Homosexuality and the DSM (lecture and reading)

Guidelines for Psychotherapy with Lesbian, Gay, & Bisexual Clients

16 guidelines relating to: - Psychologists' attitudes toward homosexuality and bisexuality - LGB relationships and families - Issues of diversity - Education "Over 25 years later the implication of this resolution have yet to be fully implemented in practice" (Division 44, 1998).

Clark's (1987) guidelines...

5. Don't be afraid to touch your client as a means of demonstrating that you value and trust physical contact. 6. Encourage your client to establish a gay support system. 7. Support political activities and involvement in gay community activities. 8. Desensitise shame and guilt surrounding homosexual thoughts, feelings and behaviour. 9. Use the weight of your authority to affirm homosexual thoughts, behaviour and feelings when reported by your client.

Removal of Homosexuality from DSM

Board of trustees unanimously voted to remove homosexuality per se from the DSM in December 1973. "If homosexuality were still considered a mental illness, business and insurance companies would not be offering health coverage for domestic partners, the army would still be using psychiatry to screen suspected homosexuals for discharge, and many of the other advances in gay rights would not be part of our culture. Nevertheless, the accomplishments should not be exaggerated; there are still enormous difficulties that beset gays and lesbians. But there has been great progress, and the first step was the action by the APA to remove the homosexuality diagnosis from DSM." (Kutchins & Kirk, 1997: 77)

Ellis

Challenged the idea that marriage was a treatment for homosexuality Hetero relationships and children wouldn't work - they'd would pass on defectiveness in their children - believed that you shouldn't tell people to get married and have children

What other factors influenced the shift between disease and liberal thinking around homosexuality?

Social class - moral relapses associated with the middle class and sinful perverts were the working class

Ego dystonic homosexuality as a new disorder

"Predictably enough, there is no such category as 'egodystonic heterosexuality'." (Kitzinger, 1990: 391). EDH 'quietly dropped' in 1987 (it did not appear in DSM-IIIR) in response to pressure from gay and feminist activists. Official explanation: "This category has been eliminated for several reasons. It suggested to some that homosexuality itself was considered a disorder. In the United States almost all people who are homosexual first go through a phased in which their homosexuality is ego-dystonic. Furthermore, the diagnosis of Ego-dystonic Homosexuality has rarely been used clinically and there have been only a few articles in the scientific literature that use the concept. Finally, the treatment programs that attempt to help bisexual men become heterosexual have not used this diagnosis. In DSMIII-R, an example of Sexual Disorder NOS are cases that in DSM-III would have met the criteria for Ego-dystonic Homosexuality." (APA, DSM-III-R, 1987)

Resolution passed in 1975 by the APsychA Council of Representatives

"The American Psychological Association supports the action taken on December 15, 1973 by the American Psychiatric Association, removing homosexuality from that Association's official list of mental disorders. The American Psychological Association therefore adopts the following resolution: Homosexuality, per se, implies no impairment in judgement, stability, reliability, or general social or vocational capabilities: Further, the American Psychological Association urges all mental health professionals to take the lead in removing the stigma of mental illness that has long been associated with homosexual orientations." (quoted in Garnets et al., 1991: 971)

THE PATHOLOGICAL MODEL OF HOMOSEXUALITY

"The best way to appreciate how mental disorders are invented is to understand how one diagnosis, homosexuality, was expunged from DSM." (Kutchins & Kirk, 1997: 55) "Whether or not homosexuality is classified as a psychiatric illness depends upon what psychiatrists consider to be normal and what they define as a mental disorder." P. 56) Pathological standpoint: homosexuality is the consequence of disordered sexual development, deviation from biological norm, deeply disturbed individuals => disorder comes from disturbed family environment => but not everyone in these environments are gay => disturbed individuals because of prejudices from society => if you're saying that homosexuals are ill because of simultaneously held mental illnesses, then heterosexuals are also ill for the same reason =>deviation and pathology are used synonomously - different meanings!

