Homosexuality: Some Diagnostic Perspectives and Dynamic Considerations F R A N K
M .
L A C H M A N N ,
P H . D . *
| New
York,
N.Y.
Homosexuality as a diagnostic category has been of limited value since the sexual functioning, ego development, and object relations of patients are not always correlated. Considering homosexuality as a complex configuration resulting from the interplay of unconscious drives with defensive processes and adaptive implications offers a comprehensive dynamic approach. Illustrative case material is presented.
The recent debate and decision by the American Psychiatric Association over the status of homosexuality eventuated in the substitution of the term "sexual orientation disturbance" for the previously held view that homosexuality, per se, constituted a psychiatric disorder. While a ballot box may not be the place to decide matters which ought to be the subject of scientific inquiry, the decision by the APA has nevertheless raised some important questions while side-stepping some central issues. A definition of psychopathology and the formulation of criteria for diagnostic categories were avoided. However, the necessity for re-evaluating the concept of homosexuality may prove to be of benefit to the psychoanalyst as a diagnostician and a therapist. The Status of Homosexuality Within Psychoanalytic Theory Psychoanalysis, at its inception, proposed a comprehensive theory of personality development based on psychosexual stages (oral, anal, phallic, oedipal.) This was embodied in the ontogenetic table of Abraham and later revised by Fliess (1). From this table one could gather considerable knowledge about a person by simply looking up his point of libidinal fixation and thereby ascertaining the quality of his object relations and the level of his ego development, especially the sense of reality. All these developmental attributes and achievements were believed to be highly correlated. The goal of psychoanalytic treatment was to arrive at the genital level as described, for example, by Reich (2) : T h e genital character has fully reached the post-ambivalent genital stage. . . . the incestuous desire and the wish to do away with the father
(the mother)
have been abandoned, genitality has been transferred to a heterosexual object . . . . potency is reliable. * Mailing
254
I f the primacy of the intellect is both a claim of social
address: 333 West E r 4 Ave., New York, N , Y 10023, f
HOMOSEXUALITY
255
development and at the same time its goal, it is inconceivable without the primacy of genitality (2, p. 132-137).
Thus, sexual potency, heterosexuality, and social and intellectual maturity were inextricably linked. Pathology in the sexual sphere, fixation at a pregenital level made the other aspects of mental health unattainable. Homosexuality, within this framework was correlated with a preoedipal libidinal organization, predominantly narcissistic object relations and an immaturity in ego development. A diagnosis of homosexuality would therefore convey more than the sex of a person's sexual partner. Over the years, psychoanalytic formulations of personality organization have become broader and more fluid in an attempt to encompass the wide range and complexity of behavior. Ross ( 3 ) evaluated the implications of genital primacy as a concept of normality and as a goal of psychoanalytic treatment. He grappled with the clinical finding that some patients whose ego functions are markedly disturbed may have sexual capacities intact while a successfully analyzed person who functions well in areas reflecting ego integration and interpersonal relations may yet remain sexually frigid or impotent. Sexual functioning thus may or may not reflect, indicate, occur coincidentally with, or be affected by other psychologic difficulties of the individual. For better or worse, it may be isolated from other areas of the person's life. The correlations among sexual development, intellectual functions, and interpersonal relations are more circumscribed than was initially believed. The presence of homosexual behavior as the exclusive or preferred form of sexual activity in an adult may have limited predictive value for other aspects of the personality since it can be more or less successfully isolated. The ego, using the defense of isolation enables the sexual life of a person to turn toward homosexuality and remain walled off from other nonsexual areas of functioning. Secondarily then, the large-scale use of isolation may take its toll on psychologic functioning. The observation that the defense of isolation may both serve to preserve functioning and inhibit it was reported by Eissler (4). He described the various ways in which isolation may operate, specifically contrasting its place in the lives of Goethe and Leonardo da Vinci. The creativity of the former thrived through walling off his political-social life while the creative output of the latter suffered from an inability to isolate his artistic life. This takes into account the adaptive, self-preservative aspect of the defense. Complex interrelationships between sexual functioning, ego development, and object relations, more or less isolated, must be considered in assessing homosexuality. In attempting to study the various, subtle dynamic interrelationships we move beyond what can be encompassed in a diag¬ nostic category,
