Psychotherapeutic Work with HIV Infected Gay Men
A View from Self Psychology on Recent HIV Infections


Nowadays the massive loss of beloved friends because of AIDS is for many gay men leading to an unbearable survival experience. Meanwhile one of the main problems in the gay community in the late nineties is the fact that new HIV infections still continue to occur. Despite prevention campaigns, through which a lot of information about safe sex is available on a cognitive level, the transmission of the virus goes on. The Australian psychologist Ron Gold stated in a paper recently, that contrary to what we would like to believe there is no safe sex culture among gay men, and that the incidence of unsafe behaviour remains disturbingly high (Gold 1994). He also illustrated how difficult it can be for gay men to discuss this subject and to admit a slip-up.
The pressure on the gay community to behave safely, the obvious appeal towards gay men to use condoms, seems to me not so self-evidently effective in light of the deficits which many gay men suffered during their childhoods. In fact, the obviousness of the appeal to the gay community is not natural at all. To quote Walt Odets (1994): "The idea that gay men would readily adapt to condoms ( ... ) is rooted in bomophobia ( ... ). In a broader sense bomophobia has generated the expectation that gay men be better, more compliant, more motivated, and more competent in this epidemic then any other population would have been expected to be. "
I want to join Golds and Odets statements and further elaborate this problem for the practitioner in the consulting room who is confronted with unsafe sex behaviour. How can we understand these risks in an empathic way? I will try to give an explanation for the fact that gay men risk their lives through unsafe sex behaviour from the view of self psychology. Maybe this view can in the first place stimulate the communication about those unsafe sexual encounters. In the second place I hope to illustrate how to deal with this issue in a psychotherapeutic setting, so clients become able to support themselves and can discover the feelings of there true self. The dominant transference reactions of clients, - who practice unsafe sex -towards their therapist, reveal important clues about the self esteem.
First some short remarks about some central concepts in self psychology, before presenting some vignettes to illustrate the therapeutical appraoch.


The view of self psychology can give us an explanation for this, on first sight incredible, risky behaviour of gay men. Early injuries of the self during the pre-coming out period, will be related to actual unsafe sex behaviour. Both aggressive feelings towards earlier often unaccessible significant others, as well as deprived desires for merging with earlier love-objects, will be explored. I will focus on the functional strategies (or transferences in psychotherapy) of idealizing other men, longing for being mirrored by them, and the wish to find alter egos or supportive twinship objects, which are originally described in Kohut's self psychology (Kohut 1972). Idealizing, mirroring and looking for twinship are potential strategies for individuals to construct a coherent self. Also in a working alliance between therapist and client, the preference of those strategies become manifest through so called transference reactions; because of earlier deficits or deprivations there can rise a strong desire to be confirmed, even if that implies risk taking behaviour. As such, they can be analyzed and become useful in the interpretation of risky behaviour. I will illustrate the view of self psychology by presenting and analyzing three recent cases of HIV infection from my practice.
You should keep in mind that I am not talking about just some exceptions of recent HIV infections, but these cases in my counselling practice are adding up to dozens in the course of the years.
Looking at these vignettes, the question arises why these gay men are behaving unsafely, what could be their underlying motives or hidden agendas, and why they didn't listen to their inner voice? All three of them were well informed about safe sex rules. Nevertheless, this cognitive knowledge was insufficient to prevent risky behaviour. I will try to give an explanation of these inconsistencies, that simultaneously reveals important psychological conflicts gay men have to solve. These conflicts can be reinforced in the AIDS area. Even in the so called gay mecca of Amsterdam. Let me elaborate the three cases.

Andy: A masochistic scenario

The first case is about Andy, a truckdriver who is 30 years old. He asked for psychological help because he suffered from depressive episodes since his recent seropositive test result. For a couple of years he lead a wild sex life and through slightly exhibitionistic behaviour in gay bars, was out to be seduced by virile men. He was well informed about safe sex rules, but nonetheless he had unprotected anal intercourse on several occasions in bars in saunas and in his own bedroom. He did not understand why he was taking these risks. Afterwards he mostly felt depressed which he tried to combat by drinking. After a silence in one of the first sessions he blurted out: "You know, probably I did commit long term suicide".
In the first case self-destruction and longing for admiration are both at the same time present and can result in unsafe sex.


