15. Corsini B@Rosenberg B: Mechanisms of
group psychotherapy: processes and dynamics. Journal of Abnormal and So cialPsychology5l:406—411, 1955 16. Brabender V, AlbrechtE, SillittiJ, et al:A study of curative factors in short-term group psychotherapy. Hospital and Corn munity Psychiatry 34:643-644,1983 17. KahnEM,WebsterPB,StorckMJ:
Cura
tive factors in two types of inpatient psy chotherapygroups.InternationalJournal
of Group Psychotherapy 36:579—585,
20. Yalom ID: The Theory and Practice of Group Psychotherapy, 3rd ed. New York, Basic Books, 1985 18. Schaffer JB, Dreyer SF: Staff and in patientperceptions ofchange mechanisms 21. Hoge MA, Farrell SP, Strauss JS, et al: ingrouppsychotherapy.AmericanJournal Functions of short-term partial hospital ofPsychiatry 139: 127—128,1982 ization in a comprehensive system of care. International Journal of Partial 19. Strauss JS, Estroff SE (eds): Subjective Hospitalization 4:177—188, 1987 Experiences of Schizophrenia and Re lated Disorders: Implications for Under 22. Lieberman PB, StraussJS: Brief psychi standing and Treatment (special issue). atric hospita'ization: what are its effects? Schizophrenia Bulletin 15:177—346, American Journal of Psychiatry 143: 1989 1557—1 562, 1986
1986
The Coming-Out Process forHomosexuals Harold P. Martin, M.D.
ing-out process is more complex than those two behaviors alone. Het
Coming
erosexual psychotherapists who are unaware ofthe process are at a disad vantage in helping patients deal with the developmental task it presents. The general psychiatric literature contains fewguidelines on data to as sist the clinician in working with
out
is a core develop
mental processfor homosexualper sons that spans manyyears. It usu ally begins in childhood with fed ings of being different and progress es through various stages, indud ing acknowledgment of homosex uality, disclosure to others, accep
tance ofa homosexual identity, ex perimentation and exploration, and intimacy. ideally, the process ends in consolidation, a stage in which homosexuals no longer view themselves primarily in terms of sexual orientation. The authorde scribes the various stages of the coming-out process and discusses the clinical implicationsfor thera
homosexual patients. The coming out process has been described primarily in books and journals rare
developmental processes. Therapy
ego-dystonic
homosexuality
was
neither diagnosis, although the con
9th Avenue, Campus Box C270, Denver, Colorado 80262.
158
This paper explores the various
In 1968 DSM-II listed homosex uality as a mental disorder (1). Only
Coming out is a developmental pro cess unique to homosexuals. At the most simplistic level, it involves ac knowledging that one is homosexual and disclosing that sexual orienta tion to others. However, the corn
at the University of Colorado Health SciencesCenter,4200 East
bance and low self-esteem and may be at greaten risk for depression and suicide (4—8).One factor that may add to the stress of HIV infection is the pressure for premature dis closure of homosexuality.
ofthe homosexual person.
ly read by most psychiatrists. So it seems timely to open a dialogue with the general psychiatric community regarding a cone developmental task
listed in DSM-III (2). The more recent revised edition (3) lists
the Denver Veterans Affairs Med ical Center and assistant professor in the department of psychiatry
large percentage have mood distur
components of the coming-out pro cess and discusses some ofthe clini cal implications for the therapist. Im plicit in the paper is the assumption that although homosexual persons vary considerably in their personali
py with homosexual patients.
Dr. Martin is staff psychiatrist at
(HIV) are increasingly seeking help in dealing with the psychological ramifications ofthis lethal disease. A
cept was retained under the clas sification of Sexual Disorder Not Otherwise Specified. Homosexuals
who present for psychotherapy to day are likely to assume that their sexual orientation will not be viewed
as a primary problem
to be ad
dressed but that the therapist will as
sist them with their perceived prob lems. A recent phenomenon bringing more homosexuals
that is and cli
nicians together is the AIDS epi demic. Homosexuals infected with
ty profiles,
they share some unique
is facilitated when the therapist un denstands the special struggles of homosexuals in the development of
selfand identity.
The coming-out process Coming out is more than “¿coming out of the closet.― It is a develop mental process that takes many years, sometimes alifetime. Accord ing to McDonald (9), at aminimum it involves “¿adopting a non-traditional identity, restructuring one's self
concept, reonganizingone's personal sense of history, and altering one's relations with others and with soci ety.―It includes cognitive and affec
tive transformations as well as chang
the human immunodeficiency
virus
es in behavior. The coming-out process does not
February 1991
No. 2
Hospital and Community Psychiatry
Vol. 42
follow an identical sequence for all homosexual persons. Based on data from 199 homosexual males, Mc Donald (9) reported that while 18 percent of respondents labeled themselves as homosexual before participating in a sex actwith another male, another 2 3 percent considered themselves homosexual only after a same-sex relationship. A variety of models have been proposed for the coming-out pro cess (10—12). Coming out involves certain stages regardless ofthe speci fic sequence in which they occur. The stages described below are not an invariant template for coming out; rather they are issues with which almost all homosexuals struggle as they are learningwho they really are. Feeling different. Most male homosexuals report feeling different from others long before they can identify that difference as a homo sexual orientation. Troiden (13) has said that 70 percent of homosexuals report experiencing this feeling, which usually starts at age four or five (14). They may feel confused about why they seem different and also feel alienated or estranged from others. It is impossible to always know from the adult's retrospective view exactly what the components of this feeling state were. Clearly many heterosexuals also experience feel ing different in childhood, although they recall such feelings much less often (12). Coleman (10) em phasized that feeling different may progress during adolescence on adulthood into denial on other defenses to avoid acknowledging one's sexual self. Self-acknowledgment. This is @he painful task of shifting the whole concept ofone's self. It forces homo sexual persons to confront their in tennalized homophobia. Homosex
cause of the homosexual's difficult life (15,16). In a group of 57 men newly ad mitted to an HIV clinic at a VA med ical center, nine denied being homo sexual despite a pattern of many
years of regular sexual activity with other men. Such denial may be a long-lasting phenomenon. Smith (17)and
Sophie (18) have discussed
how ego-dystonia or internalized homophobia in the homosexual
It may be years before a person who has acknowledged homosexual feelings can accept a
homosexual identity. Coming to peace with one's identity is quite a different task from acknowledging one's sexual orientation.
