II. ETHICAL ISSUES

The practice of medicine involves a body of knowledge, a body of practitioners, and the people who seek healthcare services. Homosexuality is of moral interest to medicine in all these areas. The term homosexuality was coined in 1869 by Karoly Maria Benkert to refer to same-sex eroticism, and it has prevailed over other proposed names, such as sodomy, contrary sexual feeling, inversion, and Uranism (Kennedy). To be sure, same-sex eroticism predates contemporary terminology and has a long—if contested—cultural history. The relationship between medicine and homosexuality has reflected both cultural prejudices as well as scientific advances.

History and Prevalence

In ancient Greek and Roman cultures, same-sex interactions were part of the cultural background, notwithstanding critics in those very societies. Educational relations among the Greek aristocracy took the form of mentoring relationships between older men and adolescent males, and schools for women sometimes followed this model (Marrou). It is not surprising that intimate mentoring relationships would sometimes become sexual. Roman civilization also had its share of same-sex eroticism, with some notorious emperors having harems of male lovers at their disposal (Gibbon). The Emperor Hadrian was so distraught after the death of a beloved youth, Antinous, that he deified him, erected statues of him through the empire, and founded a city in his name (Birley).

In later times, the social and religious circumstances of medieval Europe worked to limit the visibility of homosexuality, but subcultures and literary and artistic expressions of same-sex love were far from unknown even in ecclesiastical communities (Boswell). Homosexuality has expressed itself elsewhere around the globe, as well, including Africa, China, and among Native American cultures.

In ways without precedent in human history, a samesex culture has emerged in the large contemporary cities of the developed world and, it is a social force in communication, entertainment, business and commerce, and politics. Men and women who acknowledge their homosexuality hold prominent and influential social positions, as do men and women who choose not to disclose their homosexuality. The social visibility of homosexuality has not dispelled all moral and religious condemnation. In less developed parts of the world, homosexuality is sometimes far less visible but not altogether absent.

The extent of homosexuality in a given human society is difficult to estimate, for a number of reasons. Studies of sexual behavior face certain methodological problems, including adequate study samples and reluctance to discuss sex freely. Several ambitious studies have nevertheless tried to estimate the extent of homosexuality among men and women in the United States. In the mid–twentieth century, one Kinsey study of approximately 6,000 men showed that about 4 percent of them behaved exclusively as homosexuals after adolescence, and that 37 percent of men overall had some sexual experience with another man to the point of orgasm at some point during their lives (Kinsey). Another study showed that 1.32 to 2 percent of approximately 6,000 women behaved exclusively as homosexuals after adolescence, and that 13 percent of the women overall had had sexual experience with another woman to the point of orgasm at some point during their lives (Kinsey). At the end of the century, Laumann and colleagues also found that many people engage in homosexuality at some point. They found that 2.8 percent of their 1,749 male subjects and 1.4 percent of their females subjects claimed a homosexual identity (Laumann et al.).

Taken together, these studies show that many adolescents, and adult men and women, have same-sex fantasies and desires and engage in same-sex behavior. That said, there is often a fluidity to human sexuality that does not allow any easy division of humanity into homosexuals and heterosexuals, even if most people come to have entrenched sexual interests in males or females alone. This fluidity sometimes stands in the way of precise definitions of homosexuality, and of scientific accounts of why people behave a certain way.

Scientific Study

For most of human history, the origins of homosexuality did not elicit scientific interest. Neither was homosexuality treated as a pathological state. Instead, homosexuality was evaluated in moral and religious terms, and it was often condemned. In nineteenth-century Europe, however, many researchers and physicians began to study homosexuality in a systematic way and treat it as pathological. Describing homosexuality as a disease or disorder laid the foundations for discovering its causes and for developing treatments. For a variety of reasons, these researchers were often more interested in the origins and treatment of male homosexuality than female homosexuality. This emphasis may have resulted from greater social visibility of male homosexuality and a bias toward the selection of male subjects in medicine.

Many studies worked to show that homosexuality represented a kind of degenerate or defective human biology (Kraft-Ebing). Locating the origins of homosexuality in biology did not, however, always impose a pathological interpretation. For example, the German sex researcher Karl Heinrich Ulrichs (1825–1895) argued that homosexual men and women represented a third sex, and he offered an elaborate account of how the biological natures of men and women were blended in this sexual variation (Ulrichs). This view led Ulrichs to argue that homosexual men and women should not be punished by the law or mistreated by medicine for acting according to their biological natures (Hirschfeld).

