Joseph M. Amico, M.Div., C.A.S.

Gays experience something like a second adolescence as part o f
the coming out process. During that time, behavior could be confused
with sexually compulsive behavior. Gays also experience
shame due to heterosexism. Coping mechanisms for shame can
include the use of mood altering substances as well as compulsive
sexual behavior. The Sexual Behavior Assessment Tool (SBAT) is
a way to assess the sexual behavior and delineate sexual compulsivity
from coming out behavior. Case examples are given in this
article to demonstrate the difference between coming out issues
and sexually compulsive behavior in gay men.

INTRODUCTION
The key factor in assessing the gay, lesbian, or bisexual client for
sexual compulsivity is understanding the stages of the coming out process.
Behavior, commonly understood as sexual compulsivity, may actually be
a phase in the client’s process of coming out to him or herself. Before
concluding that a gay, lesbian or bisexual client is sexually compulsive,
determine the client’s developmental stage of coming out. The “coming out
process” could be compared to a second adolescence. It is a developmental
stage but can happen during any age of the chronological process. Two
such theoretical models were developed by Cass (1979) and Coleman
(1981/1982).

Vivienne Cass (1979) identified six stages of the coming out process in
a theoretical model. This model was used at Pride Institute, a treatment center
exclusively for chemically dependent gay/lesbian/bisexual/transgender clients, in
assigning coming out levels to each client for the purpose of developing a sexual
behavior instrument. The six stages are Identity Confusion, Identity Comparison,
Identity Tolerance, Identity Acceptance, Identity Pride, and Identity Synthesis.
Eli Coleman (1981/1982) developed a similar developmental model using
five stages. The five stages are pre-coming out, coming out, exploration, first
relationships, and identity integration.

There are two purposes in writing this article. The first is to assist the
clinician in differentiating between sexual compulsive behavior in gay males
and behavior common to coming out issues. The second purpose is to assist
the clinician in understanding the role sex addiction plays in some chemically
dependent gay men.

Methods
Through comprehensive assessment tools conducted on intake we discovered that
forty percent of our clients reported some type of compulsive sexual behavior.
Originally, we used an instrument known as the Gay Sexual Addiction Screening
Test (SAST). We quickly determined that this instrument was geared more to gay
male behavior and not sensitive to the issues surrounding lesbians and bisexuals.

A task force was developed to create a new comprehensive instrument.
During the process, primary counselors assigned a coming out level to each
client as they conducted interviews for our comprehensive psychosocial. During
the interview, clients gave a full sexual history and answered the following
questions regarding their sexual orientation:
1. Who in your family, friends and workplace knows of your sexual
orientation?
2. What is the level of acceptance by family of your sexual orientation?
3. If you could change your sexual orientation, would you? 4. How
do you feel about your sexual orientation?
Based upon the answers of these questions, counselors then assigned a
level for that person’s stage of coming out.
Counselors were provided a sheet with a synopsis of Cass’s (1979) six
stages of homosexual identity formation. One hundred thirty-seven clients were
surveyed using this process. Over two thirds of our clients were assessed
Chemically Dependent Gay Men 293
as being in the first three stages of identity formation (Identity Confusion,
Identity Comparison, and Identity Tolerance).

In order to do a more adequate assessment, we have asked the following
questions as part of conducting a sexual history:
1. How old were you when you had your first sexual experience? How
old was the other person?
2. Describe your first sexual experience with an adult.
It is not uncommon to hear a response like age 16 with another 16- or 17year-old
in answer to the first question followed by a story where the client was much
younger in the answer to Question 2. Question 2 often involves stories with
family members, teachers, clergy, counselors, Boy Scout leaders, neighbors,
babysitters or other adults in “nurturing” positions.

The correlation of chemical use and these sexual histories is also important
for the assessment. All of our clients complete a Chemical Use History in three
stages. It is not unusual to see marked increase in chemical abuse at the onset of
coming out issues and abuse issues described above. For the person exhibiting
compulsive sexual behavior we have developed the following tools:
1. The primary counselor completes the psychosocial including the
sexual history and sexual orientation issues.
2. All clients attend instructional workshops on “What Is Abuse” and on
“Sexual Compulsivity and Addiction.”
3. A support group for those who identify sexual compulsivity is offered to
discuss such issues in confidence with peers and a trained facilitator.
If a client or the primary counselor questions sexual compulsive behavior,
the SBAT (Sexual Behavior Assessment Tool) is administered. The SBAT is
the instrument we developed after our clinical study using the Cass model and
looking at the behavior of our trial population. Once the client completes the
SBAT, the primary counselor or facilitator of the Sexual Compulsivity Support
Group consults with the client regarding his/her answers. If sexual compulsivity is
deemed an issue, the client completes a Sex and Love History, which is presented
in the Sexual Compulsivity Support Group. If this issue continues to be assessed
as a barrier to recovery, the client completes a First Step for sexual compulsivity
followed by relapse assignments on dual addictions. Prior to discharge, a client
is expected to develop a definition of abstinence and boundaries for sexual
behavior.
Results and Discussion

