Professional Papers

  • History of Treatment/The Medical Treatment of Homosexuality. In Cabaj & Stein,
    (Published in Textbook of Homosexuality and Mental Health, edited by Cabaj & Stein, American Psychiatric Association, 1996. 2,800 words.)****
There has always been a close fit between social norms and medical diagnosis and treatment. The treatment of homosexuality is a case in point. In no other diagnostic area can one find greater confusion between social mores and scientific judgment. Homosexuality, which traveled from sin to sickness, was illegal and immoral almost everywhere in the United States until recent years. Until recently, homosexuals might have committed suicide because they were doomed to a life of depression and misery. These people suffered because they were taught to suffer, first by their society at large and then by the scientific community, which declared that homosexuality was a medical illness.

The Treatment of Homosexuality as a Disease
Until 1973, when the American Psychiatric Association officially removed homosexuality from its list of mental disorders, the body politic feared homosexual behavior. It did everything possible to prevent homosexuality, control it, and when nothing else worked, punish it. As perceptions of the "causes" of homosexuality reflected the fears of society, so the treatment reflected the appropriate punishments for the transgressions. The psychiatric and psychological establishments had previously invented theories to explain the genesis of homosexual behavior. Freud suggested psychodynamic factors. Rado, objecting to Freud's acceptance of bisexuality, originated the phobic theory of homosexuality.

The behaviorist school in psychology also attempted to convert gay people into heterosexuals. Some of their treatments were caustic. Three forms of aversion therapy were used. The first was electrical aversion therapy, in which an electric shock was administered to the patient if he responded erotically to a picture of a new man. Another technique was called covert sensitization, in which disgust and images of vomit were thought to cure homosexual desire. The third type of aversion therapy used the drug apomorphine, which induces nausea in the patient. Gay liberationists viewed these aversive procedures as punishment, not treatment.

Davison, who later rejected his early work, called his system "Playboy therapy," in which a gay man masturbated to pictures of naked women. A good review of the aversion therapy literature is provided by Bancroft, who himself contributed significantly to the aversion therapy literature. Masters and Johnson also attempted to change the sexual orientation of gay people.

Perhaps the most bizarre attempt to reorient the sexual orientation of a gay man was performed by Heath at Tulane University in 1972. Heath implanted electrodes into the brain of a gay man. The patient was then placed in a room with a woman prostitute, who was hired to seduce him. As the same time, Heath stimulated the pleasure centers in the brain of the man. This attempt was not a success.

Underlying these attempts by psychiatry and psychology to change sexual orientation is a basic philosophical belief: an assumption that human behavior and sexual orientation are potentially malleable.
Of those gay people who volunteered for "cure," few were able to claim a change in their sexual orientation. Thus, these homosexuals could be seen as "failures," and invariably, researchers blamed the patient's themselves for not been sufficiently motivated. Never did they seriously consider the possibility that sexual orientation unfolds naturally like the buds of a flower, rather than as a result of subterranean psychical forces.
The Positive Approach to Psychotherapy With Gay People
The formation of gay counseling centers signified one of the most significant steps for providing an alternative form of treatment for gay people. In the early 1970s, gay counseling centers were formed in New York, Philadelphia, Pittsburgh, Boston, Seattle, and Minneapolis. Some were staffed only by peer counselors, and others were staffed by both peers and professionals. All provided low-cost service to gay people who were experiencing emotional distress but did not want to change their sexual orientation. Thus, these clinics’ services were distinguished from the pathology-focused psychotherapy offered in traditional clinics. Whereas previously the professional community had been obsessed with the etiology and cure of homosexuality, the gay counseling centers ignored these issues and treated the person.

The gay community centers also provided a place where gay professionals could learn more about the emotional problems of gay people and meet with other gay professionals. Many gay psychiatrists, psychologists, and social workers who worked in the centers authored a new literature or on gay-affirmative psychotherapy.

The foundations for these gay counseling centers came from two sources. The first was the gay liberation movement. The second, and more important source for the purposes of this chapter was the rise of sex research as a scientific discipline, as represented by the work of Kinsey and his colleagues. Kinsey provided the first meaningful studies of sexual behavior ever completed in the United States by documenting the actual sexual experiences of men and women. These researchers published the material to a chorus of anger from traditional religious and psychiatric groups, who reacted, for example, to findings such as one-third of the adult male population had had some homosexual activity to orgasm since puberty.

Sex research, unfettered by psychoanalytic theory, became a new discipline, and two new journals appeared, The Journal of Sex Research, and Archives of Sexual Behavior. Both are multidisciplinary and publish statistical and clinical papers about all facets of human sexuality. In 1976, the first issue of the Journal of Homosexuality was published, giving rise to an ever-increasing collection of published papers on psychotherapy with gay people. This journal also devoted whole issues to descriptions of therapeutic approaches to working with gay people. These authors rejected the medical model of homosexuality.