Biology was only one field of study, of course, and not all theorists held that biology dictated the nature of one's sexual interests. Many psychologists looked to experiences in development for the factors that determined the nature and scope of homosexuality in men and women (Ellis). By contrast, the father of psychoanalysis, Sigmund Freud (1856–1939), drew no sharp distinctions between biology and psychology. He looked rather to an interplay of psychology and biology, believing that some people developed homosexually for psychological reasons, while biology played a more decisive role in the sexual development of others (Freud, 1953). In any case, Freud did not think that homosexuality was inherently pathological, though he did not think it represented full sexual maturity.

In the United States, organized psychiatry in the twentieth century first affirmed, and later repudiated, the view that homosexuality was pathological (Bayer). In 1952 the American Psychiatric Association (APA) described its categories of disease for the first time, and it labeled homosexuality as a "sociopathic personality disorder" (APA, 1952). A 1968 revision of this classification described homosexuality as a "personality disorder," and in 1973 the APA formally abandoned the view that homosexuality was pathological. Yet another revision, in 1980, led the APA to identify homosexuality as an "ego-dystonic disorder," meaning that it could be treated as a disorder if an individual suffered from it. There is no specific mention of homosexuality in the most recent versions of the APA diagnostic nomenclature, but the APA does recognize "sexual orientation distress," which involves persistent and marked distress about sexual orientation (APA, 1994). However, sexual orientation distress would apply to all unwanted and distressing orientations, not just homosexuality. In 1981 the World Health Organization removed homosexuality from its list of diseases. Despite this sea change in the views of the medical profession generally, some physicians and psychologists still maintain that homosexuality is a serious disorder.

Even after the APA depathologized homosexuality, debates about the relationship of homosexuality to health, disease, and illness continued. Some commentators in bioethics tried to describe health and disease in naturalist, or objective, terms that transcended cultural and social variation. These commentators described disease in terms of impediments to the central species functions of survival and reproduction. Heart dysfunction, for example, poses a threat to individual survival no matter the culture in which it occurs. Other commentators were not persuaded that categories of disease and health could be identified apart from moral evaluations about the worth and merit of particular states. For these normativist commentators, human moral evaluations always played a role in determining how a given society defined its states of disease and health (Engelhardt). From either the naturalist or normativist perspectives, it is hard to make the case that homosexuality is necessarily pathological.

Arguing from a naturalist perspective, the philosopher Christopher Boorse has maintained that homosexuality can be treated as a disease because of its interference with reproduction—whatever else it is, homosexuality is sterile (Boorse). In fact, however, homosexuality does not rule out having children, and some cultures manage to accommodate the marriage and parenting of people whose sexuality is primarily homosexual.

It is also doubtful that homosexuality is always a threat to species survival. Sociobiologists have hypothesized that homosexuality might even confer survival advantages to groups, since homosexual men and women may play roles in a society that offset any reduced number of children they might have (Ruse). As to their own survival, homosexual men and women may face individual health risks that others do not, but these risks may be tied to social circumstance rather than to homosexuality itself. For example, even if homosexual men face increased risks of disease and death, those risks are contingent, in the sense that successful treatments and vaccines could significantly dispel the danger.

As for normativist evaluations, it is clear that many men and women embrace their homosexuality without complication, and many cultures have also accommodated those people in one way or another. It is therefore hard to argue that—all other things being equal—homosexuality must lead to disorder and suffering. This is not to deny that some people and some cultures may disapprove of homosexuality, but the variance of response seems to show that it is not homosexuality per se, but how it is valued and treated that sometimes provokes its designation as disease.

For most of human history, medicine did not think of homosexuality in terms of disease. As both naturalist and normativist approaches show, what counts as disease—and what therefore deserves biomedical study and treatment—very much depends on one's theoretical starting points.

More recent commentary has challenged not the roles of health and disease in the study of homosexuality, but the very idea that homosexuality has root causes that science can discover. Indeed, the very fluidity of sexuality—both in individuals and in the sexual roles of various cultures—leads some commentators to maintain that sexual orientations are socially constructed. In this view, there are no homosexuals or heterosexuals in the sense that these are distinct kinds of people (Halperin). It would therefore be a mistake to look for genetic or hormonal causes of sexual orientation, just as it would be a mistake to study the biology of human beings in order to learn why some people are baseball fans and some people are not. Circumstance and society shape baseball fans, not human nature, and some commentators, known as social constructionists, hold the same view of sexual orientation.