256
AMERICAN
JOURNAL OF P S Y C H O T H E R A P Y
The literature on homosexuality is replete with attempts to delineate the specific dynamics that can account for it. Several writers have emphasized various familial configurations and motivational forces. For some patients their dynamic formulations offer an accurate description of decisive unconscious motivations but there are always patients for whom they miss the mark. Within the psychoanalytic literature on homosexuality, two dynamic formulations are frequently cited. Weideman's (5) survey of this literature concludes that homosexuality is "one of the pathological outcomes of the Oedipal phase" (5, p. 405). Subsequently Socarides (6) has shifted the emphasis to the wish, by the homosexual, for a symbiotic, nongenital union with the preoedipal mother. An interesting research program by Silverman et al. (7) has provided experimental verification for both of these propositions by studying homosexual men who were not in psychotherapeutic treatment. These general formulations, however, require elaboration of the nuances which may be decisive in veering a particular person toward homosexuality. Such details and individual variations are supplied by the study of specific case material. Four patients who identified themselves as "homosexual" and who examplify a wide range and variation in dynamics will be described. This illustrative material will then serve for comparisons of the various motivations for homosexual behavior and of the ego structures and object relations associated with homosexuality. CASE 1 M r . E . sought psychoanalysis because of mounting anxiety attacks and depressions reaching suicidal proportions.
H i s career as a singer h a d come to a standstill.
H e was subjectively most distressed by his increasing involvement i n homosexuality. H e could trace his attraction to men back to his teens and its expression was always associated with profound guilt.
D u r i n g his latency years he had been subjected to
a series of traumatic enemas by both parents. rage and humiliation evoked by this trauma.
I n his analysis he uncovered the T h e enemas were experienced as a
sexual assault with both gratification and punishment for incestuous wishes.
In
his homosexual practices he had attempted to relive the furtive pleasurable excitement, master the pain, and revenge himself upon his parents via his sexual partners.
A s this ambivalent relationship to the parents was expressed and worked
through in the transference, the homosexual behavior became superfluous. CASE 2 Miss F . a school teacher, sufficiently to read.
ing emotionally stressful times. and
came for
psychotherapy,
unable
to
concentrate
She also suffered from blackouts a n d tended to doze off durShe would then describe aloud dreamlike images
fantasies. Overt homosexuality began at about the time she began treatment.
A n only
child, she had enjoyed a physically close relationship with her mother until the age of four when her father, who had abandoned the mother when she became
257
HOMOSEXUALITY pregnant, returned to live with her.
Intense jealousy of the father who literally
displaced her from her mother's bed became a powerful motivating force.
Her
wish to replace and displace the father was expressed in childhood in her doll play w h i c h included sexual scenes she had observed between her parents.
T h i s led to
attiring herself in her father's clothes when her parents went out and, during her adolescence, masturbating while so dressed. As
a young adult, she began to frequent
clothes. had
homosexual bars dressed i n men's
T h e blackouts h a d begun during her adolescence while bathing after she
masturbated.
CASE 3 M r . G . sought analysis because he found his asexual life intolerable.
I n his late
teens he h a d h a d two brief affairs with women w h i c h he felt were "mechanical." Subsequently, there were a few homosexual contacts.
H e considered himself to be
homosexual and his social life and friendships were predominantly with homosexual men.
H e hoped analysis would help h i m to accept either homosexuality or hetero-
sexuality. T h o u g h the presenting problems centered on his conflicted sexuality, his rigid, emotionally detached, obsessional character structure served as the central treatment problem.
T w o motivational currents led to his sexual life style.
A circum-
cision at the age of two had been experienced as a castration for w h i c h his mother was blamed.
Women were thus generally distrusted, but specifically he could not
entrust his penis to anyone.
H e was convinced that it was already "too small" a n d
might, in the sex act, be further diminished. H i s attraction to homosexuality was motivated by a wish for a larger penis expressed in a fantasy of body boundary dissolution during orgasm with the expectation of averaging out penis sizes when the body boundaries would be re-established after orgasm.
