"Homosexuality is assuredly no
but it is nothing to be ashamed of,
no vice, no degradation.
It cannot be classified as an illness;
we consider it to be a variation
of the sexual functions
produced by a certain arrest of sexual development."
In the past decade there has been a considerable resurgence of psychiatric as well as public interest in the problem of homosexuality. Homosexuals have become more visible and vocal, and their demands for more equitable treatment under the law have grown stronger.* Concurrently, their objection to traditional psychiatric assessments of them as people who are mentally or emotionally ill has taken on vigorous proportions, and the presence of angry, protesting "gay militants" has become a familiar scene at psychiatric conventions.
Psychiatrists themselves continue to disagree about various aspects of the problem- its definition, its nature and etiology, its prevention and treatment. In what follows, and within the limitations of the space allotted to me, I shall present a summary overview of some aspects of these controversial issues.
Definition. Homosexuality has been defined most simply as behavior involving sexual relations with a member of the same sex.4 However, a simple operational definition does not do justice to the wide variety of motivations that can underlie such behavior. Some men engage in homosexual behavior only because females are unavailable, as in prison; others are forced into it by threat or violence;5 still others indulge in it for money, or out of a compulsive need to please, or out of boredom, loneliness, curiosity, rebelliousness, or psychotic confusion. Homosexual exchanges are also common as transitory phenomena among many adolescents and pre-adolescents as an expression of their intense sexual needs and curiosity in a society that interdicts the heterosexual explorations they would prefer.
A psychodynamic definition of homosexuality should attempt to differentiate those individuals with strong preferential erotic attraction to members of their own sex from those who indulge in homosexual acts for other reasons, but whose primary erotic preference is for members of the opposite sex." Thus, if homosexuality is to be clearly differentiated from heterosexuality, it should imply the same kind of strong and spontaneous capacity to be aroused by a member of one's own sex as heterosexuality implies in regard to members of the opposite sex. In this context, it is the preferential arousal pattern that is crucial, not the overt behavior. Some individuals with such feelings may avoid overt homosexual behavior out of intense social fears or internalized moral prohibitions; they are analogous in this regard to inhibited or repressed heterosexuals.
From a purely behavioral standpoint, moreover, homosexuality and heterosexuality in humans are by no means discrete or clear-cut phenomena; they are points on a continuum of sexual behavior that ranges from exclusive heterosexuality through various degrees of bisexual experience to exclusive homosexuality. In general, when the term "homosexual" is used in psychiatry, it refers to individuals who rate either 5 or 6 on the Kinsey scale; that is, those who are exclusively or predominantly homosexual. Practically all people in this range satisfy the psychodynamic criterion of being strongly and preferentially attracted to members of their own sex.
Prevalence. Homosexual activities of some kind probably occur in all societies, and evidence of such practices can be found in the writings and graphic arts of ancient civilizations. The attitudes of different societies toward such practices, however, vary widely. Jn a study of 76 societies other than our own, Ford and Beach* noted that in 64 percent of them homosexual activities were considered normal and socially acceptable at least for certain members of the community. In the other 36 percent, such forms of sexual expression were strongly condemned and prohibited, although there was suggestive evidence that in some of these societies such practices continued to take place in secret.
In our own culture, homosexual individuals can be found in all walks of life, at all socioeconomic levels, among all cultural and ethnic groups, and in rural as well as urban areas. The opprobrium with which this behavior is regarded, however, causes many people to conceal it from investigators, so that its actual incidence may be impossible to ascertain. Kinsey and his associates1' concluded that 37 percent of the post-pubertal males in our society have had at least one homosexual contact which resulted in orgasm. The significance of this figure, however, is affected by the fact that Kinsey included in these figures the transitory same-sex transactions of adolescents. A more meaningful statistic, roughly corroborated in other studies," was the finding that about four percent of white adult males are exclusively homosexual throughout their lives, and that about ten percent are more or less exclusively homosexual for at least three years between the ages of 16 and 55. Another significant finding was that about 13 percent of their sampie reacted erotica! Iy to other males even though they never had any overt homosexual contacts after adolescence.
