(49)   Mon 30 Nov 92 16:58                             
By: Paul Moor
To: All
Re: Psychiatric news  (1/3)
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[In the February 7, 1992 issue of Psychiatric News, in the space 
headed "From the President", Lawrence Hartmann, M. D., President of 
the American Psychiatric Association (APA), writes an introduc- 
tion to the ensuing contribution by his colleague (and my good 
friend) Richard Isay, formerly Program Chairman for the American 
Psychoanalytic Association.  I find Dr. Isay's piece so full of 
important material that I've taken the time and trouble to copy it 
here entirely unabridged.  First, APA President Hartmann's intro- 
duction:]

   Homosexuality, in which I have long been interested, seems to 
me, years after APA's helpful step of 1973 [read on], to continue 
to have considerable scientific interest for psychiatry, aside from 
or in addition to its major social policy and human-rights aspects. 
 It challenges and helps us define our ideas of health. It tests 
our biopsychosocial thinking.  It reminds us of areas of ignorance, 
and of discomfort and stigma and subtle or overt prejudice in 
others and ourselves.
   Dr. Richard Isay has written well on homosexuality.  He builds 
on the work of such clinicians and thinkers as Marmor, Stoller, 
Money, and Green in unpejoratively confronting the complexity of 
sexuality and homosexuality.
   I do not agree with Dr. Isay that "most" dynamically [i.e., 
psychoanalytically] oriented psychiatrists still think that 
homosexuality "can and should be changed".  Many possibly still do, 
but not, I think, "most".  We have no good statistics, but I have 
talked to many psychoanalysts and dynamic psychiatrists about this, 
and I hope but also think that "most" has not been true for some 
years now.  I guess most American psychiatrists in 1992 accept 
homosexuality as complex, compatible with excellent mental health, 
not routinely a complaint, the object of much prejudice, and of 
interest as part of a patient's or other person's life.
   Dr. Isay is a clinical professor of psychiatry at Cornell 
Medical College and chair of APA's Committee on Gay, Lesbian, and 
Bisexual Issues.

                      [Dr. Isay's article:]

