The big issue: When gay doesn’t mean happy
Therapy Today, June 2021

It was in 2008 that things really started getting too much for me. Despite being one of the most high-profile gay men in the country – the editor of the UK’s bestselling gay magazine, Attitude – I was drinking too much, trapped in a spiral of low self-esteem and anxiety, always desperately looking for the next relationship in the hope it would fix me.

It wasn’t just brought on by the pressures of the job. My issues had been building and manifesting in complex ways from as early as I can remember. But no partner could or should take on that burden; nothing could shake the feelings of worthlessness, and gradually the looking for relationships evolved into compulsively looking for connection through sex. I started to lose control and yet no one – friends, family, therapist, gay or straight – seemed to have any answers. Nor did gay culture, which didn’t allow any discussion of how the relentless pursuit of hedonism might contribute. Other gay people were doing great, it said. If that was the case, then why wasn’t I?

Eventually I came to realise that I was not alone. Of course, it’s not true for everyone, but a pattern of self-destructiveness seemed startlingly familiar among many LGBT people I have known. Shortly after I came out, one young friend told me, ‘I’m a piece of s***, Matt. I deserve to get HIV.’ Someone I knew through work killed himself. A boss of mine passed out high and drunk in the office one afternoon. A man I’d been on two dates with years before killed himself. A friend I’d known for years was sectioned.

Many others struggled with relationships and compulsive sex. It seemed drugs were omnipresent on the gay scene. At Attitude, I noticed a pattern of staff taking Mondays off. I found one asleep on his desk. Then the gay brother of our advertising manager, someone who worked with us for a while, who had struggled with drink and drugs, took his own life.

Of course, it’s true that today there are more LGBT people than ever with wonderful, fulfilling lives. It’s also true that there are more straight people in the world with these issues than LGBT folk, but multiple studies from across the world show that the LGBT community reports disproportionately high levels of depression, anxiety, addiction, poor body image, self-harm and suicide ideation. Until I wrote a 10-page feature for Attitude in 2010 about the issue, after the publication of the groundbreaking US book The Velvet Rage,¹ and then published my own book, Straight Jacket² in 2016, it was barely discussed. Even now, there is still limited understanding. Meanwhile, we still have to find out what is wrong almost on our own.

Shame and trauma

In my case, I found a gay therapist by a circuitous route. A close friend of mine, who had been struggling all his life with compulsive overeating and bulimia, hit rock bottom and told his GP that he wanted to kill himself. The GP suggested trying Overeaters Anonymous, which was facilitated by a seemingly rare gay therapist, David Smallwood, who I ended up seeing too. Finally, things started to make sense. When I told him my history, he said, ‘Of course you’re screwed up, you’re a gay man.’

He explained that it wasn’t being gay in itself, but growing up in a society that stigmatises and marginalises anyone who is not heterosexual or gender-conforming that leaves a devastating impact. It was a revelation that gave me permission to finally begin to piece together my problems and, crucially, the solutions.

There is a generation of gay men still alive today who were criminalised and imprisoned. Being gay is still illegal in 70 countries and subject to the death penalty in around 11, and thousands of gay people still come to London from across the world for sanctuary. Even in the UK, it’s only in the past 20 years that legal inequalities have begun to significantly improve. And while we can eliminate laws, the shame and trauma inflicted on people over generations are not so easy to erase. Although young people today are growing up in a very different world to that experienced by previous generations, it is still hard to be different.

The root cause of these problems is trauma caused by shame. Many of us learn very early on that not conforming to gender expectations, let alone expressing our sexuality, is met with negativity, shame and sometimes even violence, from families, friends and wider society. For instance, I loved musicals and hated football – something that should not be a big deal but that attracted derision and bullying from those around me at school. When a child is told enough times that they are not OK, eventually they begin to believe and internalise it. And, of course, the stress of living in a prejudiced world as an adult can also take its toll.

