Medicine, Medicalization, and the Medical Model
MEDICINE, MEDICALIZATION, AND THE MEDICAL MODEL
One of the most dramatic revolutions in lesbian and gay history, and perhaps the greatest victory of the gay rights movement, is the transformation in medical attitudes toward homosexuality. Many historians, such as Michel Foucault, argue that nineteenth-century physicians constructed the modern concept of homosexuality. "Sodomy" and "pederasty" had long been studied by legal, religious, and medical forensics experts as criminal or immoral acts. However, it was only in Victorian medical literature that the "sexual invert" or "homosexual" emerged as a distinct category of human being with characteristic anatomical, physiological, and neuropsychiatric pathology. In light of many earlier documents attesting to same-sex relationships and identities before and during this period, historians have debated the relative importance of nineteenth-century doctors in constructing homosexual identity. Nevertheless, it does seem clear that the medicalization of homosexuality brought the issue to broad public attention and continues to be a rallying point for homosexual activists.
Contrary Sexual Sensation
Victorian doctors certainly believed that they had discovered a new phenomenon that perplexed, if not terrified, them. The emerging leaders in psychiatry and sexology believed same-sex attraction had to be a profound mental aberration with a biological causation. Initially, German neuropsychiatrists dominated the study of homosexuality. In 1869, Dr. Karl Westphal first described a female patient with "contrary sexual feeling" (conträre Sexual-empfindung), which consisted of masculine behavior and dress during childhood, and sexual attraction toward women as an adult. Westphal's interest had been sparked in part by a Hanoverian jurist, Karl Heinrich Ulrichs. In a series of pamphlets published from 1864 to 1879, Ulrichs argued that Uranism (as he called it) was congenital, natural, and, therefore, undeserving of legal persecution. Like many of the liberal physicians who studied homosexuality, Ulrichs trusted that science could dispel legal, religious, and cultural prejudice.
Ulrichs was aware of recent discoveries that all mammalian embryos at an early point in development are "bi-sexual." In other words, they possess both male and female primordial genital tissue before differentiating in either a female or male direction. This original hermaphroditic state suggested that some degree of male and female elements might persist in adults. Ulrichs described himself and others of his kind as possessing "a female soul in a male body." It was the persistent female psychic element of "Urnings" that stimulated their attraction to men. This "psychosexual hermaphroditism" model of homosexuality remained current into the twentieth century. It still underlies neurobiological and endocrinological hypotheses that gay men's brains or the hormonal balance of gay men is more feminine than that of heterosexual men.
The psychosexual inversion model was criticized by European doctors such as Richard von Krafft-Ebing. In Psychopathia Sexualis (1886), his ever-expanding encyclopedia of sexual perversities, Krafft-Ebing emphasized that most inverts did not display cross-gendered anatomy. Nevertheless, he believed that homosexuality was an innate neuropsychiatric disorder resulting from hereditary degeneration. Many of the homosexuals who corresponded with him were educated, masculine men, and his stance on their degenerate nature softened in his later years. He even testified on behalf of homosexual men and opposed German anti-sodomy laws.
Magnus Hirschfeld, who lived in Germany, was the first openly homosexual physician to promote biological studies of homosexuality. He conceptualized it as an intermediate state between complete maleness and complete femaleness and attributed it to the balance of sex hormones. Until the Nazis closed his Institute for Sexual Science in 1933, Hirschfeld lobbied tirelessly on behalf of homosexual rights. Hirschfeld usually encouraged his patients to accept their sexual variation, yet on several occasions he did refer distressed homosexual patients to Dr. Eugen Steinach for experimental castration and transplantation with heterosexual testes. In most of the published medical cases, distraught homosexuals voluntarily subjected themselves to painful and dangerous medical procedures hoping to conform to familial and social norms.
Pathologization Versus Biologization
Many of the doctors who engaged in biological research of homosexuality hoped this work would provide a means of detecting and potentially treating what they regarded as inversion. Following humoral conceptions of illness, some nineteenth-century physicians recommended dietary therapies and exercise just as they did for the treatment of masturbation. Steinach's endocrinological approach gained credibility after the discovery of the sex hormones in the 1920s. Claims that male homosexuals had low levels of male hormones, however, proved false. This did not stop some clinicians from using androgen shots—which tended to increase homosexual behavior, not transform it into heterosexual behavior.