A second motivational current for the sexual conflict stemmed from
his fajther's unusual self-preoccupation.
T h e father reportedly spent long periods
of time examining and admiring himself before a mirror.
M r . G . felt as a child
that he had to compete for his father with the father's fascination with his own mirror image.
As an adult, M r . G . felt compelled to attract men but afraid of
the sejxual consequences that might ensue. CASE 4 M r . D . described his m a i n purpose in seeking treatment as a feeling of alienation from people and a concern that he was not living up to his potentialities i n his work as an advertising executive.
F r o m early childhood on he had remained his
mother's confidant and ally against his gruff, alcoholic father.
H i s involvement
with people was based on his need to have them reflect back to h i m a favorable image of himself.
A prominent sexual expression was masturbation in front of a
mirror while imagining seeing and merging with a more perfect version of himself. H i s homosexual partners were chosen to serve the same purpose.
A n implicit goal
in treatment was to become a more perfect version of what he already was.
The
homosexuality, the masturbation, and the social relationships were all i n the service of self-esteem regulation, to maintain an organized, coherent, ongoing, and positive self-image.
258
AMERICAN
JOURNAL
OF PSYCHOTHERAPY
DISCUSSION
These cases exemplify the varying personality organizations in which homosexuality can be contained. The homosexuality ranges from playing a peripheral role (Mr. D.) to occupying a central position in the lives of these patients. From the standpoint of diagnosis, the label "homosexuality" would be inexact. The problems for which they sought treatment can be more accurately and inclusively described as the symptoms of an anxiety hysteria (Mr. E.), a borderline personality organization (Miss F.), an obsessive-compulsive neurosis (Mr. G.), and a narcissistic personality disorder (Mr. D . ) . In the case of Mr. D., though in his work he did not attain his grandiose expectations, he actually performed very well, and gave evidence of wellintegrated ego functions. His relationships with people, however, were on a blatantly narcissistic basis. For Mr. E. the reverse was true. His ability to work was markedly constricted but his relationships with people remained complex, emotionally rich and with an appreciation of individual differences clouded by only minor distortions. The presence of the homosexuality in these patients dictated neither their general ego organization nor important aspects of their interpersonal relationships. It also appears that no one dynamic formulation can do justice to this sample of patients. For Mr. E. homosexuality was seized by the ego to allow sexual feeling, bind reactive aggression toward the parents, and master a sense of humiliation by turning a passively endured trauma into an active expression. The homosexuality was a compromise formation in dealing with an intrapsychic conflict. For Miss F., however, the homosexuality was an attempt to refind a lost paradise. I t was her inability to recapture the exclusive relationship with her mother that distressed her. Putting on her father's clothes had been a detour of her desire to return to her mother's bed. For Mr. G. the homosexuality was to a lesser extent and for Mr. D. to a greater extent an aspect of what could be described as narcissistic pathology. I t was predominantly in the service of self-esteem regulation rather than a repetition of a specific early relationship though such motivation was not absent. Therapeutic and Prognostic Implications These various contexts for the homosexuality would indicate differing treatment approaches based on a general understanding of the patient's dynamics rather than the presence of any particular symptom. Mr. E. and Mr. G. were treated psychoanalytically, while for Miss F. a more interactive psychoanalytically oriented psychotherapy seemed appropriate. For Mr. D. the extensions of psychoanalysis described by Kohut (8) were useful
HOMOSEXUALITY
259
