"Sexual orientation" is a term frequently used to describe a person's romantic, emotional or sexual attraction to another person. A person attracted to another person of the same sex is said to have a homosexual orientation and may be called gay (both men and women) or lesbian. Individuals attracted to persons of the other sex are said to have a heterosexual orientation. Sexual orientation falls along a continuum and individuals who are attracted to both men and women are said to be bisexual. Sexual orientation is different from gender identity, which refers to the internal sense of whether one is male or female. Sexual orientation is a relatively new concept. In fact, although same sex behavior has always existed, the idea of a homosexual identity or a homosexual person is only about 100 years old.
The concept of sexual orientation refers to more than sexual behavior. It includes feelings as well as identity. Some individuals may identify themselves as gay, lesbian or bisexual without engaging in any sexual activity. Some people believe that sexual orientation is innate and fixed; however, sexual orientation develops across a person's lifetime. Individuals maybe become aware at different points in their lives that they are heterosexual, gay, lesbian, or bisexual.
No. All major professional mental health organizations have gone on record to affirm that homosexuality is not a mental disorder. In 1973 the American Psychiatric Association's Board of Trustees removed homosexuality from its official diagnostic manual, The Diagnostic and Statistical Manual of Mental Disorders, Second Edition (DSM II). The action was taken following a review of the scientific literature and consultation with experts in the field. The experts found that homosexuality does not meet the criteria to be considered a mental illness.
No one knows what causes heterosexuality, homosexuality, or bisexuality. Homosexuality was once thought to be the result of troubled family dynamics or faulty psychological development. Those assumptions are now understood to have been based on misinformation and prejudice. Currently there is a renewed interest in searching for biological etiologies for homosexuality. However, to date there are no replicated scientific studies supporting any specific biological etiology for homosexuality. Similarly, no specific psychosocial or family dynamic cause for homosexuality has been identified, including histories of childhood sexual abuse. Sexual abuse does not appear to be more prevalent in children who grow up to identify as gay, lesbian, or bisexual, than in children who identify as heterosexual.
"Coming out" is the term used to describe the experience in which a person identifies himself or herself as gay, lesbian or bisexual. Coming out is not a one-time event, but a lifelong process of identifying as gay, lesbian or bisexual to family friends and other significant members of one's social world. Each person's experience in coming out is unique and the process always stimulates anxiety as well as provides challenging possibilities for personal empowerment and emotional growth. There are many resources available to people coming out. See below for some of these resources.
Yes. Fears and misunderstandings about homosexuality are wide spread. They present daunting challenges to the development and maintenance of a positive self-image in gay, lesbian and bisexual persons and often to their families as well. "Homophobia" is a term that refers to the irrational fear and prejudice against homosexual persons.
Public opinion polls in the United States show that in the past twenty years, feelings toward gay men, lesbians and bisexuals have moved in a significantly positive direction. Nevertheless, when compared to other social groups homosexuals are still among the most stigmatized groups in the nation. Hate crimes are prevalent. Gay men and lesbians are still banned from serving openly in the U.S. military service. Child custody decisions still frequently view gay and lesbian people as unfit parents. Gay and lesbian adolescents are often taunted and humiliated in their school settings. Many professional persons and employees in all occupations are still fearful of identifying as gay or lesbians in their work settings. Gay relationships are not recognized in any legal way.
In 1992, the American Psychiatric Association, recognizing the power of the stigma against homosexuality, issued the following statement:
"Whereas homosexuality per se implies no impairment in judgement, stability, reliability, or general social or vocational capabilities, the American Psychiatric Association calls on all international health organizations and individual psychiatrists in other countries, to urge the repeal in their own country of legislation that penalized homosexual acts by consenting adults in private. And further the APA calls on these organizations and individuals to do all that is possible to decrease the stigma related to homosexuality wherever and whenever it may occur."
Such organizational recognition of homophobia has been important in changing attitudes about homosexuality.
