COMMENTARY
Homosexuality: how therapists can help?
Mudassir Hassan
Clinical Psychologist, New Delhi, India
Abstract
The American Psychiatric Association removed homosexuality from its list of mental disorders in 1974. Before that, for more than a century, homosexuality and bisexuality were assumed to be mental illnesses. Studies have shown that there is no difference between homosexual and heterosexual individuals with regard to psychological functioning. However, an effect of stress related to stigmatisation was observed in the cases of homosexuality. Such kind of stress may increase the risk of suicide attempts, substance abuse, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), and emotional distress. Findings of researches have suggested that there is a need for better education and training of mental health practitioners in this area. Therefore, in the present paper, few cases of homosexuality are discussed in the context of effect of stigmatisation and aspects of intimate relationships in these individuals. Further, the role of psychologists/professionals as therapists in providing their help to homosexual clients has also been presented.
Hassan M. Homosexuality: how therapists can help? Open J Psychiatry Allied Sci. 2015;6:152-5. doi: 10.5958/2394-2061.2015.00016.6. Epub 2015 Jan 24.
Keywords: Stress. Stigma.Psychology.
Correspondence: sunsaif_2007@yahoo.co.in
Received on 5 November 2014.Revised on 30 November 2014.Accepted on 31 December 2014.
Homosexuality has been an issue since the time history can be recalled. Every country in world have different attitude towards homosexuality and it depends upon the type of society, cultural, moral, or political situation. In the early 20th century, Freud considered homosexuality a developmental arrest, rather than an illness; but by the 1940s, neo-Freudians reclassified homosexuality as a psychiatric disorder. Their view dominated American psychiatry until it was challenged by sexologists of the same era whose research supported a view that homosexuality is a normal variant of human sexual expression. In many countries, repression continued until the first well-known gay activist Karl Heinrich Ulrichs (1825-1895) initiated the process of decriminalisation of homosexuality.[1] Magnus Hirschfeld wrote a book “Sappho and Socrates”; he stood against homosexuality discrimination in the period between the First and the Second World Wars in Germany. In 1919, he founded first sexuality knowledge institute and continued his research until Hitler came to power.[2]
In 1973, the board of trustees of the American Psychiatric Association voted for deleting category of ‘homosexuality’ from its list of official diagnosis.[3] The association decided however to keep in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) the term ‘ego-dystonic homosexuality’,[4] which referred to homosexuality who are unhappy about their orientation, according to the Hatter’s presumption that “as for homosexuality being a sickness, it most certainly is a sickness when it makes a person feel sick”.[1] This term was also removed from the list in the more recent fourth edition of DSM (DSM-IV),[5] and also from the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10),[6] the World Health Organisation’s list of disorders, ‘homosexuality’ was removed much later, in 1991. But many clinicians, therapists, and social workers who continue, for personal, political, or religious reasons, to consider homosexuality as a pathological human condition, continue as well to diagnose it as such.[7]
If we look into different ways of viewing homosexuality and its origin, behaviourism is the school which define homosexuality as learned behaviour. Later on RJ McGuire, JM Carlisle, and BG Young revised the behaviouristic theory for sexual orientation. They stated that even though the first sexual experience might not fix the sexual orientation, the individual is likely to use the sexual experience as a mean to sexual arousal when masturbating. Thus the individual might turn a negative sexual experience into a positive reinforcement when masturbating.[1] Therefore, behaviourists claimed that homosexuality is learned and would therefore be able to be unlearned.
Psychoanalysis explains homosexuality in relation to Oedipus complex,[8] which has source in two basic instincts: eros - instinct of life, and thanatos - of the death and destruction. Pilecka[2] also mentions fixation described by Freud, concerning the parent of the opposite sex which is the other way to develop homosexual interests. Many researchers have found that the presence of disturbances within relations of gay people with their fathers, not a single gay that had good contact with father.[2] Usually fathers were distanced and hostile, but there were also cases of fathers, who were not respected enough because of their mother’s attitude towards them. van den Aardweg[9] examined 120 gays and only three of them had satisfying relationships with their fathers. In literature and other relevant sources, we can find lists of significant events in children’s life that may have an impact on later sexuality development. Some of them are:
- Delivery trauma (great physical and psychic pain for a newborn),
- Loss or absence of mother,
- Emotional deprivation in early childhood,
- Treating a child as one of the opposite sex (strong parent’s desire to have a boy instead of a girl and the other way),
- Lack of contact with parent of the same sex,
- Rejection from the peer group,
- Strong fear of failing during sexual intercourse.
Following are few cases discussed in detail.
Case 1
Mr X: “I was suffering and one day thought that I should better go to a psychiatrist. And when I discussed my problem with the psychiatrist, his behaviour was very harsh and he said to me, “Get out of the room”... which affected me and at that time I tried to commit suicide.”
