Royal College of Psychiatrists
Submission to the Church of England’s Listening Exercise on Human Sexuality.
This report is prepared by a Special Interest Group in the Royal College of Psychiatrists. We have limited our comments to areas that pertain to the origins of sexuality and the psychological and social well being of lesbian, gay and bisexual people (LGB), which we believe will inform the Church of England’s listening exercise.
The Royal College of Psychiatrists holds the view that LGB people should be regarded as valued members of society who have exactly similar rights and responsibilities as all other citizens. This includes equal access to health care, the rights and responsibilities involved in a civil partnership, the rights and responsibilities involved in procreating and bringing up children, freedom to practice a religion as a lay person or religious leader, freedom from harassment or discrimination in any sphere and a right to protection from therapies that are potentially damaging, particularly those that purport to change sexual orientation.
We shall address a number of issues that arise from our expertise in this area with the aim of informing the debate within the Church of England about homosexual people. These concern the history of the relationship between psychiatry and LGB people, determinants of sexual orientation, the mental health and well being of LGB people, their access to psychotherapy and the kinds of psychotherapy that can be harmful.
1. The history of psychiatry with LGB people.
Opposition to homosexuality in Europe reached a peak in the nineteenth century. What had earlier been regarded as a vice, evolved into a perversion or psychological illness. Official sanction of homosexuality both as illness and (for men) a crime led to discrimination, inhumane treatments and shame, guilt and fear for gay men and lesbians (1). However, things began to change for the better some 30 years ago when in 1973 the American Psychiatric Association concluded there was no scientific evidence that homosexuality was a disorder and removed it from its diagnostic glossary of mental disorders. The International Classification of Diseases of the World Health Organisation followed suit in 1992. This unfortunate history demonstrates how marginalisation of a group of people who have a particular personality feature (in this case homosexuality) can lead to harmful medical practice and a basis for discrimination in society.
2. The origins of homosexuality
Despite almost a century of psychoanalytic and psychological speculation, there is no substantive evidence to support the suggestion that the nature of parenting or early childhood experiences play any role in the formation of a person’s fundamental heterosexual or homosexual orientation (2). It would appear that sexual orientation is biological in nature, determined by a complex interplay of genetic factors (3) and the early uterine environment (4). Sexual orientation is therefore not a choice, though sexual behaviour clearly is. Thus LGB people have exactly the same rights and responsibilities concerning the expression of their sexuality as heterosexual people. However, until the beginning of more liberal social attitudes to homosexuality in the past two decades, prejudice and discrimination against homosexuality induced considerable embarrassment and shame in many LGB people and did little to encourage them to lead sex lives that are respectful of themselves and others. We return to the stability of LGB partnerships below.
3. Psychological and social well being of LGB people
There is now a large body of research evidence that indicates that being gay, lesbian or bisexual is compatible with normal mental health and social adjustment. However, the experiences of discrimination in society and possible rejection by friends, families and others, such as employers, means that some LGB people experience a greater than expected prevalence of mental health and substance misuse problems (5, 6). Although there have been claims by conservative political groups in the USA that this higher prevalence of mental health difficulties is confirmation that homosexuality is itself a mental disorder, there is no evidence whatever to substantiate such a claim (7).
4. Stability of gay and lesbian relationships
There appears to be considerable variability in the quality and durability of same-sex, cohabiting relationships (8, 9). A large part of the instability in gay and lesbian partnerships arises from lack of support within society, the church or the family for such relationships. Since the introduction of the first civil partnership law in 1989 in Denmark, legal recognition of same-sex relationships has been debated around the world. Civil partnership agreements were conceived out of a concern that same-sex couples have no protection in law in circumstances of death or break-up of the relationship. There is already good evidence that marriage confers health benefits on heterosexual men and women (10, 11) and similar benefits could accrue from same-sex civil unions. Legal and social recognition of same-sex relationships is likely to reduce discrimination, increase the stability of same sex relationships and lead to better physical and mental health for gay and lesbian people. It is difficult to understand opposition to civil partnerships for a group of socially marginalised people who cannot marry and who as a consequence may experience more unstable partnerships. It cannot offer a threat to the stability of heterosexual marriage. Legal recognition of civil partnerships seems likely to stabilise same-sex relationships, create a focus for celebration with families and friends and provide vital protection at time of dissolution (12). Gay men and lesbians’ vulnerability to mental disorders may diminish in societies that recognise their relationships as valuable and become more accepting of them as respected members of society who might meet prospective partners at places of work and in other such settings that are taken for granted by heterosexual people.
