Irving Bieber et al., Homosexuality: A Psychoanalytic Study, 1962
Chapter I - Concepts of Male Homosexuality
This is a study of male homosexuals in psychoanalysis. It is only fitting that such a study should begin with Freud's contribution since Freud was the first to question the concept that homosexuality was a degenerative disease -- a concept that was a pseudoscientific reformulation of a moralistic attitude which considered homosexuality synonymous with degeneracy.
Freud's formulation of the etiology of homosexuality postulated a continuum between constitutional and experiential elements. As a consequence, he regarded homosexuality as resulting in some cases solely from constitutional predisposition and in other cases from exclusively experiential factors, although he cited no clinical or experimental proof for either contention. He regarded the vast majority of cases as products of the interaction of both inherent and extrinsic factors, the relative dominance of each varying in different cases.
One of Freud's basic premises was that all individuals differed in their hereditary biologic endowment. He felt that the physical differences among people which distinguished them as individuals must be reflected not only in underlying physiologic, metabolic, and other characteristics of the biologic organism but also in terms of needs, drives, action potentials, and activity-passivity tendencies. He offered the concept of the inherent nature of the individual's tendencies toward activity or passivity which, he felt, must influence the way in which drives and experiences were dealt with. In terms of sexuality, he saw the child as reacting to sexual needs according to the intensity of its active or passive tendencies without any initial conceptualization of masculine or feminine roles. Only after the child becomes aware of gender does it identify itself with the sex that represents the active or passive tendency in its own constitution. If the child tends to be active, it identifies with masculinity, and if passive, with femininity. Freud, therefore, regarded the form of the homosexual activity as determined, in part and independent of experience, by the relative intensities of innate active or passive tendencies. While he did not imply that experiential factors could not accentuate these components, he did postulate that inherited action potentials must be influential in determining the outcome.
The concept of bisexuality was another fundamental idea emphasized by Freud as essential to the understanding of neuroses and perversions. He viewed the sexual impulse as initially nonspecific concerning the sex of the object from whom satisfaction is sought and even as indifferent to the species of the object. Consequently, the homosexual object-choice was not regarded as biologically abhorrent. Only later developments channelize the sexual impulse into heterosexuality or homosexuality.
Freud believed that the homosexual component can be sufficiently strong to be dominant in some cases, and that in others its intensity can be hypertrophied by specific experiences. However, in terms of his concept of libidinal development, he maintained that the existence of homosexual tendencies is permanent since a portion of the libido is assigned to this component of the sexual constitution.
The innate strength of the various components of sexuality was seen by Freud as the source of additional constitutional determinants of homosexuality. For example, he viewed congenitally intense libidinization of the anal zone in certain individuals as favoring a homosexual propensity; or, some individuals might fail to master the Oedipus phase because of an inherent weakness of the phallic organization. It is, of course, impossible to assess clinically or experimentally the congenital intensity of any of the constitutional components enumerated by Freud, so that this concept must remain conjectural.
The manner in which the sexual instinct and the mental apparatus evolve and affect personality structure was regarded by Freud as most explanatory of the homosexual adaptation. He viewed the sexual instinct as arising from somatic sources and as being continuously operative, although predominantly expressed at different stages through different erogenous zones; the experiences occurring during the various phases result in various personality precipitates, as well as in accentuations or inhibitions of the partial impulses contributed by the various erogenous zones. These zones continue to make libidinal demands which are either gratified, repressed, or sublimated.
Freud correlated the development of object relationships with libidinal phases of development. He saw the child as evolving from autoerotic and narcissistic phases to object love. The particular quality of the libido which is cathected determines the nature of the object relationship; and, in turn, once cathected the object then directs the development, expression, and vicissitudes of that particular phase of libidinal development. He thus regarded homosexuality as resulting from this development in the following principal ways:
The autoerotic phase partially persists and object cathexis is partially accomplished, but on a narcissistic level. As a consequence, the individual seeks a love object representing himself and, therefore, necessarily having to possess the male genital. The individual is thus sexually involved with himself and his own genital in the form of another male who symbolizes himself.
