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Psychiatry has served both to reﬂect and to help deﬁne Western societal attitudes toward homosexuality for much of the past two centuries. Perspectives on homosexuality—concerning its origins, its social and personal meanings, its diagnostic implications, and its clinical relevance—persistently represented one of the most contentious issues within American psychiatry during the latter part of the twentieth century. With a primary emphasis on the American experience, this research paper presents current deﬁnitions related to homosexuality and sexual orientation and examines the history of psychiatric theories and ﬁndings about homosexuality. The relationship between homosexuality and psychiatry in other countries and cultures has often paralleled what took place in the US but also reﬂects the diverse attitudes and policies regarding both sexuality and mental illness throughout the world. An example of such diversity is the recent legislation of gay and lesbian relationships by some European countries in contrast to the continued opposition to such acceptance in the United States.
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Increased understanding of sexuality in general has led to greater speciﬁcity in the use of terms related to sex, gender, sexuality, and sexual orientation. Terms such as gender identity and gender or sex role tended to be confused with sexual orientation in early writing about homosexuality; however, it is now recognized that these are related but discrete characteristics that may interact with but are not synonymous with homosexuality.
Sexual orientation refers to a person’s erotic response tendency, homosexual, bisexual, or heterosexual, toward persons of the same or other sex as reﬂected in such indicators as the proportion of dreams and fantasies directed to one or the other sex, the sex of one’s sexual partners, and the extent of physiological response to erotic stimuli associated with one or both sexes. Sexual orientation consists of three components, desire, behavior, and identity, which may or may not be congruent in an individual. The Kinsey scale—a 7-point continuous scale, with 0 representing exclusive heterosexuality, 6 representing exclusive homosexuality, and 3 representing equal amounts of both, or bisexuality—is the most widely used scale for describing sexual orientation. The terms homosexuality, heterosexuality, and bisexuality have not been applied consistently in theoretical, research, or popular discourse; they have been used to refer to a wide range of constructs, including categories of sexual desire, gender role attributes, forms of sexual behavior, personal and social identities, types of personalities and persons, degrees of normality and abnormality, and the presence or absence of mental illness.
The presence of erotic desire for someone of the same or other biological sex does not imply the concurrent existence of any other characteristics in that individual. Thus, for example, a woman may engage in homosexual behavior, demonstrate typical feminine gender role characteristics, be married to a man, and experience a heterosexual identity; or a man may have homosexual desire, have sex only with women, and show gender role nonconformity.
The terms gay, gay man, lesbian, and bisexual are used to refer to men or women who have developed a sexual orientation identity that is homosexual or bisexual. While gay sometimes is used as an inclusive term to refer to both men and women, reference to two distinct groups, gay men and lesbians, is more appropriate because of the signiﬁcant diﬀerences between these groups in their development and experiences.
Homosexual, or lesbian and gay, and bisexual identities are the subjective experiences of being homosexual or bisexual—being signiﬁcantly or exclusively attracted to someone of the same sex—with the identities being both self-and other-ascribed. Models of lesbian, gay, and bisexual identity development usually portray a series of linear progressive stages involving tasks such as coming out (the process of recognizing one’s homosexual or bisexual attraction and acknowledging it to oneself and to others), involvement in lesbian, gay, and bisexual communities, establishing same-sex relationships, and integration of one’s sexual identity into other aspects of the self. Not all persons who experience homoerotic desire or participate in homosexual behavior also develop a lesbian, gay, or bisexual identity.
In contrast to sexual orientation, gender identity generally is understood to refer to a persistent sense of oneself as being male, female, or ambivalent and is contrasted with sex, which refers to the biological attributes of being male or female. While gender identity describes an inner experience of being male or female, gender role and social-sex role are deﬁned as the degree to which an individual’s outer behavior or appearance can be described as masculine, feminine, or androgynous. The large majority of persons, regardless of their sexual orientation, have a gender identity and gender role consistent with their bio-logical sex, though sometimes gay and lesbian persons may demonstrate a greater range of gender role attributes.
