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In reality, there are all kinds of reasons why a gay man might not want to have sex. Straight people tend to define sex as penetration because, for them, intimacy is often connected to having children, Guggenheim said. This stereotype, like the others, can be damaging. Many straight and gay people tend to consider sex to be "sex" only if there's penetration, said Mark, a 29 year-old living in Washington, DC. And it reflects a sort-of selfish projection of straight relationships onto gay ones, according to Ryan, a 28 year-old living in NYC. Many men push back against the very idea that top or a bottom is a fixed state.

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It’s Time to Take Your Temperature on Topping and Bottoming

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And Guggenheim's perspective, based on conversations with hundreds of patients, supports that claim.

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That's especially true if he hasn't received before, or in a while, he added. This is not a reality for many gay men, and there are a few reasons for that. Otherwise, he said, anal sex can be painful.

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