Mental attitudes that exist during the phallic phase; here the male child reaches a stage where sexual impulses formerly expressed through other zones and instincts now become organized, so that the penis becomes the principal organ of discharge and pleasure. The boy begins to place enormous value on the male organ as the chief executor of the sexual function. As a result of earlier experiences with deprivation of other sources of pleasure (breast, feces, etc.), there develops during this (phallic) phase an unconscious fear of the loss of the prized organ. And, when the male child discovers the absence of the penis in the female this knowledge confirms the fear that the penis can be lost or removed. Females are consequently avoided to prevent the arousal of castration anxiety, and are devaluated because of their lack of the narcissistically overvalued male genital.
Difficulties associated with the Oedipus phase. A second type of castration anxiety fostering homosexuality is associated with unconscious incestuous feelings for the mother, later transferred to all women. The castration anxiety in this context derives from fear of retaliation for wishes to castrate the father who is perceived as a sexual rival for the mother.
Freud believed that the sexual practices in the homosexual relationship symbolize regressions to developmental fixation points. For instance, if there is an anal fixation, the individual may identify with his mother and then attempt to play the mother's role through the symbolic equation of the anus with the vagina. On the other hand, if there is stronger identification with the father, the homosexual might subject other males to a passive role in the sodomitic act, which symbolically transforms these men into females and at the same time covertly expresses hostility toward them as males. Homosexuality, therefore becomes one way of coping with rivalry with the father while at the same time gratifying sexual wishes.
Neither Freud nor his followers assumed that only one mechanism underlies homosexuality in any given case. In most cases, various kinds of feelings toward the mother and the father are acted-out through many homosexual symbolizations. Thus, there is a more frequent alternation of roles and a greater variety of sexual practices and identifications between homosexual partners than between heterosexual partners. The multiple roles enacted in homosexual relationships are related to the three basic phases in the development of object relations described above.
Adherents of the libido theory have laid stress on still other mechanisms. Abraham (Karl Abraham, "Sexuality and Alcoholism", in: Selected Papers on Psycho-analysis, London, 1948), for instance, described homosexuality as an attempt to compensate for the failure to achieve the Oedipus goal by substituting the father as the love object. Ernest Jones (Papers on Psycho-analysis, London, 1912) emphasized two features: an unusually strong oral eroticism, and an unusually intense sadism. Anna Freud ("Clinical Observations on the Treatment of Male Homosexuality," in Psychiatric Quarterly, 20:337-338, 1951 (abstract)) stressed the conflict between desires for active and passive roles as the major determinant for identification mechanisms.
Melanie Klein (Developments in Psycho-analysis, London, 1952), whose viewpoint on homosexuality is shared by Bergler (Edmund Bergler, Homosexuality: Diease or Way of Life, New York, 1957), regarded the oral phase as most determining of a homosexual outcome. In her analyses of children she found that oral fixation affects all post-oral phases of psychosexual development, not in the sense of merely contributing elements to the genital phase but in determining the very nature of genital organization. For example, oral frustrations in the infant result in cannibalistic fantasies toward the mother's breast and her total person. Because the child projects its feelings and fantasies, it also views the external world as cannibalistic and develops fears of objects in it. This results in an unconscious fear of being devoured by the love object. The vagina, which is unconsciously equated with the mouth, comes to represent the castrating, devouring organ.
Such anticipations result in avoidance of the heterosexual object, and only a relationship with a male - in whom the male genital, symbolizing the breast, is reassuringly present - becomes suitable as a sexual object. The determinants of homosexuality were thus extended by Klein to earlier levels than Freud had conceptualized.
Harry Stack Sullivan (The Interpersonal Theory of Psychiatry, ed. Helen Swick Perry and Mary Ladd Garvel, New York, 1953) held a similar viewpoint. He wrote: "The oral zone is involved in such varied functions that it is perhaps the central trunk, the main stem for evolution of the self." Sullivan elsewhere discussed the dream of a boy in which he cannibalistically incorporated a girl's nipple. However, Sullivan interpreted this as an expression of genital tendencies.
