I. CLINICAL AND BEHAVIORAL ASPECTS

It is believed that 2 to 10 percent of the U.S. population is gay or lesbisan (Gadpaille). However, there is no consensus among clinicians and behavioral scientists about the definition of homosexuality (Mondimore) and there are multiple definitions of the terms bisexual, gay, and lesbian (Francoeur, Perper, and Scherzer). Researchers, for instance, often fail to distinguish between sexuality (I am gay/lesbian), sexual behavior (I have sex with men/women), and community participation (I am a member of a gay/lesbian community) (Rothblum). These three dimensions, although somewhat overlapping, are not synonymous. Additionally, individuals' self-identity may change over time and in different contexts (Rothblum), as may the meanings ascribed to these terms by society.

Historically, homosexuality has been defined by reference to a person's physical behavior. An individual's orientation was determined by his or her biological sex and by the sex of his or her sexual partners. This view focuses on behavior as determinate and assumes that (1) only two sexual orientations—homosexuality and heterosexuality—exist and (2) an individual acquires his or her sexual orientation when he or she has sex for the first time.

Additional perspectives, however, may be critical to an understanding of sexual orientation. The self-identification view posits that sexual orientation may be discordant with behavior. Accordingly, the fact that an individual self-identifies as a homosexual does not preclude the possibility of that person having sexual relations with an individual of the opposite sex. Similarly, self-identity as a heterosexual allows for the possibility of sexual intimacy with a person of the same sex. The dispositional view of sexual orientation also considers an individual's sexual desires and fantasies and the sexual behaviors in which he or she is disposed to engage in ideal circumstances.

Dimensionality of Sexual Orientation

In the past sexual orientation was understood somewhat simplistically. Sexual orientation was treated as a binary construct: An individual was either heterosexual or homosexual. However, that understanding failed to explain bisexuality. The bipolar view of sexual orientation utilized by Alfred Kinsey conceived of sexual orientation along a continuous scale, with exclusive homosexuality at one end and exclusive heterosexuality at the other. According to this view, bisexuals are individuals who (1) are strongly attracted to people of the same sex and to those of the opposite sex, (2) are moderately attracted to those of the same sex and to those of the opposite sex, or (3) are weakly attracted to those of the same sex and to those of the opposite sex. The bipolar conceptualization of sexual orientation has been criticized for being one-dimensional and characterized as being similar to seeing masculinity and femininity as the opposite ends of a scale.

Most recently clinicians and researchers have employed either a two-dimensional or a four-dimensional scale to determine sexual orientation. The two-dimensional view posits that one dimension represents the degree of an individual's attraction to individuals of the same sex whereas the second dimension represents the degree of that person's attraction to those of the opposite sex. The four-dimensional view, which considers the varying levels of complexity inherent in defining sexual orientation, focuses also on an individual's choice of a sexual object, that is, the sex and sexual orientation of the individual and of those to whom that individual is sexually attracted, such as gay men, gay women, and straight men.

Theories on the Cause of Homosexuality

Same-sex eroticism and sexual behavior often have been viewed as abnormal or maladaptive. For instance, Richard von Krafft-Ebing, a late nineteenth-century neurologist, concluded that homosexuality represents an aberration in sexual behavior that results from the effect of worldly stress on a neuropathic disposition; thus, it constitutes a pathological condition rather than an immoral, criminal act (Mondimore). Havelock Ellis, a late nineteenth-century physician with a strong interest in anthropology, viewed homosexuality, or sexual inversion, as an inborn trait that reflects a permanent deviation in sexual development.

In contrast to those views, Kinsey concluded from his research that homosexuality is the product of cultural and socialization processes and therefore should not be considered criminal or the basis for the social ostracism of individuals (cited in Pomeroy). John Money, a sexologist, ultimately determined that homosexuality is a normal variation of sexual expression that results from prenatal influences interacting with environmental influences at critical unspecified periods.

A number of biological models have been developed in an attempt to explain sexual orientation and, specifically, homosexuality. The permissive model asserts that biological factors shape the brain structure on which experiences inscribe sexual orientations, whereas genetic factors constrain the period during which that experience can affect an individual's sexual orientation. The direct model attributes the responsibility for sexual orientation directly to genes, hormones, and other biological factors and their direct influence on the brain structures that underlie sexual orientation. The indirect model posits that biological factors shape an individual's temperament and/or personality, which in turn shapes the development of sexual orientation; genes may predispose a person to homosexuality in certain environments.

Proponents of biological theories of homosexuality have claimed support for their view from various findings. First, precursors of the reproductive organ systems of both sexes are present in the both male and female embryos. Second, various conditions related to sexual differentiation are thought to support the role of biology in determining sexual orientation. For instance, androgen insensitivity syndrome results from an inherited defect in the receptor molecule for testosterone; in persons with this syndrome testosterone has no effect on any of the target tissues. Individuals with this condition appear to be women and most often are attracted to men. Individuals with congenital adrenal hyperplasia experience abnormally high levels of circulating testosterone during embryonic development. As a result, genetic females develop masculinized genitalia. The condition 5-alpha-reductase deficiency results in the absence in genetic males of the enzyme required to develop external genitalia. At puberty females with this condition may experience an enlargement of apparently female organs into a penis-size organ, the secretion of testosterone, and a deepening of the voice.

