Psychiatric Annals

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Sexuality and Homosexuality 

Sexual Orientation and Mental Disorder

Richard C Pillard, MD

Abstract

Homosexuality is no longer classified as a mental disorder in the United States,1»2 because lesbians and gay men are judged not necessarily impaired or distressed by their sexual orientation. However, homosexuality is retained as a diagnosis in the International Classification of Diseases. It remains to be determined whether homosexuality is associated with particular mental disorders as some clinicians have suggested. Addictions, depression, schizophrenia, paranoia, and various types of character pathology have been claimed, usually on the basis of clinical samples of uncertain generalizability, to be more common in gay men.

As one result, our government's security policy denies certain security clearances to homosexuals, presumably because their alleged character pathology predisposes them to be a greater security risk. This prevents the participation of gays in important aspects of the governmental process. Is there evidence that such a policy is justified?

On the theoretical side, comparing mental disorders in gay and heterosexual populations may give a clearer understanding of the biological, intrapsychic, and cultural factors associated with mental illness. This comparison does not bear on the question of whether homosexuality per se is or is not a mental disorder. By analogy, if it were established that alcoholism is more common in Northern Europeans, for example, we would not conclude that membership in this group is itself a sign of pathology. Likewise, the relative excess or dearth of particular diagnoses in gay men or lesbian women relative to comparative population samples does not lead to the presumption that homosexuality is a mental illness.

Probably the best research on this issue was done by Saghir and Robins.3 They compared diagnoses of samples of homosexual and heterosexual women and men using a structured diagnostic interview. Thirty percent of the homosexual men reported "excessive and problem drinking" (this was prior to DSM-III) versus 20% of the heterosexual men - not a significant difference. However, there was some evidence that alcohol abuse may have been more severe among homosexual men.

In the female sample, "excessive and problem drinking* ' occurred in 35% of the lesbian versus only 5% of the heterosexual women (P < .01). Also, more parents of lesbians than of heterosexual women suffered from alcoholism (20% v 5%).

The Family Study of Sexual Orientation was planned in 1978 to answer three interrelated questions. First was whether a homosexual orientation is significantly familial. The second was to investigate certain personality traits hypothesized to be associated with homosexuality, and finally, to see if the pattern of mental disorders differed between gay and heterosexual individuals.

This third question is the focus of this article. The family study included both women and men, but because data from the female section of the study are still being analyzed, the comments to follow will pertain only to the men and their first degree relatives (parents, brothers, and sisters).

METHOD

We recruited a sample of 51 predominantly homosexual (HS) and 50 predominantly heterosexual (HT) men (probands) through newspaper and radio advertisements who met specific acceptance criteria (ie, age 25 to 35, unmarried, having at least one sibling living and age 20 or older, native speaker of English, good general health). The probands came to the laboratory for a day of interviewing and psychological tests. We then obtained information about their siblings and studied the sibs themselves (238 in total) by mailed questionnaire and by interviews in person or by phone. Information about parents and more distant relatives was obtained only from the probands and their siblings - we did not interview those relatives.

Information on mental disorders was gathered for each family member in several ways. Current levels of distress were measured…

Homosexuality is no longer classified as a mental disorder in the United States,1»2 because lesbians and gay men are judged not necessarily impaired or distressed by their sexual orientation. However, homosexuality is retained as a diagnosis in the International Classification of Diseases. It remains to be determined whether homosexuality is associated with particular mental disorders as some clinicians have suggested. Addictions, depression, schizophrenia, paranoia, and various types of character pathology have been claimed, usually on the basis of clinical samples of uncertain generalizability, to be more common in gay men.

As one result, our government's security policy denies certain security clearances to homosexuals, presumably because their alleged character pathology predisposes them to be a greater security risk. This prevents the participation of gays in important aspects of the governmental process. Is there evidence that such a policy is justified?

On the theoretical side, comparing mental disorders in gay and heterosexual populations may give a clearer understanding of the biological, intrapsychic, and cultural factors associated with mental illness. This comparison does not bear on the question of whether homosexuality per se is or is not a mental disorder. By analogy, if it were established that alcoholism is more common in Northern Europeans, for example, we would not conclude that membership in this group is itself a sign of pathology. Likewise, the relative excess or dearth of particular diagnoses in gay men or lesbian women relative to comparative population samples does not lead to the presumption that homosexuality is a mental illness.

