Professional Papers

  • Psychological and Medical Treatments of Homosexuality
    (Published in Homosexuality: Research Implications for Public Policy, edited by Gonsiorek & Weinrich, Sage Publications, 1991. 4,000 words)
This chapter examines the two moments in time, separated by centuries of social change. The first occurred in 1641 in Boston. According to the record, William Hackett was hanged in the public square for the crime of sodomy. Because of the nature of his crime, we know almost exactly what this unfortunate man did to bring himself to the attention of the city fathers and to end with his public execution. He had sex with a cow, probably anal intercourse. We know this because the city fathers executed the cow as well! This extra bit of foolishness was based upon the prevailing belief that animals had “free will!”

The second event took place on Dec. 15th, 1973, when the American Psychiatric Association announced that homosexuality per se was no longer on the list of mental disorders. This event, also a public one, was announced at a news conference, rather than by the town crier. It caused a stir around the world that effected the lives of millions of people, rather than that of one man (and cow) in the first event. Seventeen years have passed since the APA made the brave the decision to reverse their long-standing judgment that homosexuality is a mental illness. It may be enough time to stand back from the controversy, to consider its meaning as a social event, and to examine the ways in which it has resolved some social problems, while at the same time has created new ones.

Medical Diagnosis and Society

The Western world is replete with examples of diagnosis used to enforce correct social behavior. The witch hunts of the 16th and 17th centuries are a good example. Most of the ostensible witches who were burned, stoned, and drowned were old, ignorant, poor women who were considered unusual. There are, however, lessons to be learned from this period. Women confessed to being recruited by the devil and to participating in witches’ Sabbaths. Were they demented? Were they lying? No doubt some confessed in order to reduce the level of torture applied to them, but others probably succumbed to the intense social pressures and believed that they were deviant.

In 1924 the Congress of the United States passed an immigration act excluding or severely limiting immigration from many Eastern European countries. Most historians interpret this law as racist and nativist. The work of Goddard (1917) was often cited as scientific evidence for the inferior genetic intellectual endowment of certain national groups, particularly those from Eastern Europe. Testing 178 steerage passengers with his new IQ test, Goddard found feeble-mindedness in:

83 percent of Jews
80 percent of Hungarians
79 percent of Italians
87 percent of Russians

One researcher of this period wrote:
Researchers recall with sad smiles the miraculous finding, some years after the Ellis Island test, that Jews and Italians improved dramatically in intelligence after they had lived in this country for awhile, and that their children, raised as English speakers, seem to somehow to have been spared their parents’ feeble minded genes.

The greatest confusion between social order and scientific judgment is found in the perception of sexual behavior. Masturbation was socially acceptable until the end of the 17th century, when it suddenly became a medical concern. It was believed that excessive self-indulgence would lead to neurological damage and eventual insanity. John Kellogg developed Corn Flakes with the intention of producing a food that would reduce libidinal feelings that he hoped would eliminate masturbation in children. Nowadays, masturbation is considered a healthy expression of one's sexuality and is even used as a technique in sex therapy. Homosexuality was considered another sexual deviation. It traveled from sin to sickness and has been illegal and immoral almost everywhere in the United States until recent years.

How then does a society decide what behaviors to diagnose? Psychotherapy has a facile answer. Those who suffer are treated. But this is circular reasoning. We now understand that, as a society, we train people to suffer. We decide which behaviors are acceptable, we tell people they are deviant, we stigmatize and oppress them, and when they come to us unhappy about their lives, we tell them to get into treatment. Witches did not invent themselves, their society did. Goddard's steerage passengers knew they were poor, but they did not know they were also feeble-minded until they were turned away from our shores. Women who masturbated were forced to undergo clitoridectomies. Homosexuals, doomed to a life of depression and misery, committed suicide.

All of these people suffered because they were taught to suffer, first by their society at large, and then by the "scientific" community that confirmed the social condemnation by inventing a medical illness to explain their "immoral" behavior. A primary purpose of psychiatric diagnoses, therefore, is an attempt by society to control those people whom it fears.
The Treatment of Homosexuality As A Disease
Perceptions of the ostensible causes of homosexuality reflected the fears of society, and the treatments offered reflected the strength of these fears. This is as true today as it was in the 1641 sodomy case. The psychiatric/psychological establishment had previously invented many theories to explain the genesis of homosexual behavior. Freud believed it resulted from a faulty resolution of the Oedipus complex. Stekel (an associate of Freud's), who like Freud, subscribed to 19th century notions of bisexuality, believed that homosexuality occurred because of the forces of repression. Rado, in 1940, objecting to Freud's acceptance of bisexuality, developed the "phobic theory" of homosexuality and from his work the Adaptation School of Psychoanalysis was born. Although this theory has been discredited, the phobic theory remains popular with some psychoanalysts.