Experiential theories of homosexuality encompass four major perspectives. One view focuses on the nature of an individual's early sexual experience and posits that through the process of operant conditioning an early pleasurable experience with an individual of the same sex will result in same-sex attraction. This theory has provided the basis for the seduction and first-encounter theories of homosexuality, which assert that individuals are recruited into a homosexual lifestyle. Other experientialists focus on the importance of family dynamics, theorizing that male homosexuality results from the influences of a strong mother and a distant father. This theory has served as the basis for many of society's stereotypes about the development of homosexuality and the characteristics of homosexuals and their families. Childhood gender roles are also a focus: It is believed that gender-atypical children such as girls who are "tomboys" and boys who are "sissy boys" develop into homosexuals.

Unlike these first three perspectives, experience-based developmental theory recognizes the potential role of biology and posits that biological factors code for childhood personality types and temperaments, which then are molded into gender roles. Once children develop gender roles, those who are different are seen as exotic and other. Lesbians develop from girls who fit masculine gender roles, and heterosexual women develop from girls who fit feminine gender roles. This theory is similar in many respects to the indirect biological model of homosexuality.

These biological models have proved to be controversial for a number of reasons. First, replication studies are lacking. Second, the results have significant implications for society's response to individuals who self-identify or are labeled as homosexuals. Some individuals argue that if homosexuality results from biology and does not signify a lifestyle choice, homosexuals cannot be considered morally depraved or criminal and consequently should receive the same legal rights and social recognition as any other identified group. Others fear that the identification of a biological basis for homosexuality ultimately will lead to attempts to correct what is perceived of as a biological mistake.

Only relatively recently has psychiatry declassified homosexuality per se as a mental illness by eliminating it as a category of illness in the Diagnostic and Statistical Manual, which guides clinicians in the diagnosis of mental disorders. However, the concept of illness has been retained through the incorporation into that text of a category for "sexual disorder not otherwise specified," which applies to individuals who experience "persistent and marked distress about sexual orientation" (American Psychiatric Association, p. 582). This definition does not recognize that the distress may result not from a person's sexual orientation but from the societal response to that orientation. Despite these changes some professionals and laypersons continue to view homosexuality as the result of an abnormal process of development and as reflective of an underlying pathology (Socarides).

The Formation of Gay Identity

Research suggests that individuals develop their sexual identity in stages. However, the specific process by which people develop sexual identity is not well understood and is subject to great variation across individuals.

Troiden (1989), who has written extensively about the process of identity formation among homosexuals, has posited that identity formation proceeds through four phases: sensitization, identity confusion, identity assumption, and commitment. Troiden observed that children may first feel a sense of "differentness." For example, boys may feel less interested in sports than do their male peers. Often this sense of differentness is experienced at an early age. Troiden has labeled these years of sensitization to one's differentness as the "sensitization stage," which generally spans the ages of six through twelve. During these years, children do not think of themselves as sexually different and the term homosexual has little, if any, meaning for most of them. In addition to feelings of differentness, children may become sensitized to a set of labels and attitudes inflicted on them by their peers; those labels may include terms such as faggot, dyke, and queer. An antihomosexual bias may be absorbed by children from their parents and peers, resulting in an internalized homophobia that causes extreme psychic damage during adolescence and adulthood.

It is during adolescence, generally before the age of fifteen, that children may recognize an incongruity between their sexual feelings and those reported by their peers. This stage in the process of identity formation has been labeled identity confusion (Cass; Troiden, 1988). The confusion often results from the conflict between an awareness of their sexual feelings toward members of their own sex and the others' assumption that they are like everyone else. A child's confusion may exacerbated by fears that he or she is not normal but instead is abnormal, perverted, or sinful.

As a result the child may experience cognitive dissonance, a psychological state that results when one is confronted by contradictory facts that both appear to be true. This disorienting state often is accompanied by intense fear and anxiety. The conflict may be resolved through an acceptance of one's homosexuality or a complete refusal to acknowledge one's feelings, that is, denial. Adolescents who are in denial may isolate themselves from individuals of the opposite sex or, conversely, engage in a frenzy of heterosexual dating. Denial may be accompanied by alcohol and drug use in an attempt to create distractions from these uncomfortable feelings. Some individuals may experience identity foreclosure, in which they use their energy to deny, avoid, or redefine homosexual thoughts and feelings in an attempt to prevent their incorporation into their identity (Cass). It is believed that most homosexuals go through a period of cognitive dissonance.

