543709 research-article2014

ISP0010.1177/0020764014543709International Journal of Social PsychiatryMaroky et al.



‘Ego-dystonicity’ in homosexuality: An Indian perspective

International Journal of Social Psychiatry 1­–8 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764014543709 isp.sagepub.com

Ami Sebastian Maroky1, Aswin Ratheesh1, Biju Viswanath1, Suresh Bada Math1, Channapatna R Chandrashekar1 and Shekhar P Seshadri2

Abstract Background: Homosexual persons are targets of verbal and physical abuse, discrimination and face legal disadvantages in many countries, including India. These external factors could play a role in determining discomfort with their sexuality. Aims: We ascertained the association between ego-dystonicity of sexual orientation and indices of perceived acceptance, stigma and awareness of possible normative lifestyles. Methods: Fifty-one self-identified adult homosexual men were assessed using online questionnaires that covered information including their socio-demographic details; a Visual Analog Scale (VAS) that measured their degree of discomfort with their sexuality; Reactions to Homosexuality Scale, Perceived Acceptance Scale, Modified China Men Who Have Sex with Men (MSM) Stigma scale; and trait version of the Positive and Negative Affect Scale. The participants were also asked to provide a written narrative of their experiences which influenced their comfort with their sexuality. Results: Discomfort with sexuality significantly correlated with education, acceptance by friends and family, legal disadvantages, awareness and accessibility to non-heteronormative lifestyles and support systems and trait affect. Only acceptance by friends and awareness showed significance on linear regression. Qualitative analyses revealed external attributions for discomfort. Conclusions: Modifying external factors, reducing legal restrictions and improving societal acceptance and support systems could reduce ‘ego-dystonicity’. ‘Ego-dystonicity’ as a determinant for psychiatric classification and intervention needs to be reexamined. Keywords Homosexuality, ego-dystonicity, sexual minority

Introduction Men and women who identify as being same-sex attracted have been targets of verbal abuse, discrimination or physical assault because of their sexual orientation (Berrill, 1990; Herek, 1989; Levine, 1979; Levine & Leonard, 1984; Paul, 1982). There have also been a number of reports of overt discrimination and hate crimes (Narrain, 2001). Compared with their heterosexual counterparts, they suffer from more mental health problems including substance use disorders, affective disorders and suicide (Cochran, 2001; Gilman et al., 2001; King et al., 2008; Meyer, 2003). It has also been postulated that the explanation for the cause of the higher prevalence of disorders is that stigma, prejudice and discrimination create a stressful social environment that can lead to mental health problems in these people who belong to stigmatized minority groups (Kalra, Gupta, & Bhugra, 2010; Meyer, 2003; Sathyanarayana Rao & Jacob, 2012).

In India, homosexual individuals are subject to many legal disadvantages such as illegality of the sexual act itself, lack of legal validity for same-sex unions, inability to adopt and absence of insurance benefits (Narrain, 2001). Indian Penal Code (IPC) 1860: Section 377 states that whoever voluntarily has carnal intercourse against the order of nature with any man, woman or animal shall be


of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India 2Department of Child Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India Corresponding author: Ami Sebastian Maroky, Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore 560 029, India. Email: [email protected]

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International Journal of Social Psychiatry

punished. The Indian courts over the decades have interpreted and constantly redefined ‘carnal intercourse’ read conjunctively with the ‘order of nature’ to include other non-procreative sexual acts (Gupta, 2006). This ambiguity has left it to the judges to determine what kinds of sexual acts qualify as unnatural offenses (Phillips, 1999). Although it applies to both heterosexual and homosexual individuals, over the years, the general offense of sodomy became a specific offense of homosexual sodomy (Sathyanarayana Rao & Jacob, 2014). The Delhi High court, in 2009, legalized consensual homosexual activities between adults, citing IPC 377 to be violative of Articles 21 (Right to Protection of Life and Personal Liberty), 14 (Right to Equality before Law) and 15 (Prohibition of Discrimination) (Kumar, 2009). However, this was set aside by the Supreme Court in 2013, which led to further re-criminalization of sexual acts between homosexual individuals (Sathyanarayana Rao & Jacob, 2014. The role of medical and psychiatric systems and classification in medicalizing aspects of sexual orientation is considered to contribute to the negative legal perspectives on same-sex-attracted persons (Kalra, 2012b). Unfortunately, the International Classification of Diseases (ICD)-10 still retains the diagnostic category of ego-dystonic sexual orientation which is considered controversial due to (a) absence of a diagnosis of ego-dystonic heterosexuality and (b) vagueness of the term ‘ego-dystonic’ which is defined only as ‘the person wishes it were not so’. It must be noted that since 1973, the American Psychiatric Association (APA) officially accepted a normal variant model and removed homosexuality from its Diagnostic and Statistical Manual of Mental Disorders (DSM) and replaced it by sexual orientation disturbance in DSM-II. It was further revised to ego-dystonic homosexuality in DSM III, and finally removed in DSM-III-R in 1987 (Sadock & Virginia, 2005). Much of the existing research on ‘ego-dystonicity’ has revealed that discomfort and stress associated with homosexual desire is viewed using heterosexuality as the frameof-reference. In a heteronormative society, there is only a binary choice for one’s sexual identity and sexual orientation. The constructs of Heterosexism and Homophobia have evolved from this perspective. Heterosexism has been defined as an ideological system that devalues and stigmatizes non-heterosexual behavior, relationships and community (Herek, 1996), and Homophobia is the ‘irrational fear, hatred, and intolerance of homosexual individuals, lesbian, and bisexual persons’ (Gelberg & Chojnacki, 1996). The internalization of these societal attitudes is conceptualized as internalized homophobia (Herek, 1996). Generally, internalized homophobia comes to clinical attention as an egodystonic form of homosexuality (Kalra, 2012a, 2012c; Williamson, 2000). There have been many studies in European and North American settings (Ross & Rosser,