2. Historical Conceptualizations Of Homosexuality Within Psychiatry
Prior to the time homosexuality was ﬁrst studied as a psychiatric condition in the second half of the nineteenth century, the meaning of homosexual behavior was very diﬀerent than it is today in Western culture. Homosexual behaviors take place in all societies and homosexual acts have been both ritualized and prohibited in various cultures. However, the contemporary idea of identifying a type of person based on regular participation in homosexual behavior and on development of an identity associated with this behavior is generally believed to be a product of the medicalization of homosexuality during the nineteenth century.
2.1 Medicalization Of Homosexuality
During the second half of the nineteenth century a number of individuals in Europe began to study homosexuality scientiﬁcally. The term homosexual was ﬁrst coined by the Hungarian physician Kertbeny in 1869. The conceptual basis for homosexuality arose from the earlier ideological construction of two genders, male and female, with dichotomous characteristics, and the attempt to ﬁnd explanations for homosexuality derivative from these male and female categories. Thus, the homosexual was conceived of as a person of one biological sex with the sexual longing of the other sex, as portrayed, for example, in the German jurist and homosexual rights advocate Karl Heinrich Ulrich’s description of the male homosexual as a female soul in a male body.
Subsequently, the German psychiatrists Carl Westphal and Richard von Kraﬀt-Ebing adopted many of Ulrich’s ideas, but they considered the traits he described to be unnatural. The German physician and sexual emancipator Magnus Hirschfeldalso believed that there was a genetic basis for homosexuality. While he understood homosexuality to be a malformation in development and ascribed to a number of diﬀerent biological etiologies, he also asserted that it was natural. Similarly, the English sex reformer Havelock Ellis based his eﬀorts to alter attitudes about homosexuality on the belief that homosexuality was an inborn trait. Speciﬁc biological theories about the origins of homosexuality began to be examined during this period, including a variety of constitutional factors, such as diﬀerent anatomical structures in the brains and in nerves in the rectums of homosexual men, and endocrinological determinants, including atrophied and abnormal testicles in homosexual men.
These early biological theories about the origin of homosexuality, with their emphasis on heredity, endocrinological inﬂuences, and anatomical or structural diﬀerences between homosexual and heterosexual persons, presage many current eﬀorts to ﬁnd a biological basis for homosexuality. Their almost exclusive emphasis on the study of homosexuality in men also parallels later twentieth-century biological research, which largely has ignored homosexuality in women. Further, the biological arguments helped to create the notion of a homosexual person by emphasizing the existence of fundamental constitutional diﬀerences between those who are attracted to persons of the same sex and those who are attracted to persons of the other sex.
2.2 Psychoanalytic Approaches
During the latter part of the nineteenth and the ﬁrst half of the twentieth century, psychoanalysis, with its emphasis on intrapsychic and interpersonal development, represented an alternative approach to the biological sciences for studying and understanding homosexuality. Freud believed that heterosexuality was the natural outcome of normal development and that homosexuality represented an arrest in development from an instinctual bisexuality to a mature heterosexuality that arises as the result of a variety of factors. However, he did not view homosexuality as a sign of degeneracy and even asserted that homosexuality could occur in persons who had no other signs of deviation and no impairment in their functioning. Later psychoanalytic theorists, including Sandor Rado, who refuted Freud’s model of innate bisexuality and developed his own theory of homosexuality as a type of phobia, emphasized far more heavily the beliefs that homosexuality is the result of problems in psychosexual development and that its occurrence is a sign of severe psychopathology.
The outcomes of the growth of interest in studying homosexuality within the biological and psychoanalytic ﬁelds during this period were similar: to establish a focus of interest about homosexuality outside of the realms of morality and religion within science and medicine; to reify a category of person, the homosexual, associated with homosexual behavior; and to conﬁrm the abnormality and the pathology inherent in homosexuality.