Probably the best research on this issue was done by Saghir and Robins.3 They compared diagnoses of samples of homosexual and heterosexual women and men using a structured diagnostic interview. Thirty percent of the homosexual men reported "excessive and problem drinking" (this was prior to DSM-III) versus 20% of the heterosexual men - not a significant difference. However, there was some evidence that alcohol abuse may have been more severe among homosexual men.

In the female sample, "excessive and problem drinking* ' occurred in 35% of the lesbian versus only 5% of the heterosexual women (P < .01). Also, more parents of lesbians than of heterosexual women suffered from alcoholism (20% v 5%).

The Family Study of Sexual Orientation was planned in 1978 to answer three interrelated questions. First was whether a homosexual orientation is significantly familial. The second was to investigate certain personality traits hypothesized to be associated with homosexuality, and finally, to see if the pattern of mental disorders differed between gay and heterosexual individuals.

This third question is the focus of this article. The family study included both women and men, but because data from the female section of the study are still being analyzed, the comments to follow will pertain only to the men and their first degree relatives (parents, brothers, and sisters).

METHOD

We recruited a sample of 51 predominantly homosexual (HS) and 50 predominantly heterosexual (HT) men (probands) through newspaper and radio advertisements who met specific acceptance criteria (ie, age 25 to 35, unmarried, having at least one sibling living and age 20 or older, native speaker of English, good general health). The probands came to the laboratory for a day of interviewing and psychological tests. We then obtained information about their siblings and studied the sibs themselves (238 in total) by mailed questionnaire and by interviews in person or by phone. Information about parents and more distant relatives was obtained only from the probands and their siblings - we did not interview those relatives.

Information on mental disorders was gathered for each family member in several ways. Current levels of distress were measured by the HSCL-80, a shortened form of the popular SCL-90, which measures symptoms of psychological distress "during the past week."4 The nine symptom scales are somatization, anxiety, depression, obsessive-compulsive, phobic anxiety, interpersonal sensitivity, anger-hostility, schizoid tendency, and sleep difficulty. It is a recent-time-oriented symptom measure. Because this scale has been widely used, scores are available for various patient and "normal" samples.

An estimate of lifetime episodes of mental disorder was obtained using the SADS-L interview schedule.5 Data from this interview permit diagnoses to be made using either the DSM-III or the Research Diagnostic Criteria (RDC). We elected the RDC, which are comparable to but somewhat more stringent than DSM criteria. For each subject, the diagnosis, number of episodes, and age of onset of each episode were obtained. In addition, we obtained information about psychiatric hospitalizations, suicide attempts, psychotropic medication use, and best and worst levels of functioning. To those items, we added a set designed to tap schizoid and schizotypal personality patterns which are not queried in the SADS-L.

Diagnoses of siblings were also obtained from the SADS-L for those we were able to interview in person, and from the Family History Interview Schedule for those whom we were not able to interview.6 This is obviously a less satisfactory method of ascertainment because episodes of mental illness in one family member are often not known to other members.

In tabulating these data, we assigned only one principal diagnosis to each person according to a diagnostic hierarchy.7 Many subjects had more than one mental disorder or more than one episode of a given disorder. Comparisons of age at onset, severity, etc., have yet to be made.

The interview battery concluded with a detailed sex history interview, from which we made Kinsey scale ratings of sexual orientation for each member of the family. Information on the sexual orientation of parents and more distant kin was again necessarily less complete because we relied on data from siblings.

RESULTS

Sexual orientation data have been published,8 so I present here only a few words of summary. A HS orientation is significantly familial in the male kindred (Table 1). That is, HS male probands had significantly more HS brothers (as well as more HS male second and third degree male relatives) than did HT male probands. Interestingly, there was not an excess of lesbian sisters in this group (Table 2). We conclude that a homosexual orientation runs in the male lineage.

A first look at the female data suggests that lesbian probands have more lesbian sisters (Table 3). They may also have more gay brothers (Table 4). Thus, our preliminary conclusion is that male and female homosexuality are at least two separately transmitted traits, although by what mechanism(s) they are transmitted is still unresolved.