(19) gave examples of the many dif ferent rationalizations people use to deny their homosexuality. Such denial is illustrated by the cases of two homosexual men who entered individual psychotherapy after managing to successfully avoid self-acknowledgment for at least 30 years. Patient A had become aware of his homosexual impulses in his late forties. He now recalls having had sexual feelings toward other
Patient B
ended this stage ofdenial in his early fifties. Both men had joined a reli gious order in early adult life for many reasons, one being an attempt to deny and repress all sexual feel
uals have grown up internalizing
ings and impulses. The sexual ab stinence of these two men helped
society's views of homosexuality, making it difficult to label them selves as homosexual. Self-loathing and repudiation of the self may be the basis for the concept of ego-dys tonic homosexuality. Certainly many homosexuals wish that they did not have such a sexual onienta tion, and most lesbian mothers wish their children to be heterosexual be
them defend against the awareness oftheir homosexuality. Disclosure to others. Disclosure to others is a lifelong process. Homo sexuals must make judgments about when and to whom to disclose their identity; disclosure to everyone may be imprudent. While disclosure is a stage of the coming-out process, de cisions about disclosure to new
Hospital
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and Community
Psychiatry
1991
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are never
ending. Cass (20)argued that homosexual identity cannot fully develop with out complete disclosure to both homosexuals and heterosexuals. As long as the homosexual's real iden tity is a secret, a false self (2 1) oc cupies the biggest share of day-to day life. Persons may feel valued for what others want them to be rather than for what they really are. They often feel quite deceitful because of their silence. Disclosure involves realistic risks, such as the loss ofparental love, job,
and children, and even criminal sanc tions(22). In a survey of 1,000 physi cians by Mathews and associates (23), 46 percent said they would not refer a patient to a gay pediatrician and 43 percent would not refer to a gay psychiatrist,
patient may be managed. Hencken
boys in adolescence.
friends and acquaintances
even
if they
had
done so before the physician's homosexuality was disclosed. Nega tive attitudes toward homosexuals are common among the health professions (24—29).Realistic socie tal repercussions can also be used defensively when homosexuals are
not fully accepting of their sexual orientation; some may project onto friends or the community their own homophobia. Thus disclosure of one's homosexuality is not only a component ofself-acceptance, but it is also an issue ofidentity manage ment (30). Disclosure to parents is an espe cially difficult hurdle, as noted by Wells and Kline (3 1). Some homo sexuals are never able to make such a disclosure. Of48 self-acknowledged gay men newly admitted to an HIV clinic, 1 1 (mean age 43) had not dis closed their homosexuality to their parents. Another two patients had told their parents only after learning oftheir HIV-positive status. Acceptance ofidentity. It may be
years before a person who has ac knowledged homosexual feelings can accept a homosexual identity. Coming to peace with one's identity is quite a different task from simply acknowledging
one's sexual onienta
tion. There needs to be a progres sion from tolerating one's self to
being content on even pleased with who one is. Acceptance of homosex
159
uality includes discarding long-held
assumptions about how one's life will unfold. Identifications with both parents must be modified. One must feel okay about one's new life. Interviews with 48 male homo sexuals seen consecutively
by the au
thor revealed that seven still disap proved of their homosexuality. Their mean age, 39 years, suggested that rather than being in an early stage of the coming-out process, these men had an arrested identity as homosexuals. Twenty-three percent had married in order to feel and act “¿straight,― hoping their hornosex uality would go away. Problems in accepting a homo sexual identity are exemplified by Patient B, mentioned above, and by Patient C. Patient B had gradually become aware of his homosexuality over a three-year period before start ing therapy. At one point the thera pist asked the 55-year-old man to verbalize what came to mind when he thought ofgay men. He respond ed, “¿self-centered, weak, dishonest, selfish, promiscuous.― Much of the short-term therapy with this patient dealt with his homophobic preju
dices that made
so painful for him
to accept and like himselfas a homo sexual. Patient C, age 50, entered treat ment to deal with his pedophiia. He
had been aware of being homosexual from childhood. When he entered treatment, he was more comfortable thinking of himself as a pedophile than as a homosexual. He felt pedophilia, unlike homosexuality, was a disease that could be cured through medication and psycho therapy. Over 18 months of therapy, he came to accept his homosexuality.
We both came to see that his pedophilia was in large part a de fense against acceptance of himself as a homosexual adult male. Experimentation and explora tion. The task in this stage is to ex penimentwith and practice at being a homosexual person. Unlike hetero sexuals, who have been exposed to movies, novels, television shows, and advertisements showing how men and women act with each other, the homosexual has not had role
behave with someone ofromantic or sexual interest. Thus at this stage of the coming-out process, some homosexuals enter into a period of promiscuous sexual behavior. Clear ly, sexual promiscuity is a very com plex set ofbehaviors, fueled by many motives and determinants. One im pontant basis for such behavior is
quick assimilation into a gay life style.
homosexual identity from friends or family. These issues are illustrated by the case of Patient D, a professional woman in her thirties. Early stages of the coming-out process had been fa cilitated through close friendships with women, membership in fern mist groups, and involvement with a shelter. After apeniod ofexperimen tation, she fell in love with another female professional. They bought a house and set up a lesbian marriage.