2.3 Normalization Of Homosexuality
The publication of the two volumes on male and female sexuality by Kinsey et al. (1948, 1953) marked the beginning of the move away from the view of homosexuality as pathology and toward an understanding of homosexuality as a normal variant of sexual desire and behavior. Kinsey’s studies demonstrated the widespread presence of homosexual feelings and behavior among samples of several thousand American men and women thereby suggesting that homosexuality was not an isolated and aberrant phenomenon. Kinsey’s conceptualization of sexual orientation as a continuum also introduced the idea that homosexuality and heterosexuality were not dichotomous categories, but rather occurred in varying degrees in individuals.
Ford and Beach (1951) demonstrated that homosexuality was common across cultures and occurred in almost all nonhuman primate species. The psychologist Hooker’s (1957) publication of the results of her ground-breaking study comparing the projective test results from 30 homosexual men and 30 heterosexual men showed that experienced judges could not distinguish between the two groups based on their test results, a ﬁnding which established for the ﬁrst time that homosexuality in men was not associated with mental illness. The eﬀect of this signiﬁcant ﬁnding was to require that future views of homosexuality as an illness could only be based on an a priori assumption that homosexuality itself was pathological. By the 1970s, inﬂuential psychiatrists like Judd Marmor, a psychoanalyst and president of the APA, began to publish works that moved the psychiatric profession further away from the perspective of homosexuality as a type of mental illness and toward a consideration of the perspectives oﬀered in the newer research ﬁndings.
During this period of transition and in spite of the availability of contradictory ﬁndings from empirical studies, some psychologists, particularly behaviorists who attempted to extinguish homosexual expression through aversive techniques, and psychiatrists, primarily psychoanalysts such as Irving Bieber and Charles Socarides, persisted in publishing works that presented homosexuality as the outcome of developmental disturbance and as a sign of severe psychopathology. Bieber’s work (Bieber et al. 1962), which has been criticized extensively for its methodology, was particularly inﬂuential in its portrayal of a pathogenic family type, consisting of a detached and rejecting father and a close-binding and domineering mother, that led to homosexuality in adult men.
3. Classiﬁcation Of Homosexuality By The American Psychiatric Association
Homosexuality was classiﬁed as a type of mental disorder in the ﬁrst Diagnostic and Statistical Manual of Mental Disorders (DSM-I) (1952). It was designated, along with the other conditions labeled as sexual deviations, as a type of sociopathic personality disturbance, deﬁned by the existence of certain behaviors and not by the presence of distress or dysfunction. This classiﬁcation of homosexuality as a form of mental illness was not controversial at the time DSM-I was published, reﬂecting as it did the negative societal attitudes about homosexuality and the prevailing medical views of homosexuality. In DSM-II (1968), homosexuality continued to be listed as a type of sexual deviation.
Beginning in 1968, gay activists began to confront the APA about its classiﬁcation of homosexuality as a type of mental disorder. Following a series of dramatic encounters between gay rights advocates and psychiatrists at several annual meetings of the APA, the organization began oﬃcially to re-evaluate its position. Following further political protest and signiﬁcant scientiﬁc study of the issue, a proposal from the Nomenclature Committee of the APA to eliminate homosexuality from the DSM was approved by the APA’s Council on Research and Development, Reference Committee, and Assembly of District Branches before being accepted by the APA’s Board of Trustees in December 1973. As a result, for the ﬁrst time in modern history homosexuality per se, was not classiﬁed as a type of illness. This action had enormous social signiﬁcance in shifting the predominant and oﬃcial view of homosexuality from one of sickness to one of acceptable behavior. The decision to declassify homosexuality was accompanied by passage of a position statement by the APA that supported the protection of the civil rights of homosexual persons:
Whereas homosexuality in and of itself implies no impairment in judgment, stability, reliability, or vocational capabilities, therefore, be it resolved that the American Psychiatric Association deplores all public and private discrimination against homosexuals in such areas as employment, housing, public accommodations, and licensing, and declares that no burden of proof of such judgment, capacity, or reliability shall be placed on homosexuals greater than that imposed on any other persons. Further, the APA supports and urges the enactment of civil rights legislation at local, state, and federal levels that would insure homosexual citizens the same protections now guaranteed to others. Further, the APA supports and urges the repeal of all legislation making criminal oﬀenses of sexual acts performed by consenting adults in private.