The biologization of homosexuality, however, did not necessarily imply its pathologization. From the mid-nineteenth century until today, homosexual researchers and heterosexual scientists sympathetic to the social plight of gays have tried to prove that homosexuality is "natural," biological, and unalterable, hoping that this might result in homosexuality's wider acceptance. Like Ulrichs or Hirschfeld, these gay-friendly scientists have insisted that homosexuality is not a pathology but a natural biological variant. Particularly from the Roaring Twenties until World War II, there were numerous positive depictions of homosexuality in the medical literature (see sidebar).
Freudian Views of Inversion
Sigmund Freud's groundbreaking Three Essays on the Theory of Sexuality (1905) introduced the fundamental psychoanalytic notions of infantile sexuality: the oral, anal, and phallic stages of psychosexual development; the castration complex; and penis envy. Despite his lack of clinical experience with homosexuals until then, Freud made sexual inversion the subject of the first essay as well as the final section, entitled the "Prevention of Inversion." Freud disagreed with Krafft-Ebing's neurodegenerative model of the sexual perversions. Instead, Freud argued that "sexual aberrations" were universal, primitive, infantile capacities. The newborn could potentially find any part of the body erotogenic; furthermore, all children went through a phase of "latent homosexuality" until conventional heterosexual object choice developed at puberty. Although Freud was surprisingly radical in suggesting the universality of homosexuality, he was nonetheless a man of his time, since he believed that heterosexual, reproductive sexuality was the only normal, healthy developmental outcome. For Freud, homosexuality was a form of arrested, infantile sexual development resulting from pathological parent-child dynamics. However, Freud did not believe that homosexuals were necessarily unhappy or dysfunctional people, nor did they need to be "cured." Indeed, he was not optimistic about the psychoanalytic treatment of homosexuality per se.
Dr. Abraham Brill, one of Freud's early American promoters, was even more adamant about this. He noted that "Homosexuality is a very wide-spread manifestation…. [I]t affects persons from every stratum of societyand every walk of life….Homosexuality is not a sign ofinsanity or of any mental deficiency" (p. 249). He claimed to have been consulted by over five hundred homosexuals, few of whom sought treatment "with the idea of becoming sexually normal" (p. 250). Those who did were either neurotics with deep conflicts about their sexuality or were forced into treatment by their families. Brill argued that psychoanalysis of homosexuals who were coerced into therapy and did not want to be cured was a waste of time and money. It was more useful to encourage the family to be broad-minded: "[Homosexuals] should be allowed to follow their own existence, and very often you will find that some of them will turn out to be persons of the highest types, who will contribute much to the understanding and welfare of mankind" (p. 252).
Screening Out Homosexuals
In print, American analysts did not criticize Freud's liberal stance on homosexuality. Privately, however, many harbored a moralistic disdain for homosexuality and American analytical institutes refused to admit openly homosexual candidates into training. Upon Freud's death in 1939 and with the U.S. entry into World War II, the psychoanalytic literature on homosexuality took a vocal turn toward pathologization—if not demonization. In 1940, psychoanalyst Sandor Rado challenged Freudian orthodoxy by denying the universality of infantile bisexuality and insisting that homosexuality was distinctly pathological and potentially curable. Typically, analysts found a pathological family dynamic behind homosexuality: a "close binding," overprotective mother and a detached, hostile father. Some psychoanalysts even advocated the use of hormone and shock therapies to break down the resistance of recalcitrant homosexual patients.
Psychoanalysts also gained enormous professional clout thanks to their involvement in the war effort. The Selective Service wanted to screen out homosexual inductees who might falter under pressure and later be a burden on the veteran health system available to veterans of the U.S. armed forces. "Homosexual proclivities" was one category of the mental handicaps to be referred for expert scrutiny and exclusion. Psychiatrists also assessed for "reclaimability" (i.e., the capacity to return to service) the thousands of servicemen diagnosed with "pathological sexuality" (most of whom were accused of homosexuality).
