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Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
Homosexuality—Illness or Life-style? Paul J. Fink M.D.
a
a
Department of Psychiatry and Behavioral Sciences , Eastern Virginia Medical School , 721 Fairfax Avenue, Norfolk, Virginia, 23507 Published online: 14 Jan 2008.
To cite this article: Paul J. Fink M.D. (1975) Homosexuality—Illness or Life-style?, Journal of Sex & Marital Therapy, 1:3, 225-233, DOI: 10.1080/00926237508405292 To link to this article: http://dx.doi.org/10.1080/00926237508405292
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of Sex & Marital Therapy Vol. 1, No. 3, Spring 1975
HomosexualityIllness or Life-style?
Downloaded by [Central Michigan University] at 10:27 10 October 2014
Paul J. Fink, M.D.
ABSTRACT: This paper addresses the issues of the labeling and selective discrimination of homosexuals. Psychiatry is encouraged to adhere to the medical model and treat the homosexual patient who is in conflict and motivated by inner turmoil and distress rather than assuming the job of society’s regulator and the judge of acceptable behavior. The author discusses the concept of gender identity and presents evidence for the idea that homosexual behavior has its etiology in early child development. The cultural stigma of gender dysphorias is also discussed in detail as playing a significant role in the eventual character formation of an adult homosexual.
The issue of homosexuality as an illness versus a life-style is not a debate over psychiatric definition or the extent of our knowledge regarding etiology and diagnosis. Rather, it is a philosophical problem about the ideal man, a utopian view of the power of psychiatric therapy, and a sociological problem regarding labeling and its effects on the person who acquires the label. It is more of a Szaszian than a Freudian problem. I should begin by saying that I acknowledge that there are sick homosexuals who both seek and need psychiatric treatment; however, I do not regard all homosexuals as ill persons. Nor is homosexuality a crime, a sin, an act against nature, or a threat t o the continuation of mankind. Throughout the last several hundred years we have had all of these ideas promulgated by people concerned with the eradication of homosexuality which has doggedly persisted in accounting for approximately 10% of the population whether they resided mostly in the “closet” or paraded “brazenly” up Fifth Avenue. At this point in history the failure of psychiatry to cure the social and psychological ills of the world should be obvious. The early implied promise of the psychoanalytic movement to eradicate mental suffering and develop a society of men with freedom of choice, unencumbered by unconscious, destructive conflicts, has been followed in the past 20 years with a frantic
Dr. Fink is Professor and Chairman, Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, 721 Fairfax Avenue, Norfolk, Virginia 25507.
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search for other more “scientific,” quicker, more manipulative technicques that lend themselves to “accountability” and “validation.” We tread on very dangerous territory when we include a label for everyone in our nomenclature and extrapolate from the fact that all human beings have unresolved, unconscious conflicts to the idea’that therefore all people have a diagnosis and require, or as we euphemistically say, “could use” treatment. When we take such an approach, we move dangerously away from our role as physicians working in the medical model and become instead judges of human behavior. This latter maneuver forces us to become theologians and social planners, but not truly caretakers of those people who are in pain and seek our help. Freud’s “Letter to an American Mother” is still a significant document that states clearly that homosexuality is not an illness, that man has a biological and developmental predisposition toward bisexuality, and that the psychiatric profession should be consistently objective in judging a human being neither by his object choice nor the world’s view of his life-style-but rather his inner turmoil and anguish which can be ameliorated “whether he remains a homosexual or gets changed.” Freud’ states: 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 function produced by a certain arrest of sexual development. Many highly respectable individuals of ancient and modern times have been homosexuals, several of the greatest men among them, Plato, Michelangelo, Leonard0 da By asking me if I can help, you mean, I suppose, if I can abolish Vinci, etc. homosexuality and make normal heterosexuality take its place. The answer is, in a general way, we cannot promise to achieve it. In a certain number of cases we succeed in developing the blighted germs of heterosexual tendencies which are present in every homosexual, in the majority of cases it is no more possible. It is a question of the quality and the age of the individual. The result of the treatment cannot be predicted. What analysis can do for your son runs in a different line. If he is unhappy, neurotic, torn by conflicts, inhibited in his social life, analysis may bring him harmony, peace of mind, full efficiency, whether he remains a homosexual or gets changed.
...
Freud’s great contribution to the study of human sexuality resides in his theory of psychosexual development which tells us that early life events set the tone for lifelong patterns of behavior. To say that an arrest in development is by definition an illness is to say that all criminals who are arrested in their superego development are ill, that all hard-driving, aggressive businessmen who are arrested in their Oedipal development are ill, that all delightfully seductive, scatterbrained, hysterical characters who continue t o seek fatherly heterosexual relations are ill, and so on. In nonpsychotic conditions there must be ego-dystonic behavioral patterns in the realms of thoughts, feelings, or actions that are subjectively felt t o be distressing before the label of illiness should be applied.