1996; Shildo, 1996) addressing the concept of internalized homophobia. Dimensions of internalized homophobia (identity, social discomfort and sexuality) have also been researched in recent studies (Lingiardi, Baiocco, & Nardelli, 2012). But operationalizing internal homophobia has proved difficult due to overlap with other concepts (self-esteem) and a lack of clear differentiation between internalized homophobia and intrapsychic or behavioral consequences (depression) (Williamson, 2000). Another trend in this area is the conceptualization of internalized homophobia as a component of minority stress. This concept views homosexual individuals as a minority group subject to chronic stress related to their stigmatization. Long before they realize their own homosexuality, homosexual individuals internalize societal anti-homosexual attitudes resulting in internalized homophobia (Meyer, 1995). The determinants of the reported discomfort with one’s homosexuality need to be further characterized in Asian, and specifically, Indian settings. It is not clear whether the perceived ‘ego-dystonicity’ is primarily related to internalization of reactions from society or whether these are determined by intrapsychic factors, and whether these are moderated by the availability of buffers, support systems, role models and companionship. This study proposes to explore the determinants of ‘ego-dystonicity’ among an urban male population of homosexual men using online questionnaires. Broadly, the measures attempted to ascertain whether the ‘ego-dystonicity’ experienced by homosexual individuals is related to interpersonal factors such as stigma, discrimination, awareness of non-heteronormative lifestyles and family acceptance as well as trait measures of anxiety and affect, which could capture individual variability in responding to these factors.

Methodology Participants The sample consisted of 51 self-identified homosexual men (cis-gender males) aged 18 years and above, who were recruited from a non-governmental organization (NGO) (Swabhava) and through social networks using the snowballing technique. Swabhava has been active for the last 15 years providing support services to lesbian, gay, bisexual and transgender (LGBT) community in Bangalore, India (www.swabhava.org). Two investigators (A.S.M. and B.V.) visited the NGO and introduced the research proposal in a meeting of homosexual individuals. Subsequently, they were contacted telephonically for personal interview appointments, but only two individuals consented for the same. This was taken as the pilot phase. Some of the other individuals consented to answer the online questionnaire; their social networks were used for contacting further participants using the snowballing technique. Confidentiality of information was assured and has

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Maroky et al. been maintained. The study was approved by the ethical committee of the National Institute of Mental Health and Neurosciences, Bangalore, India. The information was collected through online distribution of a self-answerable questionnaire, along with the consent form, with the instruction that replying back with a completed questionnaire would be taken as consent for the study.

Measures 1. Socio-demographic details were collected using a proforma covering the participants’ age, marital status, educational status, occupation, income per month, place of residence, whom the subject stays with and whether currently staying in India or not. 2. The Visual Analog Scale (VAS) for comfort regarding sexuality. A visual scale from 0 to 10 was used to assess comfort regarding one’s homosexuality with 0 denoting not being comfortable at all (least) to 10 denoting complete comfort with their sexuality (maximum). This was used as a single measure of discomfort with the participants’ homosexuality and was the main outcome variable. No specifiers were used to ascertain reasons for discomfort in the scale in concordance with the ICD-10. 3. Reactions to Homosexuality Scale (RHS). The validity of the VAS in measuring ego-dystonicity was tested using a previously validated measure of participants’ reactions to their sexual orientation. The RHS is a 26-item self-reported questionnaire with items covering comfort relating to various aspects of sexual orientation, rated on a 7-point Likert scale. It was devised as a measure of internalized homophobia. Higher total scores indicate relatively higher levels of internalized homophobia (Ross & Rosser, 1996). 4. Perceived Acceptance Scale (PAS). The PAS is a 44-item questionnaire on a 5-point Likert scale. The participant has to self-answer questions about perceived acceptance from the father, mother, family and friends. There are 10 items each pertaining to father and mother, and 12 items each pertaining to family (as a whole) and friends. A higher score indicates higher degree of perceived acceptance (Brock, Sarason, Sanghvi, & Gurung, 1998). 5. Modified China Men Who Have Sex with Men (MSM) Stigma Scale. This is a 15-item selfanswered questionnaire that covers a number of areas of stigma along with added items on religiosity and legal disadvantages (Neilands, Steward, & Choi, 2008) and scored on four grades (never, once or twice, many times, often), without any particular time frame. The questions on religiosity are based on the Strayhorn’s scale that measures religiosity (Strayhorn, Weidman, & Larson, 1990). Added