In the case of Andy it became clear in the course of the therapy that he had suffered a lot from humiliations since his childhood. He had not been able to defend himself against these indignities and had felt deep rejections from both parents as well as from his brothers. As a little boy he was punished physically many times mainly by his father who beat him up, for instance, because he had poor marks on his school report card. His first vague feelings of being different than other boys, and his later more explicit homosexual feelings, had never been mirrored or were never affirmed by his parents or brothers, or peers. This rejection went on until recently, when his brother married. Andy appeared on the wedding together with his partner at that time. His brother reacted furiously and demanded the partner to leave. So instead of being affirmed, Andy was rejected and humiliated. Ultimately, he got the feeling of being a bad boy: good for nothing.


He could not express his aggression towards the members of his family, so finally directed his tremendous rage against himself. His slogan became: "If I am a bad boy who is good for nothing, I will prove that everything I do will fail". He created self-destructive scenarios, which included expressing his aggression passively. By playing the bad guy he not only punished himself, but he semi unconsciously knew that he was provoking his parents and, later on, all kinds of parental and peer objects. But: and this is a main point, by being provocative, he could at least get attention. During his childhood, for instance, this worked with his father. By developing this destructive scenario he kept away his true self
The unsafe sex behaviour of Andy has to be understood as part of the self-destructive, or masochistic scenario, directed towards himself and others, hiding diverse inconsistent motives. The internalized homophobic feelings lead to a desire to punish the bad boy, and to kill himself at the end by committing suicide, Andy did work out his slogan of being good for nothing very literally. This however is not the complete explanation of his risky behaviour.


The mistreated Self of this man was expressed through behaving unsafely or taking big risks in seeking affirmation. Andy resorted to seduction by going to gay bars scantily dressed, playing with an erotic appeal. He built up a certain reputation. He felt the admiration for his body, for his cock, and enjoyed the glances in the eyes of admirers and the fondling of his breast by potential sex partners. After so many humiliations, he felt mirrored through the gleam in the eyes of other men. In his sexual encounters he could merge with idealized virile men.
On one hand, he manifested his self-hate through committing suicide by infecting himself with the deadly virus, and expressed his murderous rage by eventually infecting the one he loved. On the other hand, there was a tremendous desire to merge with idealized men, to experience sameness and alikeness, and to feel affirmation by mirroring. This merging desire seemed only imaginable in a masochistic way, which here is not just a sexual game any more, but has penetrated all the interactions with significant others.
The latest unsafe sex contact happened in a sauna, and the explanation Andy gave afterwards was: "I saw in his eyes that this boy wanted to be fucked right away at that moment by me, and as condoms were not available, he wanted it without. With a begging look he made clear to me what to do. I couldn't resist at that moment and the sexual act overwhelmed me". The three strategies of being mirrored, idealizing another boy, and experiencing twinship come here together in a raging passion out of control.

Transferenc reactions towards the therapist

Because Andy maintained a passive -aggressive posture, I explained to him that he probably would unconsciously undermine the therapy, by staying away or by other tactics of acting out behaviour. My prediction about acting out became true. After a working alliance had developed, Andy tried to provoke me several times. He showed up provocating me by dressing very sexy in the sessions. He stayed away several times without leaving a message. The ultimate provocation was during about the 15th session when he confronted me with the threat that he probably would commit suicide within a week, and that he was most likely unable to prevent himself. So an admission in a crisis centre seemed indicated. After this, the threat of suicide passed, and I got the feeling that he could trust me more deeply. He had felt himself taken seriously, protected and rewarded.
In a way Andy tested the working alliance with his therapist: was he taken seriously and would he get the protection a child wants from his idealized parents. Since he got the prove of being protected he felt himself accepted and not again rejected. After this experience he could further develop an indealizing transference towards me as a parent-object, and undergo a corrective emotional experience. He did not stay away any more and became angry when I had to cancel a session, because of illness.
Because Andy knew I was gay he also developed mirroring and twinship transferences towards me. He felt the affirmation as a gay person, and support to his own gay life. He could experience an unconditional positive regard and a supportive atmosphere in which he could more easily talk about his sexual phantasies. He was able to use the working alliance to share his proud feelings of being admired, at the same time feeling mirrored by me as a gay therapist. What the gay aspect of this alliance concerns, he did find in the working alliance also a realistic twinship obect. We both belonged to the gay community, which generated the feeling of sameness.


The humiliations from which Andy suffered can be generalized to a broader population of gay people. The self awareness of many gay men was damaged during childhood, maybe not in such a brutal way by physical violence, but in more subtle ways. Denial and rejection of deviant sexuality by parents and peers can easily result in a fragmented self of future gay boys before their coming out. Probably gay men have little or no experience of affirmation of their homosexual feelings especially from their father or their male peers.
During therapy the transferences of idealizing, mirroring and searching twinship bonds became usefull to correct earlier deficits during childhood, the acting in behaviour diminished, and the fragmented self could be partly restored.

