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Psychoterapy and the Culture Wars
Earlier this year, the American Psychological Association released a position statement regarding so-called ‘conversion therapies,’ stating that mental health professionals should avoid telling clients that they can change their sexual orientation through therapy or other treatments. The near-unanimous resolution came as a result of the recommendations of a task force in charge of reviewing all literature on Sexual Orientation Conversion Efforts (SOCE). Their recommendations were released in the report Appropriate Therapeutic Responses to Sexual Orientation.
The "Resolution on Appropriate Affirmative Responses to Sexual Orientation Distress and Change Efforts" also advises that parents, guardians, young people and their families avoid sexual orientation treatments that portray homosexuality as a mental illness or developmental disorder and instead seek psychotherapy, social support and educational services "that provide accurate information on sexual orientation and sexuality, increase family and school support and reduce rejection of sexual minority youth."
Author of Psychoanalytic Therapy & The Gay Man(1998) and Gay and Lesbian Parenting, American psychiatrist and psychoanalyst Jack Drescher is currently one of the most active scientific advocates for the critical revision of psychiatric and psychoanalytic doctrine regarding sexual orientation. Besides his contribution to the SOCE debate, he has recently completed a review of the history of the homosexuality and gender identity as part of the DSM-V Work Group on Sexual and Gender Identity Disorders (Drescher, 2009).
In this interview with CLAM, Dr Drescher analizes the evolution of psychiatric and psychoanalytic thinking in and out of a pathological model, and how mental health professionals should respond to issues of sexual orientation in clinical settings.
Why did the view of homosexuality as mental illness predominate in 20th century western medicine, despite the existence of alternative, less pathologizing views such as Havelock Ellis’ or Freud’s?
A "normal variant" view of homosexuality did not capture the imagination of large segments of the American public until the mid-20th century publication of the Kinsey Studies in 1948 and 1953. The most influential proponent of the pathological of homosexuality, which began in Europe in the 19th century, was Richard von Krafft-Ebing, a German psychiatrist. Krafft-Ebing's 1886 opus, Psychopathia Sexualis, made the case that homosexuality and other expressions of unconventional sexual behavior could be understood as symptoms of "nervous degeneration," that is as mental illnesses rather than as religious sins. Although degeneracy theory was scientifically discredited as a "cause" of mental illnesses, many of its implicit assumptions, including the belief that homosexuality is a mental disorder, persisted.
In the 19th century, as religious views of nature waned and secular and scientific views increased in importance, a process of medicalization of socially unacceptable behaviors began which would continue well into the 20th century. Demonic possession would become "insanity," drunkenness would become "alcoholism," and sodomites would become "homosexuals." A normalizing view of homosexuality was a distinctly minority viewpoint. Society might be willing to accept that sins could be reformulated as illnesses if scientific and medical experts made the claim that "homosexuals are not bad, they are just sick." However, to consider homosexuality as "normal" was a more difficult stretch of the imagination for most mental health professionals of that era.
After Freud's death in 1939, a more pathologizing view took root among psychoanalysts of the mid 20th century, who embraced a more critical view of homosexuality than he did. In The Psychoanalytic Theory of Male Homosexuality, Ken Lewes argued that in America, European émigré analysts equated homosexuality with the excesses of Nazism and that this association was an underlying factor in the continuing pathologization of homosexuality in the US. This view predominated in American psychoanalysis until the early 1990s when the American Psychoanalytic Association reversed its historic positions on homosexuality and opened up its institutes to openly gay faculty and candidates (Drescher, 2008).
What is the social and scientific context for the recent reemergence of pathologizing views of homosexuality in the United States, after having been clearly discredited by scientific wisdom?
In 1973, the American Psychiatric Association (APA) removed the diagnosis of homosexuality from its Diagnostic and Statistical Manual (DSM). The story of this event is meticulously and thoughtfully chronicled in Ronald Bayer's Homosexuality and American Psychiatry: The Politics of Diagnosis (1981). Yet as APA and other scientifically-grounded professions adopted a normal variant paradigm and rejected theories of homosexuality as pathology, those theories were being embraced by traditional religious institutions that historically condemned homosexuality.
It is noteworthy that the APA decision deprived religious, political, governmental, military, media, and educational institutions of any medical or scientific rationalization for discrimination. Without that cover, a historically unprecedented social acceptance of openly gay men and women ensued. Now no longer ill and in need of treatment, society has had to come to moral and legal terms with how gay people were to openly live their lives. However, it yet remained to be seen under what conditions they could love, work, and create new families. Today these moral, political and legal debates have come to be known as the "culture wars."