Upon completion of psychoanalytic therapy, even the reasonable expectations held by patient and analyst at its start are not always fulfilled. Mr. E. found himself secure and gratified in his heterosexual marriage, yet remnants of his vulnerability to anxiety remained. Miss F. was able to concentrate, read, and engage in creative writing. Her tenuous ego organization developed to a point where the dramatic regressions and disintegrations disappeared. The need to refind her lost paradise as expressed through her homosexuality remained and left her particularly vulnerable to disappointment. The painful repetitions of specific aspects of her relationship with her mother, provoking separations and reunions, diminished. Her predominantly masochistic homosexual contacts gave way to a lasting, predominantly affectionate homosexual attachment. For Mr. D. the fact of the homosexuality had barely been an issue in the treatment though the quality of his relationships was extensively explored. His improvement was conspicuous here. For Mr. G., however, to shift or not to shift, was a constant struggle and was eventually resolved in favor of heterosexuality. For both, especially for Mr. D., the adaptive value of the homosexuality took precedence. The alternative would have been social isolation, a fragmentation of the sense of self, and unbearable feelings of loneliness and emptiness. Reconsideration of Status of Homosexuality For each of the four patients, homosexuality developed out of specific and different life circumstances. Is it better described as psychopathology or as a sexual orientation? For example, to view the homosexuality in the case of Mr. D., as purely psychopathologic would not do justice to its vital adaptive function. Conversely, to consider homosexuality simply as a sexual orientation errs in the direction of relegating it to a social phenomenon. This would not do justice to the profound personal distress it caused Mr. E. To view it as an illness is too limited, as a "life style" too broad and vague. Implicit in this paper has been a view based on an elaboration of a formulation used by Brenman (9) in her discussion of masochism. That is, homosexual behavior is " . . . a complex configuration resulting from the interplay of ( 1 ) . . . unconscious drives with (2) defensive processes and (3) adaptive implications" (9, p. 264). To assess the dynamics of a patient's homosexuality the contribution of each of these must be understood. For Miss F. unconscious drives played a decisive role, for Mr. E. and Mr. G. the defensive aspects predominated and for Mr. D. the adaptive functions were noteworthy. However, all three aspects were discernible in each case. Therapeutic efforts are usually most successful when applied to the analysis of defenses. Where homosexuality was predominantly a manifestation of a defensive process (Mr. E. and Mr. G.) causing subjective pain, it gave way
260
AMERICAN
JOURNAL
OF PSYCHOTHERAPY
to heterosexuality in the course of treatment. Where the homosexuality was the carrier of an unconscious drive such as the wish to refind a lost paradise (Miss F.) or essential for the integrity of the self-image (Mr. D.) it remained. SUMMARY
So long as the concept of genital primacy holds sway, homosexuality as a diagnostic category describes a patient's sexual life, ego development, and the quality of his object relations. With the recognition that these three aspects of the personality are not always so clearly correlated, the necessity arises for more detailed dynamic formulations which take these subtle interrelationships into account. No single formulation applies to every case of homosexuality. Clinical material is presented to exemplify homosexuality in an intact and in a decompensating ego structure and with constricted as well as with emotionally rich object relations. Placed on a conceptual level similar to masochism, homosexual behavior can best be understood as a complex configuration resulting from the interplay of unconscious drives with defensive processes and adaptive implications. In any particular case, one or another of these factors may be decisive which, in turn, has prognostic implications. REFERENCES 1. Fliess, R . A n Ontogenetic Table. I n The Psycho-Analytic Reader, Fliess, R . E d . International Universities Press, New York, 1962. 2. Reich, W . T h e Genital Character and the Neurotic Character. I n The PsychoAnalytic Reader, Fliess, R . E d . International Universities Press, New York, 1962. 3. Ross, N . T h e Primacy of Genitality in the Light of Ego Psychology: Introductory Remarks. J. Am. Psychoanal. Ass., 18:267, 1970. 4. Eissler, K . T h e Effect of the Structure of the Ego on Psychoanalytic Technique. /. Am. Psychoanal. Ass., 1:104, 1953. 5. Weideman, G . Survey of the Psychoanalytic Literature on Overt Male Homosexuality. J. Am. Psychoanal Ass., 10:386, 1962. 6. Socarides, C . Psychoanalytic Therapy of a Male Homosexual. Psychoanal. Quart., 38:173, 1969. 7. Silverman, L . , Kwawer, J . , Wolitzky, C , and Coron, M . A n Experimental Study of Aspects of the Psychoanalytic Theory of Male Homosexuality. /. Abnormal. Psychol, 82:178, 1973. 8. Kohut, H . The Analysis of the Self. International Universities Press, New York, 1971. 9. Brenman, M . O n Teasing and Being Teased: A n d the Problem of "Moral Masochism." Psychoanal. Study Child, 7:264, 1952.
