By Kenneth Ashley, M.D.

Until the early 1970s, professional literature on homosexuality was limited, most often assuming that homosexuality was abnormal or pathological. However, some significant exceptions in the research caused a scientific review of the literature. Consequently, in 1973 this review and broader political issues prompted the American Psychiatric Association (APA) to conclude that there was no basis for considering homosexuality to be a mental illness, so editors removed it from the list of mental disorders in the Diagnostic and Statistical Manual (DSM).1

Subsequent to this decision, there was a significant increase in objective, non-biased studies on homosexuality in numerous disciplines. Therefore, the exponential growth in literature on homosexuality began with topics such as:

• Defining sexual orientation
• Bisexuality
• Rates of homosexuality
• Etiology of sexual orientation
• Rates of psychiatric and psychological problems caused by and/or associated with sexual orientation
• Developmental issues
• Aspects of treatment
• Relationship and family issues
• General health issues

Definitions
As research on sexuality has developed, there have been changes in specifics, but three basic terms that remain are sexual orientation, gender identity and social sex/gender role. Sexual orientation refers to a person's erotic response tendency as indicated by the gender/sex choice in dreams and fantasies, perhaps not coinciding with the gender/sex chosen for sexual contact. Gender identity, which may diverge from biological gender, is the inner sense of being male or female. Social sex/gender role describes behaviors associated with either men or women.

Terms of sexual orientation are heterosexual, bisexual and homosexual. In the literature, homosexual is often used interchangeably with lesbian (women), gay man or gay (men, women or both). The latter terms are generally felt to be less clinical and less associated with pathology; they also may have a political connotation.

Prevalence
Studies have been conducted attempting to determine prevalence rates of homosexuality. Depending on demographic factors, concept of sexual orientation, construction of research methods and methodology, the results will vary. Given the degree of stigma associated with homosexuality, it is presumed that most studies have some degree of underreporting. Some general trends that have been consistent are higher rates of homosexual behavior in men and higher rates in adolescents, especially males.

Etiology
Causes of sexual orientation are not known. Active research attempts to identify a biological cause at the genetic level, of hormones on the developing fetus and the environment. Current research indicates that some combination of biology, environment and perhaps sociological factors are involved in the development of sexual orientation, but the ultimate cause or causes remain elusive.

Coming Out, Homophobia and Heterosexism
There are several concepts useful to work with lesbian, gay and bisexual individuals due to the prevalence and relevance of the ideas. "Coming out" is the process by which an individual recognizes his/her feelings of same-sex attraction and the subsequent acquisition of a lesbian, gay or bisexual identity (identity formation). The process is often complicated, involving change in both the internal and social spheres, occurring across a person's life and taking place in various aspects of one's life at varying times. As this is an individual experience, an enormous degree of variation exists.2

Weinberg originally used "Homophobia" in 1972 to describe a fear or hatred of homosexuality and homosexual persons arising from a variety of societal and intrapsychic sources.3 The term has been used to refer to a wide array of negative feelings, attitudes and behaviors directed toward homosexuality and lesbian, gay and bisexual people, as well as homosexuals' self-loathing (internalized homophobia). Although the term is often criticized as imprecise and overly general, not clinically a phobia and conveying a sense that antigay prejudice is an individual, clinical entity rather than a social phenomenon, it remains the most widely used and understood term of reference for the widespread prejudice directed against gay people in society. Some prefer, however, "anti-homosexual bias."

"Heterosexism" has been defined as the ideological system that denies, denigrates and stigmatizes any non-heterosexual form of behavior, identity, relationship or community; it is manifested at the cultural and individual levels.

Rates of Mental Disorders/Psychiatric and Psychological Problems
There has been increasing interest in attempting to determine whether there are differing rates of psychiatric and psychological problems, possibly correlated with sexual orientation. Some studies have shown differences in rates of substance use, depressive disorders and personality disorders, but methodological problems raise questions about their validity; most of the studies did not use random samples of the lesbian and gay community, nor were there appropriate control groups.4 There is evidence that the increased rates of distress found in some other studies was, in part, the result of issues related to anti-homosexual bias and the effects of heterosexism.5 In spite of the previously mentioned difficulty of determining prevalence rates of homosexuality, with similar issues making studies that will provide data for use in the general lesbian, gay and bisexual community, further research must be performed to identify populations at risk for mental health issues to assist in allocation of resources, prevention and intervention.

Critical Issues for Lesbian, Gay and Bisexual Youth
As sociocultural changes result in increasing numbers of lesbian, gay and bisexual youth disclosing their sexual orientation, there is a growing awareness of the mental health issues in this population. The forces of heterosexism and homophobia combine with other developmental issues most adolescents struggle to deal with, resulting in several critical mental health issues, including: stress associated with the management of lesbian, gay and bisexual identity. There may also be disruption in peer relationships; conflicts about disclosure; emotional reactions to close relationship development; isolation from lesbian, gay and bisexual contexts; distress caused by discrimination, harassment and violence based on sexual orientation and anxieties related to sexual health, especially HIV infection.

