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Joumal of medical ethics, I980, 6, 130-132 J Med Ethics: first published as 10.1136/jme.6.3.130 on 1 September 1980. Downloaded from

Psychosocial aspects of

Sidney Crown Department of Psychiatry, The London Hospital, London

Editor's note elective, 'facultative' or situational homosexuality with a prevalence of 37 per cent. Thus over one third of the This paper and that which follows by M 7 MacCulloch male population has some homosexual experience in were prepared for a London Medical Group symposium adulthood. entitled 'Homosexuality: congenital or acquired?' held at Another way of classifying homosexuality is to the Middlesex Hospital Medical School in October 1979. express in terms of a spectrum or Dr Crown deals with thepsychological and socialfactors scale as Kinsey and his collaborators do. Their 7-point of homosexuality. While he believes that part of scale has homosexuality and at the two homosexual behaviour may begenetic, DrCrownfeels that extremes and, at the central point, in which the acquired factors are likely to remain more salient the sexual expression is equally homosexual and especially the intrafamily ones. heterosexual. In between these nodal points are per- who are either more hetero- than homo- or more Clinicians and researchers of a wide variety oftheoreti- homo- than heterosexual. cal backgrounds accept that sexual orientation and The question arises whether homosexuality forms a sexual expression relate to the interaction of many perversion of the normal sexual instinct, as factors - inborn, psychological, social, cultural and psychoanalysts still hold' because a psychoanalyst's

situational. essential criterion for is that a person copyright. I am concerned in this paper with psychological and should form a mature relationship with someone of social factors. Obviously there is a constant interaction the opposite including having children. Opposed between what is 'psychological' and what is 'social', to this is the view of the organisations, never more clearly demonstrated than in the forcefully argued by Tripp2 that homosexuality is a environment and its impact on the individuals within normal sexual variant. A mid-way position, followed it. by many who find homosexuality difficult to regard My contribution to this symposium is to suggest that either as a perversion or as a normal sexual variant, psychosocial factors are important in the background is that of sociologists who use the term sexual http://jme.bmj.com/ to, and expression of, homosexuality and to the treat- deviance. ment of problems arising in relation to it. There are, however, many forms of sexual deviance. I restrict myself to male homosexuality. The What seems of fundamental importance to the present research literature on lesbianism is scattered, patchy in writer3 is that, compared with expressions of quality and difficult to synthesise. Also, like many sexual deviance, homosexuality is unique in that a male clinicians working with psychosexual problems - relationship is not only formed with a whole person as partly, perhaps, because we are male - my of a a foot fetish); but compared say, to part person (eg on September 24, 2021 by guest. Protected psychotherapeutic experience with homosexu- also that homosexuality between consenting adults als has been meagre. involves an appropriate person, whereas other sexual deviances may involve an inappropriate person (eg a Homosexuality or as in paedophilia or a dead body). The more reading, thinking and psychotherapy one We are dealing therefore with homosexualities does with homosexuals the more one realises that the rather than with homosexuality. It is also relevant to general label 'homosexual' is as non-discriminatory as remind the reader that if sexual orientation towards the label 'heterosexual'. Just as there are many, one's own sex is difficult to understand so is the fact perhaps an infinite number of, ways of expressing that the majority of persons tend to develop a sexual heterosexuality so there are a very large number of orientation towards the opposite sex. Bancroft4 under- ways of expressing homosexuality. In this sense the lines a further paradox: why is not suffi- term should be in the plural. cient to reduce the sexual drive? Why is a sexual part- This plural expresses itself in several ways. In the ner needed at all? first instance there is a differentiation between A consideration of the major research literature on 'obligatory' homosexuality which Kinsey says has a male homosexuality seems to me to suggest that, while prevalence in the USA of 4 per cent and in which the the importance of inborn factors remains to be estab- person concerned is homosexual from childhood and lished, especially prenatal hormonal effects, during expresses his sexuality in no other way, compared with 'sensitive' periods of development of the nervous sys- Psychosocial aspects of homosexuality 131J Med Ethics: first published as 10.1136/jme.6.3.130 on 1 September 1980. Downloaded from tem, it is the complicated learning ofthe sexual therefore, there is probably little to differentiate male drive within a social-cultural milieu, that guides the homosexuals from appropriately matched controls, a minority of persons towards a homosexual orientation. conclusion also reached after a critical review of the It also seems likely, in terms of clinical practice and research literature by Hart et al.8 However, where published research, that the more important psychoso- there are suggestive minor differences, these are in the cial factors are those happening in early life especially direction of greater disturbance among the early family life. homosexuals. Given the establishment of a homosexual orienta- tion, social-cultural factors are highly relevant too as to how the individual homosexual expresses his sexuality. FAMILY CONSTELLATIONS Social factors also are of significance therapeutically Accepting that male homosexuals are not significantly because therapeutic systems and the therapists who psychologically disturbed, it is still important, in terms practice them live in the same social system and are of the emphasis placed on family factors by subject to the same social pressures as their clients. psychoanalytically orientated psychiatrists, to consider the evidence. Bieber's research9 is seminal in this area. Question- Psychological aspects of homosexuality naires were completed by psychoanalysts for IO6 male This is a confused and confusing area with dogmatic homosexuals and their responses compared with those statement and equally dogmatic counter-assertions - a of IOO heterosexual male patients. A family constella- situation all too frequent in psychiatry because of the tion of the homosexuals was described where the paucity of reliably established facts. There are two mother is close-binding intimate (CBI), seductive, important broad areas: First, are homosexuals more inhibiting and over-controlling. of homosexu- psychologically disturbed than appropriately matched als tended to be detached, hostile, minimising and comparison groups? Secondly, as regards causation, openly rejecting towards the potentially homosexual can significant family constellations . The combination of a close-binding, intimate and of attitudes and dominant mother and a hostile detached is espe- emotions be regarded as contributory? cially important for the development of homosexual-