M .
L A C H M A N N ,
P H . D . *
| New
York,
N.Y.
Homosexuality as a diagnostic category has been of limited value since the sexual functioning, ego development, and object relations of patients are not always correlated. Considering homosexuality as a complex configuration resulting from the interplay of unconscious drives with defensive processes and adaptive implications offers a comprehensive dynamic approach. Illustrative case material is presented.
The recent debate and decision by the American Psychiatric Association over the status of homosexuality eventuated in the substitution of the term "sexual orientation disturbance" for the previously held view that homosexuality, per se, constituted a psychiatric disorder. While a ballot box may not be the place to decide matters which ought to be the subject of scientific inquiry, the decision by the APA has nevertheless raised some important questions while side-stepping some central issues. A definition of psychopathology and the formulation of criteria for diagnostic categories were avoided. However, the necessity for re-evaluating the concept of homosexuality may prove to be of benefit to the psychoanalyst as a diagnostician and a therapist. The Status of Homosexuality Within Psychoanalytic Theory Psychoanalysis, at its inception, proposed a comprehensive theory of personality development based on psychosexual stages (oral, anal, phallic, oedipal.) This was embodied in the ontogenetic table of Abraham and later revised by Fliess (1). From this table one could gather considerable knowledge about a person by simply looking up his point of libidinal fixation and thereby ascertaining the quality of his object relations and the level of his ego development, especially the sense of reality. All these developmental attributes and achievements were believed to be highly correlated. The goal of psychoanalytic treatment was to arrive at the genital level as described, for example, by Reich (2) : T h e genital character has fully reached the post-ambivalent genital stage. . . . the incestuous desire and the wish to do away with the father
(the mother)
have been abandoned, genitality has been transferred to a heterosexual object . . . . potency is reliable. * Mailing
254
I f the primacy of the intellect is both a claim of social
address: 333 West E r 4 Ave., New York, N , Y 10023, f
HOMOSEXUALITY
255
development and at the same time its goal, it is inconceivable without the primacy of genitality (2, p. 132-137).
Thus, sexual potency, heterosexuality, and social and intellectual maturity were inextricably linked. Pathology in the sexual sphere, fixation at a pregenital level made the other aspects of mental health unattainable. Homosexuality, within this framework was correlated with a preoedipal libidinal organization, predominantly narcissistic object relations and an immaturity in ego development. A diagnosis of homosexuality would therefore convey more than the sex of a person's sexual partner. Over the years, psychoanalytic formulations of personality organization have become broader and more fluid in an attempt to encompass the wide range and complexity of behavior. Ross ( 3 ) evaluated the implications of genital primacy as a concept of normality and as a goal of psychoanalytic treatment. He grappled with the clinical finding that some patients whose ego functions are markedly disturbed may have sexual capacities intact while a successfully analyzed person who functions well in areas reflecting ego integration and interpersonal relations may yet remain sexually frigid or impotent. Sexual functioning thus may or may not reflect, indicate, occur coincidentally with, or be affected by other psychologic difficulties of the individual. For better or worse, it may be isolated from other areas of the person's life. The correlations among sexual development, intellectual functions, and interpersonal relations are more circumscribed than was initially believed. The presence of homosexual behavior as the exclusive or preferred form of sexual activity in an adult may have limited predictive value for other aspects of the personality since it can be more or less successfully isolated. The ego, using the defense of isolation enables the sexual life of a person to turn toward homosexuality and remain walled off from other nonsexual areas of functioning. Secondarily then, the large-scale use of isolation may take its toll on psychologic functioning. The observation that the defense of isolation may both serve to preserve functioning and inhibit it was reported by Eissler (4). He described the various ways in which isolation may operate, specifically contrasting its place in the lives of Goethe and Leonardo da Vinci. The creativity of the former thrived through walling off his political-social life while the creative output of the latter suffered from an inability to isolate his artistic life. This takes into account the adaptive, self-preservative aspect of the defense. Complex interrelationships between sexual functioning, ego development, and object relations, more or less isolated, must be considered in assessing homosexuality. In attempting to study the various, subtle dynamic interrelationships we move beyond what can be encompassed in a diag¬ nostic category,