Paul J. Fink
22 7
Downloaded by [Central Michigan University] at 10:27 10 October 2014
Homosexuality is a developmental variation of gender identity, identification, and object choice. We have been unable to find a single dynamic explanation for it, since its genesis is quite complex and there are multiple combinations of variables that can lead a person t o have a confused and ambivalent gender identity leadning t o an object choice that is opposite (inverse) to the bulk of the population. Evelyn Hooker has concluded as follows: 1. Homosexuality as a clinical entity does not exist. Its forms are as varied as are those of heterosexuality. 2. Homosexuality may be a deviation in sexual pattern which is within the normal range, psychologically. This has been suggested, on a biological level, by Ford and Beach. 3. The role of particular forms of sexual desire and expression in personality structure and development may be less important than has frequently been assumed. Even if one assumes that homosexuality represents a severe form of maladjustment to society in the sexual sector of behavior, this does not necessarily mean that the homosexual must be severely maladjusted in other sectors of his behavior. Or, if one assumes that homosexuality is a form of severe maladiustment internally, it may be that the disturbance is limited to the sexual sector alone.6
This famous study by Hooker was one of the few to study overt homosexuals with matched heterosexual controls. The results have been forgotten, or should I say repressed, in favor of more subjective, patient-derived data that tend to be more responsive t o the preservation of the diagnostic manual than t o some of the basic questions concerning etiology in the field of psychiatry. This would certainly include homosexuality. Among the questions t o be answered would be the effects of societal forces on the distress felt by the homosexual-versus the societal forces that help to create the homosexuality initially. At this juncture we must ask what societal forces have led to the alteration of psychiatry from a scientific, medical specialty that attempts to explore human behavior and treat people in mental and emotional distress, to a conservative subjective subgroup of the social sciences that deals with matters of values, morality, and social issues, and inadvertently becomes the vehicle for preserving the status quo. Psychiatry is seriously threatened when it abandons the scientific guidelines that Freud tried to inspire with his persistent demand for objectivity, more data, biological explanations, and repetitive hedging in the areas of his exploration. Admittedly he was persuasive and seductive in his arguments, but he would never (I don’t think) have made a statement such as the one S o c a r i d e ~made ~ ~ ~ recently that homosexuality is a “dread dysfunction, malignant in character, which has risen to epidemic proportions.” If, in fact, Socarides’ metaphor of an epidemic were t o be given serious credence, we, as medical practitioners, should have been overwhelmed with an enormous number of distressed, truly nonfunctioning individuals, begging for our intervention to reduce the suffering and return them to “working and loving.” The specialty of psychiatry is more prone to the introduction of
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bias into the therapeutic situation than any other medical field. Clinical judgment should be based on scientific data derived from the “basic” sciences, but our basic investigative sciences are soft and are often neglected in favor of information and attitudes derived from samples of a single case, or a therapeutic series, rather than true experimental studies. The treatment of sick homosexuals is not truly a scientific way to understand the psychodynamics of all homosexuals. Changes in the culture cause changes in the criteria that we use for diagnosis. Nowhere else is the diagnosis and treatment of people so vulnerable to opinion, societal norms, and the treater’s own psychology. The problem of transsexualism provides a perfect example. Since a delusion is defined as a fixed irrational belief uncorrectable by reality and not consistent with the norms of the society, anyone prior to 1952 (Christine Jorgenson) requesting that his penis be cut off would have been judged delusional and psychotic by definition. As soon as surgery made the possibility of sex change a reality, it was no longer possible to apply the criterion of delusion to such requests. My only point is that the fluidity of our diagnostic criteria makes us particularly vulnerable to scandals such as the Rosenhan study could produce. Rosenhan and co-workers reported in the January 1973 issue of Science that patients admitted to mental hospitals were treated more OA the basis of their label than observable facts. We must free ourselves of the burden that we have helped t o create. In a small way we can d o this by paying scrupulous attention to the application of strict scientific criteria t o the problem of psychiatric diagnosis and treatment. I would like to suggest three important issues concerning homosexuality for consideration in this regard. First of all, it is important that we pay attention to studies in anthropology, sociology, and psychology, which are conducted in a scientific manner and can act either t o support or refute theory and practice as we in the clinical sphere apply that theory on a day-to-day basis. The work of Ford and Beach that studied homosexuality cross-culturally is a significant study and demonstrated that 64% of the societies that they studied considered homosexuality a normal variant of sexual behavior. If we combine that information with our own society’s treatment of and attitude toward homosexuals, we are left with the imperative question of how much of our theory and the homosexual’s emotional distress is a result of environmental, cultural forces, and how much is a response t o dynamic, conflictual, developmental forces. The studies of Kinsey and the work of Gebhart demonstrate that homosexual behavior is extremely common in our society, and is often not a significant factor in the overall sexual adjustment of persons who have had such activities in their lives. Schofields has made the following observation and suggestions: Anthropologists have found that homosexuality is more often found in the more restrictive communities where sexual customs are subject to formal rules (Mead,
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1949; Ford and Beach, 1952). For example homosexuality was rare in the very uninhibited culture of the Trobriand Islands (Malinowski, 1932) but quite common among the Mohave Indians (Devereux, 1937). This Indian tribe had very strict rules about the type of work a man should do. The men were warriors and fighters, but if a man wanted to stop at home and work with the women, he was allowed to do this, and indeed he was permitted to marry another man and act out the part of the wife as far as this was physically possible. In modem society the most obvious mincing effeminate homosexuals are to be found, not in London, but in the small provincial towns. This is because in alarge city a man can have a private homosexual life unfettered by social pressures from neighbours. But in a small community where everyone knows everyone else, the homosexual’s predilections will soon become common knowledge and before long he will have to give up trying t o appear normal to his friends and workmates, and there will be no point in trying to keep up any pretence. Indeed as a compensation for the social disapproval he finds, he goes to the other extreme and becomes more and more effeminate-like a Mohave Indian. This is just one way in which the social pressures can cause the personality of the homosexual to deteriorate. Many of the problems that beset the homosexual are created by the hostility of society. He is compelled to feel ashamed of his sexual desires and it is often suggested that he is mentally ill. If he gives way to his desires he is filled with guilt, and these feelings are often more destructive than the actual homosexual act. He must conceal his true identity and on occasions he may be required to agree with others and pretend to condemn his own interests and activities. This paranoic split in his life may prove to be difficult to maintain and lead t o breakdown. If he openly expresses his predilections, he is said to be so disturbed that he is seeking conflict, scorn and ridicule from his fellow men. He is denied the comforts and companionship of the marriage and family life. If he attempts to settle down and live with another man, the difficulties put in the way may make it impossible for the affair t o survive. Instead he may have to seek gratification in public and sordid places.
