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The Royal College of Psychiatrists Improving the lives of people with mental illness

Psychiatry and LGB People

Psychiatry And LGB People



Psychiatry And LGB People


The history of psychiatry with LGB people


Opposition to homosexuality in Europe reached a crescendo in the Nineteenth Century. What had earlier been regarded as a vice, evolved into a perversion or psychological illness.  Official sanction of homosexuality both as illness and (for men) a crime led to discrimination, inhumane treatments and shame, guilt and fear for gay men and lesbians (King and Bartlett, 1999).  In 1973 the American Psychiatric Association removed homosexuality from its diagnostic glossary of mental disorders. The International Classification of Diseases of the World Health Organisation followed suit in 1992. 


This unfortunate history demonstrates how marginalisation of a group of people who have a particular personality feature (in this case homosexuality) can lead to harmful medical practice and a basis for discrimination in society. 


Despite almost a century of psychoanalytic and psychological speculation, there is no substantive evidence to support the suggestion that the nature of parenting or early childhood experiences have any role in the formation of a person’s fundamental heterosexual or homosexual orientation (Bell and Weinberg, 1978). 


It would appear that sexual orientation is biological in nature, determined by genetic factors (Mustanski et al, 2005) and/or the early uterine environment (Blanchard et al. 2006). Sexual orientation is therefore not a choice, though sexual behaviour clearly is. 


Thus LGB people have exactly the same rights and responsibilities concerning the expression of their sexuality as heterosexual people. However, until the beginning of more liberal social attitudes to homosexuality in the past two decades, prejudice and discrimination against homosexuality induced considerable embarrassment and shame in many LGB people and did little to encourage them to lead sex lives that are respectful of themselves and others. We return to the stability of LGB partnerships below.

Psychiatry And LGB PeopleThe origins of homosexuality


Psychiatry And LGB People


Psychological and social wellbeing of LGB people


There is now a large body of research evidence that indicates that being gay, lesbian or bisexual is compatible with normal mental health and social adjustment. However, the experiences of discrimination in society and possible rejection by friends, families and others, such as employers, means that some LGB people experience a greater than expected prevalence of mental health and substance misuse problems (King et al, 2003; Gilman et al, 2001). 


Although there have been claims by conservative political groups in the USA that this higher prevalence of mental health difficulties is confirmation that homosexuality is itself a mental disorder, there is no evidence whatever to substantiate such a claim (Bailey, 1999). 



There appears to be considerable variability in the quality and durability of same-sex, cohabiting relationships (Mays and Cochran, 2001; McWhirter and Mattison, 1996). 


A considerable amount of the instability in gay and lesbian partnerships arises from lack of support within society, the church or the family for such relationships. Since the introduction of the first civil partnership law in 1989 in Denmark, legal recognition of same-sex relationships has been debated around the world. Civil partnership agreements were conceived out of a concern that same-sex couples have no protection in law in circumstances of death or break-up of the relationship. There is already good evidence that marriage confers health benefits on heterosexual men and women (Kiecolt-Glaser and Newton, 2001; Johnson et al, 2000) and similar benefits could accrue from same-sex civil unions. 


Legal and social recognition of same-sex relationships is likely to reduce discrimination, increase the stability of same sex relationships and lead to better physical and mental health for gay and lesbian people. It is difficult to understand opposition to civil partnerships for a group of socially marginalised people who cannot marry and who as a consequence experience more unstable partnerships. It cannot offer a threat to the stability of heterosexual marriage. Legal recognition of civil partnerships seems likely to stabilise same-sex relationships, create a focus for celebration with families and friends and provide vital protection at time of dissolution (King and Bartlett, 2006). 


Gay men and lesbians’ vulnerability to mental disorders may diminish in societies that recognise their relationships as valuable and become more accepting of them as respected members of society who might meet prospective partners at places of work and in other such settings that are taken for granted by heterosexual people.



Psychiatry And LGB People

Stability of gay and lesbian relationships



Psychiatry And LGB People

Psychotherapy and reparative therapy for LGB people

The British Association for Counselling and Psychotherapy has recently completed a systematic review of the world’s literature on LGB people’s experiences with psychotherapy (King et al., 2007). This evidence shows that although LGB people are open to seeking help with mental health problems they may be misunderstood by therapists who regard their homosexuality as the root cause of any presenting problem such as depression or anxiety. 


Unfortunately, therapists who behave in this way cause considerable distress. A small minority of therapists will even go so far as to attempt to change their client’s sexual orientation (Bartlett et al, 2001). This can be deeply damaging.  Although there is now a number of therapists and organisation in the USA and in the UK that claim that therapy can help homosexuals to become heterosexual, there is no evidence that such change is possible. 


The best evidence for efficacy of any treatment comes from randomised clinical trials and no such trial has been carried out in this field. There are however at least two studies that have followed up LGB people who have undergone therapy with the aim of becoming heterosexual. Neither attempted to assess the patients before receiving therapy and both relied on the subjective accounts of people, who were asked to volunteer by the therapy organisations themselves (Spitzer, 2003) or who were recruited via the Internet (Shidlow and Schroeder, 2002). 


The first study claimed that change was possible for a small minority (13%) of LGB people, most of who could be regarded as bisexual at the outset of therapy (Spitzer, 2003). The second showed little effect as well as considerable harm (Shidlow and Schroeder, 2002).  Meanwhile, we know from historical evidence that treatments to change sexual orientation that were common in the 1960s and 1970s were very damaging to those patients who underwent them and affected no change in their sexual orientation (King, M. and Bartlett, A., 1999).


In conclusion the evidence would suggest that there is no scientific or rational reason for treating LGB people any differently to their heterosexual counterparts. Socially inclusive, non-judgemental attitudes to LGB people who attend places of worship or who are religious leaders themselves will have positive consequences for LGB people as well as for the wider society in which they live. 

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