Therapeutic Attitude In the Treatment of Male Homosexuals

I was very surprised when I was told I would receive the honor of the Sigmund Freud Award at this luncheon. I am an old man; and it is said about old people that as they get more experience and wisdom with their years, they have more answers. But the truth is, they get asked fewer questions.

To be asked to speak implies that I have answers to your questions, but experience teaches us to be less satisfied with old answers and to ask new questions. When Gertrude Stein was on her deathbed, she was asked, "What is the answer?" She replied, "What is the question?"

I have always tried to maintain a strictly neutral technique with a patient in psychoanalysis, although I use other methods with patients who are not in analysis.

Over the years I had observed that a psychoanalysis is the best treatment for those patients who are analyzable, so I always wanted to conduct a psychoanalysis when it was indicated.

I had observed, and taught, that homosexual patients often tried to please the analyst by premature attempts to date women. I had usually interpreted this as a transference manifestation which would impede the analytic work. It required transference exploration and interpretation rather than accepting the manifest content and encouraging the patient to carry it out. However, when I began to work with Dr. Socarides in the psychoanalytic study group on sexual aberrations, I heard his opinion that the therapist should strongly encourage any attempt at heterosexuality by a homosexual patient. He had much more experience than I had in treating homosexuality so I had to question my orthodox approach.

The question reappeared from another source. Several years ago I was working on a chapter for a book, edited by Dr. Harvey Schwartz, on psychotherapy with different kinds of patients. I had been asked to write a chapter on the treatment of sexual perversions and homosexuality.

As an aside, when I sent in my chapter entitled "The Treatment of Perversions and Homosexuality," I was told that some associate editors did not like the title. It was politically incorrect, although that was my assigned topic. I tried to change the title to "The Treatment of Sexual Aberrations," but that didn't fly either. Then I tried "The Treatment of the Paraphilias," thinking that they might not know what it meant, but they didn't like it. Since it happened that the two case examples most fully described were depressed, you can now read the chapter entitled, "Treatment of the Depressed Homosexual Patient" in a book entitled, Psychotherapy in General Psychiatry. I had to accept the title compromise to preserve everything else I said in the chapter. (However, if a homosexual therapist is enticed by the title to read the chapter, he might learn something.)

To get back to the question of encouraging or not encouraging heterosexuality in a homosexual patient, I was discussing with Harvey the technical problem of how to handle the patient's report of dating a woman. He knew my interest in the problem of identification in the treatment of sexual aberrations. He asked, "If you become the father in the transference, doesn't a father in a normal family feel happy about his son's masculinity and always encourage it?"

Harvey's question was one that I should have asked myself. However, there are other considerations. Homosexuality is often a defensive adaptation to preserve phallic power against castration anxiety. A premature push to heterosexuality might interfere with this defense when it is still needed, and might also prematurely close off further analysis. So here is my answer to our question of when to encourage heterosexuality in a homosexual patient. AFTER analysis of the sources of castration anxiety and the defensive functions of the homosexuality, and AFTER the appearance of identification with the therapist-father (or oedipal strivings toward a female therapist), the therapist should encourage any signs of heterosexuality as they appear in dreams, fantasy or behavior.

Another thing learned over the years is--always listen carefully to your critics, because they will tell you some things that your supporters won't. Homosexual politicians accuse us of harming homosexuals by forcing them into heterosexuality. I doubt that may therapists force them, but if the word premature were placed before the word heterosexuality, they could be correct in some cases.

People with bisexual conscious thoughts and fantasies or overt behavior usually identify themselves as heterosexual or homosexual. The fact of bisexuality has been disparaged by gay society, and often also by the general culture. Bisexuals trying to act as an identifiable group have often been unwelcome in gay rights demonstrations.

The gay rights groups have this same bias--they would have us classify anyone who has ever shown same-sex attraction as homosexual, and they have moved the public to this position. What should be our professional opinion?

A few months ago, Ann Landers published a letter from a mother of a teenager who said that her son was upset over fantasies about men. Ann Landers replied that the boy was genetically homosexual and should be helped to accept his condition. I have not seen published the letter I wrote to her explaining the facts clearly and how her advice could do public harm by interfering with diagnostic evaluation and treatment of such cases. Homosexual politicians had convinced her and a large segment of our population that any homosexual behavior OR EVEN FANTASY, at any age, was evidence of a genetic, unchangeable homosexual condition.