There is a great need to repeat these studies in the light of our increasing sophistication in this area, and to include not only all socioeconomic levels, but also all minority groups in such taxonomical surveys. Nevertheless, it is obvious from these findings, with all their statistical limitations, that the propensity for homosexual reactivity is quite widespread even in a culture such as ours in which every effort is made to discourage it. The question that concerns us is why it is that, in spite of such cultural taboos, a substantial number of males become strongly activated toward homosexual behavior.
Theories of etiology. The most influential theory of homosexual etiology has been that of Freud, who combined a biogenetic concept of organic bisexuality with an epigenetic theory resting on psychosocial factors. Freud's view was that there is a basic biological bisexual predisposition in all human beings, and that in the normal course of development all persons go through a homoerotic phase. When homosexuality develops later in life, it is considered an arrest of normal development, or else a regression to an earlier fixation point as a result of castration anxiety mobilized by pathogenic family relationships.
Another view, advocated by Bieber,4 rejects the theory of bisexuality in favor of one of basic biological heterosexuality. According to this conception, heterosexuality is the biological norm in humans (as well as In lower animals), and the appearance of homosexual patterns is always due to hidden fears of heterosexual functioning which have been produced by pathogenic life experiences. Thus Bieber denies the Freudian hypothesis that all heterosexuals are latent homosexuals, and argues instead that "all homosexuals are latent heterosexuals." In his view, also, homosexuality in any society is a reflection of psychopathology, since it represents a deviation from the biological norm.
Evidence from comparative zoology,6, 9 however, does not support the thesis that homosexual behavior per se is a pathological deviation. All lower animals, including the infrahuman primates, frequently display patterns of homosexual behavior despite the fact that heterosexual partners are usually preferred. Moreover, although such behavior tends to be more frequent in the absence of heterosexual partners, it is also displayed even when heterosexual opportunities exist. What do not exist among lower animals are patterns of exclusive homosexuality or exclusive heterosexuality. The anxieties and guilt feelings that set up absolute psychological barriers to ambisexual behavior are unique to humans! Beach', in a lecture at Yale in 1948, has expressed this most cogently:
... to describe [homosexual] behavior as 'unnatural' Is to depart from strict accuracy. The zoological evidence shows that iemale mammals frequently display masculine coital behavior when confronted with sexually receptive members of their own sex. This has been observed in more than a dozen species and undoubtedly occurs in many others not yet studied. . . . The physiological mechanisms for feminine sexual behavior are found in all males and those for masculine behavior exist in all females. The same stimuli that elicit feminine copulatory reactions in the female will, under appropriate conditions, produce similar reactions in many males; and the stimulus configuration evoking masculine responses in males is the one which most effectively calls forth these same responses on the part of the female. Human homosexuality reflects the essential bisexual character ol our mammalian Inheritance. The extreme modifiability of man's sex life makes possible the conversion of this essential bisexuality into a form of unisexuality with the result that a member of the same sex eventually becomes the only acceptable stimulus to arousal . . .
Biological theories. Efforts to demonstrate a biological basis for homosexuality have focused on genetic, chromosomal, and hormonal studies. The most potent evidence for a genetic predisposition to homosexuality comes from Kallman," who reported 100 percent concordance in overt homosexual behavior in 40 pairs of monozygotic twins. If verified, this would point to a decisive genetic factor, but Kallman's findings have not been borne out by other studies of monozygotic twin pairs. Thus KoIb" has reported seven monozygotic twin pairs in whom there was no such concordance, one member of each pair being homosexual, the other heterosexual. There is a preponderance of evidence, nevertheless, that concordance is definitely greater in monozygotic than in dizygotic twins, so that the possibility of some hidden genetic predisposition interacting with subsequent environmental experiences cannot entirely be ruled out.
Chromosomal studies of homosexuals have shown no differences from normal heterosexual males in the vast majority of instances. Although occasional male homosexuals are found with Klinefelter^ syndrome (XXY to XXXY), these findings are not considered significant since most males with such chromosomal abnormalities are not homosexual in their inclinations."9, M
Slater" has speculated that there may be a hidden, as yet undemonstrable, chromosomal abnormality in homosexuality, based on the fact that a number of studies of birth orders of homosexuals show a significant shift to the right; that is, they were born later in the sibship than would be theoretically expected. However, in view of what we know concerning the influence of certain kinds of familial relationships on the development of homosexual object-choice, it would seem more plausible to assume that the "shift to the right" may simply indicate that mothers are apt to become more deeply involved emotionally with later children, particularly if this is a time, as it often is, when their husbands' conjugal attentions have begun to diminish. A younger child in the family is also more apt to be babied, or to develop feelings of inadequacy in relation to older siblings, or to be a target of homosexual seduction by them.