5. Psychotherapy and reparative therapy for LGB people
The British Association for Counselling and Psychotherapy recently commissioned a systematic review of the world’s literature on LGB people’s experiences with psychotherapy (13). This evidence shows that LGB people are open to seeking help for mental health problems. However, they may be misunderstood by therapists who regard their homosexuality as the root cause of any presenting problem such as depression or anxiety. Unfortunately, therapists who behave in this way are likely to cause considerable distress. A small minority of therapists will even go so far as to attempt to change their client’s sexual orientation (14). This can be deeply damaging. Although there is now a number of therapists and organisation in the USA and in the UK that claim that therapy can help homosexuals to become heterosexual, there is no evidence that such change is possible. The best evidence for efficacy of any treatment comes from randomised clinical trials and no such trial has been carried out in this field. There are however at least two studies that have followed up LGB people who have undergone therapy with the aim of becoming heterosexual. Neither attempted to assess the patients before receiving therapy and both relied on the subjective accounts of people, who were asked to volunteer by the therapy organisations themselves (15) or who were recruited via the Internet (16). The first study claimed that change was possible for a small minority (13%) of LGB people, most of whom could be regarded as bisexual at the outset of therapy (15). The second showed little effect as well as considerable harm (16). Meanwhile, we know from historical evidence that treatments to change sexual orientation that were common in the 1960s and 1970s were very damaging to those patients who underwent them and affected no change in their sexual orientation (1, 17, 18).
In conclusion the evidence would suggest that there is no scientific or rational reason for treating LGB people any differently to their heterosexual counterparts. People are happiest and are likely to reach their potential when they are able to integrate the various aspects of the self as fully as possible (19). Socially inclusive, non-judgemental attitudes to LGB people who attend places of worship or who are religious leaders themselves will have positive consequences for LGB people as well as for the wider society in which they live.
Professor Michael King
Report prepared by the Special Interest Group in Gay and Lesbian Mental Health of the Royal College of Psychiatrists.
31st October 2007
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(6) Gilman SE, Cochran SD, Mays VM, Hughes M, Ostrow D, Kessler RC. Risk of psychiatric disorders among individuals reporting same-sex sexual partners in the National Comorbidity Survey. Am J Public Health 2001 June;91(6):933-9.
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(8) Mays VM, Cochran SD. Mental health correlates of perceived discrimination among lesbian, gay, and bisexual adults in the United States. Am J Public Health 2001 November;91(11):1869-76.
(9) McWhirter DP, Mattison AM. Male couples. In: Cabaj R, Stein TS, editors. Textbook of Homosexuality and Mental Health.Washington: American Psychiatric Press; 1996.
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(12) King M, Bartlett A. What same sex civil partnerships may mean for health. J Epidemiol Community Health 2006 March 1;60(3):188-91.
(13) King M, Semlyen J, Killaspy H, Nazareth I, Osborn DP. A systematic review of research on counselling and psychotherapy for lesbian, gay, bisexual & transgender people. Lutterworth: BACP; 2007.
(14) Bartlett A, King M, Phillips P. Straight talking: an investigation of the attitudes and practice of psychoanalysts and psychotherapists in relation to gays and lesbians. Br J Psychiatry 2001 December;179:545-9.
(15) Spitzer RL. Can some gay men and lesbians change their sexual orientation? 200 participants reporting a change from homosexual to heterosexual orientation. Arch Sex Behav 2003 October;32(5):403-17.
(16) Shidlo A, Schroeder M. Changing sexual orientation: A consumers' report. Professional Psychology: Research and Practice 2002;33:249-59.
(17) King M, Smith G, Bartlett A. Treatments of homosexuality in Britain since the 1950s--an oral history: the experience of professionals. BMJ 2004 February 21;328(7437):429.
(18) Smith G, Bartlett A, King M. Treatments of homosexuality in Britain since the 1950s--an oral history: the experience of patients. BMJ 2004 February 21;328(7437):427.
(19) Haldeman DC. Gay Rights, Patient Rights: The Implications of Sexual Orientation Conversion Therapy. Professional Psychology - Research & Practice 2002;33(3):260-4.