Most current thinkers
However,
agree with Leavy, who
how they dealt with the coming-out
posits that psychotherapy of the homosexual
be impossible if psychiatry persists in conceptualizing homosexuality as a defense or a deficiency. Homosexuals can also turn to gay support groups, political groups, or other homosexually oriented ac
tivities. Many gay and lesbian pa is in the
exploration stage to meet other homosexuals with whom they can identify. To find other gay physi cians, Vietnam veterans, on clergy, for example, helps make the homo sexual person not feel so unusual on so isolated. Gay bars, the Catholic
Dignity groups, feminist groups, and other gay support groups are but a few ofthe poorly known parts of the homosexual world that the
newly aware homosexual learn about.
must
intimacy. Many homosexual persons reach a point where sexual or social experimentation has served its purpose and loses its intrigue. Wishes for intimacy and a close
monogamous
was
relationship
may
emerge. There are few role models
for how two loving persons of the same sex function as a couple. one's identity as a homosexual
in
process. For example, invitations to office panties that included a “¿sig nificant other― led to agonizing struggles between the patient and hen partner over whether one on both would attend. For the patient, intimacy included having her mate accompany hen to important social gatherings. For hen partner, sharing such public events threatened hen wish to blend in with her heteno
will
tients describe howhelpfulit
their relationship
seriously stressed by differences
If is
sexual professional
colleagues.
The tasks ofintimacy are difficult regardless ofsexual orientation. The internal struggle to accept one's homosexuality as well as pressures from the heterosexual world are added stresses in the development of an intimate relationship for homo sexuals. Consolidation. This stage has also been called identity integration (10) or identity synthesis (32). Mm ton and McDonald (33) charac tenized this stage as one in which homosexuals no longer view them selves primarily in terms of sexual orientation. People define them selves in a variety ofways, such as by profession, ethnicity, religion, and parenthood status. At the point of identity consolidation, the homosex ual is no longer primarily agay ones bian. Sexual orientation continues to be important, but is not the pne dominant component of identity. A more holistic perspective on one's identity is the goal ofthis final step in the coming-out process.
poorly consolidated, difficulties will lationship because of the strain such
Clinical implications Much of the literature about homo
models from whom to learn how to
a relationship puts on identity. When one is pantofacouple, it is also much more difficult to conceal one's
sexuality published before 1970 is replete with prejudice and en noneous conceptualizations. For ex
160
February 1991
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surely arise in a close one-to-one
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No.2
and Community
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ample, Isay (34) notes that Bengler in 1956 described six traits of homo sexuals, including flippancy, malice, and general unreliability. He in sisted that “¿the most interesting fea tune of this sextet of traits is its universality. Regardless of the level ofintelligence, culture, background, on education, all homosexuals pos sess it.―Most current thinkers agree with Leavy (3 5), who posits that psy chotherapy of the homosexual will be impossible ifpsychiatry persists in conceptualizing homosexuality as a defense on as a deficiency. Some nel atively current articles ( 15,17,18, 34—42) can help the clinician in working with homosexual patients. The homophobia of the psycho therapist can interfere with clinical
work. Therapists have also assimi lated societal views toward homo sexuality and must examine them selves for vestiges of bias or un resolved conflict. Mental blocks may take the form ofnot obtaining an im pontant sexual history, not wanting to hear certain disturbing material, or unconsciously viewing homosex uality as a perversion and hoping to cure the patient. Therapist homophobia is illus trated in the case ofPatient E, a med ical student who presented in crisis after discovering the infidelity of his gay lover. Only after supervisory consultation did the senior psychiat nc resident seeing the patient be come aware ofhis difficulty in listen ing empathically to the patient. The resident's unconscious aversion to homosexuality interfered with his usual capacity to sitand listen and try to understand. In another case, Patient F felt un comfortable with his homosexual life-style and entertained impulses to start dating women to “¿get back on the night track.―The female then apist encouraged the patient's het enosexual behavior, assuming the homosexual behavior to be a defense against a fear ofwomen. Once the therapist's homophobia was recog
the primary issue is the patient's dif ficulty in accepting his sexual onien tation. It is also prudent to assume that homosexual patients have some de gree of internalized homophobia. One needs to be alert to unconscious shame on guilt. One may falsely as sume that apatient who has acknowl edged homosexuality has come to accept it and made peace with it. But as with Patient B above, a patient may still harbor negative views about homosexuals as a class and about himselfas a member ofthat class. Patients who are HIV positive endure tremendous stresses in addi tion to accommodating to a diagnosis of a lethal disease whose course is often unpleasant and painful. They frequently face loss of employment, loss offniends from AIDS, and loss ofvigor and physical health. Even the discontinuation of maladaptive sexual patterns can be a major loss. Additionally, many HIV-infected patients decide to disclose their homosexuality to family or friends for the first time. The disclosure can be abrupt or premature without the preparatory work that usually precedes such openness. For example, Patient G had told his parents and siblings that he had had pneumonia the previous sum men but found it impossible to let them know he had AIDS and a prog nosis of only a few months. He believed they could deal with his medical condition but would never be able to accept him as their son and brother if they knew he was homo sexual. While homosexuality need not be considered pathologic, I do not wish to stifle the clinician's interest in un derstanding the genesis of homosex uality in a specific patient. With any patient, a therapistmight find it help ful to explore
the development
of a
namics with the patient without premature closure on a specific one. While homosexual behavior may be a defense, it is equally possible that
number of nonpathological charac tenistics, for example, the choice of a specific profession or why one is at tracted to certain kinds of romantic partners. There may be important and understandable explanations for a homosexual's particular path of de velopment. However, it is not fruit ful to cast the question in the old na ture-versus-nurture paradigm. Mon
Hospital and Community Psychiatry
February 1991
nized and looked at, she was able to explore a number of possible dy
Vol. 42
No. 2
ey (43) discussed and presented per tinent data to avoid this dichoto
mization. The explanations are mul tifactonial: hormonal, genetic, expe riential, and psychodynamic. To be sure, a curiosity about the patient's homosexuality can be precarious, as it can be misunden stood as a search for the genesis of pathology. However, it need not be a search for the etiology ofa disorder but rather a shared self-examination by the patient and therapist in an ef font to understand the patient as fully as possible. Much is yet unknown about the inner life experiences and the devel opment of homosexual persons. Datain these areas have been limited but are increasing, albeit much has not reached the literature usually read by general psychiatrists. Few psychiatric residency programs ad dress developmental issues in homo sexuality. Another reason for the limited dataon homosexuality is that the coming-out process is largely an aspect of adult development; the data on homosexuals' development as children are limited exclusively to retrospective self-reports. A developmental approach to adults has largely been ignored until quite recently (44,45). While Erik son (46) gave notice that develop ment does not end with adolescence, only in the last ten years have re searchers started to study carefully the development of young adults, the middle-aged, and the elderly.