Most hormonal studies have disclosed normal hormonal balances in both male and female homosexuals, and endocrinologists, up until recently, have been in agreement that apart from their importance in the development and maturation of the genital organs and secondary sexual characteristics, the so-called "sex hormones" have no effect on the choice of sexual object.30 Estrogens given to males simply diminish their libido. Androgens increase libido in both males and females, but do hot alter the object-preference.
Recent sexual research in lower animals, however, indicates that fetal hormones in the developing embryo have an Influence upon the hypothalamus and subsequently on the regulation of sexual functioning. In lower animals a failure of these fetal hormones to function at the critical period may have an important effect on subsequent sexual behavior of the animal, ever? though there may be no abnormalities in their gross external anatomy. Dörner' has demonstrated that in geno- and pheno-typically normal male rats which have been castrated on the first day of life, female sexual behavior can be induced by androgens given after they have achieved maturity. If, however, after castration they are given a small injection of testosterone on the third day of life (which appears to be the critical differentiating period of their hypothalamic mating center), they will exhibit perfectly normal heterosexual behavior after androgen treatment in adulthood. On the basis of these experiments, Dörner and Hinz* offer the hypothesis that an absolute or relative androgen deficiency in the human male fetus during the critical period of differentiation of the "hypothalamic mating centre(s)" will result in "a predominantly female-determined direction of the sex drive- even in the subsequent presence of normal testosterone production." Money,*1 while warning that one must be careful not to draw parallels and inferences from such lower animal experiments to primates, nevertheless suggests the possibility that at least some homosexuals may be born with a "hidden predisposition, perhaps lurking in the neurohumoral system of the brain, that makes [them] more vulnerable to differentiate a psychosexual identity as a homosexual- not in any automatic or mechanistic sense, but only if the social environment happens to provide the right confluence of circumstances."
Some recent endocrinological investigations, however, suggest that there actually may be some hormonal differences between heterosexuals and most homosexuals. In 1970 Loraine et ai." reported a study of three male homosexuals, two of whom were exclusively homosexual and one of whom was bisexual. They found the 24-hour urinary testosterone levels to be abnormally low in the two exclusive homosexuals, but within the normal range in the third subject. In the same year, Margolese*1 reported a study of urine samples from 24 adult Caucasian males, ten healthy homosexuals, ten healthy heterosexuals, and four heterosexuals who were "not in good health" (one had diabetes mellitus and three were depressed). Analyses of these 24-hour urine samples for androsterone (A) and etiocholanolone (E), both breakdown products of testosterone, revealed a clear and unequivocal discrimination between the healthy homosexual and heterosexual groups. The homosexual group all tended to show E values that were greater than the A values, except that in one case A and E were equal, and in two others the A was very slightly greater than the E. On the other hand, in all of the healthy heterosexuals, A was distinctly greater than E. The "sick" heterosexuals, however, had A/ E ratios closer to those in the homosexual group, thus indicating that although an altered A/E ratio seems to be associated with homosexuality, it can occur in other conditions also. Inasmuch as females in general also have lower A's than E's in their urine, Margolese offers the hypothesis "that the metabolic condition which results in a relatively high A value is the cause of sexual preference for females by either sex, whereas a relatively low A value is associated with sexual preference for males by either sex."
The studies of Margolese and of the Loraine group remain to be validated by other workers, and until then cannot be considered definitive. As Perloff" pointed out, studies involving urinary excretory products of the basic sex or related steroids are "fraught with difficulty because many metabolic metamorphoses occur between formation of a hormone within a gland, secretion from the gland, binding to the protein and transportation within the body, degradation within the liver, and conversion into a form excretable by the kidney into the urine ..." Furthermore, not only may illness affect these hormonal ratios, but also, as Rose et al.3' have demonstrated, non-specific physical and emotional stress may also result in reversed A/ E ratios.