There is no published scientific evidence supporting the efficacy of "reparative therapy" as a treatment to change one's sexual orientation, nor is it included in the APA's Task Force Report, Treatments of Psychiatric Disorders. More importantly, altering sexual orientation is not an appropriate goal of psychiatric treatment. Some may seek conversion to heterosexuality because of the difficulties that they encounter as a member of a stigmatized group. Clinical experience indicates that those who have integrated their sexual orientation into a positive sense of self-function at a healthier psychological level than those who have not. "Gay affirmative psychotherapy" may be helpful in the coming out process, fostering a positive psychological development and overcoming the effects of stigmatization. A position statement adopted by the Board in December 1998 said:
The American Psychiatric Association opposes any psychiatric treatment, such as "reparative" or "conversion" therapy, which is based upon the assumption that homosexuality per se is a mental disorder, or based upon a prior assumption that the patient should change his/ her homosexual orientation." (See full position statements, below)
When a person "comes out" to their parents, it can be a very emotionally trying experience for all involved. Most parents are concerned for the welfare of their children, recognizing the difficulties posed by being a member of a stigmatized group. Often parents also fear rejection by their own family, friends, religious, or social groups. Fortunately, support exists for parents who are struggling to come to terms with their child's homosexuality. PFLAG (Parents and Friends of Lesbians and Gays) is an organization comprised of the families of gay men, lesbians, and bisexuals that provides information and assistance to parents and families. Family or individual psychotherapy can be very helpful in dealing with questions and concerns about a gay child. Other resources are listed below.
Many gay men and women are parents. For example, estimates of the numbers of lesbian mothers range from 1 to 5 million and with the number of children ranging from 6 to 14 million. Most gay parents conceived their children in prior heterosexual marriages. Recently an increasing number of gay parents have conceived children and raised them from birth either as single parents or in committed relationships. Often this is done through alternative insemination, adoption or through foster parenting. Numerous studies have shown that the children of gay parents are as likely to be healthy and well adjusted as children raised in heterosexual households. Children raised in gay or lesbian households do not show any greater incidence of homosexuality or gender identity issues than other children. Children raised in nontraditional homes with gay/lesbian parents can encounter some special challenges related to the ongoing stigma against homosexuality, but most children surmount these problems.
Position Statements on Therapies Focused on Attempts to Change Sexual Orientation ("Reparative" or "Conversion" Therapies)
The Board of Trustees of the American Psychiatric Association removed homosexuality from the DSM in 1973 after reviewing evidence that it was not a mental disorder. In 1987, ego-dystonic homosexuality was not included in the DSM-IIIR after a similar review.
The American Psychiatric Association does not currently have a formal position statement on treatments that attempt to change a person's sexual orientation, also known as areparative or conversion therapy. There is an APA 1997 Fact Sheet on Homosexual and Bisexual Issues, which states that there is no published scientific evidence supporting the efficacy of reparative therapy as a treatment to change ones sexual orientation.
The potential risks of reparative therapy are great; including depression, anxiety and self-destructive behavior, since therapist alignment with societal prejudices against homosexuality may reinforce self-hatred already experienced by the patient. Many patients who have undergone reparative therapy relate that they were inaccurately told that homosexuals are lonely, unhappy individuals who never achieve acceptance or satisfaction. The possibility that the person might achieve happiness and satisfying interpersonal relationships as a gay man or lesbian is not presented, nor are alternative approaches to dealing with the effects of societal stigmatization discussed. The American Psychiatric Association recognizes that in the course of ongoing psychiatric treatment, there may be appropriate clinical indications for attempting to change sexual behaviors.
Several major professional organizations, including the American Psychological Association, the National Association of Social Workers, and the American Academy of Pediatrics, have all made statements against reparative therapy because of concerns for the harm caused to patients. The American Psychiatric Association has already taken clear stands against discrimination on the basis of sexual orientation.
Therefore, the American Psychiatric Association opposes any psychiatric treatment, such as reparative or conversion therapy, which is based upon the assumption that homosexuality per se is a mental disorder or based upon the a priori assumption that the patient should change his or her homosexual orientation.
