Studies of Homosexuality Volume 9 Introduction
[03/10/92] [vol. 9: medicine & science]
At the end of the nineteenth century, the pioneers of the German homosexual rights movement looked to science as a liberating force. With its rigor and "objective" methodology, science (which, many believed, was certain to demonstrate the biological basis of homosexuality) would, in an ironic reversal of the traditional demonology, exorcise the ghosts of Christian bigotry and medieval superstition, showing everyone the pointlessness of treating homosexuals as inferior sinners and criminals.
The twentieth century, however, has produced numerous examples of science as a tool of oppression. In the early and middle parts of the century, some scientists did undermine earlier misconceptions, but many more reinforced popular attitudes and all too many proved themselves willing to support schemes for the eradication of homosexuality—and in Nazi Germany, of the homosexuals as well—-through social and psycho¬logical engineering.
Medicine in particular embraced concepts of homosexuality as a disease, providing the rationale for further discrimination; its offspring, psychiatry, proved every bit as hostile as the Christian establishment.
Towards the middle of the present century, however, and just as psychiatric theories of homosexual pathology were reaching their apogee of influence, another, less subjective, branch of science, biology, in the person of entomologist Alfred C. Kinsey, came riding to the rescue.
Kinsey's massive investigation, which reached the world through his 1948 volume Sexual Behavior in the Human Male (followed in 1953 by the female volume), not only shocked the general public with its high incidence rates for homosexuality, but established a new standard of objective language to describe homosexuality. Discarding even such vague terms as "homosexual," "heterosexual," and "bisexual" in favor of a continuum of sexual orientation and practice, Kinsey created a seven-step numerical scale to measure the proportions of heterosexual and homosexual "outlets" in the behavior of white Americans. (The continuum concept, while joining the vocabulary of scholars as more accurate than simple binary or even triadic classificatory schemes, never became popular among activists, possibly because it did not lend itself to a politics of "gay and lesbian identity.") Kinsey's training as an entomologist was no doubt instrumental in his ability to discard conventional viewpoints in order to examine sexual events with the same dispassion he employed in studying gall wasps.
The tradition of objectivity in the study of homosexuality which Kinsey established in the United States suffered first as a result of massive opposition to his work in the conservative fifties, and more recently from the other side as a result of an overriding commitment to political objectives among activist-oriented scholars who came to dominate the subject in many disciplines. Nevertheless it has become more and more the norm for scientific research. Today Kinsey's quest for objective measurements of sexual phenomena continues with new techniques such as plethysmography, which records the engorgement of blood vessels in the pelvic area due to sexual arousal, and electroencephalographic recording of brain waves ("evoked potentials") in response to erotic stimuli.
The Czech researcher Kurt Freund first used plethysmography in determining that aversion therapy to change sexual orientation was not productive. Plethysmography is useful in quantifying such areas as sexual orientation, changes in sexuality with age, and the discrepancies between biological reactions and conscious reporting by the subject.
Brain researchers have also used electrode recording of evoked potentials to measure sexual orientation independent of conscious reports. After discovering that the anticipation of pleasure produces a characteristic electrical pattern in the brain, neuroscientists measured the strength of this reaction in response to visual images.
Both techniques could potentially be of use to repressive governments or private organizations in invading the privacy of people's sexual feelings or thoughts, and thus they raise issues of ethical application, so far more for hypothetical future misuse than for present research, which relies on volunteers.
A new entry in the field is neuroanatomy, where Simon LeVee's pioneering work at the Salk Institute measuring variations in very small brain structures has aroused both intense interest and considerable scepticism.
Another area in which scientific objectivity has begun to make itself felt is genetic and hormonal studies, though here the methodologies are more complicated and the results more controversial. Twin studies, however, appear to have made considerable progress in establishing solid data pointing to genetic factors.
Work in these areas, combined with theoretical studies in sociobiology, has occasioned a revival of interest in biological explanations of homosexuality. The ground for this revival was broken by the Kinsey Institute, which, using path analysis techniques, discredited the major psychiatric theories of homosexual etiology.
Perhaps science is, a century late, finally beginning to fulfill the role the founders of the gay rights movement predicted for it.
Medical theorists have concerned themselves with homosexuality since classical antiquity, when writers associated with the Hippocratic and Aristotelian schools formulated different physiological explanations for the rare cases of adults who crossed the boundaries of traditional gender behavior; neither school thought that pederastic behavior required such explanations. The Greeks, whose model of homosexuality was age differentiated, thought the gender differentiated and androphilic types to be abnormal, thus displaying the tendency towards cultural bias which has characterized medical theory in this area for millennia.
