Abstract: Gay Male therapists often practice in milieus where it is virtually impossible not to have contacts with clients
outside of the therapy room. The necessity of maintaining appropriate boundaries can be strained when client-therapist
contacts occur in situations that are overtly or even potentially sexual. This article addresses professional challenges and
various approaches to these situations while maintaining necessary therapeutic appropriateness.
Almost all discussions of violations of professional boundaries between client and therapist are framed in a heterosexual context. These discussions usually refer to incidents of sexual impropriety between a male therapist and a woman client. A recently publicized and very sensational case involved a woman psychiatrist and a male resident who was her patient who subsequently committed suicide. Gonsiorek (1988) authored a seminal article on sexual exploitation of gay men and lesbians by psychotherapists. Over the years, at conferences and meetings focused on mental health for gay men and lesbians, there have been panels and presentations on issues of practicing in a small community that one is also a part of and socializes in. For sexually active gay men this is an issue that needs immediate and urgent conversation.
(Because my practice is almost exclusively with gay men, and all of my supervisees are gay men, this column is specifically referencing only this client and therapist population. I welcome the comments or an entire column by women therapists and clients, who I am certain will be able to enlighten our readers about the reality of these issues for lesbians and other women, in their roles as social service providers and as clients.)
It is currently fashionable to discuss authenticity in contemporary clinical practice. Because there are specific differences between heterosexual and gay male cultures, these differences need to be addressed in any discussion of authenticity to ensure that it will be relevant to the lives of gay male therapists practicing in any geographic location. An additional concern regarding authenticity is the need of the therapist to express his or her own sexual and social needs within the gay community. For therapy to be effective it has to be a situation where both people can be authentic without the fear of social repercussions as the result of what is discussed between therapist and client. The balance of this note will raise questions and illustrate that finding a balance between the right of the therapist to have a private life and ensuring that the therapist not behave in a manner that negatively impacts the treatment of his patients, is often a difficult road to tread.
The gay community is a small town, even in large cities like New York, San Francisco, and Los Angeles. This makes it imperative for gay male therapists who have large gay practices to expect to run into their clients outside the therapy room. It is imperative that therapists use supervision and consultation with peers to prepare themselves to handle these encounters appropriately and with sensitivity to the needs of clients both outside the consulting room and during the therapeutic hour. In order to be good therapists we have to have rich and satisfying lives outside of work where we enjoy ourselves and play. When clients run into you in public whether you are out with a friend, on a date, with a boyfriend or your partner, this is bound to raise feelings that are rich material for therapeutic exploration. This is especially true if the client has dated, had sex with, or even has any history of social interaction with the person they encounter you with. Living and working in Chelsea, I regularly see patients on the street, in the market and at the gym. Infrequently I have arrived at a dinner party and on one occasion at a weekend house party only to find one of my clients is also a guest. Obviously this affects how completely relaxed I can become, what topics I will discuss, and how personally I will share while at those gatherings.
Recently a patient consulted me to explore beginning treatment. Early in the consultation he told me that he had been working with a colleague of mine for about a year and was generally satisfied with the therapy. That was until the previous Saturday night when he had been out dancing with a date at a local club and observed his therapist shirtless on the dance floor. "I thought that he might be high," the client told me. "I do a little bit of recreational chemicals every once in a while when I go out dancing so that did not bother me. What bugged me was that at least three different times I observed him snorting some kind of drug. But the final straw was that on my way to the bathroom I saw him going into the back room area. Look, I enjoy playing around in that way myself, but it just freaked me out to think that there might be a possibility that in the darkness of a back room I could wind up having sex with my therapist." I nodded empathetically and began to explore all of his feelings.
When he expressed a desire to continue working with me, I encouraged him to honestly discuss all of this with his current therapist before making a final decision on whether or not to end what sounded like an effective therapy. Two weeks later in our first session following the initial visit, he told me that he had followed my advice and told his therapist what he had observed and how it made him feel. How he reported his therapist responded caused him to decide to stop therapy with my colleague. The other therapist had supposedly gotten defensive and insisted upon his right to be at those locations, doing what he wanted as long as it did not affect the way he did therapy. My thoughts that I kept to myself was that it was precisely that how my colleague chose to spend one particular weekend evening was impacting on this client's treatment, or else we would not now be engaged in this conversation.