Ron: A dependant partner scenario

The second case is about Ron, a student who is 29 years old, which illustrates a relationship oriented interpersonal problem.
He was seized by panic when he was waiting for his test result. He feared an unfavourable outcome and indeed appeared to be seropositive. He could not understand why he was behaving unsafely and felt very ashamed about it. Ron told me he had unprotected anal intercourse even after his partner told him he was seropositive. They had condoms at their disposal while having sex, but neither took the initiative to use them. So the rubbers lay untouched on the bedside table. They were not able to communicate about this issue. When Ron was abandoned by his partner he realized what kind of risks he had taken.
In this second case we will see that longing of exclusiveness and optimal dedication to an ideal partner can lead to risky behaviour.

Exclusive unsafe

The case of Ron shows how difficult it is to keep sexual behaviour safe in a relationship. Ron is astonished about his risky behaviour and feels ashamed talking about it. In later sessions, he disclosed that he had several incidental sexual contacts which were always safe. Only in relationships he took so many risks. He and his first partner had often unprotected anal intercourse, during which Ron took both, the passive and the active role. They never talked about safe sex and never used condoms together, even though at some moments he was aware that there was something wrong about their sexual behaviour. Then one time he brought up the subject. His partner brushed aside his complaints, pretending that he was seronegative and nothing was wrong. He gave him the feeling it was annoying to talk about such a thing. Ron remembers that he went along with his partner at that time and did not want to lose him.

Playing safe

In his second relationship unprotected anal intercourse was practised, again without talking about it, and again with a vague awareness that he was behaving wrongly. Ron explained to me that he and his partner bought condoms together but did not use them. Even before having sex they put the condoms into the bedroom and layed them ready on the night stand. While having sex, they ultimately had unprotected anal intercourse. Then the condoms were put back into the bathroom without a word. After this happened a couple of times, Ron thought that it was too late now to use condoms the next time. So it did not matter anymore. They nevertheless played having safe sex, bringing the condoms in the bedroom without using them.
Except the idea that they did wrong, Ron explains to me that having anal intercourse in an unprotected way created a special feeling, because both of the partners knew that they had unsafe sex only together, not with anybody else.

Neglected Self

In later sessions, Ron disclosed his earlier sceptical attitude towards his homosexuality. His father had predicted to his mother that their son would become gay, because Ron was a sissy boy during his childhood. He felt himself neglected by his father: the man he idealized disliked him instead of being affirmative.
When he himself became aware of being different because of his sexual orientation he felt very ashamed and hid these gay feelings from parents and peers until he moved out of house. He started studying medicine because that was his fathers preference and discovered that some of his fellow students were gay. Nevertheless he found it difficult to talk about it, he broke off his study and moved to Amsterdam where he threw himself into gay life.

Depended attitude

It became apparent during therapy that Ron had a lot of superficial contacts in the gay scene and that he exhibits profound dependency upon significant others, almost afraid of not being accepted. The awareness of being different, of being gay, from earlier childhood on, became a barrier between himself and other boys. As I already mentioned, his father foresaw his homosexual orientation, but Ron never felt mirrored by him, never felt affirmed in his different sexual preference. There was no intimacy between them, and he experienced his father as a cold per. son; always keeping distance. So Ron himself did not become a good talker, was afraid of rejection by significant others, was inclined to hide his homosexuality, and was at the same time longing very strongly to become affirmed by men, to merge totaly with the one who had always been so far away. Talking about using condoms was too risky, fraught with fears of rejection by the one he had longed for so deeply.
Remarkable in this context is that Ron continued to have unsafe sex after his partner disclosed that he was tested seropositive. At first Ron thought it would not matter any more, the damage was already done. But when he discovered that the partner was tested because he had another lover, he awoke from a nightmare. Remember: he was shocked even more by the divorce than by his own HIV infection.