In contrast, essentialists argue that human beings have sexual orientations by reason of their given nature, and that sexual orientation is likely rooted in biology. In other words, people are of natural kinds in regard to their sexual nature, and there are homosexuals and heterosexuals in the same way that there are elm trees and maple trees or people with blue eyes and people with brown eyes. From this perspective, sexual orientation amounts to an essential trait, and people express sexuality according to their natural kind (Stein). To essentialists, it is not a mistake to search out the root causes that distinguish people by sexual orientation.

The scientific study of fantasies, desires, and behaviors does not commit social-science researchers to either social constructionism or essentialism. It is possible to study many aspects of sexual psychology and behavior whether sexual orientation is rooted in nature or is simply a reflection of habits and patterns that people acquire in the course of their social development. However, the debate between constructionism and essentialism does have important implications for the causal study of sexual interests. It would be a mistake to look for the root biological causes of sexual interest where they do not exist.There is no well-validated account of how human beings come to have the entrenched sexual interests they have, though it is clear that genetics, anatomy, hormones, and psychological history all play a role. So it is not unscientific to ask why homosexuality comes to the fore in some people, why heterosexuality comes to the fore in others, and why others blend their sexual interests. There may well be genes or neurological features that dispose some people to the sexual interests they have. To be sure, there may be dubious motives behind some researchers' quest to understand the pathways of sexual development, but it is not unscientific to investigate the origins and determinants of sexual orientation.

The origins of sexuality—and homosexuality in particular—have attracted a good deal of scientific interest. Researchers across the life sciences have looked to see whether homosexual men and women have traits in body or mind that others do not have, and to learn whether those traits are causally connected to their sexual interests. Researchers have looked at body shape, the nervous system, hormones, genetics, and so on to discern the influences behind sexual orientation. They have also looked at psychological and behavioral differences, including the ability to whistle, the preference for certain colors, and relationships with family members (LeVay, 1996). There has been no shortage of studies along these lines, and contemporary researchers have continued to add to this domain of research.

In 1991 the neuroanatomist Simon LeVay published a report showing that some brain structures in homosexual men are statistically smaller than the same structures in heterosexual men. But because the size of these structures does not correspond exactly with sexual orientation, this study could not establish any definitive link between neuroanatomy and sexual interests. In 1993 the geneticist Dean Hamer and colleagues published a study showing that homosexual men are more likely than others to have male homosexual relatives, and the pattern of distribution of these male homosexual relatives suggests a genetic inheritance passed through mothers. The study also showed that male homosexual brothers are more likely to share a genetic region in common than nonhomosexual brothers, which also suggests there is a genetic contribution to sexual orientation. Again, however, because this shared genetic region does not correspond exactly with sexual orientation, these patterns do not prove that there is a "gay gene."

Both the LeVay and Hamer studies are preliminary and suggestive, but they are not definitive. Some commentators have nevertheless interpreted these studies as showing that homosexuality is natural, in the sense that there is a describable biology behind it (LeVay, 1993). These commentators think scientific study will protect homosexuality from social condemnation by confirming it as part of human biological nature. Others fear that these studies will revive theories that homosexuality is pathological (Bersani).

Where there is scientific uncertainty, there will be speculation and disagreement. For this reason, many analysts turn to ethics rather than science as a guide to the meaning and significance of homosexuality. Ethical analysis of homosexuality has a far longer history than its scientific study, and it will continue to have a role as the findings of science unfold.

Ethical and Legal Evaluation

Ethical theories try to describe an overarching view of what is good for human beings and to describe ways of distinguishing among states, choices, and behaviors that contribute to—or at least do not detract from—that overarching good. Ethical theories vary in their interpretations of homosexuality.

PREMODERN ETHICAL THEORIES. In ancient Greece, there were disagreements among intellectuals about erotic interactions between males. According to his chroniclers, Socrates (470–399 b.c.e.) experienced attraction toward other males, but he saw it as a means to achieve spiritual wisdom rather than physical gratification. Plato's (427–347 b.c.e.) views modulated over his long lifetime—from prudential accommodation of the spiritual aspects of homosexuality to more or less outright condemnation of this sexuality as being contrary to nature (Dover). His sympathetic references to erotic attraction between adult and adolescent males do not undercut his more fully considered view. Aristotle (384–322 b.c.e.) had less to say about homosexuality, though he also disapproved, describing homosexuality, in his Nicomachean Ethics, as a pleasure of those with bad natures.