Homosexual Panic and Schizophrenia
The stresses of war and crowded all-male living conditions seem to have prompted numerous cases of panic or psychotic reactions associated with homosexual anxiety. Dr. Edward Kempf first called this "homosexual panic" and subsequent psychiatrists sometimes referred to it as "Kempf's disease." In Kempf's textbook on Psychopathology (1921), he described typical cases in which a young soldier became convinced that friends or comrades believed he was homosexual, stared at him oddly, whispered insults like "cock sucker," "woman," "fairy," and tried to engage him in fellatio or sodomy. Kempf explained that homosexual panic resulted from repressed "perverse sexual cravings" (p. 477). In the most severe cases, it became chronic and was indistinguishable from dementia or schizophrenia.
Freud (1911) had proposed earlier that paranoia was frequently the result of repressed homosexuality being transformed through the defense mechanisms of reaction formation ("I hate him") plus projection ("he hates me"). Analysts suspected that homosexuality was at the root of all cases of schizophrenia. One analyst even called schizophrenia the "twin brother" of homosexuality. Homosexuality increasingly became the culprit for much other psychopathology, such as neurotic disorders, alcoholism, even promiscuous heterosexuality. Thus, homosexuality was a central problem for psychoanalysis as well as a common reason for lengthy treatment.
Sexual Inversion and Transsexualism
The psychosexual hermaphroditism or inversion model focused on same-sex loving men with supposedly feminine temperaments, behavior, and bodily traits. Conversely, lesbians were characterized as mannish in personality, dress, and anatomy. Some inverts, such as Ulrichs, endorsed these stereotypes because they genuinely seemed accurate. However, some homosexuals and experienced doctors noted that many "inverts" were completely unremarkable in their gender presentation. Early-twentieth-century doctors began to separate the different components of sexuality and gendered behavior and identity. Freud in 1905 made the distinction between "sexual object" and "sexual aim": the object being the type of person or fetish one found erotic, the aim being the type of acts that were erotic.
In The Transvestites (1910), Hirschfeld coined the term "transvestitism" to describe the erotic impulse to cross-dress. However, sexologist Havelock Ellis noted that for some people cross-dressing was not titillating, but the natural expression of their sexual identity. Indeed, many of Hirschfeld's cases would be characterized today as "transsexual. "Hirschfeld was the first to use this term, but he did so in connection with "intersexual" or hermaphroditic constitution. He was also the first physician to refer patients for partial sex reassignment surgery, beginning in 1912. The first complete male-to-female "genital transformation" surgeries were performed in Berlin in 1931 on two patients classified as "homosexual transvestites."
The matters of sexual object, sexual aim, dress, and gender identity continued to be jumbled together until the 1950s. For example, George Jorgensen made world headlines in 1952 when she returned from Denmark as Christine, yet her doctors had diagnosed her with "genuine transvestitism." It was only in the 1960s that specialists, such as endocrinologist Harry Benjamin, began to distinguish transsexualism from homosexuality or transvestitism. Sex reassignment surgery and hormones became legitimized as a treatment for transsexualism after the Johns Hopkins Hospital began to offer them in 1966. The diagnoses of "transsexualism" and "gender identity disorder of childhood" were first included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM)—the official classification manual published by the American Psychiatric Association (APA)—in 1980. It remains a contested diagnosis, like that of homosexuality, which was listed in the DMS-I (1952) as a type of sociopathic personality disturbance.
Challenges to the Medical Model
The pathologization of homosexuality was undermined with the publication of Sexual Behavior in the Human Male (1948) by Alfred C. Kinsey, Wardell Pomeroy, and Clyde Martin. Popularly known as the "Kinsey Report," this survey of over five thousand men revealed astoundingly high rates of homosexual behavior (as well as masturbation and other extramarital sex) among white American men. Kinsey found that 37 percent of his subjects had engaged in at least one homosexual act to the point of orgasm at some time between adolescence and old age (p. 650). This statistic spurred activist Harry Hay to organize the hidden gay population, forming the first "homophile" group—the Mattachine Society in Los Angeles.
