Homosexuality and the Mental Health Professions

The Impact of Bias

Jack Drescher

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134903214
• Edition: 1
• Topic: Psychology
• Subtopic: Human Sexuality in Psychology
• Index: Psychology

For more than half a century, The Group for the Advancement of Psychiatry (GAP) has produced position statements on relevant and controversial psychiatric topics. This latest monograph, Homosexuality and the Mental Health Professions: The Impact of Bias, continues a tradition of timely publications dealing with specific aspects of bias, discrimination, and human sexuality. This monograph acutely identifies problems of bias, overt and covert, as they affect the treatment of lesbian and gay patients and as they influence the training of mental health professionals. Incorporating clinical vignettes that detail actual incidents from a wide range of clinical and professional encounters, the report enables the clinician not only to review his or her own experience, but also to envision alternative possibilities of constructive and caring intervention. As psychiatry enters a new era of understanding the full range of normal variation in human sexuality, this monograph will serve both as an indispensable teaching tool and as an invaluable touchstone for assessing quality of care with gay and lesbian patients.

1	DIMENSIONS OF ANTIHOMOSEXUAL BIAS

Historical Influences on AHB

Negative perceptions of homosexuality are rooted in many aspects of our history and culture. These include:

1. Biblical interpretation: From early in the history of Judeo-Christian cultures, there has been a tendency to condemn homosexual behavior, by emphasizing Biblical admonitions against it (Genesis 19, Leviticus 18: 7, 22, Leviticus 20:13, Judges 19, I Kings 22:46, II Kings 23:7, Romans 1:27, I Corinthians 6:9, I Timothy 1:9–10).

2. Sin to illness: The scientific and medical construction of a category representing a particular social group, the term homosexual was coined in the 19th century. Its rapid and widespread usage by the public, as well as by the medical profession, reflected an attempt to replace religious, condemning explanations with more compassionate, scientific ones. The homosexual/heterosexual binary obscured the variety of ways in which one could characterize sexual or other conduct (Bullough, 1979; Gonsiorek, 1991).

3. Degeneracy theory: Influential in Europe and the United States in the 19th century, degeneracy theory proposed that traits associated with undesirable social behaviors were inherited. According to this theory, homosexuality, like violent criminality, enuresis, and alcoholism, was seen as manifestations of hereditary degeneracy. Thus, this was an early biological theory of homosexuality. Degeneracy theory also illustrated how the concepts of vice and illness are often interchangeable (Krafft-Ebing, 1886; Walter, 1956; Foucault, 1978; Greenberg, 1988).

4. Antisexual Victorianism: In the 19th century, the Victorian culture’s repressive stance toward sexual pleasure was expressed in diverse ways, including the widespread belief that masturbation caused insanity or could lead to homosexuality (Acton, 1865; Rosenthal, 1985; Duberman, 1986, 1991). Victorian sensibility also nourished the concepts of contagion and quarantine, beliefs that both fostered and were derived from degeneracy theories. It was popularly believed, for example, that homosexuality could be transmitted by sexually active people and that people who otherwise would develop as heterosexuals could be “corrupted” by mutual masturbation with a person of the same sex (Bullough, 1979; Weeks, 1985).

5. Idealization of the nuclear family: Social philosophers of the 18th and 19th centuries emphasized the intimate link between the health of society as a whole and the stability of the nuclear family organized around traditional sex roles. The so-called traditional family became a symbol not only of social cohesion and economic stability, but of correct moral behavior as well. This belief contributed to the development of a heterosexist ethic (Greenberg, 1988).

6. Heterosexism: Heterosexism is a belief in the inherent superiority of social practices and cultural institutions associated with heterosexuality, such as monogamy, marriage, and child rearing in two-parent, heterosexual families. In its more benign form, it might be referred to as “heterocentrism.” In its more malignant presentations, heterosexism is the ideological system that denies, denigrates, and stigmatizes any nonheterosexual form of behavior, identity, relationship, or community (Greenberg, 1988; Herek, 1990, 1995).

Attitudes Toward Homosexuality

Attitudes in the General Population

There is a dearth of articles in the psychiatric literature on attitudes toward homosexuality in the general population. We hope to stimulate further research in this area.