Meanwhile, however, other evidence is also accumulating. In an even more recent study William Masters and a group of his co-workers in St. Louis" have reported finding that the plasma testosterone levels in a group of Type 5 and 6 homosexuals were significantly lower than those in a matched control group of heterosexuals. These findings, too, remain to be validated and evaluated. The possibility that other variables (general health, diet, stress, sexual activity, etc.) may be playing a part in these results will have to be ruled out. In any event all of these studies have opened wide the issue of whether there may indeed be certain innate genetic or hormonal differences between homosexuals and heterosexuals, and for the time being the question must be regarded as still unsettled.
Theories of family background. The view of most contemporary dynamic psychiatrists is that homosexual behavior represents an adaptation to certain environmental vicissitudes, although the full complexity of these environmental factors is not yet totally understood. Bieber and his associates' believe that the constellation of a detached, hostile father and close-binding, overly-intimate, seductive mother who dominates and minimizes her husband is the most significant factor in the genesis of homosexuality or of "heterosexuality with severe homosexual problems." In their study the Bieber group recognized that there were variants to this pattern- such as disinterested or even hostile mothers, or overly close but nevertheless demeaning fathers- but never, they believe, a truly loving father. The presence of the latter, in their opinion, precludes the development of homosexuality in a son, even in the presence of a "homosexually inducive" mother.
Clinical studies confirm the fact that the type of parental constellation described by the Bieber group is found more frequently than any other in the background of homosexual males. That it is not a specific determinant of homosexuality in and of itself, however, is indicated by the fact that not all males with such parental backgrounds become homosexual. Moreover, quite different family patterns are found in the histories of some homosexuals, not only patterns of distant or hostile mothers and overly-close fathers, but also of intensely ambivalent relationships with an older brother, and families with no mother, or no father, or even with idealized fathers.
Social factors. Other elements besides family background may also be of significance in the genesis of homosexuality. For example, if the "strong mother/weak-or-absent father" pattern were a crucial determinant in and of itself, one would expect to find an abnormally high incidence of homosexuality in urban Negro males, where for many decades the circumstances of ghetto life have created unusual numbers of broken or fatherless homes in which the mother was the mainstay of family life. However, no evidence has thus far come to hand to suggest any significant difference in the incidence of male homosexuality in blacks as compared with whites. Two possible explanations come to mind for this: first, Harlow's work with monkeys" has shown the overriding importance of good peer associations in compensation for deviant mother relationships. Thus, it is probable that the rich peer relationships that are available in ghetto life offer models for masculine identification which compensate for the absence of such models within the family itself. (Peer relationships can have a negative effect also, of course. The child who, for one reason or another, is rejected by his same-sex peers may withdraw into deepseated feelings of loneliness and inadequacy which may impair his gender identity and play a role in the development of a subsequent homosexual behavior pattern.) Second, ghetto life, for all of its bleakness and misery, does not have the antiheterosexual bias that so often characterizes middle-class family life; and there is much clinical evidence pointing to the fact that both male and female homosexuality tend to develop more frequntly in an atmosphere of antisexual Puritanism.
Another contributory social factor, to which Hooker has called attention,1* is the significance of the homosexual community in enabling wavering and still uncommitted homosexuals to find a congenial and accepting social milieu with available love-objects. The "gay bars" that constitute one of the most prominent aspects of the homosexual community function as "induction, training, and integration centers" which may provide the turning point for some young men that starts their active participation in homosexual behavior- a phenomenon referred to in the gay world as "coming out."
Economic factors. Economic factors may also play a contributory role in the genesis of homosexual behavior. There is some reason to think that the growing complexity of Western civilization renders the achievement of masculine identity increasingly difficult for males and enhances their need to flee from the demands and responsibilities of the masculine role. Parallels to this are seen in some primitive cultures (e.g. Chukchee) where the high incidence of homosexual behavior seems to be correlated with the difficulty in accumulating the high purchase price of a wife.