According to Jules Masserman ("Some Current Concepts of Sexual Behavior", in Psychiatry 14:61-62, 1951), sexuality is engrafted on primitive oral incorporative patterns. He views sexuality as a derivative rather than as a primary form of libidinal activity. The polymorphous perverse sexuality, regarded by Freud as basic, is described as "our mammalian heritage" by Masserman, but the subsequent vicissitudes of the sex instinct are attributed by him to the fate of orality rather than to Oedipus complex displacements or to castration threats. He finds that sexual patterns vary with oral conflicts and with the resolution of such conflicts, but the reverse does not obtain. As he writes: "Genital conflicts are, therefore, not essential to etiology of neurosis." In his experience, the more basic difficulties of patients, including homosexuals, lie at the far deeper levels of oral dependencies, primal anxieties, reactive aggressions, neurotic object cathexes, and autistic withdrawals. It is the solution of these deeper problems that restores genitality rather than the directing of attention to secondarily derived sexual maladjustments.
Kolb and Johnson ("Etiology and Therapy of Overt Homosexuality", in Psychoanalytic Quarterly 24:506-515, 1955) regard homosexuality as deriving from the unconscious sources described by Freud, but state that the impetus for the transformation of latent homosexuality to an overt form often results from parental suggestion. This may consist of parental encouragement of acting-out by the child of unconscious parental wishes or forbidden impulses, unconscious permissiveness by one parent, with the other parent more or less condoning, or the parents' conscious or unconscious image of the child. Parental fears, hopes, wishes, frustrations, and interests may be perceived by the child in their gestures, intonations, body movements, provocative smiles, and maneuvers. This attitudinal network stimulates the child to act-out homosexually, because his unconscious tendencies are now reinforced by suggestions derived from the parents. These findings are emphasized again by Litten, Griffin, and Johnson ("Parental Influence in Unusual Sexual Behavior in Children", in Psychoanalytic Quarterly 25:1-15, 1956): "Perversion and antisocial sexual behavior in children and adolescents result from adaptation of the child's ego to subtle attitudes of its parents which distort the instinctual development of the child. The parental influences operate reciprocally with the needs of the child so that eventually each participant stimulates the other. Many patients have strong latent homosexual, exhibitionistic, and transvestite trends, but do not act-out these impulses until there is unconscious permission and subtle coercion by the parents."
Bychowsky ("The Structure of Homosexual Acting Out", in Psychoanalytic Quarterly 23:48-61, 1954) regards homosexuality as the outcome not only of sexual development as outlined in the libido theory but of ego and superego development which represents the individual's experiences with reality and with the parents on nonsexual levels.
Sullivan regarded homosexuality as resulting from experiences which have "erected a barrier to integration with persons of the other sex." He found one of the important sources of homosexuality in the preadolescent period, since it is during this era that the child first develops an intimate relationship with a "chum." He viewed the "chum" relationship as prognostically favorable and believed it to be an important counterinfluence against the development of a permanent homosexual adaptation. Sullivan cited a group of preadolescents in which two members who had failed to become somewhat homosexually involved with other members of the group were the only ones to become homosexual as adults. Homosexuality may also result, in Sullivan's view, if the preadolescent is driven to form a relationship with an older boy or adult. He saw another possible source of homosexuality in maturational retardation which separates the boy from his chronologic peers. When this occurs, the immature individual may become fixated at the preadolescent level. The failure to fulfill the need for a "chum" in preadolescence while the lust dynamism undergoes biologic maturation may, in some cases, result in a homosexual orientation. During the adolescent period, homosexuality may result from "collisions of lust, security, and the intimacy need." The collision between lust and security, for instance, may occur when the adolescent is burdened with culturally prohibitive attitudes towards heterosexuality, so that a "primary genital phobia" may develop and homosexuality may be resorted to. Homosexuality may also result if there is parental prohibition of heterosexual interests during the adolescent period. A collision between lust and the need for intimacy may occur if there is an underlying fear of intimacy with a heterosexual object, or if sexual guilt results in the division of females into "good" girls with whom emotional intimacy without sex is possible, and "bad" or "sexy" girls with whom genital contact but not an emotional relationship is conceivable -- a mechanism also described by Freud. Sullivan recognized that the fear of female genitals may exist in men even when they regard women as pleasurable sexual objects -- "a fear amounting to a feeling which is literally uncanny, which is quite paralyzing," and which is able to force the male to escape from this "uncanny feeling" into homosexuality. The origin of this fear, he believed, may derive from the "not me," indicating a serious dissociation in the personality.