In Medieval Europe, it was Thomas Aquinas (1225–1274) who—from a Catholic background—offered the next major treatment of homosexuality, calling it the most sinful species of lust. He did so in the context of natural law—a law defined in terms of the goals said to be inherent in human life. In his Summa Theologiae, he describes homosexuality as a violation of animal nature and of the order of sexual acts generally. The historian John Boswell has criticized this view by arguing that bodies and body parts have multiple purposes, and that the use of human genitals is meaningful only in sexual acts capable of begetting children. It is also the case that that there are analogues to homosexuality in other animals (Bagemihl), though even if there were not, it is unclear why animal behavior should be taken as a guide for human beings capable of reasoned evaluations of their choices.

MODERN ETHICAL THEORIES. The German philosopher Immanuel Kant (1724–1804) had a number of things to say about homosexuality, though he found doing so distasteful. Kant defended the categorical imperative as the central guide to human action. There are various formulations of the categorical imperative. What they share in common is the counsel to abide by rules that one would wish to see function as universal law. To use a negative example of how this would apply, one should not like because one would not wish to live in a world where lying was the universal norm. To use a positive example, one should be charitable because one could possibly want charity from others in the future. Kant argued that homosexuality was wrong because it could not function as a universally accepted practice. Applied to everyone, the sterility of homosexuality would put an end to the birth of children. Kant also found same-sex erotic behavior especially degrading to the parties involved.

By way of response to the Kantian view, it should be noted that it is sometimes difficult to see how precisely, or how broadly or narrowly, a moral maxim should be drawn. For example, it might be possible to frame a maxim of behavior this way: if—and only if—people find themselves sexually attracted to their own sex, then they should act accordingly, but not otherwise. In this way, the future of the human race would be secure and people would not have to act contrary to their actual sexual interests. And, of course, some heterosexual acts are just as disrespectful of sexual partners as homosexual acts—selfish sexual gratification is not the province of one sexual orientation alone.

In striking contrast to Kant, the British utilitarian philosopher Jeremy Bentham (1748–1832) came to almost the opposite conclusion about the morality of homosexuality. In works that were not published in his lifetime, he defended homosexuality for those inclined to it, saying it gives them pleasure and leads to happiness. In keeping with his utilitarian view that actions should be judged in terms of their capacity to contribute to human happiness through pleasure, Bentham thought it undeniable that homosexuality was one way to human pleasure. For some people, therefore, the pursuit of same-sex relations would be a positive good. Bentham was not especially worried that social accommodation of homosexuality might lead to more homosexuality, for if there is nothing wrong with homosexuality (for those interested in it), then increasing the amount of homosexuality in a society is not wrong either. He was convinced, too, that the forces of heterosexual lust were stronger than any threat to the birth rate that homosexuality might pose. In a strict sense, from this point of view, homosexual orientation and behavior are not of inherent moral interest.

Another utilitarian philosopher, John Stuart Mill (1806–1873), also believed that actions were moral to the extent that they promoted happiness. Given that adults are ordinarily the best judges of what makes them happy, Mill wanted to limit social interference with individual pursuits. He articulated his "liberty principle" in order to define a sphere of behavior that did not warrant social action. To Mill, social interference with the actions of others is justified only to prevent harm to others. Harm to one's own self is not a sufficient reason for interfering with an adult's beliefs and choices. With this conceptual background, it is possible to articulate a formidable boundary against social interference with homosexuality. Unless their behavior harms others—as in rape, for example—men and women should be able to pursue same-sex partners without social interference.

Alan H. Goldman, a commentator on sexual ethics, has argued that there are no moral rules specific to sexuality alone. He argues that the moral rules or precepts that apply across the range of human relations are the rules that should apply to sexuality as well. This means that the same rules that apply in heterosexual relationships should apply in others as well: if sexual fidelity is promised, it should be honored; there should be no deception or mistreatment; and so on. In one sense it is this very attempt to make social relations consistent across sexual orientations that has led to ambitious attempts to reform laws that criminalize homosexuality.

