PSYCHOTHERAPY, COUNSELLING, AND RECOVERY PROGRAMS

The declassification of homosexuality as a mental disorder by the American Psychiatric Association in 1973 marked a watershed moment in the attitude of mental health professionals toward same-sex sexual orientation. In the official eyes of one of the most influential mental health organizations in the world, sexual orientation to the same sex was no longer viewed as an "arrest of psychosexual development" to be cured with psychotherapy or analysis. Noting that a large body of empirical data gathered since the 1950s supported the conclusion that homosexuality is a normal variation of human experience and has no implication per se of pathology, the association gave its blessing for practitioners of psychotherapy to provide support for their LGB clients and to facilitate their positive adjustment to a stigmatized identity.

Since 1973, the American Psychiatric Association's position on same-sex orientation has been endorsed and expanded upon by many other mental health professional organizations. So prevalent in the early twenty-first century is the nonpathological view of homosexuality that in 1998 the American Psychoanalytic Association, traditionally considered one of the most conservative professional groups in its attitudes toward same-sex orientation, endorsed same-sex marriage. And professional publications, such as the Journal of Gay and Lesbian Psychotherapy (begun in 1989), regularly offer "gay-positive" articles on research, theory, and clinical practice.

Controversy and Lingering Bias

In 1973, however, the controversy was not over. A referendum showed that 37 percent of psychiatrists opposed their association's decision. In response to their disapproval, a compromise diagnosis was entered into the third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (1980). "Ego-dystonic homosexuality" referred to those gay and lesbian patients who experienced dissatisfaction over their orientation and desired to become heterosexual. However, noting in 1987 that a period of distress and dissatisfaction with one's sexual orientation is a normal phase of identity development among gays and lesbians in the United States, the association deleted "ego-dystonic homosexuality" from its diagnostic manual.

Despite the spread of more positive attitudes, the wariness of LGB people toward mental health professions has persisted and was dramatically borne out by a 1991 study conducted by the American Psychological Association. It found that 58 percent of the 2,544 members of the association who responded to the survey reported personal knowledge of biased practice toward LGB clients. The examples cited of biased practice ranged in character from ignorance to overt repulsion and hostility. In response to this apparently high incidence of inadequate care, the American Psychological Association in 2000 approved its "Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients." The guidelines establish a minimum standard of care by which psychologists are urged to examine their own as well as society's prejudicial beliefs and to be aware of how such beliefs can affect the client and the therapeutic process. They are also called upon to recognize and respect the relationships and families of LGB people, to consider the special problems of diverse populations (including bisexuals) within the community, and to engage in ongoing education about LGB issues.

Although most biased and nonaffirmative treatment of LGB clients has undoubtedly been the consequence of ignorance, some mental health professionals deliberately reject an affirmative stance to their same-sex oriented clients and practice "reparative," "conversion," or "reorientation" therapies. The historical antecedents for these approaches are in psychoanalytic theory, which regarded the mature stage of psychosexual development to be heterosexuality. Due in part to the ambiguity of Sigmund Freud's writings, both proponents and opponents of conversion treatments cite Freud's writings as support for their stance on the relative health, or lack thereof, of a positive homosexual identity and life. Later psychoanalytic theorists reconstructed Freud's original thinking to portray homosexuality as due to an intrapsychic conflict, which then met the psychoanalytic definition of an illness. The descendants of these thinkers, many of whom are affiliated with the National Association for Research and Therapy of Homosexuality (founded in 1992), continue to practice conversion therapy. There is no empirical evidence that such treatments are effective. Indeed, they may be quite damaging. Both the American Psychological Association (in 1997) and the American Psychiatric Association (in 2000) have cautioned their members against practicing conversion therapy on both ethical and scientific grounds. Most other prominent medical and mental health associations have adopted similar policies.

Self-Help, Peer Support, and LGB-Affirmative Therapy

Concurrent with the debate within the mental health professions in the 1970s and 1980s, many LGB clients, recognizing that a large number of clinicians continued to consider their orientation a sickness, eschewed traditional psychotherapy for more trusted peer counselling or peer-led support groups. This tradition of reliance on peer counselling and self-help continues in the LGB community. A quick perusal through travel guides (such as Damron's) published for LGB people reveals the existence of community centers in most major cities in the United States, many of which offer gay-affirmative support groups, psychotherapy, and counselling. These community centers also often host meeting sites for Alcoholics Anonymous and other twelve-step programs that address various addiction issues for clients who have felt unwelcome, uncomfortable, or unsafe in groups such as these that are populated by heterosexuals. In fact, the recovery movement in the LGB community has been motivated by the unmet needs of those clients in general substance recovery programs. Substance use issues seem to be of paramount concern, whether due to the stigmatized social oppression this population faces or to the fact that one of the primary social outlets for connection to this community has been in bars and other settings in which substance use is intricately woven. Recovery programs that affirm the experience of LGB people have been a welcome addition to treatment options available.