In the past, defining homosexuality as an illness buttressed societys moral opprobrium of same-sex relationships.2 In the current social climate, claiming homosexuality is a mental disorder stems from efforts to discredit the growing social acceptance of homosexuality as a normal variant of human sexuality. Consequently, the issue of changing sexual orientation has become highly politicized. The integration of gays and lesbians into the mainstream of American society is opposed by those who fear that such integration is morally wrong and harmful to the social fabric. The political and moral debates surrounding this issue have obscured the scientific data by calling into question the motives and even the character of individuals on both sides of the issue. This document attempts to shed some light on this heated issue.
The validity, efficacy and ethics of clinical attempts to change an individuals sexual orientation have been challenged.3-6 To date, there are no scientifically rigorous outcome studies to determine either the actual efficacy or harm of "reparative" treatments. There is sparse scientific data about selection criteria, risks versus benefits of the treatment, and long-term outcomes of "reparative" therapies. The literature consists of anecdotal reports of individuals who have claimed to change, people who claim that attempts to change were harmful to them, and others who claimed to have changed and then later recanted those claims.7-9
Although there is little scientific data about the patients who have undergone these treatments, it is still possible to evaluate the theories, which rationalize the conduct of "reparative" and conversion therapies. Firstly, they are at odds with the scientific position of the American Psychiatric Association which has maintained, since 1973, that homosexuality per se, is not a mental disorder. The theories of "reparative" therapists define homosexuality as either a developmental arrest, a severe form of psychopathology, or some combination of both.10-15 In recent years, noted practitioners of "reparative" therapy have openly integrated older psychoanalytic theories that pathologies homosexuality with traditional religious beliefs condemning homosexuality.16-18
The earliest scientific criticisms of the early theories and religious beliefs informing "reparative" or conversion therapies came primarily from sexology researchers.19-27 Later, criticisms emerged from psychoanalytic sources as well.28-39 There has also been an increasing body of religious thought arguing against traditional, biblical interpretations that condemn homosexuality and which underlie religious types of "reparative" therapy.40-46
Bias-related incidents, arising from racism, sexism, intolerance based on religion, ethnicity, and national/tribal origin, and anti-gay and -lesbian prejudice are widespread in society and continue to be a source of social disruption, individual suffering and trauma. These incidents are ubiquitous and occur in both urban and rural areas. Such hate-based incidents consist of acts of violence or harassment. These incidents result in emotional and physical trauma for individuals, as well as stigmatization of affected groups. Ethnic and cultural biases, vividly manifest in bias-related incidents, serve to frustrate the basic human need for dignity, resulting in despair and hopelessness among the victims that ultimately affect the whole nation.
The APA deplores such bias-related incidents. Moreover, the APA encourages its own members and components to take appropriate actions in helping to prevent such events, as well as to respond actively in the aftermath when such bias-related incidents occur locally.
The American Psychiatric Association supports the right to privacy in matters such as birth control, reproductive choice, and adult consensual relations conducted in private, and it supports legislative, judicial, and regulatory efforts to protect and guarantee this right. (December 1991)
The American Psychiatric Association strongly opposes all public and private discrimination against homosexuals in such areas as employment, housing, public accommodations, and licensing and immigration and naturalization decisions.
The Immigration and Naturalization Service, at least until 1990, considered homosexuality to be a mental illness and used this determination as a basis for the discriminatory exclusion of homosexual visitors and immigrants to the United States.
The American Psychiatric Association successfully opposed the continued inclusion of homosexuality as a mental illness by the Immigration and Naturalization Service. The APA believes that neither physical illness nor mental illness nor sexual orientation per se should be a basis for immigration or naturalization exclusion.
