Problems of Homosexuality

NORMAN REIDER, M.D., San Francisco

HARDLY ANY MEDICAL SUBJECT is more ambiguous * Moral, religious and legal attitudes in attempts
and confused than that of homosexuality, and it is to control sexual behavior have interfered with
a clear view of the medical and psychological
a most difficult subject for the clinician to delineate aspects of homosexuality. This phenomenon is
in a scientific or even empirical way. For centuries probably much less destructive of social aspects
homosexuality has been more a moral and legal than of our society and culture than is generally be-
a medical concern. Throughout the ages people have lieved, since it is actually more widespread than
is generally acknowledged.
tried to make criminal law enforce their ambitions
regarding moral law, especially in their attempts to Homosexuality probably has hormonal and
undoubtedly social and psychological factors,
control sexual behavior. Among sex laws, none are the latter of which are the only ones which can
so punitive or inequitable as those concerning homo- be worked with successfully in our present state
sexual acts, particularly male homosexual activities. of knowledge. A general practitioner's task is to
aid those who wish and need help with this prob-
Religious traditions and attitudes against homo- lem in finding psychiatric treatment in the same
sexuality have thus been extended into substantive way that persons with any other emotional dis-
law out of all proportion to the social damage in- turbance are referred. This should be carried
volved in most homosexual acts. Sin is confused with out without bias just as with any other emotional
crime, and vague laws about sexual behavior give disturbance.
law enforcement officers a dangerous discretionary
power. Sexual acts are not differentiated from crim-
inal acts. Of course there are sexual acts that harm THE EXTENT OF HOMOSEXUALITY
others and against which society must protect itself.
But these are not clearly differentiated from sexual The problem of homosexuality is even more exten-
behavior that merely "tends to affront certain peo- sive than the Kinsey data showed. According to Kin-
ple"; and men are imprisoned for acts that did no sey, about a third of white males between adoles-
damage to another person. cence and old age have had some type of homosexual
contact to the point of orgasm, but only four or five
The great majority of homosexual acts do not per cent are exclusively homosexual. A much smaller
endanger the social structure or disrupt the family. proportion of females at any age are primarily or
No doubt many early societies considered homosex- wholly homosexual; and very few continue their
ual activity a threat to family and societal solidarity, homosexual activities as long as do men. Men are
and taboos arose; but when these are examined they likely to be far more promiscuous than are women;
can be seen as part and parcel of man's fears of his only about half restrict their relationship to a single
own impulses-drives for which he sought controls. partner or two, as compared to three-fourths of the
Modern studies like those of the late Dr. Kinsey and women. These and other Kinsey data point to a
his associates serve to show that society has little to greater extent of homosexuality than is commonly
fear from homosexual activity. Yet the fear remains, believed.
in that a homosexual person continues to be the ob-
ject of extraordinary punishment or the butt of de- CLINICAL VIEW OF HOMOSEXUALITY
risive jokes and contempt. We should remember,
when we participate in such attacks, that we follow The Kinsey studies reported the amount of homo-
the age-old formula of trying to fight off or laugh off sexual behavior in various persons, but did not
something that we either do not understand or fear. determine clinically who was a homosexual. Are all
This extension of old taboos into moralistic and legal 37 per cent of males who have had at least one
attitudes still muddles the issue of what is essentially homosexual contact homosexuals-or just the 4 per
a biological and psychological phenomenon and cent who have only homosexual outlets? If we de-
only secondarily a social one. fine a group midway between these extremes as
Presented before the California Academy of General Practice, Los homosexual, we ignore the fact of a gradation of
Angeles, October 14, 1956. sexual activity, interest and preoccupation that
From the Department of Psychiatry, Mount Zion Hospital, San ranges from one to the other extreme. We overlook
Francisco.
Submitted December 20, 1956. the historical and developmental approach that de-
VOL. 86, NO. 6 * JUNE 1957 -381
notes both biological and psychological roots for next one "or else." Next time he complained of no-
homosexuality. ticing no improvement at all. On the third visit he
The biological roots are clear: A phase in our told the nurse he was depressed and said that he and
ontogenetic development when the undifferentiated his boy friend had fallen out and might separate.
organism has the potential of developing into either Next time he was more depressed and was moving
sex. Psychologically, too, we receive tenderness, af- out, he said, because he could not tolerate his boy
fection, abuse and cruelty at the hands of both men friend. The fifth time he carefully implied he was
and women. So many factors in the history of each less depressed, and reported no difference except
person shape his sexual destinies that to make the that he had no desire for anything or anybody. On
cause of homosexuality a simple one is not to face the sixth visit he told the nurse: "A simply fantastic
the facts. thing happened. I've been going to a local bookstore
Some observers believe that homosexuality is for years and never noticed before a very pretty girl
merely a matter of constitution and biochemistry, who works as a clerk there." By the seventh visit he
although present knowledge shows no basic differ- reported making a date with the girl and at the end
ence in either constitution or biochemistry between of treatment he claimed satisfactory sexual relations
the homosexual and the heterosexual. One should with her. This case figured in a published report of
therefore strongly suspect claims about a cure of successful treatment. Meantime this patient and his
homosexuality by hormonal treatment. A British companions who had also been treated went on with
report on recent developments in psychoendocrinol- their homosexual activities, except that some of them
ogy stated that homosexuals cannot be changed to a suffered from an increased drive-the result of the
more masculine attitude. "In most of them," the re- injections of androgens. How much of the exacerba-
port said, "testosterone merely accentuates the ho- tion was biochemical and how much psychological,
mosexuality. In general, its action is to increase the no one knows. Nor does anyone know to what extent
quantity of the sex drive without in any way altering similar ruses may have distorted medical results re-
its main direction." Far more evidence indicates that ported in the literature.