This was a rather lengthy example of a sociologist’s viewpoint. Schofield’s theoretical conclusion, which lacks an in-depth intrapsychic psychological point of view, does alert us to more global facts, which we in turn tend to neglect in our own theorizing. The second area requiring our perseverence is related to the first. W e must be inspired by intellectual curiosity to simultaneously treat the distressed patient and be responsive t o the extraordinary phenomena derived from patient care that are inconsistent with our own theoretical formulations. In many ways the study and care of transsexuals has forced us to reexamine our view of homosexuals and is adding to our in-depth knowledge of such people. The work of Stoller and Green is of particular interest because they responded with psychoanalytic curiosity while most psychiatrists wrote the transsexual off as psychotic, by definition. As a result of their clinical work and research they have been able t o treat effeminate boys and reverse the effeminacy, thereby helping the child to find comfort in identifications in the sex of birth. More importantly, they have contributed significantly to changes in theoretical concepts concerning the process of gender identity. Green has collected data and devised theories based on a combination of his observations of children and their parents in treatment, knowledge of child development, and the psychoanalytic theory of intrapsychic processes.
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Stoller’s response to the paradox between the demand of some men to have their penis removed and the concept of castration anxiety led him and his colleagues to look at identification and gender identity formation more closely. The transsexual seems t o present himself, at least on the surface, as a person with an unambivalent, nonconflicted wish t o be a member of the opposite sex. The homosexual’s problem lies in the area of the object choice rather than gender identity. Both the male-female transsexual and the male homosexual have a feminine identification that seems t o have been created at different times and in different ways during psychosexual development. We are still not clear on the exact nature of these developmental phenomena; however, the information available relies less on retrospective speculation of events based on intrapsychic responses and more on patterns of child rearing-those childhood events that create the internal distortions leading to the choice of an ego-syntonic life-style of transsexuality or homosexuality. Green has given the following composite description of the child-rearing and other factors leading to a gender dysphoria, that is, a disorder of gender identity and identification: 1. A mother considers her infant male child to be unusually attractive. 2. The mother’s time commitments are such that she is able to devote considerable attention to this boy. Her affective or emotional commitments are such that she has few other avenues for channeling her feelings of caring and love. 3. The child begins to play with many colorful accessories belonging to his mother. He imitates the person with whom he is primarily in contact, his mother. These early behaviors are considered to be cute. The responses obtained by the child are supportive-additional attention, benign laughter, being shown off. 4. The father, if present, is a much less significant person in the boy’s life than his mother. His possessions and accessories are not so attractive as objects for early play and role taking. The father, too, when witnessing his son’s early play with feminine objects, experiences it as funny, cute, or neutral, and does not object. 5. Peer Telationships begin; girls are primarily available. The few boys available are more aggressive than he, intimidate him, and meet with parental disapproval. The boy asserts that he likes to play with girls because boys are “too rough.” Possibly here, too, an innate feature is operating to influence early socialization. A lower level of aggressivity, influenced perhaps by an intrauterine endocrine factor such as lowered androgen levels, may facilitate his companionship with girls because he is more comfortable in their play activities. Hence, his earliest learned social skills are those more typical of girls. 6. The boy is more in tune with the calmer domestic activities of his mother. The father experiences rejection from his son and deems him a “mama’s boy.” A degree of father-son alienation ensues. The frustration of the father is transmitted to the son.