256
AMERICAN
JOURNAL OF P S Y C H O T H E R A P Y
The literature on homosexuality is replete with attempts to delineate the specific dynamics that can account for it. Several writers have emphasized various familial configurations and motivational forces. For some patients their dynamic formulations offer an accurate description of decisive unconscious motivations but there are always patients for whom they miss the mark. Within the psychoanalytic literature on homosexuality, two dynamic formulations are frequently cited. Weideman's (5) survey of this literature concludes that homosexuality is "one of the pathological outcomes of the Oedipal phase" (5, p. 405). Subsequently Socarides (6) has shifted the emphasis to the wish, by the homosexual, for a symbiotic, nongenital union with the preoedipal mother. An interesting research program by Silverman et al. (7) has provided experimental verification for both of these propositions by studying homosexual men who were not in psychotherapeutic treatment. These general formulations, however, require elaboration of the nuances which may be decisive in veering a particular person toward homosexuality. Such details and individual variations are supplied by the study of specific case material. Four patients who identified themselves as "homosexual" and who examplify a wide range and variation in dynamics will be described. This illustrative material will then serve for comparisons of the various motivations for homosexual behavior and of the ego structures and object relations associated with homosexuality. CASE 1 M r . E . sought psychoanalysis because of mounting anxiety attacks and depressions reaching suicidal proportions.
H i s career as a singer h a d come to a standstill.
H e was subjectively most distressed by his increasing involvement i n homosexuality. H e could trace his attraction to men back to his teens and its expression was always associated with profound guilt.
D u r i n g his latency years he had been subjected to
a series of traumatic enemas by both parents. rage and humiliation evoked by this trauma.
I n his analysis he uncovered the T h e enemas were experienced as a
sexual assault with both gratification and punishment for incestuous wishes.
In
his homosexual practices he had attempted to relive the furtive pleasurable excitement, master the pain, and revenge himself upon his parents via his sexual partners.
A s this ambivalent relationship to the parents was expressed and worked
through in the transference, the homosexual behavior became superfluous. CASE 2 Miss F . a school teacher, sufficiently to read.
ing emotionally stressful times. and
came for
psychotherapy,
unable
to
concentrate
She also suffered from blackouts a n d tended to doze off durShe would then describe aloud dreamlike images
fantasies. Overt homosexuality began at about the time she began treatment.
A n only
child, she had enjoyed a physically close relationship with her mother until the age of four when her father, who had abandoned the mother when she became
257
HOMOSEXUALITY pregnant, returned to live with her.
Intense jealousy of the father who literally
displaced her from her mother's bed became a powerful motivating force.
Her
wish to replace and displace the father was expressed in childhood in her doll play w h i c h included sexual scenes she had observed between her parents.
T h i s led to
attiring herself in her father's clothes when her parents went out and, during her adolescence, masturbating while so dressed. As
a young adult, she began to frequent
clothes. had
homosexual bars dressed i n men's
T h e blackouts h a d begun during her adolescence while bathing after she
masturbated.
CASE 3 M r . G . sought analysis because he found his asexual life intolerable.
I n his late
teens he h a d h a d two brief affairs with women w h i c h he felt were "mechanical." Subsequently, there were a few homosexual contacts.
H e considered himself to be
homosexual and his social life and friendships were predominantly with homosexual men.
H e hoped analysis would help h i m to accept either homosexuality or hetero-
sexuality. T h o u g h the presenting problems centered on his conflicted sexuality, his rigid, emotionally detached, obsessional character structure served as the central treatment problem.
T w o motivational currents led to his sexual life style.
A circum-
cision at the age of two had been experienced as a castration for w h i c h his mother was blamed.
Women were thus generally distrusted, but specifically he could not
entrust his penis to anyone.
H e was convinced that it was already "too small" a n d
might, in the sex act, be further diminished. H i s attraction to homosexuality was motivated by a wish for a larger penis expressed in a fantasy of body boundary dissolution during orgasm with the expectation of averaging out penis sizes when the body boundaries would be re-established after orgasm.
