Saturday, July 25, 2009

Homosexuality, medicine and psychiatry

The Hindu, Chennai ed.
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Opinion - Leader Page Articles
Homosexuality, medicine and psychiatry
K.S. Jacob

There is need to change the widely prevalent prejudice and to focus on
people’s humanity rather than on their sexual orientation.

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

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.

(Professor K.S. Jacob is on the faculty of the Christian Medical
College, Vellore.)

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