Many psychiatrists and sexologists objected to Kinsey's findings and were offended by his stinging critiques of both hormonal and psychoanalytic theories of homosexuality. Most notably, Kinsey argued that sexual orientation was not binary (either hetero-or homosexual) or fixed over one's lifespan. He introduced a 0 to 6 scale to classify behavior on a continuum from exclusively heterosexual (0) to exclusively homosexual (6). He found that 10 percent of men are "more or less exclusively homosexual (i.e., rate 5 or 6) for at least three years between the ages of 16 and 55" (p. 651). This became the oft-quoted "10 percent" figure of gays in the population. If indeed homosexuality was so prevalent, it was either the most common psychiatric disorder or not a disorder at all.
Further challenges to the pathological view of homosexuality came from psychologist Evelyn Hooker at the University of California, Los Angeles. One of her homosexual students introduced her to the gay community of Los Angeles and urged her to examine non-clinical subjects. Previous research had been skewed by its reliance on prison cases or homosexuals seeking psychiatric treatment. In the 1940s, Hooker began conducting psychological testing of non-patient homosexuals and found that they did not significantly differ in their psychological adjustment from heterosexual controls matched for age and educational level. She started to publish her findings in the late 1950s and was a welcome speaker at homophile meetings. Hooker chaired a National Institute of Mental Health research panel on homosexuality that ultimately criticized the widespread mistreatment of homosexuals. Rather than recommending conversion, the panel suggested that the best way of improving homosexuals' mental health was by decriminalizing homosexuality and promoting social acceptance.
Analysts Defend Their Practice
Psychoanalysts reacted with skepticism, if not outright fury, to research suggesting that homosexuality was not a severe disorder. Edmund Bergler, a Viennese analyst who emigrated to New York in 1937, was the most strident critic of Kinsey. Bergler insisted that homosexuality was intrinsically a severe neurotic disease; therefore, if Kinsey's percentages were to be believed, homosexuality would be the most common psychopathology in the U.S. He feared that any public acceptance of homosexuality would only promote it. Writing in the midst of the Cold War, Bergler warned that Kinsey's work would be exploited to stigmatize the image of the U.S. Bergler was a tireless self-promoter whose publications and media statements reiterated his conviction that homosexuals were "psychic masochists" with an aggressive oral compulsion that fueled promiscuous, self-destructive sex. Analysts found a scientific validation of sorts in a large survey by Irving Bieber titled Homosexuality: A Psychoanalytic Study, and published in 1962. Members of the Society of Medical Psychoanalysts answered a long questionnaire about their homosexual patients; these were compared to results on heterosexual patients. Bieber made no attempt to study non-patient homosexual men. He interpreted the findings as reinforcing analytic dogma that homosexuality was an irrational defensive reaction to a pathological, emasculating childhood. Bieber was nevertheless optimistic that younger homosexuals who persevered in analysis (beyond 350 hours) could achieve a "heterosexual adaptation."
A variety of behaviorist conversion therapies were being actively promoted in the 1950s and 1960s. Electrical shock aversion therapy (first used to treat alcoholism in the 1920s), chemical aversion therapy with emetics (developed in the 1950s), covert sensitization, and other conditioning techniques all tried to reorient erotic attraction by associating homoerotic images with discomfort. Like other forms of "treatment" for homosexuality, they generally failed in the long run and provoked visceral opposition by homophile activists in the 1950s and 1960s, proponents of gay liberation, lesbian feminists, and gay rights activists who had become more vocal after the Stonewall riots of 1969. At the 1970 annual meeting of the APA, Dr. Nathaniel McConaghy's presentation on aversive conditioning exploded in gay pandemonium as gay activists accused him of being a vicious torturer.
The work of Kinsey, Hooker, and others all emboldened a new generation of post-Stonewall gay liberation activists ready to engage in dramatic and confrontational tactics, including disrupting APA meetings and demanding equal time to refute the theories of pathologizers. With the assistance of key supporters within the APA, a panel of non-patient gays spoke at the 1971 APA meeting. At the association's 1972 meeting, a gay psychiatrist appeared in disguise to discuss the prejudice he faced within the profession. That year the APA's Nomenclature Committee began considering the pathological status of homosexuality as presented in the second edition of the DSM in 1968. There was extensive debate on the subject at the 1973 meeting, and more psychiatrists supported reform. After much behind-the-scenes lobbying both for and against depathologization, the APA Board of Trustees voted on 15 December 1973 to delete homosexuality from the DSM. Sensitive to many psychoanalysts' deep theoretical and emotional commitment to the pathological status of homosexuality, the Board added the diagnosis of "sexual orientation disturbance" (later named "ego-dystonic homosexuality") for individuals who are distressed by their homosexuality. Newspapers around the world reported on the decision, with one journalist wryly noting that it was the single greatest cure in the history of psychiatry.
