiced on homosexuals throughout the 20th century, a horrifying chapter in the history of psychoanalysis that led analyst Rita Frankl to declare in 1995: “We analysts have to admit that we have committed atrocities on our homosexual patients”

Underpinning all of this ‘curative’ work was the theory that homosexuality was a problem arising from faulty parenting or aberrant brain chemistry. Following political and social protest in the 60s and 70s, these attitudes, thankfully, changed. Homosexuality was removed from the DSM as an illness in 1973 {see This American Life: 81 Words} and all major mental health professional bodies in the US and UK now agree that sexual orientation is a given that cannot be changed and that attempts at ‘conversion’ therapy are dangerous and counter-productive.

Nonetheless, a 2009 research paper reported that a significant minority of counsellors and therapists in the UK thought a service should be available for those who wish to change their sexual orientation from gay to straight. And a high-profile investigation of a BACP counsellor, Leslie Pilkington who prayed for her client to free himself from his homosexuality, only proves that there is still a long way to go before this damaging strain of ‘anti-gay‘ therapy dies out.

Perhaps it is useful to examine the fundamental tenet that underlies homophobic thinking: the idea that heterosexuality and reproduction are the ‘normal‘ goal of human life. Bruce Bagemihl’s fascinating romp around animal homosexuality questions this premise from a biological point-of-view. He points out that reproductive heterosexuality as the ‘norm‘ is not born out by the biological facts: “Animal social organization and biology do not revolve exclusively around reproduction and , in many cases, appear to be designed specifically to prevent procreation. Although heterosexual mating can (and frequently does) lead to reproduction, this is often an incidental consequence rather than an overriding ‘goal’.“ Instead Bagemihl posits the idea of biological exuberance, where variety and variation are seen as the goal of life’s ‘energy expenditure’: “Earth’s profusion simply will not be ‘contained’ within procreation… Lives of intense briefness or sustained incandescence – whether procreative or just creative – each is fuelled by the generosity of existence.”

Shifting the fundamental value we put on hetero- and homo-sexuality can be an important part of working with homophobia. Of course, as gay men and women, we shouldn’t feel the need to justify our orientation by biological comparison (there is much in the human realm that is ‘unnatural’ in the animal kingdom – law and culture, for example). But an understanding of some of the ideas that underpin homophobia can be enlightening.

Theoretical considerations 2: homophobia as a problem

Since the pioneering work of gay activists in the 1970s the theoretical underpinnings of therapy with gay clients has shifted away from the notion of homosexuality as a problem towards ways of supporting clients who have grown up gay in a society that stigmatized and silenced them. In short, the problem has become homophobia rather than homosexuality.

Dominic Davies, the pioneer of ‘pink’ gay-positive therapy in the UK, says that “it is practically impossible for a lesbian, gay or bisexual person who has grown up in British society not to have internalized society’s negative messages about their sexuality” and Don Wright goes further and compares homophobia to sexual abuse with “deep lasting effects on the bisexual and gay male, undermining his sense of self as a male, and tainting what for him is a natural attraction to his own gender”

Unlike black or Asian children, gay children grow up without the support of a similarly ‘other’ family. Their difference is unseen and unspeakable and the very people who are supposed to support them – their parents – may be actively homophobic or seem to invalidate the very core of their identity. Worse, the gay child internalizes the hatred that it detects all around it and blames itself for its isolation. Religious or social stigma only rocket-fuels this cycle of abuse.

This idea of gays and lesbians reaching adulthood with the scars of invisible abuse is extremely important. If we are, in fact, looking at victims of recurrent trauma over a long period – then there is danger not only of re-traumatization by clumsy therapy but also mis-diagnosis of PTSD-like symptoms.

The American therapist, Joe Kort has written extensively on this subject. He contends that most lesbian and gay clients are de facto survivors of what he calls ‘covert sexual abuse’: “chronic, verbal, emotional, psychological and sometimes sexual assaults against an individual’s gender expression, sexual feelings and behaviours”.

From a straight point of view this might seem extreme and, indeed, most gay clients would also not willingly describe their childhoods as traumatic. Indeed, some were not traumatic. But from our knowledge of abuse, we know that it is comparatively rare for survivors to recognise their childhoods as abusive. Indeed, they often protect the people or organisations that abused them.