Psychodynamic formulations. Although countless articles and books have been written about the psychodynamics of "the homosexual personality," it is highly questionable whether there is a specific psychodynamic structure to homosexuality any more than there is to heterosexuality. There is as wide a spectrum of variation among homosexual personalities as there is among heterosexuals, and their psychiatric diagnoses, apart from the homosexual pattern, run the entire gamut of modern nosology. This is not to deny that the spectrum of personality distribution in homosexuals tends to be more heavily weighted toward neurotic patterns of behavior than is that of heterosexuals. This is inevitable in a society that labels such behavior ipso facto maladaptive. The inability of most homosexuals to make the transition to heterosexual behavior despite the fact that many of them would like to, and despite powerful social sanctions against homosexuality, also suggests significant restrictions in adaptive capacity. It is not surprising, therefore, that such individuals are statistically more likely to feel inadequate and to show evidences of less adequate ego formation.
One of the important unresolved problems concerning homosexuality, however, is the question of whether or not there are certain primary psychodynamic patterns which are etiologically relevant or unique to homosexual objectchoice, as distinguished from those secondary psychodynamic patterns that are the results of such an object-choice in our society. Psychoanalytic authors have described a number of psychodynamic mechanisms as being essential features in the development of a homosexual object-choice. The most commonly mentioned, first emphasized by Freud, is that of an unconscious "castration anxiety" which makes all women phobic objects because their lack of a penis calls to mind the feared state of castration; the castration anxiety presumably derives from strong unconscious incestuous desires for the seductive mother, and the fear of castrative retaliation from the father. Another frequently-mentioned pattern is the homosexual's supposed hatred of women which turns him away from them as potential love objects; behind this pattern is a relationship with a dominating, castrating, possessive mother who often is unconsciously represented by the symbol of the "dentate vagina." Another popular view stresses the assumption that the homosexual love-object is really a narcissistic extension of the homosexual himself, that the homosexual seeks someone like himself or his idealized self as a love-object. Still another view holds that the essence of the homosexual pattern rests in the identification with the mother, either because she was the more attentive, more significant parent, or because she was perceived as the source of power and danger (identification with the aggressor); in this context, the love-object becomes a man because of the homosexual's feminine identification.
It is obvious that some of these mechanisms are contradictory to one another, and that they cannot all be true simultaneously. Nevertheless, there is little doubt that in many Type 5 or 6 homosexuals one or another of these psychodynamic patterns can be shown to exist. The crucial research question is whether any of these patterns exist also in men who are predominantly heterosexual I believe they do); or conversely whether none of them exist in some homosexuals. If so, then no one of these patterns can be considered as pathognomonic or prerequisite to the development of a homosexual objectchoice.
Other commonly described characteristics of homosexuals- such as feelings of inadequacy, lack of masculine self-esteem, chronic anxieties, and various defensive attitudes of arrogance or hostility- are quite probably, in large part at least, secondary consequences of our culture's attitudes toward homosexuality. One would expect these findings to be less frequent in societies that are less condemnatory of such behavior.
A critical issue is whether "hidden fears of the opposite sex" (Rado) are always present in those who seek homosexual outlets. Although there is considerable clinical evidence for such fears among most homosexuals seeking psychiatric help, is this necessarily true of all homosexuals? At the behavioral level, for example, there is no doubt that many homosexuals, especially those who rate 3 and 4 on the Kinsey scale, are fully capable of adequate heterosexual performance. Moreover, from what we know of how sexual object-choice can be conditioned in human beings, there is no reason to assume a priori that homosexuality cannot develop on the basis of positive conditioning toward a same-sex object rather than only on the basis of negative conditioning toward heterosexual objects. I have seen a number of individuals, for example, in whom the homosexual object preference clearly appeared to have become well established in childhood and pre-adolescence by nighty gratifying sexuai relations with a much -admired older brother. Whether similar positive conditioning experiences have played an important role in any significant number of homosexuals in our culture is a subject for further research.