Beginning with the Renaissance, medicine acquired a forensic tradition which sought physical evidence for the crime of sodomy. Under the cloak of psychiatry, this forensic tradition produced the modern Western concept of sexual orientation in the latter nineteenth century.
Meanwhile theorists had ascribed homosexuality to degenerative diseases of the nervous system, moral insanity, erotic monomania, and sexual inversion.
The modern medical theories of homosexuality (which seldom went beyond the androphilic type familiar to modern middle class northern Europeans) originated in an unsuccessful attempt on behalf of defendants to attack criminal sanctions, but then turned against their sponsors, becoming vehicles to deny the legitimacy of homosexual expression. Eventually the United States went so far as to bar homosexual immigration on medical grounds as a psychiatric pathology. Thus the strategy of defense against the medieval sodomy laws opened the door to a new and in many ways more pernicious enemy, cloaked in the mantle of "science."
Beginning in the mid 1960s, however, gay rights advocates vigorously attacked these theories, beginning with logical arguments and proceeding through pickets and demonstrations (1968 on) to the use of disruptive tactics at psychiatric conventions. They succeeded in persuading the American Psychiatric Association to remove homosexuality from its list of mental diseases in 1973, a decision confirmed in a subsequent mail ballot of APA members. This reform finally (and quietly) reached the United Nations sponsored World Health Organization in 1992.
Biology and Etiology
The medical theorists did not stop to consider the question of homosexuality in animals, assuming as they did that human homosexuality was "unnatural." Ethologists beginning with Konrad Lorenz, however, following a path blazed long ago by Aristotle, have observed homosexual behaviors in fish, birds, lizards, goats, dogs, monkeys, dolphins, and many other species; often this appears to be related to dominance contests among males; for females no such correlation has suggested itself.
The presence of homosexuality—especially exclusive long term homosexuality in humans—poses an outstanding theoretical problem to evolutionary biology, which is rooted in Darwinian concepts of reproductive fitness. This challenge, supported by findings that sexual orientation does tend somewhat to run in families, and strongly among genetically identical twins, has elicited various responses from sociobiologists. G. Evelyn Hutchinson developed a theory of heterozygote advantage, which may apply best to bisexuality, in 1959. James D. Weinrich developed kin selection theory to account for gender differentiated types of homosexuality in 1976; a later essay by Weinrich is included herein. Other types of homosexuality, such as the Greek pederastic model, situational homosexuality, adolescent experimentation, and dominance-enforcement, do not have significant effects on marriage and reproductive rates and thus do not pose such puzzles for evolutionary theorists. Modern androphilia (usually reciprocal relations between two adults, both identified with the same gender and of formally equal status) remains the most difficult case, but it may be too recent a development as a common type for Darwininan selection to have had significant effects.
Twin studies of homosexuality go back to Franz J. Kallmann's pioneering, but flawed, 1951 research with monozygotic (genetically identical) twins, which found startlingly complete concordance for sexual orientation of the twin pairs. Taken as a whole, twin studies show that identical male twins, sharing the same genes, whether raised together or apart, ordinarily share the same sexual orientation. Fraternal twins, on the other hand, with only half their genes in common, whether raised together or apart are far less likely than identical twins to develop similar sexual orientations. Even fraternal twins raised apart, however, are more likely to show similar sexual orientations than mere chance would indicate. Further confirmation of these findings appeared in a major study published in late 1991 by J. Michael Bailey and Richard C. Pillard. In addition to showing that environment alone cannot account for the development of male homosexuality, the studies cast doubt on theories of prenatal hormonal factors in the mother's womb, since such theories cannot account for the greater concordance of sexual orientation of identical twins as against fraternal ones, each pair being subject to the same hormonal influences.
A 1985 study of identical twins reared apart by Elke D. Eckert and others (included herein) concluded that "it is hard to deny genetic factors an etiological role" in the formation of male homosexuality. Eckert suggested on the basis of a comparison of male and female twin pairs that lesbianism may have entirely different, non genetic, roots. He did find a significant difference in the age of first menstruation between the heterosexual and lesbian members of a pair of twins, with the lesbians maturing later; Eckert noted no differences in the age of puberty in the male twins.
The debate over the etiology of homosexuality—or more accurately, the etiologies of various types of homosexuality, any common denominator other than some type of same sex behavior having yet to appear—has had serious consequences for the ways society treats the people who exhibit such phenomena. These can range from burning sodomites at the stake for their willful sins through compulsory electroshock therapy for psychopathic inverts and a resigned acceptance of homosexuality as the unalterable condition of homosexuals to seeing homosexuality as one in a repertoire of many normal human sexual behaviors, one not associated with any particular character or personality traits, much less a fixed identity.