An important national survey of sexual morality and experience was carried out under the auspices of the Institute for Sex Research at Indiana University in 1970 (Klassen, Williams, and Levitt, 1989). With the help of the National Opinion Research Center, the investigators obtained a representative national sample of more than 3,000 men and women. Interviews revealed that 60% of these individuals believed that lesbians and gay men have unusually strong sex drives and that those who are older commonly seduce younger ones who, as a consequence, then become homosexual. Seventy per cent were concerned that lesbians and gay men seek to become sexually involved with children; half the 70% strongly believed this to be the case. The fear that lesbians and gay men constitute a threat to children was substantial even among the subgroup of the sample whose overall attitudes toward homosexuality were not particularly negative. More than two-thirds of the sample felt that lesbians and gay men should be barred from teaching, the ministry, the judiciary, medical practice, and government service. Almost 50% believed that homosexuality can cause the downfall of civilization. In this investigation, the most powerful predictor of attitudes toward homosexuality was the intensity of religious belief. People with these attitudes were more likely to come from the deep South or Midwest and from religious families that tended to be sexually repressive. A subsequent study by Nyberg and Alston (1977), of a representative sample of more than 1,000 white American adults, found that over 72% believed that homosexual relations were “always wrong.”

With the passage of time, public opinion has become more accepting and tolerant. For example, a Gallup poll in 1989 revealed that 71% of respondents believed that gay men and women should have equal job opportunities (Colasanto, 1989). The reasons for this shift in public opinion are not entirely clear. Certainly, the emergence of articulate gay and lesbian spokespeople may be a factor. The AIDS epidemic may have played a role as well. According to polls, the public perception of a minority group struggling valiantly with a dread disease led to the diminution of prejudice and discrimination in some quarters.

The equating of AIDS with homosexuality, however, has also led to an escalation of fearful and hateful attitudes toward gay men and, ironically, to lesbians. Reports of escalating violence against people perceived to be gay suggest that opinion polls do not fully measure the extent of antihomosexual attitudes in the general population. The reported incidence of violence against gay and lesbian persons is increasing in many major American cities and appears to be increasing more rapidly than other bias-related crimes, such as racially motivated hate crimes. Major problems with antigay and lesbian violence and harassment have been reported at college and university campuses, including Yale, Rutgers, Penn State, the University of Massachusetts at Amherst, the University of Illinois at Champaign-Urbana, and other sites. At Yale, of 166 gay and lesbian students studied, 24% had been threatened, 24% followed or chased, and 5% beaten. Fifty-seven per cent reported that they feared for their safety. At the high school and junior high school levels as well, antigay and antilesbian violence and harassment are widespread (Cort and Corlevale, 1982; Herek and Berrill, 1992; Klinger and Stein 1996). Teenagers surveyed about bias responded more negatively to gay people than to other minorities.

In a review of research on those holding negative attitudes toward lesbians and gay men, Herek (1984) found several similarities among diverse samples. When compared with those with more favorable attitudes toward lesbians and gay men, people with AHB were less likely to a) have had known personal contact with lesbians or gay men; and b) report having engaged in homosexual behavior or to identify themselves as lesbian or gay.

They were also more likely to c) perceive their peers as manifesting negative attitudes toward gay people, especially when the respondents are males; d) have lived in areas where intolerance of homosexuality is more the norm (e.g., the Midwestern and Southern United States, the Canadian prairies, and in rural areas or small towns), especially during adolescence; e) be older and less educated; f) be devoutly religious, attend church frequently, subscribe to a conservative religious philosophy; g) express traditional, restrictive attitudes about sex roles; h) manifest guilt or negativity about sexuality and to be less permissive sexually; and i) manifest high levels of authoritarianism and related personality characteristics.

Herek noted that negative attitudes may serve different functions for a person and that people may share similar attitudes for different reasons:

First, such attitudes may be experiential, categorizing social reality primarily on the basis of one’s past interactions with lesbian and gay people. Second, attitudes may be mainly defensive, helping a person to cope with some inner conflicts or anxiety by projecting it onto gay men and lesbians. Finally, attitudes may be symbolic, expressing abstract ideological concepts that are closely linked to one’s own notion of self and to one’s social networks and reference groups [p. 8].

In general, men manifest more negative attitudes toward gay people than do women. Violence against lesbian and gay victims is usually perpetrated by males, as is true of violence in general (Moyer, 1974; Herek and Berrill, 1992). Heterosexually identified men and women alike tend to have more negative attitudes toward people of their own gender who are perceived to be lesbian and gay than toward people of the other gender (San Miguel and Millham, 1976). There are no studies of the profiles of mental health professionals or how likely they are to share some of the culture’s stereotypical beliefs about lesbian and gay people.

Attitudes Within Dynamic Psychiatry

Persistent AHB is often rooted more in personal value systems and experiences than in the scientific literature. Since bias is often rationalized or denied, its effects may be especially pervasive and debilitating. An example of a common rationalization of bias is that a homosexual orientation is intrinsically more pathological than a heterosexual one. This kind of rationalization may lead to discrimination against patients and trainees.

