This was published in another form in the NARTH bulletin 11(2):25-28, 2002
Summary: Most homosexuals are not mentally ill. However, recent studies show homosexuals are at much greater risk than heterosexuals, particularly for substance abuse, suicide, depression, bulimia and antisocial personality disorder. This paper highlights some new and significant points in those papers, and also argues that some more extreme forms of homosexual behavior are in themselves a mental illness, though not by present DSM criteria. Those showing such behaviors are the people least likely to present themselves as clients for therapy.
In spite of substantial protest (see for example Socarides, 1995) the American Psychiatric Association removed homosexuality from its diagnostic list of mental disorders in 1973. The APA , reasonably enough, wanted to reduce the damaging rejection suffered by homosexuals, but one effect of their action has been to add the authority of the APA to the activist claim that homosexuals are mentally healthy.
Gonsiorek (1982) in a review argued there were no data showing mental health differences between gays and straights (or if there were it was society’s fault). Similarly Ross (1988) in a cross-cultural study found most gays were in the normal psychological range.
However some papers gave hints of inherent psychiatric differences between homosexual and heterosexual. One study (Riess, 1980) used the MMPI, that venerable and well-validated psychological measurement, and found that homosexuals showed definite “personal and emotional oversensitivity”.
Similarly (Kalichman et al. 1992) another study showed that when using the MMPI, one cluster of results was typical of homosexuals – it included a “psychopathological deviate”. In 1991 the complete normality of homosexuality was still being defended (Gonsiorek, 1991) in a paper called “The empirical basis for the demise of the mental illness model”. Apparently it was not completely dead even 18 years after the APA decision. Only in 1992 was homosexuality dropped from the International Classification of Diseases (King and Bartlett, 1999) so, either inertia, or doubt held the decision up for nearly two decades for the rest of the world.
Are homosexuals mentally normal? Clinicians and researchers approached the problem of normality from opposite ends. In the words of Bailey (1999) "Gay people undergoing therapy seemed dysfunctional while volunteers [for surveys] from homophile organizations seemed well". Strong self-selection occurred in both cases.
Good random samples of homosexual people and studies of their mental health were needed, and such surveys are now increasingly available.
One earlier important and carefully conducted study found suicide attempts among homosexuals were about 6x normal (Remafedi et al. 1998). New studies show increased psychopathology. Recently in the Archives of General Psychiatry, an old and well-respected journal, three papers appeared with extensive accompanying commentary (Fergusson et al. 1999, Herrell et al. 1999, Sandfort et al. 2001, and e.g. Bailey 1999). Bailey’s conclusion in that commentary was "These studies contain arguably the best published data on the association between homosexuality and psychopathology, and both converge on the same unhappy conclusion: homosexual people are at substantially higher risk for some forms of emotional problems, including suicidality, major depression, and anxiety disorder, conduct disorder, and nicotine dependence…" "The strength of the new studies is their degree of control".
The first study was on male twins who had served in Vietnam (Herrell et al. 1999). It concluded that on average, male homosexuals were 5.1 times as likely to show suicide-related behavior or thoughts than their heterosexual counterparts. Bearing in mind the rule of thumb for surveys that a factor of 2 higher is probably not significant, but a factor of 3 probably is, we see that a factor of 5.1 is highly significant. However some of this factor of 5.1 was associated with depression and substance abuse, thought to be independent of homosexuality. When these were allowed for, the factor of 5 decreased to 2.5; still probably significant, but less so. The authors therefore believed there was an independent suicide factor probably closely associated with some features of homosexuality itself.
The second study (Fergusson et al. 1999) followed a large New Zealand group from birth to their early twenties (hence almost certainly freeing it from most biases which bedevil surveys). It showed significantly increased occurrence of depression, anxiety disorder, conduct disorder, substance abuse and thoughts about suicide, amongst those homosexually active. A new point was that their parents had often been convicted of criminal offenses.
The third paper was a Netherlands study (Sandfort et al. 2001) again showing increased mental health problems, but remarkably HIV status was not a factor. People who are HIV positive should at least have anxiety as a diagnosable mental problem! The paper suggested without being dogmatic that pressure from society causes mental health problems (even in the Netherlands) and HIV status does not. That seems very unlikely in Holland's the liberal climate, and suggests pressure from society must be a very minor factor. At least three issues arising from the studies were mentioned in the commentaries.
Association of mental health problems with homosexuality
First, there is now clear evidence that mental health problems are associated with homosexuality and this supports those who opposed the APA actions in 1973. However the present papers do not answer the question; is homosexuality itself pathological? That must be argued another way. The papers do give evidence that since only a minority of a non-clinical sample of homosexuals have any diagnosable mental problems (at least by present diagnostic criteria) not all homosexuals are "mentally ill". In New Zealand conditions for example, lesbians are about twice as likely to have sought help for mental problems as heterosexual women, but only about 35% of them over their lifespan, never more than 50% (Anon 1995, Saphira and Glover, 2000, Welch et al. 2000). There are similar US results.