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7. Earlier socialization to feminine skills and companionship now poses an obstacle to same-sex peer integration during the first years of school. Because of his feminine interests and greater comfort with female companions, he is teased, resulting in further alienation from his male peer group. 8. The mother continues to respond positively to the boy’s interest in cross-dressing or improvising feminine costumes and t o his attentiveness t o her clothing and grooming. She may be encouraged by his play with girls as a sign of his later being “a lady’s man.” 9. The emotional distance between father and son continues t o increase because of the boy’s low interest in his father’s activities. The father begins to feel that he has failed in his responsibility for providing a male image for his son. He tends to deny the existence and/or meaning of his son’s femininity, using such statements as “All boys go through that” and “It’s only a passing phase.” 10. During the next few years the boy’s increasing identification with females is revealed by a degree of feminine affectation, and causes the child to be labeled a sissy or “a girl.” Finally, an adult outside the family, typically a schoolteacher or neighbor, repeatedly brings the boy’s behavior to the attention of his m ~ t h e r . ” ~ Stollerg*l o has delineated etiological factors that once again stress the early infantile development of children who eventually become transsexuals. He includes “excessive, blissful physical and emotional closeness between mother and infant, extended for years and uninterrupted by other siblings; strong transsexual tendencies in the mothers throughout their own midchildhood which goes underground during adolescence; passive and/or effeminate fathers who are absent and an empty, angry marriage which is preserved.” What are the variations in these descriptions that may cause a homosexual rather than a transsexual predisposition? Add to this a more accurate look at the multiple variables in intrapsychic factors, and one begins t o develop an etiological theory based on scientific observation, independent of one’s feelings about homosexuality and free of the bias created by automatic labeling with its severe sociological effects. With transsexuality a t the far end of a continuum and heterosexuality at the other extreme, we could bend our efforts toward a clearer, more refined delineation of the concepts of drive and object choice. Psychiatric research should study the interplay between infantile events and intrapsychic phenomena. Instead of labeling and changing people who want neither a label nor a change, so that they will be suitable to the intrapsychic needs of the therapist, perhaps we should attempt to microscopically, scientifically dissect the relationship between parents, mostly mother, and child that allows some people to retain their male gender identity but have a strong, feminine identification and a male object choice as occurs in homosexuality. Stoller, Greenson, Green, Marmor, Money, and others6-12 have begun this investiga-
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tion, but it cannot be done by them, while the bulk of the profession equates variations in development leading to unusual adult forms of internal organization of self-perception and object relations in a pejorative fashion and as an illness in need of therapeutic repair. Freud’s original description of a drive with a source, an aim, an intensity, and an objcct stresses the malleability of human Tnkb. We have stressed the difference between an instinct in animals and an “instinctual drive” in humans. It is the very malleability that allows some individuals to end up in adulthood with a love object that is different from the “norm.” In psychiatry we delude ourselves that, in treating a homosexual who has become a husband and father for all the world t o see, we have eradicated the desire, the fantasies, the intensity of the wish for love, sex, closeness, penetration, domination, whatever, for someone of the same sex. Some of us are apparently satisfied that we have helped this mythical person to become a more acceptable person in other people’s, and perhaps his own, eyes, and a “more useful citizen.” The study of the variation in object choice should give us a clearer understanding of human drives. In the consultation room we must use our empathy t o recognize the intensity of a homosexual’s desire for a partner of the same sex. If we treat this desire with the idea that it is sick, defensive, and conflictual, we have no appreciation of the feelings of the patient and the difference between his drive for a male partner and a female partner. In treating men who have sustained lifelong homosexual fantasies but who have chosen a heterosexual life-style, the difference in the intensity of the drive and the true internal object choice is immediately apparent. Therapy implies change in behavior. Let us treat those who wish t o be treated and through them help to develop greater understanding of the basic cornerstones of our theory of human behavior. Let us not extrapolate from this highly selected population of patients and arrogantly presume a complete understanding of human variation and a secure knowledge of such fundamental concepts as drive, identification, object choice, and gender identity.
REFERENCES 1. Freud S: Letter to an American mother. 2. Ruitenbeek HM: The Problem of Homosexuality in Modern Society. New York, EP Dutton, 1963. 3. Socarides C: Homosexuality and medicine. JAMA 212: 1199-1202, 1970. 4. Socarides C: The Overt HomosexunL. New Yo&. Gmne & Stratton, 1968. 5. Schofield M: Sociological Aspects of Homosexuality. London, Longmans, Green, 1965. 6. Hooker E; The adjustment of the male overt homosexual. In HM Ruitenbeek (Ed), Sexual Identity Conflict in Children and Adults. New York, Basic Books, 1974. 7. Green R, Money J (Eds): Trunssexualism and Sex Remstpment. Baltimore, Johns Hopkins Press, 1969. 8. Green R: Sexual Identity Conflict in Children and Adults. New York, Basic Books, 1973.
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9. Stoller RJ: Parental influences of male transsexuals. In R Green & J Money (Eds), Transsexualism and Sex Reassinment. Baltimore, Johns Hopkins Press, 1969. 10. Stoller RJ: Sex and Gender. New York, Science House, 1968. 11. Marmor J: Homosexuality and objectivity. Sex Inform Ed Council US Newsletter 6:1, 3, 5 , December 1970. 12. Money J, Ehrhardt A: Man and Boy, Woman and GirL Baltimore, Johns Hopkins Press, 1972. 13. Ovesey L: Homo and Pseudohomo. New York, Science House, 1969.