Knowing and respecting my colleague for several years, I was skeptical of my new patient's report. Figuring that either confirming or refuting the client's story would be an important component of formulating a diagnostic assessment, I asked for and obtained his permission to speak with his former therapist, who verified my patient's report. With me he was contrite, but rationalized his reaction as coming from the fact that he and his long-term partner had recently broken up and he was out in the scene as a single man for the first time in five years. I respected my colleague's honesty with me and did not judge him, but felt badly that he did not handle the discussion with his patient in a more constructive and therapeutic manner.
At a dinner party with several other gay men who were also therapists the conversation got around to cyber cruising the chat rooms. Each of the men described using an anonymous screen name in an effort to mask his true identity. There was a lengthy discussion of whether it was ever appropriate as a therapist working within the gay men's community to send a nude or sexually explicit photo over the Internet. One of the men admitted to sending photos of himself that were full frontal nudes to men he was negotiating a liaison with. I asked him what would have happened if one of the men he was flirting with turned out to be a patient? His response was that he never sends his photo until after he has received the other man's picture, precisely to avoid such a situation. I agreed that waiting to see if the other man was a current or former patient before sending him a photo was cautious and certainly one way to proceed. An interesting conversation then ensued about the potential impact on a client of finding his therapist cruising in a chat room. (A normal part of being in gay chat rooms is sharing sexually explicit fantasies and desires in order to facilitate a rendez vous.) Obviously this is not information that a client would normally have access to about his therapist. We also talked about how, if at all was this different than a client seeing his therapist out in full leather or drag. We tried to dissect what if anything was different about cruising a chat room than cruising a gay bar, gay bath house, or attending a sex party or public sex venue as a therapist with a large gay clientele?
Prior to beginning to date my current partner, one Saturday afternoon I was cruising the chat rooms looking to connect. I chatted with an interesting sounding young man who expressed interest in getting together depending on whether we each liked what we saw when we exchanged pictures. The photo I sent is a professional head shot in which I am wearing a shirt, so I did not think it was risky to have it out there. Upon receiving the other man's picture I let him know that I found him very attractive and asked what he thought of my photo? He responded "Dr. Shernoff, I have always thought you were very hot, but it is just too close so I don't think it will work. Too bad." I politely told him that I of course understood and then corrected him about my not being a "Dr." I was stunned because I had never before laid eyes on this man. To this day I do not know if he was a partner or close friend of one of my patients or if he had just heard me speak at a community forum. But this was a reminder that as a public person and a professional, there is very little anonymity. This was further confirmed when last year I ran into a client of mine in Sydney, Australia, as he was exiting a sex club that I was entering, erroneously thinking that there, half way around the world I would be free from concerns about meeting clients.
The anonymity of the Internet is both a blessing and a source of potential problems. I had referred Byron, one of my clients, and his partner to another colleague for couple counseling. They stopped therapy after the therapist helped them realize that they needed to end their relationship. A few weeks ago Byron (not his real name) was telling me about trying to organize a sex party with men he met over the internet one rainy weekend afternoon. Two men had already arrived when his doorman buzzed him that the third was on the way up. As he opened the door it was the couples therapist he and his late partner had seen for a couple of months. There was a very awkward moment for both until my colleague left.
Clearly some of these problems will not arise if the therapist is partnered and in a monogamous relationship. But what is the single therapist to do when he is out looking to have fun and runs into a client in a situation with blurred boundaries? A supervisee of mine related the following incident. He had been to a sex party a couple of weeks earlier and was just proceeding to play with someone when he happened to glance up and saw one of his patients watching him and simultaneously unzipping his own fly. "I immediately lost my erection, buttoned up, excused myself and went home," he reported as we began to discuss how he should handle this with his patient in their next session. In the subsequent supervision he told me that he had raised the issue by inquiring how his client had felt seeing him at the sex party? His client had been surprised, but also thrilled since he was attracted to his therapist, but knew that they could never become involved. He had thought that this was an appropriate way for him to satisfy his sexual curiosity about his therapist without violating professional boundaries. He also replied that he was surprised because he had assumed that his therapist was partnered and monogamous.