environmental and developmental factors help to In the etiology of homosexuality, constitutional
shape the individual's avenues of sexual outlet. But and hereditary factors cannot be ruled out as possible
research in the whole area has only begun to tackle factors. From a pragmatic view, a large amount of
the problem of cause. evidence points to developmental factors, chiefly
A story of my clinical experience in southern Cal- those connected with masculine or feminine identi-
ifornia some years ago will illustrate the complica- fications, as probably the most important ones. There
tions involved in the evaluation of hormonal treat- are multiple reasons why a young boy might fear
ment. The medical literature at that time contained to identify himself with what he considered mascu-
favorable reports of treatment of homosexuality by line trends and so be forced to adopt feminine atti-
androgens, and it acquired a certain vogue. Several tudes, habits and wishes. In our society a happy
California jurists who knew the futility of sentencing male child evidently goes through various stages of
homosexuals to jail began sentencing the convicted identifications and choices of the object of his af-
person to undergo treatment. Some persons were fections. At first he prefers himself, then he is greatly
sentenced to have hormonal treatment, others to attached to his mother. In later childhood, under the
have psychiatric treatment. As a result of these ef- molding influence of environment, the boy for a pe-
forts further articles reported successful treatment riod prefers his father and spurns as "sissy" any
with androgens-successes that I as a psychiatrist show of affection toward women. With adolescence
envied. his interests begin to shift once more toward girls.
One day a young man came to my office to consult The things that may block this normal development
me about a problem that only skirted on his homo- or stop it at any stage because of one trauma or an-
sexuality. A confirmed homosexual, he had little other-threats as to sexual activity, rejection by one
anxiety about his activities because he considered or the other parent-are too many to list and even
himself a constitutional homosexual and felt rela- more difficult to evaluate. Even in clear-cut his-
tively blameless. In the exploratory course of our tories of early seductions, their role in the causation
discussion he said that he had once been treated by of homosexuality is hard to determine.
androgens, not entirely of his own will, as the result However obscure the etiologic trails, we know more
of a court sentence. He then described how he and about the vicissitudes under which homosexual man-
several of his associates had contrived to "respond" ifestations take place. The homosexual is not alone
to the treatment, varying their stories so as to give in taking only a member of his own sex as object
them the hue of veracity. He said that he arrived choice. We all have homosexual object choices which
late for his first appointment and grumbled at the indeed most of us satisfy in so called sublimated
injection. The nurse reminded him to return for his ways. Our pursuits with pals, our most intimate in-
382 CALIFORNIA MEDICINE
tellectual and social friendships, our arm-in-arm TREATMENT
singing at the piano after a few beers, our sports ac- Very little is known about therapy of homosexual-
tivities-all have in the broad sense some sort of ity. Just as the extent of homosexuality is greater
homosexual connotations. These we value and enjoy than commonly believed, so the recoveries from dis-
without guilt or shame. No one is so masculine as tressing homosexual conflicts are probably more
not to expect some friendship or tender affection than we think. Doubtless a good many persons
from a member of his sex. These things stem from through experience, kindness, tenderness and under-
our early childhood sexual wishes-sexual in the standing are helped to get over their difficulties in
widest meaning-from the emotional life so inti- ways we can now only speculate about. Many a ho-
mately connected with our physical beings and the mosexual person embarks upon heterosexual expe-
spiritual aspects of love. This point needs emphasis rience or even marriage in the attempt to cure him-
because of too much palaver about spiritual expres- self and sometimes he is successful. Clinicians do not
sions of love as somehow being unconnected with see these successes, but rather the failures of such he-
our biological history. roic attempts. Sometimes hormonal treatment is suc-
Besides the mild and socially acceptable expres- cessful. I get the impression in review of such "suc-
sions of sublimated homosexuality, many other man- cesses," that psychological, suggestive factors have
ifestations appear. Although not particularly abnor- had more importance than the chemical ones, and
mal or peculiar in the course of ordinary masculine that no real cure has resulted.
activity, they yet indicate how protean are the forms Psychological treatment does not offer a much
and relics of homosexual wishes. For example, many brighter picture. Homosexuality as such can hardly
a man is more potent and has a much more satisfac- be treated because treatment of the underlying emo.