Karen Horney (The Neurotic Personality of Our Time, New York, 1937; Our Inner Conflicts, New York, 1945) focused attention on the importance of nonsexual needs in sexual activity. Her remarks on homosexuality were based on observations of bisexuals in whom she found needs to conquer and subdue, or needs to please, of such intensity that the sex of the partner became a matter of indifference. These elements, then, became part of a homosexual personality. In addition, she thought, the homosexual has such a fear of injury to his neurotic pride that he withdraws from competition with his equals and inhibits heterosexual attraction.
Clara Thompson ("Changing Concepts of Homosexuality in Psychoanalysis", in Psychiatry 10:2-13, 1947), who shared Sullivan's views, regarded the term "homosexual" as "a wastebasket to which all friendly and hostile feelings toward members of one's sex are applied." She considered homosexuality not as a specific entity having characteristic determinants but only as a symptom of a character problem. She agreed with Freud that all people are biologically polysexual and bisexual, and that uncritical enjoyment of body stimulation exists in childhood. Consequently, she asserted, sexual pleasure in childhood may be derived from either sex. In a permissive culture this basic biologic tendency would result in recourse to homosexual relationships whenever heterosexuality was not available. On a biologic level, therefore, human beings resort to the best type of interpersonal relationship available to them: when heterosexual objects are accessible there is a biologic tendency towards heterosexuality since it is the most "satisfactory." Thompson did not regard the biologic polysexual and polymorphous tendencies as having any influence in personality development, and maintained that these tendencies did not demand that defenses be in constant readiness against their expression. Her conclusion was that homosexuality is a consequence of dependency, hostility, attitudes towards familial or other figures, security operations, and so forth, all covertly expressed in the homosexual relationship. She found that homosexuality disappears as general character problems are solved.
Rado (Sandor Rado, "A Critical Examination of the Theory of Bisexuality", in Psychosomatic Medicine 2:459-467, 1940; "An Adaptational View of Sexual Behavior", in Psychosexual Development in Health and Disease, ed. Paul Hoch and Joseph Zubin, New York, 1949; Report of the Committee on Homosexual Offences and Prostitution (Wolfenden Report), London, 1957) discarded the concept of bisexuality and attributed homosexuality to the following factors:
"Hidden but incapacitating fears of the opposite sex which result in a homosexual adaptation, which through symbolic processes is in fantasy a heterosexual one, or in which problems of rivalry with isophilic partners who represent father are solved"; temporary expedience when heterosexual partners are not available; a consequence of "a desire for surplus variation." The latter, Rado believes, stems from the fact that in humans the sex drive has ceased to be a mechanism related exclusively to procreative purposes and has become autonomously pleasure striving. The "healthy" individual, therefore, may even under ordinary circumstances yield to a desire for "variation in performance because of the latter's pleasure value." This occurs because such a desire is either culturally sanctioned or represents "an individual enterprise."
Ovesey ("The Homosexual Conflict", in Psychiatry 17:243-250, 1954; "The Pseudohomosexual Anxiety", in Psychiatry 18:17-25, 1955), following Rado's adaptational. theory, classified homosexuality as a neurosis divisible into true and pseudohomosexual types. He attributed the first type to early and excessive sexual discipline; homosexuality is resorted to with the objective of achieving orgastic satisfaction. The pseudohomosexual type is equated with "latent" or "unconscious" homosexuality. He regards this form as motivationally determined by the wish for dependency, or as the consequence of inhibited assertiveness which the individual unconsciously equates with castration - therefore with femininity and homosexuality.
Kardiner (discussion in Psychosexual Development in Health and Disease, ed. Paul Hoch and Joseph Zubin, New York, 1949), in reviewing Kinsey's findings as well as the evidence obtained from the study of various animal species and many primitive cultures, arrived at a different conclusion. He regarded neurosis and perversion as deriving from social efforts to institute sexual control in adolescents and preadolescents who are unable to assume mature responsibility for procreation. To prevent sexual irresponsibility in the immature, social efforts "terrorize the child out of its sexual interests, so that the sexual drive is deflected into channels other than heterosexual." This produces neuroses and perversions and is the indirect consequence of social efforts to limit population growth. As for societies in which homosexuality exists despite the lack of sexual restrictions, Kardiner held that biogenetic factors may possibly be responsible.