While the etiological issues remain a subject of intense interest, progress in this area will require not only dispassion¬ate scientific objectivity (as rare among gay activists as among their opponents) but a recognition of assorted types of homosexuality, an integration of disciplines, a cross cultural perspective, a recognition that sexual patterns may change over an individual lifetime as well as over centuries within societies, and a willingness to accept empirical evidence instead of reliance on abstract theorizing alone.
Turning to health care, which with the spread of the AIDS epidemic has become of primary importance to the gay community, one should first note that the particular medical concerns of gay men and lesbians did not become a subject for discussion until the 1970s, and the organizers of health care systems did not acknowledge or accomodate the gay or lesbian patient. For a discussion of lesbian medicine, see the article by Susan R. Johnson and J. L. Palermo; on the male homosexual see the article by Michael W. Ross, both included herein.
Only in recent years have health care providers who are themselves homosexual become visible, but today gay and lesbian medicine has become a recognizable specialty among physicians, and there are professional associations of gay and lesbian physicians, nurses, and other health workers. One of the consequences of the general lack of a gay oriented medical practice has been a turn to medical self help, most notably in the case of such organizations as New York's Gay Men's Health Crisis.
Students of alcoholism have long maintained that the rate of alcohol abuse is higher among male and female homosexuals than among the general population; for most Americans the gay bar is the central homosexual social institution. Various and often conflicting theories have sought to account for this. Recent therapy has tended to focus on adaptational responses to a homophobic environment, encouraging gay alcoholics to enter treatment programs where they are encouraged to be themselves. Articles on alcoholism and homosexuals are included from Stephen Israelstam and Sylvia Lambert and from Edward Small and Barry Leach.
Other drug use among homosexuals has drawn less attention. It appears that the illegal status of various substances has had less of a deterrent effect among those whose sexual life was illegal to start with, leading to widespread scepticism about government pronouncements concerning the use of one's own body to perform victimless crimes. Living in a subculture which already included an aura of illicit pleasure, gays and lesbians proved hospitable to "recreational" drug use in the 1960s and 1970s. Use of nitrate inhalants, marijuana, snort¬able cocaine, and hallucinogens was widespread, though the gay subculture has apparently generally avoided the more destructive drugs such as opiates, crack, methamphetamines, barbiturates, and PCP. Nicotine addiction has followed patterns in the general culture. See articles by Ellen Herman and John A. Newmeyer, included herein.
Until the 1980s, the main health concerns of gay and bisexual men (and to a diminishing extent, of bisexual women and lesbians) were the conventional sexually transmitted diseases, gonorrhea and syphillis, which were reputedly more common among male homosexuals than in the general population. Antibiotics are effective against both, but awareness and diagnosis does not always come easy when the gonococcus bacteria lodges in the rectum (it does not survive in the mouth) or remains asymptomatic, or when the initial manifestations of syphillis go unrecognized. Genital herpes occasioned considerable alarm in the late 1970s, but turned out to be chiefly a problem for heterosexuals.
Due to its spread through anal oral contact, infectious hepatitis affected ten times as many gay as straight men until a vaccine proved effective in the early 1980s.
Concerns developed around physical traumas associated with the practice of inserting a fist inside the rectum ("fisting"), a practice which appears to have drastically declined since the 1970s.
Also controversial was the use of legal amyl or butyl nitrate inhalants ("poppers") during the sex act, a habit which was once widespread among homosexuals but never caught on among heterosexuals. Apart from occasional transient headaches and cautions over their use by elderly heart patients (for whom they were originally devised as vasodilators), these inhalents were considered harmless. Then in 1986 a sensational book by John Lauritsen and Hank Wilson suggested that they caused or contributed to AIDS, leading to legal restrictions in some states and a drastic decline in use. Conclusive evidence for this claim has not developed, however, and AIDS has gone on to strike down vast numbers of non-users; thus a low residual level of use by sceptical gay men in major urban centers continues.
The Acquired Immunodeficiency Syndrome (AIDS) first came to public awareness in the early 1980s as a mysterious and fatal disease which seemed to afflict only homosexuals, hence it acquired a reputation as a "gay disease," a misconception which lingered in the public mind long after it had disappeared from the health professions.