tory heterosexual relationship after "a night out tional disturbance is the essential thing. If homosex-
with the boys." Many a man, often without realizing uality is touched, all to the good; if not, treatment
it, feels keener, more intense interest in the woman's can often enable the patient to accept his condition
sexual experience than in his own. Indeed his part- with more grace and ease, with less shame and guilt,
ner's frigidity may cause him much frustration in so that he tends to get into less trouble than before.
his sexual life not only because he feels he is not With some gain in clinical knowledge, satisfactory
proving himself a man but also because she does not cures by psychiatric and especially by psychoanaly-
let him share in feminine pleasures. Many men se- tic treatment have slowly increased, but as yet the
cretly envy women's creating and nurturing quali- number is very small. Treatment is long and most
ties and activities. Fortunately, the social trend now difficult, and the course of a successful treatment
makes acceptable such masculine envy of women; very hard to report and explain.
the tables turn and we hear much less about femi- To understand part of the difficulty, take one anal-
nine envy of men. The line is hard to draw between ogy: It is in general just as hard to change a homo-
these normal manifestations of homosexuality and sexual's object choice as it would be to change a
near-pathological activities. Surely a patient ad- heterosexual into a homosexual. A case in point is
dicted to prostatic massage satisfies some homosex- that of a man prominent in public life, who consulted
ual needs that may bear scrutiny under a psycho- a well known psychoanalyst, saying bluntly: "I'm a
logical microscope. Likewise a physician who un- homosexual with many compulsions and obsessions.
wittingly plays partner to this game may well scru- I can't pass a gate without wanting to run my fin-
tinize his role. gers or cane along the pickets. I have to go back ten
Such complex psychological attitudes clearly show times to make sure I've locked the door. I have to
that psychologically we are not wholly one sex or count to a certain number before starting any under-
the other. Our deeper understanding of homosexual- taking. I feel perfectly comfortable with my homo-
ity has also affected our nosological concepts of men- sexuality. I have many agreeable companions who
tal illness. For instance, often homosexuality, as share my views. But my compulsions interfere with
such, harms a person less than does the fear of ho- my life and I would like treatment for them without
mosexuality. Many homosexual conflicts that bring touching the homosexuality. Will you treat me under
a patient to a physician or psychiatrist for the first these conditions?"
time have little to do with homosexuality. The pa- The analyst replied that because homosexuality is
tient really fears some dissolution of his psychic ap- so extremely difficult to cure they could undertake
paratus or of his integrity as a person, and he picks treatment, with the patient's understanding how
on homosexuality as a first sign of dissolution. Many small the chance for such outcome. The man entered
schizophrenic breaks first began with fears of homo- treatment and at the end of two years he was cured
sexuality; that is, the concern about homosexuality of homosexuality. He married happily and had two
is symptomatic, just as alcoholism is symptomatic of children. But, alas, all his compulsions and obses-
a much more important underlying emotional illness. sions remained intact and untouched.
VOL. 86, NO. 6 * JUNE 1957 383
 THE GENERAL PHYSICIAN AND THE HOMOSEXUAL PATIENf suasions, even threats. Often he will insist that be-
cause he has great confidence in him, the general
The general physician in his role with homosexual physician continue the attempts at therapy. This
patients had best restrict his activities to what may places the physician in a most difficult dilemma.
be called minor psychiatry. To practice it, he must Sometimes he may be strongly tempted to work some
form his attitudes from some understanding of med- magic trial of hormonal treatment or to delve into
ical psychology and not from the statute books. He the patient's psychic apparatus. The physician would
or anyone who handles these problems must drop do best to withstand the temptation to an involve-
his judgmental attitudes and not discuss homosex- ment that may indeed carry him away into dark seas
uality with the patient or his parents as if it were a of interpersonal relationships where even the most
sin. The physician should allay parental anxiety, gifted mariners may lose their way.
especially with patients in childhood or early adoles- It is encouraging to see that a favorite treatment
cence, in whom experimental curiosity may play a of a generation ago has waned-the attempt at cure
large role. by arranging a sexual alliance with a prostitute or a
If the physician believes that a real problem exists knowledgeable substitute, a device not infrequently
because of a conflict to be resolved, the patient used even by some psychiatrists. Such attempts to
should be referred to a psychiatrist for evaluation teach the homosexual the facts of life or to make a
and a consideration of means of treatment. If psy- man of him have precipitated more than one schizo-
chiatric help is advised and the patient refuses it, phrenic break.
the general physician at best can only counsel him The general physician, often the first to be con-
to keep out of trouble-to choose his companions sulted by the homosexual, must be prepared to deal
discreetly, not to pick up strangers in public toilets at the start with cases of great psychological com-
or invite them to his home for homosexual purposes plexity. Homosexuals are liable to be hostile or para-
-and inform him about the chances of blackmail noid and to present problems bordering on addiction
or other entrapment and arrest. Because treatment or psychosis. Again, however offensive the behavior,
is so difficult, only those with the greatest knowledge, shaming or deriding or reviling has no more place
training and experience should attempt it. in the treatment of such persons than in the treat-
At times the patient will refuse even a referral for ment of any other medical condition.
psychiatric evaluation. He may try arguments, per- 2235 Post Street, San Francisco 15.

384 CALIFORNIA MEDICINE