This phenomena is variously known as traumatic bonding or the Stockholm Syndrome where the lack of safety during a period of abuse is so pervasive that the victim has no choice but to think well of their abuser and internalise the blame. This is doubly true for gay children – who often internalize the homophobic values not only of their family, but also school, friends and culture.

Kort explains it as “The perfect crime because the perpetrator offends, the victim forgets, and the offender gets away scot-free.” He specifies that our job as therapists is to help these victims realise, after they come out, that their problem lies mainly in what has been done to them and not as a result of who they are.

This way of thinking leads to a radical re-assessment of presenting issues in gay and lesbian clients in therapy.

Take a look, for example, at this list of symptoms arising in adult survivors of child abuse:

– inappropriate sexualised affection – preoccupation with sex – deadening of all feeling to avoid sexual arousal – isolation from others – short-lived relationships – settling for very little – self-abuse, self-injury and suicide

It is, according to Kort, no coincidence that these are also familiar issues within the gay and lesbian population. As noted earlier, lesbian and gay clients have a higher than average incidence of self-harm. Gay men, particularly, are prone to sexual addiction, confuse sex and intimacy and stereotypically have many, short-lived relationships. Both gays and lesbians – especially those still in the closet – may suffer what the write Patrick Carnes calls, ‘sexual anorexia’, “an obsessive state where the physical, mental and emotional task of avoiding sex dominates ones life.”

A homo-ignorant standpoint might view these as symptoms or traits of ‘the homosexual’ , but Kort’s model reveals them to be symptoms of childhood abuse.

It is important to consider that not all human functioning is conditioned by trauma. It would be counter-therapeutic to insist on relating all of a client’s presenting problems to a traumatic childhood. Just as abuse survivors correctly resist being put in a box marked ‘victim’, it does not serve gay and lesbian clients to ascribe their every anxiety or adult behaviour to covert abuse. There, of course, other factors at play.

Kort himself mentions a lesbian client who entered a deep depression after the breakup of a 7-year relationship. She withdrew from the lesbian community and became very bitter. After exploring the possibility of covert sexual abuse and accepting that her warm description of her parents and childhood was not a form of traumatic bonding, Kort concluded that the powerful reaction to the break-up was a delayed expression of the grief she felt around her mother’s death of cancer when she was a child.

Working with gay and lesbian clients in therapy

Without being too theoretically rigid, there are important areas in which we can work with gay and lesbian clients in a non-damaging way.

Perhaps most central is an understanding of the process of ‘coming out’ as a gay or a lesbian. The classic model outlines six stages:

identity confusion: a pre-coming out stage where gayness is hidden or minimized identity comparison: a phase where information is gathered, other gay people are encountered identity tolerance: going out on the scene, often disappointed and critical of what is there identity acceptance: starting to self-identify as gay, have gay friends, come out to friends and family identity pride: exuberant, often teenage-like tribalism. can demonize heterosexuals identity synthesis: can accept heterosexuals and tolerate difference without being judged

Importantly, clients can be in different places on this continuum and behaving in different ways according to the stage. For example, the transition from stage three to four often involves a whole process of grieving the heterosexual privilege one is leaving behind by identifying as gay. For older gay men and women this sometimes involves giving up a straight partner and children or grieving a teenage that never happened. Elizabeth Kubler Ross’ model of grief moving through denial, anger, guilt, depression before coming to acceptance is important here.

Similarly, at stage five, lesbian and gay people might be exhibiting either very narcissistic “now, it’s my time to enjoy myself” behaviours or very partisan and aggressive splitting – ‘I only want gay friends and I don’t trust ‘breeders’”. Not recognizing this as a phase of coming out (typically lasting 2-3 years) might lead clinicians to pathologies what is just a developmental stage.

Other clinical considerations when working with gay clients might include:

therapeutic style: As with survivors of abuse, the ‘blank screen’ style of classic analysis is often counter-therapeutic with gay and lesbian clients integrating the fall-out of covert sexual abuse. The writer Alice Miller names silence as one of the most powerful weapons of child abuse, so a silent therapist might re-traumatize clients. In contrast when a therapist reveals a bit of their lifestory, this can dramatically reduce the client’s sense of alientation.

appreciation of the effect of covert abuse on relating styles: One of the most pernicious aspects of covert abuse for gay children is growing up with a sense of profound insecurity within their own family. The very core of their identity is associated with damnation, disgust, perversion or ostracism. Unwittingly, family members who should be providing loving security provoke hyper-vigilance, suspicion and fear. This often leads to defensive relating styles which are common in gay and lesbian clients and can be confused with Borderline Personality Disorder, especially if it is combined with fundamental insecurities formed in the first years of life.