It is striking that many therapists have assumed that a client who would selfidentify
enough to enroll in a gay identified treatment center would be in the
later stages of identity formation. Not true. Many of our clients were struggling
with their identity, which contributed to relapse issues with chemicals as well as
with unwelcome sexual acting out practices. The discerning clinician needs to
delineate the difference between outward labeling of sexual orientation and inner
integration of what it means to accept one’s sexual orientation.

A surprising number of clients continue to state that they would change
their sexual orientation if that were possible, although they recognize that it is
not possible. These are often individuals who are fully out to family and friends.
Without such examination, these individuals were traditionally seen as accepting
of their sexual orientation because they were “out” to others; when in fact, they
only quality for Stage Two of the process: somewhere between accepting their
behavior as homosexual but devaluing what it means to be homosexual.
Consider “Bill.” Bill was in his mid twenties and came to treatment with a
dual diagnosis of Chemical Dependency and Sexual Addiction. Bill had grown
up in a conservative Southern Baptist preacher’s home. At an early age, Bill
determined that he was gay. His father preached that gays were an abomination
and going to hell. Out of desperation to find a “positive” identification for being
gay, Bill moved to New York City when he turned 18. Bill found other men “like
him” in subway bathrooms, gay bars and sex clubs. He became immersed in
compulsive sexual activity with much guilt but telling himself that this is what it
means to be gay. As his guilt and shame about his behavior deepened, so did his
use of alcohol and drugs until inpatient treatment was required. Once Bill was
in an all gay environment where he learned of diverse homosexual behavior, he
learned that the sexual practices that he defined as gay were not necessary as part
of the acceptance of being gay. Bill was not sexually compulsive after all: he had
been practicing multiple anonymous sex because that was the only gay life that
had been introduced to him. He so desperately needed to identify with others
who were gay that he was willing to compromise his sexual values in order to “be
gay.” What a relief he felt when he realized that he now had options regarding his
sexual behavior and still be identified as gay.

Another key factor in assessing gay and bisexual men is the issue of
sexual abuse. Many gay and bisexual men do not identify adolescent experiences
with older men as abuse even though the experiences meet clinical
definitions of abuse. We found a significant number of clients answering
“No” to the question of “Have you ever been sexually abused?” in our
Chemically Dependent Gay Men 295 initial assessments. During our thorough sexual histories we discovered that a number of these same clients reported having sex with older men in their adolescence. When questioned, these clients would report such comments as “It wasn’t abuse. I went looking for it. I enjoyed it. I wanted it. I returned for more.”

Take the case of Jed.
Jed reported a lonely childhood. He knew that he was different from other
boys. Other children had made fun of his effeminate behavior. Several of the
boys in Jed’s neighborhood warned him to stay away from the “weird” guy down
the street. Jed suspected that the “weird” guy may be weird in the same way that
he was. Jed went to the “weird” guy’s home to discover that this man understood
Jed’s “problems,” comforted him, and made him “feel good” by having sex with
him. For the first time in Jed’s adolescence, he felt affirmed and accepted. He
continued to return to the home to participate in this “acceptance.”
During the process of sharing Sex Histories in the peer group, the ability
to assess the compulsive behavior as part of the coming out process rather than
needing treatment for addiction becomes clearer. Let’s look at a couple of case
studies for examples.