The ravages of AIDS among the gay male community are too well known to require elaboration here; the fact that the bulk of the articles in this volume are concerned with the epidemic speaks for itself. At the beginning of the closing decade of the century this scourge showed no sign of abating, though the rate of increase in cases among homosexuals showed a significant decline (presumably due to changes in sexual practices which also reduced the incidence of venereal disease), the opportunistic infections which usually caused death were under better control, new experimental drug programs were on the way, and hope existed for an eventual post-infection "vaccine" which, if it would not eliminate the HIV virus which was linked to the disease, at least might keep it harmless. Researchers suggested that newly infected people should no longer expect a necessarily fatal outcome, but rather a disability comparable to, say, diabetes, which could be kept under control through continuous surveillance and treatment. Twelve years after the first cases became known, it remained unclear what percentage of those infected with the virus would develop "full blown" AIDS or what the eventual mortality rate was; such progression seems to have occurred in most but not all cases of early infection.
While the scientific establishment has accepted the evidence for the Human Immunodeficiency Virus (HIV) as the primary causal agent, and information about the workings of that virus had multiplied many times over after a decade of intensive research, others remained unconvinced. Conspiracy theorists continue to believe that the agent, whatever it is, was unleashed from government laboratories. A growing body of opinion among professionals now suggests that the HIV virus is a necessary but not sufficient causal agent, requiring as yet unknown (though sometimes strongly suspected for epidemeological reasons, such as the presence of other sexually transmitted diseases) co factors for its activation, virulence, and for disease progression.
Understanding of the progress of HIV infection has much improved, though major gaps in knowledge remain despite intense research efforts. New diagnostic tests have established general correlations between various levels of T4 cell counts and the progression from asymptomatic infection (which may last years or even a lifetime) through ARC (AIDS Related Complex) to "full blown" AIDS, and the controversial drug AZT has been prescribed even for asymtomatic HIV positives in an effort to retard this progressive deterioration.
The usually fatal prognosis and lack of conventional treatments has encouraged persons with HIV infection or AIDS symptoms to experiment with a wide range of unconventional methods, new and unproven drugs, and holistic pro¬grams, some of which have claimed to be able to cure the dis¬ease. The desperation of the stricken patient facilitates exploitation and quackery, but exploration of many of the "alternative" non allopathic medical techniques (such as acupuncture, megavitamins, and herbal remedies) has been quietly encouraged by medical professionals who have little else to offer and who believe that these methods would at least not harm the patient; the net result is a growing familiarity among the gay male community with holistic systems of health care and a scepticism regarding the commitment of the medical establishment to explore any remedies which do not promise major profits for the pharmaceuticals industry.
The political questions surrounding the AIDS epidemic and the response to it have generated considerable debate, with gay activists charging that the American government was slow to react to the crisis because it appeared at first to kill only homosexuals and then drug addicts. This perception was aided by pronouncements from conservative leaders close to the Reagan White House that AIDS was "God's punishment" for homosexuals. Certainly the crisis has had profound effects on the homosexual movement and on public awareness of and opinion with respect to homosexuality. Impatience with government agencies dealing with the epidemic has spawned a new wave of militancy and even civil disobedience on the part of such groups as ACT UP, while public and internal debate has focused on serious questions about funding for research, treatment, and disabled victims and on the very lengthy approval process for new drugs. Changes in this process, stimulated by the AIDS crisis, have taken place as reluctant government agencies responded to the public and political pressure to make experimental drugs available to patients who had little left to lose. A patient self medication movement is another by product of the approval process.
AIDS has also had major effects on homosexual behavior, though documentation for this conclusion is spotty and based primarily on a decline in veneral diseases and anecdotal evidence. The major consequences appear to be a decline in anal intercourse, especially without condoms, a greater reluctance on the part of heterosexuals to engage in homosexual acts, a decline in promiscuity in favor of monogamous pairs, and an increase in mutual masturbation (often via telephone).
For the most part, lesbians have remained medically unaffected, though the lesbian community has been very active in efforts to help victims of the disease. The epidemic, which could have driven a wedge between male and female homosexuals, has instead served to bring them together in a common cause.
Bisexuality, which was almost becoming chic in the mid-1970s, appeared as a dangerous source of contagion to the heterosexual majority and hence became heavily stigmatized even as its extent became more obvious. The bisexual movement, which had shown a preponderance of men in the seventies, reemerged from the eighties with female leadership and mostly female rank-and-file.
The rate of "coming out" and adoption of a homosexual identity seems to have slowed among healthy males, while death and disease "outed" many celebrities, but little or no documentation on these effects has been forthcoming.
Another area in which AIDS has had major consequences has been in the public awareness of homosexuality. The last mass media taboos in the West against mentioning homosexuality have all fallen, so that it has become virtually impossible for a Westerner to come to adulthood thinking he is the only one with same sex desires, as often happened in previous eras. On the contrary, homosexual AIDS victims seem to be everywhere, often confounding stereotypical assumptions in the process. The most "macho" occupations and ethnic groups, the most rural settlements, the most conservative priests and politicians, have all offered up their victims for public examination. Terms like anal intercourse have appeared in television news programs and family newspapers, while "lovers" and "companions" have become a standard feature of obituaries.