Gay rights movement

"The stigma of the old meanings surrounding 'homosexual' had to be removed and a new, more positive definition substituted. Under these circumstances homosexuals gradually would become 'gay' and proud and public... Underlying this transformation, however - and this is perhaps the centre of the irony involved - is the assertion that indeed there are homosexuals and there is something called 'homosexuality' - the entity on which most traditional moral opprobrium rested. But it has become an entity morally transformed. Leaders of movement organizations, supported by a much larger population of sympathetic others, have de-emphasized questions of etiology. They argue that, short of academic and rarefied scientific debates about sexuality in general, there is no particular importance to search[ing] for the cause of something that is good. Although the question of cause may remain important at the individual, biographic level, redefinition has turned attention to what homosexuality is. It has become a 'sexual preference', an 'identity' (or 'role'...) and a life 'style'. (Conrad & Schneider, 1980: 2000)

APsychA Task Force on Bias in Psychotherapy with Lesbians & Gay me

"This survey is designed to collect information about the experiences of lesbians and gay men in psychotherapy. You may know about this topic from friends or colleagues, from experiences you may have had as a client, or-if you have engaged in practice-in your role as a therapist. Our goal is to obtain a wide range of information from diverse sources." 2,544 surveys completed and returned. 1,481 respondents (58.2%) indicated they knew of psychotherapy experiences of LG clients, 23% of those respondents identified as LG. "We were... dismayed and disheartened at the evidence that, despite APA's formal, repeatedly stated nondiscriminatory policies, understanding, acceptance, and adherence to those goals are seriously lacking." (Garnets et al., 1991: 971)

Homosexuality and the DSM

"lesbians and gay men were characterised as the sick products of disturbed upbringings... Psychology textbooks routinely presented material on lesbians and gay men under headings implying sickness (for example, 'sexual deviation' or 'sexual dysfunction')" (Kitzinger & Coyle, 2002: 1). "female homosexuality has important and significant social and psychological effects. It is severely disruptive of the family unit. Any child of an overtly homosexual mother is exposed to a variety of psychological trauma of intense proportions. The disorder can, inactuality, destroy the family structure, produce divorce and great unhappiness" (Socarides, 1965: 467).

Medical treatments for homosexuality included...

"long-term psychotherapy... chemically induced seizures (to 'free energy' for its proper use), castration and clitoridectomy, implanting of 'normal testes', administration of estrogen (to decreased 'abnormal' sex drive) or androgens (to increase 'normal' sex drive), and even lobotomies. Numerous forms of behavior therapy were also invoked, such as aversion therapy (associating electric shocks or nausea-inducing substances with homosexual stimuli or fantasies), and orgasmic reconditioning (associating heterosexual stimuli or fantasies with masturbation" (Bohan, 1996: 18) Psychotherapy more popular treatment and than aversion therapy Aversion therapy = pairing electric shocks/ vomiting - associating same sex behaviours with disgust - bare in mind how unpleasant this treatment was => Doesn't work because human adults are not that simple. Punishment in mind as much as cure. Patients would claim they were cured to avoid further torture But investment in wanting to believe they are straight (if found as gay - cast out from society, lose job, divorce, abandoned by family and friends) Bohan - treatment for both men and women, drug to induce seizure = successful in eliminating sexual desire

Homosexuality = pathology

"psychology provided a 'scientific' justification for the oppression of lesbians and gay men: psychological 'evidence' has been invoked as a rationale for locking us up in mental hospitals, and prisons, breaking up our relationships with our lovers, taking our children away, denying us jobs, and blatantly discriminating against us in law and social policy." (Kitzinger, 1997: 203)

What is affirmative lesbian & gay psychology?

