Psychiatry and homosexuality

Insight, Advice - Mind, Body and Family, Apr '14
By Dr. Tirthankar Guha Thakurta

On February 8, 2014, the West Bengal chapter of the Indian Psychiatric Society organized an interactive event in Kolkata to clarify their stand on homosexuality (see A Mental Boost! in the February 2014 issue of Varta). Among a host of issues debated, one was the use of reference books with outdated information on gender and sexuality by students of the MBBS course, the future doctors of India. Varta decided to delve deeper into the matter, and Dr. Tirthankar Guha Thakurta brings you the second and final in a series of articles that analyse the content of some standard reference books (the first article – The Homophobic Doctor – was published in the March 2014 issue of Varta).

Some excerpts from The Essentials of Forensic Medicine and Toxicology, 21st edition, 2002, by Dr. K. S. Narayan Reddy, MD, DCP, PhD, FAMS, FIMSA, FAFM, FAF Sc., FIAMS; Professor of Forensic Medicine, M.R. Medical College, Gulbarga; Retired Principal, Osmania Medical College, Hyderabad:

"Voluntary sexual intercourse against the order of nature with any man, woman or animal is an unnatural sex offence. These offences are punishable with imprisonment for life or upto 10 years and also with fine”.

“Homosexuality means persistent emotional and physical attraction to members of the same sex. As such it is an abnormal personality development . . ."

The author also describes how a medical examiner can identify a ‘passive’ and an ‘active’ agent of sodomy by examining the anus and penis, respectively, the common element in both being the presence of sexually transmitted diseases.

These excerpts are just an example of the relationship between medical and mental health sciences and sexuality, which has been one of great ups and downs over the past century. It became even more complicated with the interference of the state and law. Let us take a look at how the opinion of psychiatry, psychology and medicine on homosexuality has evolved with time.

By the end of the 19th century, medicine and psychiatry were effectively competing with religion and law for jurisdiction over sexuality. As a consequence, discourse about homosexuality expanded from the realms of sin and crime to include that of pathology. This historical shift was generally considered progressive because a sick person was less blameful than a sinner or criminal. But today such a stand on homosexuality would invite criticism and ridicule from many quarters.

In 1949, Sandor Rado, a famous psychologist of his time, stated that heterosexuality is an inherent trait of the human mind and that homosexuality is a phobic response to members of the other sex. Other analysts later argued that homosexuality resulted from pathological family relationships during the oedipal period (around 4-5 years of age) and claimed that they observed these patterns in their homosexual patients (Bieber and others, 1962). Charles Socarides, in 1968, speculated that the cause of homosexuality was due to developmental disorders of the mind.

Even within medicine and psychiatry, however, homosexuality was not universally viewed as pathological. Richard von Kraft-Ebing described it as a degenerative sickness in his Psychopathia Sexualis, but Sigmund Freud and Havelock Ellis both adopted more accepting stances. Early in the 20th century, Havelock Ellis (1901) argued that homosexuality was inborn and therefore not immoral; that it was not a disease, and that many homosexuals made outstanding contributions to society.

In a now famous letter to an American mother in 1935, Sigmund Freud wrote:

"Homosexuality is assuredly no advantage, but it is nothing to be ashamed of, no vice, no degradation, it cannot be classified as an illness; we consider it to be a variation of the sexual function produced by a certain arrest of sexual development. Many highly respectable individuals of ancient and modern times have been homosexuals, several of the greatest men among them (Plato, Michelangelo, Leonardo da Vinci, etc.). It is a great injustice to persecute homosexuality as a crime, and cruelty too . . .

"If [your son] is unhappy, neurotic, torn by conflicts, inhibited in his social life, analysis may bring him harmony, peace of mind, full efficiency whether he remains a homosexual or gets changed . . ." (reprinted from the American Journal of Psychiatry, 1951).

However, a close study of the so called supportive statements would reveal that they came in the guise of diluting a ‘crime’ by calling it a ‘disorder’, or replacing the word ‘illness’ by synonyms like ‘developmental arrest’. It was made to look like an act of god or nature, and as we could not punish either of them, so we could spare the victim but still call their sexual orientation an error or disorder. Sigmund Freud went ahead to suggest that sexual orientation could be changed by psycho-analysis.

Such psycho-analytical studies in themselves posed some problems. First, the analyst's theoretical orientations, expectations and personal attitudes were likely to bias their observations. This is why scientists take great pains in their studies to ensure that the researchers who actually collect the data do not have expectations about how a particular research participant will respond. An example is the double blind procedure used in many experiments. But such procedures were not used in clinical psycho-analytic studies of homosexuality in Sigmund Freud’s times.