Homosexuality and mental health. Should homosexual behavior properly be regarded as an "illness" requiring medical intervention, or is it merely a different "way of life" that happens to be regarded with disfavor in our time and milieu? Freud did not consider it an illness. In his now famous "Letter to an American Mother," in 1935," he wrote: "Homosexuality is assuredly no advantage, but It is nothing to be ashamed of, no vice, no degradation, it cannot be classified as an illness; we consider it to be a variation of the sexual functions produced by a certain arrest of sexual development." On the other hand, many psychiatrists and psychoanalysts tend to consider it "incompatible with a reasonably happy life.'" Part of the problem is that most psychiatrists and psychotherapists derive their views from the study of homosexuals who have sought or have been referred to psychotherapy because of emotional difficulties. If our views about heterosexuals were based only on our patients, would we not have a similarly skewed Impression of heterosexuals as a group? Hooker's investigations," which dealt with the homosexual community at large and consequently included many homosexuals who felt psychologically and socially well adjusted and who were never motivated to seek psychotherapy, led her to a different conclusion. She found that apart from the specific difference in sexual orientation, psychological testing of many of the homosexuals that she studied revealed no "demonstrable pathology" that would differentiate them in any way from a group of relatively normal heterosexuals. Her views are supported by other investigators of the homosexual community.
If human sex-object-choice is learned, as most current investigators believe, then we must conclude that there is nothing "sick" or "unnatural" about homosexual object-choice except insofar as this preference represents a socially condemned form of behavior in our culture. As Becker2 puts it, "deviance is not a quality of the act the person commits, but rather a consequence of the application by others of rules and sanctions to an Offender.' " In societies in which homosexuality is not pejoratively regarded, as in ancient Greece, preMeiji Japan, and others,*5 such an object-choice does not carry with it the derogatory self-image nor the maladaptive social consequences that can make this a source of "dis-ease.'' Admittedly, in a society like ours, we can expect that a significant proportion of homosexuals will suffer from emotional conflicts and impaired self-image. Nevertheless, there is evidence that for at least some homosexuals, their sexual deviance in itself does not necessarily mean social maladjustment, and may not Interfere with a reasonably satisfactory life adjustment. It may be argued that it is impossible for a person to have a pattern of behavior that is as strongly condemned by his culture as homosexuality is by ours and not end up with basic feelings of insecurity, inadequacy, and selfrejection. We must recognize, however, that mental health is a relative concept, not only qualitatively but also quantitatively. No one is absolutely or perfectly healthy. Furthermore, persons who are strongly convinced that their value systems are correct and that the mores of the dominant group are wrong may be able to maintain their unpopular positions or behavior patterns without inner feelings of inadequacy or self-rejection. History is replete with examples of religious dissenters, conscientious objectors, and scientific rebels who took firm, and in retrospect what many would consider mentally healthy, positions of dissent from the conventional standards or the accepted values of their times.
Prevention and treatment. Granting all of the above considerations, the psychiatrist is nevertheless often faced with the problem of dealing with homosexuals psychotherapeutically. Not all homosexuals who seek psychotherapy do so for the same reasons. Some present themselves because of difficulties in functioning in their homosexual world, difficulties analogous to those that heterosexuals have- e.g. impediments in finding or attracting partners, or emotional problems secondary to friction in, or break-up of, an important dyadic relationship. Such individuals need help in resolving their problems, but to try to shift them towards a heterosexual object-choice against their will is neither justified nor feasible. On the other hand many homosexuals are unhappy with their life patterns and want to change to heterosexual ones if possible. Under such circumstances it is a desirable and legitimate objective on the part of the psychiatrist to make every effort to assist them in achieving such a goal. I see no ethical or scientific justification, however, for ever forcing psychiatric treatment on an unwilling or uncooperative homosexual. If a homosexual's behavior violates public decency, it becomes a matter for the application of legal sanctions just as would corresponding behavior in a heterosexual, but there is a growing trend in our society to regard homosexual behavior that is carried on with discretion and in privacy between consenting adults as not being "the law's business."
Nevertheless, considering the difficulties that a homosexual way of life creates for most people who choose that route in our culture, every effort should be made to prevent its development wherever possible. The time for this is clearly in childhood. Our growing understanding of family relationships should enable us to recognize earlier those types of parental constellations that may render a child vulnerable to a homosexual object-choice. Strong emphasis shoudl be placed on enabling the child to develop a positive identification with the same-sex parent and affectionate and unambivalent feelings toward the opposite-sex parent. Children or adolescents who are failing to form appropriate gender role identifications or healthy peer relationships should be regarded as potentially vulnerable to homosexual development, and adequate family diagnosis and treatment should be undertaken in such cases wherever possible. Important areas to explore should include not merely the patterns of mothering and fathering but also the anti-heterosexual bias which often exists in these family situations.