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
Homosexuality—Illness or Life-style? Paul J. Fink M.D.
a
a
Department of Psychiatry and Behavioral Sciences , Eastern Virginia Medical School , 721 Fairfax Avenue, Norfolk, Virginia, 23507 Published online: 14 Jan 2008.
To cite this article: Paul J. Fink M.D. (1975) Homosexuality—Illness or Life-style?, Journal of Sex & Marital Therapy, 1:3, 225-233, DOI: 10.1080/00926237508405292 To link to this article: http://dx.doi.org/10.1080/00926237508405292
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Journal of Sex & Marital Therapy Vol. 1, No. 3, Spring 1975
HomosexualityIllness or Life-style?
Downloaded by [Central Michigan University] at 10:27 10 October 2014
Paul J. Fink, M.D.
ABSTRACT: This paper addresses the issues of the labeling and selective discrimination of homosexuals. Psychiatry is encouraged to adhere to the medical model and treat the homosexual patient who is in conflict and motivated by inner turmoil and distress rather than assuming the job of society’s regulator and the judge of acceptable behavior. The author discusses the concept of gender identity and presents evidence for the idea that homosexual behavior has its etiology in early child development. The cultural stigma of gender dysphorias is also discussed in detail as playing a significant role in the eventual character formation of an adult homosexual.
The issue of homosexuality as an illness versus a life-style is not a debate over psychiatric definition or the extent of our knowledge regarding etiology and diagnosis. Rather, it is a philosophical problem about the ideal man, a utopian view of the power of psychiatric therapy, and a sociological problem regarding labeling and its effects on the person who acquires the label. It is more of a Szaszian than a Freudian problem. I should begin by saying that I acknowledge that there are sick homosexuals who both seek and need psychiatric treatment; however, I do not regard all homosexuals as ill persons. Nor is homosexuality a crime, a sin, an act against nature, or a threat t o the continuation of mankind. Throughout the last several hundred years we have had all of these ideas promulgated by people concerned with the eradication of homosexuality which has doggedly persisted in accounting for approximately 10% of the population whether they resided mostly in the “closet” or paraded “brazenly” up Fifth Avenue. At this point in history the failure of psychiatry to cure the social and psychological ills of the world should be obvious. The early implied promise of the psychoanalytic movement to eradicate mental suffering and develop a society of men with freedom of choice, unencumbered by unconscious, destructive conflicts, has been followed in the past 20 years with a frantic
Dr. Fink is Professor and Chairman, Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, 721 Fairfax Avenue, Norfolk, Virginia 25507.
225
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Journal of Sex &Marital Therapy
search for other more “scientific,” quicker, more manipulative technicques that lend themselves to “accountability” and “validation.” We tread on very dangerous territory when we include a label for everyone in our nomenclature and extrapolate from the fact that all human beings have unresolved, unconscious conflicts to the idea’that therefore all people have a diagnosis and require, or as we euphemistically say, “could use” treatment. When we take such an approach, we move dangerously away from our role as physicians working in the medical model and become instead judges of human behavior. This latter maneuver forces us to become theologians and social planners, but not truly caretakers of those people who are in pain and seek our help. Freud’s “Letter to an American Mother” is still a significant document that states clearly that homosexuality is not an illness, that man has a biological and developmental predisposition toward bisexuality, and that the psychiatric profession should be consistently objective in judging a human being neither by his object choice nor the world’s view of his life-style-but rather his inner turmoil and anguish which can be ameliorated “whether he remains a homosexual or gets changed.” Freud’ states: 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 function produced by a certain arrest of sexual development. Many highly respectable individuals of ancient and modern times have been homosexuals, several of the greatest men among them, Plato, Michelangelo, Leonard0 da By asking me if I can help, you mean, I suppose, if I can abolish Vinci, etc. homosexuality and make normal heterosexuality take its place. The answer is, in a general way, we cannot promise to achieve it. In a certain number of cases we succeed in developing the blighted germs of heterosexual tendencies which are present in every homosexual, in the majority of cases it is no more possible. It is a question of the quality and the age of the individual. The result of the treatment cannot be predicted. What analysis can do for your son runs in a different line. If he is unhappy, neurotic, torn by conflicts, inhibited in his social life, analysis may bring him harmony, peace of mind, full efficiency, whether he remains a homosexual or gets changed.
...
Freud’s great contribution to the study of human sexuality resides in his theory of psychosexual development which tells us that early life events set the tone for lifelong patterns of behavior. To say that an arrest in development is by definition an illness is to say that all criminals who are arrested in their superego development are ill, that all hard-driving, aggressive businessmen who are arrested in their Oedipal development are ill, that all delightfully seductive, scatterbrained, hysterical characters who continue t o seek fatherly heterosexual relations are ill, and so on. In nonpsychotic conditions there must be ego-dystonic behavioral patterns in the realms of thoughts, feelings, or actions that are subjectively felt t o be distressing before the label of illiness should be applied.
