The recent debate about gender conformity and sexual identity sparked by last week's J. Crew advertisement controversy has me thinking a lot about gender stereotypes. Stereotypes can be dangerous. They frequently lead to the type of black-and-white thinking that is so often associated with discrimination. Our own psychiatric field is not immune to this phenomenon; in fact, at times we have even been responsible for perpetuating it. While our field has done much to educate others about the dangers of stereotyping, we have not always practiced what we preach. Take, for example, the use of psychological science to perpetuate homophobia.
Throughout history science has been appropriated to support morality, particularly as it related to sexuality. Often scientific theories have been presented as objective truths, analogous to the laws of physics or evolution. It is certainly understandable why moralists would wish to use science to support their beliefs. In our Western world, good science is thought to be irrefutable. Science often provides a framework for understanding natural and human phenomena without the apparent bias of emotion and subjective experience. It relies on detached observation, logic, and reason. Unfortunately, those who practice science have sometimes allowed themselves to be blinded by morality when studying human sexuality (Mohr, 2010).
American Psychiatry and Homophobia
Given all the evidence to the contrary, why did it take so long for psychiatry to publicly denounce the pathologization of homosexuality? The answer to this question is rooted in morality, not science.
In 1973, the American Psychiatric Association made the much belated decision to delete homosexuality as a diagnostic category from the Diagnostic and Statistical Manual (DSM). Ironically, this decision was not based on new scientific evidence but the result of political pressure from activists in and out of the Association (Mohr, 2010).
American psychiatry, as with clinical psychology, has suffered from "scientific heterosexism," an idea that rests on the very unscientific assumption that heterosexuality is "normal" and all other form of sexuality - such as homo- and bi-sexuality - are aberrant. If that were not bad enough, psychiatrists and psychologists have created empirical-supported treatments designed to correct these so-called sexual aberrations.
Contradicting their own medical training, the American Psychiatric Association for much of the 20th century argued against the idea that homosexuality was biologically-based, claiming instead that it was a response to environmental conditions interfering with "normal" psychosocial maturation (Terry, 1999). This belief led the profession to develop a disease-based model of homosexuality that remained on the books until recently. The original DSM (1952) listed homosexuality as a "sociopathic personality disorder." It was later upgraded in 1968 to a "sexual deviation" but it was not until 1973, after the APA's proclamation against homophobic diagnoses, that homosexuality was removed entirely from the diagnostic manual. However, the revised DSM-II continued to make reference to a less pathological "ego-dystonic homosexuality," a classification reserved for homosexuals who were distressed about their sexual orientation. In essence, this more benign form of homophobia allowed psychiatrist and psychologists to continue to treat their patients' homosexuality as though it were a disorder. It was only in 1987 that reference to ego-dystonic homosexuality was removed entirely from the DSM-III.
Psychoanalytically Informed Homophobia
Perhaps, the most blatant form of homophobia practiced in our field was committed by psychoanalysts, who, armed with poorly developed theories of sexuality, purported to treat homosexuality as a pathology in need of alteration. Many psychoanalytic theories were created to account for homosexuality. Concepts such as autoeroticism (i.e., love of the self), genital fears of the other sex, and the concept of "arrested development" have all been in vogue within psychoanalytic literature at different times. In analyzing gay men, it was not uncommon for a psychoanalyst to blame their patient's "overprotective mothers" and "absent fathers" for their homosexuality. In lesbians, psychoanalysts often argued that their patients suffered from some form of "penis envy," as well as an anger directed at their fathers.
Interestingly, the grandfather of all psychoanalysts, Sigmund Freud, was anything but homophobic. In fact, Freud warned his contemporaries of pathologizing homosexuality and openly opposed any form of discrimination against homosexuals that was based on sexual orientation. Early in his career, Freud wrote unambiguously that homosexuality was no illness, stating "homosexual persons are not sick."
While Freud never wrote a definitive treatise on homosexuality, he often discussed the topic in his case reports and correspondence with clinicians. In a frequently quoted letter (1935) to the mother of one of his gay patients, Freud wrote: "Homosexuality is assuredly no advantage but it is nothing to be ashamed of, no vice, no degradation, it cannot be classified as an illness; we consider it to be a variation of the sexual function produced by a certain arrest of sexual development" (as cited in Mohr, 2010). Hardly the words of a homophobe.
In fact, it was Freud's later apostles who felt compelled to pathologize homosexuality, presumably because they had difficulty tolerating the ambiguity of human sexuality. Such analysts argued for a more bifurcated notion of sexuality, one that unfortunately has continued through the present time. Freud on the other hand was far more comfortable with the ambiguity of human sexuality. He frequently argued that we are all bisexual to some degree but that heterosexuality is the preferred orientation - not for reasons of morality, but simply for the purposes of procreation and evolution. I would invite anyone in the psychoanalytic community who thinks otherwise to consult Freud's Three Essays on the Theory of Sexuality (1905).
Scientific heterosexism operates in a very similar fashion to that of scientific racism in that it starts with a priori view - in this case the belief that homosexuality is an aberration - and then creates a body of empirical evidence designed to confirm the very theory it purports to scientifically prove. The result is a circular form of logic that ultimately has been responsible for creating a body of literature used to pathologize a group of people who, as we now know, are no more capable of changing their sexual orientation as you or I are capable of changing our DNA.
American psychiatry and clinical psychology have suffered from unscientific reasoning when conceptualizing and treating homosexuality. While this post has focused more on the former, it is the treatment of gay men and lesbians who have been the unfortunate victims of poor science and moral relativism. While the fields of psychiatry and clinical psychology can come out with public statements denouncing their past positions of homophobia and intolerance, the real test to our field will be how we integrate newer, more scientifically-informed clinical material into our understanding and treatment of our LGBT patients.
Freud, S. (2000). Three essays on the theory of sexuality. New York: Basic Books (originally published in 1905).
Mohr, J.A. (2010). Oppression by scientific method: The use of science to "other" sexual minorities. Journal of Hate Studies, 77 (22): 21-45.
Terry, J. (1999). An American obsession: Science, medicine, and homosexuality in modern science. Chicago: University of Chicago.
Tyger Latham, Psy.D. is a licensed clinical psychologist practicing in Washington, DC. He counsels individuals and couples and has a particular interest in sexual trauma, gender development, and LGBT concerns. His blog, Therapy Matters, explores the art and science of psychotherapy.