Homosex

Definition: A strong or exclusive preference for sexual activity with members of the same sex for at least a few years.

There has been a tremendous change in attitude towards sexuality over the last 2 decades, in particular with regard to male and female homosexuality. In Western culture, homosexuality has been considered an illness or deviation that required treatment. Techniques such as aversion therapy, drugs, psychotherapy or the advice "to marry or take a pretty girl to bed" were considered to hold out hope of a "cure".

In the United States in 1974 "homosexuality" was removed from the register of psychiatric disorders and termed instead "sexual orientation disturbance" if individuals are disturbed by, or in conflict with, or wish to change their sexual orientation. Increasing use of the term "gay" helps to distance the subject from a mental illness (Bath, 1981). Most homosexual men and women prefer to be called "gay". This term may have arisen because homosexuals are freer in their sociosexual interactions than heterosexuals, and they are more creative and innovative in terms of having fun involved in recreation not procreation (Strydom, 1982).

Homosexuality has gradually come to be considered as a variation of sexual activity rather than a deviation. Despite changing attitudes, problems for homosexuals remain formidable in many countries mainly due to religious and societal disapproval. Women have special problems because of their historically and socially imposed role of housewife, mother and financially dependent partner, and spinsters are generally more socially disadvantaged than bachelors.

Incidence:

Men: Gagnon (1973) reanalyzed Kinsey's data (1948) and reported that 30% of men studied had at least one time had homosexual experience, 3% were exclusively homosexual and 3% had extensive homosexual and heterosexual experiences.

Women: only 6% had at least 1 homosexual experience, 2% had significant homosexual experiences, and less than 1% were exclusively homosexual (Gagnon, 1973).

It is not known whether the rates for homosexual preference are increasing and there is no data to suggest that they are, but homosexual and bisexual behavior is now more open.

Presentation: many years elapse from the time that the individual becomes aware of his or her sexual identity before acknowledging it or "coming out". Latent homosexuality refers to homosexual impulses that are disguised or hidden. Individuals vary from those whose sexual acts are exclusively homosexual to those who are exclusively heterosexual with all gradations in between. Kinsey (1948, 1953) described a continuous spectrum of sexual preference and behavior and fantasy on a rating scale of 06:

exclusively heterosexual

I predominantly heterosexual and only incidentally homosexual

2 predominantly heterosexual and more than incidentally homosexual

3 equally heterosexual and homosexual

4 predominantly homosexual and more than incidentally heterosexual

5 predominantly homosexual and only incidentally heterosexual

6 exclusively homosexual

Exclusive homosexuality: individuals who are exclusively homosexual can satisfy their sexual needs only with persons of the same sex, and homosexual erotic activity is preferred and persistent.

Ambisexual or bisexual: individuals are also called "AC DC" or "both ways". They may go up and down the continuum of the rating scale depending on age, and life circumstances. Their erotic preference is homosexual, but they can enjoy heterosexual relations and are unwilling to deny themselves opportunities for sexual exchange out of regard for societal or cultural restrictions.

Bisexuality is probably more difficult than an exclusive sexual orientation for individuals to handle (Bell, 1980). The ambisexual experience belies the notion that homosexuality and heterosexuality are mutually exclusive. If the person is married, decisions have to be made with respect to how homosexual interests will be handled with the marital partner.

Individuals may present with anxiety about homosexuality because of their thoughts, dreams or impulses. This occurs particularly among students who have not yet recognized or accepted their orientation, and middle aged men who are struggling with the conflict of whether or not to act out their homosexual desires (Woods, 1981).

Pseudo homosexuality: motivation is based on imagery, but not erotic arousal or behavior (Woods, 1981).