The study of homosexual develop ment, much ofwhich is embedded in adult life, is still in the embryonic stage. Any model of the coming-out process is an oversimplification and may not accurately delineate the exact process for any one individual. Stollen and associates have em phasized that there are homosex ualities, not one invariant type (36). They pointed out that just as a single heterosexual character or invariant life history cannot be defined,
neither can it be for homosexual per sons. Nonetheless, issues in identity regularly recurring ing-out process for
there are special formation and tasks in the corn homosexuals. As
Coleman (10) noted, it can be of
161
great help to the patient ifthe thera
pist is acquainted with the develop mental concepts
involved
in the
coming-out process.
AcademyofPsychoanalysis
lesbian identity. journal of Homosex uality 14:53—65, 1987
19. Hencken jD: Conceptualizations of homosexual behavior which precludes homosexual self-labelling. journal of
References
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Illness concerns, attitudes towards homosexuality,
and social support in gay
men with AIDS. General Hospital Psy chiatry 8:395—403,1986 5. MarzukPM, Tierney H,TardiffK, etal: Increased risk ofsuicide
in patients with
AIDS.JAMA 259:1333—1337,1988 6. Perry SW, Markowitzj: Psychiatric in
terventionfor AIDS-spectrumdisorder. Hospital and Community Psychiatry 37:1001—1006,1986 ME: Psychiatric
aspects
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AIDS. Americanjournal of Psychiatry 144:551—556, 1987 8. AtkinsonjH, Grant!, Kennedy Cj, etal:
Prevalenceofpsychoticdisordersamong men infected with human immunodefi ciencyvirus.
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atry45:859—864, 1988 9. McDonald
Gj: Individual differences
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10. Coleman E: Developmental stages of the coming out process. journal sexuality 7:31—42, 198 1-82
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11. Chapman BE, BrannockjC: Homosex ualidentity formation asadevelopmental process.journalof Homosexuality 9:91—
104, 1983—84 12. Sophiej: A critical examination of stage theories oflesbian identity development. journal of Homosexuality 12:39—51, 1985—86
13. Troiden RR: Homosexual identity de
velopment. journal of Adolescent HealthCare9:105—1 13,1988 14. IsayRA:The developmentof sexualiden in homosexual
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Studyofthe Child 4 1:467—490, 1986 I 5. Wolfson A: Toward the further under standing of homosexual women (panel). journal of the American Psychoanalytic
Association 35:165—173,1987 16. Kirkpatrick M: Clinical implications of lesbian mother studies. journal of Homosexuality 14:201—211, 1987 17. Smith j: Treatment of ego-dystonic homosexuality: individualandgrouppsy
chotherapies. journal of the American
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21. Winnicort DW: Ego distortion in terms
oftrue andfalseself,inThe Marurational Processesand the FacilitatingEnviron ment. New York, International Univer sities Press, 1965 22. Carlson j, Steuer j: Age, sex-role
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37. Cabaz RP: Homosexuality and neurosis: considerations for psychotherapy. jour
nalofHomosexuality 15:13—23, 1988 38. Stein TS: Theoretical considerations in bians.journal
ofHomosexuality
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95,1988 39. Raymond CA: Addressing homosexuals' mental health problems.jAMA 259:19, 1988 40. Berzon B: Permanent Partners: Building Gayand Lesbian RelationshipsThatLast.
New York, Dutton, 1988 41. Isay BA: Being Homosexual: Gay Men
health
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in American homosexual and hetero
rar, Straus & Giroux, 1989 42. IsayRA: Analyticallyoriented therapy of
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23. Mathews W, Booth MW, TurnerjD, et al: Physicians' attitudes towards homo sexuality: survey of a California county medical
society.