“Lester” was a middle-aged lawyer with multiple chemical dependency
treatments. After a family intervention with support from his employer, Lester
entered our facility for extended care. His counselor picked up on sexually
compulsive behavior during the biopsychosocial interview. He was given a
SBAT and referred to the Sexual Compulsivity Support Group. When Lester
presented his Sex History in the group, it became evident that his behavior was
focused around his shame about being gay. Lester used chemicals to get the
courage to act out with men, while in his heterosexual marriage and since his
divorce. He did not act out sexually when sober but had great fears regarding his
performance with men. He was referred to a local support group for men who
have sex with men. He continued in the Sexual Compulsivity Support Group
by his own choosing but did not identify any further compulsive behaviors or
preoccupation throughout his treatment.
“Doug,” in his late 20’s, came to the “optional” Sexual Compulsivity
Support Group his first day in Chemical Dependency treatment. In the next
group session, he presented his Sex History, which demonstrated progressive
compulsive sexual behavior. Doug’s history began at age 6-10 by playing doctor
with peers. From age 11-15 he was “picking up older men.” By age 16-20, his
interest turned to Sado Masochistic behavior. In the 2 years prior to treatment
Doug was using hustlers one to two times a week and is “addicted to violent hard
core sex” (Doug’s words) with one person for 4-hour sessions. He expressed
shame over revealing secrets he had never shared before. In his first step, Doug
was clear about preoccupation and failed attempts at being able to control his behavior. Consequences included dropping classes in school because he was having sex in the bathrooms, contracting herpes and anal warts by age 15, bruises from the S & M activities, lack of sleep due to cruising for hours, two suicide attempts, and an HIV diagnosis 2 weeks prior to entering treatment.

Lester clearly acted out sexually after using chemicals and used the
chemicals to reduce the shame due to heterosexism. During treatment, Lester
“came out” to his adult sons and involved them in the family program. The
combination of working a program of sobriety for chemicals and becoming
comfortable with his sexuality may reduce ongoing sexual compulsive behavior.
Doug had been acting on his sexual addiction long before chemicals were
a problem in his life. Although he is now chemically dependent, he will also
need to work a program for his sexually compulsive behavior in order to
reduce the pain of his shame and guilt to stay sober.

Doug also has a great deal of shame about being gay and will need
to work on that issue as part of his continuing care plan; however, both
the drug and sex addictions will need to be addressed in order to do this
emotional work. Following the presentation of his Chemical Use History in
the group, Doug expressed a strong desire to get drunk. Following his First
Step for Sexual Addiction in the group, Doug could not initially identify
any feelings but expressed the urge to leave treatment. The “flight or fight”
syndrome of addiction was at work. After feedback from the group, Doug
was able to express the pain, shame, and guilt of his behavior as well as the
uncomfortableness with his sexual orientation. He demonstrated there in
the group how he had used chemicals and sex to dissociate from his feelings.
With the group’s help he was able to express the feelings. 1t is this practice in
12 Step groups for both addictions that will make therapy as well as recovery
a workable tool for Doug. Because shame is a driving force for addiction,
and shame due to heterosexism is such a force in a gay man’s life, addiction
is a “natural” to deal with feelings. The power of the dual addictions works
in the following way: a gay man attempts to stay sober from alcohol and
drugs, he acts out sexually, which produces shame (due to heterosexism).
The shame pushes the urge to use and he relapses.

Conclusions
There are several factors to weigh in assessing sexual compulsivity/addiction
in gay men, lesbians, and bisexuals. Clinicians need to obtain thorough sex
histories as well as determine where the client lies in the process of coming
out. Assessment tools then need to be used or developed regarding the actual
sexual behavior in relationship to coming out behavior. Gay men, lesbians,
and bisexuals undergo a second adolescence in the process of coming out.

Chemically Dependent Gay Men 297
During that process, which can be quite prolonged, especially if alcohol and drugs
are involved, a client may be exhibiting behavior that commonly is diagnosed as
sexual addiction. For some, finding ways to cope with the shame of being gay will
reduce the sexually compulsive behavior. For others, the behavior has been a longer standing way of coping with shame and other feelings that have turned into a true addiction, often a dual addiction with chemicals, spending (especially shopping for gay men), eating disorders, gambling, and any other compulsive behavior. Because gays learn early in life how to hide their true identity in order to be accepted, the secret life of sexual addiction is a natural. It was often begun long before they used chemicals or other compulsive behaviors and is so much a part of who they are they define their behavior as what it means to be gay. The skillful clinician will ferret out the coming out issues apart from sexual compulsivity and addiction.
REFERENCES
Cass, V. (1979). Homosexual identity formation: A theoretical model. Journal
of Homosexuality, 4, 219-235.
Coleman, E. (1981/1982). Developmental stages of the coming out process.
Journal of Homosexuality, 7, 31-43.
Neisen, J. (1994). Counseling lesbian, gay and bisexual persons with alcohol and
drug abuse problems. Arlington, VA: NAADAC Products.
Neisen, J. (1993). Healing from cultural victimization: Recovery from shame
due to heterosexism. Journal of Gay and Lesbian Psychotherapy, 2, 49-
63.