We as professionals should understand that homosexuality is not a mental illness. All major American mental health associations have affirmed that homosexuality is not a mental illness. In 1975, American Psychological Association (APA) urged all psychologists to “take the lead in removing the stigma long associated with homosexual orientations”.[10] When studies have noted differences between homosexual and heterosexual individuals with regard to psychological functioning,[11-13] these differences have been attributed to the effects of stress related to stigmatisation on the basis of sexual orientation. This stress may lead to increased risk for suicide attempts, substance abuse, and emotional distress.
Psychologists should be encouraged to recognise how their attitudes and knowledge about homosexuality issues may be relevant to assessment and treatment, and seek consultation. The APA ethics code calls on psychologists to “strive to be aware of their work”.[14] The APA ethics code further urges psychologists to evaluate their competencies and the limitations of their expertise - especially when treating groups of people who share distinctive characteristics. We professionals should understand the ways in which social stigmatisation (i.e., discrimination, prejudice, and violence) poses risks to the mental health of homosexual clients.
Case 2
Mr Y, an educated male, said, “I came to a metropolitan city because it was hard to live in village, and I don’t want to change myself. After coming to the metropolitan city, I still find that we have been decimated and people do not understand us”...
Research has shown that gay men are at risk for mental health problems[15] and emotional distress,[12] as a direct result of discrimination and negative experiences in society. After interacting with them, we also found stress and some negative thoughts which were changed by using cognitive behavioural therapy. Ghosh and Bhuyan[16] described a 22-year-old male presenting with history of wearing female garments for sexual arousal. He was treated successfully with the help of behaviour therapy. Negative thoughts are mentioned below.
Case 3
“Yes, sometimes I do have anxious feelings and...” Anxiety was checked by using the Hamilton Anxiety Rating Scale (HAM-A).[17] Total score obtained was 28, which indicated a moderate to severe anxiety. “...I had a friend who committed suicide because of all these... He was abused physically as well as verbally.” Antigay verbal and physical harassment has been found to be significantly more common among gay and bisexual male adolescents who had attempted suicide compared with those who had not.[13]
Out of three cases, two of them said that they are in Delhi, because it was impossible for them to live and share their thoughts to someone in village. Those who live in rural communities may experience stress related to the risk of disclosure because anonymity about their sexual orientation may be more difficult to maintain. They also reported that they were feeling social isolation when they were in village.
As a professional, it is moral duty to check the ways they are being involved with the surroundings, so that we can help them in reducing stress. Because within these three cases, one of the important findings was that many people try to use them, they can abuse substance, which may lead to other illnesses like human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS).
Psychologists working with lesbian and gay people should be encouraged to assess the client’s history of victimisation as a result of harassment, discrimination, and violence. Psychologists should also understand how inaccurate or prejudicial views of homosexuality may affect the client’s presentation in treatment and the therapeutic process. Bias and misinformation about homosexuality and bisexuality continue to be widespread in society.[18] Fear of multiple personal losses - including family and friends, and career leads fear of self-identification, which creates person’s discomfort with his or her sexual orientation.
APA’s[18] “Appropriate therapeutic responses to sexual orientation” policy offers a framework for psychologists working with clients who are concerned about the implications of their sexual orientation. The policy highlights those sections of the APA ethics code that apply to all psychologists working with lesbian, gay, and bisexual clients. These sections include prohibitions against discriminatory practices (e.g., basing treatment on pathology-based views of homosexuality or bisexuality), a prohibition against the misrepresentation of scientific or clinical data (e.g., the unsubstantiated claim that sexual orientation can be changed), and a requirement for informed consent.[14] Based on the APA ethics code, the “Appropriate therapeutic responses to sexual orientation” policy calls on psychologists to discuss the treatment, its theoretical basis, reasonable outcomes, and alternative treatment approaches. In providing clients with accurate information about the social stressors that may lead to discomfort with sexual orientation, psychologists may help to neutralise the effects of prejudice and inoculate clients against further harm.
If psychologists are unable to provide this or other relevant information because of lack of knowledge or contravening personal beliefs, they should obtain the requisite information or make appropriate referrals.[14] When clients present with discomfort about their sexual orientation, it is important for psychologists to assess the psychological and social context in which this discomfort occurs.
Psychologists should rely on scientifically and professionally derived knowledge, and avoid discriminatory practices. Psychologists should provide accurate information and they correct misinformation in their work with parents or with others.[19] It is also important that psychologists ask clients whom they consider to be part of their family. Psychologists should be aware of the stress that clients may experience when their families of origin, employers, or others do not recognise their family structure.
It is useful for psychologists to be aware of the nature and availability of homosexuals and their families. Of particular use are organisations that provide support to the parents, young and adult children and friends of lesbian, gay (e.g., Parents, Family, and Friends of Lesbians and Gays; Children of Lesbians and Gays Everywhere); programmes that provide special attention to the victims of hate crimes; programmes for lesbian and gay, and groups that focus on parenting issues, relationships, or coming out. There are also professional organisations and groups for lesbian, gay; groups for people with HIV issues; groups for socialising and networking in business; and groups that can provide spiritual assistance. Electronic resources such as internet news groups, mailing lists, and web pages can be used by clients and psychologists as valuable sources of information and support.
Source of support: Nil. Declaration of interest: None.
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