As part of the workshop, based on a detailed analysis of a typical clinical case (compiled following several sessions of analytical therapy), the psychodynamics of relationships in couples where one partner is HIV-positive and the other is not (HIV-discordant couples) will be examined and discussed.
Disclaimer: To protect client confidentiality, various cases have been combined and adapted. However, for ease of reading, the report is presented as a description of a single specific case.
Case description
Reason for seeking help, symptoms and context: as a young man, the patient left his provincial town and emigrated to Germany — partly to be able to live openly without hiding his homosexuality.
The decision to seek psychotherapy was made whilst they were already in a relationship and was actively supported by the patient’s partner. The partner observed that the patient was constantly in a distressed, depressed state, and that their life together had turned into a series of endless conflicts. The couple received a specific referral from a specialist at a local counselling centre for LGBTQ+ people.
The situation was further complicated by a medical factor: during joint testing, the patient’s partner was found to be HIV-positive. The patient, however, tested HIV-negative. Initially, he believed that the infection could have occurred as a result of shared or his own multiple sexual contacts (a non-monogamous lifestyle) within their relationship. He was convinced that if anyone in the couple had been infected, it was him.
The fact is that, in an effort to maintain the vitality of their sexual attraction whilst avoiding serious conflicts in their intimate relationship, both partners often chose a non-monogamous lifestyle, engaging in sexual relationships with other people — both together and separately. In doing so, they frequently practised unprotected sex.
The patient described his sex life with his regular partner as extremely painful. He admitted that he was forced to feign passion that he did not actually feel. He wanted to make his partner happy, but suffered from his own insincerity. At the same time, he categorically did not want to break up, even despite meeting other attractive men. The patient noted that he had never truly felt like a man: as a teenager, he had been subjected to severe bullying, and was now trying to compensate for this by exhausting himself with training. The high frequency of changing partners and an active sex life were, for him, a way of gaining confirmation of his worth and feeling alive.
The patient was overcome by particularly intense grief when he spoke of the moment he received his HIV test results. As mentioned above, he himself tested HIV-negative, whilst his partner, who had had far fewer sexual encounters outside their relationship, tested positive. The patient felt no relief at being healthy. On the contrary, he was overcome by depression, chronic fatigue, a loss of joy in life and a powerful sense of guilt.
Psychodynamics
Below are indications of psychodynamic patterns that manifested in a similar way across various, comparable cases:
The patient was raised in a family system where the mother faced difficulties in supporting and accepting the child’s gender expression. She found it difficult to adequately ‘mirror’ (accept and support) her son’s physicality and role behaviour. At the same time, she succeeded in instilling in the child a desire for education and a refined emotional organisation. However, the patient’s identification with his own male body proved so weak that at the onset of puberty he experienced a strong rejection of his physicality, and by the end of adolescence he swung to the other extreme, attempting to ‘mould’ himself in accordance with the masculine ideal.
During his school years, the patient managed to build good friendships and establish rapport with the teaching staff, which provided him with positive social experiences. Ultimately, he found a partner but was unable to build a relationship with him that would bring lasting sexual satisfaction.
Instead, their relationship was always overshadowed by a chronic condition linked to his partner’s HIV-positive status. [Editor’s note: In 2026, it is important to remember that with regular ARV treatment and the achievement of an undetectable viral load, there is no risk of transmission (U=U), and PrEP is available for the additional protection of the HIV-negative partner. However, during the period described, the diagnosis was perceived by the couple as an existential threat]. In the context of a non-monogamous lifestyle, thoughts and feelings increasingly revolved around the possibility of infection. It could be said that this constant preoccupation became the very ‘unifying Third’ within the couple.
The question arises: did the patient possess a sufficiently developed capacity for triangulation (introducing a third element into a relationship between two people to reduce anxiety), or were the relationship dominated by desires for symbiosis (merging), which they attempted to resolve through the theme of possible infection? In any case, HIV status was used to regulate closeness and distance within the relationship.
Highly intensive therapy was intended to give the patient the opportunity, within the context of emigration (which also symbolised his inner homelessness), to work through early traumatic experiences within a safe and trusting relationship with the therapist. Within this relationship, he could relive his early deficits and slowly work through them.