Partly as a response to LGB distrust of the mental health professions, a post–Stonewall Riots generation of psychotherapists, many of whom identified as LGB themselves, became in the 1970s and 1980s proponents of gayaffirmative therapy. This approach, with roots in its precursor, feminist therapy, affirms same-sex orientations as equal to heterosexuality and views psychological adjustment difficulties in same-sex oriented clients as due primarily to social bias. Gay-affirmative therapists support their LGB clients in the development of positive identities and coping strategies for the oppression they encounter.

Bisexuality and Transgenderism

While their gay and lesbian compatriots made advances, bisexuals faced additional difficulties with the psychotherapy community. Often even gay-affirmative therapists have failed to view bisexuals as possessing a legitimate identity. Rather, they have assumed that bisexuals uals are actually exclusively same-sex oriented persons who have failed to form their gay or lesbian identities fully or that they are attempting to retain the privileges of heterosexuality by claiming partial orientation to the other sex. However, the idea that bisexuality is often a lifelong identity and no more a social or psychological construct than other sexual orientation identities appears to be taking hold among practitioners of psychotherapy.

The relationship between transgender persons' experiences and the mental health profession has also slowly evolved in a fashion similar to that followed by the history of LGB people, at least with regard to the slow process leading toward supportive therapies. It has, however, been delayed as scientists have been slower to understand the transgender phenomenon and to remove the stigma of pathology associated with it. Until the distinctions between gender identity, sexual identity, and sexual orientation became more widely understood, transgender persons were often (and still are) assumed to be homosexuals or simply cross-dressers. This misunderstanding has often resulted in rejection and oppression from LGB people as well as the larger culture.

From the late 1960s through the 1980s, the principal focus of treatment for persons who identified as transgender was the facilitation of the transition to a new sex, a process culminating in sexual reassignment surgery. Since the 1990s, however, there has been a movement away from sexual reassignment surgery as the only option for transgender persons. Many transgender advocates note that while a desire to alter one's sex may be a core characteristic of gender dysphoria for some, a perhaps more problematic experience is facing the intense and sometimes brutal oppression of a culture that remains inflexible in its tolerance of diverse gender presentations. For this reason, some mental health professionals are encouraging their transgender clients to express their gender orientations through behaviors that do not involve reassignment surgery, behaviors ranging from unobtrusive cross-dressing (such as wearing other-sex undergarments) to cosmetic surgeries and procedures. They are also helped to accept their same-sex sexual fantasies and to develop relational and vocational coping strategies to mitigate the complications resulting from the oppression associated with their identities.

As the understanding of transgenderism, its oppression, and its variety of expressions widens, the inclusion of "gender identity disorder" in the 1980 edition of the Diagnostic and Statistical Manual has become increasingly controversial. While some fear the removal of this diagnostic category would severely restrict access to sexual reassignment surgery for those who desire it, others argue that it pathologizes a phenomenon that, like homosexuality and bisexuality, does not per se impair psychological adjustment. Further, since studies show that a large percentage of children who identify as same-sex oriented as adults exhibit cross-gender behaviors, the diagnosis pathologizes their gender expression as well, to say nothing of heterosexual children and adults who do not conform completely to cultural gender norms.

Transgender persons continue to experience misunderstanding and nonacceptance both within and without the mental health professions. However, with the inclusion of transgender issues in the focus of activist and support organizations formerly devoted only to LGB concerns, some headway appears to be occurring.

Bibliography

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Committee on Lesbian, Gay, and Bisexual Concerns Joint Task Force on Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients. "Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients." American Psychologist 55 (2000): 1440–1451.

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Raj, Rupert. "Towards a Transpositive Therapeutic Model: Developing Clinical Sensitivity and Cultural Competence in the Effective Support of Transsexual and Transgendered Clients." International Journal of Transgenderism 6 (2002).

Shidlo, Ariel, Michael Schroeder, and Jack Drescher, eds. Sexual Conversion Therapy: Ethical, Clinical, and Research Perspectives. New York: Haworth Medical Press, 2001.

Wilson, Katherine K. "GIDreform.org: Challenging Psychiatric Stereotypes of Gender Diversity." Gender Identity Center of Colorado Inc., 2002. Available from http://www.transgender.org

James H. Hodnett,

Karen M. Taylor

see alsoalcohol and drugs; intersexuals and intersexed people; medicine, medicalization, and the medical model; psychology, psychiatry, psychoanalysis, and sexology.