Table

TABLE 1Sexual Orientation of Brothers of Male Probands

TABLE 1

Sexual Orientation of Brothers of Male Probands

Table

TABLE 2Sexual Orientation of Sisters of Male Probands

TABLE 2

Sexual Orientation of Sisters of Male Probands

Table

TABLE 3Sexual Orientation of Sisters of Female Probands

TABLE 3

Sexual Orientation of Sisters of Female Probands

Table

TABLE 4Sexual Orientation of Brothers of Female Probands

TABLE 4

Sexual Orientation of Brothers of Female Probands

Scores on the various HSCL scales were, on average, well within the normal range (Table 5). There was a difference between the HS and HT men on only one symptom factor, "Sleep Disorders," and it favored the HS men (P < .05).

Table 6 shows that HS men altogether - probands plus their HS brothers - were about twice as likely to have had psychotherapy, extended therapy, or a psychiatric hospitalization. In many cases, psychotherapy was specifically undertaken to deal with problems of "coming out, " so it is unclear from this information alone whether these men actually had more mental disorder.

We looked at the heterosexual siblings of HS and HT probands to see whether there was a differential risk for extended psychotherapy or for psychiatric hospitalization by virtue of having a HS brother. This was not the case.

Proband RDC major and minor diagnoses are presented in Table 7. For the subjects as a whole, a diagnosis of some sort was more common than not. It is hard to know whether this is a true estimate of mental disorder in urban, unmarried, 25 to 35 year old men - there probably are no entirely comparable data from household surveys - or whether this high incidence of illness results from a selection bias, ie, our subjects may have been attracted to the study in part by the opportunity to talk about themselves and their problems.

Table

TABLE 5HSCL-80 Scores for 51 Homosexual and 50 Heterosexual Men

TABLE 5

HSCL-80 Scores for 51 Homosexual and 50 Heterosexual Men

There was no significant difference between HT and HS men on the number of diagnoses overall or in specific diagnoses in the anxiety spectrum (including generalized anxiety disorder, panic, phobic and obsessive-compulsive disorders), on major and minor depressive disorders, schizophrenia, somatoform disorder or antisocial personality. (As would be expected, the tallies in some of these categories are very low.) On the other hand, eight HS versus only two HT men were judged to meet the RDC criteria for alcoholism (P < .10). "Possible alcoholism, " "heavy drinking," and "drug use disorder" did not distinguish the groups (Table 8).

The bipolar spectrum of disorders (including bipolar 1, bipolar H, cyclothymic and labile personality) occurred significantly more often in HS men (12 HS versus four HT men in all the bipolar categories combined; (P = .03, Fisher exact multinomial probability) (Table 9).

Finally, the suicidal behavior category from the SADS-L shows six HS versus only two HT probands. One of these two is a bisexual Kinsey 2 with a HS brother (Table 10).

These indications that there may be increased risk to HS men in the categories of bipolar affective disorder and alcoholism heighten interest in the relatives' diagnoses. Again, caution is advised because the "best estimate" diagnoses for parents and siblings are based on less exact information. However, the data are instructive. Alcoholism occurs more frequently in fathers of HS men (14 fathers of HS men versus five fathers of HT men; P < .04). One of the five alcoholic fathers of a HT proband had a bisexual daughter (Table 11).

Looking now at the mothers, 13 mothers of HS men versus only six mothers of HT men had depressive disorder (P < .07) and five HS versus two HT mothers had alcoholism or drug use disorder (P = .23) (Table 12).

An examination of diagnoses on the 15 predominantly HS brothers shows that three (20%) are alcoholic, and four (27%) have bipolar spectrum disorders. All three of the predominantly HS sisters record at least one episode of major depressive disorder.

Table

TABLE 6Experience with Psychotherapy and Psychiatric Hospitalization- All Males

TABLE 6

Experience with Psychotherapy and Psychiatric Hospitalization- All Males

Table

TABLE 7Major and Minor RDC Diagnoses

TABLE 7

Major and Minor RDC Diagnoses

Table

TABLE 8Alcoholism and Drug Use Disorders in Heterosexual and Homosexual Probands

TABLE 8

Alcoholism and Drug Use Disorders in Heterosexual and Homosexual Probands

Table

TABLE 9Bipolar Spectrum of Affective Disorders in Homosexual and Heterosexual Probands

TABLE 9

Bipolar Spectrum of Affective Disorders in Homosexual and Heterosexual Probands

Table

TABLE 10Suicidal Behavior in Probands and Their Sibs

TABLE 10

Suicidal Behavior in Probands and Their Sibs

To summarize, the evidence from the family study shows that there is no difference between homosexual and heterosexual men on a measure of current symptom distress; both groups were well within the normal range on all nine symptom clusters from the HSCL-80. Nor is there any significant difference in number of lifetime diagnoses overall. There is, however, an increased risk for bipolar mood disorders in HS men. Their mothers appeared to have an increased risk of unipolar affective disorder.