The opposing sides in today's culture wars argue from either the belief that 1) homosexuality is normal and acceptable or 2) that homosexuality is neither normal nor acceptable. The former position is what I call the normal/identity model. Its underlying proposition is that homosexuality is a normal variation of human expression. This position rejects historical cultural beliefs that homosexuality represents either illness or immorality. The acceptance of one's normal homosexual orientation is regarded as a distinguishing feature of a gay or lesbian identity. This position further defines individuals with a gay or lesbian identity as members of a sexual minority. As members of a minority, this position holds, gay men and lesbians need protection from discrimination by the heterosexual majority.
The opposing position in this debate adheres to what I call the illness/behavior model. One of its central tenets is a forceful rejection of the normal/identity model. This position regards any open expressions of homosexuality as pathognomonic of psychiatric illness, a moral failing, or both. A normal identity cannot be created from illness or sin, nor does it provide the basis for defining membership in a (sexual) minority group. Thus, those who engage in homosexual behavior are not akin to racial, ethnic or religious minorities (Drescher, 2002a, 2002b).
After 1973, the illness/behavior model was gradually marginalized from the mental health mainstream. However, it was born again elsewhere as the clinical argument that homosexuality is an illness meshed seamlessly with a social-conservative, political message: homosexuality is a "behavior," not an "identity." Further, if homosexual behavior can be changed in just one person, then gay people cannot be considered a minority entitled to legislative protections.
What is the role of religious fundamentalisms in this process?
As a tactic in the culture wars, historic psychoanalytic theories of immaturity and pathology – now discarded by the mental health mainstream – have been adopted by many religious denominations that were struggling to temper their compassion for homosexual individuals with their historic, antihomosexual traditions of outright condemnation. This process led some religions to adopt a modern moral imperative to "love the sinner but hate the sin." From this contemporary religious perspective, a gay man or woman does not have to be automatically expelled or shunned by their community of faith. Instead they are embraced if they will renounce their homosexuality and seek to "cure" it. This changing environment led to a growing movement of religiously based self-help groups for individuals who refer to themselves as "ex-gay."
In the US, the ex-gay movement has been politicized by religious groups on the political right to make the case that gay people can change their sexual orientation if they only try and therefore there is no reason to provide civil rights protections for gay people.
Further, some secular therapists, like the late psychoanalyst Charles Socarides (1995), were willing to make common cause with fundamentalist religious groups. By the early 1990s, no longer finding receptive audiences in the mental health mainstream, they found leaders of these religious groups more than willing to promote their now discredited theories (Drescher, 1998a). Socarides was one of the founders of the National Association for Research and Therapy of Homosexuality (NARTH), a marginal group that claims to be secular but which has strong support and relationships with religious, social conservative organizations that promote NARTH's beliefs that homosexuality is a "treatable" condition.
What is the actual scope of therapeutic responses to sexual orientation today?
There is little empirical data available to answer the question of what is being done with patients. One recent exception is a study done in the UK (Bartlett et al., 2009) that surveyed over 1300 mental health professionals of various disciplines.
Although only 4% of therapists reported that they would attempt to change a client's sexual orientation if asked for such therapy, 17% reported having assisted at least one client/patient to reduce or change his or her homosexual or lesbian feelings. Counseling was the commonest (66%) treatment offered and there was no sign of a decline in treatments in recent years.
Seventy two percent of the 222 (17%) therapists who had provided such treatment considered that a service should be available for people who want to change their sexual orientation. Client/patient distress and client/patient autonomy were seen as reasons for intervention; therapists paid attention to religious, cultural and moral values causing internal conflict.
The authors concluded that although there is no evidence that this kind of treatment is effective, and evidence that it may be harmful, a significant number of British mental health professionals (17%) are still attempting to help LGB clients to become heterosexual.
Is it possible to think clinical ways to understand sexual orientation that are neither pathologizing nor strictly affirmative?
In my book, Psychoanalytic Therapy and the Gay Man (1998), I offer an alternative to the poles of ideological approaches. While it is hard to summarize all of the points in this format, therapists need to be able to tolerate working within a conflict model.
For example, contemporary psychoanalysts do not believe that a therapist’s own biases are easily put aside. Consequently, no therapist can ever be in a position to “neutrally” help patients resolve a conflict between their religious beliefs and their homosexual attractions. Therapists need to be honest about their own beliefs, both with themselves and with their patients. If the patient is conflicted between following their religious beliefs and acting on their sexual feelings, then the role of the therapist is to help the patient better tolerate the pain of conflict, the anxiety of uncertainty. Ultimately, it is the patient’s ability to tolerate this psychic pain with the assistance of the therapist that may help them come to their own conclusions.