DEVELOPMENTS IN THE LAW. The ethical standards reflected in laws around the world are widely variable. In some nations, sex between males or between females is strictly forbidden and severely punished. In others, homosexuality is illegal as a matter of formal statutes but is not punished in practice. In other countries, homosexuality is not an object of legal interest in itself, only insofar as sexual relations may be involuntary or public. In 1957, in England, the Committee on Homosexual Offenses and Prostitution issued a report, commonly known as the Wolfenden Report, that recommended that the United Kingdom decriminalize consensual "sodomy" among adults. In coming to this conclusion, it drew heavily on notions of privacy and protection from social intrusion. In this regard, the report shared parallels with the Napoleonic Code, put in place in 1804. In that code there was no explicit mention of homosexuality, only of criminalization of involuntary and public sexual crimes, regardless of the sex of the parties involved. Lord Patrick Devlin argued against the conclusions of the Wolfenden Report by saying that society's moral revulsion toward homosexuality should count as a valid reason for legal restrictions. Devlin argued that a society requires shared moral values and political beliefs and that even acts that occur in private threaten the existence of society, and are not beyond the reach of social suppression. Nevertheless, Britain did decriminalize homosexuality among adults.

In 1986 the U.S. Supreme Court, in Bowers v. Hardwick, affirmed the right of states to enact laws prohibiting homosexuality among adults. In the case of Romer v. Evans (1996), however, the Court maintained that states could not deprive homosexual men and women of particular rights. As of this writing, the Court has heard a sodomy case which may undercut the conclusions of Bowers v. Hardwick.

In general, there is a trend in the United States to decriminalize homosexuality. In many other jurisdictions around the world, the legal battles have shifted away from the simple question of whether sexual relations between men and between women should be criminal or not. Newer legal battles have engaged such topics as protection from discrimination in employment, housing, and public accommodations, and many jurisdictions are debating broader civic rights for same-sex couples. For example, the Netherlands and Belgium have recognized same-sex marriage. In the United States, the state of Vermont recognizes a civil union that parallels marriage. Other issues advancing on the legal frontier for homosexual men and women are the right to custody of children and the right to serve openly in the military.

The Uses of Sexual-Orientation Science

Despite social and legal acceptance in many quarters, the place of homosexual men, women, and adolescents is not secure in all societies. Many societies, for example, lack basic protections for homosexual men and women. For this reason, some observers are wary of going forward with sexual-orientation research. Some observers believe that sexual-orientation science is not valuable (Suppe), while others believe it will be harmful to homosexual men and women (Bersani). Such research might be used to "treat" homosexuality in adults, or even to control the sexual orientation of children, sometimes through prenatal interventions. Each of these uses raises moral concerns.

SEXUAL-ORIENTATION THERAPY. As a matter of ethics, sexual-reorientation therapies should be guided by the standards of informed consent that guide clinical treatmentin other areas. At the very least, patients should understand and freely consent to treatment, appreciate the risks and benefits of treatment, and be advised about alternatives to treatment. These conditions have not always been met in sexual orientation therapy, especially involuntary treatment imposed by family and the state. As a matter of science, a broad array of techniques has been used with men and women to redirect sexual orientation from homosexuality to heterosexuality. Techniques used toward this end have generally reflected prevailing treatment methods of the time. Drug and hormone treatment, behavioral therapy, surgery, and psychotherapies have all been deployed at one time or another (Murphy, 1992). While some of this therapy has gone forward with professional integrity, there has also been involuntary treatment, gruesome castrations in the Nazi camps, and chemical and electrical aversive therapies that can only be called abusive.

While there are some reports in the scientific literature that describe successful re-orientations (Spitzer), it is unclear that sexual orientation therapies consistently deliver what they promise, especially when applied to randomly selected groups of people. Reports of success in reorientation come most typically from psychoanalysts, behavior therapists, and religious programs. These reports have been criticized for problems related to method, sample size, the lack of long-term assessment, a focus on behavior change (instead of psychic change), and the lack of control groups.

For therapists and their patients who still maintain that homosexuality is pathological, research that led to truly effective therapy would be all to the good. Other therapists do not maintain that homosexuality is pathological, but still believe that some treatments are justified in the name of respecting wishes about unwanted traits (Schwartz and Masters). For these therapists, research into treatments is also highly desirable, but it would remain a matter of debate whether the extinguishing of unwanted traits is a legitimate objective for medicine. Some commentators have argued that sexual-orientation therapy is immoral because it contributes to social prejudice against gay men and lesbians. For these commentators, further investigation into causes and therapies for sexual orientation is objectionable. The psychologist Gerald C. Davison has held that the mere availability of such therapy encourages its use, thereby perpetuating oppressive views about homosexuality. In contrast, the philosopher Frederick Suppe has pointed out that such an argument is persuasive only if the therapy: (1) presupposes that homosexuality is inherently inferior to heterosexuality, and (2) is socially influential in perpetuating injustice. It is not always clear that therapy programs meet these two conditions. It can be said, however, that pursuit of sexual orientation therapy may be an artifact of social injustice rather than an injustice in itself. In other words, people might look to therapy as a remedy for mistreatment in society at large.