The rationale for removing homosexuality from the DSM was based, in part, on the clariﬁcation of the deﬁnition of a mental disorder as meeting the criteria of either experience of subjective distress or of generalized impairment in social eﬀectiveness or functioning as a result of the condition. Neither of these criteria applied to homosexual persons who were satisﬁed with their sexual orientation and who did not demonstrate impaired functioning. In what appeared to be a compromise between opposing views, a new diagnostic category, ‘sexual orientation disturbance,’ was introduced to apply to those homosexual persons who ‘are either disturbed by, in conﬂict with, or wish to change their sexual orientation.’ When the DSM-III (1980) was published, sexual orientation disturbance was replaced with a new diagnostic category, ‘egodystonic homosexuality,’ a type of general psychosexual disorder that labeled homosexuality as a mental disorder only when it was accompanied by persistent distress. Finally, after further review of the appropriateness and utility of this diagnosis, all reference to homosexuality was removed from DSM-III-R (1986), representing the ﬁnal acknowledgment by the American psychiatric profession that homosexuality is not a type of mental illness. This change in the oﬃcial view of homosexuality signiﬁed a dramatic conceptual shift in the cultural meaning and signiﬁcance of homosexual behavior within American society.
4. Eﬀects Of Declassiﬁcation
The decision to remove homosexuality from the DSM led to widespread eﬀects within psychiatry. At the organizational level, groups of lesbian, gay, and bisexual psychiatrists formed and many issues relevant to the mental health of lesbian, gay, and bisexual persons could now be considered. At a clinical level, while controversy has persisted among psychiatrists about how to conceptualize homosexuality, new understandings and techniques for evaluation and treatment based on gay and lesbian aﬃrmative approaches were developed.
These changes were accompanied and shaped by larger contextual shifts that occurred as a result of removing homosexuality from the realm of pathology. Thus, for example, once homosexuality was no longer viewed as a disease, it became a topic that could more legitimately be studied within a variety of ﬁelds outside of psychiatry and medicine with their emphasis on pathology, such as the law, the social sciences, and the humanities. The expansion of gay and lesbian identities, communities, and culture in the years since the APA’s action produced a plethora of new issues that interacted with and inﬂuenced mental health, such as coming out, relationship concerns, childbearing and raising, family interactions, and spirituality. Finally, new health concerns, particularly AIDS, substance abuse, and reproductive issues, have created a whole set of additional mental health issues relevant to lesbian, gay, and bisexual persons.
Following the APA’s action to depathologize homosexuality, the formerly secretive ‘GayPA,’ consisting of an informal group of closeted homosexual psychiatrists, began to evolve into a more open and extensive social and political network of gay and lesbian psychiatrists. At the 1978 annual meeting, a formal structure was adopted for the Gay, Lesbian, and Bisexual Caucus of the American Psychiatric Association, which was subsequently re-named the Association of Gay and Lesbian Psychiatrists (AGLP). Consisting of several hundred members, the AGLP is an aﬃliated group of the APA and is one of the largest organizations of gay and lesbian physicians in the world. Many of its members served as founding members of other gay and lesbian medical groups, and it has continued to provide support to members and to raise political and clinical issues relevant to gay, lesbian, and bisexual mental health within the psychiatric profession. In addition, a Committee on Gay, Lesbian, and Bisexual Issues was established within the structure of the APA to study and make recommendations regarding mental health concerns. As a designated minority and underrepresented group within the APA, members of the Caucus of Lesbian, Gay, and Bisexual Psychiatrists elect representatives to the Assembly of District Branches, and openly lesbian and gay psychiatrists have been appointed and elected to many leadership positions within the APA.