A second motivational current for the sexual conflict stemmed from
his fajther's unusual self-preoccupation.
T h e father reportedly spent long periods
of time examining and admiring himself before a mirror.
M r . G . felt as a child
that he had to compete for his father with the father's fascination with his own mirror image.
As an adult, M r . G . felt compelled to attract men but afraid of
the sejxual consequences that might ensue. CASE 4 M r . D . described his m a i n purpose in seeking treatment as a feeling of alienation from people and a concern that he was not living up to his potentialities i n his work as an advertising executive.
F r o m early childhood on he had remained his
mother's confidant and ally against his gruff, alcoholic father.
H i s involvement
with people was based on his need to have them reflect back to h i m a favorable image of himself.
A prominent sexual expression was masturbation in front of a
mirror while imagining seeing and merging with a more perfect version of himself. H i s homosexual partners were chosen to serve the same purpose.
A n implicit goal
in treatment was to become a more perfect version of what he already was.
The
homosexuality, the masturbation, and the social relationships were all i n the service of self-esteem regulation, to maintain an organized, coherent, ongoing, and positive self-image.
258
AMERICAN
JOURNAL
OF PSYCHOTHERAPY
DISCUSSION
These cases exemplify the varying personality organizations in which homosexuality can be contained. The homosexuality ranges from playing a peripheral role (Mr. D.) to occupying a central position in the lives of these patients. From the standpoint of diagnosis, the label "homosexuality" would be inexact. The problems for which they sought treatment can be more accurately and inclusively described as the symptoms of an anxiety hysteria (Mr. E.), a borderline personality organization (Miss F.), an obsessive-compulsive neurosis (Mr. G.), and a narcissistic personality disorder (Mr. D . ) . In the case of Mr. D., though in his work he did not attain his grandiose expectations, he actually performed very well, and gave evidence of wellintegrated ego functions. His relationships with people, however, were on a blatantly narcissistic basis. For Mr. E. the reverse was true. His ability to work was markedly constricted but his relationships with people remained complex, emotionally rich and with an appreciation of individual differences clouded by only minor distortions. The presence of the homosexuality in these patients dictated neither their general ego organization nor important aspects of their interpersonal relationships. It also appears that no one dynamic formulation can do justice to this sample of patients. For Mr. E. homosexuality was seized by the ego to allow sexual feeling, bind reactive aggression toward the parents, and master a sense of humiliation by turning a passively endured trauma into an active expression. The homosexuality was a compromise formation in dealing with an intrapsychic conflict. For Miss F., however, the homosexuality was an attempt to refind a lost paradise. I t was her inability to recapture the exclusive relationship with her mother that distressed her. Putting on her father's clothes had been a detour of her desire to return to her mother's bed. For Mr. G. the homosexuality was to a lesser extent and for Mr. D. to a greater extent an aspect of what could be described as narcissistic pathology. I t was predominantly in the service of self-esteem regulation rather than a repetition of a specific early relationship though such motivation was not absent. Therapeutic and Prognostic Implications These various contexts for the homosexuality would indicate differing treatment approaches based on a general understanding of the patient's dynamics rather than the presence of any particular symptom. Mr. E. and Mr. G. were treated psychoanalytically, while for Miss F. a more interactive psychoanalytically oriented psychotherapy seemed appropriate. For Mr. D. the extensions of psychoanalysis described by Kohut (8) were useful
HOMOSEXUALITY
259
