Psychosomatics 42:89-90, February 2001
© 2001 The Academy of Psychosomatic Medicine
Homosexuality and the Mental Health Professions: The Impact of Bias
Formulated by: The Committee on Human Sexuality the Group for the Advancement of Psychiatry, Hillsdale, New Jersey, The Analytic Press, 2000, 152 pages, ISBN 0–88163–318–615, $29.95
Susan K. Ball, M.D.
Key Words: Homosexuality
Dilip Ramchandani, M.D.
BOOK REVIEW EDITOR
This monograph is written and edited by the members of the Committee on Human Sexuality of the Group for the Advancement of Psychiatry. They have produced a concise, informative, and timely body of work replete with an excellent list of references on the subject of bias towards gays and lesbians in the mental health professions.
The Group for the Advancement of Psychiatry (GAP) was started in 1946 by a group of young psychiatrists who produced monographs on controversial and relevant psychiatric issues. GAP has continued in that tradition and has strongly influenced psychiatric practice and attitudes over the ensuing decades. GAP has produced a number of monographs dealing with human sexuality, forensic and social issues in psychiatry, and the issues of bias and discrimination in psychiatric practice.
Most of us in the practice of psychiatry and mental health will have the opportunity to treat gay and lesbian patients. We cannot do this successfully without exploring the bias we bring to the therapeutic relationship. This gem of a monograph more than fulfills its mission to heighten the readers' awareness of their own biases and to stimulate readers to pursue further education on this topic.
The premise of this monograph is that despite all the strides of the gay rights' movement toward acceptance and understanding of homosexuality in our society, there still remains a tremendous amount of individual personal bias toward homosexuality. This bias subtly impacts mental health professionals in their work. Mental health professions continue, for the most part, to use a heterosexual model of human development in which they base their understanding of all patients.
The authors indicate that despite the impressive number of books and articles in the psychiatric literature on the subject, few psychiatrists have received any formal training in the assessment of gay and lesbian patients. Most of us are woefully ignorant of the complex societal pressures facing our gay and lesbian patients in their everyday lives. These pressures affect individual development and individual response to stress. By educating ourselves in the psychodynamic issues of our homosexual patients, we can be more open and empathetic to their emotional struggles.
The monograph is divided into five chapters. The first covers the dimensions of homosexual bias, starting with a historical view on the cultural and historic roots of antihomosexual bias. The authors point to a paucity of research on the attitudes toward homosexuality in the general population.
The second chapter explores antihomosexual bias in the clinical setting. The main tenet of this chapter is that patients should be seen as patients who need treatment and not as a homosexual patients with problems that are most likely connected with their homosexuality.
The authors discuss five patterns of clinical bias: pathologizing (the tendency to give more serious diagnoses to homosexual patients and see homosexuality as a psychological disorder); stereotyping, stigma, and misattribution (the tendency to see the patients' problem as a result of their homosexuality only); empathetic failure (the lack of recognition of the degree of distress patients are experiencing as a result of their symptoms); heterosexism (the lack of understanding of the developmental milestones in the coming-out process and the belief that heterosexuality is the superior lifestyle); and unsolicited attempts to change their patients' sexual orientation.
The third chapter assesses the impact of an antihomosexual bias in the setting of supervision and professional training. Case vignettes are extremely helpful in understanding the bind of the trainee trying to sidestep the bias of the supervisor in the treatment of homosexual patients. There is a compelling description of the struggles of the homosexual trainee trying to decide if it is safe to come out to teachers and supervisors.
The fourth chapter reviews the legal progress that has been made in this area and outlines the struggles that remain for gays and lesbians in our society. Although there may be referenda on some state ballots endorsing gay marriages, 24 states continue to have sodomy laws. There are no current federal protections for homosexual men and women in the area of housing, education, or employment.
The fifth chapter deals with HIV and antihomosexual bias in mental health. The advent of AIDS has further served to increase bias, especially toward gay men. It has served as a "reinforcing stigma." However, the epidemic has also brought about a positive change in the attitudes of many mental health professionals who have had exposure to patients with HIV and the stigma their patients' experience.
The authors illustrate the biases that we bring into the therapeutic relationship no matter what our educational background and sexual orientation. In chapters two through five, they use 25 very compelling and instructive case vignettes to exemplify clinician bias. The authors illustrate the errors that even the most experienced psychiatrist can make when we bring our biases into the therapeutic relationship. The vignettes can also serve as wonderful teaching cases for those involved in the teaching and supervision of residents and students.
Dr. Ball is the section chief of Geriatric Psychiatry at Crozer Chester Medical Center. She has a private practice in which she subspecializes in the treatment of gay and lesbian patients.
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