"psychology that challenges the whole notion of homosexuality as pathology, investigates the reasons for prejudice and discrimination against lesbians and gay men, develops theoretical and practical responses to lesbian and gay concerns, and attempts to create effective changes in the world such that lesbians and gay men might be spared some of the injustices to which we are currently subjected." (Kitzinger, 1997: 203). "psychology which is explicit about its relevance to lesbians and gay men, which does not assume homosexual pathology and which aims to counter prejudice and discrimination against people who are not conventionally heterosexual and to create a better world for lesbians and gay men" (Kitzinger & Coyle, 2002: 2). "Since the mid-1970s, North American psychology has led the way in creating a lesbian and gay psychology that starts from the assumption that homosexuality falls within the 'normal' range of human behaviour" (Kitzinger & Coyle, 2002: 3).

Socarides

American psychoanalyst. Active in promoting his views, women as lesbians = instrumental in women losing their custody of their children if they pleaded as lesbians.

Recognition within professional bodies

Association of Gay and Lesbian Psychiatrists, established mid-70s: http://www.aglp.org/ Division 44 (Society for the Psychological Study of Lesbian and Gay Issues) established in 1984 (now LGBT issues): http://www.apa.org/divisions/div44/ • Lesbian & Gay Psychology Section established within the BPS in 1998 (now Psychology of Sexualities): http://pss.bps.org.uk/

The 'ex-gay' controversy

At the 2001 American Psychiatric Association convention, 2 papers were presented on conversion therapy (Spitzer, 2001; Shidlo & Schroeder, 2001). Spitzer interviewed 143 men and 57 women and found that 66% of the men and 44% of the women achieved 'good heterosexual functioning' as a result of conversion therapy. Shidlo and Schroeder surveyed 202 homosexuals, 88% reported that efforts to change their sexual orientation had failed, only 6% achieved a heterosexual shift, and many were harmed by the attempt to change. Spitzer has since apologised to the gay community and victims of conversion therapy for his 2001 study...

Robert Spitzer

At the centre of the fight to declassify homosexuality Angry demonstrations by militant gay activists at APA conventions (1970-1973), protested sessions on the treatment/cure of homosexuality, demanded the removal of homosexuality from the DSM; mobilised whatever scientific reports were available to support declassification Spitzer - did listen to gay liberation. Ambitious - boost profile to sit on committee for next provision of the DSM. Not a psychoanalyst but wanted to change psychiatry - away from private practise in hospitals and university. Arranged panels to discuss homosexuality. Gay organisation in the American psychiatry association meet up at every conference. Dr Anomalous, gay psychiatrist. 1972 convention: pro-gay panel including Dr. Anonymous (gay psychiatrist) 1972 meeting of behavioural scientists disrupted by gay activists - Spitzer spoke with the leader of the protest Ron Gold He pushes the issue and removes homosexuality from the DSM through a vote. Endorse removing stigma from mental illness surrounding homosexuality. 1973 convention: panel debated the controversy

Psychoanalysis and homosexuality

Beginning C20th, Freud called into question the idea that homosexuality was inborn and inherited Individuals were essentially 'bisexual' (polymorphously perverse), homosexuality was a stage in normal childhood development Homosexuality became a neurotic personality disturbance when the individual could not adequately mature (without neuroses) to the cultural demands of sexual repression and heterosexual reproduction Then, homosexuality was an infliction in need of psychotherapy =>self-invested interest to promote therapy for homosexual conversion - scpetical of motives.

Diagnosing unwanted homosexuality

But the DSM-IV still allowed for diagnosis and treatment of unwanted homosexuality... 302.9 Sexual Disorder Not Otherwise Specified. This category is included for coding a sexual disturbance that does not meet the criteria for any specific Sexual Disorder and is neither a Sexual Dysfunction nor a Paraphilia. Examples include... (3) Persistent and marked distress about sexual orientation. (DSM-IV) • Dropped from DSM-