The behaviorist school in psychology also attempted to change gay people into heterosexuals by employing techniques that were often caustic. Aversion therapy is a good example. In it a gay man is shocked by an electrical current if he becomes aroused (erect) to pictures of men having gay sex. Masters and Johnson, though not strict behaviorists, described attempts to change the sexual orientation of gay people. Paradoxically, they also described homosexuals as better lovers than heterosexuals in another section of their study. Their work has often been attacked as lacking scientific credibility and theoretical consistency.

Modern psychotherapists have developed an extremely controversial form of treatment. It is like an alcoholics anonymous 12-step group and uses drug addiction as the paradigm to treat "sexual addiction.” The conceptual soundness and therapeutic rationale for this treatment has been questioned by many. Their patients are encouraged to seek treatment for compulsive masturbation, frequent sex, failure of monogamy, and guilt over sexual behavior. Critics find the conceptual framework elusive, the treatment puritanical, and the judgment of the therapists suspect. It seems as if the advocates of treatment for sexual compulsions are influenced as much by the moral code as by concern for their patients. They claim that patients request this help is reminiscent of the claim of women patients who requested clitoridectomies for their masturbation, or women who admitted to being witches, and gay men who volunteered to be "cured" of the homosexuality.

Underlying these attempts by psychiatry and psychology to change sexual orientation is a basic philosophical believe concerning the nature of humankind. One must make an assumption about the potential malleability of human behavior. Are people like wet clay that can be molded at will? Is a therapist a potter at the wheel, remaking the patient according to the aesthetics of the day, or, once fired, will the pot be impenetrable? It would have been enough for the psychotherapeutic community to teach gay people to suffer and to believe that they were deficient members of their society. On top of that, as attempts to change sexual orientation failed, homosexuals were judged failures even at that! Alternately, researchers suggested improvements in their therapeutic approaches. Never did they seriously consider that sexual orientation couldn’t be molded like wet clay.

The Removal Of Homosexuality As A Mental Illness
How, then, was it possible for the American Psychiatric Association to remove homosexuality from the list of mental disorders, when they knew their decision would meet the rage of those members who had made their reputations by treating it? Bayer, in 1981, has provided a fascinating historical record of the political wrangling that went on behind the scenes. Many people believe that social science research changed the minds of committee members. It seems more plausible that the committee responded to new social values, just as an earlier committee voted to define homosexuality as psychopathic behavior because it was congruent with the social values of the day. The APA decision came during a period of egalitarianism in our society, as gay liberation followed on the heels of the black civil rights movement and the women's liberation movement.

Some critics upset by the removal of homosexuality from the list of mental disorders, have argued that a vote of hand's (referring to the committee vote) is not science. They forget that it was another vote of hands that placed homosexuality on the list in the first place.

Biomedical Treatments of Homosexuality

It would seem that the battle over the diagnostic status of homosexuality has ended. However, while some forms of social control masquerading as science have fallen out of favor, others have emerged to take their place. The latest is the work of biomedical research is in the United States and Germany. Three techniques have been developed that attempt to prevent the development of homosexuality: surgery, hormone treatment, and prenatal treatments. These techniques are built on the belief that biology is destiny.
Surgical Techniques
In 1917, Steinach, a physician, was the first to use a surgical technique to "cure" homosexuality. He performed a unilateral castration on a homosexual man, and then transplanted testicular tissue from a heterosexual man into the castrated patient, in the hope that he would be cured. At least 11 men were operated on from 1916 to 1921. The experiments failed.

In 1962 a new surgical technique was introduced in Germany. Seventy-five men considered sexually abnormal were subjected to hypothalamotomies. Most of these men had either been imprisoned or involuntarily committed to mental institutions. 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 of the patients showed that three refused to participate in the evaluation, one died, and three had "examination findings that are normal in every respect” -- whatever that means. The last two patients were found not to have changed their sexual behavior adequately; both were surgically castrated. Sex researchers in Germany were able to create enough publicity about the surgery that a moratorium was placed on the use of the surgical techniques.

In a bizarre study, one researcher at Tulane University in Louisiana implanted electrodes in the brain of a gay man and introduced a current when the subject (victim?) was in the presence of a female prostitute. According to the theory, the electrical current in the brain would bring pleasure to the man who would associate it with heterosexuality. Needless to say, the experiment was a failure. The report did not say what happened to the man afterward.