Transference reactions towards the therapist

Ron was at the start of the therapy very ashamed and expected that I as therapist would find him stupid, and a loser, which in fact were projections of his own internalized negative feelings. Also he expected me te react to him as parent-objects in the past, which meant that he was not supported and mirrored. As a gay boy he felt deprived of twinship figures.
Now in this working alliance with a gay therapist, after these negative feelings of rejection were explored, he was able to develop more positive feelings about himself during the sessions. For Ron this also implicated to accept his homosexuality and a gay lifestyle, and to strengthen his weak self. He several times met me in gay bars I frequented, and in the first sessions after this had happened he told me that he felt ashamed. These feelings were explored in the next sessions, as well as the influence of these feelings on his attitude towards me as his (gay) therapist. In later sessions when we discussed this subject he experienced sameness with me as a realistic (gay) person. He also felt himself accepted by me, and significant others, as such a person, instead of being rejected. Later on Ron joint a self help group of younger seropositive gay boys, and in this group he did feel strong mirroring reactions and twinship bonds of other group members, and vice versa. This was for Ron the end of being isolated as a gay seropositive person.


As already concluded, many gay men will have experienced the absence of mirroring of father-objects and the absence of affirmative male idols during childhood and adolescence. After having accepted a gay identity, and after the experience of being affirmed in the homosexual preference, the desire to merge with a partner can become very strong in gay men, because they were so long deprived during childhood and adolescence of intermale intimate feelings. Experiencing sameness in a twinship bond, feeling protected through an idealized partner, or being affirmared and mirrored by him, can result in denials or repressions of the risks of unprotected intercourse. As I illustrated communication about the dangers of this merging encounter is avoided. The overestimated self does not want to lose its grandiosity, and prefers to keep the privileged position in the meanwhile achieved paradise. Couples who are unexpected test positive, can react with massive denials and continue as a result with unsafe sex (Mattison and McWhirter 1994).
As illustrated Ron was in the beginning declined to repeat his negative transference reactions towards me as his therapist. After working through these negative feelings he could develop and admit more positive feelings and experience me as a supportive parent figure, as well as a equal person (twinship figure) in a gay community.

Sam: A coming out in the nineties scenario

The third case is about Sam, a student in philosophy who is 22 years old. He came to therapy because he tested seropositive. He was an AIDS educator and interviewed gay men, about their possibly unsafe sex experiences. Meanwhile, he was having sex in darkrooms and sometimes he had unprotected anal intercourse, somehow unable to keep sex consistently safe. He intensely enjoyed the anal sex encounters, but at the same time he found it difficult to introduce safe sex rules with his lovers.
The third case shows how anal sex can be attractive on one side, but when not being communicable on the other side it can result in unsafe behaviour.
The case of Sam reveals how difficult it can be to experiment with gay sex in the coming out period, and how safe sex can be taken for granted, because the intense enjoyment of anal sex can be overwhelming. He feared that talking about condoms was disrupting the excitement.

The rejecting father

Something more about Sam's background: At the age of eleven he became aware of his homosexuality when he watched an AIDS programme on TV. Earlier when he was eight years old, he had sex with his older brother and they were found by their mother while looking at pornographic pictures. Later that evening they received a sharp reprimand from father, with whom Sam had a bad relationship. When he was thirteen years old his mother found a letter Sam had written to a gay personal ad. His parents and sister didn't speak to him for a week. The subject of homosexuality was never brought up in the family. Sam also decided to hide his sexual feelings away. He constantly got the impression that he failed in the eyes of his father, because he had trouble with the work on the farm. He had numerous conflicts with him, and when they quarrelled he often cried. Because his father reacted furiously to his crying, he decided at a certain moment, never to cry again: to keep his emotions suppressed.

Experimenting unsafe

In 1991 when he was 19 years old, he moved to Amsterdam where he started his studies at the university. From the beginning, he went to gay pornoshops and cinemas where he experimented with sex. There he had unprotected anal intercourse several times. He was not able to keep it safe, to introduce condoms, because everything happens so quickly, he told me. Later he added that he did not know how to introduce this subject, but also that it would disrupt the enjoyment. Afterwards he didn't dare talk with anyone about his difficulties with safe sex behaviour.

A jump forwards

He signed on as a volunteer in AIDS education and participated in different educational projects, which also expanded his introduction to gay life in Amsterdam. Now he had a special position which gave him the opportunity to talk with other gay men about their sexual experiences in the neutralizing safe sex language. Without, however, connecting this cognitive language with his own feelings, which he did split off. He was not able to share and communicate his feelings during his sexual contacts. When a sexual encounter developed into a more serious contact, he broke it off. He did not yet want to attach himself, he told me, because he was too young and wanted to lead a free and easy life.
Because he hardly underwent the experience of being mirrored as a child, and had lacked equivalent twinship bonds as well as idealized male objects, Sam now was searching for an overkill of reinforcement. It seems to me he could get those experiences by making a jump forward, by becoming an AIDS educator while he experimented yet in his coming out period.