being homo-avoidant around sex: There is often a surprisingly puritan reluctance to talk about sex with gay and lesbian clients (from both straight and gay therapists). This reluctance only reinforces the client’s discomfort, especially if it is around sexual behaviours that might be draw stigma, like SM practices. A 2004 paper by Michelle Crossley on the practice of unprotected gay sex, ‘barebacking’, had all the instances of the word fucking censored as ‘f**king’ which seems unusually prudish considering the subject matter of the paper (which was heavily criticized for its moralizing tone). Therapists should have a general awareness of gay sex practices but not be afraid to clarify details when appropriate

the opposite polarity to this prudishness is a voyeuristic prurience about the details of gay sexuality. Research into a school class in sexual diversity highlighted straight students who felt they had the right to intimate details about the gay students’ sex lives, a “privileged sense of entitlement to access the stories and bodies of the marginalized”. Insufficient respect for the client’s sexual privacy can often lead gay and lesbians feeling like freak-show exhibits.

not erasing difference: all therapists (gay or straight) can have a tendency to look for communality where none exists. There is a basic human need to find common ground but this can sometimes elide a difference that is crucial to understanding our client’s situation. For example, when a heterosexual therapist tells a lesbian client that ‘a couple is just a couple’ and therefore the same dynamics apply in all relationships, they erase the very salient difference of two women living together rather than a man and a women. The research shows that there are several very significant differences between male-male, male-female and female-female pairings. A 12 year study on 21 gay, 21 lesbian and 42 control heterosexual couples showed that same sex couples are less jealous, more able to weather negativity, much more congruent in discussing sexuality and their sex life, more optimistic. A 2002 study showed that 75% of gay male relationships become non-monogamous after 5 years.

Not foregrounding ‘gay’ material to the detriment of the bigger picure: certain behaviours have become associated with gay stereotypes – gay ‘circuit queens’ indulging in drug and sex orgies; long-term lesbian relationships ending with ‘lesbian bed death’; certain visible presentations like lesbians having short hair and no make up; gay men being promiscuous and into ‘leather’. The tendency is to latch on to these behaviours as ‘gay’ and not look behind at the wider picture. I had a client at the Terence Higgins Trust where I work, who grew up in a suburban Scottish town. To escape the violent and dramatic rows his parents would have during his childhood, he would disappear for hours and sit in the public toilets in the centre of the town. Familiar as I was with the gay practice of ‘cottaging’, I resisted the idea that this was simply his ‘gay gene’ coming to the fore – as if his gayness predestined him to such behaviour. Was it his gayness that pulled him there or rather his family who pushed him?

Mislabelling different as dysfunctional: the gay and lesbian community has over the years used its marginal status to explore and validate other modes of co-habitation and sexual expression. The philosopher Michel Foucault in his later writing spoke of gay men seeking to “actively develop alternative moral frame works to understand their lives… rather than simply mirroring or mimicking heterosexuality.” Similarly the lesbian theorist Dossie Easton has promoted ‘polyamory’, “a relationship orientation that assumes it is possible and acceptable to love many people and to maintain multiple intimate and sexual relationships”. The fact that these arrangements are not typically found in heterosexual society doesn’t mean they are problematic.


Research has shown that 50% of lesbian and gay clients reported dissatisfaction with their therapy – largely as a result of negative attitudes and lack of understanding towards their sexual orientation. The same survey from the mid-90s showed that none of the sample of counsellors interviewed had received specific training in this area. Writing this piece, I was made aware that currently – seventeen years on – there is still no training institute in the UK that offers specific LGB training in their syllabus.

I hope that I have shown how this lack of informed training definitely impacts our work with lesbian and gay clients – even if we are gay and lesbian ourselves. Despite positive shifts in British society in general, active homophobia is still very much in evidence. A YouGov survey in 2008, showed that one in five gays and lesbians had experienced a hate crime in the previous three years. One year earlier, a Stonewall survey recorded 65% of LGB school children experienced bullying at school for their sexual orientation. Unless we fine-tune ourselves to the impact of this sort of overt and covert abuse in society and its echoes in the therapy room, we are doing our lesbian and gay clients a grave disservice.