Silverberg (W.V. Silverberg, Childhood Experiences and Personal Destiny, New York, 1952) distinguished between homosexual behavior and true or neurotic homosexuality. He regarded the former as deriving from disciplinary problems with the father or, more commonly, from attempts to substitute the father for the mother as a source of oral gratification. This dependency upon the father, he believed, may account for the high incidence of "homosexual outlets" reported by Kinsey (37 per cent of American adult males) in individuals whose homosexuality was transient or sporadic.
Silverberg's concept of "true" homosexuality is identical with Freud's to the extent that it is regarded as an outcome of the Oedipus complex. Homosexuality is viewed as an unconscious maneuver to separate the parents and bind the father symbolically in the homosexual relationship, thereby making him unavailable to the mother. This sexual solution is attempted because of the unconscious idea that parental sexuality is determined by the father's insistence on phallic satisfaction. The homosexual, therefore, offers himself to the symbolic father as a substitute for the mother and thereby interferes with the parental sexual relationship. The oral factors emphasized by Klein and Bergler are regarded by Silverberg as consequences of regression rather than as primary determinants. He concurs with Freud in according psychogenetic importance to an unconscious view of women as genitally castrated.
Various other writers who have attempted to ascertain the etiology of homosexuality have found other determining causes. The factors held to be responsible are often unidimensional and oversimplified. Some of the unitary causes adduced are: strong attachment to a man; immaturity with lack of comprehension of sex drives; lack of virility in the fathers; excessive defeat in assertiveness; feminization by being dressed as a female; incidents, such as venereal diseases, which render heterosexuality unpleasant; disillusionment in marriage; being treated by homosexuals as an equal; inherent or acquired timidity; persistence of childhood concepts that heterosexual coital activity is degrading, humiliating, dirty, prohibited, painful, mutilating, etc. Mantegazza (Paolo Mantegazza, Anthropological Studies of Sexual Relations of Mankind, New York, 1932) suggested that in certain cases homosexuality represents an attempt to achieve sexual satisfaction by means of homosexual sodomy as a consequence of a lack of adequate stimulation by the female genital organ, owing to the latter's expansiveness ("la desolante larghezza").
Another line of inquiry raises the fundamental question as to whether homosexuality is a disease, or simply a natural form of human behavior which becomes categorized as a disease only in specific cultures. The view that homosexuality is a disease originated in the organic approach characteristic of the nineteenth century. Krafft-Ebing attributed it to "hereditary neuropathic degeneration," without demonstrable degenerative pathology in the central nervous system. He also postulated that excessive masturbation acted as the stress which uncovered the latent neuropathic taint. Others attributed the neuropathic state to other varieties of somatic disease in the parents. Some suggested that homosexuality resulted from the presence of a female soul in a masculine body while others conceptualized it as the occurrence of a female brain combined with masculine sex glands. Another hypothesis of Krafft-Ebing's was that male and female sex centers existed in the brain, with the female center predominating in the homosexual. Mantegazza, writing as recently as 1932, ascribed homosexuality to either psychic or organic causes. The latter, he rather ingeniously postulated, consisted of a reversal of nerve supply to the genitals and rectum, so that sexual satisfaction could only be obtained perversely. Ellis and Hirschfeld regarded homosexuality as of congenital origin and even Freud and Glover assumed that at least some cases were congenitally determined. Lombroso (Cesare Lombroso, Criminal Anthropology, New York, 1895) concluded that homosexuality, like criminality, resulted from the persistence of an atavistic sexual instinct. Carpenter (Edward Carpenter, The Intermediate Sex, New York, 1912) viewed homosexuality as representing another sex, intermediate between the male and female. He did not regard this intermediate type as possessing specific somatic characteristics, but only mental attributes indicative of a contrasexual temperament. In the male pervert this expressed itself, he wrote, in "a rather gentle emotional disposition with defects, if such exist, in the direction of subtlety, evasiveness, timidity, vanity, etc.; the mind is generally intuitive and instinctive in its perceptions, with more or less artistic feeling." He also considered this intermediate sex to be a "sport or variation" which had the important functions of acting "as reconcilors and interpreters of each sex to each other." -- "The homogenic affection," he stated, "is a valuable social force and in some cases a necessary element of noble human character."