The substantive issues discussed within the APA relevant to gay, lesbian, and bisexual concerns have involved a variety of topics, such as parenting and custody, education, reparative therapy, and AIDS. This activism and openness could not have occurred without the radical paradigm shift that took place when homosexuality was no longer considered a disease. The reconstruction of homosexuality as a normal variation of sexual desire, behavior, and identity allowed its introduction as a legitimate topic for discussion within the ﬁeld of psychiatry.
Within the 1980s and 1990s psychiatrists in academic settings have been acknowledged and promoted for their work on gay and lesbian topics. Openly gay and lesbian researchers and clinicians have helped to establish a whole new ﬁeld of gay and lesbian mental health. Publication of a section on homosexuality in the Review of Psychiatry (Oldham et al. 1993), a comprehensive Textbook of Homosexuality and Mental Health (Cabaj and Stein 1996), a curriculum for learning about gay, lesbian, and bisexual issues in psychiatry training programs (Stein 1994), a Journal of Gay and Lesbian Psychotherapy, and numerous scholarly articles and volumes on aﬃrmative approaches to working with gay, lesbian, and bisexual patients has provided a breadth of valuable resources for helping gay men and lesbians within mental health settings. As a result of this material, many mental health facilities and practitioners are increasingly sensitive to gay and lesbian needs and informed about gay and lesbian concerns.
Problems have remained even after the revolution in perceptions of homosexuality precipitated by the diagnostic change made by the APA in 1973. Some psychiatrists and other mental health professionals continue to view homosexuality and gay, lesbian, and bisexual persons in negative ways and to perpetrate harmful practices, such as involuntary hospitalization of gay, lesbian, and bisexual youth because of their sexual orientation and presentation of unsubstantiated claims for ‘curing’ homosexuality. Groups within the APA concerned with gay, lesbian, and bisexual mental health concerns have worked to enact new policies that will eradicate the vestiges of heterosexism and anti-sexuality. In December 1998 they were successful in having the APA approve a Position Statement on Psychiatric Treatment and Sexual Orientation which states that:
… the American Psychiatric Association opposes any psychiatric treatment, such as ‘reparative’ or ‘conversion’ therapy which is based on the assumption that homosexuality per se is a mental disorder or based on the a priori assumption that the patient should change his her homosexual orientation.
5. Future Of Homosexuality And Psychiatry
While the discourse within psychiatry regarding homosexuality has been expressed primarily in the form of scientiﬁc arguments about developmental and therapeutic conceptualizations related to sexual orientation, these arguments reﬂect the larger social debate within the US about attitudes and policy toward homosexuality. The psychiatric profession speciﬁed a clear governing principle—that homosexuality is not a type of mental illness—in its 1973 decision to depathologize homosexuality, but struggled for the next 25 years to articulate a consistent strategy for dealing with the implications of this decision. Perhaps oﬃcial psychiatric policy was ahead of the larger society in its unequivocal rejection of a view of homosexuality as a type of disease. Like American society in general, however, psychiatry continued to maneuver to accommodate two totally conﬂicting viewpoints about sexuality, morality, and social values that were condensed in attitudes toward homosexuality. It remains to be seen if the deﬁnitive opposition to reparative therapy approaches to homosexuality expressed in the 1998 position statement represents ﬁnal closure within psychiatry on this enduring debate.
The impact of diagnostic and treatment changes in relation to homosexuality within psychiatry during the past three decades has extended far beyond the mental health ﬁeld. First, in 1973, by removing homosexuality itself from the medical spheres of etiology and pathology, the psychiatric profession yielded dominion over sexual orientation to those who dealt with normal variations of behavior, such as psychology, sociology, and other biological and behavioral sciences. The freeing of homosexuality from its century-long ownership by psychiatry can be seen as a major impetus to the expansion and deepening of understanding about the topic within many ﬁelds and to the burgeoning growth and expression of gay and lesbian identities and communities. Once the gate to the prison of pathology had been unlocked, those who had previously been incarcerated because of their sexual identities lost no time in claiming their newly found freedom and, at the beginning of the twenty-ﬁrst century, are demanding assertively equal access to fundamental social institutions and rights such as marriage, parenting, and legal protection based on an assumption of their normality.
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