THERAPY WITH ADOLESCENTS. Sexual orientation therapy is not confined to adults. In the past, parents have turned to punishment, moral exhortation, religious counsel, reform school, and even electroshock therapy in order to bring their children to heterosexuality. Both ethics and the law converge in the view that the people with the strongest immediate interest in protecting children are their parents. For this reason, parents are ordinarily entrusted to make even profoundly life-affecting decisions about their children. However, if parents' choices interfere with their children's well-being, then those children are entitled to protection. For example, the state can intervene when parents endanger children, deprive them of essential food and medical treatment, interfere with their education, and so on. Should ethics and the law recognize the right of parents to choose the sexual orientation of their children? The answer is "it depends."

To the extent that children do not have an interest in one sexual orientation over another, it would seem that parents should be able to plot the course of their children's lives, provided their actions are not harmful. For example, if parents wanted to ensure that they have only heterosexual boys, they might encourage their young boys to act in ways that they think (rightly or wrongly) will ensure that sexual orientation. They could therefore encourage boys to play vigorous contact sports and socialize with other boys. Unless it is hectoring and abusive, this encouragement does not by itself interfere with the child's well-being.

However, as they mature, children develop some degree of moral right to protection from parents' choices, even if those choices are well-meaning. Both ethics and the law recognize, for example, the rights of maturing adolescents to enroll in clinical trials and to refuse life-sustaining treatment when they are profoundly ill. That is, maturing adolescents are entitled to act in ways that protect their interests, even if their parents profoundly disagree with the choices made. This model can be extended to sexual orientation therapy as well: if maturing adolescents are profoundly unhappy about their emerging sexual interests, they might well accede to their parents' wishes and seek therapy. If, however, adolescents are not unhappy about their emerging sexual identity, it is unclear, as a matter of morality, why their parents' choice ought to prevail, especially if therapies or treatments carry risks that outweigh the possible gains of success.

PRENATAL INTERVENTIONS. Some commentators worry that research programs aimed at identifying the origins of homosexuality may lead to the elimination of homosexual progeny through prenatal interventions. They worry that markers for sexual orientation might be discovered that could predict a child's eventual sexual orientation. If this were possible, some parents might want to use various interventions to control the sexual interests of their children. This might be done—hypothetically speaking—through gamete selection, embryo biopsy, genetic manipulations, fetal treatments, or even abortion. This discussion is speculative, but it does illuminate key moral issues in parents' choices about their children.

In the United States, women are entitled, as a matter of ethics and law, to the prenatal information that bears on their choice whether to have children or not, as well as information related to fetal well being. They are also entitled to make abortion decisions for reasons of their own. The question under debate is whether this general approach is appropriate for choices about the sexual orientation of children. On one level, it would be idiosyncratic to forbid the use of prenatal diagnostics or even abortion when there are no legal barriers to doing so in regard to other traits of children (LeVay, 1996; Murphy, 1999). Some commentators worry, however, that the use of prenatal interventions could jeopardize the status and well-being of homosexual men and women in general (Stein). If used widely, these interventions could reduce the total number of homosexual men and women in the world, making group self-protection more difficult. By the same token, legal interference with parents' choices about the use of prenatal diagnostics could lead to circumstances in which homosexual children are born into families that do not want them. Parents could also use these techniques as a way of having homosexual children, and some parents no doubt would choose this option.

These considerations weigh against a moral conclusion that society should forbid prenatal interventions in the name of protecting homosexual men and women in general. In order to reach that conclusion it would have to be shown that sexual minorities could only be protected by such intrusive measures, and that these measures are ultimately more important than allowing parents to have children according to their own best judgments. It is to be remembered that this discussion is hypothetical, and there are no known means for ensuring the sexual orientation of a child.