ity. Bieber and others particularly note the father'scopyright. HOMOSEXUALITY AND PSYCHIATRIC MORBIDITY influence for good or ill. Psychiatrists have tended to regard homosexuality as In a follow-up report Bieber and Bieber'° note that abnormal and to make homosexuality a diagnosis. In by this time they have seen over IOOO male homosexu- the USA the American Psychiatric Association offi- als in psychoanalytically focused psychiatric interviews cially removed the designation of homosexuality as a and IOO pairs of parents. The socio-economic stratum mental disorder in 1974.5 was lower than in their original sample and there were The suggestion that there is no demonstrable three ethnic groups; white, black, Puerto Rican. The psychological disorder in homosexuals is supported by previously noted family psychological constellationhttp://jme.bmj.com/ two studies. Hooker (quoted by Kolodny et al5) was confirmed and the negative relation with the father showed that when psychological tests of a projective particularly emphasised: 'we have never interviewed a type were given to 30 homosexuals and 30 matched male homosexual whose father openly loved and heterosexuals, no valid differentiation, including sex- respected him'. Bene"' used a projective test, the Fam- ual orientation, could be established by an expert out- ily Relations Test, from which was derived a quantita- side assessor shown the test results 'blind'. O'Connor7 tive score for early family relationships. Eighty-three made a systematic clinical comparison of 50 homosex- male homosexuals were compared to 84 married men. uals with 50 neurotics seen in RAF psychiatric prac- A negative, hostile and affectionless, relation of the on September 24, 2021 by guest. Protected tice. The two groups were indistinguishable as regards homosexual with the father was noted but there was. neurotic traits in childhood and family history of also a hostile relationship of the homosexuals to the neurosis; homosexualityas such was the only factor that mother - an unusual finding. O'Connor7 in the study differentiated the groups. previously referred to found statistically significant In contrast Saghir et a16 systematically compared 89 differences between his homosexuals and his neurotic male homosexuals contacted through homophile patients on several aspects of family interpersonal rela- organisations with 35 unmarried men. Although the tionships. The homosexuals were more attached to differences were only slight they were in the direction mother than to father than the neurotics; more fre- of an increase in difficulties among the homosexual quently had a poor relationship with their father; and group. These included a slightly greater prevalence of the father was away from home for a long period during manifest psychopathology and difficulty in coping childhood and more for the homosexual with it, especially affective disorder. A higher pro- group than the neurotics. portion had experience of psychotherapy; had more - On balance, therefore, the family psychological con- although not statistically significantly more - trouble stellation seems relevant to the development of male with excessive drinking; a greater proportion had homosexuality. More detailed investigation is needed attempted ; there were more college dropouts. of parental relationships and major interest attaches to So far as psychological adjustment is concerned, the supposedly poor relationship with the father. 132 Sidney Crown J Med Ethics: first published as 10.1136/jme.6.3.130 on 1 September 1980. Downloaded from