My supervisee and I decided that there were several areas that needed exploration. One topic was included how the client's desire to sexualize the relationship with his therapist, even while claiming to understand the dangers and total inappropriateness of sexual contact between client and therapist, might be similar to how he related to the other men in his life. The therapist also probed why the client thought he was partnered? The client's response was: "You are successful, attractive and not old, so I just figured that you had to be in a relationship. I also thought that since I want a monogamous relationship, that if you were partnered, it had to be sexually exclusive." The client's response to both of these areas of inquiry provided a lot of important material for therapy without the therapist ever feeling the need to deny or validate the client's assumptions about his being single, partnered, monogamous or nonmonogamous.
Quite a few years ago, another one of my supervisees shared the following. On occasion he enjoyed renting sex workers. He had telephoned a "rent boy" whose ad he saw in one of the local gay rags. When the man arrived at his apartment it turned out to be one of his clients who was a medical student. He told his patient "Obviously this is not going to happen," and then gave the young man roundtrip taxi fare telling him that they would of course talk about this at their next session, which turned out to be prior to our next supervision. At their next session my supervisee reported feeling a bit awkward and uncomfortable that he claimed stemmed more from being embarrassed than anything else. He did not report feeling conflicted about paying for sex, just foolish that he had not considered that there was the possibility that he might put himself in such a situation knowing that this client was helping to pay for medical school in this particular manner. Supervision explored what might have been contributing to his carelessness in not asking directly if by chance the man's real name was…., while they were in the midst of making their arrangements. The way the supervisee described the session sounded like it was sound clinically, except for one mistake. He did not charge his client for that session. The client never returned to therapy with this therapist and only called to say that he was stopping treatment. He did not return any phone calls by the therapist so we can only conjecture about the causes of his terminating treatment.
I am by no means trying to say that just because someone is a therapist that he should not go dancing, drink, do drugs, flirt, have public sex, or cruise the Internet. What I am suggesting is that as therapists we always have a responsibility to understand and be prepared for the fact that anytime we encounter a client outside the therapy room it needs to be an interaction that does not damage the fragility of the carefully constructed therapeutic relationship. How the therapist responds to clients outside the therapeutic hour must also fall within the parameters of a broadly defined therapeutic interaction. For instance, if the therapist is tattooed, the client who sees him on the dance floor, beach, or gym locker room, may have a reaction to the body adornment that the therapist must be prepared to handle in a sensitive and professional manner. Each time I run into a client on the beach, at a community event, or social function, I always ask about any feelings that the encounter may have stirred up. If I am shirtless I have to be prepared to field reactions to the fact that I have a pierced nipple.
Ultimately it is up to each individual therapist to decide if pursuing a particular aspect of his life style is worth any potential
negative repercussions in his professional life. I am not suggesting that there should be any one standard of behavior. But I
do believe that each time a client responds to something he or she has observed in our personal life, we need to make a
commitment to not become defensive. An honest discussion with our clients where we openly elicit all of their feelings that
we ourselves may have stirred up, can only improve the therapeutic interaction. This is true whether or not the client elects
to continue in treatment with us. In any case, I encourage my colleagues to create forums where these kinds of issues can be
safely discussed by queer therapists with their peers.
Gonsiorek, J. (1988). Sexual exploitation by psychotherapists: Some observations relevant to Lesbians and Gay men. In M.
Shernoff & W. Scott (Eds.), Sourcebook on Lesbian/Gay health care (Second Edition) (pp. 97-106). Washington, D.C.:
National Lesbian/Gay Health Foundation.
Key Words: Psychotherapy, gay men, homosexuality, boundaries, professional ethics, sexuality, countertransference, supervision