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Medicine 144:106—110, 1986 24. Kelly jA, Lawrence jS, Smith 5, et al: Medical students' attitudes towards
AIDS and homosexualpatients.journal ofMedicalEducation62:549—556, 1987 25. Kalman TP, Kalman CM, Connelly M:
Homophobia reassessed.Hospital and Community
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26. Kalman TP, Kalznan CM, Douglas Cj: Homophobiaamongphysicians nalofPsychiatry
144:1514—1515, 1987
27. Royse D, Birge G: Homophobia and at titudes towards AIDS patients among dents. Psychology Report 61:867—870, 1987 28. Douglas Dj, Kalman CM, Kalman TP: Homophobiaamongphysicians
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es: an empirical study. Hospital and Corn munity Psychiatry 36:1309—1311, 1985
29. Anstett R, Kiernan M, Brown R: The gay-lesbian patient and the family physi
cian.journal ofFamilyPractice25:339— 344, 1987
30. Troiden RR: Self, self.concept, identity, and the homosexual identity: constructs in need ofdefinition and differentiation. journal of Homosexuality 10:97—109, 1984 31. Wells jW, Kline WB: SeW-disclosureof
homosexualorientation.journal of So cial Psychology 127:191—197, 1987 32. Cass VD: Homosexual identity forma tion: a theoretical
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43. Moneyj: Sin, sickness, or status: homo sexual gender
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45. ColarussoCA, NemiroifRA: AdultDe velopment. New York, Plenum, 1981 46. Erikson EH: Childhood and Society. New York, Norton, 1963
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Audiovisual
Reviews
From H&CP Compiled in New Publication Reviews ofmore than 60 videotapes and films that appeared in Hospital and Community Psychiatry's bi monthly audiovisual column be tween 1984 and 1990 have been
compiled into a booklet published by the Hospital and Community Psychiatry Service. The 64-page booklet includes an introduction by Ian Alger, M.D.,
editor of H&CP ‘¿s audiovisual col umn and consultant to the audio visual library maintained
by the
H&CP Service. Almost 30 of the videos reviewed
in the booklet are
included in the H&CP Service video
collection. Topics covered include schizophrenia, manic-depressive process.journalofHomosexuality9:91— disorder, malpractice, teenage preg 104, 1983—84 nancy, and AIDS. 34. Isay RA: On the analytic therapy of homosexual men. Psychoanalytic Study The booklet is available from the ofthe Child40:235—254, 1985 H&CP Service, 1400 K Street, 35. Leavy SA: Male homosexuality recon N.W., Washington, D.C. 20005, for sidered. Internationaijournal of Psycho $8.50 a copy. analytic Psychotherapy 11:155—174, identity
formation
as a developmental
1985—86
February 1991
Vol. 42
No. 2
Hospital and Community Psychiatry
group psychotherapy: processes and dynamics. Journal of Abnormal and So cialPsychology5l:406—411, 1955 16. Brabender V, AlbrechtE, SillittiJ, et al:A study of curative factors in short-term group psychotherapy. Hospital and Corn munity Psychiatry 34:643-644,1983 17. KahnEM,WebsterPB,StorckMJ:
Cura
tive factors in two types of inpatient psy chotherapygroups.InternationalJournal
of Group Psychotherapy 36:579—585,
20. Yalom ID: The Theory and Practice of Group Psychotherapy, 3rd ed. New York, Basic Books, 1985 18. Schaffer JB, Dreyer SF: Staff and in patientperceptions ofchange mechanisms 21. Hoge MA, Farrell SP, Strauss JS, et al: ingrouppsychotherapy.AmericanJournal Functions of short-term partial hospital ofPsychiatry 139: 127—128,1982 ization in a comprehensive system of care. International Journal of Partial 19. Strauss JS, Estroff SE (eds): Subjective Hospitalization 4:177—188, 1987 Experiences of Schizophrenia and Re lated Disorders: Implications for Under 22. Lieberman PB, StraussJS: Brief psychi standing and Treatment (special issue). atric hospita'ization: what are its effects? Schizophrenia Bulletin 15:177—346, American Journal of Psychiatry 143: 1989 1557—1 562, 1986
1986
The Coming-Out Process forHomosexuals Harold P. Martin, M.D.
ing-out process is more complex than those two behaviors alone. Het
Coming
erosexual psychotherapists who are unaware ofthe process are at a disad vantage in helping patients deal with the developmental task it presents. The general psychiatric literature contains fewguidelines on data to as sist the clinician in working with
out
is a core develop
mental processfor homosexualper sons that spans manyyears. It usu ally begins in childhood with fed ings of being different and progress es through various stages, indud ing acknowledgment of homosex uality, disclosure to others, accep
tance ofa homosexual identity, ex perimentation and exploration, and intimacy. ideally, the process ends in consolidation, a stage in which homosexuals no longer view themselves primarily in terms of sexual orientation. The authorde scribes the various stages of the coming-out process and discusses the clinical implicationsfor thera
homosexual patients. The coming out process has been described primarily in books and journals rare
developmental processes. Therapy
ego-dystonic
homosexuality
was
neither diagnosis, although the con
9th Avenue, Campus Box C270, Denver, Colorado 80262.
158
This paper explores the various
In 1968 DSM-II listed homosex uality as a mental disorder (1). Only
Coming out is a developmental pro cess unique to homosexuals. At the most simplistic level, it involves ac knowledging that one is homosexual and disclosing that sexual orienta tion to others. However, the corn
at the University of Colorado Health SciencesCenter,4200 East
bance and low self-esteem and may be at greaten risk for depression and suicide (4—8).One factor that may add to the stress of HIV infection is the pressure for premature dis closure of homosexuality.
ofthe homosexual person.
ly read by most psychiatrists. So it seems timely to open a dialogue with the general psychiatric community regarding a cone developmental task
listed in DSM-III (2). The more recent revised edition (3) lists
the Denver Veterans Affairs Med ical Center and assistant professor in the department of psychiatry
large percentage have mood distur
components of the coming-out pro cess and discusses some ofthe clini cal implications for the therapist. Im plicit in the paper is the assumption that although homosexual persons vary considerably in their personali
py with homosexual patients.