Nonetheless, mass media squeamishness about particular sexual techniques, combined with a conservative American government's inclination to suppress all homosexual activity and innate cautiousness on the part of health professionals have prevented media coverage of the stark difference in transmission danger between unprotected anal and oral activities. The latter are at least far less risky than the former, and may well be virtually risk free, but studies tending to exculpate oral transmission gathered publicity only in parts of the gay press, not in media directed at the general public or in government sponsored publications in the United States. The Canadian government, on the other hand, has included such information in its AIDS education program. Another important area of information which has been similarly neglected is the fact that anal transmission of the virus normally goes from penis to anus rather than vice versa.
Homophobia appears to have increased in the wake of the epidemic, with the incidence of violent assaults against homosexuals reportedly rising in the United States, prompting the formation of gay vigilante groups and agitation for "hate crimes" legislation in several areas. The movement for gay rights and for decriminalization appeared to have lost momentum for a decade, in part because the attentions of the gay community have been focused on AIDS and in part because of growing public resistance. On the other hand, Congress adopted federal legislation protecting the civil rights of those infected with the HIV virus, in marked contrast to its treatment of gay rights bills, which have never even reached the committee hearing stage.
The Christian religious establishment has reacted to the epidemic in predictable ways, with liberals emphasizing compassion for the victims and conservative fundamentalists preaching God's plague on the sodomites.
The decimation of the gay male community has had major effects in the cultural sphere, not only through the loss of key creative talents but through the refocusing of cultural attention on the disease and its consequences through innumerable books, films, plays, songs, and benefits. Notable also has been the revival of a long dormant folk art in the Names Project Quilt, begun in 1987.
AIDS has also taken its toll on gay institutions, resulting in the closing of gay baths around the USA and in a major reduction in the number of gay bars.
Tourism has been affected, especially "sex tourism" in the Third World, and some countries have required HIV testing of visitors; the United States sought to exclude HIV-positive persons from entry altogether.
Legal questions relating to discrimination against persons with AIDS and HIV positives have multiplied, with the U.S. government adopting antidiscrimination legislation based on classification of AIDS as a "handicap" in 1990. Many gay males have lost employment and/or housing as a result of public hysteria over AIDS contagion. Proposals for quarantines and camps continue to surface, though as yet they have not come near adoption as public policy.
The counseling professions have also been affected in major ways, having to deal with numerous consequences of AIDS, including depression, grief, and paranoia; social workers have become involved on a major scale in the living problems of homosexuals suffering simultaneously from the ravages of the disease and from the rejection of a fearful and homophobic public.
Public health and epidemiological needs for reliable information on risky sexual behavior has highlighted the absence of such data and focused attention on the need for further empirical research, which has made little progress since the 1947 Kinsey report. In 1990 and 1991 conservatives in Congress blocked a project for a new survey of American sexual behavior sponsored by public health agencies.
New ethical and sometimes legal issues have arisen in connection with hypothetical vaccine trials, the confidentiality of HIV testing, and the moral obligations of infected persons with respect to sexual partners.
While the United States has shown the greatest number of cases of homosexual transmission of AIDS, the number of men afflicted in other countries as a result of homosexual acts is steadily growing (while the proportion of new cases due to heterosexual transmission, usually from man to woman, rises both in the United States and abroad). In general, these nations have looked to the USA for leadership on this issue. France has taken a prominent role in the international research effort, and Britain in the area of public education. In central Africa, AIDS appears to be spread mostly heterosexually and has become a demographic catastrophe comparable to the medieval plagues of Europe.
Major funding problems loom for the treatment of the ever increasing number of AIDS patients, who are already over¬loading health care systems in major American cities. Often deserted by insurance companies and employers, persons with AIDS may have little to contribute financially to their intensive and expensive care. At the same time, financially hard-pressed state and city governments are under intense pressure to cut back on Medicaid funding and disability benefits. In the future, this sad fact may prompt triage application and the lowering of standards of treatment, a development which may show the consequences of homophobia on the part of the taxpaying public.
The slow but progressive spread of AIDS to the heterosexual citizenry of the United States may transform the landscape of public concern dramatically, as would the development of either a preventive vaccine or a successful (at least in terms of preventing illness) treatment. Eventually, though perhaps decades off, the epidemic will take its course and recede in medical importance, but in many ways it has already drastically altered the history of homosexuality and these changes will reverberate into the future for a long time to come.
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