Table

TABLE 11Paternal Diagnoses from the Family History RDC

TABLE 11

Paternal Diagnoses from the Family History RDC

Table

TABLE 12Maternal Diagnoses from the Family History RDC

TABLE 12

Maternal Diagnoses from the Family History RDC

These data also support the trend reported by Saghir and Robins3 of an increased risk for alcoholism in HS probands. A new finding is the increased risk of alcoholism in their fathers.

COMMEMT

An additional point about methodology: the risk of mental disorder is likely to be influenced by demographic factors such as age, socioeconomic and marital status, and rural/urban residence. Survey studies such as this must take care to identify and control for these variables, a task that is hard to accomplish on strictly rational grounds. Our HS sample was unmarried and we judged that an appropriate comparison group would be unmarried heterosexuals. However, with advancing age, the cohort of unmarried heterosexual men is likely to contain an increasing number of individuals with mental disorder. Therefore, we set the upper age limit for probands at 35. Such decisions are "best guess" and might bias the results in ways that are hard to know even after the study is completed.

It would be useful at this point to have a persuasive explanation of why alcoholism and bipolar mood disorders in particular are more common in HS men. I have none, except to note the evidence that both these disorders have a hereditary component. Our familial data are compatible with the hypothesis that a homosexual orientation itself is in part hereditary. The qualifier in part needs to be emphasized because there is convincing evidence that homosexuality has no simple or single cause and that environmental variables play an important part in the development of sexual orientation.

I conclude by expressing the belief that the family study method is a powerful research strategy, and that we are likely to learn a good deal about both sexual orientation and psychopathology by its use.

REFERENCES

1. Bayer R: Homosexuality and American Psychiatry. New York, Basic Books, 1981.

2. Spitzer RL: The diagnostic status of homosexuality in DSM-III: A reformulation of the issues. Am J Psychiatry 1981; 138:210-215.

3. Saghir MT, Robins E: Male and Female Homosexuality: A Comprehensive Investigation. Baltimore, Williams and Wilkins, 1973.

4. Derogatis LR: Administration, Scoring and Procedures Manual I. Baltimore, Clinical Psychometrics Research, 1977.

5. Spitzer RL, Endicott J: Schedule for Affective Disorders and Schizophrenia - Lifetime Version. New York, Biometrics Research, New York State Psychiatric Institute, 1978.

6. Endicott J, Andreasen N, Spitzer RL: Family History - Research Diagnostic Criteria, ed 3. New York, Biometrics Research, New York State Psychiatric Institute, 1978.

7. Gershon ES, Hamovit I, Guroff IL et al: A family study of schizoaffective, bipolar I, bipolar II, unipolar, and normal control probands. Arch Gen Psychiatry 1982; 39:1157-1167.

8. Pillard RC, Weinrich ID: Evidence of familial nature of male homosexuality. Arch Gen Psychiatry 1986; 43:808-812.

TABLE 1

Sexual Orientation of Brothers of Male Probands

TABLE 2

Sexual Orientation of Sisters of Male Probands

TABLE 3

Sexual Orientation of Sisters of Female Probands

TABLE 4

Sexual Orientation of Brothers of Female Probands

TABLE 5

HSCL-80 Scores for 51 Homosexual and 50 Heterosexual Men

TABLE 6

Experience with Psychotherapy and Psychiatric Hospitalization- All Males

TABLE 7

Major and Minor RDC Diagnoses

TABLE 8

Alcoholism and Drug Use Disorders in Heterosexual and Homosexual Probands

TABLE 9

Bipolar Spectrum of Affective Disorders in Homosexual and Heterosexual Probands

TABLE 10

Suicidal Behavior in Probands and Their Sibs

TABLE 11

Paternal Diagnoses from the Family History RDC

TABLE 12

Maternal Diagnoses from the Family History RDC

10.3928/0048-5713-19880101-15

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