Homosexuality, medicine and psychiatry

(The Hindu Jul 25 2009) The recent gay rights - in the backlight

There are many theories on the origins of homosexuality, its social and personal meanings and its implications. The American Psychiatric Association in 1973, and the World Health Organisation in 1992, officially accepted it as a normal variant of human sexuality. Many countries have decriminalised homosexual behaviour and some have recognised same-sex civil unions and marriage.


Medicalisation of homosexuality: The shift in ideas from a religious understanding of homosexuality, which held that such acts were sinful, to considering it a pathological state occurred in the late 19th and early 20th centuries. Early theories included genetic, endocrine and anatomical differences, which were said to produce a particular orientation. Others argued for imperfect sexual differentiation, immaturity and pathology, which led to claims that homosexuality could be cured. Studies and explanations within medicine and psychoanalysis led to the removal of the responsibility of defining homosexuality from the realm of religion and secured it within science and medicine. However, it also created a category of persons — the homosexual. This was in contrast to the religious belief that homosexuality was a behaviour rather than identity. It also perpetuated the social stigma by moving it from the domain of sin to that of pathology. The term “homosexual” is pejorative as it considers only one aspect of a person and uses that to sum up his or her entire identity.

Normalisation of homosexuality: The work of Kinsey and his colleagues in the mid-20th century was a scientific and cultural watershed. They documented a high prevalence of same-sex feelings and behaviour in men and women. Other workers documented homosexuality across cultures and among almost all non-human primate species and argued that it was natural and widespread. Investigations using psychological tests could not differentiate between heterosexual and homosexual orientation in men. Research also demonstrated that people with the homosexual orientation did not have any objective psychological dysfunction or impairments in judgment, stability and vocational capabilities. This led to a movement within American psychiatry, which argued against the a priori assumption that homosexuality is pathological. Psychiatric, psychoanalytic, medical and mental health professionals now consider homosexuality a normal variation of human sexuality.

The debate: The debate on homosexuality is polarised with arguments for its being innate and fixed, versus constructed and mutable. The essentialist theory argues that it is innate and an expression of biological factors. Constructivists argue that homosexuality is a result of social and external influences. The argument that homosexuality is a stable phenomenon is based on the consistency of same-sex attractions, the failure of attempts to change and the lack of success with treatments to alter orientation. There is a growing realisation that homosexuality is not a single phenomenon and that there may be multiple phenomena within the construct of homosexuality. Those opposing these views argue that heterosexuality has been the norm throughout history and in different cultures. They are not willing to accept homosexuality as part of a normal identity. They also argue that it will lead to the breakdown of the family. Nevertheless, the threat today to marriage and family in India is from heterosexual men with their high rates of alcohol abuse, physical and sexual violence, harassment for dowry, unprotected extramarital sex and the abandonment of the wife and children.

Prevalence: The prevalence of homosexuality is difficult to estimate for many reasons including the associated stigma and social repression, the unrepresentative samples surveyed and the failure to distinguish among desire, behaviour and identity. The figures vary among age groups, regions and cultures. Western figures are said to approach 10 per cent but reliable Indian data is not available.

On the origins: Medicine and science continue to debate the relative contributions of nature and nurture, biological and psychosocial factors, to homosexuality. The proposed biological models argue for genes and hormones organising brain circuits that mediate sexual orientation, biology playing a permissive role by providing neural circuits through which neuronal connections are inscribed or through indirect effects working through temperament and personality. Despite many hypotheses and much research, there is no definite evidence to suggest specific genetic, neural or hormonal differences that determine sexual orientation.

Anthropologists have documented significant variations in the organisation and meaning of same-sex practices across cultures and changes within particular societies over time. The universality of same-sex expression co-exists with variations in its meaning and practice across cultures. Cross-cultural studies highlight the limits of any single explanation of homosexuality within a particular society.

Classical theories of psychological development hypothesise the origins of adult sexual orientation in childhood experience. However, recent research argues that psychological and interpersonal events throughout the lifecycle explain sexual orientation. It is unlikely that a unique set of characteristics or a single pathway will explain all adult homosexuality.

Anti-homosexual attitudes: Anti-homosexual attitudes, once considered the norm, have changed over time in many social and institutional settings in the West. However, hetero-sexism, which idealises heterosexuality, considers it the norm, and denigrates and stigmatises all non-heterosexual forms of behaviour, identity, relationships and communities, is also common. The recent judgment of the Delhi High Court, which declared that Section 377 of the Indian Penal Code violates the fundamental rights guaranteed by the Constitution, was in keeping with international, human rights and secular and legal trends. However, the anti-homosexual attitudes of many religious and community leaders reflect the existence of widespread prejudice in India. Today’s religious leaders seem to define their religion by whom they exclude rather than by what they embrace and those they include.

Societal challenges: The secularisation of societies has resulted in the withdrawal of religion from public spaces. The separation of religion from the state is widely accepted in many countries. However, religious leaders who interpret ancient texts literally have viewed such liberal ideas with suspicion. Prejudice against different lifestyles and against the minorities is part of many cultures, incorporated into most religions and is a source of conflict in several societies.

In addition to the challenges of living in a predominantly heterosexual world, the diversity within people with homosexual orientation results in many different kinds of issues. Sex, gender, age, ethnicity and religion add to the complexity of issues faced. The stages of the life cycle (childhood, adolescence, middle and old age), family and relationships present diverse concerns.

Clinical approaches: In most circumstances, the psychiatric issues facing gay, lesbian and bisexual people are similar to those of the general population. However, the complexities in these identities require tolerance, respect and a nuanced understanding of sexual matters. Clinical assessments should be detailed and should go beyond routine labelling and assess different issues related to lifestyle choices, identity, relationships and social supports. Helping people understand their sexuality and providing support for living in a predominantly heterosexual world are mandatory. People with homosexual orientation face many hurdles, including the conflicts in acknowledging their homosexual feelings, the meaning of disclosure and the problems faced in their coming out.

There is no definitive evidence of the effectiveness of sexual conversion therapies. In fact, there is evidence that such attempts may cause more harm than good, including inducing depression and sexual dysfunction. With the acceptance of homosexuality as a normal variant by mainstream health professionals, there has been a reduced emphasis on using and evaluating sexual conversion therapies within medical and psychiatric circles. However, faith-based groups and counsellors pursue such attempts at conversion using yardsticks which do not meet scientific standards. Clinicians should keep the dictum “first do no harm” in mind. Physicians should provide medical service with compassion and respect for human dignity for all people irrespective of their sexual orientation. Training physicians and psychiatrists in the assessment of sexuality is mandatory. Research into the issues in India is crucial for increasing our understanding of the local and regional context.

Human sexuality is complex and diverse. As with all complex behaviour and personality characteristics, biological and environmental influences combine to produce a particular sexual preference. We need to focus on people’s humanity rather than on their sexual orientation.