Themes of hiding abound in the developmental narratives of boys who grow up to be gay. Their need to hide is reinforced by the traumatizing public humiliation that ensues from either open expressions of same-sex desire or gender- nonconforming behavior. The experience of being discovered, punished, and humiliated for showing or acting on such feelings or behaviors can lead to hiding activities that persist long after the actual trauma is forgotten. When open expressions of same-sex intimacy are driven underground, clandestine and forbidden sexual activities, highly tinged with interpersonal anxiety, may become a significant mode of relatedness. This papers offers a clinical psychoanalytic approach for working with gay men that distinguishes the concept of sexual compulsion from that of sexual identity. Harry Stack Sullivan’s conceptualization of dissociative defenses is useful in clinically understanding and therapeutically working with gay men in general, and with sexually compulsive gay men in particular. This approach allows the sexual identities of gay men to be respected while addressing the compulsive behaviors that some of them find so troubling.

Jack Drescher is a psychiatrist and psychoanalyst in private practice in New York City, a Clinical Professor of Psychiatry at Columbia University and a Faculty Member of their Psychoanalytic program and their Division of Gender, Sexuality and Health. He is an adjunct Professor at the New York University Postdoctoral Program in Psychotherapy and Psychoanalysis and a Training and Supervising Analyst at the William Alanson White Institute. He also serves as a consultant to IPA’s Committee on Gender and Sexual Diversity.

Reed GM, *Drescher J, Krueger RB, Atalla E, Cochran SD, First MB, Cohen-Kettenis PT, et al. Revising the ICD-10 Mental and Behavioural Disorders classification of sexuality and gender identity based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry, 15:205–221.                                                                   

Drescher J, Schwartz A, Casoy, F, McIntosh CA, Hurley, B, Ashely K, et al: The growing regulation of conversion therapy. Journal of Medical Regulation, 102(2):7-12.

Drescher J, Cohen-Kettenis PT, Reed GM: Gender incongruence of childhood in the ICD-11: Controversies, proposal, and rationale. Lancet Psychiatry, 2016, 3:297-304.

Drescher J, Cohen-Kettenis PT, Winter S: Minding the body: Situating gender diagnoses in the ICD-11. International Review of Psychiatry, 2012, 24(6): 568–577.

Drescher J: Queer diagnoses: Parallels and contrasts in the history of homosexuality, gender variance, and the Diagnostic and Statistical Manual (DSM). Archives of Sexual Behavior, 2010, 39:427–460.