Homosexuals are not stereotyped and cannot be recognized by dress, mannerisms or artistic traits. Males are not always effeminate "nellies" these constitute only 14 27% (Bancroft, 1972). Some young men go through a crisis of masculine identity after acknowledging their homosexuality, and they may adopt effeminate behavior until their identity crises recedes (Gagnon, 1973). The broad shouldered, striding, "butch" females are a small minority of gay women. The majority of homosexuals are indistinguishable from the heterosexual population in psychological measures of femininity or in terms of body s ape (Bancroft, 1983). Homosexual individuals exist in all walks of life, but many gravitate to social systems (art, theatre) which do not consider homosexual behavior sinful or sick. The majority of homosexual men and women are well adjusted and productive and not different from heterosexual individuals in terms of anxiety, depression and psychosomatic symptoms, emotional stability and maturity (Sagir, 1973). There appears to be no higher incidence of criminal or antisocial behavior among homosexuals than among heterosexuals except where homosexual activity itself is deemed a criminal offence (Gadpaille, 1981a).

Aetiology: causes of homosexual behavior are enigmatic and controversial. In the past it was considered that the main factors in causing male homosexuality were a domineering, overprotective, close binding and possibly seductive mother, and a weak, detached, passive, hostile or absent father: mother son closeness and father son distance. A close binding, overly intimate father was thought to be the predominant cause of lesbianism. Freud (1953) hypothesized that everyone goes through a homeo erotic phase in childhood, and that, without resolution of the Oedipal conflict, a homosexual preference remains.

Aetiological factors: unconscious conflicts arising from childhood influences that cause confusion in sexual identity or make heterosexuality unappealing or unattainable: failure in the relationship between the child and mother with feelings of being unlovable the opposite sex parent was a deficient sex model resulting in ambivalence or hostility toward someone of that sex neurotic failure of heterosexuality (Haslarn, 1976) arrest of sexual development during adolescence Homosexuality may be facilitated in certain situations (prison, army) but heterosexual men will revert to heterosexuality once women are available.

Lesbians may lack resolution of penis envy.

Girls typically develop a crush on woman teachers or older girls. Mutual masturbation of same sex individuals occurs commonly in adolescence, but is usually exploratory and does not become a fixed pattern, nor does it imply homosexuality. However this natural experience may cause confusion and concern, as a youngster may consider this to be a homosexual experience, and draw the conclusion of a homosexual identity. Same sex preference typically occurs in late adolescence or young adulthood.

These postulated factors are too varied and unconnected to be conclusive.

Endocrine studies are conflicting and inconsistent, but the finding that one third of lesbians studied have testosterone levels above the normal range is relevant (Bancroft, 1983). It is possible that high testosterone levels in women are associated with psychological characteristics which conflict with conventional heterosexual relationships.

There is no evidence of chromosomal or physiological differences between homosexual or heterosexual men and women.

It is now thought that the aetiology is multifactorial, based on genetic, fetal and hormonal factors, and that psychodynamic social learning plays a major role.

Legal aspects: in most countries homosexuality is accepted if it is practiced between consenting adults in private, provided children are not involved. However, in some countries the law and/or religions prohibit homosexuality. The legal age of consent for male homosexual behavior in the UK is 21 years (compared to 16 for heterosexual behavior).

Sexual activity: there is no difference between homosexual and heterosexual males' and females' physiological capacity to respond to similar stimuli (Masters, 1979). The range of sexual behavior reflects the degree to which individuals accept their homosexual orientation. Homosexuals who share emotional closeness are more apt to perform sexually in ways that are pleasing to their partners than to consider their own preferences. Lesbians are less promiscuous and have more stable and lasting relationships, and show less "deviant" sexual behavior (sadomasochism, transvestism) than male homosexuals. There is no female equivalent of a paedophile. The majority of lesbians (72%) interchange sex roles, and rarely indulge in mass or group sex or voyeuristic activities (Kenyon, 1980). Lesbians engage in oral genital contact (cunnilingus) and mutual masturbation which may include vaginal or anal penetration with fingers or (rarely) dildos, and tribadism i.e. friction of the clitoris against the partner's body (Degen, 1982). Lovemaking usually includes caressing and kissing and a high level of intimacy.

Men: most homosexual males in the United States prefer oral genital sex (fellatio) after mutual masturbation. A slightly smaller number prefer anal intercourse (Bell, 1980). Other activities include anilingual stimulation, nipple play, kissing, spitting, spanking, and the use of enemas. Brachioproctic eroticism (fisting) and sexual pleasure associated with urination (termed "water sports"), shaving, bondage, and whipping also occur among homosexuals as well as some heterosexuals.