Peripheral Hormone Treatment

To many people, homosexuality has meant inadequately masculine in men and hyper masculine women. Consequently, there have been attempts to cure a gay man of his homosexuality by injecting him with androgens (such as testosterone); he would thus be restored to a proper androgens/estrogen balance. This technique, like the others, failed for a good reason. Testosterone increases one’s libido, so in the end, instead of curing the gay men of their homosexuality, they produced a group of unusually horny homosexuals! No sex researcher in the United States now advocates the use of hormone treatment after puberty to change sexual orientation.
Prenatal Hormone Treatment
Biomedical researchers are now concentrating their studies on the influence of hormones during fetal development. This has caused great controversy. In one study, the researcher conducted a series of animal experiments investigating the influence of prenatal hormones upon adult rat sexual behavior. He believes that he has identified an area of the brain that he named the "dual mating center." One part of the hypothalamus is said to control male sexual behavior, mounting, intromission, and ejaculation. A different section controls female sexual behavior called “lordosis” that allows a male to mount a female. The researcher states that if perinatal androgens are high, the male center of the brain will predominate, but if androgens are low, the female center predominates. He also attempted to influence adult sexual behavior in the rat through the perinatal administration of sex hormones. He claims that male rats experimentally deficient in androgens showed lordosis, and that the male rats treated with androgens soon after demonstrated mounting behavior.

In a giant step from rat studies, he then claimed that the same prenatal theory would explain adult sexual behavior in humans. If the "female" center develops in the brain of a genetic and somatic male, a homosexual orientation results. If the "male" center develops in the brain of a genetic and somatic female, lesbianism will occur. A bisexual orientation, therefore, is explained as the effects of an intermediate level of androgens. He believes that in humans, sexual dimorphism (the difference between males and females) of the brain occurs during the fourth to seventh month. He also believes that maternal stress during fetal development causes homosexuality. He wrote the following:

It was concluded from the study that … it might be 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 at all only if it is urgently desired by the pregnant mother. (Emphasis added)

The analogy between rat studies and human behavior is obviously the first conceptual problem in this line of research. Mounting behavior in the rat is assumed to be analogous to human sexual behavior. This follows from the assumption that the "mating center" found in the rat is a homology to a human sexual behavior center. The question "Can a rat be a homosexual?" sounds absurd. While an adult rat can perform sexual behaviors, one would be hard pressed to claim that a rat has a sexual identity, a gender identity, or romantic attachments. One also could not claim that rat sexual behavior is influenced by the moral and social standards of the day. The question, therefore, forces us to look at behavior that is socially, rather than biologically, controlled.

The second conceptual problem is one's definition of abnormality. Upon what criteria does he decide what endocrinological events are normal or abnormal, and upon what criteria is behavior in the adult classified as normal or pathological? None of his research addresses these questions. For the moment let us be generous and assume that prenatal hormone differences exist. Since they do not lead to abnormal physical problems, his criteria for abnormality can only be that they create a homosexual adult. This end result is abnormal only in the sense that he, like the society in which he lives, disapproves of homosexuality. Without this opprobrium, the development of "male and female centers" of the brain become nothing more than variations in normal development in brain differentiation.

The implications of biomedical research are awesome, and the ethical problems monumental. If these efforts should succeed in unlocking the biological components of human sexuality, would parents be given the right to influence the fetal development of their children? Would such scientific knowledge advance society, or would it only pander to its fears? We have no right to expect the general population to avoid influencing the development of their children given the opportunity. We must expect that parents will want children who have socially desirable characteristics, including physical type, intelligence, coloring -- and sexual orientation.

Of course, biomedical research may fail to prevent the development of homosexuality. Even so, prenatal treatment may still be offered. This chapter argues that therapeutic treatment represents punishment inflicted on people who have transgressed the 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 criteria governing its use.
When breakfast cereals didn’t prevent children from masturbating, torturous devices were invented to prevent it from happening. Steinach tried to cure homosexuality through surgery in 1917, and then the 1970s other surgeons performed brain surgery until stopped for moral and ethical reasons, not because of their experiments were a failure.

Psychologists and psychiatrists attempted to cure homosexuals of their sexual affliction by various means. Aversion therapy ended only because it was no longer fashionable in the egalitarian 1970s, not because it did not work. 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. (This is no longer true.) Since our society has laid a veneer of guilt over one's sexual desires, any form of treatment will find a willing supply of volunteers. The problem with biomedical research is that it has eschewed moral and ethical considerations and thereby reinforced societies fear of uncontrolled sexual desire.

The Positive Approach To Psychotherapy For Gay People
It is difficult to point to the first instance of a therapy not based upon the belief that homosexuality is a pathology. However, one can point to the formation of gay counseling centers as the most significant step toward providing an alternative form of therapy 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, while 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. Previously, the professional community had been obsessed with the causes of and cures for homosexuality. Instead, the gay counseling centers affirmed the homosexuality and proceeded to treat the person. These centers provided a setting where gay professionals could gather together and exchange information and ideas. Much of the literature on gay affirmative treatment is a direct result of these counseling centers.