The American Psychiatric Association welcomes the changes presented in Title VI of the Immigration and Naturalization Act of 1990 and will be available to contribute to work intended to ensure that the immigration policies and practices of the United States are consistent with the relevant sections of that act. (June 1991)
APA, since 1973, has formally opposed all public and private discrimination against homosexuals in such areas as employment, housing, public accommodations and licensing. It follows that APA opposes exclusion and dismissal from the armed services on the basis of sexual orientation. Furthermore, APA asserts that no burden of proof of judgment, capacity, or reliability should be placed on homosexuals, which is greater than that imposed on any other persons within the armed services. (December 1990)
Irrational employment discrimination on the basis of gender and sexual orientation has received considerable attention in law, business, sociology, and, to a lesser degree, psychology. It is well known that sexual harassment and other forms of irrational gender-based discrimination have increased in recent years, and this trend is likely to continue because employees are increasingly aware of legal prohibitions against these and other forms of employment discrimination. While the psychiatric needs of self-identified discrimination victims have been under-recognized, both in and out of the workplace, psychiatrists can expect increasing consultations regarding these issues. It is important that psychiatrists appreciate and help others to understand the emotional consequences of irrational employment discrimination based on gender or sexual orientation. (June 1988)
National Association of Social Workers
750 First Street NE, Suite 700
Washington, DC 200002-4241
National Gay and Lesbian Task Force
2320 17th Street
Washington, DC 20009
Parents, Families and Friends of Lesbians and Gays
1101 14th Street NW, Suite 1030
Sexuality Information and Education Council of the United States
130 W 42nd Street, Suite 350
New York, NY 10036
Action Item: Position Statement
Proposed by APA Committee on Gay, Lesbian, and Bisexual Issues
Rationale for a Position Statement on Same Sex UnionsThe APA expresses a valid interest in the well being of heterosexual married couples in such areas as children's mental health and other aspects of family life. Heterosexual relationships have a legal framework for their existence, which provides a stabilizing force.
In the United States, with the recent exception of Vermont, same sex partners are currently denied the important benefits and responsibilities of legal marriage. Same sex couples therefore experience several kinds of state-sanctioned discrimination that affect the stability of their relationships.
The children of gay and lesbian parents do not have the same protection that legal marriage affords the children of heterosexual couples. Adoptive and divorced lesbian and gay parents face additional obstacles. An adoptive parent who is lesbian or gay is presumed unfit in many U.S. jurisdictions. Furthermore, when couples do adopt, usually one parent is granted legal rights, while the other parent may have no legal standing. These obstacles occur even though research has shown that the children raised by lesbian and gay men are as well adjusted as those reared within heterosexual relationships.
The American Psychiatric Association has historically supported equity, parity, and non-discrimination regarding legal issues affecting mental health. Educating the public about lesbian and gay relationships and supporting efforts to establish same sex legal unions is consistent with the Association's advocacy for other disadvantaged minority groups.
Position Statement on Same Sex UnionsIn light of the above,
"The American Psychiatric Association supports the legal recognition of same sex unions and their associated legal rights, benefits, and responsibilities".
The purpose of this document is to bring the mental health issues surrounding same sex marriage to the attention of APA members. We present the rationale for APA's support of legislation to allow same sex marriage.
We base this report on presentations and discussions that occurred during Committee-sponsored workshops at both the 1996 and 1997 APA Annual Meetings, involving approximately 150 participants in total. Issues raised by both speakers and participants include among others, the historic presence of same sex unions, similarities with miscegenation laws prohibiting marriage between members of different races, the important legal benefits denied same sex couples, and the mental health benefits of legal union.
There are legal, political, religious and social components of marriage. In this document the term "marriage" is used in the legal sense: the government-sanctioned union of two people, who then enjoy corresponding legal rights and benefits, as well as responsibilities. This report does not address marriage as a religious ceremony, nor does it discuss any organized religion's view of same sex marriage. This document contains information obtained from the Committee on Women, the Council on National Affairs, and the Council on Psychiatry and the Law.
Why should the APA address same sex marriage? One reason is that APA already expresses great interest in the well-being of heterosexual married couples, in such areas as marital and therapy family social problems, domestic violence, children's mental health, substance dependence, and other aspects of family life. These relationships have a legal framework for both their existence and dissolution, which provides, to varying degrees, a stabilizing force. The denial of same sex marriage serves to reinforce the prejudice against lesbians and gay men. Support of same sex marriage is consistent with the APA's strong record of anti-discrimination policies. Furthermore, our colleagues in the American Psychoanalytic Association's Executive Council recently approved the following resolution in favor of same-sex marriage:
Because marriage is a basic human right and an individual personal choice, Resolved, the State should not interfere with same gender couples who choose to marry and share fully in the rights, responsibilities, and commitment of civil marriage.