Many prominent psychoanalysts, such as Charles Socarides and Irving Bieber, were outraged and mounted a vocal battle against the change, ultimately forcing it to a vote among the APA membership. In 1974, a majority of APA members ratified the declassification of homosexuality as a mental illness. The American Psychological Association followed suit in 1975 and the National Association of Social Workers in 1977. Gay and lesbian caucuses were formally recognized within all these organizations. The American Psychoanalytic Association proved most resistant to such changes, and only in 1992 did this organization officially reversed its long-standing policy of excluding homosexuals from advancement in psychoanalytic institutes. However, in 2002 it defended gay/lesbian parenting rights before the APA took an identical stance.
The emergence in 1981 of a new and mysterious immunodeficiency syndrome among gay men reassociated homosexuality and disease in the public discourse. Acquired Immunodeficiency Syndrome (AIDS) would soon become a global epidemic. Because it particularly devastated a generation of gay men, AIDS impelled gay activists to create community-based systems of care and to lobby for greater government attention to gay health. While numerous lesbian and gay doctors and researchers have focused their attention onto AIDS, many others have explored related issues affecting the community, such as the coming-out process, queer adolescents, alcoholism and substance abuse, gay parenting, and lesbian health.
In the 1990s there was a resurgence of scientific research on the causes of homosexuality—although now conducted by openly gay scientists. In a study of twins, Richard Pillard and J. Michael Bailey claimed to have found evidence of a hereditary factor in homosexuality. Dean Hammer sought evidence of the maternal transmission of homosexuality and presented data suggesting an association between homosexuality and the X chromosome in men. Relying on a small sample, Simon LeVay found suggestive evidence of neuroanatomical differences between homosexual and heterosexual men's hypothalami. Although these studies still await further confirmation (and they have been criticized in many quarters), they received great amounts of media attention and were prematurely accepted as conclusive by some. Research into the biology of transsexualism has been quite limited, but small studies from the Netherlands suggest characteristic neuroanatomical differences between transsexuals and non-transsexuals.
While many transsexuals, like many lesbians and gay men, favor biological models of gender and sexuality, some transsexual activists in the 1990s argued that the medical model was rigid and prescriptive in its insistence on full hormonal and surgical sex transition as a means of "curing" transsexuals. Many activists preferred the term "transgender" to designate a broad range of nonconformist gender identities and roles where sex reassignment surgery may or may not be desired. Transgendered professionals have become increasingly active in health care associations. Thanks to their input the Harry Benjamin International Gender Dysphoria Association's
"Standards of Care for Gender Identity Disorders" have evolved significantly since their first version of 1979. The suggested guidelines for treatment of transgenderism are now less pathologizing, more focused on overall psychological self-fulfillment, and they have reduced the time delays and evaluation costs of obtaining sex reassignment hormones and surgery. The inclusion of Gender Identity Disorder in the DSM has also been contested. Many activists argue that this pathologizes transgenderism, whereas others see the diagnosis as a pragmatic necessity for justifying insurance coverage for sex reassignment hormones and surgery.
In the span of a century, the diagnosis of homosexuality has come full circle: from being "discovered" as a profound psychiatric illness to being declared nothing of the sort. Furthermore, people with a diversity of sexualities (such as bisexuals, transgenders, queers, and intersexuals) have gained a political voice and public attention in the process. While mainstream healthcare associations have condemned homophobia, antigay attitudes still persist in society and some clinicians continue to promote "reparative" therapy of homosexuality. As long as cultural bias persists, scientific research on homosexuality and transgenderism will undoubtedly continue to be an object of scientific and social controversy.
Abelove, Henry. "Freud, Male Homosexuality, and the Americans." In The Lesbian and Gay Studies Reader. Edited by Henry Abelove et al. New York: Routledge, 1993.