Models of gay affirmative practice begin to develop

Clark's (1987) guidelines (adapted from Davies, 1996): 1. It is essential that you have developed a comfortable and appreciative orientation to your own homosexual feelings before you can work successfully with LGB clients. 2. Attempts to eliminate homosexual feelings and behaviours imply that homosexuality is a pathology. 3. The subjective reality of the oppression that all LGB people experience must be brought into consciousness so that it can be worked with. 4. Help your client undo the negative conditioning associated with LGB stereotypes

Freud

Didn't agree with the notion of gender inversion being innate Sexuality is shaped by the environment and family relationships Psychosexual development - becoming arrested at one stage makes you homosexual Believed that we're all polymorphously perverse (born sexually neutral not bisexual) Successful development = straight, abnorma = gay When sexual drive becomes attached to an object this is when a person develops fetishes Didn't view homosexuality as a mental illness, his tolerant attitude wasn't taken forward. Sexuality can change - not fixed but fluid

Exodus closes down and apologises

Exodus is an institution in the conservative Christian world, but we've ceased to be a living, breathing organism... For quite some time we've been imprisoned in a worldview that's neither honoring toward our fellow human beings, nor biblical. From a Judeo-Christian perspective, gay, straight or otherwise, we're all prodigal sons and daughters. Exodus International is the prodigal's older brother, trying to impose its will on God's promises, and make judgments on who's worthy of His Kingdom. God is calling us to be the Father - to welcome everyone, to love unhindered.

Homosexuality the DSM

First edition published in 1952 - Homosexuality a type of 'Sexual Deviation' (one of the Personality Disorders) Psychiartry heavily influenced by DSM Second edition published in 1968 - 302 Sexual deviations. This category is for individuals whose sexual interests are directed primarily towards objects other than people of the opposite sex, toward sexual acts not usually associated with coitus, or toward coitus performed under bizarre circumstances as in necrophilia, pedophilia, sexual sadism and fetishism. Even though many find their practices distasteful, they remain unable to substitute normal sexual behavior for them. This diagnosis is not appropriate for individuals who perform deviant sexual acts because normal sexual objects are not available to them. Criminals, non-typical but benign sexual activities, coitus under bizzare cirumstances, or non coital activites = sexual deviation

Terry

For some evolutionists, the prevalence of homosexuality in the modern world "suggested a potentially dangerous turn toward extinction" (p. 37) Earliest writers viewed homosexuality as a benign but inborn anomaly (inborn sexual inversion/the third sex) Degenerationists writing in the 1880s viewed homosexuality as an inborn constitutional defect - Krafft-Ebing posited a distinction between sickly perversion and immoral perversity - Immoral perversion - casual/occasional homosexual behaviour (among sex-segregated school children, soldiers) - could be excused or punished - Sickly perverts were inherently defective and could not be corrected Americans held on to the idea that homosexuality represented something going wrong rather than embracing a liberal understanding

Removing homosexuality from the DSM

Four strands to the declassification of homosexuality: - Historical changes in the concept of homosexuality - The emergence of a militant gay movement - The transformation of psychiatry and its professional organisation (in the US) - the APA - An internal struggle in the field of psychoanalysis Broader historical shifts = gay activism Contemporary idea of gayness and gay and proud - comes from militant gay movement Shifts in psychoanalysis politics in psychiatry, social change and morality US sodomy laws - state by state

The well-adjusted homosexual and the sick homophobe (Kitzinger, 1987)

From the 1970s, homophobia is described as a "severe disturbance" (Freedman, 1978: 320) and "a mental health issue of the first magnitude" (Marmor, 1980) Diagnostic reversal - the sick homosexual is replaced by the sick homophobe Since the early 1970s a large number of scales have been devised to diagnose homophobia Homophobes "hold traditional, stereotyped attitudes towards women and define narrowly the terms of acceptable sexual behavior for themselves" (Minnigerode, 1976) Homophobes are "intolerance of specific homosexual practices and feel greater guilt concerning their own sexual impulses" (Dunbar et al., 1973)

Pathological model

Homosexuality was seen as a mental illness/ ciminality Morality and sexual norms contributed to this assumption Same sex practises in men were illegal Not true for women, vicotrians didn't make any legislation around consent age of lesbian women because they thought bringing it into public attention would make women lesbians (homosexual seduction) Thus this decision still as consequences to this day, less treatment and assessment for women Women weren't considered so much because they were thought to have less economic freedom to explore their same sex desires compared to men

Can gays convert?