Upon completion of psychoanalytic therapy, even the reasonable expectations held by patient and analyst at its start are not always fulfilled. Mr. E. found himself secure and gratified in his heterosexual marriage, yet remnants of his vulnerability to anxiety remained. Miss F. was able to concentrate, read, and engage in creative writing. Her tenuous ego organization developed to a point where the dramatic regressions and disintegrations disappeared. The need to refind her lost paradise as expressed through her homosexuality remained and left her particularly vulnerable to disappointment. The painful repetitions of specific aspects of her relationship with her mother, provoking separations and reunions, diminished. Her predominantly masochistic homosexual contacts gave way to a lasting, predominantly affectionate homosexual attachment. For Mr. D. the fact of the homosexuality had barely been an issue in the treatment though the quality of his relationships was extensively explored. His improvement was conspicuous here. For Mr. G., however, to shift or not to shift, was a constant struggle and was eventually resolved in favor of heterosexuality. For both, especially for Mr. D., the adaptive value of the homosexuality took precedence. The alternative would have been social isolation, a fragmentation of the sense of self, and unbearable feelings of loneliness and emptiness. Reconsideration of Status of Homosexuality For each of the four patients, homosexuality developed out of specific and different life circumstances. Is it better described as psychopathology or as a sexual orientation? For example, to view the homosexuality in the case of Mr. D., as purely psychopathologic would not do justice to its vital adaptive function. Conversely, to consider homosexuality simply as a sexual orientation errs in the direction of relegating it to a social phenomenon. This would not do justice to the profound personal distress it caused Mr. E. To view it as an illness is too limited, as a "life style" too broad and vague. Implicit in this paper has been a view based on an elaboration of a formulation used by Brenman (9) in her discussion of masochism. That is, homosexual behavior is " . . . a complex configuration resulting from the interplay of ( 1 ) . . . unconscious drives with (2) defensive processes and (3) adaptive implications" (9, p. 264). To assess the dynamics of a patient's homosexuality the contribution of each of these must be understood. For Miss F. unconscious drives played a decisive role, for Mr. E. and Mr. G. the defensive aspects predominated and for Mr. D. the adaptive functions were noteworthy. However, all three aspects were discernible in each case. Therapeutic efforts are usually most successful when applied to the analysis of defenses. Where homosexuality was predominantly a manifestation of a defensive process (Mr. E. and Mr. G.) causing subjective pain, it gave way
260
AMERICAN
JOURNAL
OF PSYCHOTHERAPY
to heterosexuality in the course of treatment. Where the homosexuality was the carrier of an unconscious drive such as the wish to refind a lost paradise (Miss F.) or essential for the integrity of the self-image (Mr. D.) it remained. SUMMARY
So long as the concept of genital primacy holds sway, homosexuality as a diagnostic category describes a patient's sexual life, ego development, and the quality of his object relations. With the recognition that these three aspects of the personality are not always so clearly correlated, the necessity arises for more detailed dynamic formulations which take these subtle interrelationships into account. No single formulation applies to every case of homosexuality. Clinical material is presented to exemplify homosexuality in an intact and in a decompensating ego structure and with constricted as well as with emotionally rich object relations. Placed on a conceptual level similar to masochism, homosexual behavior can best be understood as a complex configuration resulting from the interplay of unconscious drives with defensive processes and adaptive implications. In any particular case, one or another of these factors may be decisive which, in turn, has prognostic implications. REFERENCES 1. Fliess, R . A n Ontogenetic Table. I n The Psycho-Analytic Reader, Fliess, R . E d . International Universities Press, New York, 1962. 2. Reich, W . T h e Genital Character and the Neurotic Character. I n The PsychoAnalytic Reader, Fliess, R . E d . International Universities Press, New York, 1962. 3. Ross, N . T h e Primacy of Genitality in the Light of Ego Psychology: Introductory Remarks. J. Am. Psychoanal. Ass., 18:267, 1970. 4. Eissler, K . T h e Effect of the Structure of the Ego on Psychoanalytic Technique. /. Am. Psychoanal. Ass., 1:104, 1953. 5. Weideman, G . Survey of the Psychoanalytic Literature on Overt Male Homosexuality. J. Am. Psychoanal Ass., 10:386, 1962. 6. Socarides, C . Psychoanalytic Therapy of a Male Homosexual. Psychoanal. Quart., 38:173, 1969. 7. Silverman, L . , Kwawer, J . , Wolitzky, C , and Coron, M . A n Experimental Study of Aspects of the Psychoanalytic Theory of Male Homosexuality. /. Abnormal. Psychol, 82:178, 1973. 8. Kohut, H . The Analysis of the Self. International Universities Press, New York, 1971. 9. Brenman, M . O n Teasing and Being Teased: A n d the Problem of "Moral Masochism." Psychoanal. Study Child, 7:264, 1952.