One of the most significant findings has been the alarmingly high incidence of suicide attempts among lesbian, gay and bisexual youth. Several studies have shown these results, but as with many other studies the causes appear multi-factorial, such issues as depression, low self-esteem, family problems, substance use and a history of sexual abuse all seem to be possible variants.6

Lesbian, gay and bisexual youths are a vulnerable population with significant mental healthcare needs. Further research is needed to assess the needs, improve the recognition of at-risk populations, improve access to care and develop appropriate prevention and interventions.

Therapeutic Issues
Given the diversity of the lesbian and gay community, making any broad statements about working with this population is difficult, but there are some common themes. It should be noted that most lesbians and gay men enter psychotherapy with the same types of problems as the general population - to deal with family issues, relationship issues, to gain better insight into behaviors and to improve functioning.

Historically, homosexuality has been viewed as pathological, a condition that needed to be treated or cured. Although the predominant contemporary thought is that it is not pathological, the psychopathologic view remains, evidenced by the practice of "reparative" or "conversion" therapy, which has the goal of changing the patient's sexual orientation to heterosexual. Earlier this year, the APA recommended that ethical practitioners refrain from attempts to change individuals' sexual orientation until substantial scientific research is available, as there was concern about the efficacy in effecting durable change in the sexual orientation and/or sexual behavior of the patient, as well as negative effects of such treatments. 7

Currently, lesbians, gay men and bisexuals in search of psychotherapy are availing themselves of "gay-sensitive therapy" - treatment provided from a perspective that understands and accepts lesbian, gay and bisexual concerns - and "gay-affirmative therapy" - treatment provided from the perspective that being lesbian, gay or bisexual should be affirmed and that openness about sexual orientation should be encouraged.

While lesbians and gay men share same-sex emotional and erotic attachments, experiences of discriminations, stigmatization, rejection of societal gender-role and object choice expectations, each group shares more behavioral and psychological characteristics with others of the same gender.

Some general issues to be aware of in therapy are effects of childhood and adolescent experiences of difference and stigma; appreciation of multiple ways that prejudice can create problems that should be addressed in therapy; acknowledgement and acceptance in therapy; internalized homophobia as assistance to overcoming negative attitudes about homosexuality; the impact of gender on socialization; interactions and understanding. There may be spontaneously appearing topics during therapy that the therapist must deal with in the treatment of lesbians, gays and bisexuals.

Conclusion
This is a brief overview on some of the mental health issues for homosexuals, a focus of increasing research for various reasons. Perhaps this research will result in a better understanding of the mental health issues among lesbians, gay men and bisexuals, with improved mental healthcare, access to care, prevention programs and interventions/treatments.

Dr. Kenneth Ashley is a Clinical Psychiatrist at NYU School of Medicine and an Attending Psychiatrist, Department of Medicine and Psychiatry Peter Krueger Clinic at Beth Israel Medical Center. Dr. Ashley is active in the American Psychiatric Association (locally) as co-chair of the Committee on Gay and Lesbian Issues and the AIDS Committee, and nationally as a member of the Committee on Gay, Lesbian and Bisexual Issues. Dr. Ashley may be contacted by calling 212/844-1864 or e-mail at: Kashley820@aol.com or Kashely@bethisraelny.org.

References APA Position Statement on Reparative Therapies, 30 October 2000, Release No, 00-49.

1. Diagnostic and Statistical Manual of Mental Disorders (DSM), 3rd edition, Washington, DC, American Psychiatric Association, Inc., (1980). DSM, 3rd edition revised, Washington, DC, American Psychiatric Association, Inc., (1987).
2. Cohen, C.J. & Stein, T.S. (eds.): Reconceptualizing Individual Psychotherapy with Gay Men and Lesbians. Contemporary Perspective on Psychotherapy with Lesbians and Gay Men. New York, Plenum Publishing, pgs. 27-54, (1986).
3. Weinberg, G. Society and the Healthy Homosexual. New York, Anchor Books, (1972).
4. Cabaj, R. & Stein, T.S. (eds.): Substance Abuse in Gay Men, Lesbians, and Bisexuals. The Textbook of Homosexuality and Mental Health. American Psychiatric Press, Inc., Washington, DC, (1996).
5. D'Augelli, A. Lesbian, Gay and Bisexual Development during Adolescence and Young Adulthood. The Textbook of Homosexuality and Mental Health, Cabaj, R. & Stein, T.S. (eds.). American Psychiatric Press, Inc., Washington, DC, (1996).
6. Falco, K. Psychotherapy with Women Who Love Women. The Textbook of Homosexuality and Mental Health, Cabaj, R. & Stein, T.S. (eds.). American Psychiatric Press, Inc., Washington, DC, (1996).
7. Cabaj, R. & Stein, T.S. Psychotherapy with Gay Men. The Textbook of Homosexuality and Mental Health. American Psychiatric Press, Inc., Washington, DC, (1996).