What are the current challenges to appropriate therapeutic responses to sexual orientation? Are clinical psychologists, psychiatrists and counselors sufficiently trained to deal with the complexity of this issue?
The answer is definitively “no.” When I lecture and teach, both in the US and abroad, I often ask clinicians how many feel their graduate or even postgraduate training adequately included information about issues related to gender and sexuality. Few respond that they feel they have had adequate training in this area, regardless of the discipline in which they were trained.
This is unfortunate, as most people go to therapists assuming that they are seeing someone who has such training. And many patients are bound to find themselves extremely disappointed when the therapist uses their own limited knowledge and experience in place of actual data in assisting these patients.
The Group for Advancement of Psychiatry is a psychiatric think tank whose LGBT Committee recently developed an on-line curriculum (http://www.aglp.org/gap/) to teach psychiatric residents and other professionals about caring for lesbian, gay, bisexual, transgender, and intersex patients. For those whose programs do not offer any formal training, this curriculum is available for free to anyone who wishes to learn more.
In the current state of affairs, what is the importance of the recent Report by the APA's Task Force and resolutions by the Boards of psychiatric and psychological associations on the subject?
Both the American Psychiatric Association and the American Psychological Association have strong position supports for gay rights, including the right to marry. However, policy statements are not necessarily translating into adequate focus on training issues in either field. The American Psychological Association’s recent report on Appropriate Response to Sexual Orientation is a good start. Much more could be done and much more needs to be done.
In the internet age, members of the public need to easily find out the positions that professional organizations are taking in regard to conversion therapy. For example, I recall attending a conference in New York City in 2003 that was organized for Orthodox Jewish therapists wishing to learn more about mainstream mental health views on homosexuality. One panel included four people who were religious Jews who had struggled with their homosexuality and who had come to accept their feelings.
One young man of college age told his story of being troubled by his same sex feelings and having told his rabbi. The rabbi sent him to a psychiatrist who offered to do a conversion therapy to change his sexual orientation. The young man went home, did some research on the internet and found the American Psychiatric Association’s 2000 position statement opposing conversion therapies. As a result, he decided not to continue that treatment with the psychiatrist offering conversion therapy.
The most difficult part is helping the general public understand the differences between what the mental health mainstream and groups presenting disinformation about homosexuality are saying.
Bartlett, A., Smith, G. & King, M. (2009). The response of mental health professionals to clients seeking help to change or redirect same-sex sexual orientation. BMC Psychiatry, 9:11.
Bayer, R. (1981). Homosexuality and American Psychiatry: The Politics of Diagnosis. New York: Basic Books.
Drescher, J. (1998a). I'm your handyman: A history of reparative therapies. J. Homosexuality, 36(1):19-42.
Drescher, J. (1998b). Psychoanalytic Therapy and the Gay Man. Hillsdale, NJ: The Analytic Press.
Drescher, J. (2002). Sexual conversion ("reparative") therapies: A history and update. In: Mental Health Issues in Lesbian, Gay, Bisexual, and Transgender Communities (Review of Psychiatry, Vol. 21:4). eds. B.E. Jones & M.J. Hill.
Drescher, J. (2002). Ethical issues in treating gay and lesbian patients. Psychiatric Clinics North America, 25(3):605-621.
Drescher, J. (2008). A history of homosexuality and organized psychoanalysis. J. American Academy of Psychoanalysis & Dynamic Psychiatry, 36(3):443-460.
Drescher, J. (2009). Queer diagnoses: Parallels and contrasts in the history of homosexuality, gender variance, and the Diagnostic and Statistical Manual (DSM).” Archives of Sexual Behavior.
Drescher, J. & Merlino, J.P., eds. (2007). American Psychiatry and Homosexuality: An Oral History. New York: Harrington Park Press.
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Kinsey, A., Pomeroy, W., Martin, C. & Gebhard, P. (1953). Sexual Behavior in the Human Female. Philadelphia, PA: Saunders.
Krafft-Ebing, R. (1886). Psychopathia Sexualis, trans. H. Wedeck. New York: Putnam, 1965.
Lewes, K. (1988). The Psychoanalytic Theory of Male Homosexuality. New York: Simon and chuster.
Socarides, C.W. (1995). Homosexuality: A Freedom Too Far. Phoenix, AZ: Adam Margrave Books.