The publication of papers and books demonstrating an alternative approach to treating gay men and women was instrumental in teaching the professional community about the therapeutic needs of the gay community. At first, gay professionals used the term "gay-affirmative psychotherapy," described by the psychologist Malyon this way:

This theoretical position regards homosexuality as a nonpathological human potential. But while the traditional goal of psychotherapy with homosexual males has been conversion to heterosexuality, gay-affirmative strategies regard fixed homoerotic predilections as sexual and affectional capacities which ought to be valued and facilitated.

According to Malyon gay-affirmative psychotherapy should accept homosexuality as a fixed human potential and attempt to alleviate the harmful effects of internalized homophobia.

The literature on psychotherapy with gay people since the removal of homosexuality from the list of diagnoses of mental illnesses in 1973 can be divided into three areas. The first is concerned with the effects of external stressors. These stressors include homophobia, relationship to families, parenting children, civil and legal rights, coming out, problems of adolescence, impediments to successful love relationships, discrimination, and the recent epidemic of AIDS. This material defines various sources of stress and suggests ways to alleviate it. Presumably, if the external stressors were eliminated, psychotherapy for problems in these areas would become moot (to say nothing of making people's lives more productive).

Coping with a discriminatory world is the central theme in all of the literature cited above, and the role of the therapist is often that of an advocate. The gay or lesbian therapist may be open about his or her own sexual identity in the belief that coming out is an important part of the healing process for both therapist and patient. There are, however, differences of opinion on how open the therapist should be about other aspects of his or her own life. Those professionals employed in public institutions are rightly worried that disclosures of their sexual orientation will result in discrimination against them by supervisory staff.

In a second area of the literature, attempts are made to define internal psychological processes that are associated with emotional pain for gay people, both male and female. The largest number of papers published in this area are about the effects of low self-esteem and self-hate, or what has been called "internalized homophobia." Other topics include affective disorders, sexual problems, merger in lesbian relationships, identity formation, and borderline conditions. (See Paper Number 3)

A few writers have tried to bridge the gap between a gay-affirmative model and traditional psychoanalytic therapy, suggesting that one can use the techniques of analytic therapy yet reject analytic beliefs of normal (meaning heterosexual) development. Isay, writing in traditional psychoanalytic journals, described heterosexual bias in the treatment of gay people, and later supported Silverstein's suggestion that psychoanalysis ignored the special relationship between a gay son and his father. Mainstream psychoanalysis has not been sympathetic to these ideas. In general, this literature more closely approximates the general psychotherapy literature, and a larger number of the authors write from a psychodynamic point of view. The role of the therapist is also more traditional than one finds in gay-affirmative psychotherapy.

The final area of emphasis is on psychotherapy technique. One of the earliest papers on this topic described the use of group psychotherapy with gay men. Fensterheim, long known for his work in assertiveness training, used these techniques effectively with gay people. In general, behavior therapists were the earliest to report using psychological techniques to aid sexual functioning in gay men. Some, such as Davison, addressed the ethical as well as the therapeutic concerns.

This newer literature is distinctly different from the older psychoanalytic writings that focused obsessively on the etiology and cure of homosexuality. The new forms of treatment reject concepts of etiology with their emphasis on abnormality. Newer therapeutic techniques assume that same-sex desire is an acceptable variation of human sexuality and that attempts to identify the "cause" of homosexuality can lead to political, social, and legal efforts to repressing it.

In terms of current psychotherapeutic approaches to working with gay people, a significant controversy persists regarding sexual addiction. Using drug addiction as the paradigm, proponents of these approaches treat "compulsive sexuality," consisting of behaviors such as masturbation, frequent sex, failure of monogamy, and guilt over sexual acts, with an Alcoholics Anonymous 12-step program.

The conceptual soundness and therapeutic rationale for this treatment program have been questioned by others who find the conceptual framework one-dimensional, the treatment puritanical, and the potential judgment by the therapist suspect. These critics argue that advocates of treatment for sexual compulsions are influenced as much by the moral code as by concern for their patients. The claim by advocates that patients request this help is reminiscent of homosexual men who, before the 1973 American Psychiatric Association decision, asked to be cured of the homosexuality. What those men and the patients volunteering to be cured of their compulsive sexuality have in common is that they have been taught to be ashamed of their sexual desires.
Biomedical Treatments of Homosexuality
Storm clouds are growing in the treatment literature. Although it may seem that the battle over the diagnoses and treatment of homosexuality is over, that is an illusion. A new threat to gay people has arisen resulting from the work of biomedical research in the United States and Germany. These researchers have introduced a whole range of theories and treatments that can be used either to prevent the development of homosexuality or to eliminate it in adults. Three techniques for identifying the cause of, and then eliminating, homosexuality has been described: surgical techniques, use of hormones, and prenatal research. Each derives from the belief that biology is destiny.