From a very early age, I suffered from a severe anxiety disorder – I was never relaxed, always on edge, and as I got older, it got worse. Growing up in the 1980s, in the time so skilfully depicted by Russell T Davies’ recent TV series It’s A Sin, with AIDS raging and a tsunami of tabloid homophobia, I was terrified of what my future would be. When I eventually came out onto the gay scene, drinking for the first time, I realised alcohol took the edge off the anxiety and allowed me to feel like everyone else. Much of gay life has been lived through the safe spaces of bars and clubs, which are of course very ‘wet’ places. A 2021 study from University College London found yet again that lesbian, gay and bisexual people have higher levels of depression (with bisexual people reported as experiencing the highest levels), and are more likely to misuse alcohol than straight people.³

Failed by therapists?

As is so often the case, alcohol progresses to harder substances. Drugs are a common part of the gay male scene and it is in this area that the problem most visibly manifests. In the past 20 years, the use of drugs such as cocaine, ecstasy and marijuana has evolved into far more dangerous substances, such as GHB, mephedrone and crystal meth, often in a sexual setting, which has contributed to an unseen public health crisis. The British crime survey 2013/14 showed that 33% of gay men had used illicit drugs in the previous six months, three times the rate of straight men and the highest rate of any group.⁴ Over the past 10 years or so, there have been many high-profile cases of successful gay men either overdosing or taking their own lives or killing people while under the influence of drugs. These are extreme cases but not as uncommon as they should be.

For years, HIV was regarded as the public health crisis linked to the gay community when, in fact, it is the damaging way we self-medicate the trauma of existing in a society that is not safe for us. David Stuart, substance lead at London’s biggest LGBT sexual health service, 56 Dean Street, says: ‘Recreational drug use, chemsex specifically – drugs used as part of sexual activity – is currently the greatest destroyer of lives among queer communities globally. Despite being wrapped in a deceptively attractive “recreational” package, it is the product of a crucible of converging community issues related to lifestyle and mental health.’

Unfortunately, I don’t believe that the therapeutic community, or society in general for that matter, fully understands this problem exists, let alone the complexities of it. Often there is a well-intentioned presumption that it would be homophobic to consider there might be issues that affect the gay community disproportionately. There is also a lack of understanding of what it means to be gay. At university, I went to see the campus therapist after a family bereavement. She was great but when I wanted to talk about my sexuality, she told me honestly that she didn’t have any experience of gay issues. When the sessions were over, she thanked me for educating her. Similarly, around the age of 30, I saw a therapist through my GP, who told me that people weren’t as prejudiced as they used to be and there wasn’t much else to say about it.

Surprisingly, the reluctance to acknowledge problems is not restricted to straight therapists. Over the years, whenever I had any kind of sexual interaction, I’d go running to the sexual health clinic, convinced I’d contracted HIV, regardless of whether I’d taken any risks. Well-meaning gay counsellors there didn’t know how to help with my anxiety. One said something along the lines of, ‘You’re gay. This is what we do. Enjoy it!’

Meeting the need

I spoke to a number of people about their experience with therapists. Some reported positive experiences, and that they sometimes found it helpful talking to heterosexual therapists who might bring a fresh perspective. But this was not the case for everyone.

One man told me he sometimes felt inhibited. ‘I have thought, on occasion, that the therapist had a lack of understanding of how being gay works and what our collective experience has been. I have sometimes felt uncomfortable in group therapy when straight people have interpreted and responded to what I have said from a less tolerant perspective. This has led me to self-censor sometimes because I didn’t want to get into another lengthy exchange of me telling them that yes, I am fairly miserable, but no, happiness won’t come if I just try harder to be like them.’

A woman I spoke to was referred for a course of CBT through her GP. After three weeks, she had a breakthrough and realised she was a lesbian. ‘I told the therapist about my revelation, at which point she told me to get in touch with an LGBT support group and cancelled all further sessions as, she said, she couldn’t help me. This wasn’t in the 1980s, this was 2011. She was the first person I told, and it almost scared me back into the closet.’

Another gay woman told me she started a relationship with a trans woman and that the therapist ‘was so fascinated by my partner’s genitals and experiences I had to stop the session, and remind her I was the client, not my partner’.

Knowledge gap

The knowledge gap seems to start with training. Therapist Josh Hogan says the ‘diversity’ module on his course was mainly focused on race and ethnicity. ‘We were asked to reflect on our differences and how this would affect us in the therapeutic relationship, but there was no specific guidance around working with LGBT clients,’ he says.