Paul J. Fink
22 7
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Homosexuality is a developmental variation of gender identity, identification, and object choice. We have been unable to find a single dynamic explanation for it, since its genesis is quite complex and there are multiple combinations of variables that can lead a person t o have a confused and ambivalent gender identity leadning t o an object choice that is opposite (inverse) to the bulk of the population. Evelyn Hooker has concluded as follows: 1. Homosexuality as a clinical entity does not exist. Its forms are as varied as are those of heterosexuality. 2. Homosexuality may be a deviation in sexual pattern which is within the normal range, psychologically. This has been suggested, on a biological level, by Ford and Beach. 3. The role of particular forms of sexual desire and expression in personality structure and development may be less important than has frequently been assumed. Even if one assumes that homosexuality represents a severe form of maladjustment to society in the sexual sector of behavior, this does not necessarily mean that the homosexual must be severely maladjusted in other sectors of his behavior. Or, if one assumes that homosexuality is a form of severe maladiustment internally, it may be that the disturbance is limited to the sexual sector alone.6
This famous study by Hooker was one of the few to study overt homosexuals with matched heterosexual controls. The results have been forgotten, or should I say repressed, in favor of more subjective, patient-derived data that tend to be more responsive t o the preservation of the diagnostic manual than t o some of the basic questions concerning etiology in the field of psychiatry. This would certainly include homosexuality. Among the questions t o be answered would be the effects of societal forces on the distress felt by the homosexual-versus the societal forces that help to create the homosexuality initially. At this juncture we must ask what societal forces have led to the alteration of psychiatry from a scientific, medical specialty that attempts to explore human behavior and treat people in mental and emotional distress, to a conservative subjective subgroup of the social sciences that deals with matters of values, morality, and social issues, and inadvertently becomes the vehicle for preserving the status quo. Psychiatry is seriously threatened when it abandons the scientific guidelines that Freud tried to inspire with his persistent demand for objectivity, more data, biological explanations, and repetitive hedging in the areas of his exploration. Admittedly he was persuasive and seductive in his arguments, but he would never (I don’t think) have made a statement such as the one S o c a r i d e ~made ~ ~ ~ recently that homosexuality is a “dread dysfunction, malignant in character, which has risen to epidemic proportions.” If, in fact, Socarides’ metaphor of an epidemic were t o be given serious credence, we, as medical practitioners, should have been overwhelmed with an enormous number of distressed, truly nonfunctioning individuals, begging for our intervention to reduce the suffering and return them to “working and loving.” The specialty of psychiatry is more prone to the introduction of
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bias into the therapeutic situation than any other medical field. Clinical judgment should be based on scientific data derived from the “basic” sciences, but our basic investigative sciences are soft and are often neglected in favor of information and attitudes derived from samples of a single case, or a therapeutic series, rather than true experimental studies. The treatment of sick homosexuals is not truly a scientific way to understand the psychodynamics of all homosexuals. Changes in the culture cause changes in the criteria that we use for diagnosis. Nowhere else is the diagnosis and treatment of people so vulnerable to opinion, societal norms, and the treater’s own psychology. The problem of transsexualism provides a perfect example. Since a delusion is defined as a fixed irrational belief uncorrectable by reality and not consistent with the norms of the society, anyone prior to 1952 (Christine Jorgenson) requesting that his penis be cut off would have been judged delusional and psychotic by definition. As soon as surgery made the possibility of sex change a reality, it was no longer possible to apply the criterion of delusion to such requests. My only point is that the fluidity of our diagnostic criteria makes us particularly vulnerable to scandals such as the Rosenhan study could produce. Rosenhan and co-workers reported in the January 1973 issue of Science that patients admitted to mental hospitals were treated more OA the basis of their label than observable facts. We must free ourselves of the burden that we have helped t o create. In a small way we can d o this by paying scrupulous attention to the application of strict scientific criteria t o the problem of psychiatric diagnosis and treatment. I would like to suggest three important issues concerning homosexuality for consideration in this regard. First of all, it is important that we pay attention to studies in anthropology, sociology, and psychology, which are conducted in a scientific manner and can act either t o support or refute theory and practice as we in the clinical sphere apply that theory on a day-to-day basis. The work of Ford and Beach that studied homosexuality cross-culturally is a significant study and demonstrated that 64% of the societies that they studied considered homosexuality a normal variant of sexual behavior. If we combine that information with our own society’s treatment of and attitude toward homosexuals, we are left with the imperative question of how much of our theory and the homosexual’s emotional distress is a result of environmental, cultural forces, and how much is a response t o dynamic, conflictual, developmental forces. The studies of Kinsey and the work of Gebhart demonstrate that homosexual behavior is extremely common in our society, and is often not a significant factor in the overall sexual adjustment of persons who have had such activities in their lives. Schofields has made the following observation and suggestions: Anthropologists have found that homosexuality is more often found in the more restrictive communities where sexual customs are subject to formal rules (Mead,
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1949; Ford and Beach, 1952). For example homosexuality was rare in the very uninhibited culture of the Trobriand Islands (Malinowski, 1932) but quite common among the Mohave Indians (Devereux, 1937). This Indian tribe had very strict rules about the type of work a man should do. The men were warriors and fighters, but if a man wanted to stop at home and work with the women, he was allowed to do this, and indeed he was permitted to marry another man and act out the part of the wife as far as this was physically possible. In modem society the most obvious mincing effeminate homosexuals are to be found, not in London, but in the small provincial towns. This is because in alarge city a man can have a private homosexual life unfettered by social pressures from neighbours. But in a small community where everyone knows everyone else, the homosexual’s predilections will soon become common knowledge and before long he will have to give up trying t o appear normal to his friends and workmates, and there will be no point in trying to keep up any pretence. Indeed as a compensation for the social disapproval he finds, he goes to the other extreme and becomes more and more effeminate-like a Mohave Indian. This is just one way in which the social pressures can cause the personality of the homosexual to deteriorate. Many of the problems that beset the homosexual are created by the hostility of society. He is compelled to feel ashamed of his sexual desires and it is often suggested that he is mentally ill. If he gives way to his desires he is filled with guilt, and these feelings are often more destructive than the actual homosexual act. He must conceal his true identity and on occasions he may be required to agree with others and pretend to condemn his own interests and activities. This paranoic split in his life may prove to be difficult to maintain and lead t o breakdown. If he openly expresses his predilections, he is said to be so disturbed that he is seeking conflict, scorn and ridicule from his fellow men. He is denied the comforts and companionship of the marriage and family life. If he attempts to settle down and live with another man, the difficulties put in the way may make it impossible for the affair t o survive. Instead he may have to seek gratification in public and sordid places.