Anal sex

When he became ill last spring, he feared to be seropositive which was confirmed by an HIV test. He felt very ashamed and could not talk to family or friends about this situation. For that reason, he sought psychological help. Later on in the sessions, it became clear how ambivalent his attitude was about unprotected anal sex. On the one hand, it was not an easy subject to talk about. On the other hand, this renewed taboo became a fascination exactly because of its prohibited character. Forbidden fruit always tastes better (Van Kerkhof 1995).
So for Sam, who had a lot of negative experiences around disclosing homosexual feelings during childhood, it seemed the best strategy to keep his attractive little secret for himself, until he was forced to talk about it as a result of his HIV infection.

Transference reactions towards the therapist

Sam was declined to develop the working alliance into a parent -child relationship, which meant that he would leave a lot of responsibilities to me: legalizing his status; confronting me with his financial problems; complaining about housing problems; (not) making homework for school. It took quite a while before he could develop a more realistic transference reaction to me, in which he could take more responsibility for his own life, so I could give him a more realistic parental protection and support which was more according to his age. In that way he became more an adult and less the complaining child.
The same happened with his desire of being mirrored, which was quite demanding during the first sessions. Also this strong desire was explored, and at the end Sam understood that he was reacting in this way, because he had suffered strong deficits and was hardly affirmed by his parents. He learned to talk with me about sexual feelings and phantasies, his fears of relationships, his difficulties with social contacts in gay life, and taking responsibility. In this way he could develop a twinship bond with someone who not only supported and accepted him in a realistic way, but also with someone who could let him discover what the feeling of sameness is, instead of being different and bad. These experiences could then be carried over to other significant others in Sam's life.


As I already stated: after the coming out as a gay individual, the experience of being affirmed by significant gay partners is an important avenue of mirroring, idealizing and finding twinships. For gay persons who severely suffered from indignations resulting in a fragmented self, the overwhelming feeling of being admired, the desire to merge with an idealized omnipotent partner, and the urge of feeling sameness and belonging to someone, can easily provoke risky behaviour. In the case of Sam we can see how anal sexual encounters can be overwhelming, and how difficult it can be for young gay men to experiment and to disrupt an exciting experience, even if they are informed about safe sex. Sexual encounters imply the emotional state of being out of control. Anal intercourse implies an emotional state of exctasy, which is under a taboo. So how to deal with codes and rules among twinship brothers you never could trust during childhood?
Like the other vignettes the exploration of Sam's transference reactions during the sessions in therapy, was an important way to restore the maltreated self into a more open and proud person.


As demonstrated in the practice of psychotherapy with gay men who are concerned about their unsafe sex behaviour, it can be successful to detect the main strategy the client is using dominantly towards significant other partners, because he was not enough affirmated. Eventually this prevailing strategy, rooted in deprivation, can include high risks. The transference towards the therapist will reveal the dominating strategy: idealizing, mirroring, or looking for twinship bonds. The goal of therapy can be to support clients, to handle this strategy in a safer way, reinforcing reality testing.
A necessary condition however is, that the clients risky behaviour is not moralized, which counsellors should do just as little as with for instance suicidal behaviour. How understandable those hostile feelings in itself are, listening with an open mind will lead to a better understanding, and will at the end hopefully prevent, unsafe sex practice. This open attitude is a precondition for analyzing and interpreting transference reactions from clients. A moralistic stance will probably only result in staying away from the consulting room.


GOLD R. Why we need to rethink AIDS education for gay men. Plencly addres, Second International Conference on AIDS' Impact: Biopsychosocial Aspects of HIV Infection, 7-10 july Brighton, U.K. 1994 KOHUT H. The Analysis of the Self, New York, International Universities Press 1972. In: SHELBY RD. People with HIV and those who help them, New York, The Haworth Press 1995 MATTISON A, MCWHIRTER D. Serodiscordant male couples, In: Social services for gay and lesbian couples, The Haworth Press, Inc., 1994; 83-99 ODFTS W. Aids Education and harm reduction for gay men: psychological approaches for the 21st century, In: AIDS & Public Policy journal, Volume 9, Number 1 VAN KERKHOF MPN et al. Van achteren bezien. Anale seks in her AIDS tijdperk, Amsterdam, Schorerimprint 1995

Sinds 1991 is de Psychologenpraktijk gevestigd in de Voetboogstraat 7 sous, 1012 XK, Amsterdam. Telefoon: 020-6387321; fax: 020-6250877. E-mail:
Created: 11-12-98 Updated: 20-12-03