Dr. Martin is staff psychiatrist at
(HIV) are increasingly seeking help in dealing with the psychological ramifications ofthis lethal disease. A
cept was retained under the clas sification of Sexual Disorder Not Otherwise Specified. Homosexuals
who present for psychotherapy to day are likely to assume that their sexual orientation will not be viewed
as a primary problem
to be ad
dressed but that the therapist will as
sist them with their perceived prob lems. A recent phenomenon bringing more homosexuals
that is and cli
nicians together is the AIDS epi demic. Homosexuals infected with
ty profiles,
they share some unique
is facilitated when the therapist un denstands the special struggles of homosexuals in the development of
selfand identity.
The coming-out process Coming out is more than “¿coming out of the closet.― It is a develop mental process that takes many years, sometimes alifetime. Accord ing to McDonald (9), at aminimum it involves “¿adopting a non-traditional identity, restructuring one's self
concept, reonganizingone's personal sense of history, and altering one's relations with others and with soci ety.―It includes cognitive and affec
tive transformations as well as chang
the human immunodeficiency
virus
es in behavior. The coming-out process does not
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follow an identical sequence for all homosexual persons. Based on data from 199 homosexual males, Mc Donald (9) reported that while 18 percent of respondents labeled themselves as homosexual before participating in a sex actwith another male, another 2 3 percent considered themselves homosexual only after a same-sex relationship. A variety of models have been proposed for the coming-out pro cess (10—12). Coming out involves certain stages regardless ofthe speci fic sequence in which they occur. The stages described below are not an invariant template for coming out; rather they are issues with which almost all homosexuals struggle as they are learningwho they really are. Feeling different. Most male homosexuals report feeling different from others long before they can identify that difference as a homo sexual orientation. Troiden (13) has said that 70 percent of homosexuals report experiencing this feeling, which usually starts at age four or five (14). They may feel confused about why they seem different and also feel alienated or estranged from others. It is impossible to always know from the adult's retrospective view exactly what the components of this feeling state were. Clearly many heterosexuals also experience feel ing different in childhood, although they recall such feelings much less often (12). Coleman (10) em phasized that feeling different may progress during adolescence on adulthood into denial on other defenses to avoid acknowledging one's sexual self. Self-acknowledgment. This is @he painful task of shifting the whole concept ofone's self. It forces homo sexual persons to confront their in tennalized homophobia. Homosex
cause of the homosexual's difficult life (15,16). In a group of 57 men newly ad mitted to an HIV clinic at a VA med ical center, nine denied being homo sexual despite a pattern of many
years of regular sexual activity with other men. Such denial may be a long-lasting phenomenon. Smith (17)and
Sophie (18) have discussed
how ego-dystonia or internalized homophobia in the homosexual
It may be years before a person who has acknowledged homosexual feelings can accept a
homosexual identity. Coming to peace with one's identity is quite a different task from acknowledging one's sexual orientation.
(19) gave examples of the many dif ferent rationalizations people use to deny their homosexuality. Such denial is illustrated by the cases of two homosexual men who entered individual psychotherapy after managing to successfully avoid self-acknowledgment for at least 30 years. Patient A had become aware of his homosexual impulses in his late forties. He now recalls having had sexual feelings toward other
Patient B
ended this stage ofdenial in his early fifties. Both men had joined a reli gious order in early adult life for many reasons, one being an attempt to deny and repress all sexual feel
uals have grown up internalizing
ings and impulses. The sexual ab stinence of these two men helped
society's views of homosexuality, making it difficult to label them selves as homosexual. Self-loathing and repudiation of the self may be the basis for the concept of ego-dys tonic homosexuality. Certainly many homosexuals wish that they did not have such a sexual onienta tion, and most lesbian mothers wish their children to be heterosexual be
them defend against the awareness oftheir homosexuality. Disclosure to others. Disclosure to others is a lifelong process. Homo sexuals must make judgments about when and to whom to disclose their identity; disclosure to everyone may be imprudent. While disclosure is a stage of the coming-out process, de cisions about disclosure to new
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are never
ending. Cass (20)argued that homosexual identity cannot fully develop with out complete disclosure to both homosexuals and heterosexuals. As long as the homosexual's real iden tity is a secret, a false self (2 1) oc cupies the biggest share of day-to day life. Persons may feel valued for what others want them to be rather than for what they really are. They often feel quite deceitful because of their silence. Disclosure involves realistic risks, such as the loss ofparental love, job,
and children, and even criminal sanc tions(22). In a survey of 1,000 physi cians by Mathews and associates (23), 46 percent said they would not refer a patient to a gay pediatrician and 43 percent would not refer to a gay psychiatrist,
patient may be managed. Hencken
boys in adolescence.