During the years after World War II until the 1970s, American psychiatry’s formulations of homosexuality were largely based on psychoanalytic models and common cultural stereotypes of human behavior (Lewes, 1988). In the American Psychiatric Association’s Diagnostic and Statistical Manual, first edition (DSM-I: American Psychiatric Association, 1952), homosexuality was classified as a sociopathic personality disorder (Bayer, 1981). In the DSM-II (American Psychiatric Association, 1968), it was reclassified as a sexual deviation. The DSM-II was revised in 1973 and homosexuality per se was removed as a diagnostic category (Bayer, 1981).

The pathologizing psychoanalytic theories of homosexuality, as well as the interactive influence of theory and culture, are too extensive to be discussed more than briefly here. The reader interested in these areas is referred to Bieber et al. (1962), Weideman (1962, 1974), Socarides (1968, 1978), Ruitenbeek (1963), Sulloway (1979), Marmor (1980), Bayer (1981), Fisher and Greenberg (1985), Gay (1988), Greenberg (1988), Isay (1989), Lewes (1988), Friedman (1988), Holt (1989), O’Connor and Ryan (1993), Mitchell (1996), Magee and Miller (1997), and Drescher (1998b).

During the socially conservative years following World War II, policy positions taken regarding homosexuality by such institutions as the military and the law were buttressed by pathologizing psychoanalytic constructs. Lewes (1988) has pointed out that, during that era, many psychoanalysts couched their own personal endorsement of traditional religious and family values in supposedly objective psychoanalytic terminology. The image of psychological health was defined as a nuclear family organized around traditional gender roles (Bieber et al., 1962).

The psychiatric literature underemphasized and ignored lesbian and gay people whose capacities to love and work were unimpaired (Hooker, 1957). It also ignored the negative countertransference toward these patients (Mitchell, 1978, 1981; Kwawer, 1980; Lewes, 1988; Frommer, 1995) and the influence of widespread social prejudice on their psychological well-being (Stein and Cohen, 1986; Isay, 1989; Drescher, 1998b).

The psychodynamic literature of that era focused on the etiology of homosexuality, which was presumed to result primarily from preoedipal or oedipal psychic trauma, in contrast to heterosexuality which was assumed to unfold naturally and which therefore had no “etiology” (Bergler, 1944, 1951, 1956; Bieber et al., 1962; Socarides, 1968; Bayer, 1981). Homosexuality was believed to be a sign of psychosexual immaturity. Any role of neurobiological influences on sexual orientation was deemphasized and even denigrated in favor of psychodynamic hypotheses (Lewes, 1988; Friedman and Downey, 1993a, b).

After the American Psychiatric Association removed the diagnosis of homosexuality from its list of mental disorders in 1973, other organizations of mental health professionals soon reached similar conclusions. These groups included the American Psychological Association and the National Association of Social Workers. A careful review of scientific evidence indicated that there was no clear-cut, demonstrable relationship between sexual orientation and psychopathological symptoms or disorders.

The original decision by the American Psychiatric Association to remove homosexuality from the category of pathology was opposed by a substantial minority of psychiatrists (Bayer, 1981). Subsequently, however, a 1977 survey of 2,500 psychiatrists found that a majority felt that homosexuality is pathological and that lesbians and gay men are less capable than heterosexuals of mature, loving relationships (Lief, 1977). Studies of other mental health professionals found that many, sometimes a majority, have had negative attitudes about homosexuality and lesbian and gay people and continue to harbor them (Fort et al., 1971; Clark, 1975; Rudolph, 1989, 1990; Lilling and Friedman, 1995; Friedman and Lilling, 1996).

Until recently there was a notable absence of openly lesbian and gay psychoanalysts willing to criticize the inadequacy of the prevailing psychoanalytic theoretical models of sexual orientation. Although some gay and lesbian psychiatrists began speaking openly and critically of psychoanalytic theory in the mid-1980s, it was not until the 1990s that gayidentified psychoanalysts began to write or speak against prevailing models on the basis of their personal and clinical experience (Blechner, 1993; O’Connor and Ryan, 1993; Domenici and Lesser, 1995; Isay, 1996; Drescher, 1997, 1998b; Magee and Miller, 1997). Thus, an important data source was not available for decades. These new contributions can be analogized to the ways in which women mental health professionals challenged earlier, prevailing phallocentric theories (Lewes, 1988). The appearance of increasing numbers of openly gay and lesbian psychotherapists within mainstream psychiatric organizations suggests that heterosexual psychoanalytic attitudes are being challenged and may even have undergone substantial changes.