The theory of the organic etiology of homosexuality can be tested in the following research areas: hereditary transmission of potentialities for homosexuality; physiologic, anatomic, and endocrine dysfunction in homosexuals; response of homosexuals to endocrine therapy; the effects of rearing upon sexual identity.
Studies of a possible hereditary factor to account for homosexual proclivities have been, at best, only suggestive. Kallman ("Comparative Twin Studies on the Genetic Aspects of Male Homosexuality", in J. Nerv. & Ment. Dis. 115:283-98, 1952) investigated 40 monozygotic pairs of homosexuals and found only one father of a homosexual pair who was homosexual. In all cases of twins "concordance as to overt practices and quantitative behavior after adolescence" was found. "All denied any history of mutuality in overt sexual relations" and many "claimed to have developed their often very similar sexual pattern independently and far apart from each other." Kallman also asserted that the individuals of each pair had so marked a sexual taboo between them that each disclaimed knowledge of any intimate details of his co-twin's sex life. However, in 45 dizygotic twin pairs the co-twin of each of the homosexual subjects did not generally show overt homosexuality, and the incidence of homosexuals among these was only slightly in excess of Kinsey's rate for the total male population. Kallman, therefore, regarded it as clearly evident that only the uniovular twins developed identical patterns of overt practice, and these genetic studies strikingly indicated to him that homosexuality was determined basically by hereditary factors.
In support of Kallman's findings, Mayer-Gross (Clinical Psychiatry, London 1954) quotes Saunders' report of seven uniovular pairs. In six pairs both members were homosexual; in one pair, one member was homosexual and the other was not. Despite Kallman's tremendous emphasis on a genetic basis for homosexuality he nevertheless states that there is "multiple causation of homosexual behavior in the adult male," and that personality and sexual function are "easily dislocated" by experiential factors.
Witschli and Mengart ("Endocrine Studies on Human Hermaphrodites and Their Bearing on Interpretation of Homosexuality", in J. Clin. Endo. 2:279-286, 1942) postulated a sex-linked hereditary factor. They quoted Lang's ("Studies on the Genetic Determination of Homosexuality", J. Nerv. & Ment. Dis. 92:55-64, 1940) statistical studies based upon German police records. They demonstrated that there is a higher incidence of male siblings among homosexual men than might be expected statistically. This finding was explained by assuming a "sex-reversal" factor which is carried by a gene transmissible by females to offspring born anatomically male but potentially homosexual. Kallman, however, questioned the statistical adequacy of such studies on the siblings of homosexuals.
Bauer ("Homosexuality as an Endocrinological, Psychological, and Genetic Problem", in J. Crim. Path. 2:188-197, 1940) concluded that homosexuality is a genetic problem including psychologic as well as hormonal factors. "The basic underlying cause of homosexuality," he stated, "is an abnormality of the chromosomal structure with a subsequent sexual differentiation of certain cerebral portions extending, however, to other functions and structures of the body in a variable degree. Only the genetic conception of homosexuality can explain the fact that different kinds of intersexuality, both physical and, mental, occur as a hereditary trait in certain families." Kallman pointed out that if homosexual men are assumed to be genetically female but phenotypically male intersexes without a Y-chromosome, their children must all be female, and cytologic examinations must show the absence of Y-chromosomes. No such conclusive data are available.
In a chromosomal study of 50 male homosexuals Paré ("Homosexuality and Chromosomal Sex", in J. Psychosom. Res. 1:247-251, 1956) found that they had a normal male chromosomal pattern, which he cited as evidence against Lang's theory that male homosexuals are female genotypes. Raboch and Nidoma ("Sex Chromatin and Sexual Behavior", in Psychosomatic medicine 20:55-59, 1958) studied 36 men with a female type sex-chromatin. Thirty-two of the 36 were heterosexual and the remaining four eunuchoid. They also studied 194 adult exclusive or almost exclusive male homosexuals. Of the 194 only 9 were found to have hypoplastic testes, and of these 6 had masculine sex chromatin. Thirty-two of the total, selected at random, showed the male chromosomal pattern in each case. They concluded that "the finding of a female type of sex chromatin in a homosexual man would amount to pure coincidence."