Beyond Diagnosis and Treatment

Since the 1800s, the debate about the pathology of homosexuality has occupied center stage in the relationship between homosexuality and medicine. That focus notwithstanding, the vast majority of homosexual men and women never wanted, sought, or received therapy for their sexual orientation. Each one of these men and women has, however, other healthcare needs. At the very least, males who have sex with males and females who have sex with females have specific risks to their health, and this is especially true for homosexual youth who seem to be at increased risk of suicide (Gibson). Against this background, it is important to ask whether health professionals have the knowledge and communication skills necessary to meet the health needs of this group. Certainly some health professionals and academic commentators have paid attention to the healthcare needs of homosexual people (Solarz). However, medicine's own history in regard to homosexuality can stand in the way of appropriate degrees of study and effective healthcare.

No matter what their sexual interests, patients already face a problematic relationship with healthcare: medicine is distant from them by reason of its complex and intricate knowledge, cultural expectations about the role of the physician, and professional commitments within medicine (Engelhardt, p. 291). People with same-sex interests are perhaps at a further disadvantage because they cannot uniformly expect to encounter healthcare practitioners who are conversant with the specific health risks of homosexual men and women and who are comfortable with the nature of their sexual lives.

Indeed, some practitioners may believe that health risks associated with homosexuality are deserved and therefore require less social attention than other problems. In the 1980s, for example, some commentators argued that the AIDS epidemic was a divine punishment for immoral homosexuality. This view is hard to credit for a variety of reasons. In the first place, the view is suspect because the "punishment" is applied inconsistently. Some men who have sex with other men have developed AIDS, but most others—across history and even in the present—have not. Further, why should homosexuality receive this sort of punishment while other moral transgressions go unpunished? How is the punishment proportionate in its effect, and why should consensual behavior be punished so severely?

Rather than tie AIDS to divine punishment, some commentators pointed to social injustice as a root cause of the epidemic. These commentators argue that the sexual behavior of many homosexual men is affected by social prejudice. In other words, some men take sexual risks as adverse preferences, something they would not do if they had the same array of options in relationships and social status as others. Because they do not, they make poorer choices. According to these commentators, society has an obligation to make amends to those whose disease can be traced back to social inequality (Mohr).

Are there social factors that stand in the way of the health of homosexual men, women, and adolescents? One factor might be obstacles to the formation of long-term relationships and families that are especially important when it comes to healthcare and caregiving. Some homosexual people have no access to health insurance through their partner's employment, as married partners have, and others have no presumptive right of inheritance or decision making at the bedside of a partner who cannot direct his or her medical choices. The law does allow homosexual men and women to make health decisions for their partners who lose the ability to do so, but this recognition ordinarily requires advance directives such as a power-of-attorney for healthcare. When such arrangements are not put in place, some partners are excluded from decision making. Some healthcare services are not available to homosexual people. Some commentators think infertility clinics should not offer services to people in same-sex relationships, and some clinics do exactly that (Ford). For reasons like these, it is certainly worth asking whether deficits in the health and well-being of homosexual men and women are rooted in social injustice, with injustice minimally defined as the social failure to treat like cases alike.

Patients are not the only people in healthcare relationships, of course, and it is important to note that many gay and lesbian health professionals—physicians, nurses, and others—believe that certain social attitudes work against their full acceptance in the medical community. For example, some residency directors do not wish to have homosexuals in their graduate training programs. These hurdles may not have the same force everywhere and for everyone, but they nevertheless work against the equal standing of gay, lesbian, and bisexual healthcare practitioners (Potter).

The debate about the ethics of homosexuality has extended into discussions about cloned human beings. Some commentators have argued broadly that no one—single people, coupled partners, or married people—ought to use cloning to have children (President's Council on Bioethics). Others open the door to the use of cloning by some infertile couples and would allow same-sex female couples to use cloning technologies if they become safe and effective, since these couples have fewer options available to them. Still other commentators have argued that if cloning technology is safe and effective, there is no obvious reason why all same-sex couples should not have access to it. In cloning, as in other aspects of social and moral life, unwritten ethical rules and social opinion often guide the application of biomedical technologies and the distribution of healthcare benefits. When it comes to homosexuality and healthcare, it is often these unwritten rules of social opinion that are decisive and most in need of analysis.

timothy f. murphy

SEE ALSO: AIDS; Autonomy; Behavior Modification Therapies; Epidemics; Freedom and Coercion; Human Nature; Natural Law; Human Rights; Law and Morality; Lifestyles and Public Health; Narrative; Public Health;Sexual Ethics; and other Homosexuality subentries

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