The expression of homosexuality as by a strict behaviourist, to the eclectic therapist's attempt to help with problems as defined by the clients The expression of a 's homosexuality is peculiarly themselves, therapist and patient should be matched in related to factors in the social environment; from secre- values and attitudes. Unfortunately this is not some- tive, tortured, sensitive professional men terrified that thing that is usually possible in the current structure of being found out will lead to personal ruin, to the rauc- our psychiatric and psychological services. ous, aggressive, exhibitionism ofthose with a compul- sive need to demonstrate their 'liberation'. Conclusions Within one sub-, and I speak about London Insofar therefore as there is any answer to the title of which I know well, the form ofhomosexual expression this Symposium 'Homosexuality - congenital or is related not only to societal forces as they are at the acquired?' it seems likely that part of homosexuali moment but also as they have changed over the last 20 behaviour may ultimately be shown to be inborn. years. In the early I*6os a young homosexual might Acquired factors are, however, likely to remain more express the fear that 'I might be homosexual'; now his salient, especially intrafamily factors. The role of the problem is more likely to be that he would like to 'come father may be particularly important in the develop- out' in the world but is afraid to do so. Adult ment of male homosexuality. Social and cultural fac- homosexuals, from young to late middle age, vary in tors are relevant to the actual form of homosexual their sexual and coupling arrangements from the expression, whether full social acceptance is afforded! extremely promiscuous inadvertently involved in the the homosexual man or whether he is in some way, current spread ofsexually transmitted diseases (Judson socially or occupationally, stigmatised. Psychotherap- et alU2) to those living in a stable relationship with one ists dealing with homosexual problems live, as much as partner. their clients, within a specific culture which conditions It is not possible usefully to generalise about their own attitudes to homosexuality and to their homosexual expression except to underline its extreme therapy goals. Because of this, therapist and potential variability. No one therapist sees persons from the client need to discuss goals and methods before;- whole spectrum of homosexuality. One's view is embarking on therapy. inevitably through the eyes of one's clients who, by References

definition, have a problem either with their homosex- copyright. ual orientation as such or, more likely, with the limita- 'Socarides, C W (I979). The psychoanalytic theory ofl tion that, even in our apparently liberated society, homosexuality: with special reference to therapy. Ini Rosen, I (Ed) Sexual deviation (2nd edn) pp 2 1 deviant sexual expressiop has on personal, social or 2Tripp, C A (I977). The homosexual matrix. London, Quartet. occupational choice. Books. 3Crown, S (I979). Male homosexuality: perversion, deviation The social context of therapy or variant? In: Sex, hor,nones& behaviour. CIBA Found-; Therapy for homosexuality is as deeply embedded in ation Symposium 62, Excerpta Medica. our culture as is the behaviour it is designed to help. 4Bancroft, J H J (1970). Homosexuality in the male. British http://jme.bmj.com/ Outside formal psychoanalysis' the idea of 'cure' in the journal of hospital medicine, 3, i68-i8i. 5Kolodny, R C, Masters, W H and Johnson, V E (i979). sense of changing homosexual orientation is unfash- Textbook ofsexual medicine, Chapter 17. Homosexuality.C ionable, frowned upon by gay organisations, as within Boston. Little, Brown & Company. the province of despised 'change therapists'.2 Any 6Saghir, M T, Robins, E, Walbran, B and Gentry, K A' attempt even to discuss these problems in public (1970). Homosexuality III. Psychiatric disorders and arouses intense feelings of hostility and meetings may in the male homosexual. American journal of be psychiatry, I26, I079-l086.

disrupted. on September 24, 2021 by guest. Protected On the other hand most eclectic therapists, whether 70'Connor, P J (I964). Aetiological factors in homosexuality' psychodynamic or behavioural in orientation, see their as seen in Royal Air Force psychiatric practice. British task as helping homosexual clients with problems aris- journal ofpsychiatry, 110, 38I-39I. "Hart, M, Roback, H, Tittler, B, Weitz, L, Walston, B and ing directly or indirectly from their homosexuality McKee, E (1978). Psychological adjustment of nonpa- using any therapeutic method likely to be appropriate. tient homosexuals: critical review of the research litera- Bancroft'3 expresses this as 'a behaviourist's view'; but ture. Journal of clinical psychiatry, 39, 27-31. few non-behaviourists would quarrel with the thesis "Bieber, I (I962). Homosexuality. A psychoanalytic study. Basicd presented in his well argued paper. Marteau, a priest Books. New York. and psychotherapist, in a discussion of the present '0Bieber, I and Bieber, T B (i979). Male homosexuality. writer's paper,3 movingly discusses the additional Canadian joumal ofpsychiatry, 24, 4094I9. therapeutic problems presented by homosexuals with a "Bene, E (i965). On the genesis of male homosexuality: an religious background and an overlay ofreligious guilt. attempt at clarifying the role ofparents. Britishjournal psychiatry, iII, 803-813. He points out that the 'gay' scene is not always gay; 2Judson, F N, Miller, K G and Schaffnit, T R (I977). Screen-j some homosexuals feel deprived of family or of being ing for and syphilis in the gay baths: Denver,9 accepted in their society or subculture. . Americanjournal ofpublic health, 67, 740-742. With therapists varying in their attitudes and 3Bancroft, J (1975). Homosexuality and the medical approach to homosexuality from a perversion to be sion: a behaviourist's view. Journal ofmedical ethics,profes-ii,' cured as in psychoanalysis, to behaviour to be changed I76-I80.