The myth that homosexuality is untreatable still has wide currency among the public at large, as well as among homosexuals themselves. This view is often linked to the assumption that most homosexuality is constitutionally or genetically determined, but also serves an ego-defensive purpose for many homosexuals. As the understanding of the adaptive nature of most homosexual behavior has become more widespread, however, there has slowly been evolving a greater therapeutic optimism about the possibilities for change, and progressively more hopeful results are being reported.
It is true that the treatment of homosexuality, at least at this stage of our knowledge, is not easy. Part of the difficulty is the same as that found in any disorder in which the chief "symptom" carries with it a high potential for gratification. Obviously the degree to which any deviant behavior is ego-syntonic or dystonic plays a major role in the patient's degree of motivation for change. The profound pleasure which most homosexuals obtain from their behavior is a major determinant in the fact that only a small proportion of them voluntarily seek psychiatric help. Counterbalancing this, however, is the pressure of the social milieu, the impairment of self-image, and the unsatisfactory interpersonal adjustment that often accompany a homosexual way of life. The reasons for seeking help clearly have an Important bearing on what can be expected from therapy. Those who seek it for the specific purpose of altering their sexual patterns, all other things being equal, offer the best prognosis. At the opposite end of the pole, those who come unwillingly and only because of court orders growing out of legal violations tend to be the least promising.
There is no specific form of therapy that has as yet clearly established its superiority over any other. Part of the difficulty in evaluating results of various approaches rests on the fact that patient samples differ widely, and are often not adequately defined as to whether they are, for example, 3, 4, 5, or 6 on the Kinsey scale. Moreover, follow-ups are often inadequate and criteria for improvement are inconsistent or not clearly stated. For example, a change for the better in the general life adjustment of a homosexual constitutes improvement, but nevertheless is quite different from a shift in object-preference from same-sex to opposite-sex.
Granting these problems of evaluation, there is considerable evidence that a genuine shift in sexual object-choice can and does take place in somewhere between 20 and 50 percent of male patients with homosexual behavior who seek psychotherapy with this end in mind.3, 11, 13, 15, 22, 26, 27 The most important prerequisite to reversibility is a strong motivation to change. Given such motivation, other favorable prognostic signs are (1) youth- patients under 35 tend to do better, (2) previous heterosexual behavior or responsiveness, (3) recency of onset of homosexual activity, and (4) "aggressive" personality patterns as contrasted to strongly passive patterns and effeminate mannerisms, especially if they date back to childhood.
The treatment techniques employed have varied widely; from psychoanalysis four to five times weekly, to psychoanalytically-oriented psychotherapies one to three times weekly, to group therapy (some with mixed groups, others exclusively homosexual), to conditioning techniques using eversive and reinforcing stimuli. Despite difference in methods, all of these approaches share certain features in common. All require a high degree of motivation and cooperation from the patient. All, either implicitly or explicitly, discourage homosexual behavior and encourage heterosexual behavior without, however, derogation of the homosexual patient by the therapist. Most of the dynamic psychotherapies, In addition, place stress on other aspects of the patient's personality functioning with special emphasis on increasing his self-esteem and his self-assertiveness. In those instances in which therapy proves unsuccessful in reversing the homosexual pattern, efforts usually are directed at the alternate objective of enabling the patient to achieve a mature, stable relationship with one partner and to avoid the dangers of "cruising" and violations of public decency.
At best, however, all therapeutic approaches are of limited value in relation to the problem of homosexuality in its broadest aspects. It is a simple fact that the large majority of homosexuals do not seek or wish to change their sexual patterns. A humane society must develop greater tolerance to homosexuals who do not openly offend public decency. Legal sanctions against homosexual behavior have not proven effective; homosexuality is no more common in France, Sweden, and the Netherlands, where it is not a crime, than in the United States, where it is. Recognizing this fact, Great Britain in 1967 legalized homosexual behavior between consenting adults in private. There is a beginning trend in this direction in the United States also. Four states, Colorado, Connecticut, Illinois and Idaho, have already adopted such legislation, and the American Law Institute has gone on record as being in favor of it. It should be emphasized that these laws do not condone violations of public decency or the seduction of minors; such behavior, whether homosexual or heterosexual, remains illegal.
JUDD MARMOR, M.D.
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