   APA's 1973 decision to remove homosexuality from the Diagnos- 
tic and Statistical Manual and its Position Statement on Homosex- 
uality and Civil Rights have had far-reaching consequences for gay 
men and lesbians.  They played a rle in the changes in Title VI of 
the Immigration and Naturalization Act, which until 1990 was used 
to exclude homosexual visitors and immigrants to the United States 
on the basis of mental illness.  They have been used successfully 
to help promote civil-rights ordinances in some municipalities.  
They have been used in attempts to protect the visitation rights of 
gay men and lesbians with their children. They have been used in 
the preparation of briefs to prosecute bias-related murders.  
Perhaps the most important effect of the removal of homosexuality 
from the Diagnostic and Statistical Manual is its contribution to 
the self-esteem of gay men and lesbians.
   But I want to use this opportunity to write about two areas in 
which bias continues to affect judgment and policy.
   Two recent studies suggest the biological base of male homosex- 
uality.  In the August 30, 1991 issue of Science, Simon LeVay found 
nuclei measured in post-mortem tissue of the anterior hypothalamus 
to be more than twice as large in heterosexuals as in homosexual 
men who had died of AIDS.  There is a need to replicate with a 
sample of healthy homosexual men.  But most agree that this study 
suggests that "sexual orientation has a biological substrate".
   The more recent "Genetic Study of Male Sexual Orientation", by 
J. Michael Bailey and Richard Pillard in the December 1992 issue of 
Archives of General Psychiatry, showed that the rate of homo- 
sexuality in monozygotic co-twins was significantly higher than the 
rate occurring either in dizygotic co-twins or adoptive brothers.  
This study also is suggestive that homosexuality has a biological 
basis and, further, that it is inherited.  Both studies support a 
growing amount of suggestive empirical evidence and clinical 
impression that homosexuality, like heterosexuality, is 
constitutional, a theory I explored in my 1989 book Bring Homo- 
sexual [subtitled Gay Men and Their Development (Farrar Straus 
Giroux)].
   There is, nevertheless, continuing conviction among most, 
although not all, dynamically oriented psychiatrists in general and 
psychoanalysts in particular that homosexuality can and should be 
changed to heterosexuality by a "neutral" therapy that uncovers 
repressed childhood conflict that interferes with "normal" hetero- 
sexual development.  At the 1990 fall meeting of the American 
Psychoanalytic Association, there was a well-attended discussion 
group titled "The Sexual Deviations -- Theory and Therapy: A 
Successful Treatment of an Overt Homosexual Patient".  Books 
published on changing homosexuals to heterosexuals continue to 
receive wide attention.
   While sexual behavior can be changed for varying periods of time 
by a variety of methods, there is no evidence that sexual 
orientation itself can be altered.  I have seen too many patients 
who come for therapy after a traditional analysis or analytically 
oriented therapy with diminished selfesteem, depression, and 
anxiety, unable to be sexually responsive, or unable to be in a 
relationship.  Some are in a heterosexual marriage with children, 
feeling bewildered and unable to extricate themselves.  Suicide is 
not infrequently seen as the only solution to the seemingly 
insurmountable problems associated with this latter situation.
   Efforts to change homosexuals to heterosexuals persist in spite 
of APA's news release of January 26, 1990:
   "There is no published scientific evidence to support the 
efficacy of `reparative therapy' as a scientific treatment for 
homosexuality. . . .  While such methods may enable a homosexual 
person to engage in heterosexual relations and achieve a hetero- 
sexual life style, there is little, if any, evidence that they can 
change a homosexual person's deepseated feelings for others of the 
same sex."  And the even stronger statement by the American 
Psychological Association: "Research findings suggest that efforts 
to `repair' homosexuals are nothing more than social prejudice 
garbed in psychological accouterments. . . .  Clients who present 
themselves for sexual-orientation conversion treatment are acting 
out the intolerance that they have internalized from society and 
have turned upon themselves."
   I was recently sent a copy of a letter in which one of our [APA] 
members wrote, "They [homosexuals] have endangered us all and have 
contributed to the erosion of moral values.  As a consequence of 
having pursued a forbidden gratification, they have diminished 
their practical usefulness to society. . . .  In fact, many 
homosexuals have been cured by psychoanalysis and psychotherapy.  
[Prof. Alfred C. Kinsey himself once told me, Paul Moor, that 
neither he nor any of his interviewing team had turned up one 
single individual for whom that proved true, as measured by genital 
reaction, sexual fantasies, and dreams.]  As a practitioner who 
has researched and taught, I submit that it is better to confront 
the truth. . . .  If there is no cure, there is at least 
remediation and amelioration and a possible healthier adaptation to 
personality traits that are dangerous to the self and to society as 
a whole."
   The Committee on the Abuse and Misuse of Psychiatry defines 
abuse as the "institutional misuse of the psychiatrist's rle in 
order to further organizational or social objectives at the expense 
of competent or ethical care."  Efforts to change homosexuals to 
heterosexuals, I believe, represent one of the most flagrant and 
frequent abuses of psychiatry in America today.  They should be 
labelled clearly as such.
   Most psychiatrists are poorly informed about the normal devel- 
opmental issues of their homosexual patients.  Some who have a 
model of homosexuality as deviation and perversion mask bias with 
"neutrality".  They are unable or unwilling to assist their gay 
patients with sexual inhibitions or difficulties with intimacy as 
they can and do with their heterosexual patients, and they simply 
do inadequate or incompetent therapy.
   The [APA's] Committee on Gay, Lesbian, and Bisexual Issues 
believes that an educational approach to such abuse is important. 
We have prepared "A Curriculum For Learning About Homosexuality and 
Gay Men and Lesbians in Psychiatric Residencies", by Terry S. 
Stein, M. D.  It contains references and suggestions for implemen- 
tation and integration of the curriculum into current programs.
   A second area that needs to be addressed is the still extant, 
although diminishing, bias against accepting openly homosexual 
applicants in some residency training programs.  My concern is that 
this discriminatory policy is decreasing more because of fewer 
qualified applicants than because of increasing enlightenment.
   Only six years ago I treated for several months a PGY-3 resi- 
dent who was troubled until his sudden death of AIDS by what he had 
read in his admission interviews.  One interviewer had stated that 
he was effeminate and suspected of being homosexual, but since he 
probably was not, he could be admitted.  During his training he had 
heard homosexuals referred to as "deviants" and homosexuality as 
"perversion".  He made plans to die in a hospital that was not 
affiliated with his training program so that his teachers and 
supervisors would not know he was homosexual.
   I hear frequent verbal complaints about bias that has been 
covertly expressed in admission interviews.  Recently I received a 
letter from an openly gay man who felt that there had been bias 
expressed in his interview and complained that another applicant 
had been "lambasted about being a `johnny one-note' regarding his 
interest in gay people and people with HIV disease".  APA could 
remind administrators of residency programs of its position: 
"Whereas homosexuality per se implies no impairment in judgment, 
stability, reliability, or general social or vocational capabili- 
ties, . . . the American Psychiatric Association deplores all 
public and private discrimination against homosexuals . . . and 
declares that no burden of proof of such judgment, capacity, or 
reliability shall be placed upon homosexuals greater than that 
imposed on any other persons."
   In its most important policy document, the European Regional 
Office of the World Health Organization in September 1991 made the 
following statement.  I believe it has important implications for 
our clinical work: "Sexuality is a strong human force which makes a 
positive contribution to health if it is allowed appropriate 
expression. . . .  Unresolved personal attitudes and social 
conflicts concerning acceptable expressions of sexuality are 
themselves important contributors to individual health problems. 
People who hide their sexual orientation for fear of discrimina- 
tion or alienation have less fulfilling lives, encounter addi- 
tional stress, and are placed in situations that are not conducive 
to safe sexual practices. . . .  Health promotion has an important 
rle to play . . . [in] highlighting the value of a positive 
sexuality. . . ."

[Let no one here raise the issue of my having reproduced, un- 
abridged, Dr. Isay's entire article written for Psychiatric News. I 
know he wanted it to reach the greatest possible number of readers, 
and I also, knowing him and his fundamental attitudes well, 
cheerfully assume full responsibility.]

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