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 homosexuality 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 sexual orientation 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 heterosexuality at the two homosexual behaviour may begenetic, DrCrownfeels that extremes and, at the central point, bisexuality 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- sons 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 normality 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 sex including having children. Opposed between what is 'psychological' and what is 'social', to this is the view of the homophile organisations, never more clearly demonstrated than in the family 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 other 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 female 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 homosexualities child 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 masturbation 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 history 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. Fathers 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 son. The combination of a close-binding, intimate and of attitudes and dominant mother and a hostile detached father 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