questions include those which pertain to legal issues including the criminal and civil laws. The questions include both those addressing actual experiences (e.g. How often have you been told that homosexuality is a sin?; How often have you been told that your religion is incompatible with same-sex unions?) as well as opinions on discriminatory stances (e.g. How often have you felt that the Indian law discriminates against homosexuals by not allowing same-sex marriages?; How often have you felt that the Indian law violates your rights by illegalizing sexual relationship between people of the same sex?). A higher score indicates higher degree of discrimination. 6. Awareness Scale. This is an investigator-formulated scale for assessment of awareness and understanding regarding non-heteronormative lifestyles, support systems and their accessibility and opinions regarding acceptance of these lifestyle. It is a 13-item questionnaire scored on a 5-point Likert scale. Two items are negatively scored. A higher total score is believed to indicate a higher degree of awareness. The description of the items in the Awareness Scale is given in Table 1. 7. Trait version of Positive and Negative Affect Scales (PANAS). In this scale, a 5-point Likert scale is used to score for 10 positive (e.g. interested, excited, enthusiastic) and 10 negative (e.g. distressed, upset, scared) emotions to assess the trait affect (Watson, Clark, & Tellegen, 1988). The trait version of this scale was expected to be a simple measure of long-standing positive and negative affective experiences that may have had an impact on the development and normalization of sexuality. 8. A written narrative of experiences for qualitative analysis. The participants provided a self report on feelings of negativity regarding their sexual orientation, changes in this negativity across time, temporal relationships with life events and attribution of causes for this negativity. The specific questions asked were the following: (1) When did you realize that you were gay? (2) How did you feel about it at that time and why? (3) Did these feelings change over time, if so what were the reasons behind this change of attitude? Some of the tools used were standard measures, but others were investigator formulated. One of the authors (A.R.) was a self-identified gay man and a qualified psychiatrist. He was also involved in supporting the queer community in Bangalore and engaged in psychotherapeutic practice supporting homosexual men. Two senior authors (S.S. and B.M.S.) were actively involved in supporting the queer community through advocacy and

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International Journal of Social Psychiatry

Table 1.  Correlations between the degree of discomfort with their sexuality (VAS) and measures of acceptance, discrimination, awareness of non-heteronormative lifestyles and trait affect.


Modified China MSM Stigma Scale for discrimination PANAS Awareness Scale

RHS score PAS total PAS friend PAS mother PAS father PAS family Discrimination total Discrimination others Discrimination legal Discrimination religion PANAS positive PANAS negative Leading medical and psychiatric organizations consider homosexuality as a medical problem that requires treatment A few services are available in India for gay men and women (e.g. NGOs) for legal, medical and/or psychological help Homosexuality is now legally ‘decriminalized’ across India Many multi-national organizations offer equal legal rights to same-sex partners as for married couples (in India or outside) Same-sex couples enjoy equal legal rights and protection in many other countries Same-sex couples in India may be able to/already lead a ‘nearnormal’ life in this decade I know of same-sex couples in long-term relationships There are religions/denominations in some parts of the world that accept homosexuality Some Indian parents support their children in being gay/ lesbian There are support groups for parents and friends of gay/ lesbian persons in many parts of the world Same-sex couples and/or persons have been able to adopt children in India and elsewhere in the world There have been expressions of support for homosexuality by many prominent persons in India. Gay men/women have organized marches and spoken out against discrimination and harassment in many parts of the country. Awareness total

Pearson correlation

Sig. (two-tailed)

−.84** .441** .574** .103 .366* .308* .212 −.028 .563** −.138 .527** −.489** .356*

'Ego-dystonicity' in homosexuality: An Indian perspective.

Homosexual persons are targets of verbal and physical abuse, discrimination and face legal disadvantages in many countries, including India. These ext...
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