Jane Czyzselska, a therapist who is the former editor of the lesbian magazine Diva, agrees: ‘There’s a general lack of awareness of the possible lived experiences of discrimination of LGBTIQ+ clients and of the power dynamic between cisgender, heterosexual therapists and clients with non-normative sexualities or gender expansiveness,’ she says. ‘This can sometimes mean the onus is on the client to educate the therapist, which can feel like both a burden and a block to deep work around these issues.’

Simon Marks, a therapist who worked at the UK’s only LGBT-specific drug and alcohol service, Antidote, and now specialises in working with gay men and addiction, agrees: ‘The lack of training means that qualifying therapists are ill-equipped to recognise the unconscious trauma that their LGBT clients come into the room with. I hear many disturbing stories of therapists judging their clients. One gay man was told it was immoral to use Grindr [a popular hook-up app] and a trans woman was condemned for their open relationship. A client who goes on a three-day drug binge and has sex with multiple partners over a weekend may be shocking to some therapists, but clients need to be able to express their reality in a sex-positive and safe environment that won’t compound their shame.’

Relationships and boundaries

Specialist LGBT counselling services such as Spectra, Pink Therapy and London Friend, home to Antidote, continue to receive a high number of referrals, and for many services, such as Antidote, funding falls short of the demand. There are also complications that can arise from the different perspectives that LGBT therapists themselves may bring to recovery. Some LGBT people want to live less ‘heteronormative’ lives; others do not. There are conflicting opinions within the LGBT community about what healthy relationships and boundaries look like and it is hard for therapists to understand the complexities and options. These problems are widespread and have only recently been addressed. Gay therapists, like straight ones, may not have adequately looked at their own issues. A friend told me his worst experience was in a group facilitated by a gay male therapist ‘who was more conservatively prescriptive than any of the other therapists I have had’.

Both Czyzselska and Marks believe that it can be helpful if the therapist is open about their own sexuality and experience. ‘Obviously, it is up to each therapist to decide what they’re comfortable with regarding self-disclosure of sexuality,’ Czyzselska says, ‘but I wonder how useful it is to withhold this information when asked. Not to do so seems to centre heterosexuality in the consulting room. With sensitive handling, heterosexual therapists can discuss fruitfully with queer clients why they might need to know, but sometimes it can entrench the queer client’s sense of otherness.’

One of the key problems for LGBT people, especially those living outside big cities, is the difficulty of being able to easily connect with people with the same experience. Sometimes when they do, because that community is made up of many traumatised people, often drinking and partying, it can sometimes not be the most welcoming place. The need for authentic connection is vitally important. For some of the men who have attended A Change of Scene, a monthly discussion group for gay and bi men facilitated by Simon Marks, it’s their first experience of sitting with a group of other gay men and discussing their lives, even though they have been out for 20 or 30 years. Marks also runs group therapy for his clients, which he believes can particularly help gay and bi men connect. He believes one upside of the pandemic may be that more support has become available online. ‘A Change of Scene, as well as many 12-step LGBT meetings, are now being held on Zoom,’ he says, ‘which means people from across the country can access them who might not have been able to before. I hope this continues when the pandemic is over.’

It’s clear that there is still work to be done for the LGBT community to feel comfortable in therapy – and also for therapists to understand the complexities of working with LGBT people. The good news is that there are signs of positive change. Pink Therapy has a database of therapists of all sexualities and gender identities who work with gender and sexual diversity clients across the LGBT spectrum from a non-judgmental standpoint. BACP has published a Good Practice across the Counselling Professions resource for members, Gender, Sexual and Relationship Diversity.⁵

One man told me about his positive experience of working with a straight counsellor. ‘I’ve spoken in great detail about the specific challenges that gay men may face, as well as my other intersections, such as living with HIV and living in a rural area. She has followed my lead, developed a professional awareness of these issues and responded in an attuned and empathic way. It’s almost become her niche now.’

Pride Month is celebrated throughout June in the UK. It’s a time of celebration of LGBT people’s fight for our rights over the years and it’s especially meaningful for people who may have just come out after years of hiding who they are. But it’s also important that we really do understand the damage done to LGBT people by society, and begin to unpack it and heal it. Only then can we really celebrate Pride with authenticity. Therapists have a key part to play, a far more substantial one than just displaying a rainbow flag in a window.