Masters (1979) found that homosexual couples took more time in whole body sensuality and foreplay, were more sensitive to their partner's wishes and responses, and communicated more freely and fully about their sensations and emotions during sexual encounters than heterosexual couples. There is usually reciprocity of roles and techniques.

PROBLEMS

Emotional: conflicts may arise if the individual has not entirely accepted his or her homosexuality. They may feel that they have let their parents down, have not lived up to expectations, and fear rejection.

Social: discrimination, loneliness and the risk of blackmail are major problems. Many fear discovery by family, employer or the police, and therefore avoid sharing relationships openly. Some find it difficult to accept childlessness.

Relationships: the highly charged sexual atmosphere of the gay world often conspires against monogamous relationships. A successful relationship makes the homosexual orientation obvious to family, friends and employers. Males seek sexual partnerships most often in gay bars, less frequently in steam baths, on the street, at parties, in parks, on beaches, in public toilets and in movies or theatres. Some remain "in the closet" living secretive lives, revealing their homosexuality only to their closest friends (Bell, 1980). On the other hand, some homosexuals form committed, stable, long term relationships. Some are celibate and may continue to live with their parents. 12 18% of homosexual men are reported to have been married (to a member of the opposite sex) and 50 75% of those have had children (Gadpaille, 1981a). In rare instances the marriages adapt and continue, but conflicts may make the situation untenable. Lesbians appear to experience less social stigmatization and to have more enduring monogamistic relationships than men (Green, 1980).

Most of the social and psychological problems depend on legal and societal stigmatization, religious attitudes and censure of peers.

Sexual: the most frequent problem cited by lesbians is that of finding a suitable partner, and the next is insufficient sexual frequency. Anorgasmia is an infrequent complaint. Lesbians have far fewer sexual contacts than homosexual men (Degen, 1982).

Males may present with erectile or ejaculatory difficulties. The rates for homosexual paedophilia are not different from those for heterosexual paedophilia (Green, 1980).

Medical conditions: there is no evidence that homosexuals have an increased incidence of psychiatric disease (Bath, 1981). Disabled people and those living in community homes carry an added burden, as they are more isolated, have less privacy and are dependent on staff who may be unsympathetic or even hostile.

Some homosexual men tend to be highly promiscuous and are at great risk of developing sexually transmitted diseases (Talbot, 1982). Gonorrhea and syphilis may occur in atypical areas such as the throat and rectum. Enteric diseases (giardiasis, amoebiasis, and hepatitis B) may be transmitted by oral contact which follows anal contact or oral anal sex (anilingus). Mixed protozoan and bacterial infections have been reported and termed the "gay bowel syndrome" (Sher, 1983).

Acquired immune deficiency syndrome (AIDS) has been reported predominantly (80%) in homosexual and bisexual men, especially those who have many sexual partners and practice receptive anal or oral intercourse. It has also been observed in such diverse groups as Haitians, intravenous drug abusers, hemophiliacs, prostitutes, female sexual partners of affected men, and infants whose mothers were antibody positive.

The syndrome is one of pan immunodeficiency. Patients are susceptible to a variety of opportunistic infections, including pneumocystitis carinii, candida albicans, herpes simplex, cytomegalovirus and Kaposi's sarcoma. Symptoms of fever, weight loss, diarrhea, dry cough lymphadenopathy and malaise represent a programme of AIDS. The age group affected is usually 25- 44 years. Not everyone infected with the virus develops the disease, but they have antibodies, and may be infectious (asymptomatic carriers). It is believed that all overt cases will prove fatal.

Aetiology: a virus which is transmitted sexually (by semen, vaginal and cervical secretions, and blood), parenterally, transplacenta and possibly through breast milk, and by artificial insemination. The virus has been isolated in tears and saliva, but there is no conclusive evidence of transmission through these body fluids. No evidence has appeared of transmission by droplet or casual contact. Accidental needle prick transmission is extremely rare.