Research scientists have accumulated substantial data indicating that homosexuality per se is not associated with psychopathology any more than is heterosexuality. In any event, personality measures, projective tests, rates of psychiatric symptoms, and lifetime prevalence of psychiatric disorders, with few exceptions, do not distinguish between homosexual and heterosexual subjects (Gonsiorek and Weinrich, 1991; Friedman and Downey, 1994; Cabaj and Stein, 1996). Two types of psychological difficulties have been reported to be more frequent in lesbian and gay populations: attempted (but not completed) suicide in youth (Robins, 1981; Rich et al., 1986; Hendin, 1992; Prenzlauer, Drescher, and Winchel, 1992; Schafer, 1995) and substance abuse (Friedman and Downey, 1994). Even these findings await replication, however, and are not conclusive. Furthermore, studies have corroborated the role that stress plays in the lives of lesbians and gay men and the impact it has on their mental health. Increased exposure to stress might explain why the lifetime history of depression is elevated in gay men, although present history of depression is not (Williams et al., 1991).

Overall, psychodynamic psychiatry in the 1990s has discarded the paradigm that homosexuality is inherently pathological and has adopted the normal variant model. Psychodynamic psychiatric clinicians currently recognize that gay and lesbian patients usually seek treatment for the same reasons that heterosexual patients do: Axis I and Axis II psychiatric disorders, and stress, leading to suffering and disability. The full impact of these changes within psychiatry on future social, medical, legal, religious, and political institutions remains to be seen.

Attitudes in Fundamentalist Religion

Religious fundamentalists have expressed disparaging views about lesbians and gay men. Some have rationalized and others exhorted violence in their public rhetoric. For example, “When civil legislation is introduced to protect behavior to which no one has any conceivable right, neither the Church nor society at large should be surprised when other distorted notions and practices gain ground, and irrational and violent reactions increase” (Congregation for the Doctrine of the Faith, 1986, paragraph 10, in Herek and Berrill, 1992, pp. 90–91). Many conservative religious groups and movements depict lesbian and gay people as being profligate and immoral and attribute the AIDS epidemic to punishment for sexual “sins.” The category “homosexual” has become, in the minds of many, a symbol of one who rejects all of society’s rules. From this perspective, homosexual practices must be violently resisted, or else abuse and neglect of traditional family values and structures will inevitably follow.

Conservative mental health professionals appear to subscribe to similar views. So, for example, in a famous case in which a gay man was murdered after revealing his attraction to a heterosexual neighbor, one well-known psychoanalyst blamed “the gay rights movement for the Jenny Jones incident.… To turn the world upside down and say it doesn’t matter if we are homosexual or heterosexual is folly… to ask for total acceptance and enthusiastic approval of homosexuality as a normal and valuable psychosexual institution is truly tempting social and personal disaster” (Socarides, quoted in Dunlap, 1995).

Definitions and Issues

The term homosexuality refers to an erotic attraction to persons of the same anatomical gender; bisexuality, to attraction to persons of both sexes; and heterosexuality, to attraction to persons of the other sex. While the terms may suggest categorical divisions between types of sexual orientation, in fact attraction is usefully conceptualized as existing along a continuum. People experience either extremes of same or other sex attraction on the continuum, and others experience some degree of attraction to both sexes (Kinsey, Pomeroy, and Martin, 1948; Money, 1988). By erotic attraction, we mean that the person experiences the psychophysiological changes of sexual arousal with imagery of males, females, or both. We use the term sexual orientation instead of sexual preference because orientation denotes only direction of attraction, not motivation or conscious choice. Sexual preference suggests willful decision making as to the objects of erotic desire. As a general rule, homosexual, bisexual, and heterosexual orientation are not consciously experienced as volitional processes (Friedman, 1988; Isay, 1989; Money, 1989). Sexual activity, on the other hand, is frequently volitional. Thus, there are often incongruities between desire/arousal and behavior.

Many, but not all, persons who are predominantly or exclusively homosexual in their sexual orientation are referred to in this monograph as gay or lesbian. Gay or lesbian connotes an awareness of one’s homosex...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Preface
• Acknowledgments
• 1 Dimensions of Antihomosexual Bias
• 2 AHB in the Clinical Setting
• 3 The Impact of AHB on Supervision and Professional Training
• 4 Legal Aspects of Antihomosexual Bias and Mental Health
• 5 HIV and AHB in Mental Health
• References
• Index