Further doubt is cast on the simple assumption that sexual identity is definitely determined by genetic constitution in studies of the effect of rearing upon sexual orientation. Money, Hampson, and Hampson ("An Examination of Some Basic Concepts: The Evidence of Human Hermaphroditism", Bull. Johns Hopkins Hosp. 97:284-310, 1955), in a study of the sexual development and life of 76 pseudohermaphrodites and individuals with gonadal agenesis, found that in 19 cases there was a contradiction between chromosomal sex and sex assignment and rearing. In every case, however, the person established a gender role and orientation consistent with the assigned sex and rearing, and inconsistent with the chromosomal sex. This strongly indicates that sexual identity is not determined by the chromosomal factor exclusively, and illustrates the high importance of experiential elements in modifying, and even reversing, genetic constituents.
A review of the endocrinological aspects of homosexuality was made by Sawyer ("Homosexuality: The Endocrinological Aspects", in Practitioner 172:374-377, 1954), from which the following summary is quoted:
"The development of sexual responsiveness in the two sexes is dependent more upon psychological conditioning and availability of sexual outlets than upon levels of circulating sex hormones. From the fact that most individuals showing predominantly or exclusively homosexually directed libido undergo a normal puberty at a normal time, it may be inferred that the detection of significant hormonal abnormalities would be most unlikely. A homosexual cannot be diagnosed by physical examination. No convincing demonstrations of endocrine imbalance in homosexuals have been forthcoming. In patients suffering from the male climacteric, eunuchism and eunuchoidism, there is absolutely no increased incidence of homosexuality as compared with that in the general population. The one possible variety of homosexuality which may be causally related to androgen deficiency in eunuchoidal patients is the passive type. This, moreover, is the only type in which male hormone treatment may prove of some therapeutic value. In the majority of cases, the hermaphrodite assumes a heterosexual libido and sex role that accord primarily not with his or her internal and external somatic characteristics, but rather with his or her masculine or feminine upbringing."
In reviewing the sex hormone treatment of homosexuality Sawyer stated that failure "is indeed now the generally accepted conclusion." He quoted Sand and Okkels who had treated 100 cases of perversion and homosexuality by castration, which merely reduced the libido without in any way altering its direction. As for androgen treatment, it "serves merely to increase the libido which still remains homosexual in outlet." He concludes: "There is no convincing evidence that human homosexuality is dependent upon hormonal aberrations," and, "The use of sex hormones in the treatment of homosexuality is mainly disappointing."
The view that homosexuality is not a disease was the position taken in the so-called Wolfenden Report. There is no legal definition of "disease" or of "disease of the mind"; and "health" and "ill health" as well as "normal" and "abnormal" are relative terms. The Report pointed out that a particular type of aberrant behavior cannot be regarded as a manifestation of disease, if there are no other associated symptoms and if the existence of deviant behavior is compatible with "full mental health" in other respects. In those cases of homosexuality which are now associated with distressing symptoms, the latter may be determined not by the homosexuality itself but as a consequence of social attitudes. In addition, there is a lack of proof for the presence of a pathologic physical condition accompanying homosexuality, so that the designation of the latter as a "disease" necessitates a revision of the generally accepted view of the nature of a diseased state. Furthermore, the Report emphasized, none of the various theories formulated to explain the perversion is conclusive or specific to it, since the postulated etiologic factors are also found in other psychopathologic states.
The publications of Kinsey et al., also supported the concept that homosexuality is not a disease. Aberrant behavior such as homosexuality was viewed as a general capacity of all human beings, originating in an inherent capacity for indiscriminate sexual responsiveness. As a result of conditioning and social pressure, the sexual potential becomes channelized in the direction of accepted social behavior. Sporadic homosexual behavior in the general population prior to maturity was found to be the rule rather than the exception. Kinsey's statistics indicated that about 4 per cent of adult white males are exclusively homosexual after adolescence, and that about 10 per cent of the total male population is to a greater or lesser degree exclusively homosexual for at least three years some time between the ages of sixteen and sixty-five. An even more remarkable finding was that at least 37 per cent of the total male population has had some overt homosexual experience, with or without orgastic culmination, some time between puberty and old age. In preadolescent boys Kinsey found an incidence of 48 per cent homosexual genital play, and this percentage increased if nongenital activity was included. Since preadolescent heterosexual play occurred in 40 per cent of his sample, it appears that, among many males, homosexuality in some form exceeds heterosexuality during the preadolescent period.