Human T cell lymphotropic retroviruses type 111, previously known as lymphadenopathy associated virus HIV (human immuno deficiency virus), are believed to be the cause. Blood donors are tested for anti HIV antibodies, and avoidance of promiscuity, and the use of condoms may prevent transmission of the disease. Lesbians tend to have less gynecological surgery, pre menstrual tension, and depression associated with menstruation, and pelvic pathology (cystocele, rectocele and endometriosis) than heterosexual women, but have more dysmenorrhoea (Masters, 1979). Never pregnant women are more prone to cancer of the breast and endometrium; therefore lesbians require information about the early detection of these diseases.

The incidence of syphilis and gonorrhea is lower among heterosexual women. The incidence of enteric infections is extremely low, but oral genital contact should be proscribed in its presence (Degen, 1982). In theory, hepatitis can be acquired by oral sex with a woman who is menstruating. Women with genital warts (papilloma virus) must be warned of the need for regular Pap smears, and against direct contact with the lesions or sharing intimate articles. Studies suggest that the prevalence of problems of alcoholism in homosexuals is considerably higher than in the population at large. Although the mental health of lesbians is equal to heterosexual controls, there are some groups at high risk: black women, the lesbian rejected by a lover, and those who have not been able to maintain a lasting relationship. These situations could account for significantly increased prevalence of alcoholism, drug .dependency, attempted suicide, and depression (Degen, 1982).

COUNSELING

Health care professionals should set aside stereotypes about homosexuals and relate to each patient as an utterly unique human being (Bell, 1980). Homosexual preference or activity is usually only revealed if specifically asked about in the history, and this should be done even for married parents.

Until recently, homosexuality was considered a deviation, abnormal or criminal, and treatment was aimed at restoring heterosexual activity, with little success. Now management depends on the needs and desires of the individual. Assistance may be sought to:

adjust to homosexual orientation without anxiety or guilt assure the individual that he or she is not homosexual manage crises within the homosexual situation change to a heterosexual orientation resolve sexual dysfunction or psychological problems which may be associated with guilt and depression due to social pressures treat alcoholism or medical problems adjust to the homosexuality of the partner or to divorce.

History and examination should determine the presence of organic disease and appropriate treatment should be given. The individual's desires and problems should be explored.

Information: some individuals fear that they may be homosexual when in fact their sexual fantasies and arousal are heterosexual, but their shyness and difficulty in relating to individuals of the opposite sex have displaced their sexual orientation. Supportive counseling and assertiveness training may be all that is required.

Parents: every effort should be made to reduce their feelings of guilt by assuring them that they have not been responsible for causing homosexuality, and to reduce their feelings of rejection for their child. Parents must beware of humiliating adolescents about awkward behavior with the opposite sex.

Crises: relationship problems, separation from a partner, job discrimination, legal action, and the acknowledgement of homosexuality as a reality require supportive counseling. Sexual dysfunctions: sex therapy is applied in the same way as for heterosexual couples. Drugs and hormones have no place in treatment. Testosterone injections do not switch men's orientation. In women they seem to influence the strength of libido and arousal rather than its direction (Kenyon, 1980). Masters and Johnson (1979) use a modification of their couple therapy techniques for sexual dysfunction and have had greater success than with traditional psychotherapeutic approaches. Sex therapy is inappropriate for an individual who is conflicted about his or her sexual orientation. This issue must be dealt with first by psychotherapy.

Homosexual offenders commit acts with non consenting adults or children. Treatment with cyproterone acetate (100 200 mg daily) inhibits male sexual response after approximately 14 days of therapy by eliminating the compulsion toward antisocial behavior (Haslam, 1976) .

Desire for reorientation: homosexual men and women who are dissatisfied with their orientation may wish to convert or revert to heterosexual function because homosexual arousal interferes with their desired heterosexual relationship, or because homosexuality is undesired, or causes distress or shame. Behavioral techniques are based on attempts to replace homosexual by heterosexual arousal, and not aversion.

If an individual decides to explore a heterosexual relationship Bancroft (1983) advises him or her to keep his or her homosexual feelings in reserve and consider the exploration as an experiment. Treatment focuses on fantasy and real interactions with a potential partner of the opposite sex.

Where available, gay clubs and organizations, e.g. Gay Switchboard, enable homosexual men and women to socialize comfortably.