Once individuals have self-labeled as homosexuals, that is, have reached the stage of identity assumption or acceptance (Troiden, 1989), they must decide how to incorporate that information into other aspects of their lives. This decision may be extremely difficult because of the potential for stigmatization and rejection by their families and friends and in the workplace. Individuals may become increasingly aware of the discrepancy between their positive attitudes toward homosexuality and society's disparaging views and discriminatory treatment. In an effort to cope with this stigmatization some individuals may seek to separate themselves completely from the heterosexual world, viewing everything that is gay as "good" and everything that is not gay as "bad." This approach constitutes one variation of identity foreclosure (Cass). Others may proceed to the commitment phase, in which they disclose their sexual orientation to others, experience same-sex intimacy, and become involved with the homosexual community (Troiden, 1988).

A number of factors have been found to be helpful to individuals as they struggle with their identity. They include the presence of a gay or lesbian family member who has disclosed his or her own sexual orientation, the presence of a gay or lesbian role model, the support and acknowledgment of heterosexual friends, the presence of gay-positive media messages, the increasing visibility of gay issues, and open discussions in the course of receiving confidential healthcare services (Perrin).

Medical and Social Attitudes toward Homosexuals

Medical professionals have participated in widespread discrimination against individuals who self-identify as gay or lesbian. A study of 278 nursing students found that 38 percent believed that lesbians try to seduce heterosexual women and provide a negative role model for children (11%) (Eliason, Donelan, and Randall). A survey of 100 nursing educators found that 24 percent believed that lesbian behavior is wrong, 23 percent believed that lesbianism is immoral, and 15 percent felt that lesbians are perverted (Randall). Heterosexist and homophobic attitudes also have been noted among social workers (Berkman and Zinberg) and physicians (Douglas, Kalman, and Kalman; Matthews et al.; Oriel et al.; Pauly and Goldstein). These attitudes have been found to affect the quality of the care provided (Schatz and O'Hanlan; Wise and Bowman) and may interfere with the ability of gay and lesbian parents to obtain pediatric care for their children (Perrin and Kulkin).

A number of professional organizations have attempted to dispel prejudice among their members. The American Academy of Pediatrics, for example, stated:

Teenagers, their parents, and community organizations with which they interact may look to the pediatrician for clarification of the medical and social issues involved when the question or fact of adolescent homosexual practices arises.… The American Academy of Pediatrics recognizes the physician's responsibility to provide healthcare for homosexual adolescents and for those young people struggling with the problems of sexual expression. (pp. 249–250)

Various other changes reflect an increasing acceptance of homosexuals, including the adoption of antidiscrimination provisions by many state and local governments, the availability of healthcare and other benefits to partners of gay and lesbian employees, and the ability of gay and lesbian couples to adopt children (Cain). However, there also has been an escalation in the number of hate crimes reported. National attention most recently was focused on antigay sentiment as a result of the 1998 murder of Matthew Shepard in Wyoming (Loffreda).

Ethical Issues in Psychiatric and Psychological Care

Ethical issues arising in the context of psychiatric and psychological care provided to homosexual patients are similar, for the most part, to issues that arise in the context of providing care to individuals who are heterosexual. Ethical issues related to the "conversion" of homosexuals to heterosexuality arise only for those who continue to believe that homosexuality is abnormal or an illness. There is no evidence that therapy will result in long-term change in the sexual orientation of adults (Coleman). Although parents may place their children in therapy to ensure that they are or will become heterosexual, evidence indicates that such experiences may be psychologically injurious (Isay).

Nevertheless, some psychoanalysts believe that attempts to change an individual's sexual orientation are ethical as long as the individual wants that change (Nicolosi; Socarides). Significantly, Gerald C. Davidson (pp. 97–98), one of the original pioneers of conversion therapy, ultimately concluded:

Change of orientation therapy programs should be eliminated. Their availability only confirms professional and societal biases against homosexuality, despite seemingly progressive rhetoric about its normalcy. Forsaking the reorientation option will encourage therapists to examine the life problems of some homosexuals, rather than focusing on the so-called problem of homosexuality.

It is critical that health professionals create an atmosphere in which their patient can openly discuss issues related to sexuality and sexual behavior. As with heterosexual patients, the focus should be on the patient's sexual behavior, not his or her sexual orientation. (quoted in Perrin)

Additional research is needed to address many unresolved issues. Physicians and therapists may be called on to offer their professional opinions in cases involving adoption by gay or lesbian parents. There is no evidence of mental health problems among children raised by lesbian mothers in the absence of a biological father. However, a related but relatively unexplored issue is the extent to which children may be especially vulnerable to societal stressors as a result of the societal bias against homosexuality.

Further research is needed to examine whether the sexual orientation of a clinician should be a factor in the selection of a healthcare provider, whether a provider should disclose his or her sexual orientation during the therapeutic process, and what effect the disclosure of the sexual orientation of a provider may have on the therapeutic process and its outcome.

eli coleman (1995)

revised by sana loue

SEE ALSO: Lifestyles and Public Health; Mental Health, Meaning of Mental Health; Mental Illness: Conceptions of Mental Illness; Psychiatry, Abuses of; Sexual Behavior, Control of; Sexual Ethics; Sexual Identity;Sexuality, Legal Approaches to; and other Homosexuality subentries

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