The Course of Therapy (Process)
Initially, I tested the hypothesis that the partner (through his HIV infection) had made himself a ‘carrier of the problem’ for the patient. The question was whether the partner was engaging in narcissistic abuse of the patient to satisfy his own infantile-dependent desires, thereby repeating the scenario of parentification (where children take on the role of parents) on the part of the patient’s mother.
During the course of treatment, this idea was narrowed down as follows: the patient appears to have, at one time, taken on the role of emotional support for his depressed mother in order to survive psychologically himself. Having grown up, he chose an equally unstable partner and attempted to build a life with them. The non-monogamous lifestyle of both partners may indicate that they were not ready for a monogamous union, yet at the same time desperately craved exclusive and secure attachment. Both were taking the risk of infection, and both were aware of this. Against the backdrop of HIV, the patient’s partner increasingly suffered from fears and depressive mood swings, which reinforced the patient’s role as a ‘carer’.
In his relationship with me, the patient was constantly concerned about my well-being—rather than his own. He asked whether I could bear his grief, whether I could withstand his pain. As we worked through the parenting dynamic, it became clear that, due to a sense of dependency, the patient was embellishing and downplaying the seriousness of his condition.
Gradually, he managed to use my understanding of his defence mechanisms to form a more realistic perception of me. He was able to bring difficult, painful material to the sessions, which no longer served the purpose of ‘keeping the therapist in good spirits’ (as had been the case in his childhood with his mother).
Finally, he was able to name the painful experiences of his childhood and school years for what they were. When I asked, by way of interpretation, whether the patient harboured secret death wishes regarding his infected partner, he reacted with immense relief. This interpretation allowed repressed aggression to be brought to the conscious level, and the death wishes were expressed without guilt. Ultimately, this helped him learn to distinguish between desire and reality, as well as to maintain the ‘separation aggression’ that facilitates stepping out of the parental role for his partner.
Discussion
During the lively discussion, the following aspects of therapy for HIV-discordant couples were highlighted:
The sense of difference and/or migration as existential themes in the lives of LGBTQ+ people
Many biographies of LGBTQ+ individuals are linked to the theme of alienation: feeling like a stranger in one’s own environment, retreating into subcultures, moving away for the chance to live freely. Alongside stress, numerous coping strategies are developed. In therapy, these can be identified and utilised as a resource.
HIV infection as an attempt at triangulation
Once the phase of romantic infatuation has ended, same-sex couples face the task of finding a ‘Third’ element that extends beyond the couple. On an unconscious level, HIV can become this ‘third’ element. Here, a parallel can be drawn with how the arrival of a ‘third’ element (be it children or a medical diagnosis) changes the dynamics of a couple.
The illusion of ‘uninhibited sexuality’ before HIV
Many couples create an image of completely spontaneous sexuality, which they supposedly had before the infection appeared. Partners may be shielding themselves from the sadness that sexuality changes and attraction fades even without the virus. In therapy, it often becomes clear that such a projection merely masks pre-existing sexual conflicts.
Barebacking as a way of avoiding difficult feelings
Barebacking (unprotected sex) can be ‘playing with fire’, a way of experiencing the proximity of death in order to feel alive. In this way, everyday life is dramatised, allowing one to avoid confronting real-life problems.
The motive of a desire to be infected
In HIV-discordant couples, the question often arises: is the HIV-negative partner taking a deliberate risk? In the therapeutic process, it is important to distinguish between themes of couple dynamics (intimacy, fusion) and individual dynamics (risk as a lifestyle). The illusion of ‘uninhibited sex when both partners have the same status’ can also fuel this desire.
Secondary benefits of the illness
HIV infection can be used to gain attention or to keep a partner in the relationship. Here, too, it is important to distinguish between couple dynamics (care, boundaries) and individual dynamics (fear of death, depression).
Guilt and punishment
It often transpires that one’s own homosexuality is associated with a deep sense of guilt due to external pressure. The desire to become infected may be an unconscious attempt to atone for guilt through punishment.
Implications for therapy planning:
It is necessary to create an inner space for fantasies! The aim is for the client to learn to allow fantasies about infection just as they would aggressive fantasies. In this way, they learn to distinguish between the desired and the real and gain autonomy.
Author: Manuela Torelli