Currently no nation grants full legal marriage, although many countries and U.S. states specifically prohibit it. Hawaii may become the first U.S state to grant same sex marriage licenses (Baehr v. Miike) and has enacted legislation which provides limited legal rights to many types of domestic partners. In response to the possibility of same sex marriage, more than two-thirds of U.S. states have either prohibited the unions or begun legislative efforts to do so. The U.S. Congress has joined this movement as well by passing the Defense of Marriage Act in 1996.
APA District Branches are already joining the legal battle to allow same sex marriages. In March of 1998 the Vermont Psychiatric Association (VPA) became the first district branch to file an amicus curiae brief to a state supreme court to help overturn a ban on same sex marriage. The VPA argued that the existing ban was detrimental to the mental health of lesbian and gay families and had no scientific basis.
The Scandinavian countries, the Netherlands, Hungary, and many U.S. cities and countries have passed laws that provide, to varying degrees, various benefits of marriage. These range from broad governmental recognition of same sex couples -- laws which grant most benefits accorded to heterosexual married couples, with the exception of adoption rights -- to city ordinances which grant "registered partnerships" with few measurable benefits.
A partial listing of psychologically and socially important benefits and responsibilities of legal marriage in the U.S. which are rarely, if ever, available to same sex couples, includes the following:
Legal marriage will provide important mental health benefits both to members, or same sex couples and to the wider community of lesbians, gay men and bisexuals (Cabaj & Purcell, 1998). The majority of lesbians and gay men report being in a committed relationship (Bradford & Ryan, 1998; Kurdek, 1995). Wedding ceremonies, though not legally sanctioned, are common. Nevertheless, the couples lack the same legal rights and responsibilities listed above, as those accorded to heterosexual married couples. Although there has not yet been sufficient research into the psychological harm caused by the lack of legal marriage, same sex couples must endure varying degrees of state-sanctioned discrimination, which necessarily affects the stability of these relationships.
Studies of children of lesbians and gay men have demonstrated no qualitative differences as compared to children of heterosexuals (Patterson, 1992). This is true even though many barriers to establishing secure families exist. Same sex couples who wish to raise children often feel compelled to hide their relationships from the public, for a variety of reasons. A lesbian or gay parent who is not circumspect may lose his or her livelihood, for example.
Adoptive and divorced parents face additional obstacles. An adoptive parent who is homosexual is presumed unfit in many U.S. jurisdictions. Furthermore, when couples do adopt, usually one partner is granted legal parenthood, which can weaken the bond between the other partner and the child. In custody decisions, courts have routinely found homosexual relationships to be immoral situations that must be hidden from minor children. Divorced parents are then forced to choose between access to their children and participating in mature same-sex relationships (Zicklin, 1995).
Relative patterns of psychiatric illness and wellness among lesbian and gay people as compared to heterosexuals have yet to be completely understood. Nevertheless, the effects of homophobia seem to fall disproportionately on lesbian and gay youth, who are more likely to attempt suicide than heterosexual youth (U.S. Department of Health and Human Services, 1989). Same sex marriage would signal to these adolescents that emotionally fulfilling same sex relationships are not only possible, but validated by society.
Lack of recognition of same sex relationship and their families can lead to a failure to provide appropriate mental health care. If same sex marriage were legal, then the partner would more likely be included in mental health treatment and planning. Finally, same sex legal union would foster better psychological integration of the identities of lesbians and gay men, thus facilitating same sex couples' ability to integrate into supportive social networks.
American psychiatrists must be involved in the current debate over same sex marriage for reasons of both clinical practice and public policy. In any clinical work with lesbians, gays, or families involving lesbian or gay members, psychiatrists must be familiar with the psychological effects of the lack of such marriages.
The APA has historically supported equity, parity, and non-discrimination regarding legal issues affecting mental health. Educating the public about lesbian and gay relationships and supporting efforts to establish same sex legal marriage is consistent with the APAs advocacy on behalf of other disadvantaged minority groups.
The Committee on Gay, Lesbian and Bisexual Issues supports the legal recognition of same sex marriage. We offer this report to the APA in order to provide education and to stimulate discussion.