Bagemihl, B. (1999) Biological Exuberance: Animal Homosexuality and Natural Diversity, London: Profile

Bartlett, A., Smith, G., King, M. (2009) The response of mental health professionals to clients seeking help to change or redirect same-sex sexual orientation. Division of Mental Health, St George’s Hospital, University of London; Department of Mental Health Sciences, University College Hospital, University of London Bertram, C. C. and Massey, S. G. (2007) ‘Queering dialogue: Safety and Discomfort in a Lesbian, Gay, Bisexual and Transgender Psychology Course’, Lesbian & Gay Psychology Review 8(2): 127-40.

Carnes, P. (1997) Sexual Anorexia: Overcoming Sexual Self-Hatred. Center City, MN: Hazelden

Cass, V. C. (1979) “Homosexual identity formation: A theoretical model” Journal of Homosexuality, 4, pp 219-235

Crossley, M. (2004) “Making sense of barebacking: Gay men’s narratives, unsafe sex and the resistance habitus.” British Journal of Social Psychology, 43(2), 225-244

Davies, D & Neil, C. eds., (1997) Pink Therapy: a guide for counsellors and therapists working with lesbian, gay and bisexual clients. Maidenhead: OUP

Dean, T. & Lane, C. eds., (2001) Homosexuality & Psychoanalysis. Chicago: University of Chicago Press

Dick, S. (2008) Homophobic hate crime:The Gay British Crime Survey 2008 London: Stonewall Retrieved 9th March 2011 from

Dollimore, J (1991) Sexual Dissidence. Oxford: OUP

Domenici, T. & Lesser R. C. eds (1995) Disorientating Sexuality. London: Routledge

Easton, D & Liszt, C.A. (1997) The Ethical Slut, California, US: Greenery Press

Freud, S. (1905) “Three Essays on Sexuality” In Standard Edition vol 7, translated and edited Strachey, J. London: Hogarth Press

Foucault, M. (1996) Foucault Live: Collected Interviews. 1961-1984. New York: Semiotexte

Gonsiorek, J.C and Weinrich, J.D. (1991) Homosexuality: Research Implications for Public Policy. Newbury Park, CA: Sage Publications

Gottman J.M, Levenson, R.W. et al. (2003), “Correlates of Gay and Lesbian Couples’ Relationship Satisfaction and Relationship Dissolution” in Journal of Homosexuality, Vol. 45(1) Hopcke, R.(1989) Jung, Jungians and Homosexuality. Boston MA: Shambala

Hunt, R. & Jensen, J. (2007) The School Report: The experiences of young gay people in Britain’s schools Retrieved 9th March 2011 from

Jivani, A (1997) It’s Not Unusual: A history of Gay and Lesbian Britain in the 20th Century. London: Michael O Mara

King. M, et al (2008) Mental disorders, suicide, and deliberate self harm in lesbian, gay and bisexual people:a systematic review. London: National Institute for Mental Health in England

Kort, J. (2008) Gay Affirmative Therapy for the Straight Clinician. New York. Norton Press

McFarlane F (1998) Diagnosis: Homophobic: the experiences of lesbians, gay men and bisexuals in mental health services. London:PACE

Mitchell, J. & Rose, J. (1982) Feminine Sexuality: Jacques Lacan and the école freudienne. Basingstoke: Macmillan

Mohr, J. J., & Fassinger, R. E. (1998) Individual differences in lesbian/gay identity: An attachment perspective. Manuscript submitted for publication

Nimmons, D. (2002) The soul beneath the skin: the unseen hearts and habits of gay men. New York: St Martins

Rothschild, B. (2000) The body remembers: The psychophysiology of trauma and trauma treatment. New York: Norton Sanderson, C (2010) Introduction to Counselling Survivors of Interpersonal Trauma. London: Jessica Kingsley Publishers

Terr, L. (1991). Childhood traumas: An outline and overview. American Journal of Psychiatry, 148, 10-20. Verghese, A. (1994) My Own Country. New York: Simon & Shuster

Wright, D. (2000) “Illusions of Intimacy” in Cassese, J. ed. Gay men and chidhood sexual trauma: integrating the shattered self. Binghampton NY: Harrington Park

Zur, O. (2007) Boundaries in Psychotherapy: Ethical and Clinical Explorations. Washington, D.C.: APA Books.

6 views0 comments

Related Posts

See All
bottom of page