friends and acquaintances
even
if they
had
done so before the physician's homosexuality was disclosed. Nega tive attitudes toward homosexuals are common among the health professions (24—29).Realistic socie tal repercussions can also be used defensively when homosexuals are
not fully accepting of their sexual orientation; some may project onto friends or the community their own homophobia. Thus disclosure of one's homosexuality is not only a component ofself-acceptance, but it is also an issue ofidentity manage ment (30). Disclosure to parents is an espe cially difficult hurdle, as noted by Wells and Kline (3 1). Some homo sexuals are never able to make such a disclosure. Of48 self-acknowledged gay men newly admitted to an HIV clinic, 1 1 (mean age 43) had not dis closed their homosexuality to their parents. Another two patients had told their parents only after learning oftheir HIV-positive status. Acceptance ofidentity. It may be
years before a person who has ac knowledged homosexual feelings can accept a homosexual identity. Coming to peace with one's identity is quite a different task from simply acknowledging
one's sexual onienta
tion. There needs to be a progres sion from tolerating one's self to
being content on even pleased with who one is. Acceptance of homosex
159
uality includes discarding long-held
assumptions about how one's life will unfold. Identifications with both parents must be modified. One must feel okay about one's new life. Interviews with 48 male homo sexuals seen consecutively
by the au
thor revealed that seven still disap proved of their homosexuality. Their mean age, 39 years, suggested that rather than being in an early stage of the coming-out process, these men had an arrested identity as homosexuals. Twenty-three percent had married in order to feel and act “¿straight,― hoping their hornosex uality would go away. Problems in accepting a homo sexual identity are exemplified by Patient B, mentioned above, and by Patient C. Patient B had gradually become aware of his homosexuality over a three-year period before start ing therapy. At one point the thera pist asked the 55-year-old man to verbalize what came to mind when he thought ofgay men. He respond ed, “¿self-centered, weak, dishonest, selfish, promiscuous.― Much of the short-term therapy with this patient dealt with his homophobic preju
dices that made
so painful for him
to accept and like himselfas a homo sexual. Patient C, age 50, entered treat ment to deal with his pedophiia. He
had been aware of being homosexual from childhood. When he entered treatment, he was more comfortable thinking of himself as a pedophile than as a homosexual. He felt pedophilia, unlike homosexuality, was a disease that could be cured through medication and psycho therapy. Over 18 months of therapy, he came to accept his homosexuality.
We both came to see that his pedophilia was in large part a de fense against acceptance of himself as a homosexual adult male. Experimentation and explora tion. The task in this stage is to ex penimentwith and practice at being a homosexual person. Unlike hetero sexuals, who have been exposed to movies, novels, television shows, and advertisements showing how men and women act with each other, the homosexual has not had role
behave with someone ofromantic or sexual interest. Thus at this stage of the coming-out process, some homosexuals enter into a period of promiscuous sexual behavior. Clear ly, sexual promiscuity is a very com plex set ofbehaviors, fueled by many motives and determinants. One im pontant basis for such behavior is
quick assimilation into a gay life style.
homosexual identity from friends or family. These issues are illustrated by the case of Patient D, a professional woman in her thirties. Early stages of the coming-out process had been fa cilitated through close friendships with women, membership in fern mist groups, and involvement with a shelter. After apeniod ofexperimen tation, she fell in love with another female professional. They bought a house and set up a lesbian marriage.
Most current thinkers
However,
agree with Leavy, who
how they dealt with the coming-out
posits that psychotherapy of the homosexual
be impossible if psychiatry persists in conceptualizing homosexuality as a defense or a deficiency. Homosexuals can also turn to gay support groups, political groups, or other homosexually oriented ac
tivities. Many gay and lesbian pa is in the
exploration stage to meet other homosexuals with whom they can identify. To find other gay physi cians, Vietnam veterans, on clergy, for example, helps make the homo sexual person not feel so unusual on so isolated. Gay bars, the Catholic
Dignity groups, feminist groups, and other gay support groups are but a few ofthe poorly known parts of the homosexual world that the
newly aware homosexual learn about.
must
intimacy. Many homosexual persons reach a point where sexual or social experimentation has served its purpose and loses its intrigue. Wishes for intimacy and a close
monogamous
was
relationship
may
emerge. There are few role models
for how two loving persons of the same sex function as a couple. one's identity as a homosexual
in
process. For example, invitations to office panties that included a “¿sig nificant other― led to agonizing struggles between the patient and hen partner over whether one on both would attend. For the patient, intimacy included having her mate accompany hen to important social gatherings. For hen partner, sharing such public events threatened hen wish to blend in with her heteno
will
tients describe howhelpfulit
their relationship
seriously stressed by differences
If is
sexual professional
colleagues.
The tasks ofintimacy are difficult regardless ofsexual orientation. The internal struggle to accept one's homosexuality as well as pressures from the heterosexual world are added stresses in the development of an intimate relationship for homo sexuals. Consolidation. This stage has also been called identity integration (10) or identity synthesis (32). Mm ton and McDonald (33) charac tenized this stage as one in which homosexuals no longer view them selves primarily in terms of sexual orientation. People define them selves in a variety ofways, such as by profession, ethnicity, religion, and parenthood status. At the point of identity consolidation, the homosex ual is no longer primarily agay ones bian. Sexual orientation continues to be important, but is not the pne dominant component of identity. A more holistic perspective on one's identity is the goal ofthis final step in the coming-out process.