The suicide connection
Second, do the papers show that the lifestyle itself or pressures from society lead to suicide? They showed that neither inevitably led to suicide. The homosexual Vietnam veterans showed a greater rate of suicide attempts associated with homosexuality itself, but obviously not all attempted suicide. To measure the pressures from society, it is worth remembering that Saghir and Robins (1978) examined reasons for suicide attempts among homosexuals and found that when the reasons were homosexuality-related, about 2/3 were due to break ups of relationships, not outside pressures from society. Similarly, Bell and Weinberg (1981) found the major reason for suicide attempts was breakup of relationships, and, second, the inability to accept oneself. So the homosexual equivalent of Romeo and Juliet is a major factor in suicide attempts. Since homosexuals have increased numbers of partners and breakups, compared with heterosexuals it is not surprising that suicide attempts are proportionally higher. Perhaps it is coincidence but the median number of partners for homosexuals is four times higher than for heterosexuals (Whitehead and Whitehead 1999, calculated from Laumann et al 1994), and a good general rule of thumb is that suicide attempts are similarly about three times higher.
Another factor in suicide attempts is the compulsive or addictive element in homosexuality (Pincu, 1989), with addiction itself leading to feelings of depression because the lifestyle is out of control (Seligman 1975). There are some (as many as 50% of young homosexual men today), who take no precautions against HIV (Valleroy et al., 2001) who have considerable addictive problems, and this also feeds into suicide attempts.
The effect of pressures from society
Third, does pressure from society lead to mental health problems? Less than one might imagine. The Netherlands authors were surprised to find so much mental illness in homosexual people because they thought tolerance to gay people was greater in the Netherlands than almost all other countries. Another test country is New Zealand. Although suicide attempts were common in the New Zealand study and occurred at about the same rate as US results, New Zealand is much more tolerant of homosexuality than the United States, and legislation giving the movement rights is powerful, enforced throughout the country, and virtually never challenged. Ross (1988) in his cross-cultural comparison of mental health in the United States, Netherlands and Denmark - which have very different attitudes to homosexuality - found similar mental health problems and concluded these might arise from a mistaken homosexual impression of public hostility, but it could be argued that this mistaken impression is almost a mental health problem in its own right. This again suggests societal hostility to homosexuality is not closely tied to homosexual mental health.
OTHER RELATED ISSUES
There are three other issues not covered in the Archives papers which are important. The first two are DSM category diagnoses.
Ellis et al.(1995) examining patients at a clinic that focused on genital and urological problems found 38% of homosexual men had antisocial personality disorder, compared with 28% for heterosexual men. The difference was very highly significant and both were enormously higher than the 2% for the general population and approaching the 50% for prison inmates (Matthews 1997). In other words the promiscuous (heterosexual or homosexual) are often quite antisocial. It is worth noting here the comment of Rotello (1997); “…the outlaw aspect of gay sexual culture, its transgressiveness, is seen by many men as one of its greatest attributes”. This conflicts with Bailey’s commentary which predicted a rather low rate of antisocial personality disorder for men. However the finding of increased conduct disorder in the New Zealand study foreshadowed this. Therapists are not very likely to see a large number of those who are homosexual and chronically antisocial because they are probably less likely to seek help.
Secondly, it was previously noted (Carlat et al. 1997) that 43% of a bulimic sample of men were homosexual or bisexual, a rate about 15 times higher than expected, and meaning homosexual men were disproportionately liable to this mental condition. This probably arises from the very strong preoccupation with appearance and figure frequently found among male homosexuals.
Core gay ideology
The third issue is not a DSM diagnosis. However a strong case can be made that the male homosexual lifestyle itself in its most extreme form is a mental disturbance. As described by Rotello (op. cit.), the theoretical core of gay ideology is that same-sex sexual behavior is the central value of all existence, and transcending everything else - nothing else may be allowed to interfere with it. According to its theoreticians if homosexual promiscuity has produced AIDS (as it has in the West) that is unfortunate, but must not be allowed to interfere with the lifestyle. The condom code is a very reluctant concession to a major threat (you have to go on living to continue same-sex practices!). If someone wholeheartedly believes homosexuality is paramount, this will produce some very bizarre conclusions. For example according to Rotello, the idea of taking responsibility not to infect others with the HIV virus is a completely foreign concept to many groups trying to counter AIDS, and is avoided in most official condom promotion (France in the ‘80s was an interesting exception). Although the risks of HIV transference are practically universally known, many gay people wave them aside. Bluntly, core gay behavior is often suicidal.
In spite of its difficult problems, life is complex, amazing, stimulating and worthwhile. I regard it as mentally disturbed behaviour to risk life for the core ideal of homosexuality. There is quite a good case that some male homosexuality falls in this category since at least 20% of male homosexuals still regularly risk their lives with unsafe sex, one of the most extreme risks practiced by any significant fraction of society. I have so far not found any similar-sized group prepared to risk such a high rate of death. In its most extreme form then, I think homosexuality is a mental illness in its own right, but few therapists will see clients in that category because such clients will have already taken their first steps away by concluding that the lifestyle is not their fundamental ideal. However therapists should check for some of the other mental problems which are associated with the lifestyle, and refer clients as necessary.
In conclusion, if we ask the question “Are homosexuals mentally ill?” the answer at this point would have to be, “You will need to check case by case, and see”.
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