Garber gives a review of the experimental work which has reported evidence of genetic homosexuality, along with the scientific fallacies and failure of confirmation of those studies. Even the respected journal Science has published a paper with such a flawed methodology that it would not have been given a second reading if it were on any other topic.

I have asked mammalian curators at the Philadelphia Zoo whether they have ever observed or read papers on the occurrence of obligatory homosexual preference in primates or any other mammalian species. The answer is that occasional homosexual behavior is seen in all species, but not in adults when the other sex is present. If homosexuality is genetic, why only in homosapiens? The general biological rule is that the higher the development of mental faculties in a phylum, class, genus or species, the more behavior is determined experientially rather than genetically. The genetic behavior of ants and birds seems miraculous to us humans, who have to depend on experience and thought. Garber quoted Gore Vidal, "There are no homosexuals, there is homosexual behavior."

The question which the book posed for me is: If we are all bisexual as infants, why are there heterosexuals and homosexuals? Freud, in "Three Contributions to a Theory of Sexuality," wrote that infants are polymorphous perverse. We can confirm this by the observation that an infant will do anything pleasurable with anybody. Although some innate activity differences, with much overlap, between male and female infants, has been reported, the response to physical pleasurable stimulation in either sex does not depend on the sex of the stimulator.

What changes this bisexual behavior to heterosexual or homosexual behavior in most people? If we knew more about "why heterosexual?" we might was learn more about "why homosexual?" The heterosexual outcome seems to be due to an infancy that enhances a healthy narcissism and individuation, thus beginning the gender identification which is fortified during the oedipal period and by the hormonal surge and bodily changes of adolescence. But in all heterosexuals there remains the possibility of bisexual fantasy with varying degrees of conflict or behavior. Studies have shown that sixty percent of male heterosexuals have fantasies of threesomes, and pornographic filmmakers who cater to male heterosexuals know the arousal value of portraying lesbian sex.

Social ideals and group superego are probably very important in allowing only heterosexual expression, but male gender identification and phallic narcissism are the most important components of healthy narcissism in males. It is narcissistically painful for most men to doubt their heterosexuality. It is in the interest of protecting their narcissism that most men must be only heterosexual and need to constantly repress bisexual or homosexual fantasies, and cannot countenance homosexual acts by themselves or others.

In special situations, such as in prisons, homosexual rape is committed by heterosexual men as a proof of their phallic power over other men and it thereby supports their narcissism rather than injures it. The need to preserve phallic narcissism is also important--although it takes a different direction--in many men with homosexual behavior.

Thus, masculine narcissism accounts for rigid male heterosexuality, homophobia and the gay rights movement. An example of extreme homophobia is the severely narcissistically injured person, with some psychotic genetic determinants, whose bisexual or homosexual fantasy can precipitate a paranoid psychosis. Psychoanalysts see many patients with less narcissistic difficulty who have not solved the bisexual conflict, either consciously or unconsciously.

Now to "why homosexual?" when we know that there is bisexual predisposition, but no homosexual predisposition. We all know the identity problem engendered by the enveloping mother and the absent father. And we know about the oedipal conflict and castration anxiety. But what had become of his bisexual predisposition? First of all, I think that homosexuals are mislabeled; they are, like all of us, bisexuals--but many of whom have pathologically repressed the desire for the opposite sexual object. Their psychopathology may have early roots in identifying with the opposite-sex parent, or they might have a more neurotic structure of phobia for the genitalia of the opposite sex. There is a varying degree of both experiential factors in most cases.

The treatment, then, is of the identification problem and the early aggression problem (of the borderline) and the resolution of the oedipal complex (as in the phobic psychoneurotic). And, since we all know that it is easier to treat neurotics than to treat borderlines, we can expect that many people with homosexual behavior will not have therapeutic outcomes as favorable as others. An obligatory homosexual can be considered a bisexual who has a phobia for the female genitalia. Therefore, as in the treatment of the phobic object or situation in the interest of furthering the analysis, one might eventually have to encourage the person with a phobic avoidance of female genitalia to do the same. So, since we have returned in a circular manner to answering the question of when to encourage heterosexual behavior, it is almost time to stop.

As for the question of when a "homosexual" should be treated--all bisexuals need treatment when they are depressed or in conflict, no matter what their choice of sexual object.

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