Surgical Techniques
Steinach in 1917 was the first to use a surgical technique to attempt to cure homosexuality. First, he performed a unilateral castration on a homosexual man, then transplanted testicular tissue from a heterosexual man into the castrated patient. He did this in the belief, prevalent in those times, that homosexuality was a form of hermaphrodism. Steinach was in step with the belief that homosexuality represents a "third sex," and idea originated by Ulrichs and popularized by Hirschfeld. At least 11 men were operated on from 1916 to 1921. Complete castration was not performed in the belief that after transplantation of the "normal" testicular tissue, the man would be cured, married, father children, and lead a heterosexual life. The experiments were a failure.

In 1962 Roeder introduced a new surgical technique. He produced a right-side lesion in the brain of the 51-year-old man diagnosed as a pedophilic homosexual. Since then, seventy-five men considered sexually abnormal have been subjected to hypothalotomies. Most of the men were either imprisoned or involuntarily committed to a mental institution. Most had been diagnosed as either pedophiles or hypersexed; however, the criteria for diagnoses remained unclear. Other researchers claimed that "normal" homosexual men were also operated upon. They also showed that one of Roeder's patients was operated on because, at the age of 37, he masturbated daily. They concluded that the procedure was used as an inexpensive alternative to psychotherapy in the West German prison system.

The surgeons claimed that their patients had requested the operations; therefore, no coercion was involved. However, it is likely that the prisoners hoped that by agreeing to the procedures, they would be given their freedom. There is disagreement over the effects of the surgery. The surgeons make no clear claims for success, and there is no evidence that sexual orientation was changed. A three-year follow-up on 10 patients showed that three refused to participate in the evaluation, one died, and three had "examination findings normal in every respect" -- whatever that means. The last two patients were found not to have changed their sexual behavior adequately, and both were surgically castrated. Sex researchers in Germany demanded that the government declare a moratorium on the use of the surgical techniques. Publicity over the inhuman nature of these experiments has stopped them, at least temporarily.
Hormones and Prenatal Research
To summarize the work on peripheral hormone treatment, researchers have interpreted homosexuality as inadequate masculinity in men and hypermasculinity in women. From this unidimentional notion came the suggestion that one could cure a man of his homosexuality by injecting him with an androgen, thought of as the male hormone. Thus, the gay man would be restored to a proper androgen/estrogen balance and hence live a heterosexual life. It didn’t work.

Dörner et al. even advocated altering the hormonal environment of the fetus. These researchers made it quite clear that they were attempting to eradicate homosexuality. Earlier, Dörner stated,

It was concluded from these data that... it might become possible in the future -- at least in some cases -- to correct abnormal sex hormone levels during brain differentiation in order to prevent the development of homosexuality. However, this should be done, if et al., only if it is urgently desired by the pregnant mother.

Researchers at the Psychiatric Institute in New York also work toward identifying the prenatal hormonal influences on sexual orientation and gender behavior, although they reject the use of this information to alter sexual orientation.

In this chapter the author argues that many forms of therapeutic treatment imposed on gays represent punishment inflicted on people who have transgressed sexual rules of our society. The purpose of that punishment is twofold: first, to punish the transgressor and, second, to prevent others from participating in nonconformist sexual activities. The efficacy of the treatment has rarely been the criterion governing its use. Steinach tried to cure homosexuality through surgery in 1917. In the 1970s and 1980s, surgeons in Germany performed brain surgery on homosexual man. Although the experiments were a failure, the surgery was stopped for moral and ethical reasons, not because of its ineffectiveness.

Psychologists and psychiatrists attempted to cure homosexuals of their sexual desires by various means. Aversion therapy ended only because it was no longer fashionable in the egalitarian 1970s. Psychoanalysis has had an even longer life, and after years of failing to "cure" homosexuality, most psychoanalysts still maintain that homosexuality is a pathology that is curable with years of treatment. Because our society has laid a veneer of guilt on everyone's sexual desires, any form of treatment will find a ready supply of volunteers. A central problem with much biomedical research is that it largely eschews discussion of the moral and ethical implications of its findings; thereby, with respect to sex research, it reinforces society's fears of uncontrolled sexuality.

Psychotherapists are now a positive force in the lives of gay people, and loving relationships between gay men and between lesbians are reinforced by gay-affirmative therapists. At the same time, some biomedical researchers have shifted the focus from a psychological pathology to a physical one and have even suggested techniques to prevent the birth of children who might ultimately become gay.

How society will respond to biomedical research is unknown. It may use it to reinforce traditional notions of sexuality, gender, and the family. One hopes -- at least this writer hopes -- that the knowledge will be used to further appreciation for diversity among people.