Alfred Kinsey in 1948 provided the first unbiased scientific information on the sexual behaviors of men and women in the United States. He and the staff of the Kinsey Institute acknowledged the contribution of Evelyn Hooker who was the first to establish that under blind analysis, no difference could be found in the mental health status between homosexual and heterosexual men.

The concept of sex research unfettered by psychoanalytic theory became a new discipline, and two new journals were published, the Journal of Sex Research and Archives of Sexual Behavior. Both were multidisciplinary and published statistical and clinical papers about all facets of human sexuality. Then, in 1976, the first issue of the Journal of Homosexuality was published. J H gave rise to the largest collection of published papers on psychotherapy with gay people. A number of books about psychotherapy with gay people were subsequently published.

The publication of papers and books demonstrating an alternative approach to treating gay men and women was decisive in teaching professionals about the therapeutic needs of the gay community. Gay professionals began using the term "gay affirmative psychotherapy.” This suggested that homosexuality was an acceptable life-style, and that therapists should attempt to provide corrective experiences to ameliorate the consequences of biased socialization. Mosher, wrote "To understand what it is like to make homosexual choices in American society, you need to be able to see with gay eyes, to hear with gay ears, to feel with a gay heart -- you need empathy for the gay perspective."

The published literature on psychotherapy since the nomenclature change can be divided into two areas. The first is the effect of external stressors upon the behavior of the gay person. These stressors would include homophobia, relationship to the family, parenting children, civil and legal rights, coming out, problems of adolescence, impediments to successful love relationships, discrimination, and the recent epidemic of AIDS. In these topical area is one can find the greatest amount of published material, because gay people continue to experience the effects of discrimination. The published material attempts to define the sources of stress and to suggest a mechanism to alleviate it. Presumably, if the external stressors were eliminated, psychotherapy for those problems would also be unnecessary. Coping with a discriminatory world is its essential theme.

The second type of literature attempts to define internal psychological processes that cause emotional pain for gay people. The majority of these papers discusses the effects of low self-esteem and self-hate, or what has been termed "internalized homophobia." Other topics include affective disorders, sexual problems, identity formation, and borderline conditions. (See Paper Number 3)

This literature is distinctly different from the old psychoanalytic theory in one important way. Psychoanalysis was obsessively concerned with the causes and cure of homosexuality. The new forms of treatment reject the concept of etiology. New therapeutic techniques assumed that same-sex preferences are an acceptable variation of human sexuality. This is why gay affirmative therapy is a directive form of treatment as opposed to earlier techniques that maintain a guise of neutrality while drawing on the societal induced self-hate in their gay patients.

But what have we learned about the needs of gay men and women by the use of affirmative forms of therapy? Do they carry into the consulting room dreams of a life free from discrimination and internal conflict? As gay therapists look back after years of experience, and as the published papers suggest, gay women and men are trapped by subscribing to generally accepted middle-class values. They have been banging on the door of American society in the hope of fading into the mainstream of social life. Gay people are having children, buying houses, striving for success, and in general, maintaining households that are indistinguishable from those of married heterosexuals.

The mystique of gay life was abandoned with the APA nomenclature change, and even more so in light of the AIDS epidemic. The theories about the genesis of homosexuality suggested that gay people suffered degenerative brain diseases, were sexually promiscuous, and were sinful and harmful to the family structure. Although homosexuality was rejected by society, these epitaphs created an aura of uniqueness surrounding gay people. They were members of a subculture and were feared as much as they were despised.

Ironically, in their attempts to "cure" homosexuality psychoanalysts provided the very atmosphere that maintained its uniqueness. Instead of remolding gay people into a heterosexual form, they perpetuated an underground society whose insularity was strengthened by the fear of a common enemy.

Prospects For The Future
How has treatment changed since the 1973 APA decision? Before the 1970s, homosexuality was classified as a mental disorder and all treatments were designed to change it to heterosexuality. The APA decision clarified the mental status of homosexuality. It is not a mental illness. With this decision +came a wave of new therapies whose goal was to treat the societally induced ills of gay people and to assist in their integration in society. These have been successful. Gay people participate in all levels of our society, and when conditions are right, do so openly as gays.

Psychotherapists can now be a positive force in the lives of gay people, and loving relationships between gay men and between lesbians are reinforced by affirmative therapists. At the same time some biomedical research seek techniques to prevent the birth of children who might ultimately be gay.

This chapter began by noting two moments in time, one in 1641 with the hanging of William Hackett for sodomy, the second the APA nomenclature change normalizing homosexuality. Unfortunately, the issue has not yet been fully resolved. There is a third "moment" yet to come. It will arrive when more publicity surrounds the work of biomedical research on sexual orientation, and their potential claim to reverse a homosexual orientation. Other "moments" will come, too, whenever mental health professionals and researchers are irresponsible, blind, and arrogant enough to convince themselves and society that the social control of disenfranchised groups constitutes good science.