Bayer, Ronald. Homosexuality and American Psychiatry: The Politics of Diagnosis. Princeton, N.J.: Princeton University Press, 1981.
Beery, Florence. "The Psyche of the Intermediate Sex." The Medico-Legal Journal 41 (1924): 4–9.
Brill, Abraham Arden. "The Psychiatric Approach to the Problem of Homosexuality." The Journal-Lancet 55 (1935): 249–252.
Foucault, Michel. The History of Sexuality. Volume I: An Introduction. Translated by Robert Hurley. New York: Vintage Books, 1990.
Freud, Sigmund. "Three Essays on the Theory of Sexuality" . In Standard Edition, Vol. 7, pp. 125–243. London: Hogarth Press, 1955.
——. "Psychoanalytic Notes upon an Autobiographical Account of a Case of Paranoia (Dementia Paranoides)" . In Standard Edition, Vol. 12, pp. 1–84. London: Hogarth Press, 1955.
Kempf, Edward John. Psychopathology. St. Louis, Mo.: C. V. Mosby, 1921.
Kinsey, Alfred C., Wardell B. Pomeroy, and Clyde E. Martin. Sexual Behavior in the Human Male. Philadelphia: W. B. Saunders, 1948.
"Letter from an Invert, A." American Journal of Urology and Sexology 15 (1919): 454–455.
LeVay, Simon. Queer Science: The Use and Abuse of Research into Homosexuality. Cambridge, Mass.: MIT Press, 1996.
Lewes, Kenneth. The Psychoanalytic Theory of Male Homosexuality. New York: Simon and Schuster, 1988.
Oosterhuis, Harry. Stepchildren of Nature: Krafft-Ebing, Psychiatry, and the Making of Sexual Identity. Chicago: University of Chicago Press, 2000.
Rosario, Vernon A. Homosexuality and Science. A Guide to the Debates. Santa Barbara, Calif.: ABC-Clio Press, 2002.
Stein, Edward. The Mismeasure of Desire: The Science, Theory, and Ethics of Sexual Orientation. New York: Oxford University Press, 1999.
Terry, Jennifer. An American Obsession: Science, Medicine, and Homosexuality in Modern Society. Chicago: University of Chicago Press, 1999.
Vernon A. Rosario
see alsoaids and people with aids; benjamin, harry; biology and zoology; crime and criminalization; disability, disabled people, and disability movements; homosexuality and heterosexuality; hooker, evelyn; immigration, asylum, and deportation law and policy; intersexuals and intersexed people; jorgensen, christine; kameny, franklin; kinsey, alfred c.; lobdell, lucy ann; national gay and lesbian task force (ngltf); psychology, psychiatry, psychoanalysis, and sexology; sexual orientation and preference; transsexuals, transvestites, transgender people, and cross-dressers.
in defense of homosexuality
William J. Robinson was Chief of the Department of Genito-Urinary Diseases and Dermatology at the Bronx Hospital in New York City. He was a friend of homosexual sexologist Magnus Hirschfeld, whose work he frequently praised. As editor of the American Journal of Urology and Sexology, Robinson often published items on homosexuality, including a touching letter from an anonymous "invert," who wrote in 1919:
[It] is my belief that two men who love each other have as much right to live together as a man and a woman have. Also that it is as beautiful when looked at in the right light and far more equal! … May I not have as high an ideal in my love towards men, as a man towards a woman? Higher no doubt, than most men have toward women! (p. 455)
Dr. Florence Beery, who relied on the biological model of congenital bisexuality, was positively enthusiastic about homosexuals. Writing in the Medico-Legal Journal of 1924, she declared:
Homo-sexuals are keen, quick, intuitive, sensitive, exceptionally tactful and have a great deal of understanding…. Contrary to the general impression, homosexuals are not necessarily morbid; they are generally fine, healthy specimens, well developed bodily, intellectual, and generally with a very high standard of conduct" (p. 5).
She ridiculed doctors' desperate search for cross-sexed anatomical traits and insisted that generally the "homogenic woman" had a thoroughly feminine body. It was the lesbian's temperament that was "active, brave, originative, decisive," Beery asserted. "Such a woman is fitted for remarkable work in professional life or as a manageress of institutions, even as a ruler of a country" (p. 7).