In 1994, the American Psychological Association declared reparative therapy scientifically ineffective and possibly harmful. A 1995 US poll, 56% of the overall population said that lesbians and gay men can change their sexual orientation through therapy, will power or religious conversion. - 11% of gay respondents agreed. Exodus International, founded in 1976, is a (now defunct) nondenominational christian fellowship dedicated to helping homosexuals change their orientation. 'In gentle, loving language, smiling 'ex-gays' offered the bold promise: we changed, so can you' (Leland and Miller, 1995: 47).

Early sexologists

Late C19th, first scientific writings on homosexuality (inversion) published Push towards liberalism and understanding, benign but less ideal variation Disease to be cured - inversion theory "Homosexuals were contrary to nature according to the two cross-cutting axes of sexuality and gender: not only were they attracted to members of the 'same' sex, but they were presumed, on these grounds, to be inverted, with bodies, conduct, attitudes, tastes, and personalities characteristic of the 'opposite' sex. According to this logic, for a woman to desire a woman sexually, she must have some male characteristics, and for a man to desire a man he must be, in some way, female." (Terry, 1999: 35) "inverts, by combining the worst features of both sexes, represented a dangerous mixture of hypersexuality associated with masculinity and irrationality associated with femininity." (p. 36)

Morin's (1977) survey of psychological research on LGB people

More than 70% of research was dedicated to answering 3 questions: - Are homosexuals sick? - How can homosexuality be diagnosed? - What causes homosexuality and how might it be prevented?

Homosexuality law change

Prior to 1962, sodomy was a felony in every state in the US Prior to 1967 - sexual acts between men illegal in the UK 1947 - publication of the first Kinsey report 1950s - emergence of first (modern) gay rights groups - Most significant - the Mattachine Society and the Daughters of Bilitis in the US Kinsey - shifted public understanding around homosexuality - more common than previously thought Emergence of modern gay rights movements 1950s (helped by WW2 - gender segregation) 1950s - peak period of gay bars Homophile movement - concerned with civil rights, overturning sodomy laws, challenging homosexuality as a mental illness Mattachine - US society for gay men - vailed ways of referring to gay men Daughters of Bilitis - society for lesbians came a bit later Not explicit identity, because it was still illegal, conservative - important to appear normal and discouraged from behaving in ways which were not hetero-normative - encourage societal acceptance Minority research group - homophile group in UK to allow research into homosexuality to take place

'Ego dystonic homosexuality'

Sexual Orientation Disorder replaced homosexuality in DSM-II. Spitzer revised this to 'ego dystonic homosexuality' for DSM-III (1980). • 302.00 Ego Dystonic Homosexuality. The essential features are a desire to acquire or increase heterosexual arousal, so that heterosexual relationships can be initiated or maintained, and a sustained pattern of overt homosexual arousal that the individual explicitly states has been unwanted and a persistent source of distress. Seuxal orientation disorder - cateogy for people unhappy being gay (developed by Spizer) category remains until 1987. This category is reserved for those homosexuals for whom changing sexual orientations is a persistent concern. A. The individual complains that heterosexual arousal is persistently absent or weak and significantly interferes with initiating or maintaining unwanted heterosexual relationships. B. There is a sustained pattern of homosexual arousal that the individual explicitly states has been unwanted and a persistent source of distress. Lastest edition - no longer possible to treat homosexuality as a mental illness (2013!!) Religious organisations are the only people who really still try to cure homosexuality.