poorly consolidated, difficulties will lationship because of the strain such
Clinical implications Much of the literature about homo
models from whom to learn how to
a relationship puts on identity. When one is pantofacouple, it is also much more difficult to conceal one's
sexuality published before 1970 is replete with prejudice and en noneous conceptualizations. For ex
160
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ample, Isay (34) notes that Bengler in 1956 described six traits of homo sexuals, including flippancy, malice, and general unreliability. He in sisted that “¿the most interesting fea tune of this sextet of traits is its universality. Regardless of the level ofintelligence, culture, background, on education, all homosexuals pos sess it.―Most current thinkers agree with Leavy (3 5), who posits that psy chotherapy of the homosexual will be impossible ifpsychiatry persists in conceptualizing homosexuality as a defense on as a deficiency. Some nel atively current articles ( 15,17,18, 34—42) can help the clinician in working with homosexual patients. The homophobia of the psycho therapist can interfere with clinical
work. Therapists have also assimi lated societal views toward homo sexuality and must examine them selves for vestiges of bias or un resolved conflict. Mental blocks may take the form ofnot obtaining an im pontant sexual history, not wanting to hear certain disturbing material, or unconsciously viewing homosex uality as a perversion and hoping to cure the patient. Therapist homophobia is illus trated in the case ofPatient E, a med ical student who presented in crisis after discovering the infidelity of his gay lover. Only after supervisory consultation did the senior psychiat nc resident seeing the patient be come aware ofhis difficulty in listen ing empathically to the patient. The resident's unconscious aversion to homosexuality interfered with his usual capacity to sitand listen and try to understand. In another case, Patient F felt un comfortable with his homosexual life-style and entertained impulses to start dating women to “¿get back on the night track.―The female then apist encouraged the patient's het enosexual behavior, assuming the homosexual behavior to be a defense against a fear ofwomen. Once the therapist's homophobia was recog
the primary issue is the patient's dif ficulty in accepting his sexual onien tation. It is also prudent to assume that homosexual patients have some de gree of internalized homophobia. One needs to be alert to unconscious shame on guilt. One may falsely as sume that apatient who has acknowl edged homosexuality has come to accept it and made peace with it. But as with Patient B above, a patient may still harbor negative views about homosexuals as a class and about himselfas a member ofthat class. Patients who are HIV positive endure tremendous stresses in addi tion to accommodating to a diagnosis of a lethal disease whose course is often unpleasant and painful. They frequently face loss of employment, loss offniends from AIDS, and loss ofvigor and physical health. Even the discontinuation of maladaptive sexual patterns can be a major loss. Additionally, many HIV-infected patients decide to disclose their homosexuality to family or friends for the first time. The disclosure can be abrupt or premature without the preparatory work that usually precedes such openness. For example, Patient G had told his parents and siblings that he had had pneumonia the previous sum men but found it impossible to let them know he had AIDS and a prog nosis of only a few months. He believed they could deal with his medical condition but would never be able to accept him as their son and brother if they knew he was homo sexual. While homosexuality need not be considered pathologic, I do not wish to stifle the clinician's interest in un derstanding the genesis of homosex uality in a specific patient. With any patient, a therapistmight find it help ful to explore
the development
of a
namics with the patient without premature closure on a specific one. While homosexual behavior may be a defense, it is equally possible that
number of nonpathological charac tenistics, for example, the choice of a specific profession or why one is at tracted to certain kinds of romantic partners. There may be important and understandable explanations for a homosexual's particular path of de velopment. However, it is not fruit ful to cast the question in the old na ture-versus-nurture paradigm. Mon
Hospital and Community Psychiatry
February 1991
nized and looked at, she was able to explore a number of possible dy
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ey (43) discussed and presented per tinent data to avoid this dichoto
mization. The explanations are mul tifactonial: hormonal, genetic, expe riential, and psychodynamic. To be sure, a curiosity about the patient's homosexuality can be precarious, as it can be misunden stood as a search for the genesis of pathology. However, it need not be a search for the etiology ofa disorder but rather a shared self-examination by the patient and therapist in an ef font to understand the patient as fully as possible. Much is yet unknown about the inner life experiences and the devel opment of homosexual persons. Datain these areas have been limited but are increasing, albeit much has not reached the literature usually read by general psychiatrists. Few psychiatric residency programs ad dress developmental issues in homo sexuality. Another reason for the limited dataon homosexuality is that the coming-out process is largely an aspect of adult development; the data on homosexuals' development as children are limited exclusively to retrospective self-reports. A developmental approach to adults has largely been ignored until quite recently (44,45). While Erik son (46) gave notice that develop ment does not end with adolescence, only in the last ten years have re searchers started to study carefully the development of young adults, the middle-aged, and the elderly.
The study of homosexual develop ment, much ofwhich is embedded in adult life, is still in the embryonic stage. Any model of the coming-out process is an oversimplification and may not accurately delineate the exact process for any one individual. Stollen and associates have em phasized that there are homosex ualities, not one invariant type (36). They pointed out that just as a single heterosexual character or invariant life history cannot be defined,
neither can it be for homosexual per sons. Nonetheless, issues in identity regularly recurring ing-out process for
there are special formation and tasks in the corn homosexuals. As
Coleman (10) noted, it can be of
161
great help to the patient ifthe thera
pist is acquainted with the develop mental concepts
involved
in the
coming-out process.
AcademyofPsychoanalysis
lesbian identity. journal of Homosex uality 14:53—65, 1987
19. Hencken jD: Conceptualizations of homosexual behavior which precludes homosexual self-labelling. journal of
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Audiovisual
Reviews
From H&CP Compiled in New Publication Reviews ofmore than 60 videotapes and films that appeared in Hospital and Community Psychiatry's bi monthly audiovisual column be tween 1984 and 1990 have been
compiled into a booklet published by the Hospital and Community Psychiatry Service. The 64-page booklet includes an introduction by Ian Alger, M.D.,
editor of H&CP ‘¿s audiovisual col umn and consultant to the audio visual library maintained
by the
H&CP Service. Almost 30 of the videos reviewed
in the booklet are
included in the H&CP Service video
collection. Topics covered include schizophrenia, manic-depressive process.journalofHomosexuality9:91— disorder, malpractice, teenage preg 104, 1983—84 nancy, and AIDS. 34. Isay RA: On the analytic therapy of homosexual men. Psychoanalytic Study The booklet is available from the ofthe Child40:235—254, 1985 H&CP Service, 1400 K Street, 35. Leavy SA: Male homosexuality recon N.W., Washington, D.C. 20005, for sidered. Internationaijournal of Psycho $8.50 a copy. analytic Psychotherapy 11:155—174, identity
formation
as a developmental
1985—86
February 1991
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Hospital and Community Psychiatry