This was a rather lengthy example of a sociologist’s viewpoint. Schofield’s theoretical conclusion, which lacks an in-depth intrapsychic psychological point of view, does alert us to more global facts, which we in turn tend to neglect in our own theorizing. The second area requiring our perseverence is related to the first. W e must be inspired by intellectual curiosity to simultaneously treat the distressed patient and be responsive t o the extraordinary phenomena derived from patient care that are inconsistent with our own theoretical formulations. In many ways the study and care of transsexuals has forced us to reexamine our view of homosexuals and is adding to our in-depth knowledge of such people. The work of Stoller and Green is of particular interest because they responded with psychoanalytic curiosity while most psychiatrists wrote the transsexual off as psychotic, by definition. As a result of their clinical work and research they have been able t o treat effeminate boys and reverse the effeminacy, thereby helping the child to find comfort in identifications in the sex of birth. More importantly, they have contributed significantly to changes in theoretical concepts concerning the process of gender identity. Green has collected data and devised theories based on a combination of his observations of children and their parents in treatment, knowledge of child development, and the psychoanalytic theory of intrapsychic processes.
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Stoller’s response to the paradox between the demand of some men to have their penis removed and the concept of castration anxiety led him and his colleagues to look at identification and gender identity formation more closely. The transsexual seems t o present himself, at least on the surface, as a person with an unambivalent, nonconflicted wish t o be a member of the opposite sex. The homosexual’s problem lies in the area of the object choice rather than gender identity. Both the male-female transsexual and the male homosexual have a feminine identification that seems t o have been created at different times and in different ways during psychosexual development. We are still not clear on the exact nature of these developmental phenomena; however, the information available relies less on retrospective speculation of events based on intrapsychic responses and more on patterns of child rearing-those childhood events that create the internal distortions leading to the choice of an ego-syntonic life-style of transsexuality or homosexuality. Green has given the following composite description of the child-rearing and other factors leading to a gender dysphoria, that is, a disorder of gender identity and identification: 1. A mother considers her infant male child to be unusually attractive. 2. The mother’s time commitments are such that she is able to devote considerable attention to this boy. Her affective or emotional commitments are such that she has few other avenues for channeling her feelings of caring and love. 3. The child begins to play with many colorful accessories belonging to his mother. He imitates the person with whom he is primarily in contact, his mother. These early behaviors are considered to be cute. The responses obtained by the child are supportive-additional attention, benign laughter, being shown off. 4. The father, if present, is a much less significant person in the boy’s life than his mother. His possessions and accessories are not so attractive as objects for early play and role taking. The father, too, when witnessing his son’s early play with feminine objects, experiences it as funny, cute, or neutral, and does not object. 5. Peer Telationships begin; girls are primarily available. The few boys available are more aggressive than he, intimidate him, and meet with parental disapproval. The boy asserts that he likes to play with girls because boys are “too rough.” Possibly here, too, an innate feature is operating to influence early socialization. A lower level of aggressivity, influenced perhaps by an intrauterine endocrine factor such as lowered androgen levels, may facilitate his companionship with girls because he is more comfortable in their play activities. Hence, his earliest learned social skills are those more typical of girls. 6. The boy is more in tune with the calmer domestic activities of his mother. The father experiences rejection from his son and deems him a “mama’s boy.” A degree of father-son alienation ensues. The frustration of the father is transmitted to the son.