June Hopkins and the lesbian personality

She intended her study to 'fill the void in objective investigation into the personality factors of lesbians' (p. 1433). 'The traditionally applied "neurotic" label [was] not necessarily applicable' (p. 1436) to lesbians. Some of the differences between the lesbians and the heterosexual women suggested that 'a good, descriptive generic term for the average lesbian would be "independent"' (p. 1436). 'The following terms are suggested as appropriately descriptive of the lesbian personality in comparison to her heterosexual female counterpart: 1. More independent. 2. More resilient. 3. More reserved. 4. More dominant. 5. More bohemian. 6. More self-sufficient. 7. More composed' (p. 1436). Clinical psychologist, she was a lesbian but married to a man (vicor). Friends discharged from military because of sexual orientation. Expected to use projective tests as a psychologist. Decided to do a parallel study, looking at lesbian personality. Matched in age and intelligence. Lesbian = minorities research group, straight = social circle. 16pf used. Challenged lesbian neurotic notion, lesbians and straight women are different. LESBIANS WERE MORE RELISIANT, better off psychologically. More independent and self-sufficient. Makes sense in the 1960. World was not ready for these results. More focus on Hooker's research therefore.

Conversion therap

Some psychiatrists are still involved in efforts to diagnose homosexuals National Association for Research and Treatment of Homosexuality (NARTH): http://www.narth.com King et al. (2004) - survey of 30 psychologists and psychiatrists in the UK. - Most professionals who provided treatment for LGs between the 1950s and 1970s now view same-sex sexuality as mentally healthy.

The gay rights movement

Stonewall riots in 1969 Gay Liberation Movement developed shortly after - "By the late 1960s we began to see that discussing the cause and nature of homosexuality would not help us. We began to insist on our rights... to demand what was ours." (quoted in Bayer, 1981) Initially protested the psychiatric treatment of homosexuality Gay liberation = radical (different to homophile societies) militant action focus. Wanted to challenge homosexuality as a mental illness, didn't want to do research. Point - to protest and get in people's faces to change their minds.

Medical treatments for homosexuality

Surgical intervention - Castration, vasectomy, pudic nerve section, lobotomy, sterilization, clitoridectomy, hysterectomy Chemical intervention - Sexual stimulants, sexual depressants, hormone injection (estrogen, testosterone, pregnant mare serum, desiccated thyroid, pranturon [a pituitary gonadotropic]), pharmacological shock: matrazol, LSD Psychological intervention - Abstinence, adjustment therapy, psychoanalysis, hypnosis, aversion therapy (hypnotic, shock, emetic, desensitisation, covert sensitisation [the patient imagines pictures of homosexuals and vomits on them]), group psychotherapy, desensitisation (using pornographic materials), primal therapy Other procedures - Anaphrodisiac (cold sitz baths), electroshock, 'homo-anonymous' (patterned after AA)

Evelyn Hooker (1907-1996) and the adjustment of the male overt homosexual

TAT, Rorschach, maps: make a picture story tests = projective tests (diagnosing homosexuality) Asked 3 clinitians, acknowledge experts of homosexual treatment to interpret test results. Recorded their interpretations. They couldn't work out who was straight or gay. BULLSHIT TESTS. Misplaced assumption. No real difference between straight and gay men - same amount of adjustment - no pathology. Homo not homogenous, not all the same (ordinary, creative etc. diversity - hence why this term is no longer recognised as politically correct). Watershed moment for psychology. Homosexuality is not necessarily a symptom of pathology and that 'there is no single pattern of homosexual adjustment' (p. 29). Some homosexuals 'may be very ordinary individuals, indistinguishable, except in sexual pattern, from ordinary individuals who are heterosexual' (p. 29), and some 'may be quite superior individuals, not only devoid of pathology... but also functioning at a superior level' (p. 29). Affirmative research on homosexuality (not pathological) Hooker: important to look at normal population of homosexuals (majority of pathological research sampled from prisons) and looked at pure heteros and pure homos