In view of Kinsey's statistics, many social scientists and psychiatrists maintain that it is difficult to uphold on rational grounds legal, social, and individual attitudes which imply that homosexuality is exceptional and therefore should be regarded as a crime against nature. As Kinsey has written, "In all the criminal law there is practically no other behavior which is forbidden on the ground that Nature may be offended and that Nature must be protected against such offense. This is the unique aspect of our sex codes." Thus, by Kinsey's standards homosexuality should not be regarded as a disease. He speculated that only a small number of those customarily involved in perverse behavior are ever particularly disturbed by their experiences, and that personality disturbances associated with homosexuality derive from the expectation of adverse social reactions.
Anthropological data in Ford and Beach (Patterns of Sexual Behavior, New York, 1951) also support the concept .that homosexuality is not a disease. These data show that "100 per cent of the males in certain societies engage in homosexual as well as heterosexual alliances." They state that "one cannot classify homosexual and heterosexual tendencies as being mutually exclusive or even opposed to each other. Human sexual behavior is controlled and directed primarily by learning and experience. It is possible, by a process of cultural and individual conditioning, to make a person an exclusive homosexual, and this can be done precisely because human sexuality is so labile, so dependent upon individual experience." -- "Some homosexual behavior occurs in a great many human societies. It tends to be practiced more frequently by men than by women. The basic mammalian capacity for sexual inversion tends to be obscured in societies like our own which forbid such behavior and classify it as unnatural."
Two studies are oriented to the conclusion that adult male homosexuals may fall within the ranges of psychologic normality. Hooker (Evelyn Hooker, "A Preliminary Analysis of Group Behavior of Homosexuals", in J. Psych. 42:217-225, 1956; "The Adjustment of the Male Overt Homosexual", in Jounral of Projective Techniques 21:18-31, 1957; "Male Homosexuality in the Rorschach", J. Proj. Techn. 22:33-54, 1958) has reported a group of 30 homosexuals and 30 heterosexual controls, matched for age, I.Q., and education. The homosexuals were carefully chosen on the basis of good adjustment and function in the community. Subjects who were in therapy and any who showed "evidence of considerable disturbance" in the preliminary screening were eliminated. The investigation "consisted of a battery of projective techniques, attitude scales, and intensive life history interviews." Hooker's hypothesis was that homosexuality is not necessarily a symptom of pathology. The report is based on analysis of the test materials by different, independent judges who did not know whether the record was that of a homosexual or a heterosexual. The general outcome of the study was that the judges could not reliably identify whether the records were from a homosexual or a heterosexual subject. Various ratings of the subjects' "adjustment" were made based on the test results. There was no significant difference between the homosexuals and the heterosexuals. Hooker's conclusion, which is expressly presented as tentative, is that "homosexuality may be a deviation in sexual pattern which is within the normal range psychologically."
Chang and Block ("A Study of Identification in Male Homosexuals", J. Consult. Psych. 24:307-310, 1960) also could not show differences between samples of homosexuals and a control group. Their study utilized a comparison of self-ratings with ideal self-ratings; and the degree of correspondence was interpreted as a measure of "self-acceptance." Their sample consisted of 20 male homosexuals (only 1 of whom had ever been in therapy) whose homosexual pattern involved a homosexual "marriage." The "self-acceptance scores" for these homosexuals were not significantly different from the scores for the control group. Their conclusion was that the members of this homosexual group were not psychiatrically disturbed. The findings of several other studies, which will be reported in Chapter II, are not in accord with those of Hooker and Chang and Block.
The theories that have been presented fall into two major categories: those which are based on the assumption that adult homosexuality is a psychopathologic state and those which are not.
All psychoanalytic theories assume that adult homosexuality is psychopathologic and assign differing weights to constitutional and experiential determinants. All agree that the experiential determinants are in the main rooted in childhood and are primarily related to the family. Theories which do not assume psychopathology hold homosexuality to be one type of expression of a polymorphous sexuality which appears pathologic only in cultures holding it to be so.