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7. Earlier socialization to feminine skills and companionship now poses an obstacle to same-sex peer integration during the first years of school. Because of his feminine interests and greater comfort with female companions, he is teased, resulting in further alienation from his male peer group. 8. The mother continues to respond positively to the boy’s interest in cross-dressing or improvising feminine costumes and t o his attentiveness t o her clothing and grooming. She may be encouraged by his play with girls as a sign of his later being “a lady’s man.” 9. The emotional distance between father and son continues t o increase because of the boy’s low interest in his father’s activities. The father begins to feel that he has failed in his responsibility for providing a male image for his son. He tends to deny the existence and/or meaning of his son’s femininity, using such statements as “All boys go through that” and “It’s only a passing phase.” 10. During the next few years the boy’s increasing identification with females is revealed by a degree of feminine affectation, and causes the child to be labeled a sissy or “a girl.” Finally, an adult outside the family, typically a schoolteacher or neighbor, repeatedly brings the boy’s behavior to the attention of his m ~ t h e r . ” ~ Stollerg*l o has delineated etiological factors that once again stress the early infantile development of children who eventually become transsexuals. He includes “excessive, blissful physical and emotional closeness between mother and infant, extended for years and uninterrupted by other siblings; strong transsexual tendencies in the mothers throughout their own midchildhood which goes underground during adolescence; passive and/or effeminate fathers who are absent and an empty, angry marriage which is preserved.” What are the variations in these descriptions that may cause a homosexual rather than a transsexual predisposition? Add to this a more accurate look at the multiple variables in intrapsychic factors, and one begins t o develop an etiological theory based on scientific observation, independent of one’s feelings about homosexuality and free of the bias created by automatic labeling with its severe sociological effects. With transsexuality a t the far end of a continuum and heterosexuality at the other extreme, we could bend our efforts toward a clearer, more refined delineation of the concepts of drive and object choice. Psychiatric research should study the interplay between infantile events and intrapsychic phenomena. Instead of labeling and changing people who want neither a label nor a change, so that they will be suitable to the intrapsychic needs of the therapist, perhaps we should attempt to microscopically, scientifically dissect the relationship between parents, mostly mother, and child that allows some people to retain their male gender identity but have a strong, feminine identification and a male object choice as occurs in homosexuality. Stoller, Greenson, Green, Marmor, Money, and others6-12 have begun this investiga-
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tion, but it cannot be done by them, while the bulk of the profession equates variations in development leading to unusual adult forms of internal organization of self-perception and object relations in a pejorative fashion and as an illness in need of therapeutic repair. Freud’s original description of a drive with a source, an aim, an intensity, and an objcct stresses the malleability of human Tnkb. We have stressed the difference between an instinct in animals and an “instinctual drive” in humans. It is the very malleability that allows some individuals to end up in adulthood with a love object that is different from the “norm.” In psychiatry we delude ourselves that, in treating a homosexual who has become a husband and father for all the world t o see, we have eradicated the desire, the fantasies, the intensity of the wish for love, sex, closeness, penetration, domination, whatever, for someone of the same sex. Some of us are apparently satisfied that we have helped this mythical person to become a more acceptable person in other people’s, and perhaps his own, eyes, and a “more useful citizen.” The study of the variation in object choice should give us a clearer understanding of human drives. In the consultation room we must use our empathy t o recognize the intensity of a homosexual’s desire for a partner of the same sex. If we treat this desire with the idea that it is sick, defensive, and conflictual, we have no appreciation of the feelings of the patient and the difference between his drive for a male partner and a female partner. In treating men who have sustained lifelong homosexual fantasies but who have chosen a heterosexual life-style, the difference in the intensity of the drive and the true internal object choice is immediately apparent. Therapy implies change in behavior. Let us treat those who wish t o be treated and through them help to develop greater understanding of the basic cornerstones of our theory of human behavior. Let us not extrapolate from this highly selected population of patients and arrogantly presume a complete understanding of human variation and a secure knowledge of such fundamental concepts as drive, identification, object choice, and gender identity.
REFERENCES 1. Freud S: Letter to an American mother. 2. Ruitenbeek HM: The Problem of Homosexuality in Modern Society. New York, EP Dutton, 1963. 3. Socarides C: Homosexuality and medicine. JAMA 212: 1199-1202, 1970. 4. Socarides C: The Overt HomosexunL. New Yo&. Gmne & Stratton, 1968. 5. Schofield M: Sociological Aspects of Homosexuality. London, Longmans, Green, 1965. 6. Hooker E; The adjustment of the male overt homosexual. In HM Ruitenbeek (Ed), Sexual Identity Conflict in Children and Adults. New York, Basic Books, 1974. 7. Green R, Money J (Eds): Trunssexualism and Sex Remstpment. Baltimore, Johns Hopkins Press, 1969. 8. Green R: Sexual Identity Conflict in Children and Adults. New York, Basic Books, 1973.
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9. Stoller RJ: Parental influences of male transsexuals. In R Green & J Money (Eds), Transsexualism and Sex Reassinment. Baltimore, Johns Hopkins Press, 1969. 10. Stoller RJ: Sex and Gender. New York, Science House, 1968. 11. Marmor J: Homosexuality and objectivity. Sex Inform Ed Council US Newsletter 6:1, 3, 5 , December 1970. 12. Money J, Ehrhardt A: Man and Boy, Woman and GirL Baltimore, Johns Hopkins Press, 1972. 13. Ovesey L: Homo and Pseudohomo. New York, Science House, 1969.