A second problem with these studies was that they only examined homosexuals who were already under psychiatric care – in other words, homosexuals who were seeking treatment or therapy. Patients, however, cannot be assumed to be representative of the general population. Just as it would be inappropriate to draw conclusions about all heterosexuals based only on data from heterosexual psychiatric patients, we cannot generalize from observations of homosexual patients to the entire population of homosexuals.

A more tolerant stance toward homosexuality was adopted by researchers from other disciplines. Zoologist and taxonomist Alfred C. Kinsey, in his groundbreaking empirical studies of sexual behaviour among American adults, revealed that a significant number of his research participants reported having engaged in homosexual behaviour to the point of orgasm after age 16. Alfred C. Kinsey is best known for writing Sexual Behavior in the Human Male (1948) and Sexual Behavior in the Human Female (1953), also known as the Kinsey Reports.

In a review of published scientific studies and archival data, Ford and Beach (1951) found that homosexual behaviour was widespread among various non-human species and in a large number of human societies.

Berube (1990) reported the results of previously unpublished studies conducted by military physicians and researchers during World War II. These studies challenged the equation of homosexuality with psycho-pathology, as well as the stereotype that homosexual recruits could not be good soldiers.

Today, a large body of published empirical research clearly refutes the notion that homosexuality per se is indicative of or correlated with psycho-pathology. One of the first and most famous published studies in this area was conducted by psychologist Evelyn Hooker. Her 1957 study was innovative in several important respects. First, rather than simply accepting the predominant view of homosexuality as pathology, she posed the question whether homosexuals and heterosexuals differed in their psychological adjustment.

Second, rather than studying psychiatric patients, she recruited a sample of homosexual men who were functioning normally in society. Third, she employed a procedure that asked experts to rate the adjustment of men without prior knowledge of their sexual orientation.

This method addressed an important source of bias that had vitiated so many previous studies of homosexuality. Evelyn Hooker concluded from her data that homosexuality was not a clinical matter and that homosexuality was not inherently associated with psycho-pathology. Her findings have since been validated by many other investigators using a variety of research methods.

In a review of published studies comparing homosexual and heterosexual samples on psychological tests, Gonsiorek (1982) found that though some differences were observed in test results between homosexuals and heterosexuals, both groups consistently scored within the normal range. Gonsiorek concluded that "Homosexuality in and of itself is unrelated to psychological disturbance or maladjustment. Homosexuals as a group are not more psychologically disturbed on account of their homosexuality".

Confronted with overwhelming empirical evidence and changing cultural views of homosexuality, psychiatrists and psychologists radically altered their views, beginning in the 1970s. In 1973, the weight of empirical data, coupled by changing social norms and the development of a politically active gay community in USA lead the board of directors of the American Psychiatric Association to remove homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (DSM).

This is not where the story ends. Subsequently, a new diagnostic category, ego-dystonic homosexuality, was created for the DSM's third edition in 1980. Ego-dystonic homosexuality was indicated by: (1) A persistent lack of heterosexual arousal, which the patient experienced as interfering with initiation or maintenance of wanted heterosexual relationships; and (2) Persistent distress from a sustained pattern of unwanted homosexual arousal.

The new diagnostic category, however, was criticized professionally on numerous grounds. It was viewed by many as a political compromise to appease those psychiatrists – mainly psycho-analysts – who still considered homosexuality as pathological. Others questioned the appropriateness of having a separate diagnostic category that described the content of an individual's dysphoria (state of feeling unwell or unhappy). They argued that the psychological problems related to ego-dystonic homosexuality could be treated as well by other general diagnostic categories, and that the existence of a separate diagnostic category perpetuated anti-gay stigma.

Moreover, widespread prejudice against homosexuality in USA meant that "almost all people who are homosexual first go through a phase in which their homosexuality is ego-dystonic," according to the American Psychiatric Association. In 1986, the diagnosis was removed entirely from the DSM and in 1991 from the International Classification of Diseases (ICD), the manual of diseases published by the World Health Organization.

Unfortunately, many psychiatrists and other mental health professionals still consider homosexuality as a disease. This is not surprising because outdated textbooks, theories and teachers are all there to show people the wrong path.

It is necessary to realize that removing homosexuality from manuals on diseases is not sufficient to remove the stigma of pathology from it. Educational institutions must actively promote up-to-date information on homosexuality and ensure that the older protocols are no longer followed.

Next time when you come across a mental health expert explaining why homosexuality is a disease, gift him a new edition of the DSM or ICD.

Confused? Disturbed? Just inquisitive? Write in any query on the mind, body and family to vartablog@gmail.com, and Dr. Tirthankar GuhaThakurta, teaching faculty at a Kolkata-based medical college, will be happy to answer them – with due respect to confidentiality.